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Obsessive-Compulsive Disorder - Patient Treatment Manual, Treatment manuals

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Obsessive-Compulsive Disorder
Patient Treatment Manual
This manual is both a guide to treatment and a workbook for persons who suffer from
obsessive-compulsive disorder. During treatment, it is a workbook in which individuals
can record their own experience of their disorder, together with the additional advice for
their particular case given by their clinician. After treatment has concluded, this manual
will serve as a self-help resource enabling those who have recovered, but who encounter
further stressors or difficulties, to read the appropriate section and, by putting the content
into action, stay well.
©Cambridge University Press, 1994:
Purchasers of the book may wish to photocopy portions
of the text of this manual for use with their patients. This is acceptable to the publisher, who,
nevertheless, disclaims any responsibility for the consequences of any such use of this material in
clinical practice. It is not necessary to write to Cambridge University Press for permission to
make individual photocopies. This permission does not extend to making multiple copies for use
by the purchaser, for use by others, or for resale. Individuals or clinics requiring multiple copies
may purchase them from Cambridge University Press using the order form at the back of the
book.
From:
Andrews G, Crino R, Hunt C, Lampe L, Page A. (1994)
The Treatment of Anxiety
Disorders.
New York: Cambridge University Press.
Section 1
1.
The Nature Obsessive-Compulsive Disorder
Obsessive-compulsive disorder (OCD) is an anxiety disorder that, until quite recently, was
regarded as a rare condition. Recent studies have shown that OCD is considerably more common
than previously thought and as many as two in every hundred people may suffer from the
condition.
OCD is characterized by persistent, intrusive, unwanted thoughts that the sufferer is unable to
control. Such thoughts are often very distressing and result in discomfort. Many OCD sufferers
also engage in rituals or compulsions that are persistent needs or urges to perform certain
behaviors in order to reduce their anxiety or discomfort. Often the rituals are associated with an
obsessional thought. For example, washing in order to avoid contamination follows thoughts
about possible contamination. For some, there is no apparent connection between the intrusive
thought and the behavior for example, not stepping on cracks in the sidewalk in order to avoid
harm befalling one’s family. Others still have no compulsive behaviors and suffer from
obsessional thoughts alone, while others do not experience obsessions but have compulsive
rituals alone.
The one common element to the various symptoms in OCD is anxiety or discomfort. For those
suffering both obsessional thoughts and compulsive rituals, it is the anxiety or discomfort
associated with the thought that drives the ritual. In other words, the ritual is performed to reduce
the anxiety produced by the thought. For those suffering from obsessional thoughts alone, anxiety
is often associated with the thought, and mental rituals, distraction, or avoidance may be used to
lessen the discomfort. It is much the same for those with compulsive rituals alone in that the
behavior is performed in order to lessen the urge to ritualize. The role of anxiety is important in
OCD and will be discussed in much greater detail in subsequent sections.
Most OCD sufferers can see the uselessness and absurdity of their actions but still feel compelled
to perform their various rituals. They know that their hands are not dirty or contaminated and they
know that their house will not burn down if they leave the electric kettle switched on at the wall.
Because they are aware of how irrational their behavior is, many sufferers are ashamed of their
actions and go to great lengths to hide their symptoms from family, friends, and, unfortunately,
even their doctors. It is extremely important that your therapist is aware of all of your symptoms
no matter how embarrassing or shameful they may be, as this is the only way that a suitable
treatment program can be designed for you. Rest assured that a therapist experienced in the
treatment of OCD will have heard of symptoms worse than yours many times over.
1.1
Symptoms Obsessive-Compulsive Disorder
Obsessional thoughts are usually concerned with contamination, harm to self or others, disasters,
blasphemy, violence, sex or other distressing topics. Although generally called thoughts they
can quite often be images or scenes that enter the sufferer’s mind and cause distress. For example,
one sufferer may have the thought “My hands are dirty” enter his head. This thought will trigger
washing rituals. Another sufferer will actually have enter his head the scene of his house burning
down. This scene will trigger checking rituals. Individuals who suffer obsessions alone may also
experience thoughts, images, or scenes. For example, someone who has obsessions about harming
his or her children may have the thought of harming them or have a frightening scene of hurting
them or an image of the children already hurt.
As was pointed out earlier, many obsessions produce anxiety or discomfort that is relieved by
performing rituals. The most common rituals are washing and checking, although there are many
others such as counting, arranging, or doing things such as dressing in a rigid, orderly fashion.
Although rituals are performed to alleviate the anxiety or discomfort that is produced by the
obsession, the anxiety relief is usually short-lived. An individual who washes in order to avoid or
overcome contamination will often find him- or herself washing repeatedly, because either they
were uncertain whether they did a thorough enough job or because the obsessional thought that
they are contaminated has recurred. Similarly, someone who checks light switches, stoves, and so
forth in order to avoid the house burning down, often has to repeat the behavior over and over,
because he may not have done it properly or the thought or image of his house being destroyed
has recurred. Even individuals who have obsessional thoughts alone may find that they have to
repeat the cognitive rituals such as counting or praying many times over as they may not have
done them
perfectly
in the first place.
An important point to keep in mind is that many sufferers have more than one type of symptom
so that individuals may engage in more than one type of ritual or have more than one type of
obsessional thought. Another point to note is that symptoms change over time and someone who
is predominately a washer may, over time, develop checking rituals that eventually supersede the
original complaint. In addition to changes in symptoms, the course of the disorder may also
fluctuate over time, with periods of worsening and periods of improvement. Other sufferers may
find that their symptoms remain static, while yet others may find a gradual worsening of
symptoms since the onset of the disorder.
For many sufferers of OCD, these symptoms take up a great deal of time, often resulting in their
being late for appointments and work and causing considerable disruption and interference with
their lives. Apart from disrupting their own lives, it also frequently interferes with the lives of
family members as the typical sufferer often asks the other members to do things a certain way or
not to engage in certain behaviors, as this may prompt the sufferer to engage in rituals. Thus, the
symptoms are not only controlling, frustrating, and irritating to the patients, but also to their
family, friends, and workmates.
Avoidance of certain situations or objects that may trigger discomfort and rituals is also quite
common among OCD sufferers. It seems logical to avoid contact with contaminants if you are a
person who washes compulsively, or to avoid going out of the house if you must check all the
electrical equipment, the doors, and windows. While this seems like a reasonable way of coping,
it actually adds to the problem, as the typical sufferer avoids more and more situations and
gradually the problem comes to rule their life. Second, avoidance does little to deal with the
problem as it only serves to reinforce the idea that such situations are dangerous. Because the
situation or object is constantly avoided, there is no opportunity for the individual to learn that
there is no danger.
Section 2
2.
The Causes and Treatment OCD
To date, no one is certain of the causes of OCD. Though there are a number of theories that
attempt to explain the development of the condition, there is little evidence to support them. We
know that for some the onset is during childhood, while for others, the onset may be during
adolescence or early adulthood. We also know that in some cases the onset is sudden, while
others have a slow, insidious onset. Some of the theories that have been proposed to explain the
development of OCD follow.
2.1 The Biochemical Theory
This theory was put forward after it was found that certain medications were of benefit in the
treatment of OCD. These drugs mainly affect one type of chemical in the brain called serotonin.
Consequently, it was hypothesized that a problem with serotonin could be the cause of OCD.
Although the drugs are indeed effective in the treatment of this condition, there is little hard
evidence to indicate that sufferers have a deficit of serotonin in their brain.
2.2 The Genetic Theory
This theory was put forward to explain the finding that OCD can sometimes occur in families.
Although a genetic predisposition may account for some sufferers developing the condition,
there is also the strong possibility that the OCD behavior was learned from the parents or siblings.
It is extremely difficult to differentiate between OCD behavior thay may be the result of genetics
or OCD behavior that may be the result of the environment.
2.3 Learning Theory
This model suggests that obsessive-compulsive behavior has been learned through a process of
conditioning. Put simply, this theory states that a neutral event becomes associated with fear by
being paired with something that provokes fear, anxiety, or discomfort. This fear then generalizes
so that objects as well as thoughts and images also produce discomfort. The individual then
engages in behaviors that reduce the anxiety and because the behavior is successful in reducing
anxiety even if only for short periods of time it is performed each time discomfort or anxiety is
felt. The problem with this theory is that it fails to explain why particular fears such as
contamination or of harm to oneself and others commonly occur in OCD. Another problem is
that many sufferers do not recall any significant precipitating event that can explain the onset of
their symptoms. However, this theory does explain how obsessive-compulsive symptoms are
maintained, and as a result, this issue will be dealt with in much greater detail in subsequent
sections.
2.4 Psychoanalytic Theory
This theory basically states that obsessive-compulsive symptoms are attempts to keep
unconscious conflicts and impulses from conscious awareness. Unfortunately, there is little
evidence to support this theory and psychoanalysis is of little value in the treatment of the
majority of OCD sufferers. As can be seen, no theory is able to adequately explain the
development of OCD but that does not mean that there are no effective treatments. In fact, the
cause, though of considerable interest, has little bearing on treatment outcome. It is important to
note, however, that in some cases symptoms that resemble OCD may be the result of other
illnesses such as depression and schizophrenia. Effective treatment of these conditions will
generally result in a decrease in the OCD-like symptoms. Other conditions that may result in
symptoms that resemble OCD are Tourette’s Syndrome, dementia, brain trauma, or other
neurological disorders.
2.5 The Treatment Obsessive-Compulsive Disorder
There are currently two effective treatments available for OCD that may be used separately or
together. One is drug treatment, with medication that increases the availability of serotonin in the
brain; the other involves the use of behavior therapy techniques. At present, it appears that they
are both effective and there is little in the scientific literature to suggest that combining the two
results in a better outcome than using them individually. However, some sufferers who find
behavior therapy too difficult initially may benefit from a course of medication so that effective
behavior therapy can be undertaken.
2.5.1 Medication
The medications that have been found to be particularly helpful in the treatment of OCD come
from the antidepressant family of drugs and include clomipramine, fluoxetine, fluvoxamine, and
sertraline. They have specific effects on serotonin levels in the brain. Serotonin is the biochemical
substance that some researchers believe is involved in OCD. In general, these medications have
been shown to be effective for some OCD sufferers and assist them in bringing their symptoms
under control. If one of these medications is prescribed for you, you should be made aware of
possible side effects and report their occurrence to your therapist. It is important to remember that
these medications are not a cure for OCD. In addition, research indicates that ceasing the
medication in the short term generally results in a return of symptoms. It could be that sufferers
need to remain on the medication for long periods of time or that behavior therapy should be used
in conjunction with the drug.
2.5.2. Behavior Therapy
The rationale for using behavioral techniques is briefly explained in the learning theory section
above but it is important enough to state again in greater detail. Typically, the OCD sufferer has
intrusive thoughts that generate anxiety, discomfort, or an urge to carry out a ritual. Performing
the ritual results in a decrease in anxiety or discomfort, so that performing the ritual is actually
reinforcing through its ability to reduce these negative feelings. For example, an individual has
the thought that his or her hands may have touched something dirty or contaminated. This thought
produces anxiety in that the person feels uncomfortable about the possibility of being
contaminated or contaminating someone else. This unpleasant anxiety or discomfort is relieved
by washing of the hands or other contaminated objects and it feels good to rid oneself of such
negative feelings, so it feels “good” to wash. In the same manner, an individual who must check
the stove and heaters prior to leaving home in order not to cause a disastrous fire will feel some
relief after checking these items many times to ensure they are off. Thus the anxiety-producing
thought is temporarily minimized by checking, and it feels “good” to check.
This anxiety- or discomfort-reducing quality that the rituals possess is shown in the following
graph. Patients were asked to rate their levels of discomfort and urge to ritualize (1) before being
exposed to an anxiety-evoking stimulus, (2) after being exposed, and (3) after performing their
rituals. As can be seen, exposure to the stimulus results in a marked increase in discomfort and
urge to ritualize. Engaging in the ritual brings about an immediate and dramatic decrease in both
these measures.
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