Obsessive Compulsive Disorder and Its Treatment

by Nelson Zwaanstra, Ph.D.

Have you ever been half-way to work and couldn't remember turning off the iron? You know you did-you always do-but you're not 100 percent positive you turned it off this morning. You know you'll worry all day if you don't go back and check. So you head home. Of course, the iron was off.

If you've had this kind of feeling, you get a slight idea of what people with Obsessive Compulsive Disorder (OCD) experience.

OCD is an anxiety disorder. Although it occurs less frequently in the general population than the other anxiety disorders, it can be far more debilitating and can last for decades. Between 1.6 percent and 3 percent of adults suffer from an OCD. Recent research shows a slight increase in the prevalence of the disorder. Rather than meaning more people experience it, the increase is probably because with the development of new treatments, people with OCD are now more willing to admit their symptoms.

Obsessions are ruminations or thoughts that insistently intrude into the mind against a person's will and continue to reoccur despite all efforts to stop them. The thoughts often are worries about becoming contaminated, harming others or self, or going against some social or religious taboo such as making inappropriate sexual advances in public or swearing against God.

Often associated with these obsessive thoughts are compulsive rituals. Compulsive rituals are repetitive actions that people feel compelled to carry out against their better judgment. They usually realize these actions are irrational, but know if they don't complete the rituals, they'll feel anxiety and discomfort.

The symptoms of OCD usually begin in adolescence and young adulthood and affect males and females equally. Males develop the disorder earlier, between age 5 to 15, while females develop the disorder later, between age 26 to 35. The symptoms can set in gradually over years or suddenly in a few hours. Some people have episodes of varying lengths and then the symptoms will completely clear up.

Some evidence shows that responding to life experiences with obsessive compulsive behavior is inherited. The disorder can run in families and across generations. At other times, people who have OCD have no other family members who suffer from the disorder.

Research also shows that the disorder involves abnormal metabolism of serotonin, a neurotransmitter. The areas of the brain involved include the front part of the brain and the caudate structures, which serotonin neurons richly supply. It is not, however, clear whether these alterations in serotonin cause OCD or whether OCD would cause these changes in the brain.

In OCD, there are five forms of ritualizing: cleaning, checking, hoarding, orderliness, and repeating. A person with OCD can have several of these behaviors, but cleaning and checking are the most common. Cleanliness and orderliness are virtues, but when they totally control a person's life, they are part of an obsessive compulsive disorder. Washers are more common with women and checkers are equally prevalent among women and men.

Ritualistic washers or cleaners avoid "contaminates" if possible. If they think they've become contaminated, they will engage in prolonged and ritualistic washing or cleaning. These rituals may last for a few minutes or continue for an hour or more. They may wash their hands 100 or more times a day. They may avoid touching door knobs or being touched by other people. They may wear gloves or long-sleeved clothing even on a hot summer day. If they are touched or touch something "contaminated," they will immediately wash their clothing and shower for several hours.

Ritualistic checkers' fear focuses more on future harm or danger. They worry that death, some disease, or disaster may happen to them or someone close to them. They check to avoid these dangers. They may retrace their route in a car many times, looking to see if they hit anyone or they will repeatedly call the police to find out if an accident has been reported. If they fear fires, they may repeatedly check their stove or other appliances.

Other checkers may be concerned about orderliness or hoarding. Checkers will insist on doing tasks in a particular order and completing them without interruptions otherwise they must begin the ritual again. Checkers will arrange everything in its proper place. They may have all their clothes arranged by color and have every hanger the same distance from the next. Hoarders fear throwing items away. They may have to check an empty cereal box 20 times before they can throw it away. They may pick up articles off department store floors or in parking lots. Hoarders also may have collections of old newspapers or strings.

Repeating ritualizers will do tasks by numbers. They do a ritual a certain number of times or in multiples of certain numbers. They may, for example, screw on the toothpaste cap and then count to 50. They may brush their hair 30 times. Some are greatly distressed by the time and energy they consume in doing their rituals. One man did not want to eat or drink because he did not want to use the bathroom and endure his long and extensive cleansing rituals.

Sometimes rituals are related to their morbid thoughts such as unacceptable ideas about sex or violence. They may constantly check for their spouse's faithfulness or constantly seek reassurance of their spouse's faithfulness. If they have thoughts of harming themselves or others, they may hide knives or avoid being around people.

Some people with OCD show no outward rituals. They only have obsessions. I once asked a woman suffering from OCD what she obsessed about. She said she obsessed about everything from the moment she got up in the morning until she went to bed.

While not complicated by rituals, these thoughts can evoke intense anxiety. The obsessions are often unacceptable thoughts such as blasphemy against God or the desire to harm others. Others use thoughts ritualistically to reduce anxiety. They may repeat prayers to themselves or count objects in a room. They may make mental checklists.

Most people sometime in their lives will engage in such rituals or have unacceptable thoughts. These are normal. For people suffering from OCD, however, these thoughts and rituals are so extensive and time-consuming that they cannot carry on their daily lives. They also suffer severe subjective distress and disgrace because of these thoughts and endless rituals.

Some will recognize their thoughts as senseless. Others will hold the belief with such intensity that it almost becomes the truth for them. They resist treatment and lack the motivation to give up their beliefs.

The obsessions tend to increase with anxiety and decrease when a person is relaxed. When people who suffer from OCD have other stresses in their lives, they experience an increase in their obsessive thoughts and rituals. This can occur with any emotional upheaval-be it pleasant or unpleasant. Therefore, marriage, the birth of a child, or the death of a family member can all result in increased obsessive and compulsive behaviors.

People who suffer from OCD can have tremendous impact on their families. They can lose their jobs because of their OCD. Sometimes they ask family members to cooperate with their rituals or will constantly ask for reassurance such as asking a family member if they harmed anyone on their drive home. They can become angry and upset if members of the family do not cooperate or support their need to do rituals. They may ask their children to bathe often or not allow them to bring friends home. They may demand that the children stay only in one or two rooms in the house. In more tragic situations, they may not touch their children for fear of being contaminated.

As devastating as OCD can be to one's life and to one's family, it is treatable through medications and behavior therapy. These two methods can reduce the symptoms of OCD to varying degrees; a combination of both is most effective. Traditional psychotherapy has generally not been effective in reducing the symptoms of OCD.

Professionals prescribe antidepressants for treating OCD. (For more complete information, see the article by Philip Fox, M.D.). A person suffering from OCD should give serious consideration to trying these medications. Some people cannot tolerate the medications, and others find little benefit from them. Still others can have a dramatic reduction in their obsessive compulsive behaviors and become much more successful in applying the techniques of behavior therapy.

Behavior therapy for the treatment OCD began in the late sixties and its techniques have continued to be refined. Edna Foa and Reid Wilson give an excellent presentation of behavior therapy techniques in their self-help book S.T.O.P. Obsessing. They've based their book on many years of research on what have proven to be the most effective techniques in treating OCD.

There are two aspects to behavior therapy: (1) Exposure to what one is afraid of and (2) Prevention of rituals people use to reduce anxiety. By applying these two methods, people can reduce the anxiety that seems to drive the obsessive compulsive behaviors.

Exposure is essential to treating all anxiety disorders. Anxiety never goes away on its own nor do people reduce it by avoidance. People must face fear and expose themselves to the fear frequently and for prolonged periods. Gradually, the fear weakens and goes away. The technical term for this is "habituation."

In treating OCD, people also must prevent the rituals because they use the rituals to escape from the fear. In other words, they avoid the fear by using the rituals. This, too, prevents the habituation of anxiety. Methods of avoiding the fear only result in intensifying their obsessive compulsive behavior.

To use these techniques, people must have a strong commitment to getting better and overcoming their OCD. They need to experience and go into and through the fear that they spend most of their time avoiding.

The exposure and reducing of rituals is done in gradual steps. For example if a woman showers for one hour at a time, she can gradually reduce the time to 45 minutes, then 30 minutes. She should alter the sequence of her routine such as washing her hair first rather than last. In the beginning, these changes will produce anxiety. But if she makes the changes frequently enough and long enough, her anxiety gradually goes away. She needs to work at the exposure and ritual-stopping a minimum of one hour each day.

It is most effective for people to expose themselves directly to what they fear. This involves touching something they consider contaminated or messing up their room. Sometimes people must do the exposure by fantasy because they cannot do it in reality. An example is when the people have thoughts of harming others or harm happening to them. In these situations, people write out a detailed story and then tape-record it. They would then listen to the tape repeatedly until their anxiety is reduced.

For instance, a man who fears his wife may have an auto accident if he doesn't change his clothes 20 times a day would write a story about this happening. Then he'd listen to a recording of the story over and over until his anxiety is gone. Of course, he also would not be allowed to change his clothes during this exercise.

The technique used to reduce obsessive thinking also involves exposure. People with OCD often try to stop the thought. They want to get rid of it and not have it recur. This only increases their anxiety and-with it-the frequency of the obsessive thought. We encourage people to label the thought as simply a thought and not a reality. For example, they can say to themselves, "Everyone else uses public toilets and doesn't worry about getting cancer." Treatment encourages them to delay the thought and give themselves permission to think the thought later. They can say to themselves, "It is just a thought and a part of my OCD. I will think about it for half an hour at 7:00 this evening." This gradually produces a reduction in anxiety. These people also must prevent thoughts they use to reduce the anxiety such as counting or phrases that try to undo the offensive thought.

Religious rituals and blasphemous thoughts make treatment more difficult. It is often hard for people with OCD to accept that their rituals are part of a psychiatric disorder. They condemn their thoughts as offensive to God. They feel they deserve God's punishment and doubt their salvation. Their spiritual communities often value and affirm religious rituals such as prayer and Bible reading. Their rituals, however, are often not spiritually significant and often get in the way of normal religious experiences and beliefs. People with OCD can be so consumed with prayer that they do not go to church or they so condemn themselves, they refuse to go to church.

It is important to help them see that they have obsessive compulsive behaviors in other areas of their lives. They must understand that their OCD is what's driving the frequency and intensity of their religious behavior. They also need to realize they are isolating only one side of their faith.

One young man engaged in much prayer to reduce his feelings of guilt about his sexual desires. The frequency of his praying disrupted his ability to work, and he was constantly haunted by doubts as to whether he was saved. His pastor confronted his doubting and pointed out the sufficiency of Christ's sacrifice. This allowed him to give up his ritualistic praying. Without the ritualizing, his obsessive thoughts began to habituate and lessen.

It takes strength and courage to confront an obsessive compulsive disorder. Admitting a problem and then seeking professional help for that problem are the first two important steps in conquering the disorder. Those who have faced the challenge know the rewards for themselves and their families are worth the effort.

Suggested Readings: 

Foa, Edna and Wilson Reid. S.T.O.P. Obsessing. New York: Bantam Books, 1991.  

Greist, J.D. Obsessive Compulsive Disorder: A Guide. Madison, WI: Obsessive Compulsive Information Center, Dean Foundation, 1992.  

Rapoport, J.L. The Boy Who Couldn't Stop Washing: The Experiences and Treatment of Obsessive Compulsive Disorder. New York: E.P. Dutton, 1989.  

Schwartz, Jeffrey. Brain Lock. Regan Books.