People who experience OCD are very familiar with the feeling of intense anxiety. Anxiety can be uncomfortable, all-consuming, and energy-depleting. Within OCD, anxiety is the aftermath of experiencing an obsession. An obsession is an unwanted thought, image, or idea. Examples can include preoccupation with germs or safety, violent intrusive thoughts, or constant worry about the future. They are thoughts that would bother most people, but for those with OCD, these thoughts feel intolerable, and there is an urge to feel better as soon as possible. This is where compulsions come into play. Compulsions are thoughts or behaviors we do on purpose to lower anxiety and offer certainty that the obsessions are false. However, they only work in the short term. Before you know it, anxiety is heightened again by an obsession, and you are stuck in the feedback loop of obsessing and compulsive behavior. You might even reach a point where the compulsions don't lower your anxiety as much as they used to, and they begin to demand more and more from you. This can make life exhausting, challenging, and unenjoyable.

The good news is, there is treatment for this! Exposure and Response Prevention (ERP) is the gold standard treatment for OCD. The goal in ERP is to work on reducing and eventually eliminating your compulsions so that you are no longer stuck in that constant loop and you can tolerate anxiety better. So how do you resist a compulsion? How is it possible to handle intense anxiety without giving in to the urge to check, seek reassurance, or avoid something? Coping skills may be helpful in these scenarios. However, it is imperative to be cautious of over-using coping skills. If the ultimate goal in ERP is to tolerate anxiety, coping skill use can often get in the way of this opportunity.

The first step is to think about your anxiety on a 1-10 scale. There is a considerable difference between tolerating a situation that may be causing a "3" for anxiety versus a "9", which is why it is so important to differentiate and mentally label your level of anxiety in a given moment. Below, I have written a guide for how to respond to your anxiety based on your level. Please note that there can be exceptions to this on an individual basis. Consult your therapist about how to best adapt this guide to your life and OCD presentation.

Level 1: Life is good! Felt no anxiety and I am feeling present. 

What to do? → Business as usual!

Level 2: Minimal anxiety felt, still functioning great and staying present.

What to do? → Stay present and be on the lookout for urges to ritualize.

Level 3: Anxiety is increasing steadily but is still manageable. You might experience fleeting thoughts about engaging in compulsions. 

What to do? → Fight to stay present. Resist compulsions quickly as urges arise.

Level 4: Anxiety becomes constant and uncomfortable, and obsessions become repetitive. The thought of engaging in a compilation feels easy and tempting.

What to do? → Let time pass while you continue to resist compulsions completely. Then, be on the lookout for sneaky urges to ritualize and stay on guard. 

Level 5: Anxiety may begin to have a physical presence in your body at this level, such as tenseness or feeling jittery. It feels uncomfortable, and therefore urges to ritualize increase. 

What to do? → Continue to let time pass without engaging in rituals. Notice the tension in your body and try to relax physically. 

Level 6: It is hard to tolerate the anxiety at this level, and thinking may become clouded. Your physical symptoms, such as an upset stomach or racing heart, may continue to increase. In addition, you find yourself heavily thinking about engaging in compulsions.

What to do? → Begin to formulate a plan for how you will resist compulsions. Outsmart your OCD urges. At this level, it is still possible to tolerate anxiety without giving in to urges.

Level 7: It is now hard to stay present in the moment due to constant obsessions. There is an urge to avoid anything that could cause further distress. As a result, you are not present and feel very physically anxious.

What to do? → Begin to breathe and continue to try and relax your body. This may be a level where you still feel capable of tolerating anxiety and not giving in to compulsions. Again, try to let time pass before deciding on engaging in a compulsion.

Level 8: Others would likely notice you are not doing well. You may feel like crying or giving up. 

What to do? → Breathe slowly, taking a long exhale. Hang on to not ritualizing as long as you can. If this feels impossible, limit your compulsions. Take time to think about what you will allow yourself to engage in so you are still in control (whether that means limiting the number of compulsions, the time spent on them, not repeating them, etc.).

Level 9: This is a very high level of anxiety, and it is hard to function. It isn't easy to think clearly at this time. 

What to do? → Practice respiratory control slowly for 5 minutes. Completely resisting compulsions might feel impossible at this level. Only ritualize until you are at a manageable level of anxiety (like a 5 or 6), instead of ritualizing until you're at a 1. Pause often to practice respiratory control for 5 minutes. 

Level 10: The highest level of anxiety you have likely ever experienced. You may be hyper-ventilating or crying and feeling out of touch with your body or surroundings. 

What to do? → Continue to interchange breathing with limiting compulsions. The goal right now is to survive, not necessarily to feel 100% better. Once time has passed, and you are at a lower level, follow those instructions.