OCD Diagnosis and Treatment
University of Florida
University of Florida
Is OCD onset more common in childhood or adolescence?
Dr. McNamara: The research really shows that OCD for most people really gets started in childhood and earlier childhood is likely to be male and in adolescents females catch up and then by the time people reach adulthood the gender splits about even between people suffering from the disorder between males and females.
Dr. Geffken: But the smallest estimate is probably 20% have onset in adulthood and maybe as high as half or a little above that otherwise starts before adulthood.
What are the most basic behavioral elements for Cognitive Behavioral Therapy for OCD?
Dr. Geffken: Well the most basic elements are exposure, which means facing the fear and that involves presenting the patient with something that is going to make them anxious and raise their anxiety and trigger one of their obsessions and the other most basic element is response to or ritual prevention. Which involves having them reduce repetitive actions that they engage in to reduce their anxiety in most cases that’s an overt behavior or a compulsion or ritual that anybody could see in come cases though you don’t see that and probably as recent as 30 years ago not a lot of OCD people recognized that people were engaging in mental or covert rituals like counting or praying but some people are doing that to try and fend off their anxiety not to suggest there is something inherently pathological about praying it’s just if you’re spending two or three hours and it’s preventing you from doing things.
Dr. McNamara: Right and rigidity with prayers might be the case as well, so I have to say the prayer just right or I have to say it exactly this way, so very often you’ll see that. Exactly like what Dr. Geffken was saying if someone is afraid of this magazine for whatever reason the key thing would be the exposure aspect would be keeping the magazine there and then challenging them in their response prevention part of not leaving the room, not withdrawing from it and saying so right now I’m this far away from it I’m going to stay that distance and that’s engaging the response prevention part and then as the person progresses thought the treatment moving them closer and closer to the magazine and having them touch the magazine, hold the magazine or whatever it might be that is creating the anxiety in particular.
What is not an uncommon comorbity in adults with OCD?
Dr. MaNamara: Well really there are so many different comorbidities associated with OCD from other anxiety disorders, major depressive disorder, in children disruptive behavior disorders especially ODD (Oppositional Defiant Disorder) we know can be really problematic. Fortunately people still respond very effectively to the treatment which is a great thing that people still respond effectively to the treatment but the treatment response is not as robust as when it’s only OCD alone not when it’s comorbid along with something else.
Dr. Geffken: And so depression is often comorbid with OCD and often if you just target the OCD, depression will decrease as the OCD decreases. Sometimes when it’s more severe than the depression you’ll have to treat the depression before you try behavioral or cognitive behavioral therapy (CBT) because it’s pretty effortful and really depressed people don’t seem to have enough energy or effort to exert to do the CBT
Dr. McNamara: Well one of the things that so often happens with OCD after struggling with it for a long period of time people seem to very much lose hope which certainly feeds into this part of depression and so it can be very hard to work up the fortitude it takes to be able to attack the different anxieties.
What is an example of accommodation in children with OCD?
Dr. Geffken: I think an example of an accommodation we talked about was reassurance seeking, children often will ask their parents do you love me? Am I ok? Am I sick? And they want some reassurance that they are ok or loved and while that would seem to be a reasonable thing for a parent to do and it would help keep the peace what it does in the long run is it keep their anxieties and worries going because it temporarily reduces their anxiety after they ask that question and so they are more likely to ask it again to reduce their anxiety. If the parents can stop answering that question the kids will stop asking that question and stop reassurance seeking which if it’s done too much can get to be pretty bothersome.
Dr. McNamara: I had a case a number of years ago where a child was really concerned that something bad was going to be happening to mom. She was very young maybe second or third grade, and after she had been at school for about an hour would get permission from the teacher to go up to the office and she would call mom’s cell phone and say “just checking in mom to make sure you’re ok” and mom would say yes and then she’d go back to class and then about every hour on the hour this girl was leaving class to go check and make sure her mom was ok. Mom would always make sure to answer the phone because if she didn’t answer the phone the child would just start crying hysterically in the main office so we had a combination there of the teacher letting the child out of class to make that phone call, the office staff that was allowing the child to make these calls and a combination on mom’s end because she would answer these calls providing the information. So we first started by targeting and working with mom to reduce the combination of if she calls within an hour and half of the last time she called mom wouldn’t answer and then gradually expanding that. Then mom got the teacher and the office staff on board with that and eventually the child stopped calling and she would stay in the class all day and do well and not be distressed by this intrusive thought about something horrible was happening to mom.
How common is OCD?
Dr. Geffken: OCD is one of the most disabling disorders as rated by the World Health Organization it has a 2% lifetime prevalence, one out 50 people, over the course of their lifetime will show OCD. When I was in graduate school in the late 70s the estimate was one out of 10,000. It’s not really that OCD has become that much more common but it’s become much more readily identified just in the course of 30 years, OCD has had a lot of progress in terms of being recognized and treated.
Dr. McNamara: Absolutely, one of the things that is just really striking, and one of the things I talk to the potential patients that are calling our clinic with the different concerns, they think well I don’t have OCD because it’s not washing, it’s not hoarding, I’m counting all the time or it’s ok if things are asymmetrical or not perfectly neat my struggle is that I keep thinking something horrible will happen to someone I love and the thought just keeps coming and coming so there are a lot of cases I think where people aren’t recognizing that this is actually OCD but they are certainly very distressed by this recurrent thought and then engaging in some type of behavior to reduce that anxiety the key thing is that behavior actually serves to reinforce the anxiety and makes it worse in the long run.
Dr. Geffken: I think OCD is a term that a lot of people use in everyday life and I think a lot of us have obsessive compulsive characteristics but we don’t necessarily have the disorder. It becomes a disorder when it’s too time consuming, distressing or interfering with your life. There are some rituals that are healthly and good, like brushing your teeth in the morning. We general assume that’s a good thing. Putting your keys in the same place when you come in the house, putting your glasses in the same place so you don’t have to look for them. Those are good rituals, it’s ones that take up time, interfere and cause distress.
Dr. McNamara: And with those rituals, how ridge are they? I have to start by brushing the teeth on the left or can start on the left one day or can I start at the top or the bottom. Or there are five rungs on the place where I hang my keys, I have to hang it on the far left one and if there is already a key there I have to move it somewhere else so my key can go on the far left rung. So really looking for that sort of rigidity as apposed to well these is generally where I hang my keys or brush my teeth in the morning.
Can OCD be cured?
Dr. Geffken: I think for most people, they describe OCD as waxing and waning so while there can be dramatic improvements in OCD it’s… and we’ve treated a lot of children over the years where it did seem to remit or almost go away entirely but in so many people it goes up and down and up and down and so many people just don’t get treated.
Dr. McNamara: Just in the population of people that aren’t struggling with OCD there’s just random intrusive thoughts pop into our head for all different types of reasons, it might be something we see on the news, it might be someone walks by wearing a perfume that makes us think of an old friend so there are any number of different things that can trigger thoughts the key thing is would I consider this an intrusive thought, a distressing thought and very often the people who have been struggling with OCD the thoughts that might get triggered at one point or another it may or may not have been intrusive or distressing the key thing is that if they are noticing, oh that thought is bothering me a little we know the distinction and if they use the strategies they’ve learned through CBT they’ll be able to knock those anxiety symptoms back down very quickly. While it’s something that might be there for really long periods of time you can get down to the point where the intrusive thoughts while they occur, they don’t actually cause that much distress and its not really even taking minutes out of your life. Maybe a minute here and there occasionally and you think there’s that thought that really used to bother me.
Dr. Geffken: I think that’s a really good point, I wouldn’t want to leave the impression that there’s a hopelessness about it. I wanted to leave the impression that it may recurring and you may have to deal with it but I think some people can get a handle on it and keep a handle on it
Dr. McNamara: And the research on remission in kids does show that children are much more likely to reach and maintain remission than adults and particularly adults about 25 and older they’ll have a higher frequency of intrusive thoughts as they get older but again if they have the strategies and the tools they can be successful, provided they are successfully implementing those there is every reason to believe they will be able to work through those periods very effectively