OCD Treatment A Brief History
Compulsion neurosis. Obsessional neurosis. These are names given to OCD earlier in this century. It was once thought to be a rare disease. Only 0.05% of the population was estimated to be affected by OCD in1964. By 1977, those numbers grew to 0.32%. Still rare. Today, major studies estimate a lifetime prevalence rate of 2.5% and a one year prevalence of 1.5%-2.1%.
Have the numbers grown in the last three decades? Are we seeing an epidemic of OCD?
No, not at all. We are finding that OCD is not rare at all. There are no more people afflicted with the disorder now than in 1964. The mistaken rarity of OCD is due to the secrecy of people who have the disorder. Shame, guilt and self-blame keep us from exposing our secret struggle with obsessive thoughts and compulsive rituals.
Blaming internal conflicts and external frustration for OCD, Sigmund Freud used psychoanalysis to treat the disorder. The results of this treatment were not good, and OCD continued to be known as a perplexing disorder to treat. Even Freud admitted being puzzled by OCD. He promoted his psychological theories and they became widely used for many years. But even Sigmund Freud looked toward a future when biology and chemical substances would play an important role in psychiatric research and treatment.
That future has arrived. Todays techniques, such as positron emission tomography (PET), single-photon emission computed tomography (SPECT) and magnetic resonance imaging (MRI), have moved psychology from theories to research. Scientists can now look at chemical reactions in the brain. They have found that OCD is likely caused by abnormalities in specific parts of the brain, not unconscious conflicts, poor parenting or dysfunctional families.
OCD appears to be linked to problems with a brain chemical called serotonin. Five medications have been developed to help correct this chemical imbalance Anafranil, Prozac, Luvox, Paxil, and Zoloft. Most people can get reduction of OCD symptoms from at least one of these medications. Others get relief from a combination of medications. Why is this? Shouldnt one medication work for everyone afflicted with OCD? This tells us that the serotonin imbalance is not the only problem behind OCD. Next month I will discuss specific abnormalities of brain structure that affects OCD symptoms.
Until the 1960s, psychoanalysis was the therapy most used to treat OCD. While medications were being developed to successfully treat OCD, therapy was changing too. British psychologist Victor Meyer began using behavior therapy treat OCD in 1966. He exposed hospitalized OCD patients with severe contamination fears and cleaning ritual to feared objects and situations such as bathroom doorknobs and faucets. Meanwhile, he severely restricted their showering and washing. He turned the water off, except to areas used strictly for toileting!
Meyers innovative treatment worked! Out of fifteen, fourteen of his patients had rapid reduction of their OCD symptoms. By the end of treatment, ten were symptom-free or much improved, while five patients achieved moderate improvement. Since then, studies around the world have shown improvement of OCD symptoms with behavior therapy.
Unlike psychoanalytic theory, which maintains that much of our behavior is out of our control, behavioral psychology maintains that we can gain control over our behavior. Studies have shown that behavior therapy can help correct the chemical imbalance in the brain, similar to the way medication does.
In the 1980s researchers began recognizing the role of thoughts, beliefs and attitudes in predicting human behavior. Consequently, cognitive therapy was developed as a complement to behavior therapy. Cognitive therapy helps patients dispute faulty thought patterns and irrational beliefs that result in abnormal behavior. Together, this is often referred to as cognitive-behavior therapy. You will see, even in my writing, the terms behavior therapy and cognitive-behavior therapy used almost interchangeably.
The cornerstone of cognitive-behavior therapy for OCD is what we call exposure and ritual prevention (ERP). It is also called exposure and response prevention. The patient is exposed to the obsessive thoughts and fears. Then he prevents himself from responding in the usual manner with compulsive behaviors or thoughts.
Many people can use self-help books to find relief from obsessive-compulsive thoughts. Resources specifically for people with OCD are available through the Obsessive Compulsive Foundation at http://www.ocfoundation.org Others will need professional help. I strongly advise anyone who thinks they may have OCD to consult a psychiatrist for a complete mental health checkup. Accurate diagnosis is the first and most important step toward recovery.
Treatment of OCD
The most effective treatment for OCD is a combination of cognitive-behavior therapy (CBT) and medications. Studies have shown that a combination of CBT and medication produces better results than either treatment used alone. Although more difficult and time consuming, CBT has demonstrated more lasting results. Relapse is frequent when medication is withdrawn.
Medication TherapyThe medications most commonly used in treating OCD are antidepressants. The medications most often used to treat OCD treatment are fluvoxamine (Luvox), fluoxetine (Prozac), sertaline (Zoloft), paroxetine (Paxil) clomipramine (Anafranil), citalopram (Celexa), and escitalopram (Lexapro). These medications are not chemically related, but they all work by inhibiting the reuptake of serotonin.
Serotonin is one of the neurotransmitter chemicals that nerve cells in the brain use to communicate with each other. These neurotransmitters are active when they are present in the synaptic cleft between nerve cells. Transmission is ended when the chemicals are taken back up into the transmitting cell. The SRIs and SRRIs slow the reuptake of serotonin, making it more available to the receiving cell and prolonging its effect on the brain.
Increasing serotonin appears to produce changes in receptors in some of the membranes of the nerves. It is believed that these receptors may be abnormal in patients with OCD. SSRIs may also affect other brain chemicals. Sometimes a patient will not respond to the first medication and will have to try two or more of the SSRI's before finding one that works for him.
Cognitive-Behavior TherapyCompletion of a course of CBT appears to work as well as medication for the treatment of OCD. Research is finding that, over time, CBT can change a person's brain chemistry. People with OCD tend to stay in long-term remission, requiring only occasional refresher sessions.
The complication is that CBT requires great motivation and cooperation on the person's part. When used together, medication and CBT complement each other. Medication alters the serotonin available, while CBT helps modify behavior by teaching the person how to resist compulsions and obsessions.
Exposure and ritual prevention (ERP) is the cornerstone of cognitive-behavioral treatment for OCD. Cognitive-behavior therapy utilizes ERP and techniques that will help you change the faulty beliefs people with OCD often maintain.
Exposure and ritual prevention (also called exposure and response prevention) are the principal behavioral techniques for treating OCD. The purpose of exposure is to decrease the anxiety and discomfort associated with obsessions through habituation. This may be done by desensitization with brief imaginal exposure or prolonged exposure to the real-life ritual-evoking stimuli. For example, the person may be exposed to garbage or other contaminated objects without relieving the anxiety by washing his hands. As the person realizes that the feared consequences will not occur, the anxiety decreases. This is called habituation.
The purpose of ritual prevention is to decrease the frequency of rituals. The person with OCD is faced with feared stimuli without practicing rituals, such as hand washing or excessive checking. At first, the person may be allowed to delay performing a ritual, working gradually toward resisting the compulsion.
A graded hierarchy of anxiety producing activities and situations is constructed. The Yale-Brown Obsessive Compulsive Scale can help with identification. Exposure often begins with the least anxiety provoking situation. Some therapists focus on situations that produce moderate anxiety first to achieve more rapid progress. Which one is employed will depend on the therapist's choice and the person's ability or willingness to tolerate anxiety. One or two obsessions and rituals are worked with at a time to avoid overwhelming the person.
The person with OCD is assigned homework exercises. He or she may need assistance with these assignments from family members or the therapist's home visits. Participant modeling may be incorporated in exposure and ritual prevention. The person is asked to copy the therapist. I observe my family and friends to help me determine "normal" behavior. When I am not sure if my behavior is appropriate, I ask one of my support people.
Family members should be asked to participate in the therapy. Role-playing under the supervision of the therapist can help them understand homework assignments. Keeping a diary can help by serving as a reminder of progress. It also helps the therapist identify areas of resistance.
In some cases, people experience OCD symptoms only in particular situations. Exposure and ritual prevention may need to be carried out in special settings. Home visits or field trips may be required by the therapist.
For best results, the therapist needs to be well trained in CBT, the OCD person must be highly motivated and faithful in fulfilling homework assignments and the person's family needs to be cooperative. Often, finding a therapist experienced in the treatment of OCD is difficult. The Obsessive Compulsive Foundation can help you find a therapist interested in OCD treatment. But CBT can also be done on your own. The OCD Workbook uses the Self-Directed Program to guide readers through individualized cognitive-behavior therapy.
Support GroupsSupport groups help people with OCD realize that their symptoms are not unique. The family should also be involved in a support group, if one is available. This is especially important for parents of children and adolescents. Support groups can also help with education about the disorder.
GOAL (Giving Obsessive-compulsives Another Lifestyle) is a support group in Philadelphia. Founded in 1981, it is probably the oldest OCD support group in the country. Emphasis is on choosing behavioral goals to work on between meetings. Dr. Jonathan Grayson, Ph.D., one of GOAL's founders, advises having a professional experienced with OCD assist the group. This person would help keep the meeting on track, give individual assistance when needed and answer questions.
GOAL meetings are divided into three parts: discussion of a particular topic, chosen by the group leaders prior to the meeting; goal planning; and informal socializing. GOAL groups are discussed in the audio cassette, "Making and Maintaining Goals-G.O.A.L. Support Groups," by Jonathan Grayson, Ph.D. and Gayle Frankel. It is also available through the OC Foundation. I have posted an OCF Newsletter article about GOAL groups, written by Dr. Grayson. Click here to visit it.
Obsessive Compulsive Anonymous (OCA) was founded in 1988 by Roy C. OCA uses principles similar to other12-step programs. Roy C. describes the program in the book, Obsessive Compulsive Anonymous-Recovering from Obsessive Compulsive Disorder. It is available through the OC Foundation. OCA has a website at http://members.aol.com/west24th/index.html
Family Support Sometimes family members or friends recognize signs of OCD before the person with the disorder does, or the person may refuse to seek help. If you know someone with symptoms of OCD, educate yourself about the disorder, then bring educational materials into the home. Share the information in a gradual and nonthreatening way. My book, Loving Someone with OCD, is a helpful resource.
Do not assist the person with their obsessive-compulsive behaviors. It is best to withdraw help with rituals gradually. Tell your loved ones you will help them resist the compulsions and you will help them obtain help, but you will no longer be a part of their compulsions. Examples would be participating in washing rituals, checking appliances for the person, answering the same question repeatedly and offering frequent reassurance. Offer to help the person find a mental health professional that is experienced in the treatment of OCD.
Once the person with OCD begins treatment, family members play an important part in recovery. People often need a support person at home to assist them with the exposure tasks and homework assignments. Before taking on the role of support person, learn what will be expected of you. This will be a long-term project, often requiring regularly scheduled time to help with homework assignments.
Family members and friends who are not taking on the role of support person can also help the OCD person. These are steps the family can take to encourage recovery:
Exposure and Ritual Prevention
Obsessive-compulsive disorder was once thought to be almost untreatable. Over the last couple decades, two treatments have been proven effective in the treatment of OCD medication and cognitive-behavior therapy (CBT). Together they are powerful tools in the struggle against OCD.
Cognitive-behavior therapy is actually the combining of two types of therapy. Behavior therapy has been used to treat OCD for over twenty years and numerous studies prove its effectiveness. It uses methods of changing behavior. Cognitive therapy has recently joined forces with behavior therapy. It involves strategies for helping to change the faulty beliefs prevalent in OCD.
The type of behavior therapy used to treat OCD is called exposure and ritual prevention (ERP) It is also called exposure and response prevention. Patients are taught to expose themselves to that which they fear. As the anxiety rises, they then work to resist the usual ritual that reduces the anxiety. For example, a person with fear of contamination would expose himself to what he considers unclean or "contaminated," then resist hand washing or showering.
Exposure and ritual prevention is best done in stages baby steps. My biggest problem was checking. When my OCD was at its worst I checked everything, often several times. Leaving the house involved checking the lights, the stove, coffee pot, computer and any other appliances. Then checking that the back door was locked and all the cats were in the house. If I was interrupted, Id have to start over. I started at the back of the house and worked my way to the front door. Finally, I could go out the door. Then I had to lock the door, check it, lock it again, check it. When I got to the car, I was often struck with a fearful thought that made me go back and check again:
"Maybe I accidentally turned the stove on when I was checking it."
"Did I lock the door?"
"Maybe I unlocked the door instead of locking it."
"Did I let the cat out?"
When I determined to attack this problem with OCD, I made a plan. The first step was easy. Sounded easy anyway, but it wasnt easy to me. I changed the order and method of checking things each time I left the house. Instead of starting at the back of the house, I started with the kitchen. When I checked the stove, I didnt touch the knobs as I was accustomed to doing.
As I gained confidence and the initial anxiety was reduced, I got braver. I left the house for 15 minutes without checking anything. Finally I was able to leave the house for several hours or all day after just checking the appliances only once. I can now lock the door and walk calmly to the car. Usually! Sometimes, very rarely now, the fear comes back. "I was in such a hurry, did I lock the door? Maybe I forgot." I can usually continue on without going back to check. But I still feel compelled to go back and check sometimes. I feel like I cant resist. And you know what? When I go back to check, the door is always locked!
My Experience with Exposure and Ritual Prevention
When I learned about exposure and response prevention (ERP), I made goals for myself. I enlisted my husband Jim and my son James to serve as support persons and asked them to help me with my self-imposed rules. Rule #1 was "REASSURANCE ONE TIME ONLY!" When I asked for reassurance, they reassured me once. Almost always, I rephrased the question and asked again. I instructed them to remind me, "We are not allowed to answer that question again."
What kind of reassurance? I asked questions such as:
"Are you sure I locked the door when we left the house?"
"What if I didnt cover my mouth when I coughed and there was a child near by?"
"Do you think I let the cat out on the way out the door?"
"What if I didnt sign the check I just mailed?"
"I think this shirt touched the floor, should I wash it over?"
"I felt a bump, did I just hit someone with the car?"
Often I argued and pleaded. Sometimes they relented and gave me the reassurance. I knew and they knew this was not the best thing for me. Success and improvement of my OCD came only when they stood strong, with me, against the enemy, OCD.
I had some problems with hand washing and laundry. I wasnt afraid of harming myself, but of harming others. If I didnt wash my hands before touching the clean laundry, I might pass a germ on to someone else. Laundry that touched the floor became "contaminated." I made "laundry rules." No extra handwashing before touching the laundry. Clothes that touched the floor must not be re-washed.
I cheated a lot at first. But the more I obeyed my rules and resisted the urge to do the laundry rituals, the stronger I became. Today, I can do laundry without extra handwashing. Even underwear can touch the floor!
Checking was my worst problem. I made "checking rules." I allowed myself to check the door, stove and coffee pot before leaving the house or going to bed, ONCE. If I was interrupted, I was not allowed to go back and check. Once I left the house and got in the car, I could not go back and check anything again.
My son was helpful with this one. Often, his gentle, "Mom, you cant go back," was all I needed to give me strength not to jump out of the car and go check.
For a while, I had the "hit and run" problem too. I would be driving along and suddenly be struck with the fear I had hit someone. Sometimes I went back several times to check the road. My son would reassure me with, "No Mom, everything is OK, you didnt hit anyone."
When I learned more about ERP, I realized the reassurance my son gave me was only making my problem worse. It was hard, but I did it I told my son not to give me reassurance. He was to say, "Mom, I cant reassure you." I got angry with him, I cried and pleaded with him. Sometimes he gave in. Then little by little, we both became stronger and resisted.
I knew I was getting better when my son could say, "Yeah, Mom, you hit three kids back there," and I didnt get angry with him. I had other car rules too. No going back to check for dead bodies. Only "normal" looking in the rear view mirror. (I knew when I was looking in the mirror for dead bodies or fallen bicycles. If you have a problem with driving, you know when you are checking too.) No looking back at groups of kids on the side of the street.
ERP is hard work, but it is worth the effort to break free from the chains of OCD.
OCD Rules , revised
by Cherry Pedrick, RN
Reprinted from Suite101.com, November 3, 2000
Are you bound by too many
rules? Could the rules be connected to your OCD? Do you have trouble deciding if your
rules are reasonable rules that any prudent person would have?
I am very rule oriented. I
have a few rules for how other people should behave, but most of my rules govern my behavior. Rules "protect" me from
danger, discomfort and embarrassment. I tend to think that they also keep me from later
obsessing that if I follow specific rules, I wont obsess later. But the rules
get in the way when I can't remember if I did a step in the checking process. For example,
I could reduce obsessing about locking the door by going through a series of steps
and mindfully locking it.
But there comes a time when I
just automatically lock the door and go to the car. What if I didn't lock it? Do I go back
and check? Rules are fine, but Ive learned that when you do something every day it
becomes familiar, almost automatic. We get into a habit
of locking the door when we leave the house. When my OCD was moderate to severe, I must
have gone back to check the door at least a hundred times over the years. In fact, I
checked the door so much I wore out the lock and we had to replace it!
Rules are quite important,
living by them defines our characters. And
doing things mindfully is helpful for people with OCD. But we need to keep in mind that
those same rules that we use to protect ourselves from obsessing later very well may
backfire. When we forget one step, we give added importance to the rules. If I didnt follow the rules, then I may not
have locked the door. For me, that thought would grow and grow until I told myself I just know I didnt lock the door. So back I
would go to check the door. When OCD gets the best of me, I still go back and check on
occasion. And of all the times Ive gone back to check, the door was never left
My contamination fears taught
me another lesson about rules and OCD. I have had hand washing rules in the kitchen. Wash
your hands after handling raw meat or eggs. But what about milk? Or what about mayonnaise?
When I was making something for others, the rules were even stricter. I once gave up on
making a relish plate for church after the second try and ended up putting it all in the
refrigerator for my family to eat. I kept thinking I had touched an olive, then a pickle.
We stopped at the store to buy something packaged for the potluck.
I had a rule about not
touching other people's food. So if I did, it was contaminated. Most people do have rules
for good hygiene in the kitchen. But if they break a rule, they can logically decide if it
was a major rule, like not frosting a cake and taking it to a church function after the
cat took a bite out of it. I did that one time in my pre-OCD years! Or was the rule a
minor rule, like not touching a pickle? For many people with OCD, there are no minor
I still think it is fine to
have kitchen rules. But be prepared for the time when you break the rules. I think a good
prevention of the inevitable obsessions when rules are broken is to plan ahead. Write out
your rules, then sit down with a prudent person, a support person, and go over your rules.
Are they legitimate hygiene rules that most prudent people would follow? Or are they
excessive rules? Cross out the rules your support person says are excessive. Now, you have
a new list of rules, but youre not done yet. Ask your support person which of the
rules can be broken. What if I dont follow these rules? Which ones are major rules
that should never be broken and which ones are minor rules that wont hurt to be
broken occasionally? Make a new list with major rules in one column and minor rules in
When a minor rule is broken,
you can accept it as just a slip up and carry on. No need to trash the dinner. When a
major rule is broken, you can take the proper steps to correct the situation. If this
causes way too much anxiety, you could move some of the major rules into the minor rules
column. When anxiety reduces, you could move them back into the minor rules column. I
guess this is kind of an exposure. Getting rid of unnecessary rules will cause some
anxiety. Resisting following them is the ritual prevention.
So, this is an exposure and
ritual prevention exercise (ERP) ala Cherry. Im
not a therapist, doctor or counselor, but someone with a few ideas who has experienced
OCD. With a little thought you can get creative and come up with your own tailor-made ERP
by Cherry Pedrick, RN
Reprinted from Suite101.com, December 1, 2000
Someone recently wrote to me
about medication. Isnt medication crutch? Would God approve? Wouldnt He want
us to conquer the fears and doubts of OCD without medication? Isnt taking medication
an admission of failure?
Fear of taking medication is
very common in people with OCD. We tend to want to handle it ourselves. And for a
Christian or someone of another religion that fear is even worse. I had
reservations about taking medication too. But when you really think about it, it doesn't
make sense. OCD is a neurobiological disorder. A problem with the brain. And God made us.
He also allowed all the technology and research to be done. I think He works in many ways.
And one is by providing people to do the research and develop medications to help make
illnesses more tolerable.
If you are struggling with the
medication question, another way to look at it is this: medication can help you get well
enough to more fully work on cognitive behavior therapy. When the OCD is improved, you
could consult your doctor. If you both agree you are ready to give it a try, you could ask
your doctor to help you reduce and quit the medication. We don't have to decide today, to
be on medication for the rest of your life. We only need to decide if we should be on
medication now. I would set a time period to be on medication and work on therapy. Then
ask your doctor and, with his help, you could try to reduce or quit it. If it doesn't work
out, you can start medication again. If one medication doesn't work well, you can try a
different medication. Think of this as temporary decisions you are making for a few months
at a time.
My Wimpy (Gradual) Approach
to Exposure and Ritual Prevention for Checking , revised
by Cherry Pedrick, RN
Reprinted from Suite101.com, December 29, 2000
Exposure and ritual prevention
is hard work. It means exposing yourself to what you greatly fear, then resisting the
usual ritual or response. In my case, checking was my worst ritual. If I didnt check
certain things before leaving the house, something bad might happen. Someone could break
in and steal everything if the door wasnt locked. The house could burn down if the
stove was left on. The coffee pot could blow up if it was left on.
I didnt fear the harm
and hardship it would bring to me, but the harm it could bring to my family. I even
obsessed that if the car was left unlocked a child could open the car and take one of my
pills I kept in the glove box, even though it was in a childproof container. Or a child
could start the car and be injured. If I didnt put the brake on in the driveway,
which was on a slight incline, it could spontaneously roll down and hit a child innocently
Full exposure to these fears
would mean leaving the house without doing my usual checking. I didnt have formal
cognitive behavior therapy. I applied the principles I learned about in books. Leave the
house without checking? No way! That seemed much too difficult. Even visual checking,
without touching the knobs of the stove was out of the question. But I felt I could handle
a gradual approach.
I checked the stove, coffee
pot, etc. once, in a "normal" sort of way (looking at the stove knobs and not
touching, for example) then left the house for a few minutes. Then I would check and leave
for longer periods of time. Then I left the house for a few minutes without checking and
increased the time period as before. For me, if I was leaving for a short while, the
obsessions and the compulsions to check were weaker, so this helped.
Another thing I did at first
was this I did my checking in a different order. Instead of checking the toilets,
lights, computer, back door, appliances, stove, etc. in my usual order, back of the house
to front, I changed the order and checked things in a random order. The checking didn't
feel right so it was an exposure, but a weaker one and more tolerable.
But I didn't stop, I continued
to make the exposure stronger and stronger until I was only checking things once. Now I
check to make sure the lights and are off, then leave the house. For me, checking
compulsions were kind of difficult to stop because checking needs to be done in normal
life. Like eating we need to do it, but not excessively.
My approach might sound wimpy
to a lot of therapists, but then I didn't have formal behavior therapy. I learned from
books and used the principles to reduce my OCD symptoms. Because no one was pushing me, I
did it at my own speed. Im sure it took longer than if I had pushed myself more, but
in my opinion, wimpy like me is better than no exposure at all. Dont avoid exposure
and ritual prevention because you think it would be too hard. Do what you can, but do
something. If you choose a more gradual approach, keep working at it. It can be tempting
to stop when the rituals no longer seem to interfere with your life. I did this, then
realized they really did interfere with my life. Some rituals came back full force because
I eased up on exposure and ritual prevention. However you do it, keep working at it. For
me, it is a lifetime process.
to Cherry's Website
Click here for information about The OCD Workbook and Cherry's other books!