Measuring Obsessive

Measuring Obsessive-Compulsive Symptoms: Common Tools and Techniques By Eric A. Storch, Ph.D. With the increased recognition of the prevalence and severity of obsessive- compulsive disorder (OCD), increased attention has been devoted to its assessment and treatment in recent years. Currently, several different methods are used to assess obsessive-compulsive symptoms, including diagnostic interviews, clinician administered inventories, self-report measures, and parent-report measures. In fact, in the past few years, numerous OCD measures have been developed and/or published. Unfortunately, it is not possible to mention all of these; so this article is limited to an overview of measures used within our child and adult OCD clinics at the University of South Florida with an eye towards what one might expect at his/her initial visit to a provider. Diagnostic Interviews The use of structured diagnostic interviews for the assessment of pediatric OCD is quite common in research studies (but not uncommon in general clinical practice). Diagnostic interviews can be used to assign diagnoses and differentiate between other possible diagnoses. These interviews facilitate diagnostic decisions by utilizing specific questions to assess symptoms according to Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria. Within our clinic, we use the Anxiety Disorders Interview Schedule for DSM-IV for adults and the Anxiety Disorders Interview Schedule for DSM IV Child and Parent Versions for children and adolescents. Another commonly used interview is the Structured Clinical Interview for DSM-IV. Each of these is divided into sections by disorders. Detailed questions regarding each disorder are administered only if the preliminary criteria are found. Each interview usually takes between 60-120 minutes to administer. Clinician-Rated Instruments The use of a clinician-rated inventory allows trained individuals to make informed ratings of OCD related impairment and distress in comparison to cases they have seen. Perhaps the most commonly used assessment instrument within clinical and research settings is the Yale- Brown Obsessive-Compulsive Scale (YBOCS) and its counterpart for children, the Children’s Yale- Brown Obsessive- Compulsive Scale. The Y-BOCS and CYBOCS are conducted in an interview format with a trained clinician and measure OCD symptoms and severity over the previous week. The Y-BOCS and CY-BOCS consist of several parts including items querying the presence of various obsessions and compulsions and items assessing the severity of symptoms. For example, there are questions about how much time obsessions and compulsions take, as well as how much distress they cause. Scores for all items are determined by the clinician on the basis of the person’s report, parent(s)/spouse’s report and behavioral observations. Self-Report Instruments Self-report measures have several advantages in OCD assessment as they can generally be completed quickly, independently, and administered to a number of individuals at once. They are useful as screening questionnaires, and are often employed to identify potential research participants and candidates for treatment. In addition, people may feel more comfortable completing measures independently. This can guard against the under- reporting (or over reporting) of symptoms that is sometimes observed during a clinician- administered interview. However, there are some disadvantages. For example, an individual’s response style may affect his assessment of symptoms based on different interpretations of choices such as “sometimes” or “often.” In addition, some respondents may have difficulty understanding the format or wording of the questionnaire, while others may not use adequate care when completing the questionnaire. Finally, the broad and variable range of symptoms in OCD may result in an underestimate of a person’s impairment because specific and/or idiosyncratic symptoms may not be included in the measures. At the University of South Florida OCD Clinic, we use the Florida Obsessive Compulsive Inventory (FOCI) and the Obsessive Compulsive Inventory- Revised (OCI-R) for self-reporting of symptoms. In the FOCI is a symptom checklist and five questions that assess symptom severity and impairment. In the checklist, the individual marks the presence or absence of 20 common obsessions and compulsions (ten each). On the severity items, the individual rates the cumulative severity of endorsed symptoms on five items: time occupied, interference, distress, resistance, and degree of control. The OCI-R is an 18-item self-report questionnaire based on the earlier 84-item OCI. Participants rate the degree to which they are bothered or distressed by specific OCD symptoms in the past month. Besides the FOCI and OCI-R, a number of other widely used self-report instruments exist. The Yale-Brown Obsessive- Compulsive Scale—Self Report concurrently measures the presence and severity of commonly reported symptoms. The Leyton Obsessional Inventory Short Form is a 30-item self-report measure appropriate for children and adults. The presence of common symptoms is answered on a yes/no scale. The Maudsley Obsessional Compulsive Inventory contains 30 true or false items to assess the presence of common obsessions and compulsions. Finally, the Padua Inventory Revised is a 39- item self-report measure of obsessions and compulsions rated on a five-point scale according to the degree of disturbance. Other Measures To supplement the above measures, other questionnaires are often given. In children, it is very common for parents to rate their child’s behavior on questionnaires such as the Child Obsessive Compulsive Impact Scale or the Children’s Obsessional Compulsive Inventory. The former assesses the presence and severity of symptoms; the latter queries impairment related to OCD. Questionnaires about family involvement in symptoms, such as the Family Accommodation Scale (FAS), are also commonly given to family members. The FAS assesses how much others accommodated the patient’s obsessions and compulsions by providing reassurance or the help necessary for completion of compulsions, decreasing behavioral expectations, modifying family activities or routines, and/or helping the child avoid objects, places, or experiences that may cause him or her distress. Dr. Storch is an Associate Professor of Pediatrics and Psychiatry, and Associate Professor of Clinical Psychology at the University of South Florida. He is also the Director of the University of South Florida Obsessive Compulsive Disorder Program. …………………………………………………………………………………………………………………………………………. Emotional Contamination: A Lesser Known Subtype of OCD By Carol Hevia, Psy.D. Case Example Joe is a 25 year-old college drop-out who is currently unemployed and lives in an apartment above his parents’ garage. He has a lifelong history of OCD that began at age 8 when he was plagued with symmetry obsessions and scrupulosity. Now he is struggling primarily with obsessions that he will be contaminated by a former college roommate, Connor, who was wildly successful in academics and in the business world after graduation by being ruthless and nasty and by taking advantage of those who helped him and those who “got in his way.” Joe fears that if he comes into any kind of contact with his former roommate he will be at high risk of becoming like him: “ruthless, uncaring, and a cannibal of friends and foes.” During college, Joe was so terrified that he would become like his roommate that he started to avoid all friends who had contact with Connor, as well as the library where Connor studied. Joe, like Connor, was a business major and began to avoid taking any courses that would be held in the business school on campus. This became very problematic when choosing which courses to take each semester, so he switched his major to Russian Studies because that department was housed on the other side of campus. However, if Joe happened to speak to a fellow classmate who had taken a course in the business building, he needed to immediately drop not only that particular course that they shared, but also discard the clothes he was wearing at the time, his books from that class, and any current term papers in progress. Eventually, these disruptions eroded his academic success; his grades dropped, he took a medical leave from college, and he returned home to live with his parents. Since he had shared a dorm room with Connor, he felt the need to discard all clothes, books, personal belongings, and even his computer when he moved out of the dorm. But just like the college dorm room, it was inevitable that the house would become contaminated, for even when someone mentioned Connor’s name, the obsessions would be triggered and decontaminating the house became impossible due to Joe’s high OCD standards and rigid rules for decontaminating. The family had an apartment built over the garage so that Joe could keep his living quarters “free from Connor’s cannibalistic influence,” but then he stopped even stepping into his parents’ home for fear of exposure to Connor’s ruthless ways. When Joe tried to take college courses online he found that the contamination seeped into his garage apartment through the computer, since Connor had an account on a social networking site online. When Joe reached the point where he was preparing to move into another apartment in a town twenty miles from his parents, and he was about to buy his fifth computer, and he no longer uttered any words with the letter “C” in it, he called a behavior therapist to get help. Symptomatology of Emotional Contamination Joe suffers from a subtype of OCD called Emotional Contamination. Emotional contamination is a lesser known symptom cluster of OCD in which the sufferer fears that contact with a person or place will somehow contaminate and endanger him. The worry can be that the individual with OCD is at risk to take on negative personality traits that the trigger person has, such as bossiness or nastiness, or that the sufferer will take on another’s entire personality. It is fairly easy for the individual with OCD to identify the person who triggers his obsessions. Sometimes it can be a “type” of person who represents a disability that one fears contracting, such as a blind person or a person with deformed limbs. The trigger can also be a geographical location, such as a college, funeral parlor, or cemetery. Sometimes a traumatic event “marks” the physical site and is the source of the initial contamination and subsequent danger. An example of this could be the break-up of a serious relationship, a death, or a suicide attempt. Then any contact with the place where the event took place is perceived as dangerous, as if the physical contact will generate bad luck and magically endanger the person with OCD. The feared bad luck can be very specific, such as a car accident, or it can be vague, such as a general sense of impending doom. Two hallmarks of emotional contamination are the presence of magical thinking and superstitious behaviors. Both magical thinking and superstitions are clues that the sufferer believes in a phenomenon that is inconsistent with what is generally considered true and rational in the particular society in which he lives. The person with OCD often believes that random events and coincidences never occur and that all events are meant to happen, so they therefore hold special meaning and power. Any time a coincidence occurs, the sufferer uses the coincidence as “factual evidence” that their superstitious beliefs have merit and that all others who try to dissuade them are wrong. The exposure and subsequent obsessions are often “contained” through similar rituals to that of contamination fears. The person with OCD will avoid direct contact with the contaminated person and will clean him/herself thoroughly if he does touch the person or the person’s belongings. Contamination can “magically” spread through physical contact, such as a handshake or touching a pencil that the contaminated person recently used. Often, as the OCD symptoms worsen, the contamination from another person starts to look as serious as a true radiation contamination, in that the person will actually throw out all clothes worn at the time of contact and vigorously scrub themselves down in a long shower. The perceived danger of contamination can also be airborne so that merely sharing air space with the trigger can put the person with OCD at risk to suffer a catastrophic consequence. The sufferer may cover his mouth with a barrier to protect himself from becoming “ill” or might try to hold his/her breath when near the trigger. More often, the ritual would be an “undoing” of breathing in contaminated air by breathing out in a ritualized fashion, perhaps with a neutralizing thought that safely “deactivates” the danger of the contaminated air. Sometimes in emotional contamination the perceived danger can spread through language and speech so that uttering a phrase or word that reminds one of the obsession can dramatically increase the perceived risk of danger. Thus the individual with OCD avoids using specific words or names and he may even attempt to control others’ use of the trigger words in order to avoid escalating anxiety. The rituals can even spread to reading and writing; for example, the sufferer might avoid writing the trigger word, or if he reads the trigger name he might engage in neutralizing rituals to undo the effect of reading the dangerous word. The neutralizing rituals may be to reread the trigger phrase while having a “good” or opposite thought, or to skip reading the entire page. The person with OCD may decide to cease reading altogether in an attempt to quell his/her anxiety. As the sufferer becomes more symptomatic, the contamination can generalize further – the individual letters or punctuation symbols become dangerous as well, and the person writes words with letters left out so the reader must guess as to the exact content of the message. Not surprisingly, exposure to the media, whether in written form, television or the internet, can become problematic for the person with OCD. News related to the triggering topic can set a sufferer into a tailspin, so the bold type titles in a newspaper or magazine are initially skimmed in an effort to stay away from triggering topics and eventually reading a newspaper is avoided altogether. Then, even touching the newspaper becomes an issue with which to contend. Particular television shows are avoided due to implied content, and the same holds true for known internet sites. However, as with other triggers and unchecked ritualistic behavior, generalization is inevitable and a further escalation of symptoms will occur if the OCD is left untreated. For example: the computer is no longer touched or used, the room that the computer is in is never entered, and the person can deteriorate towards residing in one room of their home and not venturing out due to potential danger from exposure to anything even remotely related to the contaminated person or place. Treating Emotional Contamination Exposures for emotional contamination will, at first, mimic germ and contamination exposures. Hand washing and showering frequencies are reduced in quantity and quality. The person touches contaminated items, uses previously avoided belongings and then cross- contaminates from “dirty” to “clean” belongings. The ERP plans start to differ when the ERP is designed to expose the sufferer to avoided words and sounds. He may write one word or phrase repeatedly and then say it out loud. The written trigger is then hung up on the person’s door or walls, thus saturating both one’s awake and sleeping hours with the feared stimulus. Placing the triggering written work by one’s bedside is especially effective because sufferers often believe that they are more vulnerable to emotional contamination while they sleep. Joe started twice weekly behavior therapy outpatient sessions. He made a list of worries and triggers, both physical and mental, and rituals. Together, he and his therapist rearranged the list into a hierarchy of feared situations and triggers using a SUDS rating of 1 to 10. He agreed to cancel plans to move from his garage apartment and he kept his fifth computer. His exposures started with saying and writing Connor’s name on sheets of paper and then hanging them around his computer and bed. His family learned about accommodation and not only started to block verbal reassurance but eventually, under the therapist’s guidance, began to say words with C and even said the dreaded word “Connor” during ERPs. Once Joe experienced habituation to some of the initial ERPs, his sense of direction in the treatment, his hope, and his motivation dramatically increased and he was more able to take on challenging tasks since he knew that even when his anxiety was very high it would eventually drop, especially if he blocked ritualizing and retriggered himself when he slipped and ritualized. He started to drive to his old campus and progressed to sitting outside the business building. He started to socialize with other contaminated friends, use the internet again, and signed up for a business class in accounting. He eventually started to email Connor himself, which was at the top of his hierarchy. Even though they never became close friends, Joe was no longer haunted by Connor’s presence in his OCD life. When he would think of Connor, and even when he thought about the dreaded personality characteristics, he would not try to push the thought away, but say to himself, “Yup, that’s Connor – what a guy!” and go on with his day. Joe is now completing his third year in college and is majoring in Russian Studies with a minor in business. Carol Rockwell Hevia, Psy.D. works as a behavior therapist at the OCD Institute at McLean Hospital. She has almost twenty years of treating children, adolescents and adults with OCD. ……………………………………………………………………………………………………………………………………………… How Do I Know I’m Not Really Gay? By Fred Penzel, Ph.D. OCD, as we know, is largely about experiencing severe and unrelenting doubt. It can cause you to doubt even the most basic things about yourself – even your sexual orientation. A 1998 study published in the Journal of Sex Research found that among a group of 171 college students, 84% reported the occurrence of sexual intrusive thoughts (Byers et al, 1998). In order to have doubts about one’s sexual identity, a sufferer need not ever have had a homo- or heterosexual experience, or any type of sexual experience at all. I have observed this symptom in young children, adolescents, and adults as well. Interestingly, Swedo et al., 1989 found that approximately 4% of children with OCD experience obsessions concerned with forbidden, aggressive, or perverse sexual thoughts. Although doubts about one’s own sexual identity might seem pretty straightforward as a symptom, there are actually a number of variations. The most obvious form is where a sufferer experiences the thought that they might be of a different sexual orientation than they formerly believed. If the sufferer is heterosexual, then the thought may be that they are homosexual. If, on the other hand, they happen to be homosexual, they may obsess about the possibility that they might really be straight. Going a step beyond this, some sufferers have obsessions that tell them that they may have acted, or will act on their thoughts. A variation on doubt about sexual identity would be where the obsessive thought has fastened onto the idea that the person simply will never be able to figure out what their sexual orientation actually is. Patients will sometimes relate their belief that, “I could deal with whatever my sexuality turns out to be, but my mind just won’t let me settle on anything.” Some people’s doubts are further complicated by having such experiences as hearing other people talking or looking in their direction and thinking that these people must be analyzing their behavior or appearance and talking about them – discussing how they must be gay (or straight). For those with thoughts of being homosexual, part of the distress must surely be social in origin. Let's face it: gay people have always been an oppressed minority within our culture, and to suddenly think of being in this position and to be stigmatized in this way can be frightening. People don't generally obsess about things they find positive or pleasurable. I have sometimes wondered if those who experience the most distress from such thoughts as these do so because they were raised with more strongly homophobic or anti-gay attitudes to begin with, or if it is simply because one's sexuality can be such a basic doubt. I suppose this remains a question for research to answer. The older psychoanalytic therapies often make people with this problem feel much worse by saying that the thoughts represent true inner desires. This has never proven to be so. Doubting something so basic about yourself can obviously be quite a torturous business. When I first see people for this problem, they are typically engaged in any number of compulsive activities, which may occupy many hours of each day. These can include: Looking at attractive men or women, or pictures of them, or reading sexually oriented literature or pornography (hetero- or homosexual) to see if they are sexually exciting Imagining themselves in sexual situations and then observing their own reaction to them Masturbating or having sex repeatedly just for the purpose of checking their own reaction to it. (This may also include visiting prostitutes in more extreme cases) Observing themselves for evidence of "looking", talking, walking, dressing, or gesturing like someone who is either gay or straight. Compulsively reviewing and analyzing past interactions with other men or women to see if they have acted like a gay or straight person Checking the reactions or conversations of others to determine whether or not they might have noticed them acting inappropriately, or if these people were giving the sufferer strange looks Reading articles on the internet about how an individual can tell if they are gay or straight to see which group they might be most similar to Reading stories by people who “came-out” to see if they can find any resemblance to their own experiences Repeatedly questioning others or seeking reassurance about their sexuality Compulsive questioning can frequently take place, and usually involves others who may be close to the sufferer. The questions are never-ending and repetitive. Some of the more typical questions sufferers are likely to ask can include those in the following two groupings: For those who obsess about not knowing what their identity is: ■How do I know whether I prefer women or men? ■Maybe I really don’t know what I am. ■Maybe I’ll never know what I am. ■How does anyone tell what sex they really are? ■How will I ever be able to tell for certain? ■What will happen if I make the wrong choice and get trapped in a lifestyle that really isn’t for me? For those who obsess that they are of the opposite sexual orientation: ■“Do you think I could be gay (or straight)?” ■“How can I tell if I'm really gay (or straight)?” ■“At what point in their lives do people know what their orientation is?” ■“Can you suddenly turn into a homosexual (or heterosexual) even if you have never felt or acted that that way?” ■“Did I just act sexually toward you?” ■“Do I look (or act) gay (or straight) to you?” ■“Did I just touch you?” ■“If I get sexual sensations when viewing sexual material of an opposite orientation does it mean I am gay (or straight)?” In terms of the last question above, one of the most difficult situations for this group of sufferers is when they experience a sexual reaction to something they feel would be inappropriate. A typical example would be a heterosexual man who experiences an erection while looking at gay erotica. It is important to note that it is extremely common for people to resort to all sorts of fantasy material concerning unusual or forbidden sexual behaviors that they would never actually engage in, but that they do find stimulating. Under the right circumstances, many things can cause sexual arousal in a person. The fact of the matter is that people react sexually to sexual things. I am not just talking about people with OCD here, but about people in general. I cannot count the number of times that patients have related to me that they have experienced sexual feelings and feelings of stimulation when encountering things they felt were taboo or forbidden. This, of course, then leads them to think that their thoughts must reflect a true inner desire, and are a sign that they really are of a different sexual orientation. This reaction is strengthened by the incorrect belief that homosexual cues never stimulate heterosexuals. One further complicating factor in all this is that some obsessive thinkers mistake feelings of anxiety for feelings of sexual arousal. The two are actually physiologically similar in some ways. Things become even more complicated by a number of cognitive (thinking) errors seen in OCD. It is these errors, which lead OC sufferers to react anxiously to their thoughts, and then to have to perform compulsions to relieve that anxiety. Cognitive OCD theorists believe that obsessions have their origin in the normal unwanted intrusive thoughts seen in the general population. What separate these everyday intrusions from obsessions seen in OCD are the meanings or appraisals that the OCD sufferers attach to the thoughts. As I like to explain to my patients, their problem is not the thoughts themselves, but instead it is what they make of the thoughts, as well as their attempts to relieve their anxiety via compulsions and avoidance. Some typical cognitive errors made by OC sufferers include: ■I must always have certainty and control in life (intolerance of uncertainty) ■I must be in control of all my thoughts and emotions at all times ■If I lose control of my thoughts, I must do something to regain that control ■Thinking the thought means it is important and it is important because I think about it ■It is abnormal to have intrusive thoughts, and if I do have them, it means I’m crazy, weird, etc. ■Having an intrusive thought and doing what it suggests are the same, morally ■Thinking about doing harm, and not preventing it is just as bad as committing harm (also known as Thought-Action Fusion) ■Having intrusive thoughts means I am likely to act on them ■I cannot take the risk that my thoughts will come true The effect of the questioning behavior on friends and family can be rather negative, drawing a lot of angry responses or ridicule after the thousandth time. One young man I know questioned his girlfriend so often that she eventually broke up with him and this added to his worries since he now wondered if she did so because he wasn't a "real man". The compulsive activities sufferers perform in response to their ideas, of course, do nothing to settle the issue. Often, the more checking and questioning that is done, the more doubtful the sufferer becomes. Even if they feel better for a few minutes as a result of a compulsion, the doubt quickly returns. I like to tell my patients that it is as if that information-gathering portion of their brain is coated with Teflon©. The answers just don’t stick. In addition to performing compulsions, one other way in which sufferers cope with the fears caused by the obsessions is through avoidance, and by this I mean directly avoiding everyday situations that get the thoughts going. This can involve: ■Avoiding standing close to, touching, or brushing against members of the same sex (or opposite sex if the sufferer is gay) ■Not reading or looking at videos, news reports, books, or articles having anything to do with gay people or other sexual subjects ■Never saying the words "gay," "homosexual," (or “straight”) or any other related term ■Trying to not look or act effeminately (if a man) or in a masculine way (if a woman) (or vice versa if the sufferer is gay) ■Not dressing in ways that would make one look effeminate (if a man) or masculine (if a woman) (again, vice versa if the sufferer is gay) ■Not talking about sexual identity issues or subjects with others ■Avoiding associating with anyone who may be gay or who seems to lean in that direction (if the sufferer is heterosexual) Needless to say, it is crucial for all OCD sufferers to understand that there is no avoiding what they fear. Facing what you fear is a way of getting closer to the truth. The purpose of compulsions is, of course, to undo, cancel out, or neutralize the anxiety caused by obsessions. They may actually work in the short run, but their benefits are only temporary. OC sufferers cannot process the information they provide, and it just doesn’t stick. It is sort of like having only half of the Velcro. Also, it is important to understand that compulsions are paradoxical – that is, they bring about the opposite of what they are intended to accomplish. That is, to help the sufferer to be free of anxiety and obsessive thoughts. I like to tell my patients that: “Compulsions start out as a solution to the problem of having obsessions, but soon become the problem itself.” What compulsions do accomplish is to cause the sufferer to become behaviorally addicted to performing them. Even the little bit of relief they get is enough to get this dependency going. Compulsions only lead to more compulsions, and avoidance only leads to more avoidance. This is really only natural for people to do. It is instinctive to try to escape or avoid that which makes you anxious. Unfortunately, this is of no help in OCD. Another problem that arises from performing compulsions is that those who keep checking their own reactions to members of the opposite or same sex will inevitably create a paradox for themselves. They become so nervous about what they may see in themselves that they don't feel very excited, and then think that this must mean they have the wrong preference. When they are around members of their own sex, they also become anxious, which leads to further stress and, of course, more doubts about themselves. The flip side of this is when they look at things having to do with sex of an opposite orientation and then feel aroused in some way, which they then conclude to mean that they liked it, which means that they are gay (or straight). This is the mistake I referred to earlier when I stated that people react sexually to sexual things. People like to ask if there are any new developments in OCD treatments. Aside from a few new medications since the last article, treatment remains essentially the same. The formula of cognitive/behavioral therapy plus medication (in many cases) is still the way to go. The particular form of behavioral therapy shown to be the most effective is known as Exposure and Response Prevention (ERP). ERP encourages participants to expose themselves to their obsessions (or to situations that will bring on the obsessions), while they prevent themselves from using compulsions to get rid of the resulting anxiety. The fearful thoughts or situations are approached in gradually increased amounts over a period of from several weeks to several months. This results in an effect upon the individual that we call "habituation." That is, when you remain in the presence of what you fear over long periods of time, you will soon see that no harm of any kind results. As you do so in slowly increasing amounts, you develop a tolerance to the presence of the fear, and its effect is greatly lessened. By continually avoiding feared situations and never really encountering them, you keep yourself sensitized. By facing them, you learn that the avoidance itself is the "real" threat that keeps you trapped. It puts you in the role of a scientist conducting experiments that test your own fearful predictions, to see what really happens when you don't avoid what you fear. The result is that as you slowly build up your tolerance for whatever is fear provoking; it begins to take larger and larger doses of frightening thoughts or situations to bring on the same amount of anxiety. When you have finally managed to tolerate the most difficult parts of your OCD, they can no longer cause you to react with fear. Basically, you can tell yourself, “Okay, so I can think about this, but I don’t have to do anything about it.” By agreeing to face some short-term anxiety, you can thus achieve long-term relief. It is important to note that the goal of E&RP is not the elimination of obsessive thoughts, but to learn to tolerate and accept all thoughts with little or no distress. This reduced distress may, in turn, as a byproduct, reduce the frequency of the obsessions. Complete elimination of intrusive thoughts may not be a realistic goal, given the commonality of intrusive thoughts in humans in general. Using this technique, you work with a therapist to expose yourself to gradually increasing levels of anxiety-provoking situations and thoughts. You learn to tolerate the fearful situations without resorting to questioning, checking, or avoiding. By allowing the anxiety to subside on its own, you slowly build up your tolerance to it, and it begins to take more and more to make you anxious. Eventually, as you work your way up the list to facing your worst fears, there will be little about the subject that can set you off. You may still get the thoughts here and there, but you will no longer feel that you must react to them, and you will be able to let them pass. There are many techniques for confronting sexual and other obsessions that we have developed over the years. Some of these techniques include: ■Listening to 2-3 minute audio tapes or tape loops about the feared subject ■Leaving cell phone voice-mail messages for yourself about the feared subject ■Writing 2 page compositions about a particular obsession (and then taping them in your own voice) ■Writing feared sentences repetitively ■Hanging signs in your room or house with feared statements ■Wearing T-shirts with feared slogans ■Visiting locations that will stimulate thoughts ■Being around people who will stimulate thoughts ■Agreeing with all feared thoughts, and telling yourself they are true and represent your real desires ■Reading books on the subject of your thoughts ■Visiting websites that relate to your thoughts These are some typical exposure therapy homework assignments I have assigned to people over the years: ■Reading books by or about gay persons. ■Watching videos on gay themes or about gay characters. ■Visiting gay meetings, shops, browsing in gay bookstores, or visiting areas of town that are more predominantly gay. ■Wearing a T-shirt at home with the word ‘gay’ on it. ■Wearing clothes in fit, color, or style that could possibly look effeminate for a man, or masculine for a woman. ■Looking at pictures of good-looking people of your own sex and rating them on attractiveness. ■Reading magazines such as Playboy if you are a woman or Playgirl if you are a man. ■Standing close to members of your own sex. ■Doing a series of writing assignments of a couple of pages each that suggest more and more that you actually are gay or wish to be. ■Making a series of three-minute tapes that, based on the writings, gradually suggest more and more that you are gay, and listening to them several times a day, changing them when they no longer bother you). Some typical response prevention exercises might include: ■Not checking your reactions to attractive members of your own sex. ■Not imagining yourself in sexual situations with same-sex individuals to check on your own reactions. ■Not behaving sexually with members of the opposite sex just to check your own reactions. ■Resist reviewing previous situations where you were with members of the same or opposite sex or where things were ambiguous to see if you did anything questionable. ■Avoid observing yourself to see if you behaved in a way you imagine a homosexual or member of the opposite sex would. Some typical exposure homework for those with doubts about their own sexual identity might include: ■Reading about people who are sexually confused ■Reading about people who are transgendered ■Looking at pictures of people who are transgendered or are transvestites ■Telling yourself and listening to tapes telling you that you will never really know what you are Some corresponding response prevention exercises to go along with the above would be: ■Not checking your reactions when viewing members of either sex ■Not acting sexually to simply test your reactions ■Avoiding reviewing thoughts or situations you have uncertainty about Many of the above therapy tasks can sound scary and intimidating. Obviously, you don’t do these things all at once. Behavioral change is gradual change. Recovering from OCD is certainly not an easy task. We rarely use the word ‘easy’ at our clinic. It takes persistence and determination, but it can be done. People do it all the time, especially with proper help and advice. My own advice to those of you reading this would be to get yourself out of the compulsion trap, and get yourself into treatment with qualified people. Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and O-C related problems. ……………………………………………………………………………………………………………………………………………… Differentiating Between Asperger’s and Obsessive-Compulsive Disorder By Fugen Neziroglu, Ph.D. and Jill Henriksen, M.S. In recent years clinicians have continually seen a rise in Asperger‘s Disorder (AD), especially among child and adolescent populations. Whether this rise is due to an actual increase in AD or merely a result of improved definitions and increased awareness is unknown. In 1994, AD was first added to the DSM-IV (Kirby, 2003), therefore, it is only recently that parents and professionals are more aware of this disorder. AD is a complex disorder that resembles OCD in several ways; therefore, it becomes increasingly important to have an understanding of AD so one can better differentiate it from OCD. The purpose of this article is to help individuals, family members, and professionals better understand how these disorders are similar and how they can be differentiated from one another. A couple of case examples will be used to illustrate certain behaviors before we go on to the specific characteristics of the two disorders. For consistency purposes, the male gender is used throughout this paper because males outnumber females in AD. However, one should note that this is not the case with OCD. Case Example 1 Matthew is a 9-year old boy.* He performs well academically in school. In class, he pays excellent attention; however, his teachers have noted some underlying anxiety regarding his academic performance. For example, Matthew takes a long time to complete tests and writing assignments. His teachers report that he is well behaved and follows classroom rules, but at the same time, Matthew will report to his teacher when his peers do not demonstrate the same behavior. Additionally, Matthew becomes agitated or upset when he is rushed and is unable to complete an assignment. At home, mornings and evenings are particularly difficult for Matthew. He takes a long time getting ready for school, e.g., brushing his teeth a long time, dressing and redressing, going in and out of the room, etc. Also, he gets to bed later than he should making mornings even more difficult. He reports that he is unable to fall asleep because of “certain thoughts” and his bedtime rituals. Matthew’s mother is concerned with her son’s outbursts of anger. These fights usually occur around dinnertime when Matthew does not have his own way, such as, having his plate and silverware washed again before his food touches it. Matthew’s mother has also become increasingly concerned about her son’s peer relationships. She feels that Matthew is having difficulty making friends. As his friends become more interested in sports, Matthew has less in common with them and has started to spend more time alone. Case Example 2 Eric is a 12-year old boy. Eric’s academic performance is strong. He is currently taking advanced coursework in mathematics and science. Eric’s teachers are impressed with his language ability in these areas. He uses adult words and has an advanced vocabulary surrounding science and history. Recently, Eric has been having trouble in school. More specifically, Eric only wants to read, write, and research specific topics, such as European history. If his teacher asks him to write about something else, Eric becomes very upset and argues with the teacher endlessly. In exasperation the teacher usually allows him to write about whatever he wants. Other times he is sent to the principal’s office. Additionally, Eric becomes irritable when things are out of the routine, for instance if he has to read a book different from the one he had been told to originally. Eric has one or two friends, but does not usually initiate social contact with children. Eric frequently needs to be redirected by his teacher to complete his work. In addition, he often requires extra time to complete his exams. Eric often appears anxious in school and when he feels this way he will continually ask the teacher questions and seek reassurance from her. At home, Eric demonstrates difficulty completing his homework assignments. He becomes fixated on one small aspect of his assignment and then runs out of time to complete the rest. After school, Eric can spend hours reading about history and will engage in hours of discussion about the topic. He enjoys comparing one history book to another. He will line up his books in alphabetical order and then analyze each one of them. Eric prefers “sameness”. He enjoys eating the same kind of foods over and over again. He also prefers soft fabrics and puts his clothing on each morning in a particular order. The first case example is that of OCD and the second of AD. AD is at the mildest and highest functioning end of what is known as the Pervasive Developmental Disorder spectrum. As described by Treffert (1999), the disorder is characterized by normal speech development in childhood (e.g. single words by 2-years of age and use of communicative phrases by 3-years of age). Despite nor- mal verbal development, an individual’s speech may be repetitive or of unusual voice quality. For example, a child may repeat back what you just said, or he may repeat his own words. Furthermore, the child may demonstrate poor turn- taking skills during conversation and may dominate the conversation, especially when it concerns his special area of interest. Nonverbal skills in individuals with AD are also impaired. For example, individuals may not express a full range of facial expressions. At times, it may appear as though the child is looking through you and he evidences poor eye contact. Failure to develop social relations is another characteristic of this disorder. Some believe that the insufficient conversational and nonverbal skills lead to poor social relationships. Children with OCD do not lack the social skills as those with AD do. However, in some instances a child with OCD may develop poor relationships with his/her peers. This may occur when a child’s obsessions and compulsions occupy a lot of their time, which can lead to social withdrawal. Furthermore, if the compulsions are severe the child may be unable to hide them from his friends, which could lead to teasing. The child may also develop poor self-esteem because he views himself as being different from other children, but overall children with OCD have normal peer relationships (Fruehling, Johnston, & March, 1998). Children with OCD can follow social rules, but they may adhere to an adult moral code and become upset when their peers do not follow certain rules (Neziroglu & Yaryura- Tobias, 1997). Without training, guidance, or instruction AD children will demonstrate difficulty adhering to social rules, such as not talking while others are talking or knowing when to appropriately end a conversation. Many AD children will also demonstrate poor motor coordination and clumsiness. For example, elementary school children with AD may have penmanship problems and experience difficulty with activities during physical education class (Williams, 1995). As demonstrated by the case examples, there are several similarities between OCD and AD including: shifting, incompleteness, emotions and compulsions. In both disorders the children have strong academic skills. Children with AD often demonstrate strong rote reading skills, calculation ability, and excellent memory (Bauer, 1996). Neziroglu and YaryuraTobias (1997) also report that children with OCD usually have above average academic ability. Both children will rarely feel relaxed and they will spend most of their day feeling anxious. In AD, this is especially true if the child does not know what to expect next or is overwhelmed by stimuli such as loud noises. In OCD, the child is anxious in regards to their obsessive thoughts and whether or not they are performing their compulsions correctly. Both children may experience incompleteness and require extra time to complete assignments at school and home. For the AD child, this is because they are distracted by internal and external stimuli. Therefore, they need an adult near by to redirect them to the task at hand. For the OCD child the reason differs. The child may take a long time to complete a task because they are concerned with perfection and/or doing a task until it feels right (i.e., doing it a set amount of times). Therefore, they may rewrite a paper, erase frequently, or reread the same passage repeatedly. Children with both disorders will demonstrate a need for sameness. Usually the child with AD chooses to eat the same food each day, wear the same clothing, or play the same video game, whereas the child with OCD is looking for sameness in his/her daily routines. If the OCD child exhibits the “sameness” of the AD child it is for a different reason. Both children desire control over their environment so that they may perceive it as safe and predictable. However, children with OCD may eat the same foods each day because they are “safe” or not contaminated. In children with AD the reason varies. Children with AD have sensory issues, so they may not like certain textures, smells, fabrics, or sounds (Kirby, 2003). Sometimes children with OCD may also complain of not liking the feel of the seam on their socks, or be concerned with smells that are “dirty”. Both children will demonstrate difficulty with shifting or transitioning between tasks. For the OCD child, this is because of the need for symmetry or balance. For example, if a child is working a home- work assignment on the computer and he is called for dinner, he will want to complete the entire assignment before he begins eating. If he does not complete the assignment, he will continue to feel anxious. Another example may include a child in school who has to tap the left side of the desk the same amount of times as he tapped the right side of the desk. Individuals with AD are resistant to change in their routines, prefer “sameness,” and have difficulty transitioning between tasks. For example, the child may like to always have breakfast before getting dressed and then having the parent take the same route to school each morning. An AD child may become overly upset with even the smallest changes in his environment, such as, the teacher switching the types of crayons used in the classroom. Repetitive activities are a defining characteristic of this disorder. These activities are preferred and engaged in at length. Similarly, the individual often has an intense preoccupation with one or two areas (i.e., weather, history, trains, or dinosaurs). Therefore, the child may engage in repetitive play surrounding his area of special interest, such as, lining up his model car collection on the floor. This preoccupation is abnormal in its focus and/or its intensity. In the area of interest, the individual has an incredible capability to memorize facts. Although overall conversation ability is typically poor, when discussing his area of interest, the individual may possess advanced knowledge on the topic (Treffert,1999). However, when discussing his area of interest, the conversation is usually one sided and the child may not pick-up on social cues regarding the other person’s disinterest or know when to stop speaking. Since common features of AD include anxiety, repetitive behavior, and fixed habits, it is apparent that this disorder can mimic OCD (Yaryura-Tobias, Stevens, & Neziroglu,1998). Research studies in the psychology literature have focused on distinguishing between the restricted, repetitive, and stereotypic behavior associated with AD as compared to the compulsions found in OCD (Baron-Cohen, 1989; McDougle, Kresch, Goodman, Naylor, Volkmar, Cohen, & Price, 1995). In general, AD is typically characterized by a more severe impairment in social interactions (e.g., poor social reciprocity, poor peer relationships, and poor verbal and non-verbal skills). In addition, individuals with AD tend to have a more restricted pattern of interests and activities than those individuals with OCD. For example, a child with OCD may be obsessed and fearful of contamination and germs, whereas, a child with AD has a positive interest in a particular area. The next section will focus on some of the important differences between AD and OCD that can assist one in further differentiating between the two disorders. As previously mentioned, a defining feature of AD is that obsessive thoughts surround involvement in an activity or area of specific interest. For example, an individual with AD may have a restricted interest in the area of trains. The high level of interest in this area may appear obsessional; however, it is important to bear in mind the definition of an obsession. By definition, obsessions are recurrent and persistent thoughts, impulses, or images that cause marked anxiety or distress. Individuals with AD typically do not experience anxiety or distress surrounding their area of interest. In fact, they derive pleasure from it. However, in OCD individuals experience a marked level of anxiety or distress. Therefore, ways to further differentiate AD and OCD is to assess whether the individual experiences anxiety or distress related to his obsessive thought patterns or compulsions. If the individual derives pleasure from the repetitive behavior and not just pleasure from anxiety reduction, then this feature is more likely linked to AD than OCD. To minimize or neutralize the distress, an individual with OCD will engage in compulsive behavior. In AD, obsessional thoughts do not have specific compulsions attached to them. Researchers have hypothesized that individuals with Pervasive Developmental Disorders may be unable to monitor their internal states and report anxiety related to obsessive thoughts (McDougle et al., 1995). Therefore, it is important to also examine the content of the behavior that occurs. It has also been found that some of the more common compulsions in OCD patients, such as checking and hand washing, are rarely found in AD (McDougle et al., 1995). Although, restrictive and repetitive behavior may mimic a compulsion, it is not completed with the intent to minimize anxiety or distress, nor is it specifically associated to intrusive thoughts. Distinguishing between AD and OCD is potentially easier when each disorder is occurring on its own. However, as we have seen in our clinical experience, patients present with co- morbid AD and OCD. Co-morbidity is defined as the co-occurrence of two separate disorders at the same time. In these instances, it can be very difficult for clinicians to distinguish between what may be repetitive behaviors related to AD and what may be an OCD compulsion. Exposure and response prevention (ERP) to minimize rituals and restrictive interests in an individual with AD is not very effective because the child does not experience anxiety and therefore there is nothing to “habituate” to (habituation is the process by which anxiety is extinguished). It is through habituation that compulsions are reduced in OCD (there is neuronal fatigue occurring in the brainstem reticular formation). Rituals related to AD provide comfort to the individual and are not anxiety provoking. There is no negative situation to expose the individual to, however, one can limit some of the repetitive activity. If we attempt to strip the individual of this activity entirely, we potentially risk removing one’s positive coping strategy. On the other hand, if a clinician can distinguish between behaviors related to OCD and those that belong to AD, then one can attempt to successfully treat the OCD related symptoms with ERP. If an individual with co-morbid Asperger’s and OCD presents with an overwhelming amount of compulsions and ritualized behavior, by treating the OCD with ERP the amount of compulsive behavior that the person engages in can be reduced. After the OCD symptoms are treated, then one can proceed with other treatments to address the AD related behavior. Treatment of AD typically involves social skills training, parent training, and behavior therapy to decrease unacceptable behavior, while increasing more adaptive skills. For example, if a parent wants to increase desirable homework performance in his or her child, then the parent can make activities related to the specific area of interest (i.e., reading history books) contingent upon homework completion. One should note, that targeting undesirable behavior in AD children does not mean changing those behaviors that are considered “odd,” rather interventions should target behaviors such as repetitive questioning, inappropriate homework behavior, or increasing appropriate social skills. In summary, individuals with AD or OCD may evidence similar symptoms, including, shifting, incompleteness, anxiety, compulsions, and adherence to rituals. In general, individuals with AD are more socially impaired and demonstrate difficulty forming reciprocal relationships. In AD, individuals may have obsessive thoughts surrounding a restricted area of interest, but these thoughts do not likely cause a marked level of anxiety or distress as they do in OCD. Lastly, compulsive behavior in OCD is completed with the intent to minimize anxiety. In AD, individuals derive pleasure from engaging in these activities. * To protect confidentiality, case descriptions in this article are based on composite or fictionalized clients. Fugen Neziroglu, Ph.D., is a board certified Behavior and Cognitive psychologist involved in the research and treatment of OCD for 25 years. She is the Clinical Director of the Bio- Behavioral Institute in Great Neck, NY and Professor at Hofstra University. Jill Henirksen, MS, is a school psychologist who works with children and adolescents and interned with Dr. Neziroglu at the Bio-Behavioral Institute. …………………………………………………………………………………………………………………………………………… The Relationship Between Eating Disorders and OCD: Part of the Spectrum By Fugen Neziroglu, Ph.D., ABBP, ABPP and Jonathan Sandler, BA When people think of eating disorders they conjure up images of adolescents performing rituals around food and obsessing about what to eat, how much, whether the food will be easily digested or whether the food will sit in their stomachs and make them look ugly. Others think of individuals with eating disorders appearing very similar to those with body dysmorphic disorder, both being very preoccupied with their body image. However, most people do not think of eating disorders as being part of the OCD spectrum and the relationship between the two disorders has gone relatively unstudied. Even more troubling is the fact that, when patients seek help from mental health professionals in order to alleviate their suffering, clinicians may often mistake one for the other. In other words, since the behaviors that result from both OCD and eating disorders may appear so similar, it might be difficult to determine which of the two disorders the patient actually has if both are simultaneously present and, if so, which disorder is mainly responsible for bringing about the other. Ever since 1939, researchers have speculated on the parallels between OCD and eating disorders. Numerous studies have now shown that those with eating disorders have statistically higher rates of OCD (11% - 69%) and vice versa (10% - 17%). As recently as 2004, Kaye et al. reported that 64% of individuals with eating disorders also possess at least one anxiety disorder, and 41% of these individuals have OCD in particular. In 1983, Yaryura- Tobias and Neziroglu proposed that eating disorders may be considered part of the OCD spectrum but since then the boundaries among anorexia nervosa, bulimia nervosa and OCD remain blurred. Thus, the challenge for clinicians becomes recognizing whether the condition is a particular form of OCD or actually an entirely separate, but related, disorder with symptoms that merely have an obsessive-compulsive quality to them. More specifically, individuals who suffer from anorexia commonly diet and exercise excessively; those with bulimia usually develop a vicious cycle of binging and purging. In both instances, extreme and often life-threatening behaviors that consist of either consuming too little or too much food typically stem from intrusive, obsessive thoughts. Anorexics in particular exhibit faulty perceptions of body image, an irrational fear of gaining weight, and other food-related obsessions, thereby leading to the categorical refusal to eat. As for bulimics, their disorder is characterized by a consumption of abnormally large quantities of food, followed by overwhelming feelings of guilt and shame. In other words, the sense of helplessness or lack of control they experience during binge periods ultimately gives way to obsessions of physical sickness and self-disgust afterwards. In the cases of both anorexia and bulimia, obsessions lead to levels of anxiety that can only be reduced by ritualistic compulsions. The compulsive behaviors of anorexics can often be seen in their careful procedures of selecting, buying, preparing, cooking, ornamenting, and eventually consuming food. Just as with OCD, compulsions are commonly strengthened by many other personality traits, such as uncertainty, meticulousness, rigidity, and perfectionism (Yaryura-Tobias et al., 2001). Anorexics also often exhibit overvalued ideation, cognitive distortions such as all-or-none thinking, and attempts to gain control of their environment. For bulimics, the need to feel relieved of the obsessive guilt and shame following binges causes them to compulsively purge the food they consumed, repeating the cycle over and over again. Here too, perfectionism, an excessive desire for social approval or acceptance, and bouts of anxiety or depression play a major role. In both anorexia and bulimia, the individual clearly becomes preoccupied by incessant thoughts revolving around body image, weight gain, and food intake, leading to ritualistic methods of eating, dieting, and exercising. The common thread linking both of these disorders to OCD is the overwhelming presence of obsessions and compulsions that eventually affects the individual’s daily functioning even to the extent of becoming incapacitated. Just as the OCD sufferer feels as though the door is not locked, despite evidence to the contrary, and is then compelled to check those locks hundreds of times in order to remove this doubt, so too the anorexic feels as though she is fat, despite the reality the mirror portrays, and she is thus forever checking her stomach to make sure that she has not gained weight but she is never satisfied and therefore she is compelled to lose weight by any means necessary. As with an OCD sufferer who can never achieve that “just right” feeling on a specific task, so too is a bulimic prevented from ever reaching his or her goals of fullness and emptiness in an endless binge-purge cycle. Going one step further, there are many instances in which patients demonstrate behaviors that, at first glance, appear to be indicative of an eating disorder, but actually turn out to be a result of OCD. As an illustration, consider the OCD sufferer who may lose weight excessively and appear anorexic, yet is doing so merely as the result of contamination concerns or time-consuming rituals that prevent him or her from eating on a regular basis. Conversely, consider the anorexic patient who seems to be engaging in obsessive- compulsive rituals of cutting or weighing food, yet only doing so in the hopes of restricting food intake and losing weight in the process. The potential for one disorder to appear as the other is virtually endless; below is just a small list comparing the very different underlying causes of strikingly similar behaviors in individuals with obsessive-compulsive disorder versus those with eating disorders: OBSESSIVE COMPULSIVE DISORDER EATING DISORDERS ■Individual counts the number of mouthfuls chewed or pieces of food in a meal, according to some fixed or magical number that is “correct” or “just right.” ■Individual counts mouthfuls or pieces of food as a means of limiting portions and thus effectively losing more weight. ■Individual repeatedly washes hands, due to a fear of germs, contact with waste products, or a number of other sources of possible contamination that exist. ■Individual excessively washes hands to remove trace amounts of oil that might cause weight gain if ingested. ■Individual throws out food in a can that has been slightly dented, for fear that it might contain food poisoning and later cause serious illness to someone. ■Individual throws out food in a can because it was discovered to contain too many calories after reading the label. ■Individual repeatedly asks a waiter in a restaurant about different dishes on menu, doubtful that he or she has enough knowledge to make the perfect meal decision. ■Individual constantly asks same waiter about contents of dishes, so as to stay away from having any butter, oil, or fat. ■Individual refuses to enter the kitchen in order to eat, due to fear of accidentally mixing cleaning items with the food. ■Individual refuses to enter the same room, for it will only lead to the temptation to eat and thus get fat. ■Individual repeatedly checks refrigerator, shelves or other parts of house, in order to make sure that every piece of food bought is in its proper, designated place. ■ Individual constantly checks same locations, in search of food to eat in an extensive bulimic binge period. Thus, in order to differentiate between the two disorders and make the proper diagnosis, it is crucial for the clinician to more closely examine the specific behaviors that are being observed and the motivations behind those behaviors. Whereas patients with eating disorders are primarily driven by concerns of physical appearance and consequently alter their eating patterns in order to lose weight accordingly, OCD patients may be restricting their eating for reasons very different than body image concerns. Furthermore, for cases in which an individual qualifies for both diagnoses, such as an anorexic or bulimic who also experiences non-food related OCD symptoms like checking or contamination, it is still imperative to consider whether or not their symptoms are being motivated by both disorders simultaneously. For example, consider a patient washing his/her groceries due to the fear of contamination, as well as the fear that the products may contain high fat ingredients. It should be noted that the recommended psychological treatment for both OCD and eating disorders usually involves some combination of cognitive-behavioral therapy, antidepressant medication, and family counseling. Successful treatment for bulimics, in particular, often entails classic exposure and response prevention, in which patients are exposed to their favorite foods, asked to eat, and then prevented with careful monitoring from vomiting, using laxatives, or otherwise purging. Additional techniques involve gradual alteration of eating rituals and increased flexibility in eating behaviors, which may include breaking rituals such as the need to use the same utensils, to measure food, to time meals, and to avoid certain restaurants. Because eating disorders typically result in numerous medical complications, we strongly encourage physicians and nutritionists to be part of the team. Significant advancements have recently been made in both the diagnosis and treatment of OCD and eating disorders as separate entities, but ample scientific research into the connection between the two, the commonality of their symptoms, and the possible biochemical similarities behind them is presently lacking. Fortunately, some of the most promising psychiatric investigations into the overlapping symptoms of spectrum disorders have focused on these neurophysiological similarities. One such study asked participants to engage in a task believed to activate the prefrontal cortex and caudate nucleus of the brain, so as to compare the performance of participants with OCD to that of those with anorexia. The study found that both groups had difficulty with the task and had higher cerebral glucose metabolism, suggesting a connection between the two disorders and offering evidence that “ritualized, obsessive and compulsive behavior (with reference to eating disorders as well as washing and checking OCD) could have its origin within common neurobiological abnormalities” (Murphy et al., 2004). Although such results are clearly signs of progress, they are still indirect and speculative at best. More work is therefore needed in order to properly isolate the clinical symptoms, biochemical factors, and genetic causes behind OCD and eating disorders. In one of our studies, we found that obsessive-compulsive overeaters responded to exposure and response prevention, while another group of overeaters responded better to more traditional stimulus control methods of treatment (Mount & Nezirogulu, 1991). This shows that those eating disorders that are similar to OCD may respond better to treatment strategies used to treat more typical OCD behaviors. Consequently, for the sake of all those who suffer, the obsessive-compulsive related disorders need to be studied further in order to enhance our understanding of their similarities and dissimilarities. In doing so, we will hopefully not only arrive at better treatment strategies, but also increase our knowledge of the psychological and biological mechanisms by which the disorders develop. Fugen Neziroglu, Ph.D., is a board certified Behavior and Cognitive psychologist involved in the research and treatment of OCD for 25 years. She is the Clinical Director of the Bio- Behavioral Institute in Great Neck, NY and Professor at Hofstra University. Jonathan Sandler, BA, is a research assistant at the Bio-Behavioral Institute in Great Neck, NY, and he is involved in the research of Obsessive Compulsive Spectrum Disorders. Back to Expert Opinions References 1. Kaye WH, Bulik CM, Thornton L, Barbarich N, Masters K. Comorbidity of anxiety disorders with anorexia and bulimia nervosa. Am J Psychiatry 2004; 161: 2215-2221. 2. Yaryura-Tobias, JA & Neziroglu, F. (1983). Obsessive Compulsive Disorders: Pathogenesis, Diagnosis and Treatment. New York: Marcel Dekker. 3. Yaryura-Tobias JA, Pinto A, Neziroglu F. The integration of primary anorexia nervosa and obsessive-compulsive disorder. Eating Weight Disorder Journal. 2001; 6: 174-180. 4. Murphy R, Nutzinger DO, Paul T, Leplow B. Conditional-Associative Learning in Eating Disorders: A Comparison With OCD. J Clinical and Experimental Neuropsychology 2004; 26(2): 190-199. 5. Mount R, Neziroglu F, Taylor CJ. An obsessive-compulsive view of obesity and its treatment. J Clinical Psychology Jan 1990; 46 (1): 68-78. ………………………………………………………………………………………………………………… Co les Therapy for OCD: up When OCD Becomes a Family Affair By Jonathan S. Abramowitz, Ph.D., ABPP Joshua's Story Joshua’s problems with obsessive thoughts about violence began when he was a teenager, but when he and his wife Rachel brought their firstborn daughter Amy home from the hospital, things worsened dramatically. He began having intrusive thoughts of harming his beloved infant on a daily basis. Thoughts about punching the baby, dropping her down the steps, and even putting her in the microwave came to mind and created an enormous amount of distress. Of course, Joshua loved his baby with all his heart and never acted on any of these thoughts. They were the exact opposite of his usual personality. Still, Joshua believed he was an awful parent for having these thoughts and was at a loss for what to do. He couldn’t tell anyone about the obsessions – they’d surely lock him up! – so he avoided having anything to do with his baby. This was a disappointment to Rachel, who didn’t know what was happening, and soon resented that she was changing all the diapers, doing all the feedings, and giving all the baths without any help from Joshua. Joshua and Rachel’s relationship went downhill. They had endless arguments over caring for Amy, and the level of stress in their relationship became very high. This added stress, of course, exacerbated Joshua’s OCD symptoms. Joshua even moved in with his parents for a short time. Mary's Story Mary, who had suffered from OCD since childhood, married her high school sweetheart Tom at the age of 21. Her obsessions focused on the fear of contamination from germs from strangers. She was specifically afraid of contracting the AIDS virus. Her compulsive rituals included washing, showering, and changing her clothes whenever she thought that she might have been exposed to HIV, and she involved Tom in many rituals as well. For example, she would ask Tom for reassurance about the chances of getting AIDS from doing activities such as touching a doorknob or using a public restroom. Tom helped Mary wash off all mail and groceries that were brought into the house. At times, Mary would call Tom in the middle of the day to leave his job and come calm her down. Tom complied willingly with Mary's compulsive urges – after all, he couldn’t stand to see Mary suffer. What if she had a “nervous breakdown” or something? He ended up doing just about everything possible to prevent Mary from ever having to suffer from obsessional fear. When Tom and Mary came to our clinic for therapy, Tom was performing compulsive rituals for Mary almost as often as Mary was performing them herself. OCD and Couples Both Joshua’s and Mary's stories show how OCD can negatively impact close relationships such as marriages and partnerships. Joshua’s story is rather straightforward: His symptoms led directly to avoidance, which angered his wife and led to arguments and havoc in his relationship. But Mary's story is a little less straightforward. She and her husband Tom rarely had arguments over OCD. Tom showed his love for Mary by keeping her as anxiety- free as possible. But OCD had become a part of their relationship. Their life as a couple was centered on helping Mary complete her rituals and avoid being in distress. It was like OCD was another family member. On the surface, this kind of caretaking might seem like a wonderful way for Tom to show his love for Mary, but the fact was that that this pattern only made Mary's problems with OCD worse. As much as Tom hoped that Mary could get over her problems, and as much as he reassured her that she was not in any danger from getting AIDS, Mary continued to suffer. Ironically, Tom's accommodation of Mary's symptoms played a large role in why Mary continued to suffer with OCD. Treating OCD When it Affects Relationships Cognitive behavior therapy (CBT) using the techniques of exposure and response prevention (ERP) is the most effective treatment available for OCD – it often leads to a 60% to 70% reduction in obsessions and compulsions. But unfortunately, most CBT work is done with only the OCD sufferer, leaving out other family members who might, in one way or another, influence the course of OCD symptoms. This is particularly the case for people with OCD who are in close relationships. For this reason, at the University of North Carolina’s Anxiety and Stress Disorders Clinic, we have developed and are currently testing the effects of a CBT treatment that is conducted as a couples-based therapy. The person suffering with OCD attends all of the 16 therapy sessions along with his or her spouse or partner, and the couple learns to implement the CBT skills (primarily ERP techniques) together. We also teach couples how to improve their communication and problem-solving skills so that arguments like the ones that Rachel and Joshua were having could be more easily resolved. Recognizing and stopping accommodation patterns, as in Mary and Tom’s example, are also emphasized in our therapy. Both partners take responsibility for working hard to help the person with OCD overcome his or her problems. We are hoping to find that this treatment program improves upon the long-term outcome for individuals with OCD, especially those who are in close relationships. We also expect that it will lead to improvements in relationship satisfaction. Our Couples-Based OCD Treatment Program Our treatment program has a number of similarities to individual therapy for OCD. During the first few sessions, the therapist learns all about the patient's problems with OCD, including situations that trigger obsessional thoughts and anxiety, patterns of avoidance behavior, and patterns of compulsive rituals. Time is also spent learning about the way that the couple interacts around the OCD symptoms. For example, how does OCD play a role in the relationship? How do the partners cope when the person with OCD becomes very anxious? The therapist uses all of this information to formulate a treatment plan for the rest of therapy. This plan is discussed with the couple so that both partners understand OCD and how a couples-based approach to ERP is a sensible way to reduce its symptoms. Some Closing Words Our treatment program involves a total of 16 therapy sessions, although couples work very hard between sessions practicing ERP and relationship enhancement skills so that they have an "intensive" therapy experience. The results of our initial study have been encouraging so far: We have observed an average of 50% reduction in OCD symptoms, and substantial improvements in relationship functioning and relationship satisfaction. As difficult as it might be to find therapists who are well-trained to provide good CBT (specifically ERP techniques), it is even harder to find therapists with expertise in both OCD and couples therapy. Thus, once our study has ended, we will work hard to disseminate our treatment program through trainings and workshops so that more therapists can incorporate couples work into CBT for OCD. As a long-time practitioner of individual CBT, I am now convinced that it makes sense to consider incorporating the spouses or partners of OCD patients into therapy. Dr. Abramowitz is the Director of the Anxiety and Stress Disorders Clinic at the University of North Carolina (UNC) at Chapel Hill. …… ………………………………………………………………………………………………………………………………………. Living With Someone Who Has OCD: Guidelines for Family Members (From Learning to Live with OCD) By Barbara Van Noppen, Ph.D. and Michele Pato, MD In an effort to strengthen relationships between individuals with OCD and their family members and to promote understanding and cooperation within households, we have developed the following list of useful guidelines. These guidelines are meant as tools for family members, to be tailored for individual situations, sometimes more powerfully employed with the help of a therapist with expertise in working with OCD. (1) Recognize Signals The first guideline stresses that family members learn to recognize the “warning signals” of OCD. Sometimes people with OCD are thinking things you don’t know about as part of the OCD, so watch for behavior changes. It is important to not dismiss significant behavioral changes as “just their personality”. Remember that these changes can be gradual but overall different from how the person has generally behaved in the past. Signals to watch for include, but are not limited to: 1.Large blocks of unexplained time that the person is spending alone (in the bathroom, getting dressed, doing homework, etc.). 2.Doing things again and again (repetitive behaviors). 3.Constant questioning of self-judgment; excessive need for reassurance. 4.Simple tasks taking longer than usual. 5.Perpetual tardiness. 6.Increased concern for minor things and details. 7.Severe and extreme emotional reactions to small things. 8.Inability to sleep properly. 9.Staying up late to get things done. 10.Significant change in eating habits. 11.Daily life becomes a struggle. 12.Avoidance. 13.Increased irritability and indecisiveness. People with OCD usually report that their symptoms get worse the more they are criticized or blamed, because these emotions generate more anxiety. So, it is essential that you learn to view these features as signals of OCD and not as personality traits. This way, you can join the person with OCD to combat the symptoms rather than become alienated from them. (2) Modify Expectations People with OCD consistently report that change of any kind, even positive change, can be experienced as stressful. It is often during these times that OC symptoms tend to flare up; however, you can help to moderate stress by modifying your expectations during these times of transition. Family conflict only fuels the fire and promotes symptom escalation (“Just snap out of it!’). Instead, a statement such as: “No wonder your symptoms are worse - look at the changes you are going through,” is validating, supportive, and encouraging. Remind yourself the impact of change will also change; that is, the person with OCD has survived many ups and downs and set backs are not permanent. You must adjust your expectations accordingly which does not mean to not expect something! (3) Remember That People Get Better at Different Rates There is a wide variation in the severity of OC symptoms between individuals. Remember to measure progress according to the individual’s own level of functioning, not to that of others. You should encourage the person to push him/herself and to function at the highest level possible; yet, if the pressure to function “perfectly” is greater than a person’s actual ability, it creates more stress which leads to more symptoms. Just as there is a wide variation between individuals regarding the severity of their OC symptoms, there is also wide variation in how rapidly individuals respond to treatment. Be patient. Slow, gradual improvement may be better in the end if relapses are to be prevented. (4) Avoid Day-To-Day Comparisons You might hear your loved ones say they feel like they are “back at the start” during symptomatic times. Or, you might be making the mistake of comparing your family member’s progress (or lack thereof) with how he/she functioned before developing OCD. It is important to look at overall changes since treatment began. Day-to-day comparisons are misleading because they don’t represent the bigger picture. When you see “slips”, a gentle reminder of “tomorrow is another day to try” can combat self destructive labeling of “failure”, “imperfect”, or “out of control” which could result in a worsening of symptoms! You can make a difference with reminders of how much progress has been made since the worst episode and since beginning treatment. Encourage the use of questionnaires to have an objective measure of progress that both you and your loved one can refer back to (for example, the Yale Brown Obsessive Compulsive Scale). Even a 1-10 rating scale can be helpful. Ask, “How would you rate yourself when OCD was at it’s worst? When was that? How is it today? Let’s think about this again in a week.” (5) Recognize “Small” Improvements People with OCD often complain that family members don’t understand what it takes to accomplish something such as cutting down a shower by five minutes or resisting asking for reassurance one more time. While these gains may seem insignificant to family members, it is a very big step for your loved one. Acknowledgment of these seemingly small accomplishments is a powerful tool that encourages them to keep trying. This lets them know that their hard work to get better is being recognized and can be a powerful motivator. (6) Create a Supportive Environment The more you can avoid personal criticism, the better – remember that it is the OCD that gets on everyone’s nerves. Try to learn as much about OCD as you can. Your family member still needs your encouragement and your acceptance as a person, but remember that acceptance and support does not mean ignoring the compulsive behavior. Do your best to not participate in the compulsions. In an even tone of voice explain that the compulsions are symptoms of OCD and that you will not assist in carrying them out because you want them to resist as well. Gang up on the OCD not on each other! (7) Set Limits, But Be Sensitive to Mood (refer to #14) With the goal of working together to decrease compulsions, family members may find that they have to be firm about: 1) Prior agreements regarding assisting with compulsions; 2) How much time is spent discussing OCD; 3) How much reassurance is given; or 4) How much the compulsions infringe upon others’ lives. It is commonly reported by individuals with OCD that mood dictates the degree to which they can divert obsessions and resist compulsions. Likewise, family members have commented that they can tell when someone with OCD is “having a bad day.” Those are the times when family may need to “back off,” unless there is potential for a life-threatening or violent situation. On “good days” individuals should be encouraged to resist compulsions as much as possible. Limit setting works best when these expectations are discussed ahead of time and not in the middle of a conflict. It is critical to minimize family accommodation to OCD. (8) Support Taking Medication as Prescribed Be sure to not undermine the medication instructions that have been prescribed. All medications have side effects that range in severity. Ask your family member if you could periodically attend their appointments with the prescribing physician. In this way you can ask questions, learn about side effects, and report any behavioral changes that you notice (9) Keep Communication Clear and Simple Avoid lengthy explanations. This is often easier said than done, because most people with OCD constantly ask those around them for reassurance: “Are you sure I locked the door?” or “Did I really clean well enough?” You have probably found that the more you try to prove that the individual need not worry, the more he disproves you. Even the most sophisticated explanations won’t work. There is always that lingering “What if?” Tolerating this uncertainty is an exposure for the individual with OCD and it may be tough. Recognize that the person with OCD is triggered by doubt, label the problem as one of trying to gain total certainty about something that cannot be provided, this is the essence of OCD and the goal is to accept uncertainty in life. Avoid lengthy rationales and debates. (10) Separate Time Is Important Family members often have the natural tendency to feel like they should protect the individual with OCD by being with him all the time. This can be destructive because family members need their private time, as do people with OCD. Give them the message that they can be left alone and can care for themselves. Also, OCD cannot run everybody’s life; you have other responsibilities besides “babysitting.” You need and deserve time to pursue your interests too! This not only keeps you from resenting the OCD, it is also a good role model to the person with the OCD that there is more to life than anxiety. (11) It Has Become All About the OCD! Whether it is about asking and providing reassurance to the family member with OCD or talking about the desperation and anxiety that the illness causes, families struggle with the challenge of engaging in conversations that are “symptom free,” an experience that feels liberating when achieved. We have found that it is often difficult for family members to stop engaging in conversations around the anxiety because it has become a habit and such a central part of their life. It is okay not to ask, ”How is your OCD today?” Some limits on talking about OCD and the various worries is an important part of establishing a more normative routine. It also makes a statement that OCD is not allowed to run the household. (12) Keep Your Family Routine “Normal” Often families ask how to undo all of the effects of months or years of going along with OC symptoms. For example, to “keep the peace” a husband allowed his wife’s contamination fear to prohibit their children from having any friends into the household. An initial attempt to avoid conflict by giving in just grows; however, obsessions and compulsions must be contained. It is important that children have friends in their home or that family members use any sink, sit on any chair, etc. Through negotiation and limit setting, family life and routines can be preserved. Remember, it is in the individual’s best interest to tolerate the exposure to their fears and to be reminded of others’ needs. As they begin to regain function, their wish to be able to do more increases. (13) Be Aware of Family Accommodation Behaviors (refer to #14) First, there must be an agreement between all parties that it is in everyone’s best interest for family members to not participate in rituals (Family Accommodation Behaviors). However, in this effort to help your loved one reduce compulsive behavior, you may be easily perceived as being mean or rejecting even though you are trying to be helpful. It may seem obvious that family members and individuals with OCD are working toward the common goal of symptom reduction, but the ways in which people do this varies. Attending a family educational support group for OCD or seeing a family therapist with expertise in OCD often facilitates family communication. (14) Consider Using a Family Contract The primary objective of a family contract is to get family members and individuals with OCD to work together to develop realistic plans for managing the OC symptoms in behavioral terms. Creating goals as a team reduces conflict, preserves the household, and provides a platform for families to begin to “take back” the household in situations where most routines and activities have been dictated by an individual’s OCD. By improving communication and developing a greater understanding of each other’s perspective, it is easier for the individual to have family members help them to reduce OC symptoms instead of enable. It is essential that all goals are clearly defined, understood, and agreed upon by any family members involved with carrying out the tasks in the contract. Families who decide to enforce rules without discussing it with the person with OCD first find that their plans tend to backfire. Some families are able to develop a contract by themselves, while most need some professional guidance and instruction. Be sure to reach out for professional assistance if you think that you could benefit from it. Barbara Livingston Van Noppen, PhD is an Associate Professor in the Department of Psychiatry and Human Behavior and Assistant Chair of Education, Keck School of Medicine, University of Southern California. Dr. Van Noppen provides CBT supervision and didactic education to psychiatric residents in the USC Keck School of Medicine program. Michele Tortora Pato, MD is the Della Martin Chair in Psychiatry and Associate Dean for Academic Scholarship at the Keck School of Medicine-USC. ……………………………………………………………………………………………………………………………………………… “What Can I Do to Help?” By Barbara Van Noppen, Ph.D. and Michele Pato, MD Finally, after years of not knowing where to turn, someone has given it a name. A family member has been diagnosed as having Obsessive Compulsive Disorder (OCD) and you want to learn all you can about the disorder. Caring about your loved one with OCD you have undoubtedly wondered, “What can I do to help?” After years of working with families who have a member with OCD, we have found some repetitive themes: feelings of isolation, frustration, shame, even guilt. Families wonder, “Why don’t they just stop?” Foremost is a plea for help: “What should we do?” Family members usually feel distraught, bewildered, overwhelmed, and frustrated. In an effort to help, you have probably tried to demand that the person with OCD stop his/her “silly,” “ridiculous” behavior. Or at the other extreme, you have assisted him/her with rituals, or actually performed compulsions such as hand washing or checking just to “keep the peace” (known as Family Accommodation). Either extreme has a disruptive effect on your family’s functioning, results in family member stress and can lead to an increase in obsessive- compulsive symptoms. Family conflict inevitably results. As your attempts to “help” the person with OCD are rejected or ineffective, you begin to feel helpless or impotent. Below are four suggestions about how you can be helpful to your family member: 1. Become educated about OCD 2. Learn to recognize and reduce “Family Accommodation” 3. Help your family member find appropriate, effective treatment by a qualified professional 4. Learn strategies about how to respond if your family member refuses treatment 1. Getting Educated Education is the first step. Learn as much about OCD as you can: read books, join the Obsessive Compulsive Foundation (www.ocfoundation.org), find out if the state you live in has an OCF affiliate, attend OCD support groups, research online, etc. As you learn more about the disorder, you begin to feel hopeful that you can do things to help the person with OCD overcome their disorder. OCD is a biochemically-based disorder with clinical symptoms that go beyond personality traits. As your understanding increases, you will be able to view the irrational behaviors from a non-personalized perspective. If you have been neglecting yourself, engage in self-care that will impact your ability to problem solve and respond to your family member more constructively. Your family relationships will improve and the person with OCD will feel more supported. Positive family relationships and feeling understood greatly enhance the therapeutic benefits of treatment. 2. Recognizing and Reducing Family Accommodation Behaviors “Family Accommodation Behaviors” Families are constantly affected by the demands of OCD. Results from research investigating family and OCD suggest that family responses may play a role in maintaining or even facilitating OCD symptoms. The more that family members can learn about their responses to OCD and the impact that their responses have on the person with OCD, the more the family becomes empowered to make a difference! Consider the following responses you might engage in when responding to your family member’s struggle with OCD symptoms. Is this is something you never do, do sometimes, or do all of the time?: 1. Participate in the OCD behavior: You participate in your family member’s OCD behavior along with them. For example, washing your hands whenever they wash their hands, or ask you to wash your hands; providing excessive reassurance; performing extensive checking rituals. 2. Assist in avoidance behavior: You help your family member avoid things that upset them. For example, doing their laundry for them and following prescribed orders so it is done the “right” way; opening doors, handling raw meet, changing diapers. 3. Facilitate symptomatic behavior/rituals: You do things for your family member that allows them to engage in symptomatic behavior. For example, buying excessive amounts of cleaning products for them, providing extra storage space for hoarding. 4. Modifying Family Routine: For example, you change the time of day that you shower, or when you change your clothes in order to accommodate your family members’ OCD demands that seem to take precedence. 5. Take on Extra Responsibilities of others: For example, going out of your way to drive the person with OCD places when they could otherwise drive themselves but feel unable due to OCD fears or anxiety, doing homework or other household chores for the person. 6. Modify Leisure Activities: For example, your family member encourages you to not leave the house without them. This type of modification interferes with your interests in movies, dinners out, time with friends, etc. Another example of this is complying with the request not to have company over due to disruption in OCD rituals. 7. Interference in Work Functioning: For example, you cut back on hours at your job in order to take care of your family member, go in late because of assisting the person with OCD. Parents have often talked to us about the fact that they give in to unreasonable demands because their son/daughter is so unhappy most of the time and because they themselves feel so powerless over the symptoms. We have worked with families that go out at midnight to buy fast food, or cleaning supplies for a son or daughter who has OCD, because he/she demanded it and the parents felt it could make them more comfortable and or happy. Although understandable, this type of accommodation only inflates the person’s sense of power and control and can be detrimental to normal child and adolescent development. Blaming family members is unproductive. Rather, family members can learn how to become involved in the treatment in OCD and may play a critical role in facilitating improvement in functioning as opposed to enabling the continuation of symptoms. By learning supportive behaviors that extract you from the compulsions, as a family member, you can make a difference in the course of your loved one's symptoms and in their life! What to do Instead It has been our observation that education and an emotional understanding of what it is like to experience the symptoms of OCD should accompany the family's efforts to intervene. Since many people with OCD are otherwise very functional, it is no wonder that you may tend to see the compulsions as behaviors that are within the person’s control to initiate or cease. This is a common misunderstanding. Coming to terms with the reality that your family member has “something wrong” with him/her which requires professional attention can be a painful process. Before you can effectively help, you must acknowledge the OCD and learn about it. You must know what the problem is before beginning to solve it! If you have been an “accomplice” in the OCD and now recognize this, gently withdraw and hold the line, explaining that your continual involvement (accommodation) only worsens the disorder. On the other hand, if you have refused to have anything to do with the OCD besides yelling “knock it off”, you must stop that too and learn more so that you can say the same thing, but in a way that feels more supportive and shows your understanding of the struggle the person with OCD is experiencing. In any case, it is essential to be consistent. This may mean talking with other family members to ensure a unified approach otherwise your good intentions could be undermined. For example, in one family, the mother stopped doing the laundry for her 28 year old son, but her husband did it instead, because they did not have an agreed upon plan on how to handle the OCD symptoms. 3. Helping Your Loved One Find the Right Treatment Experienced clinicians agree that a multimodal treatment approach that includes medication, behavior therapy, and family education and support is optimal. Medication Several medications are available which have a beneficial effect for individuals with OCD. Medications that are typically tried first are ones that affect a chemical in your brain called serotonin. We believe that serotonin levels in the brain are associated with OCD. A number of these medications are marketed as antidepressants as well. This is fortunate, since many patients with OCD additionally suffer with symptoms of depression, including loss of interest and energy, poor concentration, difficulty with sleep, diminished sex drive, perhaps even suicidal thoughts. It is not always clear if these symptoms are secondary to the OCD, that is, depression in response to living with OCD, or a separate illness (primary depression). Fortunately, the medications prescribed treat both the OC and the depressive symptoms. It is important for people with OCD and family members to recognize that medication alone rarely takes away all the symptoms. Adding other treatment modalities helps the person with OCD to better control their symptoms. To date, it appears that medication only works to control and not to "cure" symptoms in most cases. Again, contrary to popular belief, medication, by itself, hardly ever completely obliterates the symptoms of OCD. When the medications are effective, most people with OCD say that it helps them to dismiss the worries and resist the compulsions more easily. Some effort by the person with OCD is necessary to decrease symptoms and medication may help to facilitate this process. Studies show that without cognitive behavior therapy, when the medication is stopped, symptoms usually return within several weeks and it once again becomes more difficult to resist urges to perform compulsions. Adding cognitive behavioral therapy, particularly, exposure and response prevention (ERP), offers the best hope of getting by with less medication or no medication in the long run. Exposure and Response Prevention Therapy – The Gold Standard Cognitive behavior therapy (CBT) is the clinically researched and proven effective treatment of choice for OCD, whether with or without medication. In particular, for OCD, exposure and response prevention (ERP) is the potent ingredient of CBT. To proceed with ERP, one must first generate a list of feared or avoided situations, objects, thoughts, images, or impulses that evoke distress. To decrease symptoms, people with OCD must expose themselves directly to those situations that are feared or avoided, in a stepwise fashion, starting with the less distressing trigger and working up. Next, the person needs to be encouraged to resist, or at least delay, the compulsions they feel must be performed because of a feared consequence or heightened anxiety. This part is called “response prevention”. As exposure and response prevention is practiced over and over, the person with OCD learns that “nothing bad happens” when the rituals are resisted and his or her anxiety starts to decrease on it’s own (“habituation”). Be aware that exposure and response prevention often evokes an initial increase in anxiety. However, if the person sticks with response prevention their anxiety will eventually come down. We have had patients and family members return to a session complaining that the OCD seems worse and that the treatment is not working. Although compulsions may decrease rapidly, anxiety and often obsessions can increase in the short term. It takes longer for anxiety and obsessions to extinguish. Persistence and repetition are essential. ERP takes an enormous amount of practice and patience as well as a strong sense of motivation to tolerate increasingly high levels of anxiety. A good analogy for exposure and response prevention is exercise. When a person begins to run, for example, they start off at a slow pace and a small distance. As strength and endurance is built, greater distances can be covered at faster paces. Sore muscles along they way are interpreted as signs of good use in areas that were lacking conditioning. Have you ever heard anyone say they are giving up exercise because their muscles were sore and that it must be bad for them? As a person begins ERP, an initial increase in anxiety is often viewed as "I must be doing something wrong because this is supposed to make me feel better", instead of "This anxiety is a good sign that I'm confronting the things that make me distressed, so I will feel more uncomfortable at first". Too often people stop behavioral treatment because of the initial increase in anxiety, unaware that the habituation process takes time to occur. Compared to the length of time someone is symptomatic with OCD, decreases in distress and compulsions occur quite quickly with consistent use of exposure and response prevention. Despite this, most people are impatient and expect the worries to go away more speedily than is realistic. Even after compulsions stop, worries will linger because behaviors change faster than thoughts and feelings. Understanding all of this helps you as a support person, to be a better coach. Family Therapy Family intervention is an important adjunct to medication and behavioral treatment. One format that has been effective is the multifamily psychoeducational group. This can follow a support group format or be run by a professional (this is called Multi-Family Behavioral Treatment or MFBT). The intention of these groups is to gather together individuals with OCD along with their family members for the purpose of learning about OCD, its impact on the family, and strategies to cope. A group format provides a rare opportunity for family members and individuals with OCD to feel less isolated and less estranged. It is an empowering process to learn about OCD, share similar experiences, and discuss alternative problem-solving approaches. You will feel relieved to know that others are struggling with the same fears, concerns, questions, and conflicts related to OCD. 4. What to Do If They Refuse Treatment I have received calls and letters describing perhaps the most difficult situation: when you have a family member who absolutely refuses any treatment or may even deny that the symptoms of a disorder exist. These are extremely trying situations that evoke feelings of despair. Sometimes you may have no choice left but to carry on with your life, while reminding the sufferer periodically that you are willing to help, that you recognize their shame and distress, and that people get better from OCD. In general, people with OCD cannot begin behavioral or medication treatment unless they are willing to or the stakes are so high that it acts as a motivator. Sometimes when the discomfort or impairment becomes so great that it affects a job, relationships, enjoyment of life, the person with OCD will come forward to accept professional advice. Families have told me of watching the bottom “fall out” and just how badly things deteriorated before their loved one would admit to a problem. This is a painful process and you have choices as a support person. Often, admission to “a problem” does not mean acceptance of the problem, or giving into it; admission is the first step in being able to identify that the person has a legitimate neurobiological disorder with distinct treatment, rather than the problems stemming from character flaws. For the whole family, acceptance is a process that takes time. Possible Responses: ■Bring literature, video tapes, and/or audio tapes on OCD into the house. Offer the information to your family member with OCD or leave it around (strategically) so they can read/listen to it on their own. ■Encourage the person with the assurance that through available treatments most people experience a significant decrease in symptoms. There is help and there are others with the same problems. ■Discuss the ways in which you have been accommodating the OCD (when applicable) and how you need to work together as you disengage, so the person with the OCD knows you are doing so to support and help hem overcome the disorder, not out of spite. ■Suggest the person with OCD attend support groups with or without you, talk to an OCD buddy through online support groups, or speak to a professional in a local OCD clinic. ■Get support and help yourself ■Seek professional advice/support for yourself from someone experienced with OCD. ■Find a family buddy (another family member going through something similar). ■Talk to other family members so you can share your feelings of anger, sadness, guilt, shame, and isolation. ■Attend a support group or find out about Multi-Family Behavior Therapy to discuss how other families handle the symptoms and get feedback about how you can deal with your family member’s OCD. Allow natural consequences to occur for the person with OCD. Inform your loved one that it is in their best interest for you to be involved as little as possible with the behaviors they feel they need to perform to reduce discomfort. You are here to help them resist their compulsions, but you cannot assist or do them. Explain that you are doing all you can to understand their pain but that your giving in to the unreasonable demands will only make the situation worse. In severe cases, when the person with OCD is simply unwilling to cooperate to negotiate agreements to reduce accommodation, you may need to refuse to be involved with the OCD - no reassurance giving, no extra hand washes, no checking, no avoidance. Remind him/her that your giving in may make him/her feel better temporarily, but that it doesn’t help the symptoms to decrease, in fact, it only makes them spiral downward. This may motivate them to seek treatment, particularly if they start to be late for work or miss school more often. In some very severe cases, a sufferer will eventually choose to move out of the house, or need to be encouraged to do so. If the sufferer is not a minor, lives alone, and is not a danger to him/herself or others, there may be only so much you can do to get him/her to seek help. Above all, remember you have a life to and a right to that life! Self care is critical as is maintaining your work and social functioning as optimally as possible. You and other family members may need to seek advice/support/CBT from a clinician experienced in OCD. The best thing you can do is take action now. . .don’t wait ! Barbara Livingston Van Noppen, PhD is an Associate Professor in the Department of Psychiatry and Human Behavior and Assistant Chair of Education, Keck School of Medicine, University of Southern California. Dr. Van Noppen provides CBT supervision and didactic education to psychiatric residents in the USC Keck School of Medicine program. Michele Tortora Pato, MD is the Della Martin Chair in Psychiatry and Associate Dean for Academic Scholarship at the Keck School of Medicine-USC.