By MARY-CATHERINE SEGOTA, Psy.D
According to the NIMH (2014), patients diagnosed with Obsessive Compulsive Disorder experience more physical ailments, including heart disease, blood pressure issues, migraines, respiratory disease, allergies, thyroid disease, and other conditions. Additionally, medical interventions can be less successful in this population due to high anxiety, distorted beliefs, obsessive rumination, and compulsive behaviors. People with OCD experience incredible pressure and exhaustion from the condition and have fewer coping skills to manage other aspects of life.
What is OCD? Memorable characters fill television and movie screens with comical symptoms that highlight many of the foundational characteristics of Obsessive Compulsive Disorder (OCD). But by taking a closer look, we can understand the difference between OCD and similar conditions. Melvin Udall from the movie As Good as it Gets demonstrates classic debilitating OCD. In comparison, Monica Geller from Friends reflects perfectionism, and Sheldon, from The Big Bang Theory, presents with Obsessive-Compulsive Personality Disorder (OCPD). A better understanding of which condition is present allows us to predict responses, treat the condition and improve our patients' quality of life. Many of your patients who struggle with managing anxiety may actually be dealing with OCD.
The perfectionist often describes themselves as being OCD. Perfectionism is a component of OCD, but not all perfectionists have OCD. Both may enjoy cleaning, organization, and are highly detailed with tasks or daily routines. The difference between OCD and perfectionism is the anxiety associated with thoughts and behaviors. Anxiety is not necessarily present in someone who is perfectionistic but is always present for someone with OCD. Additionally, the level of impairment in daily functioning differs significantly.
Another area where OCD is often confused is with Obsessive-Compulsive Personality Disorder. People with this disorder can be perfectionists, pay excessive attention to detail, have a poor work-life balance, be rigid, stubborn, and preoccupied with lists and tasks, and lose sight of the big picture. However, these are ingrained patterns that do not align with society's norms and cause interpersonal dysfunction, impulse control challenges, and cognition difficulties. An individual with OCPD experiences ego-syntonic thoughts and habits - meaning the person is not distressed by the distortion, doesn't think they are irrational or abnormal, and often likes the experience.
The true OCD patient experiences ego-dystonic obsessive thoughts – meaning they are aware that their thoughts and actions are abnormal or irrational. These thoughts typically center around orderliness, cleanliness, symmetry, safety, doubting of one’s own thoughts and perceptions, and aggression or unwanted sexual ideas. These thoughts are difficult to stop or shift and are often associated with compulsions. Compulsions are acts one feels compelled to complete repeatedly to reduce anxiety or to manage the fear that something terrible will happen.
OCD has neurological, genetic, behavioral, cognitive, and environmental factors. Everyone experiences intrusive, random, and strange thoughts. While most people can ignore these thoughts, individuals with OCD get stuck on them; the thoughts build up and become overwhelming and anxiety-producing. Neuroimaging has helped researchers identify specific areas of the brain that function differently in people with OCD. The research suggests symptoms may involve communication errors among different parts of the brain, including the orbitofrontal cortex, the anterior cingulate cortex, the striatum, the thalamus, and abnormalities in neurotransmitter systems. Environmental factors may trigger OCD symptoms, including TBI's, or post bacterial or viral infection in children (such as strep or flu), in those who are genetically predisposed, as well as the experience of chronic stress.
According to the DSM, OCD is defined by the presence of Obsessions, Compulsions, or both. Obsessions are recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive, unwanted, and that in most individuals cause marked anxiety or distress. Additionally, the individual attempts to ignore or suppress such thoughts, urges, or images or neutralize them with some thought or action (i.e., by performing a compulsion). Typical obsessions include contamination, disturbing sexual images, fear of yelling obscenities, concern with order and symmetry, intrusive thoughts of sounds, images, words, or numbers, and fear of losing or discarding something important.
Compulsions are repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession. These actions aim to prevent or reduce distress or prevent some dreaded event or situation but are not connected in a realistic way with what they intend to neutralize or prevent or are excessive. Typical compulsions are excessive washing, repeated cleaning, ordering or arranging things, repeatedly checking locks, switches, or appliances, constantly seeking approval or reassurance, and repeated counting to a certain number.
Further complicating the diagnostic picture is the presence of Co-existing disorders, as well as OCD related disorders including, Anxiety Disorders, Major Depressive Disorder, Bipolar Disorders, Attention-Deficit/Hyperactivity Disorder (AD/HD), Feeding/Eating Disorders, Autism Spectrum Disorder (ASD), and Tic Disorders/Tourette Syndrome (TS). According to the DSM V, OCD falls into a category with related disorders including: Body Dysmorphic Disorder, Hoarding Disorder, Trichotillomania (Hair-Pulling) Disorder, Excoriation (Skin-Picking) Disorder, and Other Specified Obsessive-Compulsive and Related Disorders, e.g., body-focused repetitive behavior disorder (such as nail-biting, lip biting, cheek chewing and obsessional jealousy).
So how do we help our patients? You may see patients that can’t manage their anxiety around health fears or are stuck with obsessions and compulsions and notice that they struggle with their general wellness. They have greater difficulty with changing behavior, have exaggerated fears, are easily stressed and fail to comply with medical advice. When you see patients who report these symptoms, medication is often the first consideration. However, studies have indicated that Cognitive Behavioral Therapy (CBT) is the treatment of choice for OCD. Specifically, CBT that involves the use of two evidence-based techniques: Exposure and Response Prevention therapy (ERP) and Cognitive Therapy (CT).
In more severe cases, CBT is utilized in conjunction with a medication regimen to better help patients. When medication is utilized, serotonin reuptake inhibitors have been shown to be the most effective. However, it is important for patients to be educated about the length of time to reach therapeutic doses of the medication which is typically 10 to 12 weeks. When serving patients, you suspect may have OCD, it is important to differentiate between perfectionistic behavior, personality disorder, and those behaviors that are distressing and impairing daily functioning. Most importantly, collaborating with a licensed mental health professional experienced in the treatment of OCD and related behaviors is key to addressing the complexities of the diagnosis and helping patients overcome these challenges and improve their quality of life.
With a doctorate in clinical psychology and over 20 years of experience in the field, Dr. Mary-Catherine Segota has conducted university-based behavioral medicine research, acted as a consultant to professionals and organizations, and worked with a diverse number of psychological and medical conditions. By identifying unique needs, the source of distress, and what’s perpetuating the problem, she will help develop the tools to overcome seemingly insurmountable circumstances. Visit www.CounselingResourceServices.com
