Problems that Usually Need Psychotherapy or Psychiatry Treatment

Obsessive-Compulsive Disorder or OCD

Obsessive-compulsive disorder or OCD is characterized by obsessions, which are unwanted and intrusive thoughts, and compulsions, which are very powerful urges to perform unwanted behaviors. Often the sufferer realizes that the obsessive thoughts are irrational and the compulsive behaviors strike others as strange and peculiar. Some suffer mainly or entirely from obsessions, others from compulsions, still others have both. OCD can be a lifelong problem or it can be something that is triggered or exacerbated by stress.

An example of an obsession might be a need to count certain things all the time; an example of a compulsion might be a need to check multiple times within a few minutes that the burners on a stove are turned off. Failure to go through the ritualized thoughts or to perform the compulsive behaviors causes intense anxiety. Severe OCD can be crippling because people may spend so much time on obsessions or compulsions that they are unable to do other things effectively, or they may be unable to perform many normal behaviors due to anxiety, or they may be unable to perform many normal behaviors due to anxiety, or they may damage relationships and careers because the behaviors seem peculiar to others.

One variation of OCD is called Trichotillomania, and is a compulsion or urge to pull your own hair out, especially when under stress or anxious. Sufferers are often very embarrassed by this condition, because their urge to pull their hair can result in hair loss on the face (eyebrows or eyelashes) or scalp, and can be quite noticeable in severe cases. Treatment for Trichotillomania is the same as for OCD.

OCD behaviors are created and maintained by the same mechanism as phobias. OCD behaviors develop when people form an unfounded idea of potential danger and then make themselves feel safe by avoiding it. If someone has a hand washing compulsion, then when they touch something they mistakenly believe is contaminated. This makes them anxious, and so when they wash their hands in response to this they feel they have avoided a danger and so their anxiety lessens.  As with phobias, the brain and mind then ‘learn’ that compulsive hand washing is the ‘right’ thing to do because it makes oneself feel much better and safer. Of course, what the brain and mind have learned is wrong, but when this behavior is repeated many, many times and each time the person is rewarded by feeling safer, this wrong lesson becomes very ingrained.

So what is the treatment for OCD? The standard treatment for OCD is called Exposure & Response Prevention (ERP). ERP is the proven method and intervention to combat OCD and its common manifestations. ERP seeks to identify one’s obsessions, which are intrusive thoughts, urges, and images that cause significant distress and impairment of one’s well-being. ERP also seeks to identify the subsequent compulsions, which can be mental rituals of counting, history or fact checking, undoing negative thoughts or performing of physical acts to alleviate associated worry and distress. ERP further seeks to identify avoidant behaviors and responses to prevent triggers of obsessions or unwanted thoughts, images, and urges. ERP has proven to be effective in treating  children, adolescents, and adults in conjunction with or without the use of psychotropic medications.

Although some patients may be helped at least in part with medication, for most people exposure treatment by itself or in combination with medication is necessary. An OCD sufferer must first be convinced that the OCD behavior is irrational in that it does not prevent an actual danger. Then, (this part is harder), the client must be convinced that the OCD impulse can be ignored and the anxiety will be tolerable.

Suppose a client has a compulsion to wash her hands after touching any object that has fallen on the floor. We would first explain that the object does not in fact present a danger of infection. Then we would explain that if she touches the object, her hand will feel ‘dirty’ and she will feel an impulse to wash her hands that will be fairly strong. We would also explain that the feeling of contamination will seem at first as if it will be permanent, that if she doesn’t wash her hand she will be perpetually preoccupied by the feeling of ‘dirtiness’. Most importantly, we then continue to explain that this perception of permanence is mistaken, and encourage her to utilize previously learned coping strategies.

Usually at this point an OCD sufferer will try the experiment and find that the feeling of contamination does in fact decay fairly quickly. This revelation is built on and the OCD sufferer is then taught to use graduated exposure with a hierarchy, as with phobias, so as to practice tolerating OCD impulses without obeying them. Sometimes, cognitive exercises are also employed to help with impulse tolerance when needed.

It should also be noted that OCD symptoms are exacerbated and sometimes produced by stress.  Therefore, attention should also be given to problem solving, stress reduction, and removing cognitive distortions (changing thoughts that do not actually reflect reality) that produce or increase anxiety.

Thomas B. Hollenbach, Ph.D.

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