Clinical
Corner Ð What is Obsessive-Compulsive Disorder (OCD)?
Obsession Compulsive Disorder (OCD) is an anxiety disorder where a
person has recurrent and unwanted ideas or impulses (called obsessions) and an urge or compulsion to do something to relieve the
discomfort caused by the obsession. The obsessive thoughts range from the idea
of losing control, to themes surrounding religion or keeping things or parts of
one's body clean all the time. Compulsions are behaviors which help reduce the
anxiety surrounding the obsessions. Most people (90%) who have OCD have both
obsessions and compulsions. The thoughts and behaviors a person with OCD has
are senseless, repetitive, distressing, and sometimes harmful, but they are
also difficult to overcome.
OCD is more common than schizophrenia, bipolar disorder, or panic
disorder, according to the National Institute of Mental Health. Yet it is still
commonly overlooked by both mental health professionals, mental health advocacy
groups, and people who themselves have the problem.
Many people still carry the misperception that they somehow caused
themselves to have these compulsive behaviors and obsessive thoughts. Nothing
could be further from the truth. OCD is likely the cause of a number of intertwined
and complex factors which include genetics, biology, personality development,
and how a person learns to react to the environment around them. What
scientists today do know is that it is not a sign of a character flaw or a
personal weakness. OCD is a serious mental disorder which is more treatable
than ever. It affects a person's ability to function in every day activities,
one's work, one's family, and one's social life.
Obsessions
Obsessions are unwanted ideas or impulses that repeatedly well up in the
mind of a person with OCD. Common ideas include persistent fears that harm may
come to self or a loved one, an unreasonable concern with becoming
contaminated, or an excessive need to do things correctly or perfectly. Again
and again, the individual experiences a disturbing thought, such as, "My
hands may be contaminated -- I must wash them" or "I may have left
the gas on" or "I am going to injure my child." These thoughts
tend to be intrusive, unpleasant, and produce a high degree of anxiety.
Sometimes the obsessions are of a violent or a sexual nature, or concern
illness. (NIMH)
Compulsions
In response to their obsessions, most people with OCD resort to
repetitive behaviors called compulsions. The most common of these are washing
and checking (e.g., making sure the gas is off for the oven). Other compulsive
behaviors include counting (often while performing another compulsive action
such as hand washing), repeating, hoarding, and endlessly rearranging objects
in an effort to keep them in precise alignment with each other. Cognitive
problems, such as mentally repeating phrases, list making, or checking, are
also common. These behaviors generally are intended to ward off harm to the
person with OCD or others. Some people with OCD have regimented rituals while
others have rituals that are complex and changing. Performing rituals may give
the person with OCD some relief from anxiety, but it is only temporary.
courtesy of The National
Institute of Mental Health
Psychotherapy
For many years, OCD was seen as a purely psychological disorder, related
to a desire to control one's environment or to undo some perceived wrong action. Insight
oriented psychotherapy has been singularly unsuccessful in treating this group
of disorders, however. Behavior therapies have had much more success,
especially those with specific small steps geared to the exact
obsessions/compulsions involved in the individual case.
Behavior therapy has a lot to offer individuals with this disorder. Two
common and popular techniques are systematic
desensitization and flooding. Systematic
desensitization techniques involve gradually exposing the client to
ever-increasing anxiety-provoking stimuli. It is important to note here,
though, that such a technique should not
be attempted until the client
has successfully learned relaxation skills and can demonstrate their use to the
therapist. Exposing a patient to either of these techniques without increased
coping skills can result in relapse and possible harm to the client. Relaxation
techniques may include imagery, breathing skills, and muscle relaxation. It is
important for the client to find a relaxation technique which works best for
them, before attempting something like systematic desensitization or flooding.
Flooding allows the patient to face the most anxiety-provoking situation, while
using the relaxation skills learned. Systematic desensitization is the
preferred technique of the two; flooding is not recommended except in rare
uses. Flooding's potential harm usually outweighs its potential benefits (e.g.,
traumatizing the individual further).
Additional behavior and cognitive-behavioral techniques which may have
some effectiveness for people who suffer from this disorder include saturation and thought-stopping.
Through saturation, the client is directed to do nothing but think of one
obsessional thought which they have complained about. After a period of time of
concentration on this one thought (e.g., 10-15 minutes at a time) over a number
of days (3-5 days), the obsession can lose some of its strength. Through
thought-stopping, the individual learns how to halt obsessive thoughts through
proper identification of the obsessional thoughts, and then averting it by
doing an opposite, incompatible response. A common incompatible response to an
obsessive thought is simply by yelling the word "Stop!" loudly. The
client can be encouraged to practice this in therapy (with the clinician's help
and modeling, if necessary), and then encouraged to transplant this behavior to
the privacy of their home. They can also often use other incompatible stimuli,
such as tweaking a rubber-band which is around their wrist whenever they have a
thought. The latter technique would be more effective in public, for example.
In the last 25 years, medications have been found to be fairly
successful in the treatment of OCD. First was the tricyclic antidepressant
clomipramine (Anafranil). This has been followed by several of the newer SSRI
class anti-depressants that act selectively on the re-uptake of serotonin, a
neurotransmitter. In the last few years, neuro-imaging studies have begun to
disclose the underlying pathophysiology of OCD. The area of the brain that
functions abnormally is directly next to those areas that relate to tick disorders
such as Tourette's Syndrome and to Attention Deficit Disorder. It now seems
that variable amounts of dysfunction produce clinical symptoms that may be
virtually all in one of these areas, or may be overlapping. Many people with
ADD also have tics, as do many people with OCD. Most unexpected is the finding
that children who have Rheumatic Fever and develop Sydinham's Chorea have a
significantly increased risk of OCD. Therefore
treatment with antibiotics early in an infectious illness may reduce the chances
of future obsessive thinking.
Imaging studies have also demonstrated that both medications and
behavior therapy alter brain metabolism in the direction of normalcy. This then
is one of the few areas in all of mental health where clear proof exists for
the efficacy of multiple types of treatment.
With medications, generally the dose used to treat depression is not
enough to control OCD symptoms. Patients often will take 2-4 times the amount
used to treat depression. Behavioral therapy with medications seems to offer
the best long term improvement.
The illness is cyclic, and worsens when the individual is under stress.
As of January, 2001, OCD is considered a Major Mental Illness in
California which now entitles it to coverage by
the medical portion of most insurance plans, often providing better benefits
than those allowed under the regular mental health provisions of the insurance
plan.