Obsessive-Compulsive Disorder (OCD) is a debilitating psychiatric disorder that presents in many forms. OCD is comprised of obsessions, which are persistent and unwanted intrusive thoughts, images, or urges. In OCD, these intrusive thoughts are considered ego-dystonic, meaning they are inconsistent with someone’s self-image, beliefs, and values. Therefore, these obsessions cause significant distress, anxiety, and worry and can greatly interfere with one’s life. To reduce or eliminate this distress or discomfort, OCD sufferers begin to engage in compulsions, which are ritualized behaviors or mental acts that serve to reduce their discomfort and anxiety. Unfortunately, engaging in compulsions reinforces obsessive thinking. Some subtypes of OCD include fears related to contamination, scrupulosity (religious-based fears)/morality, fear of harming others (aggressive or sexual), ordering and arranging, repeating, and checking. It should be noted that not all compulsions are outwardly observable and may include avoidance of triggers or mental compulsions.

Recommended Questions for Assessing OCD

Exposure and Response Prevention (ERP) is a type of Cognitive-Behavior Therapy (CBT). Cognitive-Behavior Therapy varies from other types of talk therapy in that it is focused on changing thinking patterns and behaviors. It tends to be directed at the present, rather than the past and is goal-oriented and solution-focused. ERP aims to change behavioral patterns, allowing someone to confront their fears and therefore, reduce their OCD symptoms. ERP is widely considered to be the “gold standard” therapy for Obsessive-Compulsive Disorder.

Exposure refers to the direct confrontation of one’s fear through voluntarily taking steps towards their fears and triggers. Response Prevention refers to someone voluntarily agreeing to reduce their usual rituals and compulsions. It is very important for someone that is working on doing exposures to simultaneously refrain from engaging in compulsions. Without reducing or refraining from the related compulsions, the person cannot learn that they can tolerate the exposure or that the compulsion is unnecessary.

How is ERP done? 

ERP is done by working with a therapist to examine the person’s specific obsessions and compulsions, generate a fear hierarchy, and begin to work on exposures while limiting engagement in compulsive rituals. A fear hierarchy is a personalized list of exposures. This list is created collaboratively by the person with OCD and their therapist. Exposures include situations, stimuli, or thoughts that evoke a strong, negative emotional response and to which the person has a fear or an aversion. Exposures on the fear hierarchy list should be very specific and can include variations of the same exposure (such as touching several different places on an object and for varying amounts of time). People with OCD often engage in avoidance of triggering stimuli to prevent unwanted distress as well. Much of the fear hierarchy can be generated by examining situations and stimuli that the person avoids. A Yale-Brown Obsessive-Compulsive Symptom (Y-BOCS) Checklist may be completed to help generate ideas. It can also be helpful to gather ideas from family members as well. The goal of exposure work is to slowly and carefully work to approach each of these triggers in a strategic manner.

In vivo exposures refer to confronting one’s fears “in life” or through direct confrontation. This type of exposure is appropriate for things that can be directly approached or confronted. Imaginal exposures refer to mentally imagining being exposed to one’s fears. This type of exposure is utilized for exposures not appropriate for direct confrontation (fear of hitting someone with one’s car). Similarly to in vivo exposures, imaginal exposures are done in a gradual manner and should always be done voluntarily. A SUDS (Subjective Units of Distress Scale) is used to communicate the person’s perceived level of distress, generated by engaging in exposures while refraining from compulsions. The fear hierarchy is arranged to allow someone to work from lower-level exposures to higher-level exposures.

The central premise of OCD is intolerance of uncertainty, with the goal of ERP being to increase the level of tolerance to uncertainty, rather than working to disprove the fear or find ways to become certain. Although it is very common for families to accommodate compulsive behavior or give reassurance when they see a loved one in distress, accommodation and reassurance exacerbate OCD by not allowing the person to learn to tolerate their discomfort. Instead, it is helpful to allow the person to gradually learn how to tolerate their distress with the help of a trained therapist.

How does ERP help with OCD symptoms? 

Exposure and Response Prevention is accomplished through gradual behavioral change, which occurs in the form of habituation and extinction. Habituation occurs with repeated exposure to a particular stimulus. This happens when we become numb or desensitized to things that we see, hear, or do on a regular basis. For example, if we live next to a noisy highway, we might initially be very aware of the noise. However, after living there for a while, we become accustomed to this constant sound, and we learn how to “drown it out.” Habituation in ERP works in a similar manner by repeatedly exposing a person to their feared triggers. Over time they habituate to those triggers and the strong emotions associated with their fears disappear. Extinction occurs when a reinforcer (something that influences behavior) is no longer effective at bringing pleasure or reducing distress. In the case of ERP, by reducing the compulsive behavior that reinforces the anxiety or distress, the obsessive thoughts decrease over time.

If you believe that you or someone you know might be suffering from OCD symptoms, it’s important to reach out to a professional with specialized training in OCD treatment. With the proper treatment, OCD can be a very manageable condition.

By: Jennifer B. Wilcox, PsyD

By: Jennifer B. Wilcox, PsyD
Staff Psychologist, OCD and Anxiety Disorders Program

 

 

 

 

What is compulsive hoarding?

Hoarding Disorder is a psychiatric illness and is considered to be a subtype of Obsessive-Compulsive and Related Disorders. The Diagnostic and Statistical Manual of Mental Disorders – 5th Edition (DSM-5) defines Hoarding Disorder (HD) as:

Persistent difficulty discarding or parting with possessions, regardless of their actual value. This difficulty is due to a perceived need to save the items and to the distress associated with discarding them.

The difficulty of discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use.

The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others).

The hoarding is not attributable to another medical condition and is not better explained by another mental disorder.

 

 

 

 

 

 

How is compulsive hoarding different from normal clutter or collections?

It is not uncommon for people to acquire a few extra possessions from time to time, resulting in occasional clutter. However, while normal clutter or collecting doesn’t usually interfere with a person’s daily functioning, compulsive hoarding often does. Compulsive hoarding also differs from normal clutter or collecting as it tends to become unmanageable, overwhelming, and causes significant distress or family discord. Though collections usually bring people joy and fill them with pride, hoarding often comes with shame and embarrassment.

Why do people hoard things?

Compulsive hoarding is thought to result from a combination of factors including genetics, environmental factors, life experiences, and learned behaviors. The reason one person hoards may not be the same as the reason someone else hoards. Some people who hoard are compulsive shoppers and acquire more things than they need or have room to accommodate. Others may have difficulty categorizing or making decisions about what to do with particular items. Sometimes they can’t remember what they own or where it is, leading to the purchase of duplicate items. Other times people hold on to possessions for emotional or sentimental reasons or get anxious when they discard things. Some people believe that the hoarded items may be useful someday and keep the items despite not needing them currently. The level of insight a person has about their struggles in these areas can vary widely from completely absent insight to good insight.

What types of things do people hoard?

The types of items a person hoards vary based on factors such as the reason they are hoarding and how severe their hoarding issues have become. Some commonly hoarded items include books, newspapers, magazines, boxes, bottles, clothes, food, items purchased in bulk, collectibles or vintage items, furniture, animals, or digital media.

How many people suffer from Hoarding Disorder and who does it affect?

While the exact prevalence of people who suffer from Hoarding Disorder is not certain, it is estimated that it affects approximately 2.5% of the general population. Studies have shown that prevalence rates in men and women are nearly equal and appear to be consistent across developed countries. Most studies report onset between 15 and 19 years of age and show a chronic course over the lifespan.

What is the treatment for Hoarding Disorder?

Hoarding Disorder is treated using Cognitive-Behavioral Therapy (CBT), a type of therapy that allows someone to work with a therapist to shift their thinking patterns and change their behavioral patterns to healthier ones. Randomized controlled trials have shown this to be an effective treatment for hoarding. While the data on the efficacy of medication for Hoarding Disorder is limited, there is some evidence to support the use of medication in the treatment of this disorder. For those hoarders who have limited insight, a Motivational Interviewing (MI) approach can help to foster their motivation and confidence. Finally, working on skills that improve the hoarder’s ability to maintain attention and focus, categorize items, and decision-making can be beneficial in treating Hoarding Disorder.

What can I do to help a loved one who seems to have issues with compulsive hoarding?

It is generally not recommended for family and friends to discard hoarded items without the hoarder’s permission. This can be extremely distressing for a compulsive hoarder and tends to make them upset, anxious, or angry. Instead, it is recommended that friends and family talk to their loved ones about their concerns and help them to seek professional treatment. Additional resources are available at the International Obsessive-Compulsive Disorder Foundation (IOCDF) and the Anxiety and Depression Association of America (ADAA).

Resources:

American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. American Psychiatric Association Publishing, Arlington, VA.

Treatment of Hoarding Disorder

https://instituteofliving.org/programs-services/anxiety-disorders-center/what-we-treat-at-the-adc/compulsive-hoarding

https://www.psychiatry.org/patients-families/hoarding-disorder/what-is-hoarding-disorder

Postlethwaite, A., Kellett, S., Mataix-Cols, D., 2019. Prevalence of Hoarding Disorder: A systematic review and meta-analysis. Journal of Affective Disorders 256, 309-316.

OCD is a common disorder and affects 1 in 40 people, it is also the 3rd most common psychiatric condition. This disorder can be very tricky and tries to tell lies to keep people trapped in anxiety. Below are the 10 common tricks it tries to use to keep the anxiety lingering as well as how to combat them.

The most common trick is OCD trying to convince you that “this time it is not OCD.” It is important to educate patients how to spot the difference and it’s helpful to emphasize that OCD tends to feel like an emergency and needs to be attended to immediately. One way to treat this lie is to do the “public service announcement” test which is basically challenging the patient to call the radio and request to make a public service announcement to warn people about their fear (i.e., please inform everyone they should not wipe less than 20 times when going to the bathroom, it is not safe to do less than this). This strategy helps them test out their belief and helps them realize they need to accept uncertainty but increase willingness to bet that is OCD and not give in to the compulsion.

The second most common trick is that OCD convinces you that “only crazy, bad, dangerous people have these thoughts.” It is important to teach patients that the content of one’s thoughts is the maker of “crazy, bad, dangerous.” Also educating patients that everyone has intrusive thoughts and how we cannot control our thoughts helps normalize this.

The third most common trick is “if only I knew why I had these thoughts I could stop my OCD.” Many patients have found the why, but actually only have recovered once applying evidence-based CBT skills. Teaching patients that finding the why will not solve their OCD is important.

The fourth most common trick is thinking “you’ll never beat me (OCD), so don’t even bother trying.” Teaching patients that short-term comfort will only lead to worse OCD and more discomfort overall, but short-term discomfort will actually lead to a more free and comfortable life is important for this trick.

The fifth most common trick is to convince you that you must control your thoughts. Teaching patients it is impossible to control their thoughts will be helpful for beating this trick. The more you try to control them the worse they get. Having patients use meditation like leaves on a stream to allow them to practice observing their thoughts is helpful for this.

The sixth most common trick is trying to convince you that compulsions must be done perfectly. To combat this helping the patient complete the compulsions imperfectly is helpful, such as changing the language of compulsions, or changing the preferred hand to complete the compulsion.

The seventh most common trick is convincing you that rituals will help give you the comfort of certainty. This is a common trick and one that patients spend a lot of time trying to obtain. Teaching patients that there is never certainty in anything is key here. Helping the patient see all the ways they are able to tolerate uncertainty in other areas of their life is helpful: while driving, while eating, when going to bed, going to the grocery store, etc.

The eight most common trick is that you will feel better with reassurance. Helping them reduce reassurances is helpful here, which can be done by tracking reassurances and reducing them by 20% each day to week.

The ninth most common trick is thinking you have a great responsibility to keep everyone safe. One cool technique for this trick is to have patients actually try to make something happen to you by thinking “I hope you break leg tomorrow” or “I hope you get a flat tire on your way home.” This helps the patient see that they don’t actually have control over things.

Finally, the tenth most common trick is thinking” if you don’t do this ritual, something bad will happen to you or your family.” To combat this last trick it can be helpful to change the way you do the ritual as mentioned previously, and to also purposefully wish for bad things to happen, which directly targets the fear.

Many who struggle with OCD are probably noticing a spike in their symptoms during these unprecedented times. Stress and uncertainty can often make OCD symptoms flare. Those who struggle with specific types of OCD may be having an even harder time: specifically those with contamination concerns and those concerned with harming others. Another symptom of OCD that may be particularly hard currently are perfectionism tendencies. While it may be harder to fight back against OCD with everything going on right now, it is more important than ever to not give in to compulsions and let them take over your life. One simple step you can take is to stay connected to your therapist, likely via telehealth at the moment. Having regular sessions during this time is key, especially as symptoms flare. Staying connected to others online or through social media options is also important, as the more you are connected to others the less stress you will notice. Another key piece is to continue to do things you enjoy and that bring you pleasure, as this will help lessen stress as well. Keeping a structured routine can be helpful and can help make things to continue to feel more normal. It can be important to try to continue with whatever routine you had going before that you are still able to do, for instance still getting at the same time in the morning and getting ready for work even if you are working from home. Adding consistent exercise into that routine will also be helpful, as this helps create endorphins and naturally lessens anxiety. Lastly, avoid reading the news all day, which will only lead to more stress and anxiety. It is important to limit access to only a couple of trusted sites and not get carried away with reading up on everything all day long.

Some specific OCD related steps you can take will vary depending on the type of OCD you have. For those who struggle with contamination concerns, get familiar with the CDC guidelines for the current pandemic and do not add other steps that are not recommended. For instance, they are recommending only washing hands for 20 seconds after being outside or in public, before eating, after going to the bathroom, and after you’ve coughed/sneezed/blown your nose. If soap and water are not available, they recommend you use hand sanitizer that contains at least 60% alcohol. They also only recommend disinfecting surfaces once per day. This should only take a few minutes per day and they suggest only focusing on the surfaces in your home that are frequently touched. It is also important to think about whether this is truly needed (for example, if you stayed home all day and had no visitors, do you really need to disinfect that doorknob?). It is also important to avoid some news sources that might not offer expert recommendations but rather their own opinions.

For those who struggle with fears of harming others, these symptoms might tackle the current pandemic and cause you to obsess about whether or not you might have infected someone or whether or not you might infect someone in the future. This might be a similar theme to past fears of contamination concerns, but it will still be helpful to alert your therapist to the new content so that new exposures can developed.

For those who struggle with perfectionism tendencies, this might be an especially trying time. The perfectionism could target all of the changes going on and adaptations people are having to make to conduct
their jobs, manage their families etc. It is important to give yourself a break and realize that it is impossible to be perfect in anything we do, but especially now during all of this change and uncertainty. Practice doing one or two things imperfectly on purpose as an exposure.

One important exercise I make sure to encourage all of my patients to do is to keep track of their victories against OCD, whether the victories are big or small. Keeping track of successes and not dwelling on everything that is going wrong is a helpful way to stay on track and to realize everything that you are doing to fight OCD, which is likely a lot. It can sometimes be hard to pick out the successes and often others only notice the failures or slips, but there are victories in there as well that deserve your attention and that can help give you confidence to fight back even harder next time

Nicole Bosse, PsyD
Lindner Center of HOPE, Staff Psychologist

By Nicole Bosse, PsyD, Lindner Center of HOPE, Staff Psychologist

Kyle has been happily married to his wife Joanne for 5 years. One night while watching a movie together, he notices the thought in his mind, “Gee, that Matt Damon is a good looking guy!” He then is suddenly flooded with a wave of panic and fear that perhaps the presence of this thought means he is gay and his whole marriage is a sham.  Although this scenario is fictional, it is an all-too common manifestation of a form of obsessive compulsive disorder.  Referred to as sexual orientation- obsessive compulsive disorder (SO-OCD).  SO-OCD is characterized by recurrent distress-producing doubts about whether one is gay or straight, fears of becoming homosexual (or becoming straight if their sexual orientation is homosexual), or fears that others might perceive the individual having the undesired sexual orientation.  (Williams, 2008). A person may have only one of these concerns or some combination. SO-OCD is very different from ordinary doubts and anxieties that are experienced by individuals attempting to discern their sexual orientation. For example, an individual coming to understand that they are gay may feel anxious about coming out or about the potential changes this will bring to their lifestyle. As clinicians, it is important to thoroughly assess if their client’s intrusive thoughts are ego-dystonic. In SO-OCD, ego-dystonic intrusive thoughts are cognitions that are inconsistent with the individual’s fundamental desires, wants, and sexual history.

Individuals with SO-OCD typically experience confusion and shame, which may unfortunately deter them from seeking appropriate treatment. Another factor that might impact entering appropriate treatment is that many of the individuals who struggle with this type of OCD have very few observable compulsions, which can prevent it from being recognized and properly diagnosed. Many of the compulsions typically take the form of cognitive compulsions, specifically mental reviewing to check the presence or absence of feelings of attractiveness or arousal, reassurance seeking, self-observation to see if one “looks”, talks, walks, or gestures like someone who is gay or straight, and avoidance of situations that might trigger fears.

Treatment for SO-OCD is very similar to treatment for other categories of OCD, specifically exposure and response prevention (ERP) is the gold standard treatment. It is important to emphasize in treatment that it is impossible to control thoughts and that typically trying to control thoughts or push thoughts away significantly increases them. Next it is key to explain ERP and to help them understand the reason why they are leaning into the anxiety. It can be particularly helpful to have them identify what in their life would be different once their OCD is no longer in the picture. Once the client is on board with and understands the importance of exposures, the client and clinician work collaboratively to create a hierarchy of exposures. It is important to begin with low distress exposures at first, and then gradually work up the hierarchy once they habituate to the low level exposures.

As with any form of OCD, exposures for SO-OCD can take various forms, depending on the client’s core fear. For example, one client’s core fear may be that they need to be 100% certain that they are attracted to individuals of the gender of their preferred sexual orientation, while another client’s core fear may be that they do not want to hurt the person they are with if they one day discover they are attracted to a different gender. In short, it is very important to first identify what their core fear is before creating the exposure hierarchy. Some common exposures for clients with whom I have worked whose obsessions focus on fears of being gay include identifying attractive individuals of the same sex, watching movies involving homosexual characters, attending pride events, writing sentences stating “I am homosexual,” or writing imaginal scripts about coming out to loved ones or sitting with uncertainty that they will never know 100% if they are in the correct relationship. It is also important to emphasize the second component of exposure and response prevention, namely response or ritual prevention. For instance, it would be necessary for the patient to not give in to reassurance seeking or mentally assess arousal before, during or after exposures.

Treatment length can vary depending on severity of symptoms. It is important to work with someone who specializes in OCD. Typically, therapy occurs once per week with the idea that once exposure work is started the client will be completing exposures each day between sessions.

OCD, Somatic Symptom Disorder, or Illness Anxiety Disorder?

By Angela Couch, RN, MSN, PMHNP-BC, Lindner Center of HOPE, Psychiatric Nurse Practitioner

Hypochondriasis has been replaced in the DSM 5 by Somatic Symptom Disorder (SSD) or Illness Anxiety Disorder (IAD), both categorized under Somatic Symptom and Related Disorders.  Previous diagnoses classified under Somatoform Disorders were often interpreted with a negative connotation, implying that the patient’s concerns were not real or valid. However, it is not appropriate to give a person a mental diagnosis for no other reason than no medical cause can be identified, nor does the presence of a medical diagnosis exclude a co-morbid mental disorder.  About 75% of persons previously diagnosed with Hypochondriasis will fall into the category of Somatic Symptom Disorder, while the other 25% will meet criteria for Illness Anxiety Disorder.  Let’s examine the differences.

Somatic Symptom Disorder (SSD), requires the patient to have one or more somatic symptoms (that is to say, pertaining to the body), that are distressing or result in significant disruption of daily life. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns are manifested by at least one of the following: disproportionate and persistent thoughts about the seriousness of one’s symptoms, persistently high level of anxiety about health or symptoms, and excessive time and energy devoted to these symptoms or health concerns.  Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent, generally more than 6 months duration. Specifiers include predominant pain (formerly pain disorder), persistent, and mild, moderate or severe. High health anxiety can be a symptom of SSD but is not necessary for a diagnosis of SSD. Patients with SSD often seek care from multiple doctors and often feel their assessments were inadequate. Reassurance given does not seem adequate nor to last for these patients. Patients with SSD may worry that excessive physical activity may damage their body and may seem more sensitive to medication side effects.  The prevalence in adults may be 5-7% of the population, likely more common in females. In comparison to Obsessive-Compulsive Disorder (OCD), the recurrent worries are less intrusive and individuals may not exhibit repetitive behaviors aimed at reducing anxiety other than seeking assessment.  Usually in OCD, the obsessions would not be confined to somatic symptoms.

Illness Anxiety Disorder (IAD), requires the patient to have a preoccupation with having or acquiring a serious illness. Somatic symptoms are either not present or are mild in intensity. If another medical condition is present or there is a high likelihood of developing a medical condition, the preoccupation is excessive or disproportionate. There is a high level of anxiety about health and the individual is easily alarmed about their health status. The individual performs excessive health related behaviors, such as body checking, or exhibits maladaptive avoidance, such as avoiding medical assessment.  In IAD, the distress has been present for at least 6 months, though the specific illness targeted may change during that time. The preoccupation is not better explained by another mental disorder such as SSD, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-compulsive disorder or delusional disorder. In IAD, the distress comes from the distress about the significance, meaning or cause of the complaint, not from a specific physical symptom or sensation. Most commonly, the physical symptoms exhibited are normal type sensations or considered benign or self-limiting dysfunction. Individuals who have IAD may be easily alarmed by reading or hearing about illnesses, and often will seek reassurance about illnesses through internet research or speaking to doctors or friends and family. In a smaller number of cases, the patient may be help avoidant versus help seeking. The reassurance given by medical professionals may potentially heighten the patient’s anxiety. Those who have IAD may avoid activities in order to avoid harming themselves or catching an illness from others.  The prevalence of IAD is possibly between 1.3-10% in the general population, and in ambulatory medical populations the 6-12 month prevalence is between 3-8%, and about equal across the sexes. The prevalence in OCD is also equal across the sexes. Persons with IAD may exhibit the intrusive thoughts about having a disease and may do compulsive behaviors such as reassurance seeking, but the preoccupations are usually focused on having a disease; in OCD, the intrusive thoughts are often about potentially getting a disease in the future or wanting certainty that they do not have one right now. In OCD, the obsessions and compulsions usually extend beyond disease concerns.

One study examined 118 treatment seeking patients with health anxiety, and gave them structured diagnostic interviews to assess for Hypochondriasis, IAD and SSD, as well as co-morbid mental disorders; additionally, the study looked at self-report measures of health anxiety, co-morbid symptoms, cognitions and behaviors, as well as service utilization. 45% of patients were diagnosed with SSD, 47% with IAD, and 8% with co-morbid SSD/IAD.  SSD and IAD were seen to be more reliable diagnoses than Hypochondriasis. Half of the sample group met criteria for Hypochondriasis, and of that sample, 56% met criteria for SSD, 36% for IAD, and 8% for co-morbid SSD/IAD.  SSD was characterized by higher levels of health anxiety, depression, somatic symptoms, and health service utilization, in addition to higher rates of major depression, panic disorder and agoraphobia.

Patients with these diagnoses often present in medical settings initially, and arrive in a mental health care setting via referral from another medical provider. It is important that medical providers validate the individual’s experience of symptoms and their anxiety, but also explain the rationale of supplementing medical interventions with mental health treatment.

Summary of Differences:

IAD                                                                             SSD

Absence/minimal distressing physical                Presence of distressing physical
symptoms                                                                  symptoms

 

High health anxiety not a requirement                 High health anxiety always present

 

Reassurance seeking common, but also             Reassurance/assessment seeking
less frequently can be care avoidant related
to anxiety

Equal across sexes                                                 More common in females

 

May engage in additional compulsions                More frequently associated with co-morbid depression, panic disorder,

higher level of health anxiety, and more utilization of medical services

 

References:

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition.  Arlington, VA, American Psychiatric Association, 2013.

Newby, J.M., Hobbs, M.J., Mahoney, E.J., Shiu, W. and Andrews, G. DSM-5 illness anxiety disorder and somatic symptom disorder: Comorbidity, correlates, and overlap with DSM-IV hypochondriasis. Journal of Psychosomatic Research, 101, 31-37.

Charles F. Brady, PhD, ABPP, Lindner Center of HOPE, Clinical Director of Outpatient Services and Staff Psychologist, OCD/CBT Psychotherapist, Associate Professor, University of Cincinnati’s Department of Psychiatry

In today’s culture the terms “obsessive” and “compulsive” have been adopted to refer to excessively repetitive thoughts and hard to resist behaviors.  In clinical situations this overly broad definition leads to substantial confusion when discussing obsessive compulsive disorder (OCD) and substance use disorders (SUDS).  Individuals who report they are always thinking about using addictive substances and “cannot stop” acting on their urges to use, are often erroneously referred to as obsessing about using or compulsively using.  Most often, someone who is struggling with a SUD does not have OCD and vice versa. However, both research and clinical practice reveal that these two conditions co-occur frequently.  Mancebo et al, 2009 documented that in their sample of OCD treatment seeking patients, twenty- seven percent were found to have SUDS.  To address the inevitable chicken and egg question, they delved further to uncover that seventy percent of the patients with co-occurring OCD and SUDS reported that their OCD symptoms preceded the onset of their SUD by at least one year.   They also found that in their sample, the participants who reported childhood onset of OCD symptoms were at higher risk for subsequently developing a SUD.  In this article, the similarities and differences between OCD and SUDS will be explained and the pertinent issues regarding the approach to treatment when a person suffers from both OCD and a SUD will be detailed.

Psychologically, the difference between a person struggling with OCD and a person with a SUD lies in what fuels the behavioral urge.   For the person with a SUD, the behavior is positively reinforced. By this we mean that the mind anticipates pleasure from completing the action (i.e., using a substance).  For the OCD sufferer, negative reinforcement describes the mechanism of striving to reduce distress as the key for driving the behavioral urge behind the compulsion.   An additional difference is that thinking about substance use initiates a pleasure experience, whereas the intrusive thought the person with OCD experiences initiates a distress response (e.g., What if I touch a door knob and die?).  There are occasions in which the person with a SUD will express that they use their addictive substance even though they do not want to.  Typically, such an individual continues to experience pleasure and pleasurable anticipation of the use of the substance, but over time they develop an aversion to the negative consequences that use of the substance has brought into their life (e.g., loss of job, legal problems., relationship damage, shame, etc…  ).

Biologically, it appears that the orbitofrontal cortex (OFC) plays an important role for both SUDS and OCD.  The OFC is a part of the brain that helps to reign in emotional reactions.  For individuals with OCD, the OFC tends to be over activated, even in neutral situations. For individuals with SUDs, the OFC becomes over active in the presence of triggers. For instance, when a person with an alcohol addiction hears or sees a beer can being opened.  When the OFC is over activated, the individual experiences an intense drive to act and is overwhelmed by their desire to act.   This is why sufferers of both SUDS and OCD struggle to resist their urges to perform a compulsion or to engage in their addictive behavior.

For the individual with OCD and a SUD, the relationship between the two may vary.  Some individuals develop addictions as an attempt to soothe and self-medicate the distress caused by their OCD. Yet others may find that their use of addictive substances follows OCD-like rules.  For example, the person who must drink 7 ounces of alcohol per night due to the obsession that if they do not, something bad may happen to a loved one.  If the use of the substance is nested within a compulsion, exposure and response prevention (ERP)targeting the compulsion may need to be started.

At times if the addiction greatly interferes with treatment for the OCD symptoms then treatment must include aggressive treatment of the SUDS early in the treatment process. There are several ways in which substance abuse disorders, if untreated can impede effective treatment of OCD. First, many substances, including barbiturates, alcohol and benzodiazepines that are involved in SUDs are depressants.  They either cause or exacerbate depressed mood. If a person’s mood is depressed, the motivation and drive necessary to engage in ERP treatment for their OCD symptoms may be severely impacted.  Also, the essential component of successful ERP treatment involves learning. The person with OCD learns that the obsessive thoughts they experienced are not as dangerous or as intolerable as they previously believed.  This learning allows them to free themselves from compulsions and helps them resist relapse. Many individuals develop SUDS in an attempt to self-medicate and soothe the distress caused by their OCD by using drugs like alcohol, benzodiazepines (e.g., valium, Xanax, Ativan,  etc…), and marijuana. Unfortunately, these substances impede learning. The patients who are unable or unwilling to reduce or cease their abuse or dependency of these substances while they engage in ERP are going to have a more difficult time accomplishing the learning needed for recovery from their OCD symptoms.

When treating a patient with a co-occurring SUD and OCD, the clinician also must consider how willing and motivated is the person to tackle both the addictive behaviors and the OCD behaviors.  It is not uncommon for a person with a co-occurring SUD and OCD to be more hesitant and resistant to let go of their addictive behaviors as they derive some pleasure from them, yet they may be very motivated to rid themselves of their time consuming compulsions and the anxiety triggered by their obsessions.  In such instances, the clinician may need to start where the motivation allows, but continue to educate and explore with the patient about how the addiction may impede their OCD recovery and how it also may be negatively impacting their health and well-being.

In conclusion, for clinicians who treat individuals with OCD or SUDs, it is of primary importance to assess for symptoms of both disorders.  The person who presents with complaints of a SUD, may be ashamed of the absurdity of their obsessions and compulsions and may not volunteer them.  Likewise, the person with OCD may also feel hesitant to report their use of substances.  When the clinician discovers that a person may have co-occurring OCD and SUDS, the patient will benefit most from a thoughtfully and collaboratively developed treatment plan to address both conditions.

References:

Mancebo et al.,  J Anxiety Disord. 2009 May; 23(4): 429–435

BY: Elizabeth Wassenaar, MS, MD, Lindner Center of HOPE, Staff Psychiatrist and Medical Director of Williams House

 

Life can be overwhelming and we all would like to take a day off every once in a while. Likely, as helping professionals, we don’t take mental health days as often as we could actually benefit from them.  This is one of the reasons why, when a child or adolescent refuses to go to school, we may be initially sympathetic.  Maybe a day or two off will help, we may think.  In too many cases, however, we see that a day or two off turns into something much more problematic as parents and professionals struggle to get a school avoider back to school.  Homework piles up, grades start to fall, and friends wonder what has happened to their classmate.  Parents try many different tactics to try to get their child back to school; bribing, negotiating, punishing, or even carrying a child through the school door.

Children want to not go to school for many reasonable causes: kids can be cruel; learning can be difficult; anxiety about performance can be overwhelming; health concerns can require special privileges that feel too identifying; and getting up early in the morning is harder for some more than others. Furthermore, mental illness can make school attendance difficult for many additional reasons.  There are good reasons to keep children home from school – physical illnesses can be contagious, some stages of mental illness are better treated with mental rest, and in some cases of bullying the safest way to deal with an unsafe situation is to remove the child.

Nevertheless, school refusal is avoidance, and anxiety loves avoidance. Nothing is more reinforcing that one cannot handle something than not doing it.  So, after one has checked on physical health and for other explanations, how can professionals support parents to keep their children in school or break the cycle of school avoidance and school refusal?

  1. Help parents identify the behaviors of avoidance and link that to anxiety.

Avoidance is a coping mechanism for dealing with anxiety, which can become maladaptive when avoidance becomes the only options. Avoidance can look a lot of different ways –tantrums, tearfulness, vague physical symptoms, negotiation (more on that later), chaos, and so on.  Parents may not be able to recognize all of the forms avoidance can take. Helping them objectify avoidance will help them strategize on how to deal with it.

  1. We have to truly believe that avoiding school will not make it better.

It can be tempting to collude with anxiety that the precipitant needs to be avoided for all the reasons laid out in this article and we need to be internally convinced that anxiety is not correctly assessing the situation. As difficult as school can be, school occupies a unique place in a child’s life.  It is the place of work, play, and love.  Learning and playing are the main jobs of childhood.  Playing looks both like playing at recess and like experimenting in relationships with both friendship and love. Identity is formed and reformed through our work, play, and love.  When a child is not in school for an extended length of time, they are abrupting their opportunity for this developmental process to proceed.

  1. Negotiation is another way of avoiding and is a dangerous game.

Many of my patients have used a variety of negotiating tactics with their parent: “Let me go in later and then I’ll go, I promise” or “Let me catch up on my work today and I’ll go in tomorrow”. Small avoidances add up to large avoidance and are not moving towards your goal.  Reverse the negotiation and set up conditions that will allow an out as long one starts the day at school.  Often, once anxiety has lost its argument that one cannot handle going to school, staying in school through the day is easier to manage.

  1. Encourage parents to work with the school

Parents and school are on the same side of this concern – both parties want the child to be successful in school. For parents, this may be the first time dealing with school refusal, but it is most certainly not the first time the school has dealt with school refusal.  Most schools have a variety of plans to help keep a child in school.  Have parents reach out to the school and let them know what is going on.

  1. Set small goals that lead to the victory

The ultimate goal of full school participation is an overwhelming prospect. Depending on how severe the school refusal is, reintroducing school can be an extended process of gradually introducing larger and larger challenges.  Perhaps, on the first day, one can only walk through the school doors.  Maybe a student will be able to be in the school building, but not in classes.  Parents can engage trusted friends to provide motivation and encouragement through social interaction and distraction while at school.

  1. School has many different forms

Many families choose alternative school arrangements including home schooling, virtual schooling, and others, for a variety of reasons and this article is not meant to convict choices that do not have a child in a classroom every day. There are many viable options for school that provide an environment that promote healthy development.  When a family is making a decision to change the way school is delivered, help them examine what factors are involved in their decision.  If they are making the decision from a place of believing that the anxiety that drives school avoidance cannot be defeated then, help them with all the ways described above.

School is a venerable and sometimes dreaded rite of passage. A great deal rides on academic and social success in school which increases anxiety and can lead to school refusal.  As a team, parents, professionals, and schools can help keep children and adolescents in school and accomplishing their goals.

On October 28, 2015, Dr. Elizabeth Wassenaar, Lindner Center of HOPE Psychiatrist and Williams House Medical Director, joined Lon Woodbury on the Woodbury Report radio show.  Their discussion focused on outlining the benefits of a residential assessment for mental health concerns in adolescents.

Click here to listen.

Private offices enable clinicians and patients to work together in a comfortable environment.

Charles Brady, PhD, ABPP, Director OCD and Anxiety Program at Lindner Center of HOPE discussed Diagnosis and Treatment of OCD on a recent One Hour at a Time episode.

To download and listen to the program, click here.

Obsessive Compulsive Disorder (OCD) was once thought to be an untreatable condition.  However, in the past 30 years psychiatric and psychological treatment advances now allow individuals with OCD to manage and overcome their symptoms and live fulfilling and meaningful lives.  Untreated OCD is a potentially disabling condition that strikes children and adults. Estimates of up to three percent of the population will battle OCD at some point in their lives and it affects men and women in equal numbers. It delivers a staggering toll for the individual and society, as individuals with OCD to have much higher than expected rates of under-employment and unemployment.  With treatment , a person suffering OCD can now expect to free themselves from OCD’s grip. Dr. Charles Brady, from Lindner Center of HOPE’s OCD and Anxiety treatment program will discuss the nature of OCD including how it is diagnosed and how current evidence based treatments are able to help individuals reclaim their lives.

 

 

Guest Bio:

Dr. Charles F. Brady directs the Lindner Center of HOPE’s Obsessive Compulsive Disorder and Anxiety treatment program. He leads the research and development of the Center’s psychiatric rehabilitation programming. Dr. Brady is a clinical psychologist with over 20 years experience on the staff and faculty of the University of Cincinnati’s Department of Psychiatry. In addition to providing clinical service at UC, he trained and supervised interns, doctoral students, post-doctoral fellows, psychiatric residents, psychiatric fellows, and psychiatrists. Dr. Brady earned his Doctorate of Clinical-Community Psychology from University of South Carolina and completed his post-doctoral fellowship in the Department of Psychiatry at the University of Cincinnati College of Medicine. He has completed training in the treatment of OCD and OCD spectrum disorders through the Behavior Therapy Institute. Dr. Brady is Board Certified in Clinical Psychology by the American Board of Professional Psychology.