OCD: Treating Obsessive-Compulsive Disorder

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OCD: Treating Obsessive-Compulsive Disorder




Guest:  Dr. Linda Austin – Psychiatry

Host:  Dr. Pam Morris - Department of Medicine


Dr. Pam Morris:  Hi.  I'm Dr. Pam Morris.  I'm here with Dr. Linda Austin.  We're discussing Obsessive-Compulsive Disorder.  Linda, let’s pretend we have a woman who is very much a neat freak or really likes her house very tidy, maybe washes her hands and keeps everything very sterile.  How do you know when you’re at point a where you may need treatment for this problem?


Dr. Linda Austin:  Well, that’s, clearly, subjective.  And part of that depends on your living circumstances.  There is kind of that gray area, you know, what is, really, an obsessive-compulsive disorder, versus what are, maybe, Obsessive-Compulsive Personality traits, or style, or just neatness?  All of us do things like run back to the house to make sure that everything is locked up, or call our kids an extra time to make sure that they landed safely, or something like that.  But, when your behavior starts to feel a little crazy, a little nonsensical, you know that you just washed your hands and yet you have to do it one more time, or people around you are starting to say, you know, you’ve really gone over the top, you’re getting on my nerves with all of this, and it’s getting in the way with your life, and yet you don’t feel you can change that without being very anxious, that’s when you might consider getting an evaluation.


Dr. Pam Morris:  Where do I begin?


Dr. Linda Austin:  Well, you could go to a psychiatrist, which is what I would suggest, because the treatment for obsessive-compulsive disorder is, both, medication, usually, and a behavioral treatment program.


Dr. Pam Morris:  Let’s start with the behavioral treatment.


Dr. Linda Austin:  Well, the kind of behavioral treatment that works in OCD is very specific, it doesn’t have to do with talking about your mother or your past; it’s called Cognitive-Behavioral Therapy.  And, basically, what you have to do is take your OCD symptom by symptom and expose yourself to whatever it is that’s making you anxious, and then the therapist helps you resist the urge to perform some behavior.


Here’s an example.  Let’s imagine you have a handwashing compulsion and you’re washing your hands 10 times or 20 times, or 100 times a day.  What the behavioral therapist will do is make you get your hands dirty, maybe make you touch the ground or the bottom of your shoes or even, by the end of treatment, the inside of the toilet bowl, and then you have to sit there and not wash your hands.  Now, what happens, Pam, is that your anxiety will go sky high.  You will get massively anxious the first few times you do this.  But, interestingly enough, the human brain cannot sustain that anxiety response.  It peaks and then it comes down, usually within about an hour. 


So, if you are prevented from washing your hands, your brain starts to understand, at a very primitive, unconscious, level, that you actually don’t have to wash your hands to relieve your anxiety, that if you just do nothing, the anxiety will go away; if you do that again and again, and again.  And, usually, with a fairly simple case of OCD, such as just having a handwashing compulsion, or just having a lock-checking compulsion, within a few weeks of intensive treatment, the symptoms will go away.


Dr. Pam Morris:  I guess I’m thinking, as I hear you discuss behavioral therapy, that if I was compelled to do it, I would need someone to monitor me so that I don’t perform that behavior.


Dr. Linda Austin:  Absolutely.  You need support.  I mean, it’s easy enough for me to say this, but to actually do it is a really difficult thing.  So, typically, with cognitive-behavioral therapy, the treatment is very intense for the first few weeks, maybe a couple hours a day with a therapist; sometimes less than that.  And sometimes, when I haven’t had the luxury of working with a psychologist, I’ve used a family member.  For example, I had a patient, some years ago, who had a driving OCD and was unable to drive, except for a tiny bit, and I had his father, actually, work with him to get him back in the saddle, actually, back in the front seat of the car, driving, and when he would get anxious, he had to continue to drive and work his way through the anxiety.


Dr. Pam Morris:  Do you ever need, in cognitive therapy, to explore any issues that might have precipitated this sudden development of OCD?


Dr. Linda Austin:  Usually not.  You know, it’s interesting, in the history of psychiatry, doing psychoanalysis on people with OCD, it’s never proven to be very helpful.  Now, sometimes there may be some kind of trauma that set it off, but not usually.  Oftentimes people just develop OCD kind of out of the blue.  And, usually, that kind of insight-oriented therapy is not particularly helpful.


Dr. Pam Morris:  Now, I would imagine there are some people who need concomitant medical therapy as well as cognitive therapy?


Dr. Linda Austin:  Right.  And, most often, we suggest both at the same time.  Pam, the medications that are used are, actually, in the class called Antidepressants.  Antidepressants are almost like aspirin.  They do a whole lot of different things, even though we call them antidepressants. 


So, the so-called serotonin-selective reuptake inhibitors (SSRIs), including Prozac, Paxil, Lexapro, Selexa, Zoloft, most of which, actually, are now available as generics, are effective for OCD, although, often the dose you have to use is much higher than with regular depression.  So, for example, it may take four pills a day of Prozac, or fluoxetine, for OCD, whereas it only takes one a day for depression.


Dr. Pam Morris:  You mentioned that anxiety is such a strong component of the compulsion, are anti-anxiety medications ever needed?


Dr. Linda Austin:  You know, we try them sometimes, but they’re actually not as useful as you might think.  Part of what happens in OCD is that you have trained your brain that, when you become anxious, you unconsciously link it to something like the thought that my hands are dirty, and then the first time you wash your hands and you feel a little bit better, you’ve trained your brain that, ah hah, the way to relieve anxiety is by washing my hands.  And if you do that enough times, it’s almost like Pavlov’s dogs.  For reasons that are not altogether clear, the anti-anxiety agents don’t seem to take that away.  They may take the edge off of some of the discomfort, but they are not effective treatments, in and of themselves, for OCD.


Dr. Pam Morris:  Any other medications that work for OCD?


Dr. Linda Austin:  Well, actually, there is another class of medications, the so-called atypical antipsychotics, like Risperdal, Zyprexa, Seroquel, Geodon.  These are sometimes used on top of the SSRI antidepressants to boost the action of those medications.  Again, this in not a psychotic illness, these medications just kind of picked up that name along the way, but they can be helpful added onto.  So, sometimes it takes a couple of medications at the same time, plus cognitive-behavioral therapy.


Dr. Pam Morris:  Does the treatment become life-long?


Dr. Linda Austin:  That really depends.  The easiest cases to treat are those where there is a single obsession or compulsion.  For example, if you have just a handwashing compulsion, that, actually, is pretty easy to treat.  And, sometimes, just an intensive course of behavioral therapy will do the trick.  And you may stay well for a very long time with, maybe, some tune-ups along the way.


The more the person, though, has of changing Os and Cs, obsessions and compulsions, it may be a combination of handwashing and checking, and driving problems, and having to think up prayers to say, and everyday there are new and different obsessions and compulsions, those situations are more difficult.  It becomes a lot more difficult to design a cognitive-behavioral treatment.  And you may, in fact, need medications for many years, and the medications may be only partially successful; they may help, but not take care of it 100 percent.


Dr. Pam Morris:  Well, Dr. Austin, thank you very much for the discussion of the treatment for OCD.


Dr. Linda Austin:  Thank you, Pam.


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