Tackling Your OCD ~ Fugen Neziroglu, PH.D

Obsessive Compulsive Disorder (OCD) is a preoccupation with thoughts, feelings, images and sensations (obsessions) and engagement in behaviors or mental acts (compulsions) in response to these obsessions. The thoughts are persistent and pervasive and cannot be repelled from the mind.  While obsessions and compulsions usually exist together they can often exist alone as well.  A category in the diagnostic manual called Obsessive Compulsive Spectrum Disorders includes disorders that are similar to OCD such as Body Dysmorphic Disorder (BDD); Excoriation Disorder (skin picking, cutting); Trichotillomania (Hairpulling) and Hoarding Disorder (HD).  In this article we will stick to just OCD.

OCD  treatment has advanced a lot over the last 30 years. We went from not having any treatments to very specific well researched treatments.  Cognitive Behavior Therapy  (CBT) is the first line treatment and specifically exposure response prevention. In the 1970’s OCD patients were being diagnosed as schizophrenic because their thoughts were viewed as bizarre, psychotic.  Of course now we know that they have thoughts that are persistent and pervasive and behaviors they need to perform to ward off their thoughts but most often they know it is senseless.  They are not psychotic at all.  When we first started talking about OCD in the late 1970's and meeting in local libraries trying to educate the public there were only three places in the world (Pennsylvania; London; Montreal) that treated OCD and we soon became one of the first to study and treat this disorder along with them.  They were beginning to explore a form of cognitive behavior therapy called exposure and response prevention.  It was believed that only a small percentage of people had OCD.  In 1980, we met in Ennis, Ireland, a handful of researchers trying to understand this underrecognized and underdiagnosed disorder. Over the course of many years OCD became a household word and is now well recognized, although many individuals still do not seek treatment or get appropriate treatment.  

What should a person who has OCD be looking for in terms of therapy?  If you ask a therapist, "Do you do CBT?",  she will probably say yes because they might have learned a technique or two.  Unfortunately if the therapists’ therapeutic orientation is not CBT they will only know how to implement a few strategies but they may not be proficient on when, at what pace, and what strategies to use for what symptoms.  They may even claim to know ERP but again do it here and there.  Therefore let’s see what should an OCD therapist being doing to treat your symptoms.

After getting a thorough background and an assessment of all your symptoms  (eg. Administering the  YBOCS ) and related symptoms they may assess some treatment outcome predictors such as depression, anxiety, shame, disgust, overvalued ideation and trauma. They will look at comorbid disorders and decide what needs to be treated first.  There are well established evidence based treatments for the OCD Spectrum Disorders.  Although engaging patients in treatment is hard for some of the spectrum disorders, most OCD patients readily seek help.

ERP, the primary treatment choice, refers to exposing someone to their fears and preventing them from engaging in their compulsions.  This is done by creating an anxiety hierarchy of situations that provoke distress and gradually putting the person in those situations at a rate that they are able to tolerate.  Sometimes this takes a lot of creativity, especially when you have a pure obsession and you need to create the situation in real life.  We often think of handwashing and doublechecking as symptoms of OCD but it takes on many forms.  You may have emotional contamination which means you avoid everything that someone you dislike or angry at touches.  You may have thoughts of being gay, a pedophile, an ax murderer, a person possessed by the devil, or you may be counting or repeating activities all day.  A good therapist needs to be able to take any symptom and create various situations to expose you to.  A good therapist will work with you outside of the office, go where the problem is or come to your home.  Let’s take the need for ordering and arranging, meaning you get anxious if your belongings are moved.  It may prevent you from letting others enter your room or you may have to check to make sure everything is in its “proper” place everynight.  The therapist would come to your home and gradually start moving things around and have you tolerate the discomfort  They may instruct family members to do the same (of course with your permission).  You learn over time to not be bothered by your compulsions. Another example, may be the fear of hurting someone with a sharp object or running someone over while driving. The therapist would have you sit next to someone with a knife and have you try to stab the person or go out driving and not check if you ran someone over.  Individuals with OCD do not act out their fears.  

Discussing the obsession or compulsion rationally, logically does not work.  It may help  the person reduce his anxiety for a little while but not long term.  Educating someone over and over on how one gets AIDS or STD does not help.  If someone has received ERP but has not reached optimal change, doing an intensive outpatient program often yields better results.  We have published a few studies showing the efficacy of intensive treatment where individuals are seen anywhere from 2 to 6 hours a day or several times a week.  Bio-Behavioral was the first to implement Intensive Outpatient Treatment for Anxiety Disorders in the United States.  Since then there have been some residential programs that have opened up.

Besides ERP we at the Bio-Behavioral Institute, are now looking at the effect of adding acceptance commitment therapy or dialectical behavior therapy to the ERP.  Also we are investigating the role of treating some of the predictor variables, especially overvalued ideation and trauma in increasing treatment response.  We just published an article on bullying in OCD and BDD vs. other disorders where by individuals with OCD were often victims and individuals with BDD the bulliers. We have several publications showing that overvalued ideation, the conviction you have about your beliefs is a predictor of treatment outcome.  We are noticing that DBT is helpful with some individuals who have OCD and have difficulty with their emotions.  We are also beginning a new medication for OCD.

To see if you have OCD or any of the spectrum disorders you may take a quiz we have on our website: www.biobehavioralinstitute.com.