Obsessive Compulsive Disorder (OCD)


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Obsessions are unwanted/intrusive thoughts, impulses, or images and are “stress causing.”  Compulsions are constant repetitive behaviors or mental acts (rituals) that respond to obsessions, and are “stress relieving.”  Compulsions are a direct response to obsessions, representing an effort to reduce or otherwise avoid perceived consequences of the obsession.  1 in every 40 American’s is affected by varying degrees of Obsessive-Compulsive Disorder (OCD).  Dr. Jeffrey Schwartz believes “we all have a touch of this.”  I think we all have a natural inclination to identify stress and attempt to eliminate it, so I tend to agree with the final statement.  Dr. Jeffrey Schwartz, renown OCD expert, contends that people can change their own brain chemistry through his “biobehavioral” 4 step processes to remove “Brain Lock.”

1) Relabeling the thought, acknowledge it is an obsession or “false message”

2) Reattribute the compulsion to something else (a chemical imbalance, or OCD)

3) Refocus, concentrate on doing another activity

4) Revalue, determine that the obsession is meaningless

Comparing and contrasting the “biobehavioral” approach with more common clinical strategies, most clinicians would treat OCD with cognitive behavioral therapy (CBT), exposure and response prevention (ERP), and/or the use of pharmacological SSRI remedies.  (Podea, Suciu, Suciu, & Ardelean, 2009; Masi, Millepiedi, Perugi, & Pfanner, 2009)  CBT/ERP techniques can be implemented in a variety of different formats including individual, group, and self-controlled versions.  The latter study found the most effective SSRI to be clomipramine, although fluoxetine, paroxetine, sertaline, and fluvoxamine were all more effective than placebo.  On the whole, the general consensus is that a multimodal approach pairing SSRIs with CBT is the most effective treatment method, followed by therapist guided CBT and/or SSRIs alone.  Although his particular study found self-controlled versions to be significantly less effective than any combination of the above treatments,  (Masi et al., 2009, expression Background) some authors (including Dr. Jeffrey Schwartz) feel that self-directed in vivo ERP is just as effective clinically as therapist-controlled in vivo ERP.  In any event, it is more cost effective.  (Ben-Arush, Wexler, & Zohar, 2008)  It would suffice to say that there is general consensus that CBT/ERP is the preferred solution, although there is considerable disagreement in its implementation.

This cognitive based therapy is based on the assumption that what differentiates OCD patients from the rest of us is not that they experience intrusive thoughts, but the manner in which these thoughts are processed.  Unlike the general population, which would commonly dismiss intrusive thoughts, OCD patients consider them important and act on them.

In the traditional method, patients learn, with the help of a therapist, to expose themselves to certain stimuli (e.g., toilets, door knobs, public telephones) which intensify their obsessive thoughts and, also, how to resist responding to those thoughts in a compulsive manner (e.g. not washing their hands, not checking things repeatedly). Exposure can take place in real life, in vivo, (e.g. at home or in a public toilet) or in an imaginary form (e.g., in the case of patients with obsessions with religious content). The purpose of exposure is to teach the patient to tolerate anxious experiences, rather than avoiding them.  (Podea et al., 2009, expression Results and discussion)

So, what would I do if I was in the care a client of a classic case of ODC?  I would probably give them a copy of Dr. Schwartz’s book as soon as the diagnosis is made, in addition to starting to ramp the client up on an SSRI like clomipramine.  On the second session I would answer questions about the book, and begin some therapist led CBT/ERP procedures, while continuing to encourage the application of self-based interventions prescribed by Dr. Schwartz.  In the end, I would utilize all three options, because they are viable, and research has shown that a multi-modal approach is solution that delivers the best outcomes.

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References

Ben-Arush, O., Wexler, J. B., & Zohar, J. (2008). Intensive outpatient treatment for obsessive-compulsive spectrum disorders. The Israel Journal of Psychiatry and Related Sciences, 45(3), 193-201. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1667555491&sid=1&Fmt=3&clientId=4683&RQT=309&VName=PQD

Masi, G., Millepiedi, S., Perugi, G., & Pfanner, C. (2009). Pharmacotherapy in paediatric obsessive-compulsive disorder: A naturalistic, retrospective study. CNS Drugs, 23(3), 241-253. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1708241661&sid=1&Fmt=4&clientId=4683&RQT=309&VName=PQD

Podea, D., Suciu, R., Suciu, C., & Ardelean, M. (2009, Sep). An update on the cognitive behavior therapy of obsessive compulsive disorder in adults. Journal of Cognitive and Behavioral Psychotherapies, 9(2), 221-234. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1895143051&sid=1&Fmt=1&clientId=4683&RQT=309&VName=PQD

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