Help & Hope for OCD

OCD Treatment – A Brief History
By Cherry Pedrick RN and Bruce Hyman PhD
Reprinted from Suite101.com, February 16, 1999

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. Today’s 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? Shouldn’t 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!

Meyer’s 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.

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.

The 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.

Completion 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.

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 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.

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.

Exposure and Ritual Prevention
by Cherry Pedrick RN
Reprinted from Suite101.com, March 16, 1999, revised

My Experience with Exposure and Ritual Prevention
by Cherry Pedrick, RN
Reprinted from Suite101.com, April 27, 1999, revised

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."

"Are you sure I locked the door when we left the house?"
"What if I didn’t 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 didn’t 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 wasn’t afraid of harming myself, but of harming others. If I didn’t 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 can’t 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 didn’t 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 can’t 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 didn’t 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
by Cherry Pedrick, RN
Reprinted from Suite101.com, November 3, 2000, revised

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 won’t 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 I’ve 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 didn’t 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 didn’t 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 I’ve gone back to check, the door was never left unlocked.

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 rules.

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 you’re not done yet. Ask your support person which of the rules can be broken. What if I don’t follow these rules? Which ones are major rules that should never be broken and which ones are minor rules that won’t hurt to be broken occasionally? Make a new list with major rules in one column and minor rules in another column.

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. I’m 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 exercises.

Medication Guilt
by Cherry Pedrick, RN
Reprinted from Suite101.com, December 1, 2000

Someone recently wrote to me about medication. Isn’t medication crutch? Would God approve? Wouldn’t He want us to conquer the fears and doubts of OCD without medication? Isn’t 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
by Cherry Pedrick, RN
Reprinted from Suite101.com, December 29, 2000, revised

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 didn’t check certain things before leaving the house, something bad might happen. Someone could break in and steal everything if the door wasn’t locked. The house could burn down if the stove was left on. The coffee pot could blow up if it was left on.

I didn’t 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 didn’t put the brake on in the driveway, which was on a slight incline, it could spontaneously roll down and hit a child innocently walking by.

Full exposure to these fears would mean leaving the house without doing my usual checking. I didn’t 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. I’m 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. Don’t 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.