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Tuesday, April 26, 2011

Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is an anxiety disorder in which people have unwanted and repeated thoughts, feelings, ideas, sensations (obsessions), or behaviors that make them feel driven to do something (compulsions).Often the person carries out the behaviors to get rid of the obsessive thoughts, but this only provides temporary relief. Not performing the obsessive rituals can cause great anxiety. A person's level of OCD can be anywhere from mild to severe, but if severe and left untreated, it can destroy a person's capacity to function at work, at school or even to lead a comfortable existence in the home.

OCD affects about 2.2 million American adults, and the problem can be accompanied by eating disorders, other anxiety disorders, or depression. It strikes men and women in roughly equal numbers and usually appears in childhood, adolescence, or early adulthood. One-third of adults with OCD develop symptoms as children, and research indicates that OCD might run in families.

Although OCD symptoms typically begin during the teen years or early adulthood, research shows that some children may even develop the illness during preschool. Studies indicate that at least one-third of cases of adult OCD began in childhood. Suffering from OCD during early stages of a child's development can cause severe problems for the child. It is important that the child receive evaluation and treatment as soon as possible to prevent the child from missing important opportunities because of this disorder.


People with OCD:

• Have repeated thoughts or images about many different things, such as fear of germs, dirt, or intruders; violence; hurting loved ones; sexual acts; conflicts with religious beliefs; or being overly neat.
• Do the same rituals over and over such as washing hands, locking and unlocking doors, counting, keeping unneeded items, or repeating the same steps again and again.
• Have unwanted thoughts and behaviors they can't control.
• Don't get pleasure from the behaviors or rituals, but get brief relief from the anxiety the thoughts cause.
• Spend at least an hour a day on the thoughts and rituals, which cause distress and get in the way of daily life.


Unwanted repetitive ideas or impulses frequently well up in the mind of the person with OCD. Persistent paranoid fears, an unreasonable concern with becoming contaminated or an excessive need to do things perfectly, are common. Again and again, the individual experiences a disturbing thought, such as, "This bowl is not clean enough. I must keep washing it." "I may have left the door unlocked." Or "I know I forgot to put a stamp on that letter." These thoughts are intrusive, unpleasant and produce a high degree of anxiety. Other examples of obsessions are fear of germs, of being hurt or of hurting others, and troubling religious or sexual thoughts.


In response to their obsessions, most people with OCD resort to repetitive behaviors called compulsions. The most common of these are checking and washing. Other compulsive behaviors include repeating, hoarding, rearranging, counting (often while performing another compulsive action such as lock-checking). Mentally repeating phrases, checking or list making are also common. These behaviors generally are intended to ward off harm to the person with OCD or others. Some people with OCD have regimented rituals: Performing things the same way each time may give the person with OCD some relief from anxiety, but it is only temporary.

People with OCD show a range of insight into the uselessness of their obsessions. They can sometimes recognize that their obsessions and compulsions are unrealistic. At other times they may be unsure about their fears or even believe strongly in their validity.

Most people with OCD struggle to banish their unwanted thoughts and compulsive behaviors. Many are able to keep their obsessive-compulsive symptoms under control during the hours when they are engaged at school or work. But over time, resistance may weaken, and when this happens, OCD may become so severe that time-consuming rituals take over the sufferers' lives and make it impossible for them to have lives outside the home.

The course of the disease is quite varied. Symptoms may come and go, ease over time, or get worse. If OCD becomes severe, it can keep a person from working or carrying out normal responsibilities at home. People with OCD may try to help themselves by avoiding situations that trigger their obsessions, or they may use alcohol or drugs to calm themselves.


The old belief that OCD was the result of life experiences has become less valid with the growing focus on biological factors. The fact that OCD patients respond well to specific medications that affect the neurotransmitter serotonin suggests the disorder has a neurobiological basis. For that reason, OCD is no longer attributed only to attitudes a patient learned in childhood -- inordinate emphasis on cleanliness, or a belief that certain thoughts are dangerous or unacceptable. The search for causes now focuses on the interaction of neurobiological factors and environmental influences, as well as cognitive processes.

OCD is sometimes accompanied by depression, eating disorders, substance abuse, a personality disorder, attention deficit disorder or another of the anxiety disorders. Coexisting disorders can make OCD more difficult both to diagnose and to treat. Symptoms of OCD are seen in association with some other neurological disorders. There is an increased rate of OCD in people with Tourette's syndrome, an illness characterized by involuntary movements and vocalizations. Investigators are currently studying the hypothesis that a genetic relationship exists between OCD and the tic disorders.

Other illnesses that may be linked to OCD are trichotillomania (the repeated urge to pull out scalp hair, eyelashes, eyebrows or other body hair), body dysmorphic disorder (excessive preoccupation with imaginary or exaggerated defects in appearance) and hypochondriasis (the fear of having -- despite medical evaluation and reassurance -- a serious disease). Researchers are investigating the place of OCD within a spectrum of disorders that may share certain biological or psychological bases. It is currently unknown how closely related OCD is to other disorders such as trichotillomainia, body dysmorphic disorder and hypochondriasis.

There are also theories about OCD linking it to the interaction between behavior and the environment, which are not incompatible with biological explanations.

A person with OCD has obsessive and compulsive behaviors that are extreme enough to interfere with everyday life. People with OCD should not be confused with a much larger group of people sometimes called "compulsive" for being perfectionists and highly organized. This type of "compulsiveness" often serves a valuable purpose, contributing to a person's self-esteem and success on the job. In that respect, it differs from the life-wrecking obsessions and rituals of the person with OCD.


Clinical and animal research sponsored by NIMH and other scientific organizations has provided information leading to both pharmacological and behavioral treatments that can benefit the person with OCD. One patient may benefit significantly from behavior therapy, yet another will benefit from pharmacotherapy. And others may benefit best from both. Others may begin with medication to gain control over their symptoms and then continue with behavior therapy. Which therapy to use should be decided by the individual patient in consultation with his or her therapist.


Clinical trials in recent years have shown that drugs that affect the neurotransmitter serotonin can significantly decrease the symptoms of OCD. The first of these serotonin re-uptake inhibitors (SRIs) specifically approved for the use in the treatment of OCD was the tricyclic anti-depressant clomipramine (Anafranil). It was followed by other SRIs that are called "selective serotonin re-uptake inhibitors" (SSRIs). Those that have been approved by the Food and Drug Administration for the treatment of OCD are citalopram (Celexa), flouxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil) and sertraline (Zoloft).

Large studies have shown that more than three-quarters of patients are helped by these medications at least a little. And in more than half of patients, medications relieve symptoms of OCD by diminishing the frequency and intensity of the obsessions and compulsions. Improvement usually takes at least three weeks or longer. If a patient does not respond well to one of these medications, or has unacceptable side effects, another SRI may give a better response. For patients who are only partially responsive to these medications, research is being conducted on the use of an SRI as the primary medication and one of a variety of medications as an additional drug (an augmenter). Medications are of help in controlling the symptoms of OCD, but often, if the medication is discontinued, relapse will follow.

Behavior Therapy

Cognitive behavioral therapy (CBT) has been shown to be the most effective type of psychotherapy for this disorder. The patient is exposed many times to a situation that triggers the obsessive thoughts, and learns gradually to tolerate the anxiety and resist the urge to perform the compulsion. Medication and CBT together are considered to be better than either treatment alone at reducing symptoms.

A specific behavior therapy approach called "exposure and response prevention" is effective for many people with OCD. In this approach, the patient deliberately and voluntarily confronts the feared object or idea, either directly or by imagination. At the same time the patient is strongly encouraged to refrain from ritualizing, with support and structure provided by the therapist, and possibly by others whom the patient recruits for assistance. For example, a compulsive hand washer may be encouraged to touch an object believed to be contaminated, and then urged to avoid washing for several hours until the anxiety provoked has greatly decreased. Treatment then proceeds on a step-by-step basis, guided by the patient's ability to tolerate the anxiety and control the rituals. As treatment progresses, most patients gradually experience less anxiety from the obsessive thoughts and are able to resist the compulsive urges.

Psychotherapy can also be used to provide effective ways of reducing stress, anxiety and resolving inner conflicts.

Ways to Make Treatment More Effective

Many people with anxiety disorders benefit from joining a self-help or support group and sharing their problems and achievements with others. Internet chat rooms can also be useful in this regard, but any advice received over the Internet should be used with caution, as Internet acquaintances have usually never seen each other and false identities are common. Talking with a trusted friend or member of the clergy can also provide support, but it is not a substitute for care from a mental health professional.

Stress management techniques and meditation can help people with anxiety disorders calm themselves and may enhance the effects of therapy. There is preliminary evidence that aerobic exercise may have a calming effect. Since caffeine, certain illicit drugs, and even some over-the-counter cold medications can aggravate the symptoms of anxiety disorders, they should be avoided. Check with your physician or pharmacist before taking any additional medications.

The family is very important in the recovery of a person with an anxiety disorder. Ideally, the family should be supportive but not help perpetuate their loved one's symptoms. Family members should not trivialize the disorder or demand improvement without treatment. When a family member suffers from obsessive-compulsive disorder it's helpful to be patient about their progress and acknowledge any successes, no matter how small.

Obsessive-Compulsive Disorder. Last reviewed 06/01/2010
Archives of General Psychiatry
British Journal of Psychiatry Supplement
Diagnostic and Statistical Manual, Fourth Edition
National Institutes of Mental Health
National Library of Medicine
Psychiatric disorders in America: the Epidemiologic Catchment Area Study
Psychopharmacology Bulletin


Wrestling with Bipolar Disorder

It's one of the most missed diagnoses in psychiatry. Bipolar disorder, involving moods that swing between the highs of mania and the lows of depression, is typically confused with everything from unipolar depression to schizophrenia to substance abuse, to borderline personality disorder, with just about all stops in between. Patients themselves often resist diagnosis, because they may not see as pathologic the surge in energy that accompanies the mania or hypomania that distinguishes the condition.

But on a few points consensus is emerging. Bipolar disorder is a chronically recurring illness. And the age of onset is dropping—in less than one generation it has gone from age 32 to 19. Whether there is a genuine increase in prevalence of the disorder is a matter of some debate, but there does seem to be a genuine increase among the young.

What's more, the depression of manic-depression is emerging as a particularly thorny problem for both patients and their doctors.

"Depression is the bane of treatment of bipolar disorder," says Robert M.A. Hirschfeld, M.D., head of psychiatry at the University of Texas Medical Branch in Galveston.

It's what is most likely to motivate patients to accept care. People spend more time in the depression phase of the disorder. And unlike unipolar depression, the depression of bipolar illness tends to be treatment-resistant.

"Antidepressants don't work very well in bipolar depression," says Dr. Hirschfeld. "They are underwhelming in their ability to treat the depression." In fact, a shift away from antidepressants is formally recognized in new treatment guidelines for bipolar disorder just released by the American Psychiatric Association.

As physicians gain experience in treating the disorder, they are discovering that antidepressants have two negative effects on the course of the disorder. Used by themselves, antidepressants can induce manic episodes. And over time they can accelerate mood cycling, increasing the frequency of episodes of depression or of mania followed by depression.

Instead, research points to the value of drugs that work as mood stabilizers for the depression of bipolar disorder, either alone or in combination with antidepressants. If antidepressants have any use at all in bipolar disorder, it may be as acute treatment for bouts of severe depression before mood stabilizers are added or substituted.

Even in cases of severe depression, the new guidelines favor increasing the dosage of mood stabilizers over other strategies.

Not so long ago, mood stabilizers could be summed up in a single word—lithium, in use since the 1960s to tame mania. But research has additionally demonstrated the effectiveness of divalproex sodium (Depakote) and lamotrigine (Lamictal), drugs that were initially developed for use as anticonvulsants in seizure disorders. Divalproex sodium has been approved for use as a mood stabilizer in bipolar disorder for several years, while lamotrigine is undergoing clinical trials for such an application.

"Optimizing the dose of lithium or divalproex has good antidepressant effects," reports Dr. Hirschfeld. "We also now know that divalproex and lamotrigine are very good for preventing recurrence in bipolar patients." A study showed that lamotrigine not only delays the time to any mood events but is notably effective against the depressive lows of bipolar illness.

No one knows for sure exactly how anticonvulsants work in bipolar disorder. For that matter, the condition has been described since the time of Hippocrates, but it is still not clear what goes awry in manic-depression.

Despite the unknowns, medications for treating the disorder are proliferating. In contrast to downplaying antidepressants in the depressive phase of the disorder, clinical research is ramping up the value of antipsychotic drugs for combating the manic phase, albeit a new generation of such drugs, collectively called atypical antipsychotics. Chief among them are olanzapine (Zyprexa) and risperidone (Risperdal). They are now considered a first-line approach to acute mania, and adjuncts for long-term therapy along with mood stabilizers.

In the long term, however, observes Nassir Ghaemi, M.D., assistant professor of psychiatry at Harvard and head of bipolar research at Cambridge Hospital, medication goes only so far. "Drugs are not effective enough. It may have to do with the overuse of antidepressants; they interfere with the benefits of mood stabilizers.

"Medications don't take you to the finish line." There seem to be residual symptoms of depression that don't clear. Even when patients stabilize into a normal, or euthymic, mood state, he says, some troubling signs can appear.

"Sometimes we see in euthymic patients cognitive dysfunction that we didn't expect in the past—word-finding difficulties, trouble maintaining concentration," Dr. Ghaemi explains. "Cumulative cognitive impairment seems to emerge with time. It may be related to findings of decreased size of the hippocampus, a brain structure that serves memory. We are on the verge of recognizing long-term cognitive impairment as a result of bipolar disorder."

He believes there is a role for aggressive psychotherapy for keeping patients well, for keeping everyday ups and downs from becoming full-blown episodes. At the very least, he finds, psychotherapy can help patients resolve the work and relationship problems that often outlast symptoms.

In addition, psychotherapy can help patients learn new coping styles and interpersonal habits. "Many of the ways patients deal with their illness are not relevant when they are well," explains Dr. Ghaemi.

For example, he says, many people develop the habit of staying up late as a way of coping with the manic symptoms. "What they couldn't change before because of the illness needs to be changed after treatment if, for example, it bothers a spouse. People have to learn to change. But the longer one is ill, the harder it is to become completely well, because the harder it is to change the habits of one's life."

And for young people diagnosed with bipolar illness, he considers psychotherapy essential. "The younger patients are, the less convinced they are that they have bipolar disorder," he says. "They have impaired insight. They're especially concerned about the need to take medications. They should be in psychotherapy to get educated about the illness and medication."

He also stresses the value of support groups, especially for young people. "It's another, important layer of validation."

By Hara Estroff Marano, published on May 01, 2002 - last reviewed on July 24, 2007


Thursday, April 14, 2011

Client's Letter to Counselor

Although I have received a fair amount of letters and feedbacks from past clients over the many years of practice, I have never considered organizing a more orderly method of collecting these much needed information.

As a start, I'd like to share a short note I received from a client; with her personal consent, of course. I've also deleted her name to protect her identity for privacy reasons. Below is the note she sent me:

salam. kak johana,

thanks for the friend approval.

also, i have to say that i'm very glad you took up psychology and having your own practice because you're really good at it.

its a big relief to have someone to not only understand but to be able to offer solutions.

i'm happy that the chronic fatigue syndrome was pointed out and really happy that the multivitamins/exercises/deep breathing are working out. i also love working at the assignments given.

looking forward to combat the post trauma stress disorder and driving phobia. truthfully still nervous thinking about driving but i hope to get over it.


here's wishing you all the best and May Allah bless you!


Any of my past and current clients are most welcomed to write comments here using pseudonyms. Given time, I will create a link specifically designed for feedback purposes only. Meanwhile, to all my clients, past and present; thank you for providing me the opportunity to be useful in your lives. Stay blessed, sweet ones.