Download Understanding Obsessive-Compulsive Disorder

Understanding Obsessive-Compulsive Disorder
Obsessive-compulsive disorder is characterized by anxious thoughts or rituals you feel you can't control.
If you have OCD, as it's called, you may be plagued by persistent, unwelcome thoughts or images, or by
the urgent need to engage in certain rituals.
You may be obsessed with germs or dirt, so you wash your hands over and over. You may be filled with
doubt and feel the need to check things repeatedly. You might be preoccupied by thoughts of violence
and fear that you will harm people close to you. You may spend long periods of time touching things or
counting; you may be preoccupied by order or symmetry; you may have persistent thoughts of performing
sexual acts that are repugnant to you; or you may be troubled by thoughts that are against your religious
beliefs.
The disturbing thoughts or images are called obsessions, and the rituals that are performed to try to
prevent or dispel them are called compulsions. There is no pleasure in carrying out the rituals you are
drawn to, only temporary relief from the discomfort caused by the obsession.
A lot of healthy people can identify with having some of the symptoms of OCD, such as checking the
stove several times before leaving the house. But the disorder is diagnosed only when such activities
consume at least an hour a day, are very distressing, and interfere with daily life.
Most adults with this condition recognize that what they're doing is senseless, but they can't stop it. Some
people, though, particularly children with OCD, may not realize that their behavior is out of the ordinary.
OCD strikes men and women in approximately equal numbers and afflicts roughly 1 in 50 people. It can
appear in childhood, adolescence, or adulthood, but on the average it first shows up in the teens or early
adulthood. A third of adults with OCD experienced their first symptoms as children. The course of the
disease is variable—symptoms may come and go, they may ease over time, or they can grow
progressively worse. Evidence suggests that OCD might run in families.
Depression or other anxiety disorders may accompany OCD. Some people with OCD have eating
disorders. In addition, they may avoid situations in which they might have to confront their obsessions.
Or they may try unsuccessfully to use alcohol or drugs to calm themselves. If OCD grows severe enough,
it can keep someone from holding down a job or from carrying out normal responsibilities at home, but
more often it doesn't develop to those extremes.
Research by NIMH-funded scientists and other investigators has led to the development of medications
and behavioral treatments that can benefit people with OCD. A combination of the two treatments is
often helpful for most patients. Some individuals respond best to one therapy, some to another.
Medications that have been found effective in treating OCD are fluvoxamine, paroxetine, sertraline,
clomipramine and fluoxetine. Others are showing promise and may soon be available.
Behavioral therapy, specifically a type called exposure and response prevention, has also proven useful
for treating OCD. It involves exposing the person to whatever triggers the problem and then helping him
or her forego the usual ritual—for instance, having the patient touch something dirty and then not wash
his hands. This therapy is often successful in patients who complete a behavioral therapy program,
though results have been less favorable in some people who have both OCD and depression.
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How Common Is OCD?
About 2% of the U.S. population has OCD in a given year.
OCD typically begins during adolescence or early childhood;
at least one-third of the cases of adult OCD began in childhood.
OCD affects men and women equally.
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OCD cost the U.S. $8.4 billion in 1990 in social and economic losses, nearly 6% of the total mental
health bill of $148 billion.
What Causes OCD?
There is growing evidence that OCD has a neurobiological basis. OCD is no longer attributed to family
problems or to attitudes learned in childhood - for example, an inordinate emphasis on cleanliness, or a
belief that certain thoughts are dangerous or unacceptable. Instead, the search for causes now focuses on
the interaction of neurobiological factors and environmental influences. Brain imaging studies using a
technique called positron emission tomography (PET) have compared people with and without OCD.
Those with OCD have patterns of brain activity that differ from people with other mental illnesses or
people with no mental illness at all. In addition, PET scans show that in patients with OCD, both
behavioral therapy and medication produce changes in the caudate nucleus, a part of the brain. This is
graphic evidence that both psychotherapy and medication affect the brain.
What Treatments Are Available for OCD?
Treatments for OCD have been developed through research supported by the NIMH and other research
institutions. These treatments, which combine medications and behavioral therapy (a specific type of
psychotherapy), are often effective.
Several medications have been proven effective in helping people with OCD: clomipramine, fluoxetine,
fluvoxamine and paroxetine. If one drug is not effective, others should be tried. A number of other
medications are currently being studied.
A type of behavioral therapy known as “exposure and response prevention” is very useful for treating
OCD. In this approach, a person is deliberately and voluntarily exposed to whatever triggers the
obsessive thoughts and then, is taught techniques to avoid performing the compulsive rituals and to deal
with the anxiety.
Can People With OCD Also Have Other Physical or Emotional Illnesses?
OCD is sometimes accompanied by depression, eating disorders, substance abuse, attention deficit
hyperactivity disorder, or other anxiety disorders. When a person also has other disorders, OCD is often
more difficult to diagnose and treat. Symptoms of OCD can also coexist and may even be part of a
spectrum of neurological disorders, such as Tourette’s syndrome. Appropriate diagnosis and treatment of
other disorders are important to successful treatment of OCD.
Obsessive-Compulsive Disorder Self-Assessment Test
PART A: Have you been bothered by unpleasant thoughts or images that repeatedly enter your
mind, such as:
1. Concerns with contamination (dirt, germs, chemicals, radiation) or acquiring a serious illness such as
AIDS?
! Yes
! No
2. Over-concern with keeping objects (clothing, groceries, tools) in perfect order or arranged exactly?
! Yes
! No
3. Images of death or other horrible events?
! Yes
! No
4. Personally unacceptable religious or sexual thoughts?
! Yes
! No
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Have you worried a lot about terrible things happening, such as:
5. Fire, burglary, or flooding the house?
! Yes
! No
6. Accidentally hitting a pedestrian with your car or letting it roll down the hill?
! Yes
! No
7. Spreading an illness (giving someone AIDS, etc.)?
! Yes
! No
8. Losing something valuable?
! Yes
! No
9. Harm coming to a loved one because you weren't careful enough?
! Yes
! No
Have you worried about acting on an unwanted and senseless urge or impulse, such as:
10. Physically harming a loved one (pushing a stranger in front of a bus, steering your car into oncoming
traffic; inappropriate sexual contact; or poisoning dinner guests)?
! Yes
! No
Have you felt driven to perform certain acts over and over again, such as:
11. Excessive or ritualized washing, cleaning, or grooming?
! Yes
! No
12. Checking light switches, faucets, the stove, door locks, or emergency brake?
! Yes
! No
13. Counting; arranging; evening-up behaviors (socks are at same height)?
! Yes
! No
14. Collecting useless objects or inspecting the garbage before it is thrown out?
! Yes
! No
15. Repeating routine actions (in/out of chair, going through doorway, re-lighting cigarette) a certain
number of times or until it feels just right.
! Yes
! No
! Yes
16. Need to touch objects or people?
17. Unnecessary re-reading or re-writing; re-opening envelopes before they are mailed?! Yes
! Yes
18. Examining your body for signs of illness?
! No
! No
! No
19. Avoiding colors ("red" means.blood), numbers ("13" is unlucky), or names (those that start with "D"
signify death) that are associated with dreaded events or unpleasant thoughts?
! Yes
! No
20. Needing to "confess" or repeatedly asking for reassurance that you said or did something correctly?
! Yes
! No
SCORING PART A: If you answered YES to 2 or more questions, please continue with Part B.
PART B
The following questions refer to the repeated thoughts, images, urges, or behaviors identified in Part A.
Consider your experience during the past 30 days when selecting an answer. Select the most appropriate
number from 0 to 4.
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1. On average, how much time is occupied by these thoughts or behaviors each day?
0 - None
3 - Severe (3 to 8 hours)
1 - Mild (less than 1 hour)
4 - Extreme (more than 8 hours)
2 - Moderate (1 to 3 hours)
2. How Much distress do they cause you?
0 - None
1 - Mild
2 - Moderate
3 - Severe
4 - Extreme (disabling)
3. How hard is it for you to control them?
0 - Complete control
1 - Much control
2 - Moderate control
3 - Little control
4 - No control
4. How much do they cause you to avoid doing anything, going any place, or being with anyone?
0 - No avoidance
3 - Frequent and extensive
1 - Occasional avoidance
4 - Extreme (housebound)
2 - Moderate avoidance
5. How much do they interfere with school, work or your social or family life?
0 - None
3 - Much interference
1 - Slight interference
4 - Extreme (disabling)
2 - Definitely interferes w/ functioning
Sum on Part B (Add items 1 to 5): ________
SCORING: If you answered YES to 2 or more of questions in Part A and scored 5 or more on Part B, you
may wish to contact your physician, a mental health professional, or a patient advocacy group (such as,
the Obsessive Compulsive Foundation, Inc.) to obtain more information on OCD and its treatment.
Remember, a high score on this questionnaire does not necessarily mean you have OCD--only an
evaluation by an experienced clinician can make this determination.
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Understanding OCD
Introduction:
Obsessive-Compulsive Disorder is one of the most difficult to understand of all psychiatric
illnesses. Persons who have this condition find themselves repeating certain behaviors or
thoughts again and again and again and again. They know the repetition is unnecessary, but are
unable to stop themselves. Common forms of this are checking locks, stoves, and lights, or
recurrent intrusive thoughts of hurting oneself or one's children.
Afflicted individuals usually experience severe anxiety if unable to complete their rituals, though
many therapies work by helping the individual learn that no catastrophe occurs when the
behaviors do cease.
Research has shown that one of the most difficult problems in OCD is in getting family members
to understand that the patient is unable to simply stop the behavior. Many times relatives
become angry and upset when they are forced to deal with the time-consuming and unrealistic
repetitive behaviors. With this background, it is no wonder that many patients do not volunteer
their symptoms, and instead complain only of anxiety or depression.
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
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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.
Medications
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 disfunction
produce clinical symptoms that may be virtually all in one of these areas, or may be overlapping.
Many people with ADD also have ticks, 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.
Summary
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 usual amount. Behavioral therapy with
medications seems to offer the best long term improvement. Virtually no treatment is curative
for OCD. Most treatment can be expected to reduce symptoms by 50-80% or more, however.
The illness is cyclic, and worsens when the individual is under stress.
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