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General Information for Prospective Patients |
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Obsessive-Compulsive Disorder
(OCD)
Obsessive-compulsive disorder (OCD) is probably the most difficult of the anxiety disorders to treat. Patients can exhibit such bizarre behaviors that have often been misdiagnosed as psychotic in the past. However, we now know that these patients are suffering from debilitating anxiety or guilt.
The disorder is distinguished from the other anxiety disorders in that the person is usually overwhelmed with repugnant or fearful thoughts, impulses or images (the obsession). The person attempts to suppress or neutralize these events by performing some sort of senseless behavior or mental act (the compulsion). The person reports that these compulsions somehow gives the relief from the obsessions. However, the relief tends to be short-lived, and the person is driven to repeat the rituals once again. Any attempt to stop the compulsion by the person usually results in a rapid increase in the obsession, driving the person to repeat the ritual.
The obsessions and compulsions take many forms, but most cases tend to center around issues such as:
• Fear of contamination - leading to excessive washing
• Fear of hurting others - leading to checking to see if someone was hurt
• Fear of repugnant thoughts - with attempts to control thinking
• Need to keep things excessively neat - wasting many hours
• Need to hoard unnecessary items - such as newspapers or clothes
People can spend hours checking locks, stoves, filing cabinets, scrubbing themselves raw in the shower, repeating a prayer hundreds of times until it feels right, filling their homes with garbage rather than taking the risk of throwing anything out that is valuable, or undergoing other compulsive behaviors which they see as ridiculous, but necessary, in order to escape the anxiety.
There are two approaches for treating the disorder: one is with behavior therapy and the other is with medication. In many instances a combination of both is used.
Using behavior therapy alone, about 75% of the patients are greatly helped, and are able to return to a normal pattern of living. The treatment involves a systematic, graded exposure of the obsessions, along with teaching the patient a series of behavioral responses that are incompatible with the compulsions. For instance, the patient would be taught how to tolerate being mildly contaminated, and resist the desire to wash. The treatment involves a careful exposure to ever-increasing disturbing obsessions, with the patient practicing responses which are more in keeping with normal behavior.
Treatment length varies, with the average length for out-patient treatment being approximately six months. Relapse rate is very low after a patient has undergone successful behavior therapy, with only about 10% of the patients relapsing over the next year. If, after several months, a patient is having trouble with the behavioral approach, medication should be added. The combination increases the chances of the patient being able to escape from the disorder.
For many people, medication alone is sufficient treatment strategy. The best medications are the tricyclic, clomipramine (Anafranil), or one of the SSRIs, such as fluoxetine (Prozac). However patients show a very high rate of relapse once they come off the medication. The best way of preventing this relapse is a gradual tapering of the medication, along with an intensive behavioral program of exposure and response prevention to help the patient maintain the gains.
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