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Sporadic photos and notes from a Psyche-midwife, cheerleader, anthropologist--aka clinical social worker in therapy practice. Photos are usually mine except for those of historical events/famous people. Music relevant to the daily topic is often included in a web video embedded below the blog. Click on highlighted links in the copy to get to source or supplemental material. For contact information, see my website @ janasvoboda.com or click on the button to the right below. Join in the conversation.

Thursday, May 27, 2010

Diagnosis of the day: Obsessive Compulsive Disorder

CHECK CHECK CHECK: Obsessive Compulsive Disorder is the label given to a anxiety disorders that have two chief characteristics: Obsessions (unwanted thoughts, images, beliefs) and/or compulsions (ritualized or repetitive behaviors). There are several subtypes. In contamination OCD, the sufferer worries about being affected by touching or being exposed to specific (although often many) people or objects, or being infected by germs. The fear is controlled where possible by avoidance (never touching doorknobs, refusing to shake hands, etc). When avoidance is unavoidable, the sufferer often develops rituals to "cancel out" the contamination. These may be logical though excessive, such as hand washing or use of antibacterial lotions. A person with contamination OCD may wash, scrub or apply chemicals to hands to the point of damaging the skin. Illogical rituals may also be used: retracing steps, saying a particular phrase, and so on. The rituals can be very time consuming and do NOT feel like a choice.

Rituals aren't limited to contamination OCD. Some OCD folks have intense fears something terrible will happen to them or someone they care about if rituals are not followed. Checking disorder, in which a person has intrusive concerns about not completing a protocol, may lead to checking and rechecking to make sure the lights are off, gas isn't leaking from the stove, or similar. Last year driving to the airport I saw a bumper sticker on a car that said "Are you SURE you unplugged the iron?" Like most people, I have a touch enough OCD (yes, that's my mushroom photo above) that it nagged me for a minute or two. For someone who really is affected by OCD, that might have led to a drive back home from over an hour away.

OCD can cause intrusive, usually illogical thoughts that cause distress. They are "ego-dystonic", a fancy way of saying the person doesn't want them. Those affected seek constant reassurance to refute them. In one case many years ago, I worked with a young man who worried he might be gay. He had never been sexually involved with a man, and never wanted to be. He had perfectly satisfying heterosexual relationships. Yet every week he would ask me "Are you SURE I'm not gay?" Reassuring someone with OCD is not effective, and in some ways contributes to the worry. The person with OCD knows their behavior or thinking is illogical. But it is not a choice to them.

"Pure O" OCD is the name given when the primary symptom is intrusive thoughts and/or images.  Disturbing sexual or violent pictures and thoughts are common in this type of OCD, but the name is misleading-- there are almost always some compulsions around being used to try to control the behavior.  For example, a person may avoid driving because of obsessive thoughts about running someone over.

I read once that the chief difference between the OCD and non-OCD person with egodystonic thoughts is the "stickiness" of their brain. We all think crazy thoughts. But if we don't have OCD, we dismiss them as random. The OCD brain worries them like the place where a lost tooth came out. They just can't leave them be.

The causes of OCD are unclear. There is an obvious genetic component that accounts for at least half of occurrences. While no one gene appears responsible, it's rare for me to treat someone with true OCD who didn't have one or more direct family members with some sort of significant anxiety disorder. But environment also plays a role. Life stresses, maternal pregnancy factors and even childhood strep infections can be factors. Hormones appear a factor at least in women-- it is common for new mothers (some say around 30%) to struggle with some intrusive thoughts and compulsive behaviors. Of course, stress and anxiety in such situations would be a clear contributing factor: is the baby breathing? Did I feed her enough? But the frequency leads researchers to conclude that hormones may exacerbate the situation. You can see in that case the evolutionary effectiveness of increased vigilance. Worried-over babies are more likely to survive than neglected or ignored babies.

OCD is different from Obsessive Compulsive Personality Disorder. People diagnosed with OCPD don't usually have rituals. Personality disorders are considered more personality types that cause trouble for people rather than isolated disorders. If you're old enough to remember "The Anal Retentive Chef" from Saturday Night Live, you've seen a classic OCPD type-- obsessed with rules and order, inflexible, fussy, perfectionistic. As I mentioned in my first blog about diagnosis, at their most basic most diagnoses describe a particular type of genetic predilection that have both strengths and weaknesses. You probably WANT your chef, your surgeon, the guy that lays your tile to be a bit on the obsessive-compulsive side. That means you will get a job done right. But when either of these slips into the really disordered arena, you get someone impacted so much by rigidity, anxiety, avoidance or time-eating practices they cannot function at all close to their potential. That's when it's time to do something.

Therapy for OCD
The most demonstrably effective treatment for OCD is not pleasant for those who have it. It involves systematic exposure to the triggering events so that the brain can rewire these to be perceived as non-threatening. OCD "boot camps" provide this quickly, though unpleasantly. A person with contamination OCD might be forced to touch a toilet, for example, then eat something without washing. Generally, in outpatient treatment, exposure is done gradually to desensitize the person.

Medication can also be helpful. SSRIs (antidepressants such as fluxoetine, better known by its brand name of Prozac, or others) seem to help some people. There are risks and benefits to using medication and it appears that they work best when exposure therapy occurs concurrently. Medications of these sort should NEVER be stopped abruptly because serious withdrawal syndromes and rebound effects (worsening of symptoms) may occur.

New treatments using deep-brain stimulation (which involves surgery), transcranial magnetic stimulation (non-invasive) and even good old ECTs are also actively being explored to treat more severe and disabling forms of OCD.

If you're worried now that you have OCD, remember that most people have a little bit of every "disorder". The key factors for figuring out whether it's a problem is how disruptive it is to your life. Who's complaining? How much is it limiting you? If it's a problem for you, there are many options. Most cities (certainly Corvallis) have therapists and psychiatrists who specialize in treatment of OCD. Here are some other resources:

ocdtribe
is an online source with chat groups and information by and for OCD sufferers.

The International OCD Foundation
, also run by persons with OCD, distributes information, research, and connects folks to treatment.

Dr. Stephen Phillipson has several good articles here at OCD Online.

Lots of successful, famous people have OCD. Click this post's title to see Howie Mandel talk to David Letterman about his.

We'll end on a lighter note: an OCD song.

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