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"I suddenly was very afraid of dying and would imagine a funeral (my own) which would just make the anxiety worse."
"I wish I could do something. What's wrong with me anyhow? This is really nuts"(1).
Do these quotes sound like someone you know? Someone who seems preoccupied with a certain thought all the time, or seems to have certain mundane rituals they must perform? If so, this person may have obsessive-compulsive disorder. Obsessive-compulsive disorder is a chronic illness, a type of anxiety disorder characterized by (appropriately enough) obsessive thoughts and compulsive behavior. Unlike other anxiety disorders, the person knows that such thoughts and behaviors are irrational and silly, but cannot prevent themselves from having them.
You should not confuse obsessive-compulsive disorder, or OCD, with obsessive-compulsive personality disorder (OCPD). OCPD is a mental disorder that is characterized by "preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency" (2). A person with obsessive-compulsive disorder is concerned with disturbing thoughts and performs rituals to rid themselves of the anxiety.
To diagnose a person with OCD, you must first understand the exact symptoms of the disorder. First, there are obsessions. "Obsessions are defined as distressing ideas, images or impulses that repeatedly intrude into the patient's awareness. These thoughts are typically experienced as inappropriate, anxiety-arousing and contrary to the patient's will or desires" (3). Common obsessions include contamination (fears of germs, dirt, etc.); imagining having harmed self or others; imagining losing control of aggressive urges; intrusive sexual thoughts or urges; excessive religious or moral doubt; forbidden thoughts; a need to have things "just so;" and a need to tell, ask, or confess (4). However, obsessions are not the only telltale sign or requirement for OCD.
Another symptom of OCD is compulsions. "Compulsions, on the other hand, are repetitive behaviors or rituals that the patient performs to counteract the anxiety and distress produced by obsessive thoughts" (3). Common compulsions are washing, repeating, checking, touching, counting, ordering/arranging, hoarding, and praying (4). Some of these compulsions are easily witnessed but this is not always true. Not all compulsions are obvious; many are mental processes like counting or praying and harder if not impossible to notice. Typically the compulsions correspond to the obsessions. For example, fears of contamination are accompanied by hand washing and cleaning; aggressive, sexual, religious and somatic anxieties result in checking; need for symmetry produces ordering, arranging, counting and repeating rituals; and an obsession with hoarding leads to hoarding and collecting (3). Patients usually have obsessions and corresponding compulsions, but may have either obsessions or compulsions alone. Observing these obsessions and compulsions may be difficult for a friend, because the person will usually hide their symptoms. Noticing obsessions and compulsions is the first step in discovering whether someone has OCD, but several other conditions must be met for the diagnosis to be made.
For you to diagnose a person as having obsessive-compulsive disorder instead of being just weird, a few other factors must be present. If your friend really has OCD, he or she will recognize that the obsessions or compulsions are excessive or unreasonable; he or she knows that what he or she is doing makes no sense. In this OCD sufferers differ from such people as depressives, who truly believe thoughts such as "I am worthless" and also from pathological gamblers, who derive pleasure from their compulsions (3). An exception to this is children; yet many people who developed OCD did so as a child, and report knowing that there was something different (and wrong) about them in comparison to other children (1). This may also be true of your friend; watch for such questions as "Do you think I'm weird?" or "Does anyone else do this?" Another factor of OCD is that the obsessions and compulsions cause marked distress, are inordinately time-consuming, or significantly interfere with the person's normal routine, occupational functioning, or social activities or relationships (3). If you notice that your friend does have obsessions or compulsions that cause them to avoid people and social activities, than your friend may indeed have OCD.
Even with all these symptoms, it is often difficult to diagnose a person with obsessive-compulsive disorder. Because the person knows their thoughts and actions are irrational, they tend to conceal their problems. Often a friend (such as yourself) or a family member will bring the person they suspect of OCD to a doctor's attention. Sometimes the disorder is revealed through secondary symptoms, such as dry hands from excessive hand washing; however, the diagnosis must be made by specific questioning by a doctor. Clinical interviews establishing a history of obsessive thought or ritualistic behavior is the primary method of diagnosis. There are some things you can do to determine if your friend has OCD. You could ask him or her such questions as "Do you find yourself doing something unusual repeatedly? Does this seem normal to you or does it seem weird?" You could also make it fun and use a diagnostic scale as a magazine quiz. (These surveys pretty much work the same way as most magazine quizzes.) The most commonly used is the Yale-Brown Obsessive Compulsive Scale (available online at (5)); also the Work and Social Adjustment Scale (often used in combination with other diagnostic scales), and the Maudsely Obsessive Compulsive Inventory. There are also several online resources, such as the Obsessive Compulsive Screening Checklist (6)and the National Institute of Mental Health Screening Test (7). (Now I have to do the disclaimer thing...) You should not attempt to make such a diagnosis on your own; these online resources are only to help you determine whether your friend has symptoms of OCD in order for him or her to seek professional help.
You might wonder what causes your friend with OCD to act this way. Well, so do the doctors! The exact cause of obsessive-compulsive disorder is still not known. Research has suggested that insufficient levels of the neurotransmitter serotonin causes problems in communication between the orbital cortex (the front part of the brain) and the basal ganglia (deeper structures) (4). For this reason, drugs that increase the amount of serotonin in the body have some effectiveness in treating the disease, which means there's still hope for your friend.
Okay, you know your friend has OCD. The question is, what can you do about it? There are several treatments for obsessive-compulsive disorder that vary depending on the nature and strength of the condition: medications and behavioral therapy. These treatments are intended not to cure the person, but to allow them to gain control over their disease. The medications used to treat OCD are serotonin reuptake inhibitors. The most common are Clomipramine (Anafranil), Fluoxetine (Prozac), Fluvoxamine (Luvox), Paroxetine (Paxil), and Sertraline (Zoloft). Many of these drugs are also used in treating depression, although with smaller doses than used for OCD. Medications can help reduce but not eliminate the symptoms of OCD; symptoms usually resume after the medication is stopped(3).
The other option of treating your friend's OCD is by behavioral therapy. Exposure and response/ritual prevention (ERP) is a way of helping the person to control their compulsions. "The treatment strategy involves exposing the individual to stimuli that trigger anxiety or discomfort, and then having the individual voluntarily refrain from performing his or her ritual or compulsion" (8). For example, a person who is a compulsive hand washer may first unload a clean dishwasher without washing hands, then use the telephone w/o washing hands, then empty the garbage without washing hands, etc. By continuing the activity until the anxiety about feeling dirty decreases and the urge to wash hands fades, the person will systematically desensitize himself or herself to discomforting situations. Thus, the compulsions will no longer be necessary, and will stop. Support of family and friends is especially important in your friend's struggle to master his or her obsessions and compulsions. Cognitive therapy is often combined with exposure and response therapy to reduce the obsessions. By giving the patients proof that and reasons why their obsessional thinking is faulty, they will be better equipped to deal with the anxiety-causing exposure (4). It is also much more helpful than you telling your friend, "That's stupid and pointless! Stop it!"
Some other techniques used to aid the behavioral therapy are thought stopping or distraction, satiation, and habit reversal. Thought stopping is the suppression or switching off of OCD symptoms; satiation is the prolonged listening to an obsession, usually by using a closed-loop audiotape; and habit reversal is replacing a ritual with a similar but non-OCD behavior (though I can't see how this is any healthier; a ritual is a ritual, no matter how normal it seems) (4). These techniques may be useful, but are not as effective as standard behavioral therapy.
Which type of treatment is the best for your friend? That depends on the condition of your friend's disorder. The most effective treatment is a combination of both behavioral and medicinal therapy, because this will help the person resist the compulsions as they learn to deal with the obsessions until they reduce the anxiety to a normal level. Adults and severe cases are more often treated with medications, while adolescents and mild cases can be better treated by behavioral therapy alone. Your friend's mindset will also determine which treatment is best. For example, your friend may be horrified at the prospect of taking "mind control drugs" but be willing to work at behavioral therapy, or vice versa (3).
Will your friend ever be completely normal? Unfortunately, obsessive-compulsive disorder has no cure. However, by mastering his or her obsessions and compulsions, your friend will be able to take control of his or her life. As someone else's friend said, "I was a new person, a fairly "normal" person, something that I never in my whole life thought I'd ever be. I was able to pursue my goals and dreams with wild abandon and I did and still do, just that" (1). So if you suspect that your friend has OCD, let them know that they don't have to live like that any more. There is always hope, and you'll help them get there.
2) Obsessive Compulsive Personality Disorder Symptoms , definition of OCPD
3) Recognition and Treatment of Obsessive-Compulsive Disorder , comprehensive look at OCD (with nice helpful tables)
4) Obsessive-Compulsive Disorder Patient/Family Handout , another good comprehensive OCD site
5) Yale-Brown Obsessive Compulsive Scale , online evaluation scale, one of the most commonly used diagnostic scales
6) Obsessive-Compulsive Screening Checklist , another online evaluation scale
7) National Institute of Mental Health Screening Test for Obsessive-Compulsive Disorder , another commonly used (online) diagnostic scale
8) Obsessive-Compulsive Disorder , good description of methods of treatment
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