Sunday, April 19, 2009

Obsessive-Compulsive Disorder Part One: The Do Do Do, The Da Da Da

OCD is a very common diagnosis. It is extremely debilitating and interferes profoundly with relationships, accomplishments and personal happiness. It manifests itself with 2 profound elements. First is the obsessive, irrational thought. There is a perceived danger in the personal environment and it is magnified in the mind to the point that one can think of nothing else. These repetitive thoughts are cause for a compulsion to do something about that perceived danger and to act on removing or altering the magnitude of that danger and alleviating fear. When the urge to perform that task is insurmountable, it creates tremendous discomfort and interferes with important daily functions that must be performed to maintain one's well-being. These urges can be categorized into types. Some frequent recognized categories are Washers (obsessed with cleanliness), Checkers (consistently check on things they associate with danger), Counters (seek order, evenness and symmetry), Sinners (believe there will be severe consequences for a past action and seek to undue it), and Hoarders (take survivalist behavior to an irrational extreme).

OCD is commonly co morbid with other diagnoses. It is frequently diagnosed with depression and the inability to satisfy the compulsion feeds into the other hopeless feelings that fuel a low mood. It is also associated with other mood disorders, such as Bipolar and PTSD. In the case of ADHD, attention enhancing medicines are often cause for people to form "loops of thought," and a repetition of ideas that often lead to repetitive actions. Pharmacologically treated ADHD can often help manifest compulsive behavior as a side effect. Psychiatrists will commonly address this effect by prescribing an SSRI/antidepressant along with the attention enhancing drug. This patchwork approach is limited in its effectiveness.

Treatment of this illness focuses on interrupting the chain of thoughts and behavior associated with the idea and the action. It is generally conceded that the compulsive thoughts will exist at some level, but the OCD client can find ways to diminish the intensity of that thought and seek secondary cognitions and behaviors that diminish the urge to wash, go back, doubt or stack up. What helps reinforce the intensity of the obsession and compulsion is that it is positively reinforced. The hand washer does not catch the disease after repeated washing and the checker does not have his house broken into. The therapist is effective in supporting and validating the client's fears initially, but diminishing the intensity of those fears and helping the client find less intrusive behaviors to satisfy his now less intense fears. The hope is to find a new and viable chain of behavior. The compulsion to "do" will become the more comfortable, socially acceptable and less debilitating "da." Once the client is able to experience the contingency between the tone-downed thought and the less-profound action, this will be reinforced to the point that the old extreme thoughts and behaviors will fade away.

I am optimistically simplifying the course of treatment as described above. Alternative behaviors that are satisfying to the client are difficult to find and require allot of probing and problem solving with the therapist. OCD behaviors are often ingrained over a long period of time and are difficult to shake. In the next section I will get more specific about the treatment approaches that are taken to cure this illness.