Obsessive-Compulsive Disorder Demystified

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A complex illness that is often difficult to identify, OCD affects approximately 6 million to 9 million Americans. In Obsessive-Compulsive Disorder Demystified, clinical psychologist and OCD specialist Cheryl Carmin offers an enlightening and useful guide for anyone with OCD, their families, and friends. In clear and compassionate language, Dr. Carmin helps those who suffer from the illness understand the true nature of OCD, the factors that complicate its diagnosis, and the benefits of treatment through cognitive behavior therapy and/or medication. With insight and anecdotes from an OCD patient-advocate, Obsessive-Compulsive Disorder Demystified makes great strides in dispelling the mystery surrounding this condition, helping readers decide if it’s time to seek treatment and providing those with this anxiety disorder the information they need to better manage their lives.

PRAISE FOR

Obsessive Compulsive Disorder Demystified

“If you or someone you love has OCD, this book is for you. OCD Demystified takes the reader on a thorough and careful journey through this perplexing disorder. Filled with clinical examples, this book illuminates the nature of OCD and explores the wide variety of symptoms that make up this disease. Carmin reviews the science and treatment of OCD with a direct and easy-to-read style. If you have OCD, this book could help change your life.”

—RANDY O. FROST, Harold and Elsa Siipola Israel Professor of Psychology, Smith College, coauthor of Compulsive Hoarding and Acquiring:Therapist Guide and Buried in Treasures: Help for Compulsive Saving, Acquiring, and Hoarding

“OCD is often a debilitating and painful problem, but effective treatment is available and this book is an excellent first step. Dr. Cheryl Carmin is one of the leading experts on OCD. Here, she uses her experience and expertise to help readers understand OCD, its possible causes, and how to get help. Her empathic tone, use of many illustrative examples, and the ‘Frequently Asked Questions’ sections in each chapter are especially effective. In short, OCD Demystified is a ‘must read’ for anyone living with OCD, or living with someone suffering from this problem.”

—JON ABRAMOWITZ, PhD, Associate Professor and Associate Chair of Psychology, University of North Carolina at Chapel Hill, Director, Anxiety and Stress Disorders Clinic

OTHER BOOKS IN THE DEMYSTIFIED SERIES:

Bipolar Disorder Demystified

Borderline Personality Disorder Demystified

Postpartum Depression Demystified

FOREWORD

OBSESSIVE-COMPULSIVE DISORDER is a challenging problem and one that is not easy to overcome. But it is also an anxiety disorder that we understand pretty well and, even more important, we have some treatments that work quite well to address the problem. Let me introduce this very helpful book that answers many sufferers’ questions by beginning where I began.

I was fortunate to study under Dr. Edna Foa beginning back in 1977 when effective behavioral therapy for OCD first began to filter into the United States. This treatment, developed in England in the mid-1960s, was pioneered by clinical researchers like Victor Meyer, Jack Rachman, Ray Hodgson, and Isaac Marks. It soon became clear that these astute practitioner researchers were onto something that was really making a difference for people who heretofore had been unable to function effectively because their OCD had taken over their lives. It was an honor to work on testing their intensive treatment methods in Edna Foa’s clinic; what a pleasure to see it work remarkably well.

I will never forget one of my first patients. He was a doctor who wanted to dedicate his life to pediatric oncology. He was a very committed man and a very smart one. OCD had begun to affect his life early in his medical career.The not-yet-doctor found himself struggling during medical school with contamination fears that stemmed from a chemical spill in a laboratory where he was studying biochemistry. His fears spread—slowly and surely. First he worried about the people who had been in the lab when the spill occurred. Perhaps they had not cleaned up properly and some of the contaminants leaked out. He saw some of them in the library and that became off limits.They used the dining hall and soon that was verboten. Eventually even the campus newspapers could not be touched.Wherever he could see or imagine that the lab inhabitants had gone became a contaminated place he had to avoid.

At the end of the day, after entering his home through the basement where he shed his working clothes, he washed long and hard, showered for 45 minutes, and finally emerged upstairs into his “clean” home. Completing medical school involved great personal sacrifices like never taking medical books to study at home, or never sitting down in seats at work that others might have contaminated. Remarkably, he finished his MD degree and went on to an internship. It was here that the OCD took over, gradually constricting his life and his movement until there were no options left. He quit his internship and took a different job in another city.

Not long after, he heard of Dr. Foa’s work and sought help at our clinic, enrolling in her research study to see if the treatments developed in England would work in the United States. He became my patient and we worked together, using cognitive behavior therapy including exposure and response prevention, a treatment you’ll learn about in detail in the coming pages.Through much work, the young doctor was able to manage his fears so that obsessions no longer controlled his life.The experience was remarkable, especially watching his face and body language gradually change from gripping fear to hesitation to resignation and eventually pleasure at his accomplishment. It took a while longer for him to master the fears and for his automatic behaviors to return to normal, no longer restricting what he did and washing and cleaning extensively. I was hooked on this therapy method and have continued to find it useful for so many clients over the years. The behavioral treatments and newer cognitive ones really are effective for the vast majority of those who truly work at it.

What I learned in the course of my work with this client and many others after him was that OCD has many forms, but they all make sense.There is a logic to the symptoms, once one understands the misguided premise the person is following. In fact, the symptoms are predictable—the thoughts, feelings and behaviors follow rules. This makes OCD very responsive to the treatments that target the source of the problem.

This appealing and extremely useful book truly does demystify OCD.With clear language, many examples and frequently asked questions that are right on target, Dr. Carmin explains this seemingly complicated problem so it makes sense.The treatment strategies described here are strongly evidence based—they have been shown to work in repeated research studies with scores if not hundreds of patients. I wish you good speed in using the methods described in this book.

GAIL STEKETEE, PHD
Dean and Professor
Boston University School of Social Work

PREFACE

TWENTY YEARS AGO, when I was caught in the grip of obsessive-compulsive disorder, no one talked about OCD. Now, it’s common to hear people say things like,“I’m a little OCD” or,“That’s so OCD.” Somehow it’s become part of our culture’s daily vocabulary, even though the vast majority of people have no idea what real OCD is like.

The reality of OCD is that it robs us of our most precious resources—time, energy, and self-confidence. Left untreated, the symptoms can worsen to the point where they take over our waking hours, leaving little room for the important things in life.

Obsessions and compulsions waste time. A lot of time. I accomplished nothing in the countless hours I spent stuck in loops of anxiety and rituals over the years, checking stove burners, door locks, alarm clocks, window screens, and many other things over and over. And not one second of it was ever fun.That’s time I’ll never get back.

Obsessions and compulsions squander energy.When I was anxious, I broke into a sweat, my heart raced, my stomach twisted in knots, and I felt like the world was closing in on me. As the list of things I checked grew longer and my checking rituals became increasingly elaborate, I fell into bed later and later at night. Then I repeated the checking in the morning before leaving for work—getting out of the house felt like a Herculean task every day. I arrived at work already tired, and by the time I got home in the evenings I felt used up.

Hiding OCD symptoms also requires an incredible amount of energy. Those of us who have it often become terrific actors:We’re so busy trying to make sure other people don’t notice the odd things we’re doing that we actually come up with rituals to hide the rituals! I never wanted anyone to realize that I was checking something to the point of obsession.Take the anxiety that’s at the heart of OCD and add the stress of trying to keep your symptoms a secret—it’s draining beyond belief.

Obsessions and compulsions erode self-confidence. It’s pretty hard to feel good about yourself when you think you’re losing your mind. One of the most insidious things about OCD is that most of us who have it know that our thoughts and behaviors are irrational, but the anxiety is so intense that we feel powerless to make it all stop. No matter how accomplished we might be in other areas of our lives, feelings of shame and weakness drag us down.

The good news, however, is that there’s also another reality of OCD—that the right kind of treatment can help most people with this disorder regain control of their lives. I’m a walking, talking example, and I hope that my own story, which runs throughout this book, will provide insights and comfort to those who are ready to make the journey to recovery.

If you have OCD, reading this book can mark your first step on that path. In clear and sympathetic language, Cheryl Carmin explains what OCD really is—and isn’t—and how it’s treated.You’ll learn that OCD is a medical condition that causes your brain to function differently from that of someone who doesn’t have the disorder.You’ll discover that effective treatment can teach you how to manage your anxiety and change your life for the better. And the personal stories recounted here, including mine, will help reassure you that you are not alone in facing this devastating, but ultimately treatable, disorder.

Getting smart about OCD is important, but it’s not enough. My greatest hope is that this book will motivate you to seek treatment from a qualified professional so you can get the relief you deserve.

If someone you care about has OCD, these pages will help you understand what causes your loved one’s strange behavior, why it may be difficult to persuade that person to seek treatment, and what you can do facilitate the recovery process. Living with someone who has this disorder can be challenging, but I hope that what you learn from Obsessive-Compulsive Disorder Demystified will increase both your patience and your compassion.

ANNE COULTER
Consulting Editor
Former Board Member of OCD Chicago

INTRODUCTION

I HAVE SPECIALIZED in treating anxiety disorders, including OCD, for over twenty years and have not lost my fascination for these conditions or my admiration for those patients who choose to face the things that terrify them the most as they engage in the very hard work involved in recovery. I am writing for those individuals who are choosing the hard road of helping themselves by taking the first steps to recover or are using this book as a reference as they work with a therapist.

My introduction to cognitive behavior therapy (CBT) and working with anxiety disorder patients during my post-doctoral fellowship training was like coming home—I’d found my niche. I was drawn to this approach to psychotherapy because of its fundamentally pragmatic nature and the way it functions to constantly test our hypotheses about the possible causes of anxiety disorders.

In the past several years I’ve also benefited from training with some of the luminaries in the fields of cognitive therapy and cognitive behavior therapy.To those who are just now learning about anxiety disorders, let me say that CBT is a type of treatment that addresses both the cognitive and behavioral aspects of a disorder: In CBT, patients change their dysfunctional thought patterns and learn healthy new behaviors to reflect their new ways of thinking. It’s the foremost treatment for OCD as well as the approach I practice in my clinic and in this book.

Over the course of my career I’ve dealt with a fairly broad range of patient populations and diagnoses. However, the majority of my career has been dedicated to working in anxiety disorder specialty clinics located in university medical center/medical school settings. It is in this area that I now have the unique opportunity to teach and supervise psychology graduate students and post-doctoral fellows as well as psychiatry residents, do research, run a clinic, and see patients. On some days wearing all of those hats is a juggling act, but it is always a rewarding one.

One of the most enjoyable aspects of working with people suffering from anxiety disorders and OCD is that no matter how severe their symptoms may be and how miserable the disorder makes their lives, anxiety patients do not seem to lose their sense of humor. And, they can get better. It is exceptionally rewarding to be able to tell someone who is desperate for help and calling our clinic that OCD is a treatable condition.

Yet I’ve found that the biggest challenge occurs when, after years or even decades of struggling with their condition, patients suddenly grasp that they actually can get better. I know it seems paradoxical—one would expect this realization to bring about a huge sigh of relief and a burst of motivation. For some of my patients it’s just the opposite. They realize just how much of their life was robbed by OCD. They are at a loss as to how to fill up time no longer being spent undergoing the rituals that have been destroying their lives. They have lost friends and possibly alienated family members.They have been forced to leave their jobs or were fired—all because of their OCD. As they recover, they find they are facing a huge and often overwhelming void that once was filled by their obsessions and rituals. It’s clearly an example of “Be careful what you wish for,” because they are so unprepared for the consequences of recovery. Indeed, if treatment is to conclude successfully, the recovering OCD sufferer must be helped to deal with these broader life issues of career, relationships, and self-worth.

What I hope people glean from this book is a better sense of what OCD is at its most human level. It’s easy to be entertained by how OCD is depicted on TV or in the movies. But the media don’t really portray the human cost. I have colleagues who refer to people with anxiety disorders, including OCD, as the “worried well.” OCD patients are neither worried nor well.They are tortured by their intrusive obsessions and held captive by their rituals.Thus, above all, I want people to gain a sense of hope. OCD is a treatable condition, and readers of this book will learn not only how cognitive behavior therapy can help them get better but also how medication can play a supporting role during their treatment. This is a comprehensive guide to conquering OCD, and it is directed both to OCD sufferers and to the people who love them. People do get better and reclaim their lives. Recovery doesn’t happen overnight and a considerable amount of work is involved, but it is entirely possible for people who suffer from this disorder to get their lives back on track.

It is my sincere hope and intention that this book will help in that endeavor.

CHERYL CARMIN, PH.D.
Professor and Director
Stress and Anxiety Disorders Clinic
University of Illinois at Chicago

ONE

OCD: It’s No Laughing Matter

If all of your information about obsessive-compulsive disorder comes from movies and television shows or even literary classics (Lady Macbeth, for example, is constantly washing her hands), you’ve no doubt thought that people with OCD are either funny or downright bizarre. In a sense, it’s fortunate that OCD is in the spotlight, as this provides an opportunity for people to learn about the disorder. But too much of the attention currently being paid to this condition shows OCD sufferers in an unrealistic, usually unflattering light.

Hollywood likes to play OCD for laughs, giving characters obvious symptoms—most often excessive cleansing habits and a fear of germs—and treating OCD-related rituals as if they were quirky personality traits. It’s amusing to see someone opening a medicine cabinet to reveal dozens of bars of soap or wearing gloves to read a magazine, right?

But if you were to spend a day in my clinic, you would see how OCD tortures people who suffer from this anxiety disorder. For them, and for their families and friends, OCD is nothing to laugh at. Indeed, people with OCD live in fear that others may find out they are having disturbing, intrusive thoughts—or, worse, may think that they are crazy and should be locked up in an institution for the mentally ill.

Fictional characters seem to overcome their OCD relatively easily, and some even parlay it into a successful career. In As Good as It Gets, Jack Nicholson’s character finds the love of a good woman, and his OCD symptoms begin to disappear. In Matchstick Men, Nicholas Cage’s character gets relief from his OCD when he takes a placebo. And in the award-winning TV series Monk, the popular detective gets into comical predicaments and ends up catching the bad guys because he has OCD.

It would be wonderful if falling in love or taking a sugar pill could cure OCD or if OCD symptoms could be leveraged into greater success on the job. But the truth is, those plot lines are like fairy tales, and real-life OCD is more like a horror story. Neither I nor my colleagues have ever seen a movie or TV show that realistically portrayed the struggles we see in our practice. Our patients’ stories are anything but entertaining.

What OCD Is and What It Is Not

OCD involves experiencing repetitive thoughts that range from annoying to extremely distressing and responding to those thoughts with similarly repetitive behaviors or thoughts—also called rituals. Some of my colleagues view OCD as a medical disorder caused by an imbalance of chemicals in the brain; others of us believe that a chemical imbalance may contribute to the disorder. But the jury is still very much out as to whether the behaviors associated with OCD are biologically based or learned and then reinforced over time. Given the large number of patients for whom there is no apparent genetic predisposition or whose disorder seems to have arisen in response to an ineffective attempt to manage anxiety-producing thoughts, many experts in the field lean toward a behaviorally based understanding of what causes and maintains OCD. Regardless of whether they believe the source is biological or learned, however, many OCD sufferers—though they know their obsessions and compulsions are irrational—cannot control their intrusive thoughts or the resulting rituals. Moreover, there are still many people who are unaware that effective treatments are available and thus don’t seek help.

That’s the short explanation of what OCD is. We may use the word “obsessive” to characterize perfectionists, stubborn people, workaholics, or bossy friends, but OCD is not a personality trait. In mild cases, OCD prevents people from living full and satisfying lives. In moderate to severe cases, careers, marriages, friendships, educational pursuits, self-confidence, and even the ability to experience joy are crippled or ruined.

If Hollywood were to show realistic portrayals of life with OCD, these are the kinds of scenarios we would see:

• A successful young attorney whose life is overwhelmed by her fears of contamination and by cleaning rituals that involve taking showers that last for hours.We’d watch her buy isopropyl alcohol, cleanser, and disinfectant by the case because she uses cleaning materials to sterilize her kitchen every day.We’d witness her quitting her job because she can no longer tolerate the anxiety she feels when she leaves her house and losing control over even some of the simplest areas of her life to the point where she stops functioning and has to be hospitalized.

• A man who doesn’t fall asleep until 3:00 A.M. every night because he spends hours “evening up” things in his house—the fringe on his living room rug, the cans in his kitchen cupboard, the books in his bookcases, the hangers in his closet. We’d watch his family life disintegrate and his performance at work slip so far that he gets fired because he’s perpetually anxious and exhausted.

• A bright teenager who constantly asks his teachers for reassurance that he has correctly understood his homework assignments and who then spends so much time writing and rewriting them until they “look right” that he rarely finishes them on time. We would watch him erase his writings so often that every page in his notebook is torn. His grades and his self-confidence soon plummet and he becomes increasingly isolated from his peers.

We came across a blog written by an anonymous OCD sufferer that illustrates some of the mental contortions the disorder can impose on a person. In an entry dated May 2008, the writer was evidently trying to find the correct spelling of “Asperger’s syndrome,” another disorder marked by restricted, repetitive behaviors: “I try to get online to check whether I should include the S. . . . I have to now go downstairs to check this out in a book....This book has a peculiar smell so I will need to wash my hands after looking up the correct way of writing Asperger.”

He went on in this way for an entire page, waffling between various spellings of the word “Asperger.” “I am now ruminating if Asperger should be capitalized,” he continued. “And now of course I have brain fog which is causing me to feel doubt all over again about the S so just to be sure I will check again.” After checking two more times, and writing on and on about his doubts and recheckings, he finally leaves his computer in frustration. Given these kinds of contortions over a simple spelling, it’s easy to see why OCD keeps people from moving forward.

CAN WE PREDICT WHEN OCD SYMPTOMS WILL APPEAR?

Some OCD patients cope with symptoms nearly everywhere they go, while others can predict their symptoms in just one or two situations. One person might be obsessed about avoiding silverware in restaurants, yet feel perfectly comfortable using forks and knives when eating at friends’ homes. Another might hoard computers and other electronic equipment but give not a moment’s thought to the idea of discarding newspapers, food containers, or other materials commonly associated with hoarding. A third OCD sufferer might “white-knuckle” her way through a day at school, avoiding embarrassing rituals around her friends, but experience an explosion of symptoms once she arrives at home.

OCD by the Numbers

Examples of such ruined lives are all around us. The medical community once thought that OCD affected only a handful of people, but with the vast improvement in definitions and diagnostic measures in recent decades, the incidence of OCD is now known to be quite extensive:

• Studies tell us that 6-9 million Americans, or 2-3 percent of the population, suffer from OCD.

• Those numbers translate to about one in forty adults and one in fifty school-aged children.

Given such statistics, most people probably know someone who is being challenged by OCD—but it’s likely the person is suffering without treatment, is ashamed of the symptoms, and does not realize that he or she has a treatable disease.

In addition to its intense emotional impact, OCD takes a huge toll economically. One study ranks it among the top ten most burdensome medical and mental health conditions in the industrialized world. In 1990, OCD’s direct costs to the U.S. economy were estimated at $2.1 billion, with indirect costs, such as low work productivity, adding over $6 billion to this amount. Further, OCD accounted for about 6 percent of the estimated cost of all psychiatric disorders. With diagnosis and treatment much more readily available since these tallies were done nearly two decades ago, you can imagine the real cost of OCD today.

The Therapist’s View

Among mental health professionals in the United States, the accepted method for diagnosing OCD is based on the American Psychiatric Association’s “official” definition of clinical OCD, published in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). This definition is technical, but it will give you a clear idea of the benchmarks a therapist would use in determining whether you have OCD.We’ve reprinted it here for your convenience.

Obsessive-Compulsive Disorder (Code 300.3)

A. Obsessions as defined by:

1. recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress.

2. the thoughts, impulses, or images are not simply excessive worries about real-life problems.

3. the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action.

4. the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion).

Compulsions as defined by:

1. repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly.

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On Sale: Jun 30, 2009
Page Count: 312 pages
Publisher: Da Capo Lifelong Books
ISBN-13: 9780786748112

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Cheryl Carmin

About the Author

Cheryl Carmin, PhD, is the director of both the Stress and Anxiety Disorders Clinic and Cognitive Behavior Therapy Program at the University of Illinois at Chicago, where she is also a professor. A nationally recognized expert in the research and treatment of anxiety disorders, Dr. Carmin is a Founding Fellow of the Academy of Cognitive Therapy and has been named a Beck Scholar, acknowledging her leadership in the field. She lives in Chicago, Illinois.

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