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Why We Have Obsessive-Compulsive Disorder and What We Can Do About It.
Dennis B. Kottler, MD
This is the fourth part in a series looking at major health concerns that affect our society in epidemic proportions. The current monograph deals with the epidemic of Obsessive Compulsive Disorder and discusses currently available treatments to combat this major health threat. It is hoped that many individuals with this disorder will find this monograph of major help.
What is Normal?
Before launching into the discussion of Obsessive Compulsive Disorder, as an illness, it is helpful to consider what is meant by normal. In the case of many behavioral variations as well as physical conditions, the concept of normal is very problematic. How much anxiety can a person have before having an anxiety disorder? What about weight and height? Is a male 5 2 tall normal? How do we view slightly elevated blood pressure?
In nature, there is no precise cut-off to any of a number of these behavioral and physical attributes. In the medical field, for practical reasons of deciding whom to treat, we often assign a somewhat arbitrary value to the upper and lower limit of normal (at least in things we can measure). Beyond this arbitrary point, quality of life might increasingly suffer or longevity might diminish. But then again, we could be difficult and ask, What is normal quality of life or longevity. Most biological traits exist on a continuum, including such behavioral traits as mood, anxiety, and in this case, obsessive and compulsive behavior.
When looking at many of the most common features of Obsessive-Compulsive Disorder, discussed below, it becomes obvious that some normal individuals have some of the symptoms of this disorder, occasionally, and to some degree. Perhaps a more utilitarian approach than normal versus abnormal would be to look at the disorder from the viewpoint of how much distress and impairment of function it causes to the individual, with the goal to maximize function and minimize discomfort.
One last caveat. It is advisable, when Obsessive-Compulsive Disorder is suspected, that the individual (and family members if appropriate) obtain suitable consultation from a psychiatrist especially skilled in the treatment of this disorder.
Obsessive-Compulsive Disorder: What is It?
Obsessive-Compulsive Disorder, a disorder once considered quite rare, is now recognized to be a prevalent and often severely disabling mental disorder affecting an estimated 5 to 6 million Americans. OCD or Obsessive-Compulsive Disorder is a mental disorder characterized by persistent and unwanted thoughts and/or compulsions or ritualized behaviors. The thoughts are often of an extremely negative and macabre nature such as the thought that one would stab ones child or the thought that some horror will befall a loved one. In one pattern of the disease, the obsessive thought is neutralized by the performance of the compulsion, or ritual. The person thinks that when he, for example, walks back and forth across the room six times (viewed as doing and undoing in psychological terms), the horrible thought wont materialize. In some cases, the thoughts and rituals do not have such a connection in the persons mind but there is a feeling that the compulsion must be performed and until it is there is an increasing feeling of tension. Intellectually, the OCD sufferer usually realizes his thoughts are irrational, and they are certainly an unwanted intrusion on his life, but he feels powerless to stop them.
Other obsessive-compulsive behaviors involve repeated handwashing and dread of germs, checking and rechecking something many times over, and constant doubting. Other compulsions can involve repetitive counting, often in ones head. Some individuals will scan a room and count the number of floor tiles or ceiling tiles repetitively. Other mental rituals involve repeating a nonsense phrase over and over. In another compulsive behavior the individual will need to touch himself or something else repeatedly for a certain number of times, till it feels right. Symmetry is sometimes a hallmark of touching behavior, with the individual having to touch each side of his body the same number of times. Certain numbers or colors may be viewed as good or bad.
Some slow readers actually suffer from Obsessive-Compulsive Disorder which causes them to read and re-read the same sentence numerous times, for fear some dreaded event will otherwise occur. Other times, the reader loses comprehension because certain forbidden words occur in the passage, which the reader cannot bring himself to read.
Obsessive-Compulsive Disorder and Spectrum Disorders
In addition to the obsessions and compulsions, many individuals with Obsessive-Compulsive Disorder also have behaviors in which they pick at their bodies and pull hairs from various areas on their bodies often to the point of denuding eyebrows and hair on the top of the head. This latter behavior has been dubbed trichotillomania and is thought to have some association to Obsessive-Compulsive Disorder. Some investigators also believe that tic disorders, involving phonic (vocal) and motor tics may have some connection to Obsessive-Compulsive Disorder. These latter two behaviors, trichotillomania and tic disorder, are sometimes thought of as OCD-spectrum disorders.
Obsessive-Compulsive Disorder What It is Not
Obsessive-Compulsive Disorder is often confused with another mental disorder known as Obsessive Compulsive Personality Disorder or OCPD. This latter disorder is characterized by certain persistent personality traits which are not usually experienced by the person as all that undesirable. These traits include such things as excessive neatness and orderliness, punctuality, attention to fine detail, indecisiveness, parsimony, difficulty experiencing emotions, difficulty delegating work to another person, and extreme perfectionism. A major difference between the disorders is that the Obsessive-Compulsive Disorder involves unwanted behaviors which are experienced as very stressful. The individual with Obsessive Compulsive Personality Disorder, or OCPD, does not generally feel his behavior is inappropriate. Usually it is the person with whom this individual lives who has a problem with his behavior. Males have a higher incidence of Obsessive Compulsive Personality Disorder than do females. This disorder may predispose to Obsessive-Compulsive Disorder and it may also coexist with it, but many people with Obsessive-Compulsive Disorder do not have Obsessive Compulsive Personality Disorder, and of course the opposite is true also. Type A Personality characterized by time pressure and generalized hostility and an increased risk of heart disease, may be a variant of Obsessive Compulsive Personality Disorder.
Finally, disorders such as compulsive gambling and compulsive eating are probably distinct from Obsessive-Compulsive Disorder in that these behaviors are generally experienced as pleasurable, although the consequences may not be pleasurable. In Obsessive-Compulsive Disorder the behavior is markedly distressing, itself.
Is Obsessive Compulsive Disorder Dangerous?
The accepted wisdom is that individuals with Obsessive-Compulsive Disorder are no more dangerous than the general population. Having an obsessive image of a dangerous act does not correlate with doing the act. In fact, one of the most anxiety-provoking aspects of Obsessive-Compulsive Disorder is the individuals belief that he will act on the obsessive thought. Repeated reassurance that this will not occur is an important part of treatment.
Driving Under the Influence of Obsessive-Compulsive Disorder
Obsessive-Compulsive Disorder may well be responsible for a number of motor vehicle accidents. Consider, for example, that compulsions can involve an individual taking his eyes off the road for variable periods of time (repetitive glancing) or performing other dangerous actions, such as multiple U-turns. What percentage of accidents may be related to Obsessive-Compulsive Disorder? There is no data available.
An important distinction must be made regarding OCD and dangerous driving. Here the individual is not acting on a particular obsessive thought which causes an accident, rather an accident might be the consequence of the inability to focus on driving while pursuing a ritualistic activity. Often such individuals report many close calls. It is my impression, the above notwithstanding, that most individuals with OCD, perhaps the overwhelming majority, seem able to control the rituals enough not to endanger themselves or others.
Conditions which frequently coexist with Obsessive-Compulsive Disorder include Major Depressive Disorder, Generalized Anxiety Disorder, Panic Disorder (see the FatBrain e-matter monograph on this subject), Anorexia Nervosa, and Obsessive Compulsive Personality Disorder.
Other Features of Obsessive-Compulsive Disorder
As described above, the obsessions and compulsions which the individual with Obsessive-Compulsive Disorder experiences are, for the most part, viewed by the individual to be very much unwanted. In psychological terms, we say that the behavior is ego-dystonic. Nonetheless, the individual feels powerless to stop himself from doing these behaviors or from having the obsessions, which often involve vivid images of himself hurting a loved one. It feels as though some external force outside the individual is compelling him to perform these often bizarre behaviors and to think these bizarre thoughts. However, the OCD individual is not delusional; he generally knows that there is indeed no external force driving the behavior, but rather that it is a consequence of his own thinking.
Unfortunately, after living with this extremely disturbing illness for a period of time, the individual with Obsessive-Compulsive Disorder often becomes quite depressed. Sometimes suicidal feelings and even completed suicides result. There is often significant social and occupational deterioration. If the individual is a student, schoolwork might suffer.
Males and females are thought to be equally affected by Obsessive-Compulsive Disorder. The disorder usually begins in adolescence or childhood. The course is waxing and waning and can be aggravated by stress. There is probably a genetic basis for this disorder, since first degree relatives (siblings and parents) have a high incidence of the disorder.
The person with Obsessive-Compulsive Disorder feels shame and disgust at the symptoms he has and tries to camouflage them. He feels helpless to control them, although he realizes they are irrational and senseless.
Relationships with Family and Friends
Many individuals with Obsessive-Compulsive Disorder become masters at camouflaging their symptoms. Thus, unbelievable as it may seem, some individuals with OCD have been married for many years (even decades) without a spouse being aware of the problem. If caught in a ritual, such as checking, the individual might explain he just likes to be sure of things. Usually individuals try to conduct most of the more obvious rituals out of sight of other people. On the other hand, family members might be aware of strange behavior, but choose not to comment on it, so as not to embarrass the individual with OCD. Most of the time these family members are not aware of the nature of the illness.
For the unfortunate OCD sufferer, this concealment of the OCD, usually out of shame, only serves to perpetuate the behavior. Thus family members and friends are excluded from the problem and are rendered in a position where they are unable to help. The OCD person suffers in silence. As the disorder waxes and wanes, sometimes correlated to the degree of stress the individual is experiencing at a particular time of life, those around him are generally ignorant of what is happening. These individuals may often be the unintended recipients of the irritability and anger, and sometimes explosive rage, the OCD individual feels, born out of the frustration he experiences in not being able to control his behavior.
In the optimal situation, the OCD sufferer is able to share with his trusted friends and family members the nature of his problem. One way to do this could involve showing these friends and family members information about OCD, such as this monograph, for example, or other printed materials by credible authors. This may be an easier approach than just initiating a discussion of the problem with no introduction about the nature of the disease. Generally, friends and family are interested in finding out more about the illness and especially what they can do to help. At this point, it is often helpful for a consultation to be arranged with a psychiatrist experienced in treating OCD. A few particularly interested family members and friends might be able to participate in, at least, part of this consultation. Many psychiatrists will facilitate further involvement of these interested, supportive, family members and friends in the treatment plan. Some of the ways these individuals can help are discussed below.
Obsessive-Compulsive Disorder: Where Does It Come From?
There are a great many theories which have evolved over the years to try to explain Obsessive-Compulsive Disorder. The psychoanalytic movement came upon the notion that perhaps a child harbors, at some point in his development, an unconscious wish for something horrible to happen, perhaps for a parent to die. This unthinkable wish is so horrific that it gives rise to a fear that the dreaded event will actually occur. To ward off this thought, the childs own creation, the child develops a series of rituals. There develops the magical thought that the practice of these rituals will prevent the dreaded fear from materializing. Thus there is a binding of the anxiety associated with the forbidden wish/fear brought about by the discovery of the ritual.
theory sees some of the compulsive rituals of the individual with Obsessive-Compulsive Disorder as being a
consequence of grooming behavior gone wild.
This theory derives from the observations of ethnologists who study the
evolution of behavior in various animals. The
licking and preening behavior of cats for example is seen as a behavior which has been
programmed into the cats brain over years of evolution. Similarly, the handwashing, and picking and hair
pulling of some obsessive-compulsive individuals is also seen as behavior that has been
programmed into the brain, but developed to excess beyond any useful purpose. In this comparison of animal behavior to human
behavior, it is noteworthy that some animals, for example dogs, have abnormal behaviors,
such as acral lick syndrome, in which the animal licks and bites itself in the flank or
extremity to such an extent that bleeding and sores result. The animal continues the behavior in spite of
apparent discomfort from the wounds. Some of
the medications used to treat human Obsessive-Compulsive
Disorder been tried in these animals with some success.
Fluoxetine (Prozac) is one such drug that has helped these acral lick dogs.
Another theory sees some of the compulsive rituals of the individual with Obsessive-Compulsive Disorder as being a consequence of grooming behavior gone wild. This theory derives from the observations of ethnologists who study the evolution of behavior in various animals. The licking and preening behavior of cats for example is seen as a behavior which has been programmed into the cats brain over years of evolution. Similarly, the handwashing, and picking and hair pulling of some obsessive-compulsive individuals is also seen as behavior that has been programmed into the brain, but developed to excess beyond any useful purpose. In this comparison of animal behavior to human behavior, it is noteworthy that some animals, for example dogs, have abnormal behaviors, such as acral lick syndrome, in which the animal licks and bites itself in the flank or extremity to such an extent that bleeding and sores result. The animal continues the behavior in spite of apparent discomfort from the wounds. Some of the medications used to treat human Obsessive-Compulsive Disorder been tried in these animals with some success. Fluoxetine (Prozac) is one such drug that has helped these acral lick dogs.
Another, recent theory of Obsessive-Compulsive Disorder views the illness as resulting from an abnormality of the brains frontal cortex and the basal ganglia. In fact, PET (Positron Emission Tomography) studies have looked at the metabolism of these structures in normals versus individuals with severe Obsessive-Compulsive Disorder and have found significant differences. In general, the individuals with Obsessive-Compulsive Disorder show much greater activity in the frontal cortex. Of course this finding does not in itself prove a direct causal relationship. It is possible that these differences are secondary effects, that once an individual has Obsessive-Compulsive Disorder for a period of time these changes occur in the brain. We just dont have the answers yet. Interestingly, with treatment and improvement, some of the abnormalities observed on the PET scans seem to diminish. Support for the biological theory of OCD is given by the familial clustering of OCD and also twin studies.
Treatment Approaches to Obsessive-Compulsive Disorder
Treatment approaches to Obsessive-Compulsive Disorder fall into the categories of medication management, cognitive/behavioral therapy, supportive psychotherapy, and family therapy. Traditional psychoanalytic treatment seems generally ineffective, although it may be of some help, just by virtue of the support rendered by the analyst.
Medications currently available which have been widely used to treat Obsessive-Compulsive Disorder include clomipramine (Anafranil), fluoextine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and fluvoxamine (Luvox). The latter four medications are in the class of antidepressants with strong and selective serotonin re-uptake blocking effects (SSRIs or Selective Serotonin Re-Uptake Inhibitors). Anafranil, some believe, is somewhat more effective that the other antidepressant medications in the treatment of Obsessive-Compulsive Disorder. However, its use is often limited by side effects. These typically include dry mouth, constipation, blurry vision, sedation, and weight gain. The SSRI antidepressants on the other hand seem almost as effective as Anafranil without these strong anticholinergic side effects and with less weight gain. The downside of the SSRI medications is that they are often associated with sexual performance problems, especially retarded ejaculation. In both sexes, these medications can inhibit orgasm. Buspirone (Buspar) has also been used as an adjunctive medication, to augment the primary medications described.
Not all patients respond well to treatment, whether medication management, cognitive/behavioral treatment or a combination of both, the latter thought to be more effective than single modality treatment.
Those patients who do show a positive response to treatment are not rid of the disease, but they may experience a 50% to 60% reduction of symptoms and occasionally an even greater response. Some patients require continued, indefinite, use of medication to keep OCD under control. Other patients can discontinue medication (tapering it off under supervision) and they can go long periods in remission. This seems especially true if behavioral treatment has also been part of the treatment plan. Patients are reassured that medication can always be resumed if an exacerbation of the illness occurs.
Behavioral treatment of Obsessive-Compulsive Disorder, as commonly practiced, involves exposure and response prevention. The individual, for example, is urged to touch the dirty doorknob and then he is not allowed to perform the anxiety-relieving ritual (usually repetitive handwashing). This individual will, of course, experience an initial surge of anxiety, but then the anxiety will abate even if the response of handwashing is prevented. After several repetitions of this exposure and response prevention, over many days and even weeks, the urge to perform the ritual, handwashing, in this case, is extinguished. Similar exposure and response prevention techniques can be used to extinguish other inappropriate behaviors.
Pure obsessions are more difficult to treat behaviorally, but some success is possible with thought stoppage techniques in combination with medication. Much reassurance is given to the individual that he is not a bad person for having the often morbid thought. This is a very important aspect of treatment, since many OCD sufferers are victims of intense guilt about their horrific thoughts. They often ask, does this mean I really do want to harm my child (spouse, mother, etc.). They must be reassured repeatedly that this is the nature of the disease, not their own, personal wish. They must get to a point where they are able to take the sting out of the thought, to divest the thought of its hold over them, by realizing it is an oddity of this particular illness. When a thought does occur they must say to themselves, it is only my OCD acting up again. These individuals must learn to switch the channel to a more pleasant thought. Sometimes they can maintain a repertoire of pleasant, non-threatening thoughts (of their choosing) to use in these situations. Professional assistance can often be of great benefit in guiding the individual through this process.
Other important modes of treatment include family therapy to help enlist the support of the family in helping the patient to practice behavioral techniques as well as for general support. The support individuals must first be educated in the nature of the illness and they must understand the ways in which behavioral techniques can be helpful. There is also the possibility that there is a secondary gain to the OCD itself. This additional complication can occur, for example, where the illness, in this case not hidden, is used, usually unconsciously, as a way to keep others involved. This dynamic must be thoroughly explored and treated if it is suspected.
Interestingly, when patients are jailed and unable to do some of their rituals they seem to improve temporarily. Perhaps the behaviors go underground in the form of more subtle activities.
It is imperative that the person with Obsessive Compulsive Disorder feels some sense of empowerment and control over his illness. This is especially true with this particular disorder, since this illness, by nature, makes one feel helpless and under the control of some external force. As mentioned previously, the individual with Obsessive Compulsive Disorder is not delusional, yet he describes feeling as though something is making him do the rituals and obsessive thinking.
To restore some sense of control over the disorder, one is encouraged to read all about the disorder and to attend support groups and discussion groups about this problem, both in real life and on the internet. (In the case of the internet, it is important to verify information by checking various different sources).
By attending these self-help forums, the person with Obsessive Compulsive Disorder will feel that he is not alone. He will realize that this is, in fact, one of the more common mental disorders. The individual may even be able to contribute his own tips about what helps him with his obsessions and compulsions.
It is also helpful for the person with Obsessive Compulsive Disorder to realize that many normal individuals also do some rituals and have obsessive thoughts. On the other hand, the illness should not be trivialized, since the person afflicted is under tremendous pain. He should be encouraged to share his experiences with close friends and family members whom he trusts will treat his disorder with proper respect and support his efforts at getting appropriate treatment.
There are several important points that the person with Obsessive Compulsive Disorder must keep in mind at all times:
1 Obsessive thoughts do not translate into actions any more in the Obsessive Compulsive Disorder individual than in anyone else who has unpleasant thoughts.
2 Compulsive behaviors are self re-enforcing and similarly, self-extinguishing. This is to say that the more the behavior is done the more it seems to get entrenched. Conversely, if the behavior can be resisted, the initial anxiety will pass, and after repeating such avoidance of the behavior, eventually the compulsive behavior will extinguish. The individual can enlist the help of good friends and family members (whom he can trust to deal with the problem in a dignified manner) to assist and support him in resisting ritualistic behaviors.
3 The individual should realize that it is in the nature of Obsessive Compulsive Disorder for the individual to obsess about those contingencies which are the most dreaded and the most reprehensible, and that this does not represent the actual desires of the individual. Some individuals will avoid dangerous places or will refuse to be around knives or other kitchen tools, for fear they will use them to harm someone. Again these individuals must reassure themselves that this will not happen. They must desensitize themselves to be around these common household implements.
4 - The individual needs to see the reward of the behavioral changes in the form of much diminished stress and much less time spent pursuing ritualistic behaviors, thus opening up more time to spend in other more productive or recreational or family activities.
5 It is helpful for the individual to learn relaxation techniques and other strategies for reducing the anxiety that accompanies Obsessive Compulsive Disorder. A lessening of general anxiety will decrease the stress level one feels and thus decrease the likelihood of exacerbations of the Obsessive Compulsive Disorder. To achieve this more relaxed state I refer the reader to the many strategies discussed in the monograph entitled, Why We Have General Anxiety and Panic Disorder and What We Can Do About It. (available through FatBrain e-matter).
6 It is helpful for the individual with Obsessive Compulsive Disorder to meet with a professional periodically, even if the symptoms feel somewhat controlled, to have the disorder periodically re-assessed as to severity by an outside, objective evaluator. Such an evaluator can evaluate the individual using such tools as the Yale Brown Obsessive Compulsive Scale, which will give a picture of the status of the disorder both as a snapshot in time and longitudinally if the evaluation is repeated periodically. Also, the professional can update the individual as to any new treatments available including new medications which may have come on the market.
7 In all cases it is important to keep a positive and hopeful attitude. This is a disorder than can be greatly helped by current treatments available, especially a combination of cognitive/behavioral treatment and medication management. And treatment will only improve in the future.
It is my hope that this monograph has provided a clear understanding of the nature of Obsessive-Compulsive Disorder and related mental disorders. It is likely that there will be many new medications, with fewer side effects than the current medications, to help psychiatrists treat individuals with Obsessive-Compulsive Disorders. In the meanwhile, it is important to encourage individuals with this disorder to come for treatment, since even with the currently available treatments, significant improvement can be expected. There is no point in suffering needlessly.
Dennis B. Kottler, MD
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