By Leslie Shapiro, LICSW
OCD is a biological disorder, not a character flaw
Obsessive compulsive disorder is considered a biological disorder and is covered under the Massachusetts State Parity Insurance Law.
I mention this first to inform sufferers that it is a biological disorder and, therefore, to challenge the social stigma associated with having OCD or any mental illness. We know many physical and mental disorders are biologically based and are unnecessarily judged by others to indicate something negative about the sufferer's personality or character. The reality is that most families are touched by some type of mental health issue. If we think about our extended families, we all know someone who might have been depressed, used substances, was especially anxious, or had odd beliefs.
Typically, a stressor will precipitate the onset of OCD in someone predisposed to the disorder. It is not the nature of the stressful event that causes the disorder, but rather that the latent OCD is precipitated by life being stressful. It should be no surprise that people can develop neurochemical glitches, which may, in turn, affect emotions and behavior. There is no shame to be had, no blame to be assigned, just acceptance that this is how some brains happen to be wired and function.
Note from the author: Like much of mental illness, OCD is a combination of a genetic predisposition and environmental stress. It is important to acknowledge that most of us are born with certain genetic predispositions. However, because we have these predispositions, we shouldn’t hesitate to do everything we can as physicians to inquire about these environmental stresses to see if we might be able to diminish the likelihood of our patients becoming “hostage” to suffering from the symptoms of obsessive-compulsive disorder.
How OCD works
Obsessive Compulsive Disorder does not discriminate and affects all walks of life. Helping to dispel the shame or guilt that the OCD is someone's fault is crucial in facilitating effective treatment. OCD will not be cured, but the sufferer and his/her family can be helped to control their responses to the symptoms. For people who don't understand the power of obsessions (always anxiety provoking, never pleasant), think back to when you might have had an unwanted commercial jingle or a song you didn’t like stuck in your head. Usually the more you fight it, the longer it seems to linger, and you become more irritated and frustrated (but, hopefully, not scared).
People who “go with it” seem to have an easier time letting it go. Obsessions are characterized as recurring intrusive, unwanted thoughts, impulses, or images, which may provoke anxiety. Most of us have these same thoughts in passing, but we don’t experience an anxiety response. Obsessions have a small kernel of reality to them, and usually seem to focus on survival instincts which go awry (hygiene, grooming, safety, nesting, etc.).
In contrast, the person with OCD cannot dismiss the thoughts because they associate their high anxiety response to indicate that something is urgently wrong/bad. Some people even fear that they are sinning due to the content of their obsessions. It is understandable that the first impulse is to find ways to reduce the anxiety and avoid having the thoughts, e.g. “if I say do not think of a pink elephant, trying not to think it IS thinking it.). Momentary anxiety reduction may reinforce the belief that the obsession needed attention.
How behavior therapy helps
Behavior therapy consists of helping sufferers learn how to face the obsessive thoughts and fears directly to normalize behavior. The sufferer and the therapist collaborate to devise the road map for how these fears will be faced. Exposures are planned using a hierarchy of feared situations that provoke the obsessions.
Response prevention is not ritualizing in the exposure situation. Blocking the behavior will enable the person to habituate (get used to) the situation in order to gain control over his/her functioning. When the person has habituated to the exposure situation, the plan is revised to move on to the next challenge. This is difficult but the triggering situations are typically part of normal daily routines.
An example, I might be having a “bad” thought that one might respond to in a superstitious way. For example, I could have a sudden thought that my family might be in a car accident unless I say a prayer perfectly, count to a certain number, or retrace my steps back to the spot where I had the thought to undo it. If I didn’t, I would feel guilty and responsible that I didn't CARE or TAKE THE TIME to do something to prevent it.
If I still feel anxious, I might make more attempts to reduce the anxiety, and if those behaviors are not done correctly, I may remain stuck until I have achieved that “just right” feeling. All the while I am acting as if my family WILL end up in an accident, and that my rituals should serve to control that event. The bind becomes: if I don’t ritualize, I will feel extremely anxious; if I do ritualize, I should be able to get momentary relief which only reinforces idea of needing to ritualize for the next obsession.
Although medications often facilitate behavioral treatment, the benefits are not typically noticed for some weeks.
“Reassurance” is a ritual
With every good intention, families attempt to respond to obsessive questions in order to provide reassurance in moments of distress. But attempting to provide “reassurance,” in fact, almost ends up ritualizing with the sufferer. No amount of reassurance is enough since the obsessive fear is irrational. The way in which the reassurance is communicated will never be good enough because the obsessive doubt can be adequately be lifted.
OCD is often referred to as the “doubting” disease and there is never an end to doubting. One obsession answered with logic begs the next doubting question. Often, the need to offer reassurance is reinforced by the sufferer's tenacity at wearing family members down. Families are often at a loss about how to provide support without providing reassurance. Behavior therapy, therefore, should include family members who will learn with the sufferer what is effective, and what is not effective support.
OCD is very treatable. With a lot of love, patience, and humor, it doesn’t have to interfere with living to life's full potential. Successful recovery can come about from hard work, trust in the treatment, and courage. It is important to get treatment at the earliest onset of an episode with a therapist that is skilled in exposure and response prevention. And remember: first change the behavior and the thoughts and feelings will follow.
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I would like to thank the following for their generous support, without whom this web site and training program would not exist: The Sidney R. Baer, Jr. Foundation, The Alden Trust, the Commonwealth of Massachusetts Department of Mental Health, Project INTERFACE (Newton Public Schools and the U.S. Department of Education), the Locke Educational Fund at Newton- Wellesley Hospital, Aetna Health Plan, the Kenneth B. Schwartz Center, and the families of my medical practice.
I hope you find this site useful and encourage any comments.
- Dr. Howard King, M.D.