When Once Is Not Enough

Isabel C. Murphy, BSN, PsyD
September 3, 2004

Introduction

What would it be like to be so consumed with the fear of germ contamination that you spend hours at the sink repeatedly washing your hands until they are red and raw? Or, imagine going through the day with the irrational thought that on your way to work that morning, you had killed someone with your car. Or visualize spending your day preoccupied with the order in which objects on your desk or in your closet are arranged.

These are scenes that characterize the life of someone with Obsessive Compulsive Disorder - or OCD as it is called for short.

What is OCD?

Worries, doubts, and even superstitious beliefs are a part of normal, every day life. But for many people, such concerns can become so extreme that their lives are taken over be seemingly nonsensical thoughts or behaviors that interfere with daily activities. These symptoms characterize OCD. One in fifty individuals will develop symptoms of OCD in the course of a lifetime¹.

What does OCD look like?

"Charles", a 70-year-old man who never married and lived alone all of his life, described the personal agony which begins each morning upon awakening.

Though eager to start his day, he would find himself sidetracked by an overwhelming need to check and recheck the locks on his doors and knobs on his stove before heading out to work. Paralyzed by the fear that someone would break into his home or that it would burn down, he engaged in what is known as a "ritualistic checking behavior" as a means of reducing his anxiety.

"It simply made no sense," he states, "I knew that what I was doing was crazy. Sometimes I would just stand there and turn the knob on my stove on and off...as many as 50-75 times. Then I would leave only to come back within minutes to repeat the whole thing all over again."

Charles' situation is not unusual. Most OCD sufferers experience similar obsessions and compulsions. Obsessions are best characterized as thoughts, images, or impulses that occur repeatedly and make one feel as if they are no longer in control of their mind or their actions.

An example might be a preoccupation with the fear of dirt or of being contaminated by germs. Another typical obsession is one where the individual fears that they have harmed someone else. Whatever the thought may be, invariably the individual with OCD engages in behaviors - or compulsions - in an effort to make the obsessions go away.

What is a "compulsive" behavior?

Some forms of compulsive behaviors might include repeated and excessive hand washing, counting numbers, or arranging objects in a particular way. For those obsessed with the fear of harming someone - as in the case of the individual who thought he hit someone with his car on the way to work - the compulsion might take the form of driving the same route to work over and over again, all the while checking the road for the feared victim.

The time spent on the compulsive behavior is so time consuming, that it frequently takes up more than an hour a day. As a result, the individual with OCD suffers both professionally and in their relationships with others, especially when the time spent on rituals interferes with other activities.

What is the culprit behind OCD?

For most of us, checking the stove and the door just once would suffice. But people with OCD suffer from a brain disorder in which information is not properly processed. Like a needle stuck in the groove of a record, the brain, too, gets stuck - only on a thought or action. Researchers believe that a deficit in the production and transmission of serotonin, an important neurochemical found in the brain, is the culprit behind OCD.

Who gets OCD?

As for who gets OCD - the answer is simple: anyone. It can strike children and adults alike. Some researchers suggest that a small percentage of children who develop OCD do so after acquiring a streptococcal infection. But this is unusually rare. Other children just seem to develop it without clear explanation.

Researchers have correlated certain types of ritualistic behaviors with slow onset and sudden onset of the disorder. For example, individuals who might engage in checking behaviors, such as checking the stove or locks on the door, probably develop their symptoms slowly over time. On the other hand, people who develop fears of germ contamination more typically have a sudden onset of their symptoms.

Approximately 25%-50% of adults with OCD state that they developed their symptoms in their childhood. The age of onset seems to fall anywhere between childhood and the age of 40. Developing symptoms in later life is more unusual, but it does occur. As in the example of Charles, some people may have low levels of worries and can function relatively well - but these can become worse when they face a crisis later on in life.

Stress and severity of symptoms

Stress can often make symptoms of OCD worse. For Charles, learning that he was diagnosed with a terminal cancer was enough for him to develop debilitating obsessive fears and compulsive behaviors. It was after receiving this diagnosis that Charles began standing in front of the stove and turning the knobs on and off in an effort to reassure himself that the stove was properly shut off. This behavior took as much as three hours out of his day.

Although Charles had concerns from time to time about such things as someone breaking into his home, or a fire destroying it, most of these fears were initially minor. Before learning of his cancer, they never prevented Charles from enjoying a productive life. But after being diagnosed with cancer, his anxieties increased to the extent that his compulsive behaviors significantly interfered with his ability to get through the day.

It seemed as though the OCD symptoms Charles experienced - the threat to his house due to fire or an intruder - was a metaphor for the threat to his physical well being that the cancer now presented. Feeling unable to take control of the cancer, Charles' OCD symptoms became his focus. On a superficial level, turning the stove on and off gave Charles a brief sense of control over things in his life, even if it was a false sense.

How does OCD affect individuals?

Individuals with OCD often feel embarrassed, ashamed, and isolated. Although they are unable to control their thoughts or behaviors, they often experience pressure from those close to them to "change"; sometimes they may be told to "stop" their behaviors, which only add to their distress.

The OCD sufferer is very aware that their behaviors and thoughts make no sense. They are highly aware that what they are doing is odd, even strange. Yet the nature of the illness renders them powerless to control their symptoms.

Impact of OCD on family members

For family members, the OCD symptoms of a loved one can be especially burdensome. Time-consuming rituals may often have to be incorporated into family life. Not participating in the ritual, or, worse still, if a family member prevents the OCD sufferer from engaging in a particular behavior, only adds further stress and is usually not helpful.

It is still uncertain as to whether or not OCD is inherited. To date there has not been a specific gene identified in the development of OCD. However, passing OCD on to one's offspring still cannot be entirely ruled out.

Some research suggests that OCD that develops in childhood does appear to run in families. In addition, there appears to be a slight increased risk of children developing OCD if one of their parents has OCD. But overall, these risks appear to be low.

When does obsessive behavior become a disorder?

Not every obsessive thought or ritualistic behavior is a clear-cut case of OCD. We all know someone with an "obsessive personality" who focuses on making money, achieving success or acquiring material things. It seem for some individuals that their lives are governed by a seemingly endless supply of lists of things to do. Their home, lacking clutter and debris, is pervaded by a sense of order and cleanliness more suited to an army barracks.

Such people usually lead normal lives and do not spend numerous hours a day engaged in obsessive-compulsive rituals. They are seen more as "driven" rather than having a full-blown disorder such as OCD. Such people tend to have a personality style that is inflexible in their approach to the world, and often struggle with issues around control. However, these are not instances of true OCD.

For such people, medications play a less significant role. However, 'talking' therapies such as cognitive behavioral therapy (CBT - where a person learns new and more adaptive ways of thinking and behaving) can be useful in helping the person become less rigid in their thinking.

Getting help for OCD

Historically, OCD has had a poor prognosis. But fortunately the combination of improved medications and CBT provide new hope and promise better outcomes for the person with OCD².

Medications such as serotonin reuptake inhibitors (SRIs), have been found to be helpful in the management of difficult symptoms. Examples include fluoxetine (Prozac) and sertraline (Zoloft).

Medication alone, however, is often not enough to treat symptoms of OCD ; rather, medication combined with CBT has been shown to be more successful.

Summary

Having Obsessive-Compulsive Disorder is a challenge for individuals and family members alike. If you think you might have OCD, it is important to contact a mental health professional and begin an intensive program of treatment.

In addition, gaining support from other individuals with OCD can also be an invaluable source of help. Knowing that you are not alone will decrease the sense of isolation that you may be feeling. Being with others who share a similar experience can provide both support and an opportunity to identify successful ways to manage this difficult illness. Below is a link to the Obsessive-Compulsive Foundation website, where sufferers can find this sort of support.

Source

• Obsessive-Compulsive Disorders: Practical Management, by Michael A. Jenike, Lee Baer, and William E. Minichiello. Publisher: C.V. Mosby; 3rd edition (June 15, 1998)

Footnotes
1. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV), American Psychiatric Association
2. Obsessive-Compulsive Disorders: Practical Management. Jenike MA, Baer L, Minichiello WE. 3rd edition, Mosby (l998)

Related Links
The Obsessive-Compulsive Foundation
What to Do When You Feel Scared, Anxious, or Excessively Worried

Related Books
Getting Control: Overcoming Your Obsessions and Compulsions by Lee Baer
Obsessive-Compulsive Disorders: Practical Management by Michael A. Jenike, Lee Baer and William E. Minichiello

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