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Why We Have Obsessive-Compulsive
Disorder and What We Can Do About It.
by
Dennis B. Kottler, MD
Introduction
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
one’s 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 won’t materialize. In some cases, the thoughts and rituals do not
have such a connection in the person’s 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 one’s 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 individual’s 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.
Comorbid Disorders
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 child’s 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.
Another,
recent theory of Obsessive-Compulsive Disorder views
the illness as resulting from an abnormality of the brain’s 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 don’t 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 (SSRI’s 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.
Self-Help Techniques
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.
Conclusion
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
Please e-mail the author with your
feedback at: doc@psychiatrix.com
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