Mastery of Obsessive-Compulsive Disorder Client Workbook

Transcription

1 Mastery of Obsessive-Compulsive Disorder Client Workbook Edna B. Foa Michael J. Kozak

2 Copyright 1997 by Graywind Publications Incorporated. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permission is hereby granted to reproduce the Practice Records in this publication in complete pages, with the copyright notice, for instructional use and not for resale. The Psychological Corporation and the PSI logo are registered trademarks of The Psychological Corporation. TherapyWorks is a registered trademark of The Psychological Corporation. Printed in the United States of America A B C D E

3 Contents Chapter 1: Understanding Obsessive-Compulsive Disorder Introduction What Is OCD? Case Example: Concern With Dirt and Germs Case Example: Concern About Harming Others Types of OCD Washing and Cleaning Checking Repeating Ordering Hoarding Thinking Rituals Pure Obsessions Do You Have Obsessive-Compulsive Disorder? How Common Is OCD and What Is Its Course? What Other Disorders Are Related to OCD? What Causes OCD? How Are You Coping With Your OCD? Treatment Options Medication Exposure Therapy Should Behavior Therapy Be Combined With Drugs? Are You Taking Non-SRI Medications? What Benefits Will You Receive From Your Program? What Price Will You Pay? Chapter 2: Identifying Your Obsessions and Compulsions Obsessions Distinguishing Obsessions and Compulsions From Other Psychological Problems Should You Seek Professional Help? Chapter 3: Understanding Cognitive-Behavior Therapy for OCD What is Cognitive-Behavior Therapy for OCD? What Is Exposure? What Is Ritual Prevention? iii

4 Why Should You Do Exposure and Ritual Prevention? Emotional Involvement During Exposure Exercises Chapter 4: Designing Your Program Beginning Your Program Setting Up Your Imaginal Exposure Exercises Planning Your Imaginal Exposure Exercises Planning Your Actual Exposure Exercises Planning to Stop Your Rituals How to Monitor Your Rituals Sample Guidelines for Stopping Rituals Setting Aside Time for Your Program Scheduling Time for Your Program Informing Family and/or Friends Selecting a Supportive Helper Beginning Exposure and Ritual Prevention Chapter 5: Model Exposure Programs A Model Exposure Program for Washing Rituals An Intensive Exposure Exercise Schedule for Washing A Nonintensive Exposure Exercise Schedule for Washing A Model Exposure Program for Checking or Repeating Rituals An Intensive Exposure Exercise Schedule for Checking/Repeating A Nonintensive Exposure Exercise Schedule for Checking/Repeating Getting the Most Out of Exposure for Checking/Repeating A Model Exposure Program for Hoarding Rituals An Intensive Exposure Exercise Schedule for Hoarding A Nonintensive Exposure Exercise Schedule for Hoarding A Model Exposure Program for Ordering Rituals An Intensive Exposure Exercise Schedule for Ordering A Nonintensive Exposure Exercise Schedule for Ordering What to Do About Mental Rituals Chapter 6: Getting the Most From Your Program Developing the Courage to Confront Feared Situations Dangerous Beast or Paper Tiger Confront the Most Distressing Situation Early Planning for the Most Difficult Exposure What Is Courage? Risk Taking Introducing Intermediate Exercises Coping With Problems Unrelated to Exposure Ways to Address Slow Progress iv

5 Chapter 7: Extending What You ve Learned to Everyday Life Returning to a Practical Routine Do You Need Guidelines for Everyday Practices? Chapter 8: Maintaining Your Gains Principles of Self-Exposure Methods for Coping With Stress Informing Your Family and Friends Finding New Activities to Fill the Space Left by OCD v

6 Acknowledgments In clinical science, we extend our scope by standing on the shoulders of those who have preceded us. We owe much to the work of those who pioneered the application of behavior therapy to OCD, such as Meyer, Marks, and Rachman. Our conceptualization of emotional processing in exposure therapy has been greatly influenced by the bio-informational theory of Peter Lang, another trailblazer. Our many colleagues in research and practice over the years have also contributed to the development of our cognitive-behavioral approach. We are especially indebted to our clients with OCD, whose courage in confronting their obsessive fears has revealed so clearly the potency of exposure treatment, and to the National Institute of Mental Health, which has been supporting our research on OCD for almost 20 years. Our appreciation is extended to various persons at The Psychological Corporation, especially for the support we have received from John Dilworth, President; Joanne Lenke, PhD, Executive Vice President; and Aurelio Prifitera, PhD, Vice President and Director of the Psychological Measurement Group. The expertise contributed by Larry Weiss, PhD, Senior Project Director, has been invaluable in ensuring the high quality of the Therapist Guide. Special thanks are extended to those individuals whose meticulous and diligent efforts were essential in preparing the Guide for publication. Among this group are John Trent, Research Analyst; Kathy Overstreet, Senior Editor; Peggy Lang, Consulting Editor; and Javier Flores, Designer. vi

7 Comments Drs. Foa and Kozak have presented a masterful approach to the cognitivebehavioral treatment of obsessive-compulsive disorder. Building on their pioneering work in this area, they show clearly how to assess and treat OCD patients having a wide range of OCD symptoms. As importantly, they include the subtle steps that distinguish expert from merely adequate behavior therapists. Their discussion of how to proceed when treatment is not going well is worth the price of the book alone. Beginning and expert behavior therapists will learn a great deal from this program; I cannot recommend it highly enough. John S. March, MD, MPH Director, Program in Child and Adolescent Anxiety Disorders Duke University Medical Center Cognitive-behavioral therapy is increasingly being recognized as one of the most useful forms of treatment for obsessive-compulsive disorder. Drs. Foa and Kozak are the acknowledged experts in the field. They do research and write papers that guide other professionals. Now they have written a wonderful workbook for clients who want to overcome OCD. This is a must for anyone affected by OCD, as well as their family members and friends. Michael R. Liebowitz, MD Professor of Clinical Psychiatry College of Physicians and Surgeons Columbia University Director, Anxiety Disorders Clinic NYS Psychiatric Institute vii

8 About the Authors EDNA B. FOA, PhD, professor at the Allegheny University of the Health Sciences (formerly Medical College of Pennsylvania and Hahnemann University), Director of the Center for the Treatment and Study of Anxiety, is an internationally renowned authority on the psychopathology and treatment of anxiety. Her research aiming at delineating etiological frameworks and targeted treatment has been highly influential, and she is currently one of the leading experts in the areas of obsessive-compulsive disorder and phobias. The program she has developed for rape victims is considered to be the most effective therapy for post-trauma sequelae. More recently she has been investigating the psychopathology and treatment of social phobia. She has published several books and over 100 articles and book chapters, has lectured extensively around the world, and was the chair of the OCD work group and co-chair of the PTSD work group of the DSM IV. Dr. Foa is the recipient of numerous awards and honors, including the Fulbright Distinguished Professor Award, the Distinguished Scientist Award from the Scientific section of the American Psychological Association, the First Annual Outstanding Research Contribution Award from the Association for the Advancement of Behavior Therapy, and the American Psychological Association Award for Distinguished Scientific Contributions to Clinical Psychology. MICHAEL J. KOZAK received his PhD in clinical psychology at the University of Wisconsin-Madison in He is currently associate professor of Psychiatry at Allegheny University of the Health Sciences and Clinical Director at the Center for the Treatment and Study of Anxiety. He has studied the process and outcome of psychosocial treatment and pharmacotherapy for anxiety disorders, including blood/injury phobia, obsessive-compulsive disorder, post-traumatic stress disorder, and social anxiety. His expertise in exposure-based treatment for obsessive-compulsive disorder has been developed over 14 years of daily clinical practice with OCD sufferers. His scholarly publications include reports of individual case studies and controlled outcome trials of cognitive-behavior therapy and pharmacotherapy for anxiety disorders, laboratory psychophysiological studies of emotion, theoretical and review articles, and philosophical analyses. He was a member of the workgroup on Obsessive-Compulsive Disorder for the DSM IV. viii

9 Chapter 1 Understanding Obsessive-Compulsive Disorder Introduction This workbook will help you recognize symptoms of obsessive-compulsive disorder and develop and put into practice a program of exercises to reduce these symptoms. What Is OCD? Obsessive-compulsive disorder (OCD) appears as a set of habits which are called obsessive-compulsive symptoms. These are habits of thinking, feeling, and acting which are extremely unpleasant, wasteful, and difficult to get rid of on your own. Usually, these habits involve thoughts, images, or impulses which habitually come to your mind even though you don t want them. Along with these thoughts, you have unwanted feelings of extreme discomfort or anxiety and strong urges to do something to reduce the distress. For example, a person might have the idea that he is going to get sick from certain germs or cause harm to others by not being very careful. These ideas cause the person extreme distress. Because of this, people get into the habit of thinking various special thoughts or doing certain actions that protect themselves or others or simply reduce the distress. These habits are called rituals. Unfortunately, performing these rituals doesn t work all that well: The distress diminishes for only a short time, then comes back again. Often, you find yourself doing more and more ritualizing to try to get rid of the anxiety. But the rituals do not reduce the distress permanently, and before long you are putting so much time or energy into rituals (which do not work that well anyway) that other areas of your life become seriously disrupted. Do you feel dominated by your own intrusive worries? Do you feel compelled to repeat thoughts or actions again and again? Most people experience 1

10 bothersome worries from time to time, but they are not consumed by these concerns. For example, parents may often worry about the safety of their child who is late getting home from school, but for the most part, they are not incapacitated by such a concern, and it goes away when the child eventually arrives home safely. A person with OCD experiences worries that are neither so realistic nor do they go away so readily. For example, a mother may have an obsession that she will deliberately hurt her child. Such an obsession sometimes feels like an urge to do harm. The obsession dominates her experience persistently, even though she loves her child and has never deliberately harmed the child. Another very common feature of OCD is repeating actions such as washing, checking, and ordering or arranging of objects well beyond what is practically useful. Many people check door locks a couple of times upon entering and leaving to secure themselves against intruders, but such extra precaution occupies little time and effort and is of some practical utility. In contrast, a person with OCD may check the lock a great many times and continue to worry throughout the day about whether he has locked the door, despite all the checking. Some people with obsessive-compulsive disorder repeat things mentally. For example, a person may repeatedly think of self-designated lucky numbers, such as 3, 6, 12, and 18, to prevent bad things from happening. Do you have obsessions or compulsions? Do you get stuck with thoughts, feelings, or actions that are distressing and unwanted? Do you repeat behavior or thoughts again and again to try to rid yourself of distress? If so, you probably have obsessive-compulsive disorder. Case Example: Concern With Dirt and Germs There are many types of obsessions and compulsions. A common problem is concern with dirt or germs, accompanied by excessive washing and cleaning. Betsy is a 33-year-old married kindergarten teacher who is consumed by fears of dirt and germs. She worries especially that she will contract a venereal disease if she uses public toilets or even if she contacts another person who has used public toilets. Because most people, including her students, routinely use public toilets, she perceives everyone in her environment as contaminated. The obsessions make her daily life extremely difficult, because it is nearly impossible to avoid contact with her feared contaminants. To protect herself, Betsy keeps a bottle of alcohol with her at all times and repeatedly cleans her hands with it as unobtrusively as possible while she is at work. When she comes home, she immediately removes all her clothes and takes a 45-minute shower, repeatedly soaping herself thoroughly. To protect her home from toilet contamination, she also requires that her husband and two children observe strict rules about cleanliness. Although her young children are generally compliant with her rules, her husband has tired of his wife s unreasonable demands, and the marriage has become increasingly tense. 2

11 Betsy was especially concerned with cleanliness even as a child and was more meticulous than average through her teenage years. However, her concerns did not start to interfere seriously with her life until after she got married, when she began to devote quite a bit of time to cleaning the toilet at home. Around the time she became pregnant with her first child, she read that venereal disease can be passed by mother to child and became obsessed with this possibility. To prevent her newborn from catching the disease, Betsy began to avoid using public toilets and increased the effort devoted to cleaning her own bathroom. These measures did not give her an adequate sense of protection, however, because she realized that others were not as careful as she around toilets, and they could contaminate her by direct or indirect contact. At the time she came to the clinic, Betsy s lifestyle was severely restricted because of her obsessional fears. She had stopped inviting friends to her home and going to restaurants, theaters, and other public places. Most recently, she had been thinking about quitting her job because of her fear of contamination, but because she couldn t afford to give up her salary, she decided to seek treatment. Case Example: Concern About Harming Others Marvin is a 30-year-old accountant who is married and has a 2-year-old son. He works in the city and drives 45 minutes each way from his home in the suburbs. Marvin worries constantly about making mistakes that could cause harm to others. He is concerned not only for the welfare of other people but also for animals, even insects. These worries lead him to check endlessly almost everything he does. While driving, he thinks that he might have hit someone, so he checks his mirror for accidents and often drives back over his route to assure himself that no one is in need of assistance. He also worries about new accidents that he might have caused while retracing his route. After an hour or two of checking the roads, Marvin reluctantly gives up and drives home, but he continues to worry about being a hit-and-run driver. Marvin carefully checks toilets for insects before flushing, lest he accidentally kill them; before going to bed, he checks every door, window, electrical appliance, and faucet in the house to prevent disasters. At work, Marvin checks his calculations so often that he is always well behind the productivity of his co-workers. Marvin s obsessivecompulsive activities and worries occupy many hours per day, cause him enormous emotional distress, and impair his day-to-day functioning. Marvin recalls that his worries about mistakes began when he was about 15 or 16 years old and were focused especially on his schoolwork. He was very anxious about learning to drive, and he began to worry about hurting people unintentionally. This concern about causing harm eventually came to include animals and his personal belongings. Because he realized that his worries and checking were taking up too much of his time, Marvin consulted a psychiatrist, who said he had OCD and prescribed clomipramine (brand name: Anafranil ). The medication gave him some relief, but he was still spending too much time on his obsessions and compulsions. 3

12 If your experiences are like those of Marvin or Betsy, or if you have other types of obsessions or compulsions, this manual might be helpful to you. Types of OCD There are many specific types of obsessive-compulsive habits. Washing and Cleaning. Individuals who engage in washing and cleaning rituals are preoccupied with obsessions about being contaminated or contaminating others with certain materials or situations. Examples of contaminating materials are chemicals (such as insecticides), germs (such as HIV viruses), bodily fluids (such as urine and blood), and radiation (such as microwaves). Contaminating situations include cities (one s hometown), people (parents), and public places (hospitals). Sometimes washing and cleaning are intended to prevent disasters (e.g., disease, death), but this is not always the case. Some individuals wash and clean to reduce discomfort connected with a sense of contamination, but they do not believe that they will be harmed by the contamination. The time occupied by washing and cleaning varies from person to person and from one day to another. Some people engage in compulsive washing infrequently but continue the behavior for very long periods. Other compulsive washing may be very brief but occurs a great many times per day. Usually, people concerned with contamination try hard to avoid contact with their contaminants, but they usually fail sooner or later and resort to washing or cleaning. Checking. Individuals who carry out checking rituals try to keep bad things from happening by excessive and repeated checking of potentially harmful situations. Common concerns of people with this manifestation of OCD are that they will be responsible for fire, flood, hit-and-run auto accidents, mistakes of all kinds, burglary, and illness. For example, the person who fears that his house will catch fire checks whether electrical appliances are unplugged before he leaves home or goes to bed. The person who fears having undetected cancer performs frequent inspections of moles or breasts. The student who fears schoolwork mistakes repeatedly checks assignments to the point that they are not turned in on time. Usually the person feels an urge to check when there is some doubt about the safety of the situation. However, checking does not relieve the doubt, and more checking follows. The chain of doubting and checking can last for hours and typically ends, not because the doubt has been eliminated, but because of exhaustion or outside demands. Sometimes a person who engages in checking recruits other people to help with the checking. Repeating. Some individuals purposely repeat actions to cancel or undo a fearful thought that has come to mind. For example, 4

13 a person walking through a doorway who gets an image of a loved one having an accident will go back and forth through the doorway until the image disappears. The purpose of this repetition is sometimes not only to cancel the image but also to prevent the accident from happening. Other individuals repeat actions until the action feels right to them. In these cases, there is no thought of preventing harm, and the repetition is done to reduce discomfort about doing something wrong. Ordering. For individuals who engage in ordering behaviors, it is important to have things around them arranged in a certain way. Sometimes this means arranging items symmetrically or in some special pattern or location. As with repeating, the purpose of ordering can be to keep a disaster from occurring. For example, a person who feels compelled to arrange items might always set down glasses, pens, and other objects several inches from the edge of a table to prevent them from falling off and being damaged or lost. Not all ordering compulsions are done to prevent harm, however. Instead, a person arranges items in a way that just feels right. For example, if furniture is not lined up at the correct angles and cushions are not evenly spaced, the person becomes extremely uncomfortable. The individual with this type of OCD does not permit family members to upset the special arrangement. Hoarding. Individuals with hoarding behaviors collect things that seem useless to other people. Compulsive hoarding is different from collecting stamps, coins, or antiques that have real value or are part of an enjoyable hobby. Usually an individual with this form of OCD feels driven to collect things because of some remote chance that they might be of some use in the future. Most people save some things they really don t need, but they would discard the items if they began to get in the way. Individuals who hoard, however, often accumulate large quantities of junk that they view as important and find it very distressing to throw away. Thinking Rituals. Individuals who engage in thinking rituals use special thoughts, called thinking compulsions, to undo or cancel their distressing obsessive thoughts, impulses, or images. Compulsive thoughts are much like compulsive actions, but people carry them out in their minds rather than outwardly. Because of this, thinking rituals are sometimes overlooked or mistakenly believed to be obsessions. Common thinking rituals are silent counting and repeatedly thinking certain words, phrases, numbers, or special prayers. For example, a person with obsessive fears of street drugs will repeatedly replace any thought of the drug LSD with a thought of the letters RCA. Another kind of mental ritual is reviewing past events or lists of things to do. For example, after leaving the bathroom, a person who washes compulsively might review whether or not she touched any contaminated surfaces with her clothes. Some people 5

14 repeatedly go over in their minds lists of things to be done that day to make sure that they don t forget something important. Sometimes, obsessions take the form of an ongoing internal dialogue, with one side voicing distressing ideas and another side expressing reassuring thoughts. For example, a combat veteran thought constantly about whether he could have saved two friends who were killed beside him in battle. He repeatedly considered ways that he could have saved them and also repeatedly concluded that there was nothing else he could have done. The reassuring voice appears to be a mental compulsion. Pure Obsessions. A few individuals spend long periods of time dwelling on intrusive distressing thoughts but do not react to these with ritualistic thoughts or actions. For example, a person might think about a song or melody to the point that it becomes annoying. Alternatively, a person might dwell on particular kinds of objects (such as shirt buttons) or certain words and have found the intrusions very distressing and interfering with routine concentration. It is important to remember that individuals with OCD typically have more than one type of obsession and compulsion. For example, many individuals who engage in washing rituals also have checking or ordering rituals. Also, the same person often has both thinking rituals and behavioral rituals. Do You Have Obsessive-Compulsive Disorder? The diagnostic system for mental disorders that is used in the United States (Diagnostic and Statistical Manual of the American Psychiatric Association 4th Edition, or DSM IV ) identifies OCD as an anxiety disorder and defines it according to the criteria listed here. DSM-IV Diagnostic Criteria for Obsessive-Compulsive Disorder A. Either obsessions or compulsions: Obsessions as defined by 1, 2, 3, and Recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress. 2. The thoughts, impulses, or images are not simply excessive worries about real-life problems. 3. The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action. 6

15 4. The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion). Compulsions as defined by 1 and 2: 1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly. 2. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive. B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children. C. The obsessions or compulsions cause marked distress, are timeconsuming (take more than 1 hour a day), or significantly interfere with the person s normal routine, occupational (or academic) functioning, or usual social activities or relationships. D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an Eating Disorder; hair pulling in the presence of Trichotillomania; concern with appearance in the presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence of a Substance Use Disorder; preoccupation with having a serious illness in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in the presence of Major Depressive Disorder). E. The disturbance is not due to the direct physiological effects of a substance (e.g., drug of abuse, a medication) or a general medical condition. Specify if: With Poor Insight: if, for most of the time during the current episode, the person does not recognize that the obsessions and compulsions are excessive or unreasonable. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994 American Psychiatric Association. 7

16 The central features of OCD are obsessions or compulsions that are seriously distressing or are interfering with day-to-day activities. In fact, research has shown that obsessions rarely occur without compulsions, and vice versa. Chances are that if you have obsessions, you also have related compulsive thoughts or actions or both. Often, obsessions provoke anxious or fearful feelings, but they can also prompt other distressing feelings such as disgust, shame, or guilt. A person concerned with getting sick because of contamination is likely to feel anxious or afraid in the presence of contaminants. Another person might feel mainly disgusted, rather than afraid, when he or she encounters a contaminant. A mother with an obsessive fear of stabbing her child would feel afraid of actually harming the child and also guilty about having such an unacceptable idea. A religious person who has an unwanted image of sacrilegious sexual activity might be overwhelmed with shame and guilt and could also be afraid of supernatural punishment. Whatever the emotion connected with the intrusive thought, image, or impulse, the emotion must be negative or unpleasant to be considered an obsession. Fear, guilt, disgust, and shame are all unpleasant emotions. Intrusive ideas connected with pleasant feelings are not considered part of OCD. For example, a person could have excessive thoughts or images about being rich, taking exciting vacations, or marrying a movie star. Although spending too much time on such pleasant fantasies could be a problem, this would be categorized as excessive daydreaming and is not a symptom of OCD. Obsessions have much in common with excessive worries. Both are thoughts that are accompanied by unpleasant feelings. However, obsessions are different in some important ways. Unlike worries that are experienced as appropriate but excessive concerns about real-life problems, obsessions are generally experienced as inappropriate. Often this difference is clear, such as the distinction between excessive worry about financial problems and an obsession about the possibility of having hit someone while driving. Sometimes the difference is not so clear, and only accompanying mental or behavioral rituals or compulsions distinguish the obsession of OCD from excessive worry. Compulsions, which can be behavioral or mental, are also called rituals. Mental compulsions are attempts to neutralize an obsession and are present only in people with OCD. Mental and behavioral compulsions can be further divided into two types: those that are done to reduce obsessional distress (such as washing to reduce fear of illness or to decrease distress about being contaminated) and those that are unrelated to obsessions (such as repeating an action until it feels right ). Research has shown that the majority of compulsions are related to obsessions. Sometimes it is difficult to tell the difference between compulsions that are not related to obsessions and complex motor tics, repetitive movements that are experienced as under limited voluntary control (such as tapping, rubbing, and eye blinking). Despite the difficulty, it can 8

17 be important to recognize whether a repetitive behavior is a tic or a compulsion, because the treatments for the two are different. A rule of thumb is that a tic is perceived as largely involuntary: The urge can be suppressed for a while, during which a feeling of tension builds, after which the tic must be expressed. In contrast, a compulsion is usually experienced as more voluntary, and the distress and urge to ritualize will fade after a time if the person refuses to perform the compulsion. Many people with obsessions suspect or believe that some disastrous consequence will occur if they do not perform their compulsions. Many recognize, at least some of the time, that the belief is mistaken. For example, when sitting in the therapist s office, a person who gets obsessions about causing hit-and-run automobile accidents can see that the concern is unrealistic. However, when the same person drives over a rut in the road on a dark evening, clear thinking is more difficult, and the person may jump to the false conclusion that the bump was a pedestrian. People who engage in washing because they fear catching venereal disease from public toilets may recognize, when they aren t near any toilets, that even if they do not wash their hands, they will not get sick. However, it can be much harder for them to recognize this when they are actually sitting on a toilet seat in a public bathroom. A small proportion of people with OCD very strongly believe that a disaster will occur unless they do their compulsions, such that the belief doesn t change much when the person is away from the situation that triggers the obsession. For example, one woman concerned with contracting leukemia believed that unless she successfully avoided or washed after contacting blood, radiation, and certain environmental toxins, she would definitely catch the disease. Now that you are familiar with the description of obsessions and compulsions in the DSM IV, you can consider whether you have OCD. Do you have obsessions, compulsions, or both? If so, are they very distressing? Do they interfere with your daily functioning? If so, do you fear certain disastrous consequences if you do not avoid or ritualize? Do you sometimes recognize that these concerns are unrealistic? How Common Is OCD and What Is Its Course? OCD is quite common. About six million individuals in the USA are estimated to have OCD. Men and women develop OCD at similar rates. It has been observed in all age groups, ranging from school-aged children to older adults. It typically begins in adolescence or early adulthood, usually starting earlier in males than in females, but it can also begin later in life. As a rule, onset is gradual, but in some cases OCD starts suddenly. Symptoms fluctuate in severity from time to time, which might be related to the occurrence of stressful life events. Because the symptoms usually worsen gradually, people often do not remember clearly 9

18 when the OCD began but can sometimes recall when they first noticed that the symptoms were disrupting their lives. Do you remember when your symptoms started, or when you found that they were actually getting in the way of things in your life? What Other Disorders Are Related to OCD? Certain emotional disorders are similar to OCD or often accompany it. Many people with OCD also experience depressed mood at the same time. Much of the time, the depression seems to have been caused by the OCD in that it is emotionally exhausting and demoralizing to suffer with OCD. In these cases, if the OCD decreases (either spontaneously or through treatment), the depression will also lift. Sometimes the depression is not caused by the OCD, as in cases where the depression began earlier than the onset of the OCD symptoms. If a person has obsessions only about being sick and consults physicians excessively but does not engage in other rituals such as checking or washing, the individual is said to have hypochondriasis. An individual with OCD may have both hypochondriacal obsessions and obsessions about things unrelated to health. A person who is generally anxious and has excessive worries about real life circumstances but not obsessions or rituals is said to have generalized anxiety disorder. Tics are commonly experienced by people with OCD. It has been estimated that about 20% 30% of clients with OCD also have tics. A tic is a sudden, rapid, recurrent, stereotyped motor movement or vocalization that is experienced as irresistible but can be suppressed for a while. If a person has motor tics in addition to one or more vocal tics, this is called Tourette s disorder. Thirty-five percent to 50% of people with Tourette s disorder also have OCD, but only 5% 7% of people with OCD appear to have Tourette s disorder also. Some scientists believe that trichotillomania ( compulsive hair pulling) is a form of OCD, but this may not be so. Even though most people with OCD have multiple obsessions and compulsions, those with OCD do not typically exhibit hair pulling. Therefore, hair pulling does not seem to go together with the compulsions of OCD. What Causes OCD? The reasons why some people develop OCD and others do not are unknown. Researchers have considered different kinds of explanations for the disorder. Some experts have tried to understand OCD as learned habits. Accordingly, a harmless object or situation becomes fearful because of a connection to a harmful one. Once this happens, escape (rituals) or avoidance patterns emerge naturally and 10

19 are maintained because they are partially successful in reducing fear. Although this idea does not explain why some people develop OCD and others do not, it fits well with how obsessions give rise to anxiety/discomfort and compulsions reduce it, and it helps to explain how the temporary reduction of obsessional distress could maintain habits of ritualizing. Other experts have suggested that some specific thinking mistakes about harm characterize OCD. Examples of such thinking mistakes include the following: (a) thinking of an action is just like doing it; (b) not trying to prevent harm to self or others is the same as actually causing the harm; (c) a person is responsible for harm regardless of circumstances; (d) not ritualizing to prevent harm is just like causing harm; and (e) a person should control his/her own thoughts. Although this theory may describe the kind of thinking mistakes made by many individuals with OCD, it does not explain why some people develop OCD and others do not. Many experts believe that people with OCD have abnormal brain chemistry involving serotonin, a chemical that is essential to brain functioning. Unusual serotonin chemistry has been found in people with OCD, and drugs that relieve OCD also change serotonin chemistry. However, it is not known whether serotonin chemistry is the key factor in the development of OCD. Some scientists have identified differences in the size and function of various parts of the brains of people with OCD. Whether these differences are important causes of OCD symptoms or are just coincidental is also unknown. There is evidence that OCD is more prevalent in some families than in others. It is difficult to know how much of this is a result of what children learn from their family while growing up, and how much is hereditary. Studies of twins suggest that at least some vulnerability to OCD is inherited. It is tempting to be overly concerned with the lack of information about how OCD develops, but this information is not required for treating the disorder. Fortunately, good treatments are available even though a thorough explanation of why some people get OCD and others do not get it is not available. How Are You Coping With Your OCD? 1. Mental resistance. Do you try to resist your obsessions? Because obsessions are unpleasant or distressing, it is not surprising that you would want to try to get the ideas out of your mind. When you have a thought that is not disturbing at all, or only mildly disturbing, and you want to think about something else, just turning your attention to what you want to think about is usually successful. When you are trying to get rid of an obsession, however, you don t just turn your attention to something else, but rather, you concentrate on not thinking about the obsession and on how bad it is to be obsessing. This way of fighting obsessions seems to backfire in that you find that the obsession becomes more persistent and annoying. 11

20 2. Avoidance. Are you avoiding situations that trigger obsessions? Another unsuccessful way of trying to cope with obsessions is to try to stay away from all situations that trigger your obsessions. There are three problems with trying to cope by avoidance. The first problem is that avoidance is only temporarily helpful because eventually you will encounter a feared situation that you cannot avoid, and the obsession will arise. Second, the more you avoid, the more you preserve your fear because you cannot find out that the situation is really not dangerous. Third, because there are so many situations that can trigger obsessions, avoiding them severely restricts your lifestyle. For example, a person who fears auto accidents might start by avoiding crowded areas at night, then all night driving, then daytime driving in crowded areas, and finally, all driving while alone. Many people with hit-and-run obsessions stop driving altogether. 3. Rituals. Do you use rituals to cope with your obsessions? Because avoidance doesn t work well in the long run for fighting obsessions, a person with OCD usually winds up facing distressing obsessions. Therefore, people resort to compulsions (rituals) to try to cope with the obsessions. There are two problems with rituals. First, like avoidance, rituals can be successful in the short run but backfire in the long run because they seem to make obsessions worse. The first reason for this is that the rituals prevent an individual from learning that no harm will come from the feared situation. For example, a person who cleans doorknobs for fear of getting sick from the germs on the doorknobs cannot discover that unwashed doorknobs don t cause sickness. Second, rituals generally expand and take increasing time and effort, to the point that they severely interfere with day-to-day life. Thus, instead of providing temporary relief, they can become distressing in themselves. For example, a person concerned with safety at home starts checking doors and window locks, then checks gas and electrical appliances, then all the faucets. Soon, one round of checking is insufficient, and several rounds are made. This can go on to the point that the individual does little at home beyond checking for safety. Do Your Symptoms Fit This Program? If you answer yes to the following questions, your symptoms probably fit the treatment program described in this book. Do you have obsessions? Do you have compulsions? Are they distressing enough to be important to you? Do they interfere significantly with your daily life? 12

21 Treatment Options There are two types of treatment that have been found helpful for OCD: cognitive-behavior therapy and medication. Both have been studied extensively with hundreds of clients in centers in different parts of the world, and both are established treatments for OCD. There are advantages and disadvantages to both types of treatments. Each treatment will be described here, along with its advantages and disadvantages, to help you make a choice. Medication Treatment with certain medications has been found to be quite helpful. Particular drugs called serotonin re-uptake inhibitors (SRIs), a class of antidepressant drugs, have shown effectiveness with OCD. It is not clear why they work, but it is clear that they do indeed often help to reduce OCD symptoms. When drug therapy is successful, obsessional distress diminishes, urges to ritualize decrease, and along with these, rituals and avoidance are also reduced. The frequency and persistence of obsessive intrusions also decrease as well, although most clients say that they still have some obsessive intrusions even after successful drug treatment. Several drugs that fall into the class of SRIs have been found helpful for OCD, and it is practical first to use only the ones that are approved by the FDA for treating OCD. Depending on the particular drug, the evidence is more or less strong for its helpfulness. The most well-established drug is clomipramine, whose brand name is Anafranil. Clomipramine has been studied with hundreds of clients, and about half of the individuals who take it do well with it, showing an average reduction in OCD symptoms of about 40%. Thus, you can see that clomipramine is a good drug: Half of those who take it improve enough that they say it makes an important difference in their lives. There are several other drugs recently approved for treating OCD: fluoxetine (brand name: Prozac ), fluvoxamine (Luvox ), paroxetine (Paxil ), and sertraline (Zoloft ). These drugs have also been studied very extensively and have been established as being helpful with OCD. It is hard to say with confidence which of the SRIs is best for OCD. Although a comparison of the available good studies of the different medications seems to show that clomipramine produces somewhat larger improvements than the other drugs, some studies done more recently have not found such differences. The drugs have the clear benefit that they are helpful for many people. They also have an advantage in that taking them does not require much effort. After a few psychiatrist visits, and once you have worked up to an effective dosage of the drug, you meet with your psychiatrist only occasionally for monitoring. Of course, these are averages, and in choosing a treatment, you are betting on averages. You could do much better than the average, or you might not improve at all with the drug. It is impossible to predict who will do well with a particular treatment and who will not. 13

22 What are the disadvantages of the drug therapy? First, even though many people do well with drug therapy, about half of those who take medication do not improve; and of those who do improve, most still experience noticeable OCD symptoms. In addition, drugs do not usually do only what you want them to do, which is to decrease OCD symptoms. They usually have some unwanted side effects also. These are readily tolerated by many people but can sometimes be unpleasant or intolerable. For example, side effects from clomipramine can include dry mouth, sleep changes, weight gain, and sexual dysfunction. Although you would probably experience some side effects, it is difficult to predict how tolerable they will be for you. One other disadvantage of the medications is that, although you will probably continue to do well as long as you keep taking the drug, many people who withdraw from medication have a return of OCD symptoms. Many people are not concerned about taking a medication for a long period, but some people prefer not to do this. (Women who wish to get pregnant are generally advised to withdraw from their medication because so little is known about how it may affect the pregnancy.) Exposure Therapy The other established treatment for OCD is a form of cognitive-behavior therapy called exposure therapy. This has also been studied very extensively with hundreds of clients in different countries and has been found very helpful. The theory behind exposure therapy is different from that behind drug therapy. With drug therapy, you ingest a chemical, it gets into your brain, changes your neurochemistry, and your experience improves. Cognitive-behavior therapy is based on the idea that obsessive intrusions, distress, and rituals are habitual ways of reacting, and because they are habits, they can be weakened. Exposure therapy is a learning-based therapy that consists of a series of exercises designed to weaken certain thinking habits, feeling habits, and overt habits. The exercises are called prolonged exposure and response prevention, which actually means abstaining from rituals. Exposure means that you purposely confront situations that trigger obsessions, distress, and urges to ritualize, and that you stay in the situation for a long period of time until the symptoms decrease spontaneously. Abstaining from rituals means that you give up using rituals as a way to reduce obsessions and distress. Excellent results have been obtained with an intensive cognitive-behavior therapy program that consists of daily 90-minute sessions for a month, including guided exposure practice with the therapist at your home. This is important because OCD habits are often especially strong in the home. In addition, this program involves daily homework practice with the exposure exercises and concentration on abstaining from rituals. There are some clear advantages to exposure therapy. It has been found to be more helpful than drugs for individuals who complete it. About 75% of clients who complete cognitive-behavior therapy do well both immediately after treatment and in the long run, showing lasting improvement of about 14