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Transcript of Obsessive-Compulsive Disorder
A Brief View of Therapy Evolving
How can these hands be dirty still,
where are these germs my brain cannot kill?
Where is the map to ease the maze,
corridors of circles, my head ablaze.
Can I not but let it lie,
to walk away without goodbye.
But you slowly creep upon my shoulder,
the doubt and fear that turns me older.
How free you are with dirty nails,
you float above with open sails.
A glance below to see me stare,
the chains that grasp, they keep me there.
The door is closed, but is it now,
another glance no more I vow.
Perhaps another, we’re never too sure,
the ultimate check, I promise no more.
The red ignites the demon clutches,
I cannot stand these chemical crutches.
What I would give to walk away,
the whispers and cries would ruin my day.
Look at me though I see the crime,
a world through eyes coated in grime.
What system must be drawn to plan,
cheat the devil and free the man.
People You May Have Heard Of...
History of Treatment
C.A. is a 14 year old male in the eighth grade. He was raised in the upper-middle-class with his biological parents and his older brother. He achieves at high levels in school. His mother considers him to be somewhat shy and introverted. There is no history of abuse or trauma, and no evidence of any drug use.
Monday, July 28th, 2014
Vol XCIII, No. 311
'As Good As It Gets'
"Brace yourself for Melvin."
Some of the Basics
Types of OCD
Melvin Udall is a writer living in New York city, he is very antisocial, cranky, and suffers from OCD. Melvin's rather repetitive life is thrown into turmoil when his neighbor Simon, whom he has a bad relationship with is hospitalized and Melvin is forced to care for his dog Vedell. During the same time Carol the server, whom he has an infatuation with, begins to become a larger part of his life after he pays for proper medical treatment for her ill son. All of this combines to completely change the way that Melvin lives his life and forces him to face his OCD and other erratic behaviors.
Poem written by Matt C.
And what is it
What is OCD?
An Elusive Answer
What Causes OCD?
As of now, scientists are still unsure about the true cause of OCD, though it is likely that is not due to a single factor. It is more than likely to be a combination of factors in play that trigger the onset of OCD.
Pharmacological Treatments & Therapy
Figure 1: Scores on the measure of the severity of OCD symptoms at assessment.
CY-BOCS: Children’s Yale-Brown obsessive compulsive scale.
Figure 2: Scores on a Measure of Disability Resulting From OCD Symptoms at Evaluation,
Post-treatment and Follow-Up. SDS: Sheehan Disability Scale.
These thoughts and fears have begun to greatly impact C.A.’s ability to function and cause him steadily increasing amount of anxiety. He constantly uses repetitive phrases and thoughts to rid his unwanted thoughts. He constantly avoids people using such chemicals as his triggers or areas that have been in recent contact with such cleaners, and if he did come in contact with these chemicals it would cause him to wash thoroughly. Breathing through his mouth and not his nose was another behavior he did to attempt to relieve his anxiety as he thought that would minimize his risk of brain damage.
Impact on Daily Life
C.A.’s initial treatment had been successful in decreasing his symptoms substantially. Follow-ups were conducted at six and twelve weeks after his CBT. During these follow he reported that he had progressively began to fail to continue exposure to his triggers and his symptoms had begun to worsen once again. He also reported that even though his symptoms had worsened he was still able to maintain a high level of functioning.
C.A.’s treatment can be classified as a partial success. His symptoms were effectively treated initially, and he was able to maintain an improvement in his ability to function in daily life. Both C.A. and his mother expressed satisfaction with his treatment and the results. Yet he did have resurgence in symptoms. This may have been caused by the failure in his follow-up care as it was only done at six and twelve weeks by phone, this being partly due to the distance between the patient’s home and the treatment center. The therapy also failed to fully prepare C.A. for his return home. Possible amendments to treatment could have been more sessions on planning and creating a written home exposure plan, and having his mother play a larger role in the follow-up. While also having more frequent phone follow-ups and maintenance therapy sessions.
C.A.’s symptoms first began in the first grade, which were constant thoughts of contamination. These thoughts triggered by saliva, bathrooms, and glue led to compulsive hand washing. These initial symptoms were treated with Sertraline, which was effective till he was in the 7th grade at which the side effects had become intolerable so it was discontinued.
Now C.A. suffers from constant intrusive thoughts of brain damage which is trigger by household cleaning products, lead paint, insect repellant, and other things of that nature.
He has anxiety caused by fears of being unable to learn or remember information particularly school readings.
He also suffers from intrusive thoughts that he will or has done illegal drugs, and he will perform sexual acts before marriage or with his mother.
Along with these new symptoms he also has had a resurgence of his past contamination fears.
C.A. and his mother stayed in a hotel during the therapy sessions due to the distance between home and the treatment center.
Treatment was initiated ten weeks after his initial evaluation, this delay was provided to allow an assessment of the stability and severity of C.A.’s symptoms. Treatment included 14 CBT sessions over three weeks, along with the medication Escitalopram and later Fluvoxamine. The CBT session focused of ERP (Exposure Response Prevention Therapy) which is meant to have the patient confront triggers. Before exposure his therapist measured the anxiety and stress caused by these triggers with the SUD scale (Subjective units of distress) to create a hierarchy for his ERP treatment.
C.A.’s planned Exposure Treatment Hierarchy
Situation or thought SUDS
Think “I have or will do drugs” 15
Think about hurting family members 25
Touch recently cleaned surface 30
Think “I have brain damage and cannot learn” 35
Think “I do not understand” while reading nonfiction 35
Be near someone else using household spray chemicals 40
Think “I do not understand” while reading science 45
Think of having sex before marriage or with mother 50
Personally use household spray chemicals 80
Touch or breathe in household spray chemicals 95
Moderate to Severe OCD
What we now know as OCD was once acknowledged as a form of religious melancholy or spiritual problems. Those that suffered, suffered in silence and those that received unwanted attention often suffered persecution, imprisonment, or was the victim of brutal experiments.
John Moore, Bishop of Norwich, England, held a sermon on religious melancholy in 1691... "naughty, and sometimes Blasphemous Thoughts [which] start in their Minds, while they are exercised in the Worship of God [despite] all their endeavors to stifle and suppress them ... the more they struggle with them, the more they increase."
When psychoanalysis increased in popularity, people started to approach OCD as if there was a meaning behind the obsessions. Later it was discovered that this method was actually counter intuitive, in fact it proved to be harmful. The idea that these obsessions have a deep-seated meaning is rejected by all modern OCD experts.
Finally, a breakthrough occurred when they began to combine behavioral & cognitive therapy to create a rational fix. This type of therapy taught patients to apply a reasonable alternative to change the irrational behavior, eventually learning that the fear or obsessive thought can be overcome.
In recent years, some psychotherapists have taken CBT and combined it with mindfulness, creating Mindfulness-Based Cognitive Behavioral Therapy. This method essentially acknowledges that everyone has bad thoughts, and that's okay! It is neither good, nor bad, but are just a part of the human experience. We just don't need to act on uncomfortable thoughts and stop trying to control them. This has proven to be very useful in treating many forms of OCD.
A common mistake people make is confusing OCD with OCPD. OCPD is obsessive compulsive personality disorder. A person with OCPD may spend hours meticulously cleaning until they receive their "perfect" outcome.
Obsessive Compulsive Disorder has been misused frequently in recent years. The key characteristic of OCD is the extreme distress that it brings.
Belittles & Trivializes
If one displays obsessive or impulsive quirks that last just a quick moment and causes hardly any distress or anxiety of any kind, does not belong to the diagnosis of OCD.
Collecting vs. Hoarding
There is a clear distinction between being a collector and a hoarder.
Collecting derives from a special interest in a subject, while hoarding is the result of fear of causing harm if they discard many of the seemingly worthless objects they've accumulated.
Impulse Control Disorders
Those that have compulsive/addicting behavior do not exhibit part of OCD, as well. Usually the people in these scenarios began their obsession by deriving pleasure out of the activity even though it may have turned to distress later on.
Alternatively, those with OCD do not and have not derived pleasure out of the compulsion, instead the undesirable intrusive obsessive thoughts drove the compulsions.
OCD vs. OCPD
Now this may seem very similar to OCD, however one with OCPD sees their behavior a desirable trait and that others are at fault for not being as orderly. A person with OCD is not happy and does not find the obsession to be pleasant.
**Hoarding has recently been recognized as its own disorder in the DSM V, though it is still related to OCD.
Checking can be carried out multiple or even 100's of times, this can lead to being late to work, school, etc. which could result in serious consequences.
Gas or electric stove knobs
Symptoms of illness online
Re-reading words or lines
Contamination involves the fear of contracting an illness that could result in serious harm. Problems that can arise from this form is that it can be costly, factoring in the soap, water, and various other cleaning supplies. The constant washing can take a serious toll on the skin. Also, the fear of illness can even result in avoidance of entire places.
Using public toilets
Touching door knobs/handles
Avoiding red objects and stains
Eating in a cafe/restaurant
Being in a crowd
Excessive Tooth Brushing
Cleaning of Kitchen and Bathroom
Similar to contamination, mental contamination is when the individual feels bad or unworthy, in-turn making them feel dirty internally. However, the distinction between the two is that MC is almost always caused by a another person instead of an inanimate object. Though the compulsion will pretty much be the same, excessive washing to rid the 'dirt'.
You are worthless trash!
Being unable to discard items that may be ultimately useless/worthless in fear that it could cause harm or that they may need that item one day.
Difficulty in getting rid of items, even in dire circumstances.
Buying, saving or collecting anything and everything.
Problems with organization of items.
Inability of discarding items due to the fear of harm it may bring. This can be targeted towards the actual throwing away of it, that someone will me harmed in the process (i.e. the garbageman). Or the fear that discarding the item will trigger harm to oneself or a loved one.
Sometimes if one has been through a traumatic event they will begin to hoard anything they can in fear that they may need that particular item one day. For example, if a person is homeless or starving, once they have the ability to provide for oneself they may collect more than they way need.
Sometimes when traumatic life experiences have occurred, the individual may place sentimental or special importance on even the most ordinary items.
Ruminations are long trains of thought that are undirected and unproductive. Often ruminations are involved in the subjects of religion, philosophy, or metaphysics. Most do not find a solution or a satisfying conclusion.
Intrusive thoughts are unwanted, repetitive, often disturbing and can even be horrific.
Since the repetitive thoughts are
, the sufferers are nonthreatening. Especially since many of the sufferers go to great lengths to prevent such occurrences from happening.
Those that suffer from 'relationship intrusive thoughts' often have a hard time maintaining relationships.
Relationship Intrusive Thoughts
Constantly analyzing the relationship
Constant paranoia of their partner or self cheating
Consistent need for reassurance and approval
Consistent questioning of one's own sexuality
This form of OCD is not frequently reported, due to the fear of the sufferer being labeled as sick or a sexual predator. They often avoid areas where children may be present, whether it be stores or even their own family. A parent suffering from this disorder wil usually lead to emotional trauma for the child as well.
Sexual Intrusive Thoughts
Fear of being a pedophile
Fear of being attracted to children
Intrusive thoughts of being attracted to a religious figure
Fear of being attracted to the same sex (Not homophobia. Homosexual OCD)
A.K.A. Thought-Action Fusion, harbors the idea that thoughts can actually trigger events or that if something is not done perfectly in one's mind, it will bring harm.
Magical Intrusive Thoughts
The consistent questioning and analyzing of religious beliefs. This can lead to the complete avoidance of their church or religious practices in fear of their thoughts.
Religious Intrusive Thoughts
Violent Intrusive Thoughts include the fear of hurting oneself or others close by. To avoid these thoughts sometimes the sufferer will avoid public places or lock away knives and other sharp objects. Many of those that suffer this form of OCD don't often seek professional help due to the fear of being labeled as a bad person.
Violent Intrusive Thoughts
Particular color, number, or letter will bring bad luck
Thoughts can cause disasters
Not following chain letters will cause harm
Hearing the word 'death', then say the word 'life' to counteract any harm.
Having bad thoughts in a religious building
The individual is always doing something sinful
Intrusive sexual thoughts about religious figures
Melvin's OCD Symptoms
● Unlocking and locking his door three times before opening or closing it
● Flipping the light switch on and off three times when either turning it on or off
● Refuses to make physical contact with other people
● Will wipe off door handles before opening them
● Throws out his leather gloves after each wear as if they were disposable rubber gloves
● Repetitive hand washing in which he throws out the bar of soap after each hand washing and repeats this several times after going out.
● Must slip on shoes or slippers three times before he will put them
● Will not step on any cracks or gaps in the road or sidewalk
● When he goes out for breakfast he will only eat at one restaurant always and must have the same server and table.
● Will only use plastic utensils when he eats out
Thoughts of praying incorrectly or the prayers being ommitted
Saying religious prayers over and over and over again
Thoughts of breaking religious laws
Violently harming children or loved ones
Killing innocent people
Using kitchen knives and other sharp objects
Jumping in front of a train or fast moving bus
Poisoning the food of loved ones
Acting on unwanted impulses, i.e. running someone over
The compulsion is to make sure things are 'just right', and the obsession is to prevent harm. This is be related to magical intrusive thinking. So much time can be spent trying to make things perfect that it can have serious impacts on a career or school.
Symmetry and Orderliness
This form does not show any outward compulsions, however that does not mean they are completely lacking. The obsessions will just manifest into compulsions that will take place as mental rituals. So even though it is commonly referred to as "pure obsessional", that is actually a misrepresentation of the condition.
Having everything neat and in its place at all times.
Having pictures hanging aligned and straight.
Having canned food items all facing the same way, usually forward.
Having clothes on the rail all hanging perfectly and facing the same way.
Having everything spotless, with no marks or smudges on windows and surfaces.
Having books lined up perfectly in a row on a bookshelf
A prime example of someone who functions completely normal with OCD. He has is OCD under control, though he still states he has to fight the urges of stepping on gum stains on sidewalks and walking through doorways multiple times. He did state that during filming of the movie
which he played Howard Hughes (Another person who suffered from OCD, however much more severely), that his symptoms worsened and it took him months to get back under control.
Billy Bob Thornton
Some of the OCD traits that Billy had were taking his mail out of his mailbox and putting it back in three times. He would also assign numbers to people, and then remember the people by those numbers.
Donald is afraid of germs and doesn't like to shake hands. He also refuses to touch the ground floor button on a lift
Though it is completely unapparent on the soccer field at home he has obsessions about everything in pairs or even numbers, things in his home have to be symmetrical and straight, and he has to color coordinate all of his clothing. He is also known to rearrange furniture in hotels as part of a ritual to ease his OCD.
For Information and Pictures
Then behavioral therapy had its turn. The treatment was to expose themselves to their fears and stop reinforcing distorted thoughts and maladaptive behavior. Results were not clear, they were typically short lived, and eventually the anxiety would come back.
A form of OCD that is the compulsive need of pulling out one's own hair. The most common locations for this to occur is on the scalp, eyebrows, and eyelashes. The hair pulling can either be done consciously or unconsciously, and while relaxed or stressed. Severe cases can lead to permanent hair loss.
A form of OCD that is the uncontrollable urge to repetitively pick at one's own skin to the extent of damage. Many individuals that suffer from this start out by picking a skin abnormality (mole or pre-existing scab) and manifesting from there. This is often done as an unconscious habit and can leave permanent skin disfigurement.
The most successful forms of therapy for OCD are CBT, ERP, and MBCBT.
CBT - Cognitive Behavior Therapy
MBCBT - Mindfulness-Based Cognitive Behavior Therapy
ERP - Exposure and Response Prevention
The therapists behavior while treating the patient can greatly affect the outcome of the therapy. Those that are respectful, understanding, and encouraging have much better results with their clients.
Prolonged exposure and response prevention has been proven more effective than shorter, separate exposures.
50% Of patients seeking treatment can benefit from CBT without medication intervention
20-30% Of patients are resistant to therapy.
20% Of patients drop out of treatment before making much progress.
6 months to 3 years after receiving treatment
65-75% Of patients are much improved
25% Of patients show no lasting success
Medication can prove very helpful by reducing the patients anxiety enough to begin therapy treatment.
The way to determine which medication and how much that will best work is by
. There is no way of knowing prior to trial-and-error to pick the most suitable treatment.
SSRI's are the most effective types of medication
. Not much is known as to why these are more effective than other types, though this leads researchers to believe that
serotonin function is a key element in OCD
. However, if the SSRI's do not work, a doctor may prescribe non-selective SRI's. Though this is not recommended due to more serious side effects occurring.
Side effects that may occur while taking SSRI's are sedation, sexual dysfunction, and weight gain. Rare reports of more serious side effects such as akathisia, bleeding, easy bruising, and dyskinesia also exist. If you wish, you may stop taking SSRI's, however it is highly recommended to be done gradually over 12 months time to ensure success against OCD. About 20% of patients who discontinue the use an effective drug will not respond if the drug is restarted. Data suggests that if a patient uses CBT while taking medication, it may delay or prevent relapse.
1. The patient must acknowledge and agree that they will need to tolerate the discomfort of not performing the compulsions or rituals.
2. Analyze the compulsion to environmental events. They will need to find what may increase or decrease the obsessions and compulsions.
3. Make note of what the patient avoids exposing themselves to avoid future anxiety.
4. Analyze the reasons behind the triggers, whether it be a thought, image, or impulse.
5. Create a hierarchy from least extreme to the most extreme anxieties.
6. Design homework for the patient to begin exposure, starting with the least anxiety-provoking situations.
Pursuit of Happiness
Commonly Recommended SSRI's (UK):
Do You Have OCD?
Have you been bothered by unpleasant thoughts or images that repeatedly enter your mind, such as...
1. Concerns with contamination (dirt, germs, chemicals, radiation) or acquiring a serious illness such as AIDS?
2. Overconcern with keeping objects (clothing, groceries, tools) in perfect order or arranged exactly?
3. Images of death or other horrible events?
4. Personally unacceptable religious or sexual thoughts?
Have you worried a lot about terrible things happening, such as...
5. Fire, burglary, or flooding the house?
6. Accidentally hitting a pedestrian with your car or letting it roll down the hill?
7. Spreading an illness (giving someone AIDS)?
8. Losing something valuable?
9. Harm coming to a loved one because you weren't careful enough?
10. Have you worried about acting on an unwanted and senseless urge or impulse, such as physically harming a loved one, pushing a stranger in front of a bus, steering your car into oncoming traffic; inappropriate sexual contact; or poisoning dinner guests?
Have you felt driven to perform certain acts over and over again, such as...
11. Excessive or ritualized washing, cleaning, or grooming?
12. Checking light switches, water faucets, the stove, door locks, or emergency brake?
13. Counting; arranging; evening-up behaviors (making sure socks are at same height)?
14. Collecting useless objects or inspecting the garbage before it is thrown out?
15. Repeating routine actions (in/out of chair, going through doorway, re-lighting cigarette) a certain number of times or until it feels just right?
16. Need to touch objects or people?
17. Unnecessary re-reading or re-writing; re-opening envelopes before they are mailed?
18. Examining your body for signs of illness?
19. Avoiding colors ("red" means blood), numbers ("l 3" is unlucky), or names (those that start with "D" signify death) that are associated with dreaded events or unpleasant thoughts?
20. Needing to "confess" or repeatedly asking for reassurance that you said or did something correctly?
This is not a test to diagnose you with OCD, however depending on your answers it may be a good indicator that you should consider seeing a mental health professional. For each of the following questions, answer with either yes or no.
Serotonin & hSERT Gene
Studies have shown that serotonin is a key element in OCD. DNA samples have been analyzed from patients with OCD and related illnesses and many have had a common characteristic. One mutation that was found (identified as I425V) on the human serotonin transporter gene (hSERT) increased its expression. This leads to more serotonin being reabsorbed due to more transporter proteins on the neuron's membrane, leaving less serotonin in the synapse for signaling. A second mutation was also identified leading to similar effects. With both of these mutations, a drastically reduced amount of serotonin is available in the synapse.