Obstacles to treating OCD
Several complicating factors arise when it comes to seeking help for OCD:
- Sufferers are secretive about their obsessions and embarrassed by their ritualized activities. Children worry about being segregated –and possibly bullied- whereas grownups are frequently attempting to carry on with their employment or careers.
- We saw in part 2 the extents to which stress as well as various mental disorders co-exist with OCD. Thus, depression, certain phobias, panic disorder and alcohol and drug abuse can bring about a fog of disorders in which OCD remains obscured for a long time.
- Public awareness of OCD has increased dramatically in the last decade or two. Prior to that, people did not know the disorder had a name -much less, a treatment. Add to that the fact that there are even today few therapists who can effectively treat OCD.
- Because of one or more of the above reasons, patients frequently ended up incorrectly diagnosed; they would thus spend several years in incorrect treatments before finally being seen by the right mental health professionals.
There is no magic wand for curing OCD. Instead, sufferers can seek professional help for psychotherapy and/or pharmacological treatments. They can also help themselves by making some lifestyle adjustments that boost their treatment plans. Treatments are frequently aimed at suppressing the severity of the symptoms rather than achievement a cure, and patients can spend many years in treatment -sometimes a whole lifetime.
- Patients should muster the strength and motivation to actively take charge of their recovery process. The road to recovery from OCD is long and requires setting small and manageable goals to stay on course.
- Patients are advised to learn as much as possible about their disorder and about the treatment plan that is developed for them. They should learn to detect warning signs of impending attacks and how best to react to these.
- Patients should take their medications as prescribed and should contact their physicians when there are changes in the symptoms or in their reactions. Patients should avoid alcohol consumption and illicit substances. They should seek help for long-standing habits to do with substance abuse.
- Patients should learn about and practice stress-relief measures with particular emphasis on exercise, hobbies and socializing with trusted family members and friends. Other stress management techniques include breathing, meditation, yoga, muscle relaxation, acupuncture, and massage therapy.
Treating OCD with psychotherapy
A mental health therapeutic process has become the benchmark since the 1970’s and 1980’s for treating a variety of conditions including OCD, mood, anxiety, personality, tic, substance abuse and psychotic disorders. This is referred to as Cognitive Behavioral Therapy (CBT). This modality studies and attacks the patient’s fears, described as “cognitive distortions”, and the process of dealing with the distortions is known as “cognitive restructuring”. In it, the patient is methodically made to confront his worst fears without falling back on compulsive or avoidant behavior, a process known as “Exposure and Response Prevention (ERP)¹”.
In this process, the psychotherapist helps the patient to accept the reality of their dreaded thoughts and urges and to purposefully choose not to react in a compulsive or avoidant way. This prompts the patient to choose new ways for reacting to obsessive images. The treatment requires that the patient accept the reality of the dreaded images while challenging their accuracy. The patient will eventually tolerate the obsessions without further ado.
Needless to say, since a good deal of the exercises have to be conducted by the patient outside of the psychotherapist’s clinic, the client can easily fall back on prior lifetime habits of compulsions following obsessions. The patient may also make the mistake of trying to resist the images or urges, thus telling the brain that there are fears being superficially subdued. This goes against the grain of accepting and tolerating the obsessions.
When it comes to treating OCD and anxiety-based conditions, Cognitive Behavioral Therapy (CBT) has become the gold standard for the following reasons:
- The goal of any treatment is to educate patients to become their own therapists, and CBT does precisely that
- Patients face and become tolerant of their fears
- Patients get acquainted with helpful methods to become more accepting of their dreaded sensations
- These methods can be practiced at the patient’s home and can serve the patient for the rest of their lives
Treating OCD with medications
Which medication to take: When CBT is not practical or insufficient, the mental health physician treating an obsessive-compulsive patient may resort to medications with the objective of reducing symptoms with the lowest possible dosage. The precise medication that works best for any particular patient may take months to uncover, and may only be arrived at after trying several medications.
No medication or combination of medications constitutes a cure for OCD, and it is always advisable that patients go through cognitive behavioral therapy (CBT) whether or not they are also on medications. At best, pharmaceuticals can provide relief from the harshest symptoms of the disorder while the sufferer is on the drug, but then the symptoms recur when the sufferer goes off the drug.
Medication Type: Selective Serotonin Reuptake Inhibitors (SSRIs)
These usually take the form of antidepressants which act in the Serotonin System. Serotonin is a chemical that transmits nerve impulses in the brain, and it plays an important part in regulating mood, sleep and anxiety. The best known and most widely used of these is Fluoxetine (Prozac).
In the U.S., the SSRIs that have been approved by the Food and Drug Administration (FDA) include:
- Clomipramine (Anafranil)
- Fluvoxamine (Luvox)
- Fluoxetine (Prozac)
- Paroxetine (Paxil, Pexeva)
- Sertraline (Zoloft)
In the UK², The SSRIs usually recommended for the treatment of OCD include:
- Citalopram (Cipramil)
- Escitalopram (Cipralex)
- Fluvaxamine (Luvox and Faverin)
- Paroxetine (Paxil and Seroxat)
- Sertraline (Lustral and Zoloft)
The most that specialists can tell as to why SSRIs are helpful to individuals with OCD is that they alleviate the anxiety associated with the obsessive fears. As such, they may also reduce the anxiety enough for a person to be able to start in therapy. Of the above lists on both sides of the Atlantic, Sertraline and Fluvaxamine are usually prescribed for the younger patients. In addition, it should be noted that these are only partial lists, and patients may be prescribed other medications instead of –or in addition to- one or more of the above.
The above is not an exhaustive list, and sufferers are often prescribed other psychiatric pharmaceuticals to enhance or augment the effects of these SSRIs. SSRIs however are deemed to be very safe, with minimal side effects, and with less withdrawal effects than other antidepressants.
How SSRIs work: In the brain, impulses are emitted between nerve cells by way of chemical “synapses”. Thse are small gaps between the cells, and the cells that send the messages release neurotransmitters into those gaps. Serotonin is one such transmitter. SSRIs work by allowing more serotonin to increase in the synaptic cleft where it is needed³. Depression and several of the anxiety disorders are often attributable to lack of Seratonin “going to the brain”.
SSRI side effects and risks: Side effects such as stomach upsets, sleep anxiety, sweating and diminished sexual desire are part and parcel of all psychiatric medications although people experience them in different degrees. Patients who have been newly put on medications are well advised to talk to their doctors about side effects as well as all other ways in which medications are affecting them, particularly as these relate to theirsumptoms.
When CBT and medications don’t work: Sometimes psychiatric and pharmacological therapies aren’t effective enough in controlling severe symptoms of OCD. In rare cases like that, other treatments exist such as psychiatric hospitalization, Electroconvulsive Therapy (ECT), and deep brain stimulation. Those therapies are still in develoment stages and to be considered by mental health physicians only in the most extreme of cases. On a more oprtimistic note: In the realm of time, the above mentioned treatments only came about yesterday. For example, both CBT and SSRIs only flourished in the second half of the 20th century. It has to be thus noted that the scientists vested with finding ways to combat the demons of OCD are active and making progress on a regular basis out of illustrious research centers worldwide.
Important reminder: Always check with your own physician before making decisions or taking steps relevant to your health or that of a loved one.
¹ OCD & Anxiety: Five Common Roadblocks to Successful Treatment by Kimberley Quinlan, MA
² OCD – UK “Medication”
³ Mayo Clinic staff
About Mike Takieddine, the author:
Mine has been a privileged life, first for having traveled all over as son of a diplomatic family, then for having had the opportunity to study at Oxford, and finally for a gratifying career in business, in geriatric home care, and in writing. I look forward to using this wonderful medium to discuss the various aspects of life that are of interest to my readers.