Spotlight: Obsessive-Compulsive Disorder Treatment
What is OCD?
Obsessive Compulsive Disorder (OCD) is a highly-debilitating disorder that affects about 1 in 40 adults at some point in their lives. According to the International OCD Foundation, between 2 and 4% of children will develop OCD prior to adulthood. Although symptoms can appear at any time in one’s life, OCD most often first appears between the ages of 8 and 12 or in the late teens/early 20s.
OCD is a term we hear a lot in our day-to-day lives, but what does it mean? The Diagnostic and Statistical Manual of Mental Disorders is the entity that practitioners use for diagnosing mental health disorders and is currently in its 5th edition (DSM-V-TR). Until the DSM-V, OCD was classified as an anxiety disorder but was re-classified in its own section in DSM-V: Obsessive-Compulsive and Related Disorders. Diagnoses in this category include OCD, Body Dysmorphic Disorder, Hoarding Disorder, Trichotillomania (Hair-Pulling Disorder), and Excoriation (Skin-Picking Disorder). These disorders are classified together because they all involve repeated actions to temporarily relieve mental discomfort.
OCD is defined by the presence of obsessions, compulsions, or both. Although it’s not required to experience both obsessions and compulsions for a diagnosis, most people do experience some of each. Obsessions are recurrent and persistent thoughts, urges, or images that are unwanted by the individual. The individual attempts to neutralize these obsessions with some other action or to ignore or suppress them. Compulsions are repetitive behaviors (hand washing, ordering, checking) or mental acts (praying, repeating words silently) that the person performs in order to get rid of the distress from the obsession. These obsessions and compulsions are time-consuming (taking more than 1 hour per day) and/or cause significant distress or problems in daily life, such as in work, school, or family life.
What Does OCD Look Like?
When we think about OCD, we often picture someone washing hands repeatedly or insisting that all of their books be arranged a certain way. Indeed, these are two common examples of OCD-related compulsions. However, individuals with OCD may also feel compelled to research medical issues repeatedly or to cancel out “bad” thoughts with “good” thoughts. In addition to contamination and perfectionism, other common obsessions include unwanted sexual thoughts, thoughts of harming someone by accident, and fear of losing control. Notably, individuals with OCD are quite distressed by thoughts of harming others as they very much do not want to hurt anyone (but fear they might cause harm to others, anyway). They may also check repeatedly to make sure they have not harmed anyone, such as retracing their path to ensure they were not involved in a hit-and-run. OCD appears all over the world, although specific obsessions and compulsions may vary by era and location. For example, the 1980s brought an increase in obsessions with contracting HIV/AIDS and associated decontamination compulsions, and 2020 saw increased obsessions with contracting COVID-19 and associated compulsions. While many people all over the world increased handwashing, mask use, and enhanced house cleaning routines during the COVID-19 pandemic, those suffering with OCD spent substantial amounts of time on their rituals and decontamination routines brought only very temporary relief from their fears. Their fears also were not relieved by increasing knowledge as the pandemic continued, such as that COVID-19 generally did not live long on surfaces and wiping down groceries was not recommended.
Where is the Line Between Habit and Having OCD?
What is NOT a sign of OCD? Good hygiene is necessary and important, and practices like washing hands after using the restroom are known to greatly reduce communicable diseases. Locking doors to houses and cars is a known deterrent to theft. Many rituals are appropriate and helpful in our lives. For example, insomnia treatment is one of our main specialties at Upward, and we encourage clients to have bedtime rituals and routines. The difference is that OCD-related rituals tend to take a lot of time and/or cause significant distress or fail to bring relief to the person doing them. Thus, someone who enjoys and finds peace in their nightly routine of drinking bedtime tea, taking a warm bath, and reading a religious devotional book would not be demonstrating OCD compulsions. However, if they must wash all dishes and disinfect the tea cup in a very specific way before they can relax, must always read an even number of pages, and must turn wash their bodies in a very specific order, these may be signs of OCD. Likewise, many religious traditions involve rituals, such as daily prayer or fasting on certain days. When these rituals bring comfort, peace, and joy to the person’s life, they are not OCD compulsions. On the other hand, even beautiful aspects of religion can become twisted in OCD. If a person constantly fears that they have sinned without realizing it and must stop and pray for cleansing, this may become a compulsion. The International OCD Foundation discusses some helpful resources for Faith and OCD.
OCD symptoms come at a high cost to the person suffering, as most report problems with family relationships, social relationships, and work/school. Many individuals with OCD are quite aware that their fears are excessive or do not make sense but cannot shake the overwhelming discomfort they feel. They would very much like to just “snap out of it” but cannot do this. Thus, they either avoid situations that trigger their obsessions or perform a ritual to neutralize the discomfort. Unfortunately, it can take many years to get a proper diagnosis and treatment, leading individuals with OCD to miss out on many joys of life. We aim to change that.
How Does OCD Develop?
As OCD may first appear in the teen years, parents should be watchful and seek professional help for any concerns, particularly if a family history of OCD is present. OCD symptoms may worsen with hormonal changes that come with puberty. Parents may believe their child could not possibly have OCD since their room is messy and disorganized. However, plenty of teens with OCD struggle with other types of obsessions and compulsions. Signs for concern may be repeatedly seeking reassurance from parents, confessing bad thoughts, and spending inordinate amounts of time on daily tasks. Teens with OCD may struggle with low self-esteem and may miss out on activities with friends. They may also struggle at school due to inability to focus, which may come from time spent on rituals, as well as lack of sleep. Teens might be misdiagnosed with ADHD due to appearing to zone out and daydream, but they are actually distracted by mental rituals such as counting or repeating words. Teens are acutely aware of their place in the world around them and standing out from their peers is a recipe for a difficult time. As teens prepare to leave home and go to college, they may struggle even more due to being outside their familiar living environment and away from family accommodations. Many teens already struggle to get adequate sleep due to the natural shift to a delayed “night owl” circadian rhythm in adolescence combined with early school start times. Therapists working with teens with OCD note that rituals can often 30 minutes to an hour to the bedtime routine, further depriving teens of needed sleep.
Postpartum or perinatal OCD occurs around pregnancy/birth of a new baby and can occur in both birthing and non-birthing parents. Common obsessions center around harm to the baby (such as fear of dropping the baby), contamination (worries that bottles contain germs and will make the baby sick), sexual thoughts (fear that someone will molest the baby or fear that others will think the parent is molesting the baby), perfectionism (sense that something bad will happen if baby items are not arranged “just right”), religious scrupulosity (fear for baby’s soul, that they will go to hell), and fear of losing control (fear that the parent is “going crazy”). Although most parents have these fleeting thoughts at times, parents with OCD are greatly distressed by them and cannot escape them without compulsive rituals to ease the discomfort. Common compulsions in perinatal OCD include excessive cleaning/sanitizing, repeated checking and recording of bodily functions, and repeated prayers for the baby.
Current estimates are that 2-3% of parents experience OCD, but this number is likely lower than the true prevalence. Parents may be hesitant to share these symptoms with their healthcare team due to fears about being seen as an unfit parent and having the baby taken from them. Unfortunately, limited postpartum visits for parents in the United States may mean that these symptoms are missed. Parents and family members who are concerned about perinatal OCD may find these resources from the International OCD Foundation helpful in identifying symptoms and considering how to talk with their healthcare providers. Exposure and response prevention is helpful in treating perinatal OCD, just as it is in treating general OCD.
Just as in puberty and postpartum hormone fluctuations, perimenopause and the onset of menopause can worsen OCD symptoms. Some women who have experienced significant improvement of their symptoms earlier in life may experience an uptick in perimenopause and may benefit from increased vigilance against returning to compulsions, as well as a possible new course of treatment.
Understandably family members want to help their loved ones with OCD but family accommodations may worsen the disorder. Parents who worry that their teenagers are already low on sleep may assist them with cleaning rituals so that they can get to bed earlier. Spouses may repeatedly reassure their partners that they do love them or that their distressing thoughts do not mean they are a bad person. Research shows that around 80-90% of relatives participate in OCD-related rituals, through helping sufferers avoid triggers, assisting with rituals such as cleaning and checking. For that reason, it is immensely helpful for household members to understand and participate in some aspects of treatment with their loved ones. The International OCD Foundation offers a wealth of resources for family members, and Upward psychologists will involve your family members in Exposure and Response Prevention treatment planning as appropriate.
People may wonder what causes OCD and parents often struggle with worry that they caused or failed to prevent OCD in their children. OCD appears to have a genetic component, and if you are suffering with OCD, you may be able to recall other relatives who have had similar symptoms. We once knew a biology professor who joked that we should choose our parents wisely since not much can be done about our genetics. Studies of brain structures also indicate that brains of individuals with OCD have some variations from those without OCD.
How Is OCD Treated?
The good news is that appropriate therapy and/or medication can actually help rewire pathways in our brains. Research tells us that about 70% of people with OCD will improve with gold-standard therapy and/or medication, and gains tend to be a bit stronger for therapy than for medication (60-80% symptom reduction vs. 40-50%).
Exposure and Response Prevention (ERP) is the gold-standard, specialized therapy treatment for OCD, and we are pleased to provide ERP for ages 14 and up. What does this therapy involve? It’s helpful to consider the function of anxiety and discomfort. We saw a funny meme online stating, “I wish my brain could understand that I need to send an email; I’m not being chased by a bear.” At appropriate levels, a dose of anxiety can be a good thing. It helps us prepare for tests and escape dangerous situations. It’s normal to worry about our finances and to feel uneasy while we are awaiting results of a big medical test. However, when someone is dealing with OCD, their body’s anxiety and distress signals have gotten off course. They might repeatedly check their bank account or spend hours researching rare medical issues.
Let’s picture a house with an alarm system. If the alarm never goes off, even if someone is breaking into the house, that’s not a good system. On the other hand, if the alarm goes off every time the heat kicks on or the family dog barks, that’s also not a good system. Exposure and Response Prevention helps to recalibrate your body’s alarm system to an appropriate level.
Here’s another example: In the Christmas movie, Elf, Buddy the Elf travels to NYC to look for his father. Buddy has led a sheltered life in the North Pole and does not know he should not pick up used gum from trashcans in the city. A healthy person might notice used gum but not touch it, realizing it could be unsanitary. A person with OCD may not be able to escape discomfort from simply being in the vicinity of the used gum and would feel increasingly anxious until they could go home and thoroughly shower and wash all clothes they were wearing in hot water and laundry disinfectant. Exposure and Response Prevention involves systematically, strategically exposing oneself to the situations that lead to anxiety while avoiding the compulsions used to bring relief. Thus, in our gum example, a person might spend time sitting near a trashcan with used chewing gum but not be allowed to shower or wash their clothes after being in the area. In considering why we ask you to engage in these procedures, it’s helpful to think about the reinforcement effect of compulsions/rituals. In the example above, the ritual of showering and washing clothes brings great relief temporarily; thus, it’s likely that you will do them again. With ERP, we stop the process of this reinforcement. Gradually your body and brain will learn that the feared outcome almost certainly won’t happen and that your anxiety will decrease even without performing a compulsion. We understand that this sounds challenging, and it is! Our compassionate and experienced therapists are here to guide you each step of the way and to troubleshoot issues that arise. We take a specialized approach to this process, one that we have spent a lot of time and practice to perfect. Our goal is to set you up for success.
Participants should generally expect to attend 15-20 sessions. We often begin treatment with 2-3 sessions per week and gradually phase to once per week. Your psychologist will work with you and any relevant family members to plan your individualized treatment schedule. Treatment will begin with a detailed examination of your specific obsessions and compulsions. You will be asked to engage in self-monitoring at the beginning of treatment. You and your therapist will then complete a hierarchy of situations that trigger obsessions and the urge to perform compulsions and begin practicing exposures. Some of these exposures will be “in vivo” which means in your day-to-day life. These are daily activities that you only do with compulsions. Other exposures may be imaginal, such as picturing, in detail, developing a rare disease. Your therapist will work with you to start with less challenging exposures and work up to more difficult ones.
Although symptoms can wax and wane over the course of a lifetime, the vast majority of people will not achieve significant remission of symptoms without professional help. You are taking a brave step! As we address your symptoms, your goals and values are always at the forefront. We know you will not and should not engage in challenging exposure exercises because we think it’s a good idea but because your OCD is keeping you from living the life you desire. Studies that take apart the treatment and look at exposure alone and response prevention alone indicate that effectiveness is greater when the two pieces are combined. Research also makes it clear that allowing yourself to truly feel the anxiety that goes with your obsessions is key. Our therapists are highly trained and experienced in helping you face this discomfort and teach your body that it can handle the things you fear. Working with a therapist who is highly trained and committed to working with you on the protocol is key.
Fortunately, ERP is equally effective via telehealth or in-person, allowing us to treat individuals in-person in the greater Birmingham area or via telehealth throughout Alabama and any participating PSYPACT state. We do not provide therapy for individuals younger than 14 but are able to assist with referrals to several excellent colleagues.
Why is Upward the Ideal Place to Receive Treatment for OCD?
Given high comorbidity rates of OCD, ADHD, depression, and sleep disorders such as insomnia, our training and specializations allow us to provide gold-standard care across these issues. We often see clients who are struggling with more than just one of these conditions since they are so closely tied to one another.
Given that individuals with OCD often have other diagnoses, how do we decide what to treat first? The biggest consideration is always your goals and values! Many of our clients may be dealing with multiple symptoms, but there is something that brought them to us. In our initial intake evaluation, we will discuss goals and concerns in detail and present options for treatment. For example, lots of clients are struggling with sleep problems. If sleep is the highest priority, it makes sense us for us to begin with insomnia treatment and then proceed to OCD treatment. On the other hand, some clients will note that sleep is definitely a concern but it seems to stem from obsessions and compulsions that are affecting their waking life too. In that case, ERP treatment may come first, followed by insomnia for residual symptoms. One client shared that he is feeling depressed but noted this seemed to arise from the many limitations his OCD symptoms placed on his life, such as his inability to attend events with his children and his constant anxiety during church services. Thus, ERP made sense as the best place to start. We considered whether he might need treatment for depression later, but ultimately the depressive symptoms improved with ERP, as he was able to enjoy his life again once he faced his obsessions directly.
Would OCD be easier to treat if we could give you definitive assurance that nothing bad will ever happen to you or anyone you love? Of course it would. Are we able to provide that for you? Indeed we are not. A key piece of therapy is learning to live with uncertainty. We all make decisions daily about risks we are willing to take. Life is full of uncertainty. Many of us scheduled vacations and events in 2020 that did not happen; however, we happily continue to plan future travels on the assumption that we will go. The world could end tomorrow, but we had probably better make plans to pick up our kids from school anyway. With ERP, we cannot take away fear altogether but help you move forward with the life you desire despite a little uncertainty. Think about what OCD is costing you and what you stand to gain by facing your fears.
Would Treatment at Upward Be Covered by Health Insurance?
Upward is an out-of-network practice and does not deal directly with health insurance. However, many of our clients are able to receive some reimbursement from their insurance carrier. Please see here and here for more information about pricing at Upward.
How Do I Get Started?
Schedule a free consultation call with Dr. Misti Norton to discuss your treatment options. You can do this through our website, by calling our office at (205) 983-4063, or by emailing us at info@upwardbehavioralhealth.com.