OBSESSIVE- COMPULSIVE DISORDER (OCD)

1. An Overview
2. In Depth
3. Treatment

1. An Overview (top)

OCD is at work when a person's compulsions and obsessive thoughts overpower their life to the point that they are unable to function normally. Unwanted, disturbing or distracting thoughts or behaviors are typical of OCD.

A compulsion, which is an irresistible impulse or urge, usually includes elaborate and repetitive rituals and often interferes with the person's normal functioning. An obsession is the preoccupation with, and repetition of, a persistent thought or behavior. The person with an obsession usually finds them disturbing and intrusive, but cannot stop doing whatever they are obsessive about. Obsessive Compulsive Disorder is an anxiety disorder, not a thought disorder.

The reason these conditions are components of the same disorder is because most people with this problem suffer from both obsessions and compulsions. A smaller percentage has only one or the other. In most cases, OCD develops in early childhood, but may not be diagnosed until adulthood.

Some common compulsions are:

• organizing and arranging things
• checking the same thing over and over
• counting and repeating
• cleaning something over and over

Some common obsessions are:

• symmetry and order
• talking, asking questions, confessing
• germs and dirt
• fear of making mistakes

The Cause of OCD

Research indicates that OCD is a biology-based disorder involving the brain chemical, serotonin. Serotonin carries impulses to and from nerves for functions such as walking, eating and thinking. It is believed that very stressful events can cause an imbalance of this chemical in the brain of certain individuals and bring on OCD symptoms.

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2. In Depth

In approximately 80% of all cases, persons performing these rituals are painfully aware that their behavior is unreasonable and irrational. However this insight provides no relief. Therefore attempting to help sufferers through reassurance has no long lasting positive effect .

The most well-studied branch of OCD involves the undoing response. The most common thought form involves contamination. Here an awareness of germs, disease, or the mere presence of dirt evokes a sense of threat and an incredible urge to reduce the presence of these contaminants. Most commonly the escape ritual involves a cleaning response (e.g., hand washing, chronic cleaning).

The next most common form of OCD involves checking. Checking typically involves door locks, light switches, faucets, stoves or items that left unchecked might pose a risk to either one's well-being or the well-being of others. It is not at all uncommon for persons with this manifestation to check items between 10 to 100 times. The overwhelming impulse to re-check remains until the person experiences a reduction in tension, despite the realization that the item is secure.

Hoarding is the excessive saving of typically worthless items such as junk mail, or excessive purchasing of certain items (e.g., owning hundreds of pairs of shoes). Other typically hoarded items include garbage, novelty items, or magazines and newspapers.

Perfectionism, in which persons feel compelled to habitually check for potential mistakes or errors that might reveal their own faults or might jeopardize the person's stature at work.

The purely Obsessional thinker. The objective involves the escape or avoidance (through excessive mental behavior) of noxious and unwanted thoughts.

Hyperscrupulosity (Responsibility) Here, the person's concern is not for themself, but directed toward the well-being of others, so as not to be held culpable. Anxiety is combined with the idea of guilt at being responsible for adversity happening to others.

Body dysmorphia is a condition wherein persons become excessively focused on some body part, which they perceive to be malformed. There are elaborate checking rituals to try to gain reassurance or assess the severity of their deformity in the mirror or go for repeated plastic surgery in the attempt to gain reassurance.

Olfactory obsession (a rarer form) involves persons entrenched in the idea that some part of their body is emitting a noxious aroma. Typically, the areas that the person is convinced emits the noxious smell involve genitalia, breath, feet, or underarms

Hypochondriasis A preoccupation with the potential of having some physical malady, typically some life threatening disease. The symptoms and endless search for reassurance fall under the diagnostic category of OCD.

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HOW IS OCD TREATED? (top)

Components Of Treatment

• Education: This is crucial in helping patients and families learn how best to manage OCD and prevent its complications.
• Psychotherapy: Cognitive-behavioral psychotherapy (CBT) is one of the key elements of treatment. In some cases, an integrative approach combining several treatment methods is needed.
• Medication: Medication can be helpful for some patients.

PSYCHOTHERAPY

What Is CBT?

Cognitive-Behavioral Therapy involves exposure and response prevention using a list of OCD symptoms that are ranked from most difficult to easiest to resist. The BT in CBT stands for behavior therapy. Behavior therapy helps people learn to change their thoughts and feelings by first changing their behavior. Behavior therapy for OCD involves ‘exposure and response prevention’ (E/RP).

• Exposure is based on the fact that anxiety usually goes down after long enough contact with something feared. Thus people with obsessions about germs are told to stay in contact with "germy" objects (e.g., handling money) until their anxiety is extinguished. The person's anxiety tends to decrease after repeated exposure until he no longer fears the contact.
• For exposure to be of the most help, it needs to be combined with Response (or Ritual) prevention (RP). In RP, the person's rituals or avoidance behaviors are blocked. For example, those with excessive worries about germs must not only stay in contact with "germy things," but must also refrain from ritualized washing. Exposure is generally more helpful in decreasing anxiety and obsessions, while response prevention is more helpful in de creasing compulsive behaviors. Despite years of struggling with OCD symptoms, many people have surprisingly little difficulty tolerating E/RP once they get started.
• Cognitive therapy (CT) is the other component in CBT. CT is often added to E/RP to help reduce the catastrophic thinking and exaggerated sense of responsibility often seen in those with OCD. For example, a teenager with OCD may believe that his failure to remind his mother to wear a seat belt will cause her to die that day in a car accident. CT can help him challenge the faulty assumptions in this obsession. Armed with this proof, he will be better able to engage in E/RP, for example, by not calling her at work to make sure she arrive safely.
• Other techniques, such as distraction (suppressing or "switching off" OCD symptoms), satiation (prolonged listening to an obsession usually using a closed-loop audiotape), habit reversal (replacing an OCD ritual with a similar but non-OCD behavior), and contingency management (using rewards and costs as incentives for ritual prevention) may sometimes be helpful but are generally less effective than standard CBT.

MEDICATION

What Medications Are Used To Treat Obsessive-Compulsive Disorder?
Research shows that the selective serotonin reuptake inhibitors (SSRIs) are effective treatments for OCD. They increase the concentration of serotonin, a chemical messenger in the brain. Five SRIs are currently available by prescription in the United States:

• Prozac
• Luvox
• Paxil
• Zoloft
• Celexa

An older medication, Anafranil (Clomipramine) is a nonselective SRI, which means that it affects many other neurotransmitters besides serotonin. This means that Clomipramine has a more complicated set of side effects than the SSRIs. For this reason, the SSRIs are usually tried first, since they can be easier for people to tolerate.

How Well Do Medications Work?
When patients are asked about how well they are doing compared to before starting treatment, they report marked to moderate improvement after 8-10 weeks on a serotonin reuptake inhibitor (SRIs). Fewer than 20% of those treated with medication alone end up with no OCD symptoms. This is why medication is often combined with CBT to get more complete and lasting results. About 20% don't experience much improvement with the first SSRI and need to try another. It is important to keep trying until you find the medication and dosage schedule that is right for you.

No single approach works best for everyone with OCD, Some people prefer to start with medication to avoid the time and trouble associated with CBT; others prefer to begin with CBT to avoid medication side effects. Many, if not most, people seem to prefer combination treatment.

The need for medication depends on the severity of the OCD and the age of the person. In milder OCD, CBT alone is often the initial choice. Individuals with severe OCD often need to start with medication, adding CBT once the medicine has provided some relief. However, since trained cognitive-behavioral psychotherapists are in short supply, when CBT is not available, medication may become the treatment of choice.

Before deciding on a treatment approach, you and your clinician will need to assess your OCD symptoms, other disorders you have, the availability of CBT, and your wishes and desires about what treatment you want. Try to find a clinician who will talk to you about these possibilities so that you can make your own best choice among the options available to you.

Maintaining Treatment Gains
Once OCD symptoms are eliminated or much reduced -- a goal which is practical for the majority of those with OCD - then maintenance of treatment gains becomes the goal.

• When patients have completed a successful course of treatment for OCD, most experts recommend monthly follow-up visits for at least 6 months and continued treatment for at least 1 year before trying to stop medications or CBT.
• Relapse is common when medication is withdrawn, particularly if the person has not had the benefit of CBT. Therefore, many experts recommend that patients continue medication if they do not have access to CBT.
• Individuals who have repeated episodes of OCD may need to receive long-term or even lifelong prophylactic medication. The experts recommend such long-term treatment after 2 to 4 severe relapses or 3 to 4 milder relapses.

Discontinuing Treatment
When someone has done well with maintenance treatment and does not need long-term medication, most experts suggest discontinuing medication only very gradually, to prevent relapse. Gradual medication withdrawal usually involves lowering the dose by 25% and then waiting 2 months before lowering it again, depending on how the person responds.

Because OCD is a lifetime waxing and waning condition, you should always feel comfortable returning to your clinician if your OCD symptoms come back. Talk to your therapist, and consider joining the Obsessive-Compulsive Foundation. A list of recommended readings and information resources is available (see Links). Being an informed client is the surest path to success.

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