The purpose of this information is to explain Obsessive-Compulsive Disorder. We hope that it may help you to decide if you may have this disorder. It suggests a reasonable approach to promote proper detection and treatment of OCD.

This is intended for educational information only. Treatment for appendicitis is not a 'do it yourself' project. Neither is treatment for OCD. If you believe, after reading this, that you might have OCD, you should see your physician who can either diagnose and treat you, or refer you to a specialist.

A Case History

Bob saw his psychiatrist for treatment of depression for six months before he finally had the courage to bring up his other "secret" problem. Since childhood he had a compulsion to count things. He had to count the letters in words and in people's names. If the letters added up to any number except 9 he felt a sense of release and could stop counting. He knew it was silly but nevertheless he had a fear that if he did not do this something bad could happen to his mom or dad. He seemed unable to stop doing this. He did poorly in school because he was distracted by his secret compulsion to count letters when he should have been paying attention to the teacher's lessons. He was later bothered as a teenager by upsetting sacrilegious mental images when he was in church. Having these sacrilegious images made him feel that he lost his soul for eternity.

In addition to these two problems, he was having trouble driving. When he felt a bump as his tire rolled over a little stone, he would think he may had accidentally run over a pedestrian. He would instantly check his rearview mirror for the injured person he feared was lying on the road. Relieved to not see an injured person, he would start to drive forward. Obsessing that the injured person might have been flung entirely off the road by the impact, he would then stop, and back up his car to the scene, and search the ditch and weeds. These obsessions and compulsions were taking over his life but he was too embarrassed to tell anyone about them, even his psychiatrist, up till now.

His psychiatrist explained that this was caused by OCD, a metabolic-physiological abnormality, and was treatable with one of about six special medications that work on a chemical in the brain called serotonin. After the medication began to work, they would employ special psychological maneuvers to help overcome this problem.

The psychiatrist told him that with the combined treatment an average person can expect improvement in 3 months. This knowledge filled him with hope for a better future.

What is It?

Anxiety about thoughts or rituals over which you feel you have little control is typical of OCD. OCD can take so many different forms. Let's try to make sense of it.

Obsessions are thoughts, often intrusive and upsetting.

Obsessions are to be distinguished from ruminations or worries about routine life issues such as finances, children or job security. Some examples of obsessions in OCD may be thoughts or mental images of an upsetting nature like violence, vulgarities, harm to self or harm to others. Obsessions may be of special numbers, colors, or single words or phrases . . . sometimes even melodies.

Here are Some Examples.

Obsessions with:

Germs
Dirt
Doubt
Order
Symmetry
Repugnant Sexual Thoughts
Repugnant Religious Thoughts
Repugnant Images
Horrific Images
Violent Images
Fear Of Forgetting
Fear That A Mistake Will Harm A Loved One

A compulsion is a repetitive behavior in response to an urge. It is difficult to stop this behavior. Obsessions provoke compulsions. Examples include washing the hands too many times, showering too frequently or washing things about the home like clothes or floors or even groceries.

How much is too much? Many experts agree that engaging in more than an hour a day raises suspicions of OCD. Compulsions are often performed repetitively and in some stereotyped or ritualistic fashion. You may be bothered by urges to perform rituals like repeatedly turning off and on a light switch until it "feels right."

Here are Some More Examples.

Compulsions to repeatedly:

Wash Hands
Shower
Check Locks
Check Stoves
Touch Things
Count Items
Order Things
Clean Things
Perform Silly Rituals Until It "Feels" Right.

Often the obsession comes first and the compulsion seems to be a response to the obsession. For example, a person may have an obsessive fear of ingesting or absorbing illegal drugs from indirect contact with people they suspect to be taking illegal drugs. Such a person may obsessively fear losing his mind from using a restaurant's public rest room after seeing someone they suspect may be a drug addict using the facility. After leaving the restaurant, he may have to throw away his shoes and floor mats in his car that may have been "contaminated." He may have to scrub his hands in bleach exactly ten times perfectly. Other articles of clothing may have to be washed repeatedly or thrown away. He may be afraid to take medicine that has been touched by a pharmacist who he thinks might be using marijuana after hours, fearing that some of the residue might have contaminated their medicine.

There is no pleasure in carrying out these rituals. There is only temporary relief from the anxiety caused by the obsession.

Interesting Facts About OCD

Although adults realize in part that these obsessions and compulsions are senseless, they have great difficulty stopping them. Children with OCD may not realize their behavior is unusual.

• There is a link between serotonin and dopamine, brain neurotransmitter chemicals, and OCD.
• Often OCD affects the family. Family members are sometimes drawn into the OCD behavior. Disability may affect family finances.
• Medication for OCD should be tried 10-12 weeks before judging effectiveness.
• OCD affects men and women equally.
• OCD can start at any age. In one third of adult patients the symptoms begin in childhood, adolescence or young adulthood.
• OCD afflicts approximately 2% of the population.
• The untreated symptoms may vary for years. The symptoms may go away, remain the same or worsen.
• Evidence suggests that OCD runs in some families and may be genetically inherited.
• It is not uncommon for a person with OCD to also have clinical depression, panic attacks, or both.
• Persons having OCD often cleverly hide their OCD successfully from family and friends and coworkers
• Few OCD patients respond to placebos in contrast to 30 ­p; 40% of depressed patients.
• Persons having OCD often exhibit abnormal rates of metabolic activity in the frontal lobe and the basal ganglia of the brain.

Yes! Up until a few years ago we did not have effective treatments for OCD. New medications and behavior therapy now give many patients significant relief. In behavior therapy, the patient faces squarely the OCD difficulties either in a gradual step-by-step manner or in an aggressive one-step way.

The technical name for this process is exposure and response prevention. Experts believe that behavior therapy is an effective treatment used by itself in certain patients with OCD if done well and vigorously. Certain other patients will only respond to medication. Many patients find the combined use of medication and behavior therapy most effective.

Some Medications Used In The Treatment Of OCD:

ANAFRANIL clomipramine

LUVOX fluvoxamine

PROZAC fluoxetine

PAXIL paroxetine

ZOLOFT sertraline

Often the first medication tried will not work for a particular patient with OCD. That should not discourage you or your doctor since another medicine may work well. Side effects vary considerably depending upon which medicine is being used. Experienced clinicians will readily attest to the fact that each medicine is unique and may behave differently especially with respect to side effects. ANAFRANIL, though having perhaps slightly more chance of effectiveness, has more disruptive side effects than the others listed. For that reason it is not used by some clinicians as a first choice.

PROZAC, ZOLOFT, PAXIL and LUVOX are convenient remedies that usually have minimal effects (about 10-20% of people have either nausea, headaches, delayed orgasm or ejaculation, decreased sexual interest, or insomnia). There are some prescription medicines that must not be used with LUVOX.

Sometimes a psychiatrist may advise adding a second medicine to your SSRI to boost the power of treatment if your OCD is not responding. Neuroleptic and benzodiazepine medicines are two commonly employed 'booster' medicines. Other medicines used for this purpose are Buspar buspirone, Pondimin fenfluramine, and the serotonin-2 antagonist/reuptake inhibitors: Desyrel trazodone and Serzone nefazodone.

If you have OCD, you would be wise to be treated by a specialist who is well versed and experienced in using these medicines and behavior therapy at least until you seem to be recovered.

Some patients actually need nothing more than the medication. They make a full recovery and need no further treatment. Other OCD patients would definitely benefit from behavioral treatment called exposure and response prevention.

Exposure and response prevention mean that you expose yourself to whatever situation triggers the problem. You then prevent yourself from engaging in your usual ritual. For example, suppose that you have OCD problems with greasy substances. You might choose to allow yourself to become greasy while adding oil to your lawnmower (exposure). Instead of washing immediately, you prevent yourself from washing (response prevention).

By exposing yourself to your fear, anxiety increases temporarily. However, by continuing to avoid your usual compulsive behavior response, your anxiety is allowed to naturally diminish. The obsessive-compulsive cycle is broken, and the obsessive thoughts weaken. Confronting such fears is not easy and it may require special guidance from a trained professional.

In summary, if you have OCD you may be plagued by persistent, recurrent, intrusive and unwelcome thoughts or images, or by an urgent need to engage in silly or upsetting rituals. The problem is now treatable with medication and special psychological techniques.

Reading List for Lay Persons

The Boy Who Couldn't Stop Washing.Judith Rapoport, Penguin Books, New York, 1991.

Obsessive-Compulsive Disorder: A Guide. John Greist, OCIC, Univ. of WI,

Madison WI 1991.

Stop Obsessing! Edina Foa PhD and Reid Wilson PhD, Bantam Books, New York, 1991.

Brain Lock, J. Schwartz, Regan Books/Harper Collins, New York 1996.

Getting Control - Overcoming Your Obsessions and Compulsions. Baer, L. Little Brown & Company, Boston, 1991.

Professional Reading List

Essential Psychopharmacology. S. Stahl, Cambridge University Press, New York, 1996.

Psychopharmacology The Fourth Generation of Progress. F. Bloom & D. Kupfer, Raven Press, New York, 1995.

This material was prepared by Stephen M. Cox MD, President & Medical Director, NAF.

Information provided by:

National Anxiety Foundation, 3135 Custer Dr., Lexington, KY 40517-4001

For more information call NAF at (606) 272-7166 or (800) 755-1576.