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Obsessive-Compulsive Disorder



                  I just couldn't get it out of my mind.  It went round 
    
                  and round.  I felt better for a little while if I did the 
                  rituals, but that was beginning to take up more and
                  more of my day.  I began to get really depressed.


The most common problem I see in my practice is Obsessive-Compulsive Disorder (OCD).  If you have it, you may be overwhelmed by persistent, unwelcome thoughts and an urgent need to perform mental or physical rituals.  Compulsive rituals are distressing, time-consuming and provide only temporary relief from the obsession.

We used to think that this condition was uncommon, but now it is clear that OCD effects about two percent of the population (60,000 people in Atlanta) at some point in their lives.  OCD is more common than diabetes.  It typically starts during adolescence or young adulthood and often continues indefinitely.

What are the most common OCD symptoms? 
  • contamination obsessions with cleaning/washing compulsions
  • aggressive or sexual obsessions with compulsive analysis, reassurance seeking, or prayer 
  • religious/moral obsessions with compulsive confession, prayer, or reassurance seeking
  • obsessions about disaster or safety with compulsive checking or slowness 
  • obsessional doubt or need to know with compulsive questioning/reassurance seeking
  • "just so" obsessions with ordering/arranging compulsions 
  • obsessions about needing to save things with compulsive collecting/hoarding
  • so-called "pure obsessions"  that usually have associated thinking /analysis compulsions
  • many other obsessions and compulsions that are quite unique to particular individuals
What causes OCD?

There is now substantial evidence that OCD is related to a biochemical disorder in the brain.  Relatively new brainscanning (PET) techniques have made it possible for researchers to identify specific brain structures that overreact.  This results in obsessions that won't go away and in intense urges to do or think things to stop the obsessions.  On the other hand, it is believed that the content of obsessions, e.g., being concerned with contamination, is more psychologically determined.

How do you treat OCD?

Most, but not all, of those who come to see me for OCD are already taking medication.  They are usually on a serotonin reuptake inhibitor (SSRI) medication like Prozac and have often had extensive trials on others.  They still have distressing OCD symptoms and have heard that a specific type of Cognitive Behavior Therapy called Exposure and Response Prevention (ERP) can help.  They are right.  Research suggests that approximately 70 percent of people with OCD have clinically significant improvement with ERP therapy even when taking no medication.  Furthermore, PET scan images of the brain before and after ERP show that it affects the same brain structures as the SSRI medications.  That is why ERP is considered the most empirically validated form of psychotherapy for OCD.

ERP consists of exposing the person to whatever triggers the problem and then helping him or her to avoid ritualizing.  For example, if the obsession is about contamination, I help them touch something dirty and then not wash.  While this sounds simple, actually doing it is often much more difficult.  The art of skillfully and sensitively doing this form of therapy requires that it be started after there is considerable trust in the therapist.  There must be confidence that I can develop ways to gradually expose you to a progressive, or hierarchical, series of situations that are challenging but doable.  Successful exposure is systematic, regularly scheduled, and prolonged enough to see some drop in fear in most practice sessions.  Prevention of rituals includes both physical and mental compulsions.

How frequent are treatment sessions?

With some forms of OCD, I see people in weekly sessions, almost always with a clear, written agreement about exposure and ritual prevention tasks (ERP) to be carried out between sessions.  I usually follow progress by getting daily voice mail messages.  Sometimes, I will suggest taking a one-week vacation from work or scheduling five days between semesters at school for daily eight-hour  ERP.  These highly structured exposure sessions are done alone or with a family member or friend serving as coach, but I always have at least brief live phone contact two or three times a day to monitor progress and to troubleshoot.  

Of course, OCD can be more severe.  Sometimes people come to my office with almost unbearable anxiety, major depression, and extreme rituals that are used in a vain attempt to gain some basic sense of control.  Often the core of the problem is OCD.  Intensive day treatment or residential care in a specialized OCD program may be needed.  Unfortunately, there are no such programs in Georgia.  Psychiatric hospitals here can be quite helpful for emergency stabilization, but that should not be confused with competent, skillful OCD treatment.  The good news is that there are a handful of such programs around the country that are well worth considering. The Obsessive-Compulsive Foundation (www.OCFoundation.org)  is a great source of information about them.  After returning home, I would begin or resume outpatient therapy to integrate what has been learned into daily life.

What other disorders are closely related to OCD? 

We now believe that there is a spectrum of disorders related to OCD that are treatable in much the same way.  These include:
  • Body Dysmorphic Disorder (BDD) is a preoccupation with some aspect of your appearance that others might regard as quite normal. 
  • Hypochondria is either imagined or exaggerated beliefs about illness or pain.  
  • Trichotillomania is a compulsive pulling of hair that is deliberate or done in a state of unawareness. 
  • Obsessive-Compulsive Personality Disorder (OCPD) is a general preoccupation with orderliness, perfectionism, and control at the expense of flexibility, efficiency and happiness. 
Depression or other disorders often occur with OCD.  Especially in these more complex cases, ability to function on the job and at home can be greatly affected.  In such circumstances, family education and support can be important adjuncts to medication and CBT/ERP. 
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