Treating OCD
Excerpted from a radio interview with Dr. Cardamone
What exactly is an obsessive-compulsive disorder?
When someone has Obsessive-Compulsive Disorder, we will call it OCD for short, he or she is troubled by intrusive, forceful, and repetitive thoughts or images that are difficult to reject. They do time consuming things and are obsessed by repetitive thoughts. A person with OCD may have irresistible urges to perform some kind of behavior or mental act.
Are there different kinds of obsessive-compulsive disorder?
Yes. OCD manifests itself in many ways. Some people who suffer from OCD are plagued by doubts or they have to engage in chronic questioning or confessing about minor things. Sometimes the thoughts are the exact opposite of the person's nature. For example, a person with genuine religious values might be troubled by thoughts that are the very opposite of what they want to think. So someone might have blasphemous thoughts about God or think completely untrue things about someone they admire or love.
A lot of people have obsessions and compulsive behaviors. At what point does it become a disorder?
That's true. Just having obsessions or compulsions isn't enough to diagnose OCD. Most of us have routines that we follow and habits that are hard to break. All of us follow certain patterns in our daily life. But for some people, patterns run wild. We would all agree that if someone washes their hands regularly it's a good thing. But if someone spends eight or more hours a day washing his hands, that would be strange. For a person to have OCD, the obsessive and compulsive patterns have to be significantly distressing. We all have things that we seem to obsess about or do compulsively at times in our lives. This doesn't mean we have OCD. It becomes a disorder when we feel we can't stop it. If it becomes time consuming or if it interferes with your daily functioning, then it could very well be a disorder. If we start doing things mechanically or feel strong and irresistible urges to do certain things it can be an indication of OCD. If we can't repel unwanted thoughts, that might be the point where we have to think of the presence of a disorder. It becomes a source of distress. It becomes beyond your control. You feel compelled to do things or think a certain way. You keep repeating a task, like washing your hands or retracing your steps or touching things a certain way, over and over when there is no need to do so. It could be that you become very upset if things are not arranged just so or are out of symmetry. You might have unwelcome thoughts and your just can't get them out of your mind. Sometimes excessive worry is an indicator of difficulty.
If someone has OCD, what kinds of things might they obsess about?
OCD is often called the doubting disease. OCD has a way of getting sufferers to doubt their core beliefs. One person I treated a number of years ago had led a very good life, never doing any thing close to kind of thought he was thinking about. He kept thinking very bad thoughts about people close to him. He was deeply embarrassed by these thoughts and felt very guilt for thinking them. But he couldn't stop even though the thought were highly repugnant to him. Some people engage in exhausting internal monologues. This type of obsessing involves pondering things over and over. One individual I know kept wondering about the meaning of life and why we do ordinary things. Now on the surface many people have philosophical questions, but for him, he couldn't stop. Anything could trigger an internal monologue that exhausted him mentally. So if he saw someone put down a book on a table or do something ordinary, he would start to wonder why and what did it mean. It was like torture for him. There are many people who worry about trivial things. Some individuals are so blocked by their obsessions that they can't make any decision. One person spent hours at a store trying to select exactly the right CD to buy. So that's the kind of doubting that we often see.
There are other common types of obsessions:
Washers and cleaners are preoccupied with thoughts about germs, disease, and chemicals. Aggressive thoughts are common. These would be thoughts that are completely counter to the person's morals. So, for example, a parent might think of drowning her child. Another example would be thinking repeatedly about pushing someone into the path of a subway or hitting a pedestrian while driving. Now the person with OCD would never respond to these thoughts but the fact that the thought occurs repeatedly is extremely troubling to the person.
Thoughts of contamination are the ones that are usually thought about in OCD. A person feels dirty or contaminated.
Some people feel compelled to do certain mental things repeatedly like saying a word over and over or counting.
Some people are pure obsessionals, and they don't do the compulsive behavior. They experience repetitive negative thoughts. They worry about things excessively like that they might go broke. They might be troubled by images and bizarre fantasies that are shameful to them, but they can't stop themselves.
I see there are many ways that someone with OCD will obsess. How about examples of compulsions?
The compulsions are the repetitive behaviors. Some people with OCD might feel compelled to wash a certain way. They have cleaning and grooming rituals. So someone will consume time washing the right foot exactly three times a certain way and then do it again for another body part. One woman I saw had a hard time resisting the urge to arrange the books on my shelf in a symmetrical way so that all the bindings would be just right. Some people make lists that serve no practical purpose. Some people with OCD are what we call repeaters. They repeat certain behaviors without any logical reason to do so. Others check locks and stoves over and over. One young man kept his parents waiting routinely for over an hour before he could leave the house. He had to check all the windows and doors is a systematic way before he could leave the house. Sometimes the compulsion is seen in a need to confess many trivial things to a key person in one's life. Hoarding is another kind of compulsion. Occasionally we hear about someone who has kept every daily newspapers or piece of junk mail.
Is OCD common?
It is estimated that 1 in 40 is likely to have OCD during any six-month period. This means that it's the fourth most common psychiatric disorder in the United States. It affects men and women equally. There are quite a few sufferers with varying degrees of the condition. OCD is actually more common than conditions like panic disorder and even schizophrenia.
So there are degrees of severity for OCD?
There is a considerable range of severity for the disorder ranging from minimal interference with functioning to the point that some people need hospital treatment because their symptoms are so extreme. When it is extreme, a person might be so disabled by it that the person is entitled to Social Security disability benefits.
Are people with OCD considered psychotic?
OCD is not a psychotic disorder. The term "psychotic" is usually reserved for disorders in which a person has hallucinations and delusions. The person who is psychotic is not likely to have insight into their condition. The person with OCD knows that what they are doing is unusual but can't stop. It is possible for someone with OCD to have a coexisting severe mental illness, but it is not always the case.
At what age do we start seeing it?
Children can have it. I often find that when I talk to adults they recall they had symptoms in childhood that seemed to go away for a while. It's common to see a pattern of changing symptoms over the years. Usually most people recognize that something is out of control during their early 20s, but there are many exceptions.
If children can have OCD, is it usually identified early?
It's unfortunate that OCD is seldom identified early in children. Children and adolescents are likely to be secretive about things like this that would make then different from their peer group. Also the signs and symptoms may not be readily obvious to a casual observer. Boys with OCD, for example, may have a thing for a particular number. They may have to count to a certain number or touch things a certain number of time.
What kind of problems can result from having OCD?
It's a cruel disorder. It consumes time. It keeps people from fulfilling their potential and doing things that everyone else takes for granted. It interferes with relationships. People with OCD tend to have a lower marriage rate. On the job, it can keep people from being productive. Many people develop depression which further complicates things.
What causes obsessive-compulsive disorder?
There is debate about what causes OCD, but we have been able to rule out some of the so called causes people causes people talked about years ago. We no longer think that family problems or attitudes learned in childhood lead to OCD. In other words, it's not due to a particular kind of parenting or upbringing. It seems to be caused by some combination of neurobiological factors plus the effects of learning. If we look at brain images of people with OCD and those without OCD using PET scans (positive emission tomography) we see that the OCD patients have patterns of brain activity that differ from people with other mental illnesses and people who are free of mental illness.
So you are saying there is a biological basis for OCD?
That's true, but it's not the whole story. There does seem to be a biological basis for OCD, possibly an abnormality in certain neurotransmitters or in certain brain centers. The neurotransmitters are the brain's messengers. The neurotransmitter chemicals in the brain bridge the gap between nerve cells when nerve impulses are sent from one cell to another.
It would seem that since medications help OCD then it is a biochemical disorder. But here's the rest of the story as far as we now know. I told you about the differences in PET scans between OCD patients and normal individuals. PET scans have also shown that there are changes when someone uses medication but also when treated with behavior therapy. One area of the brain that is affected with either medication or behavior therapy is known as the caudate nucleus. The caudate nucleus is involved in one's ability to start and stop different thoughts and activities. So through PET scans we have graphic evidence that behavior therapy affects neurobehavioral factors. We can see changes in the activity level of these brain centers when either medication or behavior therapy is used.
Are there genetic factors?
One of the ways to tell if something is genetic is to look at identical twins versus nonidentical twins. The identical twins have the exact same genetic make-up. So it a trait is genetic, you would expect both twins to have it. But the few studies available indicate that genetic transmission is not the case. However, the rate is higher in identical twins versus nonidetnical twins. This means that there may be some kind of hereditary linkage. Genetic factors alone do not account for all individuals. PET scans have also shown that there are changes when someone uses medication but also when treated with behavior therapy. One area of the brain that is affected with either medication or behavior therapy is known as the caudate nucleus. The caudate nucleus is involved in one's ability to start and stop different thoughts and activities. So through PET scans we have graphic evidence that behavior therapy affects neurobehavioral factors. We can see changes in the activity level of these brain centers when either medication or behavior therapy is used.
What types of treatment are available for OCD?
Reasoning about the obsessive-compulsive behavior usually does not help. In fact it seems to strengthen the pattern. There are two basic ways of treating OCD. One is medication. There are now several types of medication that are helpful. Most of these were not available twenty years ago. Some have just come on the market in recent years. The other is behavior therapy and specifically a particular kind of behavior therapy that is known as exposure with response prevention, sometimes called ERP for short. In many cases, medication and behavior therapy are combined.
Can you tell us a little more about what happens in behavior therapy?
There are various things that go on in behavior therapy. We will look at the way a person thinks and behaves. For OCD, the approach know as exposure with response prevention is the best researched method and seems to yield the best effects. In this approach, we structure situations in such a way that the person is deliberately exposed to situations that trigger obsessing or rituals but without performing the compulsive ritual. This is done in a voluntary and gradual way in collaboration with the patient. The person is taught techniques to help them avoid performing the compulsive ritual that goes with the trigger situation. Over time, this weakens the strength of the urge to do compulsive rituals and lessens the anxiety and urge to do them.
How does medication fit in?
Medication is certainly one of the choices. We have to keep in mind that patients differ in their responses to medication and their treatment preferences. Experts in the area have come up with guidelines about mediation. Generally speaking, cognitive therapy and exposure with response prevention should be offered to all patients. If there is no response or if the intensity of the symptoms does not go down, medication should be added. In some situations, medication will be needed immediately. If the symptoms are extremely severe, medication might be discussed as a first line approach. When a condition is severe to the point that one's job is threatened, medication may be best. Many patients prefer to attempt treatment without medication using therapy and then consider adding medication later if it is necessary. Some people prefer not be on medication because they don't like the side effects. If medication is used, it may be necessary to try several one systematically before finding one that is effective for the particular person.
Can people recover from obsessive-compulsive disorder?
People can certainly control and often eliminate many of their symptoms. Sometimes OCD symptoms return in other ways or there may be some residual symptoms. Usually if treatment is reinitiated, the symptoms can be controlled again. Maintenance might involve using medication or simply accepting occasional passing obsessional urges without acting on them. Some patients return for a few individual symptoms to learn to handle new manifestations of their disorder.
What happens if someone doesn't get treatment?
It's natural for the OCD to wax and wane. If left untreated, symptoms will continue indefinitely. Very few sufferers have a spontaneous remission of their symptoms.
Are there disorders similar to OCD?
Yes, there are many disorders that are similar to OCD. We usually call these OCD spectrum disorder. The treatment may be similar but there are also differences. I'll go over a few:
Compulsive gambling and eating disorders share many similarities to OCD
Hypochondrias is the strong preoccupation with the belief that one has a serious illness. People often seek constant reassurances and call their doctor frequently complaining of minor symptoms. It is usually based on the misinterpretation of bodily cues.
Body Dysmorphic Disorder is overconcern with a minor or imagined body flaw.
Trichotillomania is compulsive hair pulling. Usually people will pull one hair at a time on their scalp or eyebrows. In extreme case, very noticeable bald patches result.
What can friends and family do to help a loved one who has OCD?
Family members have to be patient and encouraging. Progress can be slow. Family members may have to be pleased to see small changes. The most important thing a family member can do is to be supportive and encouraging. They have to be understanding about the disorder. The most important thing is to realize that the patient with OCD is unable to control the symptoms. It's good to cultivate a nonjudgmental attitude. It may be helpful to be sure your expectations are reasonable, particularly during stressful periods. The person therapist may sometimes involve family members and they can help our exposure with response prevention procedures. If medication is prescribed, try to remind the person to take it as prescribed. Probably the most important thing to remember is that people get better at different rates. So it's important to be flexible and to appreciate small changes. A sense of humor, as long as its shared by the patient, is usually helpful.
Where can people get more information?
The Obsessive Compulsive Foundation happens to be located in Connecticut. They provide information and referrals to clinicians who have the expertise to treat OCD. Their phone number is 203 315-2190. They also have an excellent web site at www.ocfoundation.org. They will send you out a packet of information. I can be reached at my office at ProviderCare Plus in South Windsor at 860 644-4472.
Questions & Answers on Overcoming Dental Fears
An interview with clinical psychologist,
Dr. Philip Cardamone
Q How did you become interested in treating patients with dental fears?
During my training, I learned how to handle all types of unpleasant emotional responses. These anxious reactions included fears such as fear of flying, stage fright, and panic attacks. I learned about effective ways to help people overcome needless fears. Dental fears are one class of anxious problems that are easily treated.
Q Is dental phobia a big problem?
I've heard that about 12% of the population has some degree of anxiety about dentistry. Of course, if you happen to have it that makes it a big problem for you. Oral health has many consequences. Besides the obvious effects on teeth and gums, it can affect a person's self-confidence. Sometimes people who neglect their teeth by avoiding dentists develop psychological difficulties. I remember one woman who constantly had her hand in front of her mouth and was afraid to laugh out loud. This kind of self-consciousness can really hinder a person.
QHow are dental fears linked to other fears?
Most people with dental fears just have a fear of dentistry. Other people have more general fears, and dental fear is just one aspect. A common related fear is a fear of medical procedures in general. Such people avoid injections, blood tests, and visits to any medical office unless it's a dire emergency. When people have related fears, the treatment approach requires a strategy to deal with all of the fears in a systematic way.
A small number of patients have had past experiences that influence how they think or react to dentistry. Events associated with strong emotions like fear are easily remembered. A person who gets into the dental chair and gets into a fearful mood, might recall past significant traumatic events. The dental experience in this way can trigger or speeds up physical reactions. Sometimes the person may not even make the link that past situations are being recalled. Once triggered, these emotional and physical reactions become closely linked to dentistry. If a person has generalized anxiety or panic attacks, they may need specialized professional assistance to overcome these conditions as well as dental fear.
Q Besides a bad experience at the dentist's are there other causes of dental phobia?
It's usually due to a false belief. Sometimes a person had an experience that leads them to want to avoid related situations and it extends to the dental office. It's only natural. If we experience pain, we want to avoid the situation and ones like it too. Unfortunately, jokes, movies, and stories about someone's bad dental experiences can set us up for the same fears. Humans are like that. We learn things. So if we hear that a dental office is a place of pain, many of us will avoid it.
Q Since dentistry is now a relatively painless experience, what would cause a patient to be so fearful?
Yes, dentistry is relatively painless but it is a patient's expectations that are the basis of anxious reactions. It's wrong to assume that pain is the main reason people avoid the dentist. It is true for many, but not for all. There are people who endure all kinds of painful experiences, such as childbirth and contact sports, and yet avoid the dentist. The first step then is a careful analysis of exactly what the person fears. It may be that confinement without an avenue of escape is the fundamental problem. Others are fearful that they won't be able to express themselves if they feel uncomfortable. Usually it's persistent troublesome thoughts that are the real problem. People have thoughts like, "I'm going to lose control" or "I won't be able to bear the pain." These illogical thoughts motivate people to avoid dentistry. There is also the fact that while dentistry is relatively painless, dentists are human and may inadvertently do something to frighten a patient. If a dentist forgets to explain a procedure, for example, and the patient has an unexpected sensation it can affect the patient's fear level. Their expectation of pain is reinforced. They have body reactions that further motivate staying away.
Q Does dental phobia cause other life situation problems?
Most people with dental phobia have what we call a specific phobia, and it's limited to this one area. It's easily treated. What I often see with people under the age of 30 who have dental phobia is that they heard horror stories from the older generation. We also see how parents can pass on misinformation and negative attitudes to their children.
Q What role does age and gender play in dental phobia?
Most studies have not found any consistent differences in frequency, but men tend to hide their fears more than women do. Some studies have suggested that dental anxiety deceases with age but that means years of needless anxiety.
Q What should a phobic dental patient look for when choosing a dentist?
Most dentists are trained to help people feel relaxed. A good dentist makes you feel like he or she genuinely cares about you. They explain procedures and try to help you feel relaxed. The dentist should give you a way to communicate. Look for patience, trustworthiness, and competence. Ask for recommendations. The dentist should use all the modern anesthesia methods.
Q What techniques do you use to help patients overcome their fears of dentistry?
My approach is to address three areas:
Bodily responses and sensations
What and how the person thinks
Behavioral avoidance patterns
Neglect one of these areas and treatment will not be as effective. Before you can get people to give up their avoidance, you have to address how they handle sensations that are actually present. After all, even in painless dentistry, the patient has to sit in a chair, mouth open, with things going on just below their noses, right under their eyes, next to their tongues, while hearing strange sounds. We need to deal with this reality. Thinking comes in when the person interprets these sensations. Messages are sent to the person's nervous system. The patient interprets (or misinterprets) and then reacts to bodily sensations. So it is not just the needle and instruments that trigger a phobic reaction, its things like a thumping heart and breathing changes.
The first step in helping a patient with dental fears is to do an assessment. I want to determine what aspects of the dental experience are most relevant. I want to know if something specific happened in the past that started it all. This discussion in itself is often helpful because for once the person can talk comfortably about what they fear. Talking itself has desensitizing properties.
Once the severity of the problem is established and the full range of avoidance behaviors is known, the approach becomes a gradual, step-by-step one. The main technique is called systematic desensitization. First, the person is taught relaxation and breathing techniques that counter physiological reactions. Then desensitization is conducted in imagination through visualization techniques if necessary, so that the person stops reacting to their own thoughts. After a while, the person learns to relax even while experiencing previously troublesome thoughts. The connection between the thought and fearful reactions gets severed. Eventually, we break down the dental office experience into small steps so that each one can be accomplished in real life. This builds confidence.
The desensitization process is usually organized around specific themes. For example, a major fear in dentistry is fear of dental syringes. In an early phase of treatment, the patient is asked to visualize in their minds scenes involving needles while they are relaxed. Once the person handles the experience in imagination, we move on to real life applications. I might have a patient hold a syringe, noting how small the diameter of the needle really is. I might work with a patient's dental team to arrange brief visits to do a specific task. I might ask the patient to visit the dentist's office and practice having the needle in their mouth without it actually being used. Gradually, the patient builds up courage and confidence. In every case, the procedure is customized for each individual.
Patients are also taught other techniques such as mental rehearsal, coping skills, and distraction techniques.
Q How many sessions does it usually take to complete therapy?
Phobias are the easiest anxiety disorder to treat. Uncomplicated dental phobia is treated on a short-term basis. Most people are seen six to twelve times.
Q What are the costs and does insurance cover therapy for dental patients?
Fees are discussed up front. Patients are charged our usual fee per visit. It's affordable because its usually short-term, especially when you compare it to the cost of neglecting oral health. Insurance often covers a substantial portion of the charges. Treatment of a specific phobia is usually considered medically necessary and covered by most insurance plans.
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Dr. Cardamone specializes in the treatment of anxiety disorders, including dental anxiety. He can be reached at 860 644-4472.
The information provided here is for informational purposes only and should not be treated as medical, psychiatric, psychological or behavioral health care advice.
