Obsessive-Compulsive Disorder

Dr. David L. Kupfer, Ph.D.

Obsessive-compulsives have confused and frustrated their families, their doctors and themselves. Their symptoms seem bizarre at first glance. They may fear hurting relatives whom they actually like. They can be convinced that their spouses will have car accidents unless they tap their feet in certain patterns. Some may have to wash their hands 50 times a day to avoid feeling contaminated. Others may have to check dozens of times to make sure that they have locked the door. We are just beginning to understand how to make sense of these symptoms and how to help people overcome them.

One feature of obsessive-compulsive disorder (OCD) is the obsession. Obsessions are persistent unwanted thoughts or feelings that OCD sufferers usually know are senseless. Common obsessions include fear of dirt or contamination, fear of harming someone, fears of disasters such as house fires, and extreme concern with having everything in order. Obsessions tend to make a person feel more anxious.

To reduce this anxiety or distress, people with OCD get in the habit of performing compulsive rituals. They may shower for three hours to get rid of a dirty feeling. Others might drive around the block to make sure they didn’t hit a pedestrian. Still others will compulsively of a “good” number to counteract thoughts of “bad” numbers.

Researchers have looked at several factors that may be involved in causing OCD. Some have noted genetic and biological forces. OCD seems linked to an imbalance involving serotonin, a neurotransmitter that sends messages from one nerve cell to another. Psychodynamic therapists have speculated that compulsive rituals are attempts to deal with unacceptable impulses that make us feel guilty. For example, someone might be angry with his or her mother. If they can’t accept this anger, they could become obsessively fearful of harming their mother or other people, and have to wash every time they think of hurting somebody. Cognitive therapists see OCD as an extension of irrational perfectionist or excessively self-punishing thinking. Behaviorists point out that compulsions, such as repetitively checking to make sure that the stove is really off, are reinforced when they seem to succeed at preventing the house from burning down.

While it is possible for some people with OCD to get over their problems on their own, help from therapists may be necessary for those with more severe symptoms. A therapist can keep a client motivated through the harder phases of treatment, and can firmly help them face their worst fears while also showing patience and compassion. Family members may be too close to be calm and objective as helpers in the treatment process.

Mental health professionals have come up with two promising approaches to treating OCD. One approach involves medications. Several medications have been shown to relieve OCD symptoms. Behavior therapy, the second promising approach, involves work and commitment by both therapist and client, but may offer more lasting results. Medications and behavior therapy are often used together.

To begin behavior therapy, the client must first identify, list, and describe in detail each of their obsessions and compulsions. Keeping a diary for a few days can help with this. This assessment should include the real-life situations that trigger obsessions; for example, driving downtown, passing pedestrians. It should also include the disasters that the client fears, for example being found guilty of hit-and-run after running over a pedestrian.

Behavior therapists plan methods of exposing obsessive-compulsive clients to the situations they fear. This can be done in real life and by using imagination. Real life exposure techniques for a compulsive washer might include purposefully rubbing dirt or other relevant “contaminating” substances on the clients’ hands. For a checker, real life exposure might involve forcing himself to leave the house without checking the door lock, and staying out of the house for a long period of time. By directly facing these situations, the client learns that their anxiety or distress only lasts a finite length of time and then is lessened to a tolerable level. This process, called habituation or extinction by behaviorists, is similar to how we tend to adapt to initially bothersome sounds, like a highway near our home, until we hardly notice them.

Imagination can help the obsessive-compulsive client get over their fear that something terrible will happen unless they engage in compulsive rituals. The client in behavior therapy is guided to imagine being in an anxiety-producing situation, and having their worst fear come true. Someone who compulsively hoards empty containers would imagine having thrown away all their boxes and jars, encountering a situation in which they needed one, feeling upset with themselves for not having it, and hearing others criticize them for having thrown it away. This imaginal exposure helps them realize that their fears are irrational. With prolonged focusing on their “disastrous” images, the client’s anxiety drops or extinguishes.

While the client is facing his fears through exposure therapy, he must also stop himself from using any compulsive rituals. As long as the client clings to these rituals, he cannot learn that the anxiety-producing situations are harmless. A compulsive washer might have to limit his showers to once a week or wash hands just once a day to stop the compulsive ritual habit. The compulsive secretary who takes 30 minutes to make sure that the typewriter has been turned off must leave work promptly without any checking.

It’s hard to overcome OCD by yourself. Family and friends can help a lot, if they know how. They should be non-judgmental and should never force the OCD client to do anything they feel unready to face. They should be firm in preventing compulsive rituals, but caring in reassuring clients that they will be all right even without their rituals.