Visit site

People with OCD have either obsessions or compulsions, or both.

OBSESSIONS are recurrent and persistent thoughts, impulses or images that are experienced as intrusive and inappropriate and cause marked anxiety or distress. Some common obsessions include unrealistic fears of being contaminated or contaminating others, being harmed or harming others, losing things, intrusive violent or horrific images, unwanted sexual thoughts, or a need for symmetry, completeness or perfection. Obsessions can include feared outcomes that are not possible, e.g., changing into another person or becoming infected with HIV by wearing the color red.

COMPULSIONS are repetitive behaviors or mental acts, aimed at preventing or reducing distress or preventing some dreaded event or situation. A person feels driven to perform these acts in response to an obsession or according to a set of rigid rules. Common compulsions include rereading, rewriting, checking, cleaning and washing, excessive grooming, counting, ordering, mental tracing, mental prayers or mantras, reassurance seeking, touching or tapping.

Compulsions may also be complex rituals with multiple behaviors and can be very time-consuming.

Signs of OCD

Even though most sufferers attempt to hide their symptoms, some common indicators that OCD may be present include:

• high levels of anxiety or panic
• repetitive questions or other reassurance-seeking, repetitive behaviors
• avoidance of certain places, situations,
• activities or objects.

OCD sufferers can have compulsions that are not observable such as compulsions performed mentally or avoidance rituals. This sometimes leads to misdiagnosis or delays in treatment. These persons who are mainly obsessional are sometimes misdiagnosed as depressed or psychotic.

Habit Reversal Training, which uses many different cognitive behavioral techniques, is very effective in treating Impulse Control Disorders and tics.

EXPOSURE-RESPONSE-PREVENTION therapy consists of gradually learning to tolerate the anxiety associated with a triggering event or situation. For example, a child who refuses to go to school because of germs might touch something only very mildly “contaminated” (such as a tissue that has been touched by another tissue that has been touched by a book that came from the “contaminated” location, in this case the school). That is the “exposure.”

The “response prevention” is not washing, changing clothing, etc. After habituation occurs, the child moves to a more difficult task such as omitting one of the tissues, then touching the book, and ultimately going to the school.

When the feared event is a break-in and the compulsion or response has been multiple lock-checks, the exposure may be leaving the house and checking the lock only twice without going back, then checking only once without going back. Then the person can progress to leaving home without rechecking the lock at all.

When the exposure is done properly, a person can quickly habituate to the anxiety-producing situation and will discover that their anxiety level has dropped considerably without performing the response behaviors or compulsions.

Obsessions without obvious compulsions can also be treated using Exposure-Response-Prevention by addressing avoidances and subtle mental compulsions.

HABIT REVERSAL TRAINING includes awareness training, stimulus control, competing response training, and relaxation training. The first step is to become aware of the full context in which the behavior occurs. Steps can then be taken to modify the stimulus and to create a competing response.

Using relaxation training or other coping strategies can also be an important part of gaining control.

However, over the past fifteen years, developments in Cognitive-Behavioral Therapy (CBT) have resulted in a treatment protocol that is especially beneficial for individuals with OCD. In fact, numerous clinical studies conducted over the past fifteen years have conclusively found that CBT, either with or without medication, is dramatically superior to all other forms of treatment for OCD.

Compared to traditional psychotherapy, in which sessions are spent merely discussing the client’s problems, CBT is far more proactive. Working together, both the client and the therapist take active roles in assessing the problem, and in devising concrete, active steps towards alleviating the symptoms.

Exposure and Response Prevention (ERP)

Using the Yale-Brown Obsessive Compulsive Scale (YBOCS) and numerous other assessment tools, the therapist helps the client create a detailed list of his or her symptoms. This symptom list is then used as the primary tool in a form of CBT called “Exposure and Response Prevention” (ERP), or “exposure therapy.”

Using the symptom list, the client experiments during therapy sessions with exposure to his or her fears, starting with the least anxiety-provoking items from the symptom list. Regular “homework” assignments are given so that the client can continue to challenge symptoms between therapy sessions.

These homework assignments are specifically designed for each individual client, and are an essential part of treating OCD, OC Spectrum Disorders, and related anxiety disorders. They are particularly valuable in helping clients challenge certain symptoms that occur at home, at work, or at school, and that cannot easily be duplicated in the therapy office.

Imaginal Exposure

Additionally, a variant of ERP, sometimes called “imaginal exposure,” is frequently used in the treatment of OCD, OC Spectrum Disorders, and related anxiety disorders.

Imaginal exposure involves using short stories based on the client’s obsessions. These stories are audiotaped and then used as ERP tools, allowing the client to experience exposure to their fearful thoughts.

This form of exposure is particularly beneficial for obsessions that cannot be experienced through traditional ERP (e.g., killing one’s spouse or molesting a child). When combined with standard ERP, and other cognitive-behavioral techniques, this type of imaginal exposure can help to greatly reduce the frequency and magnitude of these intrusive obsessions, as well as the individual’s sensitivity to unwanted thoughts and mental images.

Treatment Approach

Following a structured CBT protocol, the client gradually challenges all of his or her symptoms, and learns new, more productive methods of coping with anxiety. Over time, the individual becomes de-sensitized to previously anxiety-provoking situations and thoughts, and the obsessions and compulsions are eliminated, or significantly reduced in frequency and magnitude.

Using this treatment approach, most clients make dramatic improvement by meeting with their therapist on a weekly basis over a period of just four to six months, followed by two or three “booster sessions.”

After a short time, many clients also become involved in an ongoing weekly OCD therapy/support group. Some clients may also benefit by having a small number of family or couples therapy sessions to address the impact OCD is having on their relationships.

A minority of clients may require a more intensive approach that includes two to three sessions per week or even home visits.

CBT Combined with Medication

Some individuals with OCD, OC Spectrum Disorders, or related anxiety disorders may also benefit from combining CBT with one or more medications that are sometimes prescribed for these conditions. The goal of medication, or “pharmacotherapy,” is to reduce obsessional anxiety, thereby increasing the individual’s ability to utilize and benefit from CBT.

This is particularly helpful with clients for whom the prospect of exposure therapy is so anxiety-provoking that they are initially unwilling to try CBT. For these individuals, after the medication has begun to reduce their obsessions, it is recommended that they complete a regimen of CBT while continuing the pharmacotherapy.

Medication may also be beneficial for individuals experiencing depression, which is sometimes present in those with OCD and related disorders, or with other psychiatric conditions. But it is important to stress that CBT is the primary treatment for OCD.

Studies Prove CBT Most Effective

Numerous research studies completed over the past fifteen years have concluded that CBT is the most effective treatment for OCD. In fact, in 1997, the Journal of Clinical Psychiatry surveyed over sixty OCD researchers and treatment specialists from across the world in order to determine the best treatment for OCD.

The resulting publication, entitled Expert Consensus Treatment for Obsessive-Compulsive Disorder, described CBT as “the psychotherapeutic treatment of choice for children, adolescents and adults with OCD” and noted that it is “the key element of treatment.”

Despite this endorsement, many clients are tempted to rely on medication alone. But four facts provide a compelling case against the “medication-only” route.

First, analyses of numerous studies comparing CBT and pharmacotherapy have concluded that CBT is more effective in both the short and long-term.

Second, the potential short-term side-effects of these medications are well-documented and include anxiety, insomnia, nausea, diarrhea, difficulty concentrating, and sexual dysfunction. Conversely, CBT has no side effects.

Third, many of these medications have not been fully studied over an extended period of time, and many researchers and clinicians are concerned about the possibility of long-term side-effects, particularly for children, and for pregnant or breast-feeding women.

And finally, studies have shown that when individuals treating OCD exclusively with pharmacotherapy discontinue the medication, as many as 90 percent may experience a complete return of their OCD symptoms. Conversely, those who complete a course of CBT usually have a far lower rate of relapse.

With CBT, the techniques you learn are always with you and provide a set of tools that can immediately be utilized if and when symptoms return.

Reprinted by permission of the OCD Center of Los Angeles

Lori Riddle-Walker, a Licensed Marriage and Family Therapist in Escondido, California (North San Diego County), specializes in treating obsessive-compulsive disorder in children and adults. She uses CBT as the primary treatment protocol.

But you are not alone. In the United States, 1 in 50 adults currently has OCD, and twice that many have had it at some point in their lives. Fortunately, very effective treatments for OCD are now available to help you regain a more satisfying life. Here are answers to the most commonly asked questions about OCD.

• What is Obsessive-Compulsive Disorder?

• What are the symptoms of Obsessive-Compulsive Disorder?

• When does Obsessive-Compulsive Disorder begin?

• Is Obsessive-Compulsive Disorder Inherited?

• What causes Obsessive-Compulsive Disorder?

• What other problems are sometimes confused with OCD?

• What is Obsessive-Compulsive Disorder?

Worries, doubts, superstitious beliefs all are common in everyday life. However, when they become so excessive such as hours of hand washing or make no sense at all such as driving around and around the block to check that an accident didn’t occur then a diagnosis of OCD is made.

In OCD, it is as though the brain gets stuck on a particular thought or urge and just can’t let go. People with OCD often say the symptoms feel like a case of mental hiccups that won’t go away. OCD is a medical brain disorder that causes problems in information processing.

It is not your fault or the result of a “weak” or unstable personality. Before the arrival of modern medications and cognitive behavior therapy, OCD was generally thought to be untreatable. Most people with OCD continued to suffer, despite years of ineffective psychotherapy.

Today, luckily, treatment can help most people with OCD. Although OCD is usually completely curable only in some individuals, most people achieve meaningful and long-term symptom relief with comprehensive treatment.

What are the symptoms of Obsessive-Compulsive Disorder?

OCD usually involves having both obsessions and compulsions, though a person with OCD may sometimes have only one or the other.

OCD symptoms can occur in people of all ages. Not all Obsessive-Compulsive behaviors represent an illness. Some rituals (e.g., bedtime songs, religious practices) are a welcome part of daily life. Normal worries, such as contamination fears, may increase during times of stress, such as when someone in the family is sick or dying.

Only when symptoms persist, make no sense, cause much distress, or interfere with functioning do they need clinical attention.

1. Obsessions

Obsessions are thoughts, images, or impulses that occur over and over again and feel out of your control. The person does not want to have these ideas, finds them disturbing and intrusive, and usually recognizes that they don’t really make sense.

People with OCD may worry excessively about dirt and germs and be obsessed with the idea that they are contaminated or may contaminate others. Or they may have obsessive fears of having inadvertently harmed someone else (perhaps while pulling the car out of the driveway), even though they usually know this is not realistic.

Obsessions are accompanied by uncomfortable feelings, such as fear, disgust, doubt, or a sensation that things have to be done in a way that is “just so.”

2. Compulsions

People with OCD typically try to make their obsessions go away by performing compulsions. Compulsions are acts the person performs over and over again, often according to certain “rules.”

People with an obsession about contamination may wash constantly to the point that their hands become raw and inflamed. A person may repeatedly check that she has turned off the stove or iron because of an obsessive fear of burning the house down. She may have to count certain objects over and over because of an obsession about losing them.

Unlike compulsive drinking or gambling, OCD compulsions do not give the person pleasure. Rather, the rituals are performed to obtain relief from the discomfort caused by the obsessions.

3. Other features of Obsessive-Compulsive Disorder

• OCD symptoms cause distress, take up a lot of time (more than an hour a day), or significantly interfere with the person’s work, social life, or relationships.

• Most individuals with OCD recognize at some point that their obsessions are coming from within their own minds and are not just excessive worries about real problems, and that the compulsions they perform are excessive or unreasonable. When someone with OCD does not recognize that their beliefs and actions are unreasonable, this is called OCD with poor insight.

• OCD symptoms tend to wax and wane over time. Some may be little more than background noise; others may produce extremely severe distress.

When does Obsessive-Compulsive Disorder begin?

OCD can start at any time from preschool age to adulthood (usually by age 40). One third to one half of adults with OCD report that it started during childhood.

Unfortunately, OCD often goes unrecognized. On average, people with OCD see three to four doctors and spend over 9 years seeking treatment before they receive a correct diagnosis. Studies have also found that it takes an average of 17 years from the time OCD begins for people to obtain appropriate treatment.

OCD tends to be underdiagnosed and undertreated for a number of reasons. People with OCD may be secretive about their symptoms or lack insight about their illness. Many healthcare providers are not familiar with the symptoms or are not trained in providing the appropriate treatments.

Some people may not have access to treatment resources. This is unfortunate since earlier diagnosis and proper treatment, including finding the right medications, can help people avoid the suffering associated with OCD and lessen the risk of developing other problems, such as depression or marital and work problems.

Is Obsessive-Compulsive Disorder Inherited?

No specific genes for OCD have yet been identified, but research suggests that genes do play a role in the development of the disorder in some cases. Childhood-onset OCD tends to run in families (sometimes in association with tic disorders).

When a parent has OCD, there is a slightly increased risk that a child will develop OCD, although the risk is still low. When OCD runs in families, it is the general nature of OCD that seems to be inherited, not specific symptoms. Thus a child may have checking rituals, while his mother washes compulsively.

What causes Obsessive-Compulsive Disorder?

There is no single, proven cause of OCD. Research suggests that OCD involves problems in communication between the front part of the brain (the orbital cortex) and deeper structures (the basal ganglia). These brain structures use the chemical messenger serotonin.

It is believed that insufficient levels of serotonin are prominently involved in OCD. Drugs that increase the brain concentration of serotonin often help improve OCD symptoms. Pictures of the brain at work also show that the brain circuits involved in OCD return toward normal in those who improve after taking a serotonin medication or receiving cognitive-behavioral psychotherapy.

Although it seems clear that reduced levels of serotonin play a role in OCD, there is no laboratory test for OCD. Rather, the diagnosis is made based on an assessment of the person’s symptoms. When OCD starts suddenly in childhood in association with strep throat, an autoimmune mechanism may be involved, and treatment with an antibiotic may prove helpful.

What other problems are sometimes confused with OCD?

• Some disorders that closely resemble OCD and may respond to some of the same treatments are Trichotillomania (compulsive hair pulling), body dysmorphic disorder (imagined ugliness), and habit disorders, such as nail biting or skin picking. While they share superficial similarities, impulse control problems, such as substance abuse, pathological gambling, or compulsive sexual activity, are probably not related to OCD in any substantial way.

• The most common conditions that resemble OCD are the tic disorders (Tourette’s disorder and other motor and vocal tic disorders). Tics are involuntary motor behaviors (such as facial grimacing) or vocal behaviors (such as snorting) that often occur in response to a feeling of discomfort. More complex tics, like touching or tapping tics, may closely resemble compulsions. Tics and OCD occur together much more often when the OCD or tics begin during childhood.

• Depression and OCD often occur together in adults, and, less commonly, in children and adolescents. However, unless depression is also present, people with OCD are not generally sad or lacking in pleasure, and people who are depressed but do not have OCD rarely have the kinds of intrusive thoughts that are characteristic of OCD.

• Although stress can make OCD worse, most people with OCD report that the symptoms can come and go on their own. OCD is easy to distinguish from a condition called posttraumatic stress disorder, because OCD is not caused by a terrible event.

• Schizophrenia, delusional disorders, and other psychotic conditions are usually easy to distinguish from OCD. Unlike psychotic individuals, people with OCD continue to have a clear idea of what is real and what is not.

• In children and adolescents, OCD may worsen or cause disruptive behaviors, exaggerate a pre-existing learning disorder, cause problems with attention and concentration, or interfere with learning at school. In many children with OCD, these disruptive behaviors are related to the OCD and will go away when the OCD is successfully treated.

• Individuals with OCD may have substance-abuse problems, sometimes as a result of attempts to self-medicate. Specific treatment for the substance abuse is usually also needed.

• Children and adults with pervasive developmental disorders (autism, Asperger’s Disorder) are extremely rigid and compulsive, with stereotyped behaviors that somewhat resemble very severe OCD. However, those with pervasive developmental disorders have extremely severe problems relating to and communicating with other people, which do not occur in OCD.

Only a small number of those with OCD have the collection of personality traits called Obsessive Compulsive Personality Disorder (OCPD). Despite its similar name, OCPD does not involve obsessions and compulsions, but rather is a personality pattern that involves a preoccupation with rules, schedules, and lists; perfectionism; an excessive devotion to work; rigidity; and inflexibility.

However, when people have both OCPD and OCD, the successful treatment of the OCD often causes a favorable change in the person’s personality.

(from the Obsessive-Compulsive Foundation)

Scrupulosity, a subtype of obsessive-compulsive disorder (OCD), is an over-concern for doing things correctly or perfectly in order to follow religious practices, to please God, or to avoid disrespect from others or from one’s own self.

This form of over-concern and over-responsibility leads to excessive anxiety and guilt. It has been referred to by some as having an excessively tender conscience. There are historical references to scrupulosity among monastic priests as they struggled to please God.

Scrupulosity can include:

• excessive prayer,

• worry that one might say or do something blasphemous,

• fear of having sinned (forgotten the sin) and not having repented of it,

• fear of having committed “the unpardonable sin”,

• difficulties with doing confession or rituals “correctly”,

• over-analysis of what “moral behavior” entails, and

• intrusive thoughts that the person considers blasphemous or sinful in nature and lead to tremendous uncertainty, anxiety, guilt, disgust, or shame.

Those suffering from OCD are generally aware that their obsessions are irrational and unlikely. With scrupulosity, there is less awareness that the obsessions are of an irrational nature because they are so closely related to their belief system and are intertwined in the individual’s religious life.

This fact can negatively impact the prognosis for treatment success. One’s own well-being and God’s approval are seen as being at stake, thus creating more resistance in the patient. A cooperative effort between a person’s religious leader and therapist sometimes proves to be an effective treatment.

***

Lori Riddle-Walker, MFT, specializes in treating OCD and scrupulosity. With degrees in counseling psychology and theology, Lori can provide the special guidance needed to help people with this disorder.

Recommended Reading

• In The Doubting Disease, clinical psychologist Joseph W. Ciarrocchi discusses current information on religion and scruples, scrupulosity, and obsessive-compulsive disorders. He also helps us to understand the anguish suffered by thousands of people of faith and how to help. More>>

• For Christians seeking a spiritual perspective, I recommend OCD: Freedom for the Obsessive-Compulsive by Michael R. Emlet, M.Div., M.D. as a good place to start. Dr. Emlet offers a balanced perspective by discussing the physiological, psychological and spiritual aspects of OCD. His short booklet includes a discussion about what he calls the “heart issues,” which are the 1) need for certainty, 2) demand for control and mastery, 3) desire for a “black and white” world, and 4) perfectionism, guilt and self-atonement.

  Dr. Emlet is a counselor and faculty member of the School of Biblical Counseling at Christian Counseling & Educational Foundation (CCEF). More>>