When you think of Obsessive-Compulsive Disorder (OCD), you may think of a rare, bizarre disease that causes people to wash their hands until they are raw or check and recheck the turning off of things, so much so that they are late for appointments and eventually become unable to function. Yet this is not the only way that OCD manifests, and the numbers of people afflicted with the disease are grossly underrepresented.
Obsessive Compulsive Disorder OCD is characterized by the presence of obsessions and/or compulsions that can be extremely time consuming and/or disrupt a person’s normal routine. According to the literature, ‘time consuming’ means that a person engages in the obsession, or compulsion, for at least 1 hour a day (Geffken, Storch, Gedford, Adkins, Goodman, 2004). Common obsessions in OCD include fear of contamination, chronic doubting, somatic (body) worries, need for symmetry or to make thinks match, and aggressive and sexual thoughts. Some of the more common compulsions include checking, hand washing, touching and tapping (Geffken, et al., 2004). The goal of these behaviors? To alleviate the anxiety caused by the unwanted, intrusive thoughts that occur over and over.
As said above, not all persons afflicted with OCD are hand washers. The majority of people with OCD are obsessed with contamination and engage in compulsive acts of cleaning, usually hand washing. However, up to 25% of OCD sufferers fall in the category of pure obsession. This is where cognitive, not behavioral, rituals predominate. People who fall into this 25% category experience repetitive and intrusive thoughts, usually of a sexual or aggressive nature. As one might guess, this last group is particularly hard to diagnose because of (the client’s) tendency towards secrecy, and because there are no observable compulsions taking place (Spengler, Jacobi, 1998).
One of the delineating factors in a diagnosis of OCD is that the person with the disorder KNOWS that their thoughts or actions are unreasonable, but they feel incapable of stopping them. In most cases, they experience their thoughts as senseless, have poorly developed schemata, and avoid disclosing to others (Spengler, Jacobi, 1998).
OCD usually begins early in life and is a chronic condition that can lead to social and occupational impairment. Onset of the disease occurs most commonly in the adolescent and college years, with men exhibiting signs earlier (17.5 years old) than women (20.5 years old). OCD does not discriminate as there are no differences in rates related to race, marital status, intelligence or educational level.
Although OCD is a debilitating disorder with a lifetime prevalence rate of 25% in adults (Geffken, et al, 2004), many diagnosed with OCD do not receive appropriate care. One of the reasons given for this failure to treat is the incorrect assumption that OCD is a rare disorder. In fact, OCD is recognized as the fourth most common mental disorder following, in order of occurrence, substance abuse, phobias, and major depression (Spengler, Jacobi, 1998). Perhaps part of the reason for this “confusion” is that several disorders manifest ideational processes that are much like the obsessional thinking in OCD. People with Generalized Anxiety Disorder (GAD) and posttraumatic stress disorder (PTSD) also have cognitive processes that are intrusive, repetitive, and exaggerated. The difference lies in how clients view their obsessions. With those that have PTSD or GAD, the intrusive, repetitive exaggerated thoughts are seen as related to one’s self-view of life circumstances. With OCD they are not. (Spengler, Jacobi, 1998). The most common co-morbid condition with OCD is depression – nearly two-thirds of OCD sufferers have lifetime histories of depression. Substance abuse is also common with OCD (24.1%) and up to half of all OCD patients have a personality disorder. (Spengler, Jacobi, 1998).
Clearly, assessment of clients should include ruling out and treating all related disorders.
Obsessive Compulsive Disorder in the Brain
OCD has a genetic and biological component that has been documented in the research. In one comprehensive study of twenty three outpatients with OCD and 27 healthy comparison subjects, MRIs revealed significant differences in the brains of these two groups of people (Szesko, MacMillan, McMeniman, Chen, et. al, 2004). The regions of interest in the study included the frontal lobe sub regions, the caudate nucleus, the putamen and the globus pallidus. The finding in the study included a positive correlation between the globus pallidus and anterior cingulated gyrus volumes in the healthy volunteers, but not in the patients with OCD. This indicates that there is a defect in the connectivity of the frontal-sub cortical circuitry in OCD brains and may play a role in the the pathophysiology of the disease (Szesko, et. al, 2004). In addition to this study, there has been evidence produced to confirm that abnormalities in the basal ganglia are linked to OCD.
Yet why is it necessary to discuss the physiology of OCD? Because the presence of abnormalities in the brain can lead to treatment that is not only technical but pharmacological. Much like the diabetic or the person with high blood pressure, it may be that those with OCD need only take a drug to counteract the problems in their brains. Given this, we are left with questions as to how to treat this disabling disease.
Given the brain etiology of OCD, it may seem surprising to find out that, in many cases, it has been documented that cognitive behavioral therapy (CBT) is more effective than psychotropic drugs when it comes to long term results. Because of its success, space will be given here to outline the CBT treatment of choice: Exposure and response prevention.
Exposure is an essential practice in CBT for OCD. Simply put, it can be described as having individuals face their fear. Through repeated trials of exposure to a feared stimuli, individuals with OCD have a decreased experience of anxiety (Geffken, et. al, 2004). Response prevention, which is also called ritual prevention, involves having a client refrain from engaging in repetitive, consuming compulsions. Numerous studies have shown that response prevention can help eventually eliminate compulsive rituals (Geffken, et. al, 2004). It is also important to keep in mind that both exposure and response prevention are forms of behavior therapy and as such result in changed cognitions.
Certain guidelines and steps are necessary when employing exposure and response prevention techniques. It is best that this type of therapy be conducted at the location of the symptoms (i.e. in vivo). This is particularly important with regard to exposure, or facing fear, because the goal is to enable the client to interact in the actual places that have previously been sources of trouble – usually places that they have come to avoid. If you are going to use this therapy, it is necessary for the client to understand what the treatment is intended to do and to believe that the treatment is likely to be helpful for them (Geffken, et. al, 2004). This is particularly true due to the nature of anxiety.
After educating the client, situational assessment begins. Questions to ask may go something like, “What ritual physical of behavioral activities or mental rituals does me client do to decrease his or her anxiety, discomfort, distress, or feelings of disgust?” Or you might ask, “What situations and thoughts does my patient try to avoid.” (Geffken, et. al, 2004). Once these are determined, the next step is to establish a hierarchy of your client’s feared situations and how difficult it may be for him/her to approach those situations. Ranking is an important part of the therapy at this point. Anxiety provoking situations can be ranked according to their “subjective units of distress” (SUDS) rating. Usually distress is expressed on a scale of 0 to 100 with 100 representing the most-feared activity and 0 representing a non-feared, neutral activity. Each feared situation on the hierarchy should be assigned a value between 0 and 100 (Geffken, et. al, 2004). Following the establishing of a hierarchy, goals are formulated jointly between client and therapist. Goals should be related to situations at the less-feared end of the hierarchy, such as easier exposures, coupled with partial response-prevention exercises. In addition, the goals should be stated very specifically, written down, and progress checked at each session.
When the symptoms of OCD include thoughts of aggression or sexual acting out, CBT often involves imaginal exposure rather than actual re-enactment. In this way, clients are encouraged to vividly picture the events they fear to enhance the reality of the exposure (Geffken, et. al, 2004).
Given that OCD has a biological and “brain effected” component, it would make sense that psychotropic medication is indicated in treatment. The best medications for OCD are the selective serotonin reuptake inhibitors because they reduce anxiety while allowing individual to experience some anxious arousal. This experience of anxious arousal is necessary to support the effectiveness of CBT. Medications like benzodiazepines prevent individuals from reaching a heightened level of anxious arousal, which can reduce the effectivenss of CBT because heightened arousal is a necessary component of the intervention. Also of note is the fact that OCD occurs very frequently with other disorders, such as depression. When this is the case, pharmacological management of the co-morbid disorder is necessary
What Really Works?
There is extensive agreement that exposure and response prevention is the treatment of choice for OCD. Data suggest that between 50% and 100% of OCD clients respond positively and most maintain changes long after treatment (Spengler, Jacobi, 1998). In some controlled studies of CBT with adults who have OCD, success rates of up to 83% were reported (Geffken, et. al, 2004). In still other studies there was data to suggest that “…CBT may be associated with slightly greater improvement (Geffken, et. al, 2004).”
This doesn’t mean that psychotropic drugs are ineffective in treatment. Researchers in one study found that 53.6% of participants (who received both CBT and setraline) showed complete recovery, that 39.3% of participants became nearly asymptomatic with just CBT, and that 21,4% of the group became asymptomatic when treated with setraline alone (Anonymous, 2004). In addition, because comorbidity is the rule rather than the exception in most OCD clients, psychotropic drugs may be necessary to get a client to a state in which he/she can engage actively in obsession and ritual reduction. Interestingly enough, exposure and response prevention have been shown to produce neurophysiological changes similar to those observed with anti-compulsive medications.
Where To Go From Here
Obsessive-compulsive disorder creates particular challenges for mental health counselors, due to the secretive nature of OCD, the unfounded belief that it is a rare disorder and the reluctance clinicians may have to intentionally increase their clients’ anxiety. Effective treatment of this disorder requires diligence and accurate observation. Attention should be paid in at least three context areas. Counselors must first identify and dispel myths and misconceptions related to OCD, as a way of building a knowledge base. Second, assessment methods for OCD must be learned. And finally, counselors must remain abreast of what is currently known about the treatment of OCD (Spengler, Jacobi, 1998).
In closing, here are three quick screening questions that can be used during an office visit to screen for OCD. Employing them may help to capture some of those silent sufferers.
1) “Do you have repetitive thoughts that make you anxious and that you cannot get rid of regardless of how hard you try?”
2) “Do you keep things extremely clean and tidy or wash your hands frequently?”
3) “Do you check things to excess?” (Zepf, 2004). Perhaps, if we were to take a minute for this simple screening, those suffering from OCD will receive the treatment they need.
Anonymous (2004). Combination therapy best for obsessive disorders. AORN Journal, 80, 1156-1157.
Geffken, G.R, Storch, E.A., Gelford, K.M., Adkins, J.W., Goodman, W. K. (2004). Cognitive-behavioral therapy for obsessive-compulsive disorder: review of treatment techniques. Psychosocial Nursing and Mental Health Services, 42, 44-56.
Spengler, P. M., Jacobi, D. M. (1998). Assessment and treatment of obsessive-compulsive disorder in college age students and adults. Journal of Mental Health Counseling, 20, 95-112.
Szeszko, P.R., MacMillan, S., McMeniman, M., Chen, S., et. Al. (2004). Brain structural abnormalities in psychotropic drug-naïve pediatric patients with obsessive-compulsive disorder. The American Journal of Psychiatry, 161, 1049-1057.
Zepf, B. (2004). Management strategies for obsessive-compulsive disorder. American Family Physician, 70, 1379-1381.