Originally published in MedioCom
Dr. Patricia Ferguson, 2001
One of the most difficult psychiatric disorders to treat is Obsessive-Compulsive Disorder (OCD). Sometimes this disorder is confused with Obsessive-Compulsive Personality Disorder. However, personality disorders are ingrained characteristic styles of interacting with the world, whereas other mental disorders are typically clusters of specific symptoms that interfere with daily functioning. Some of the characteristics of the O-C Personality include preoccupation with trivial details, perfectionism, and rigidity about morality and ethics.
In contrast, OCD is a disorder that involves severe symptoms that interfere with everyday functioning. The symptoms of OCD include specific obsessions and compulsions. Obsessions are thoughts such as fears of contamination (the most common obsession), doubts, and a need to have things in a certain order. The obsessions are beyond the typical worries of everyday life because they are not based on real-life problems.
Compulsions are actions that are attempts to reduce the anxiety that is a result of the obsessions. For instance, if someone is afraid of contamination, their anxiety is reduced if they perform the ritual of hand washing. In fact, people with OCD believe that if they do not perform the ritual, great harm will come to them.
The person is unable to not engage in these rituals and tends to be very secretive about them. However, the person does understand that the obsessions and compulsions are irrational, and this is important because it differentiates them from people who suffer from psychotic symptoms such as hallucinations and delusions. Nevertheless, the person with OCD feels helpless to stop the obsessions and compulsions even though they know they are irrational.
When I was working as a psychologist in private practice, I had a patient who washed each load of laundry three times, washed her hands to the point that they were raw, and would not open the mail for fear of contamination. When she became pregnant with her first child, she had been working as a professional career woman. Suddenly, she became fearful of germs, a very common symptom of OCD. (It is also quite common for the onset of the illness to begin with pregnancy). Unfortunately, she was unable to work with her severe illness and never returned to work.
Another patient I saw with OCD was a young man of about twenty who also engaged in hand washing and counting rituals. However, what really gave him the most difficulty was that he would fixate on a certain woman, and follow her everywhere. He never even spoke to them, but the women would become aware of his fixation and become frightened. Twice his problem with women resulted in restraining orders.
The cause of OCD is unknown, but many studies have shown that specific regions of the brain are involved. Like many other psychiatric disorders, it is not known whether the brain changes are caused by the disorder or vice versa. The disorder is not genetic, but typically depression and/or anxiety run in the family of the patient. A circuitous route in the brain involving several different areas may be the cause (or the result) of the disorder.
Obsessive-Compulsive Disorder is very difficult to treat. As a treating therapist, I was able to help the patients achieve temporary relief or a reduction but rarely elimination of symptoms. I have spoken to many other therapists who also said they found it to be one of the most difficult diagnoses to treat. One thing we also discussed was that even when the person is able to reduce the compulsions, there seem to be social problems that continue afterward. The best way we knew to describe it was just that these patients tend to be somewhat odd socially.
The most proven treatment technique is cognitive-behavioral treatment, with a medicine added to the treatment regimen. Over the course of the years I practiced therapy, the specific medications would change, but they all involved the neurotransmitter serotonin. The latest medication that is the most prescribed is probably Anafranil. According to Seligman, in his book, What You Can Change and What You Can't, about half of the patients on Anafranil do not improve, and even those who can tolerate the side effects are rarely cured on medicine alone.
Furthermore, when a patient is taken off the medication, the symptoms return. However, with a behavioral treatment known as response-prevention, success remains after treatment is stopped. With response-prevention, the patient is told to do something else, or nothing, instead of the typical ritual response to an obsession. The patient keeps careful charts to monitor the progress of symptoms in duration and number over time. Even with just a modicum of success, the patients are often pleased to have even small gains. One possible explanation for recovery is that certain patients who go on to a full recovery do so because in the first successes they have learned that they will not come to the dreaded harm if the ritual is not performed. A cognitive shift has taken place.
However, research results differ as to the efficacy of any and all treatments of OCD. Research is easier to do with cognitive-behavioral treatments than with psychodynamic (talking) treatment. Psychodynamic treatments have many variations, but essentially what is involved is having the patient resolve childhood issues that are unconsciously interfering with their functioning as an adult. In the case of OCD, therapists who work from a psychodynamic perspective believe that the person needs to overcome unconscious aggressive impulses that are causing the symptoms.
In addition to working with the patient, the therapist should also work with the family to help them understand the disorder. Usually the family does not understand why the person can't just stop performing the rituals. This is like saying to a depressed person that they should just not be depressed anymore. With family support, the patient is relieved of any anxiety that may be resulting from family pressures and the patient can focus on relieving symptoms without also having to deal with angry family members.
In conclusion, OCD is a very serious mental disorder. It is difficult to treat, but can be helped with medication and therapy. Usually cognitive-behavioral treatment, along with family therapy, is helpful in reducing symptoms. Even if all of the obsessions and compulsions are eliminated, often the patient has residual social problems and may need continued treatment to help resolve those problems.
Seligman, Martin. What You Can Change And What You Can't. New York: Fawcett Columbine