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Conservative use of drug therapy
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A psychological approach that emphasizes the present and future of the patient, rather than the past.
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Emphasis on nutrition and physical exercise
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Family participation, if appropriate
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Psychoeducation for patients and relatives
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WHAT IS OBSESSIVE COMPULSIVE DISORDER?
Obsessive compulsive disorder (OCD) is a complex neuropsychiatric disorder. It is characterized by persistent, intrusive thoughts called "obsessions" and/or urges to perform certain repetitive strange seeming behaviors called "compulsions." OCD is not simply a single, identifiable disorder. It is frequently a 'masked' disorder, mixed with other symptoms. One can suffer from thoughts alone, the behaviors alone, or both.
The current psychiatric diagnostic manual (DSM-IV) provides the following definitions:
Obsessions are:
- Recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
- The thoughts, impulses, or images are not simply excessive worries about real-life problems
- The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action
- The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)
Compulsions are:
- Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
- The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive
WHAT ARE THE SYMPTOMS OF OCD?
PRIMARY SYMPTOMS
Obsessions
An obsessive thought is quite invasive and may stay for long periods at a time. It is experienced as "ego dystonic," meaning that the individual does not truly believe in the thought, but is unable to erase it from his/her mind. Patients often express how "illogical" or "ridiculous" their thoughts are, but still experience a great deal of anxiety. It is our experience that contamination, sexual, religious, and morbid thoughts are the most common.
Obsessions thinking might be "magical" in that patients believe that the mere act of thinking can prevent or control a harmful event or wrongdoing. For example, thinking of a good word or number every time a negative thought enters the mind in order to prevent harm. Magical thinking often occurs in conjunction with particular rituals.
Extreme "doubting" is also characteristic of OCD. Individuals may engage in endless dialogues in their mind to arrive at certain decisions or answers to questions that are unnecessary or unimportant or to solve unsolvable problems. For example, trying to remember how many times one had orange juice while on vacation.
The Following are Some Common Types of Obsessions:
- Aggressive (e.g. urge to stab, push someone onto railroad tracks)
- Morbid (e.g. urge to harm oneself or others, thoughts of death, disease, tragedies)
- Religious (e.g. Blasphemous thoughts against God, being possessed by the devil)
- Sexual (e.g. believing one is homosexual, thoughts of having sex with animals)
- Reviewing of conversations (e.g. trying to recall exactly what was said in a discussion)
- Need to know (e.g. pondering over questions that intrude into the mind and are of no relevance to the present functioning of the person)
- Somatic (e.g. being overly concerned with having an illness such as AIDS)
- Right and wrong (e.g. a need to know when thoughts are right, and if they are wrong, the need to stop doing other activities until one gets the right thought)
- Obsessionality with place (e.g. difficulty recognizing where one is, e.g., one may not know whether he is awake or asleep)
- Obsessionality with light (e.g. focusing attention on luminous objects such as chandeliers, bulbs, the sun)
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Compulsions:
Compulsions are repetitive acts meant to decrease the anxiety associated with obsessions. The urge to perform the compulsions increases in intensity until the patient has no choice but to engage in the compulsion. Once the urge is satisfied, the anxiety decreases temporarily, but then builds up again. The process becomes a never ending cycle.
Compulsions can be divided into two types: "Ideational or mental" and "motor." Ideational compulsions are performed in the mind and are not physically observable. They are more discreet because they are invisible. Motor compulsions are urges to perform a certain physical act.
The Following are Some Common Types of Compulsions:
Ideational Compulsions:
- Counting (e.g. devising games in the mind for sentences, objects, or situations to end up in a certain number or some combination of a favored number)
- List making (e.g. making mental lists of activities, shopping items, trip itineraries, and continuously reviewing or revising them)
- Praying (e.g. saying prayers mechanically and without conviction, engaging in the practice of litanies, or rosary praying, with the aim of accumulating a large quantity of daily prayers without religious finality)
Motor Compulsions:
- Aggressive (e.g. verbal or physical)
- Physiological (e.g. defecating, spitting, drinking, swallowing, eating)
- Movement (e.g. touching, squeezing, jumping, throat clearing, rocking, exercising)
- Cleaning/washing (e.g. excessive showering, handwashing, grooming, housecleaning)
- Checking (e.g. locks, appliances, for accidents while driving, reviewing work to correct mistakes)
- Repeating (e.g. rewriting, rereading, standing up several times until it "feels right")
- Counting (e.g. similar to an ideational compulsion, but overtly counting and devising number configurations)
- Ordering/arranging (e.g. wanting objects in a certain place and noticing if they are slightly altered, organizing clothes in closet according to color, shape, or size, labeling cupboards)
- Hoarding/collecting (e.g. piling up newspapers, filing articles, keeping junk mail, magazines, saving shopping bags, garbage)
- Need to ask, tell, or confess (e.g. urge to ask for information, providing information that others do not ask for, seeking reassurance, providing information in different ways to make sure that it is understood)
- Retracing (e.g. exiting a room the same way one entered it, driving back on the same streets as one took to get to work, getting into bed the same way as getting out of bed)
- Somatic (e.g. taking one's pulse or blood pressure continuously, checking body for signs of illness, excessively performing breast examinations)
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SECONDARY SYMPTOMS
- Depression - Patients with OCD usually experience depression due to the loss of control over the symptoms that dominate their lives. They feel very frustrated and hopeless that they will ever feel better.
- Sexual Disturbances - Disturbances include an increase or decrease in libido, frigidity, impotence, and delayed or premature ejaculation. These may be caused by the patient's strict religious or moral views, depression, and anxiety. Patients who have a fear of contamination regarding semen, vaginal secretion, and urine also may avoid sexual contact.
- Anger - OCD causes a lot of frustration because it interferes with socializing, work, and family. Frustration can lead to anger.
- Perceptual Disturbances - Research at our institute has found that some patients complain of visual disturbances such as "transient spots" or "floaters" in front of their eyes. Other types of perceptual disturbances, similar to schizophrenic patients, have also been observed.
- Impairment in functioning - Symptoms in OCD tend to interfere significantly with all areas of functioning. Rituals can take up a valuable amount of time at work, leading to added stress. Problems frequently occur within the family. Individuals with OCD are difficult to live with, often forcing family to help perform rituals. Because of the seriousness of the disorder, socialization is often affected as well.
WHO SUFFERS FROM OCD?
According to recent research, OCD has a lifetime prevalence rate of about 2.5%. It is probably higher because individuals with OCD are secretive about their symptoms. The male to female ratio is about 1:1. The age of onset is usually between ages 10 to 30, although it is our experience that children younger than 10 can suffer from OCD. Based on our clinical experience and research, symptoms exhibited in children with OCD resemble adult OCD. Patients usually seek treatment for the first time between the ages of 25 and 35. Their tends to be a long time between the onset of the illness and the first consult with a professional; a 7.5 year lapse may occur.
Results from a study conducted at our Institute found a relationship between the onset of OCD and pregnancy. Of 59 patients with children, 39% had experienced onset during pregnancy, indicating that pregnancy may be an important precipitating factor in the onset of OCD.
WHAT IS THE TREATMENT FOR OCD?
A combination of cognitive, behavioral, and pharmacological treatment has been shown to be the most effective combination for OCD. The form of behavior therapy found to be the most effective for OCD is called “exposure and response prevention.”
WHAT IS EXPOSURE AND RESPONSE PREVENTION (ERP)?
Our Institute is one of the few facilities in the country that specializes in intensive ERP treatment for OCD. ERP is a systematic and structured method of behavior therapy that has been experimentally tested and scientifically found to be effective for OCD. It is composed of two components. The first component is “exposure” and the second is “response prevention.” Exposure consists of gradual exposure to various situations that are feared and avoided due to the OCD. At the same time, patients are asked to prevent themselves from engaging in their compulsions, which is called “response prevention”
The scientific rational behind ERP is that continuously confronting feared situations eventually leads to decreases in anxiety. During an exposure session, patients are actually asked to participate in situations that are fearful for them while resisting their urges to perform their rituals. Patients who experience an initially high level of anxiety which decreases during an exposure exercise are the most successful. Patients are NEVER asked to participate in an exposure situation that would be harmful to them. Therapy always progresses according to the pace of the patient. The benefit of ERP is that patients often see positive changes quickly. Patients are also taught the skills to do ERP exercises independently as homework assignments and for the purpose of coping with any symptoms that may reappear.
WHAT IS COGNITIVE THERAPY?
Cognitive therapy is based upon the theory that extreme emotional reactions are the result of faulty beliefs. The goal is to educate patients in the skills necessary to identify and change these mistaken beliefs and to replace them with logical ones. The result is a more balanced and moderate view of oneself, one’s life problems, and the world, leading to more positive emotional responses and more effective behaviors.
In cognitive therapy for OCD, the aim is to modify the following common OCD irrational beliefs:
- Overinflated sense of responsibility
- Overappraisal of threat and danger
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- Need for control
- Uneasiness with uncertainty/ambiguity
- Fusing of thoughts with actions
- Tremendous importance given to thoughts
- Need for perfection
It is our practice to include cognitive therapy within behavior therapy sessions. Cognitive therapy may be used initially in certain cases in which the patient is either severely depressed and/or anxious and unable to proceed with behavior therapy.
WHAT MEDICATIONS ARE EFFECTIVE FOR OCD?
Anti-depressant medication that target the brain chemical known as “serotonin” has shown the most success for OCD. The following are some common medications that target serotonin levels:
- Clompiramine
- Fluoxetine
- Fluvoxamine
- Paroxetine
- Sertraline
CLICK HERE for the Obsessive Compulsive Disorder OCD Survey
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