Scrupulosity: What It Is and Why It Needs to be Treated

A sufferer recalls: My bedtime prayers lasted longer than those recited by Benedictine monks; by the second grade, I had read the Bible start to finish (a few times by the fourth grade); I attended daily Mass, walking there on my own each day; and every Good Friday I would go down to my dad’s den in the basement and stay there for five hours as I prayed the all of the mysteries of the rosary.”
Confession and all the rites of the major religions can be a beautiful thing, and lead to a deeper faith and a sense of love and hope. However, for someone prone to OCD, these rituals can become weapons.

Thankfully there are wonderful resources available today on scrupulosity, and because of awareness, kids today are better educated on what healthy faith looks like as opposed to a form of OCD.

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NIH Clinical Research Trials and You

Does Obsessive-Compulsive Behavior Predict Eating Disorders?

Eating disorders (ED) can manifest in different ways and most often develop during adolescence. Anorexia nervosa (AN), bulimia, and binge eating are just some of the problems that teens struggle with when they develop eating and food issues. Existing research has demonstrated a link between obsessive-compulsive behaviors and disordered eating, but little attention has been given to how the presence of obsessive-compulsive disorder (OCD) in children affects the development of ED in adolescence.

The results of this study add to the existing evidence suggesting that childhood OCD does increase the risk of developing ED in adolescence. The preliminary evidence suggests that, in the context of a child/adolescent exhibiting OCD symptoms, girls, those with a family history of ED, and children presenting with disordered eating or food-related obsessions and compulsions might be at particular risk for developing a later ED.

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Is OCD linked to Immune System Problems?

New research provides insight into potential causes of OCD. During the past few years, scientists have learned that this anxiety disorder may be linked to immunological problems.
Several small studies have found that patients with OCD have smaller numbers of some immune system cells and signs of autoimmune activity.

Last year, four scientists from Firat University, a Turkish college, published research showing immunological differences between OCD patients and people who had no physical or mental problems.
By using blood tests, the scientists found that patients with OCD had lower levels of neutrophils, which are white blood cells that help the human immune system fight off invading microorganisms.
The mean neutrophil count of the OCD study subjects was lower compared to that of the control subjects say the scientists running the study.

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How Do We Help Those We Love?

As Valentine’s Day approaches, many of our thoughts turn to celebrating love. But what about those of us whose loved ones are suffering? How we can we help our spouses, parents, children, or friends who are struggling with Obsessive Compulsive Disorder?

When Someone You Love Has OCD gives practical suggestions for helping loved ones. First and foremost, we need to learn all we can about OCD. Knowledge is power, and the more we understand this often confusing disorder, the better position we will be in to help those we care about.

But nothing about OCD is that simple. Just because we know the right things to do, the right ways to act, and the right treatments to pursue, that does not always mean our loved ones will now be on the road to recovery. OCD is an insidious disorder that does whatever it can to undermine the sufferer’s desire to get well.

For example, recovery avoidance is not unusual in those with OCD, and can be deeply frustrating for family and friends who desperately want their loved one to get well. One of the common reasons why those with OCD avoid recovery is fear: fear of disrupting their “safe” world of rituals and compulsions, fear of getting better, fear of not knowing how to live without OCD. It is extremely difficult for those of us who do not have OCD to understand this fear. Even though it may not be based on reality, the fear itself is nonetheless very real and intense.

Another issue that often surfaces when dealing with OCD is enabling. When we participate at all in the rituals dictated by OCD, we are accommodating and enabling the sufferer.  Reassuring, altering family plans, and even changing our own behaviors are all examples of classic enabling. While we may help reduce our loved one’s anxiety in the short-term, we are actually prolonging the vicious cycle of OCD.

So now that we know enabling is hurting, not helping, those with OCD, we can just stop, right? Again, it’s not that easy.  As a parent, it was often difficult not to accommodate my son Dan. After all, it made him feel better (albeit temporarily) and not accommodating him caused him great distress. It can be heartbreaking to be the source of suffering for your child, or any family member for that matter, even if you know “it’s for the best.”  And sometimes it’s hard to even know when we might be enabling our loved ones. OCD is very sneaky, and I have no doubt that we inadvertently accommodated Dan many times.

But my message here is not one of gloom and doom. Yes, fighting OCD is hard, for the sufferers and those who care about them. There will be obstacles along the way. But the bottom line is that this disorder can be defeated. My son Dan went from barely being able to function to being a senior in college, living life to the fullest. OCD, no matter how severe, is absolutely treatable.

So again, what can we do to help those we love who are suffering from OCD? When we’ve learned all we can about the disorder, and we’ve stopped enabling, and we’ve dealt with recovery avoidance, what else is left?

Lots. For one thing, we can’t let OCD take the joy out of our lives. That would be letting it win. I think we need to make an effort to live our lives in a happy, productive, manner.  Being around those who are enjoying life can be a strong incentive to get well. In my family’s case, humor has always been a big part of our lives, and it was amazing to me that even throughout his darkest days, Dan could still laugh, and for a moment all would be well.

Another way we can help our family members or friends conquer OCD is by never giving up on them. Help them advocate for their rights in school, college, and the workplace. If you come across doctors or therapists who tell you that your loved one is not treatable, or will never get well, find another therapist or doctor. Make sure you deal with professionals who specialize in OCD. If recovery avoidance is an issue, let your loved ones know you are always there for them and want them to get well. Maybe they will agree to attend a support group, if not therapy.

And remember that while it is okay to feel angry, annoyed and overwhelmed when the going gets rough, these feelings should be directed toward the Obsessive Compulsive Disorder and not the person you care about. OCD is not your loved one’s fault and we need to always remember that. But the most important thing to remember, in my opinion, is that as insurmountable as OCD may seem at times, recovery is possible.  There is always hope for all those who suffer from OCD.

Hypersensitive Children May Develop OCD

Are some children more inclined than others to become adults who suffer from Obsessive Compulsive Disorder (OCD)? According to a research conducted at Tel Aviv University, Israel, some sensitivities found in children may prove so.

The study leader, Professor Dar, believes that children who are extremely sensitive to touch or smell often feel as though they are being attacked or threatened by their environment. To help deal with these feelings of anxiety, they may adopt ritualistic behaviours as a mechanism to regain their sense of control, which is symptomatic of adults who suffer from OCD.

While Professor Dar admits that all children have particular habits and preferences, he stresses that not all of them are necessarily early indicators of OCD. “If a child is very rigid with rituals, becoming anxious if unable to engage in this behaviour, it is more alarming,” said Dar. He explained that age is another factor to be taken into account: a habit adopted by a five or six year old, isn’t necessarily a predictor of OCD. However, if the same behaviour continues at the age of eight or above, it could be an indicator. Dar recommends that parents with a hypersensitive child should “gradually expose him to the various tastes and textures that are bothersome.”

Early intervention would be very beneficial for such children.

OCD Live Forum

IOCDF Annual OCD Conference

Is it still the ‘Age of Anxiety.’?

Ours is an age in which a growing number of people suffer from anxiety. According to the National Institute of Mental Health, anxiety disorders now affect 18 percent of the adult population of the United States, or about 40 million people. By comparison, mood disorders — depression and bipolar illness, primarily — affect 9.5 percent. That makes anxiety the most common psychiatric complaint by a wide margin.

Just because our anxiety is heavily diagnosed and medicated, however, doesn’t mean that we are more anxious than our forebears. It might simply mean that we are better treated — that we are, as individuals and a culture, more cognizant of the mind’s tendency to spin out of control.

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New treatment making life easier for OCD patients

Taking a pill to help get rid of fear? For many people with OCD and other anxiety disorders it sounds too good to be true. Now an antibiotic once used to treat tuberculosis, could change the way doctors treat fear disorders.

Eric Storch, PhD, Licensed Clinical Psychologist, University Of South Florida has been working to see if the tuberculosis medication D-Cycloserine, can be combined with cognitive behavioral therapy to reduce OCD symptoms in kids and help them face their fears. The pill is taken one hour before therapy. It’s thought to affect receptors in the brain that are associated with how people learn to become afraid of something or not.

Storch believes that the effectiveness of cognitive behavioral therapy can be enhanced with a very safe antibiotic.

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Compulsive Hoarding Therapy Group

New Year’s Resolutions: We Need a Plan

I have never been a big fan of New Year’s resolutions. The few times I actually made them I gave up by the end of January, with only frustration and a sense of failure to show for my efforts (or lack thereof).

I think the problem is I never really thought these resolutions through. They were just proclamations: “I’m going to eat better. I’m going to exercise more. I’m going to worry less.” I resolved to do these things, but I had no plan.

The beginning of a new year, in my opinion, is a good time to take stock of our lives and envision our hopes for ourselves and our loved ones for the year to come. And once our desires are clear, the next step is to develop a plan to make them happen.

For OCD sufferers and their families, goals may include things as general as wanting to feel better or wanting to help a loved one get well. How these goals will be achieved is where all the planning comes in. And everyone’s plan will be different.

Perhaps you or a family member has recently been diagnosed with OCD. Your plan might include learning whatever you can about the disorder. Bookstores, libraries, and websites such as OCD Chicago offer a wealth of information. Your plan may also include finding a therapist who specializes in OCD and Exposure Response Prevention (ERP) Therapy, joining a support group, or learning how to best support your loved one who has OCD.

If you have been dealing with OCD for a while, maybe your plan will involve changing your treatment plan if what you are doing now has not been helpful. Perhaps it’s time to switch therapists, or to talk with your current therapist about revamping your ERP Therapy. Maybe your plan will even involve seeking treatment for the first time. If your loved one has been suffering from OCD, your plan may involve learning how to not enable him or her.

These are just some of the many goals OCD sufferers and their families may envision when dealing with the disorder. I realize that just reading the previous two paragraphs might be overwhelming. That’s why “the plan,” for whatever goals you may have, needs to be broken down into small, manageable steps. For example, if you are looking for a new therapist, first research the best way to do this. You may decide to contact OCD Chicago or the International OCD Foundation for referrals. That is a great first step. Next you can research questions you may want to ask when contacting a new therapist. The next step may be to set up consultations with several different therapists, and the final step will involve making an informed decision. This process may take days or weeks, but as long as you are moving forward that is all that matters. I can’t stress enough how important I think it is to break goals down into doable parts. Otherwise you may be setting yourself up for failure (see first paragraph), or at least a lot of increased anxiety, and none of us needs that!

OCD aside, when thinking of some common New Year’s resolutions, it is interesting to note that they are often things that are specifically recommended to those who suffer from anxiety disorders: daily exercising, eating well, learning relaxation techniques, and helping others.

Again these are general goals and everyone’s step-by-step plan to achieve them will be different. For example, eating well may be decreasing consumption of caffeine and refined sugar for one person or becoming a vegetarian for another. If your goal is the first scenario, you may want to make a chart and plan to gradually decrease your coffee and soda consumption. The expression “slow and steady wins the race” fits well here.

In many ways, this plan for following through on New Year’s resolutions is quite similar to dealing with OCD. Coming to terms with having the disorder, learning how to fight it, and getting well, all involve goals, a well thought out plan, and small, manageable steps. New Year’s resolutions can be kept, and OCD can be beaten, but they both take a lot of work and will not happen overnight.

Here’s wishing you and your family a happy, healthy 2012, filled with goals and plans for whatever you wish to achieve.

The Politics, Stigma and Experience of Brain Disorders: A Blog Series

The holiday season is a good time to talk about brain disorders. The kind blogger S. Z. Berg talks about are more commonly referred to as mental illness, but that term detracts from the fact that depression, anxiety disorders, bipolar disorder, schizophrenia, dementia and other such conditions arise in the brain. Does it allow us to consider them less important than “real” brain disorders, such as tumors and strokes?

Mental illnesses are too often tossed aside as conditions that take place in the mind. (Last I knew, the mind was in the brain, and the brain is a pretty important organ—blogger Berg thinks you’ll agree.) People wear pink ribbons for breast cancer and other colors for other diseases and rally around them to raise money for research to eradicate these awful diseases. (And more power to these people.) But save for autism, she sees little energy going into standing up for people suffering from stigmatized brain disorders that affect thoughts and emotions and that leave their hosts losing out to fulfilling their potential.

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Teen Mental Health

Is There a Relationship Between OCD and Social Anxiety Disorder/Phobia (SAD)?

Many people experience anxiety at some point in their life as it relates to social situations.  However, some individuals are so distressed about engaging in social situations that it interferes with their daily life.  OCD and SAD are both anxiety disorders that can render someone disabled and require treatment. I am a therapist in the community and have worked with numerous people diagnosed with Social Anxiety, OCD, and Panic Disorder.  I would like to impart some of my knowledge from my years working at the UCLA OCD Intensive Treatment Program and private practice. 

People with OCD are at risk for developing depression and other anxiety disorders. Multiple reports have indicated that 11% of people diagnosed with OCD also have SAD.  It is more common to see SAD as a secondary diagnosis to OCD than the other way around.  SAD is also one of the more common mental disorders with up to 13% of the general population experiencing symptoms at some point. (Further information)

I describe SAD as (just shy of being identical) a twin of Obsessive Compulsive Disorder in the following ways: First, both involve unwanted fears/ thoughts; secondly, both involve physiological symptoms: heart pounding, heart racing, shortness of breath, lump in throat shakiness, feeling of unreality chills, flushing, tingling sensations sweating and more, and third, both involve some kind of compulsive behaviors.  With SAD, it is mostly avoidant behavior and mental compulsions.  Yes, avoidance is a compulsive behavior and identifying avoidant behaviors becomes the crux of graduated Exposure and Response Prevention therapy (ERP).

Definition: Social Anxiety Disorder

General criteria for Social Anxiety Disorder to be diagnosed include: A persistent fear of social situations in which you believe you may be scrutinized or act in a way that’s embarrassing or humiliating. These social situations cause you a great deal of anxiety. You recognize that your anxiety level is excessive or out of proportion for the situation. You avoid anxiety-producing social situations. And your anxiety or distress interferes with your life in important ways (going to school, dating, and work performance).  Of note, shyness does not mean a definitive diagnosis for Social Anxiety Disorder and one must look to the degree of impairment to contribute to an accurate diagnosis of SAD. (Further information)

Causes

Like many other mental health conditions, OCD and SAD likely arise from an interaction of the brain, life experience and genetics.  Essentially, SAD is a brain disorder that affects behavior.

Assessment

I use the Yale-Brown Obsessive Compulsive Check List and Scale as a means of teasing out OCD and SAD and for the purpose of determining the severity of symptoms.  I have also found Managing Social Anxiety: A Cognitive-Behavioral Therapy Approach (Client Workbook by Debra A. Hope, Richard G. Heimberg , Harlan R. Juster, Cynthia L. Turk) to be useful for diagnosis and treating SAD.

Prior to engaging in anxiety provoking social situations/ERP, I have my patients determine why they are in treatment at this time.  Why now?  Motivation to participate in any kind of treatment is essential.  I find it helpful when my patients have a specific yet realistic goal to achieve (job interview, date, meeting with the boss, ordering food in a crowded restaurant and so on).  The benefits of getting better must outweigh the cost remaining ill. 

Treatment

Cognitive Behavioral Therapy (CBT) is the treatment of choice for SAD and OCD.  CBT is the catch-all term for so many things and needs further elaboration.  If cognitive therapy alone (talk therapy and cognitive restructuring) was sufficient, then no further treatment would be needed.  Sadly, this is not the case and graduated ERP is a necessary component of treatment.  I develop a hierarchy of feared social situations with my patients and then have the patient choose the least difficult exposure to start with.  There must be some element of anxiety for the treatment to work. 

The process of ERP is very specific in that one does not jump from one exposure to the next without experiencing habituation within a treatment session and in between.  Once the patient is able to engage in the feared behavior/social situation with some level of independence and decreased anxiety, then another exposure can be added on.  Repeated exposures and practice are imperative.  Essentially, one exposure builds on the other and ultimately the patient is less anxious and able to tolerate minor symptoms of anxiety without engaging in the compulsion.  Keep in mind the goal is not to have the patient enjoy social interactions but be able to engage in social situations with less anxiety.  Furthermore, my patients engage in role-playing as a means of increasing social skills.

The goal is for the patient to remain in the feared situation until the anxiety decreases on its own, and that means no deep breathing or cognitive restructuring to decrease symptoms.  This process is called “Habituation” and Brad Riemann, Ph.D., Director of the OCD Center at Rogers Memorial Hospital, wrote an excellent article describing this process.

Having the anxiety drop is challenging at times, as there are so many distractions engaging in exposures outside the office. Once the anxiety is down, I will then engage the patient in the cognitive restructuring process.  It is not done immediately before the exposure, as it potentially becomes a form of reassurance, which is a compulsion.  Remember, “Fear is the problem and facing fear is the solution” (Paul Munford, Ph.D.). 

In terms of mental compulsions, I have come up with a term called “thunking” vs. thinking. Patients use the term in my practice to denote “analyzing fears and churning them in their mind”.  This means they are giving undo attention to the obsession/fear via a compulsion; which in turn validates the need to be fearful.  (Of note, I did not originate the so-called “word” “thunking” but applied it to treatment to help a patient distinguish an obsession from a mental compulsion).  I use script-writing for ERP to address mental compulsions/thunking.  I have the patient write out their worst case scenario for a feared situation.  I find script-writing to be a useful tool for two reasons: 1) the script will often times cause anxiety and the patient can habituate to the experience, and 2) the script can become a tool for helping patients focus their thoughts when they deal with unexpected exposures in the “real world”.

I will never tell my patient that no one is thinking poorly of them as people might be and it is a form of reassurance.  With that said, my patients learn that not everyone will like them but most people don’t take the time to dwell on their perceived flaws. 

I teach my patients that when anxiety increases (I use a 0-10 scale), the more believable the feared thoughts are.  A 10/10 means that the worst case scenario/fear is believed as truth.  An anxiety rating of a 3/10 typically means that a patient would have better insight and a decreased need to engage in compulsions.  Furthermore, as anxiety increases, so is the potential for the patient to be flooded by other unwanted fears/thoughts. Patients learn to focus on the original anxiety-causing thought and, once anxiety comes down from the feared thought, they can then tackle the next fear if there is a need. 

Keep in mind that, once the anxiety comes down, one might not feel so anxious by the additional thoughts and then can engage in cognitive restructuring and resist the urge to engage in a compulsion.  This skill to focus on one fear is difficult and requires practice with the clinician in identifying when flooding is happening during the exposure.

“Quality of Life Exposures” are a must! Patients also need to learn how to engage in pleasurable activities that are no longer routine.  Exposure can also been done in the office.  I enjoy using candy, as most people take pleasure in eating sweets.  I make certain that they eat the candy slowly and learn to appreciate the taste.  Some call this “mindfulness” and I call it learning to live life to the fullest.  Let the patient be the guide in identifying such exposures.

In summary, therapists must assist the patients in identifying their unwanted fears/thoughts and compulsive behaviors that maintain the underlying fear. A hierarchy of symptoms can be created and turned into ERP.  The patients learn to face their fears and experience symptoms of anxiety until they have habituated.  The patients must demonstrate habituation during and in-between sessions. In a calm state the patient can engage in cognitive restructuring (If I didn’t have anxiety what might this situation be like?). 

It is imperative for patients to PRACTICE, PRACTICE, PRACTICE as without it they will most likely not get better and/or relapse.  We must teach our patients how to learn to enjoy life again in a way that is meaningful for them.

Study Indicates Hypersensitive kids may develop OCD as adults

Hypersensitive children could develop Obsessive Compulsive Disorder (OCD) later in life, scientists from Tel Aviv University said Tuesday.

Prof. Reuven Dar, said he first suspected the link while working with OCD patients who reported sensitivity to touch and taste as children. He and his fellow researchers claim they have established a direct correlation between sensory processing—the way the nervous system manages incoming sensory information—and ritualistic and obsessive-compulsive behaviours.

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Council of Parent Attorneys and Advocates

A Serious Illness or an Excuse?

As Awareness of Mental Issues Rises, Colleges Face Tough Calls; Playing Detective. Should they relax rules for students with mental health issues and who should decide if requests for special treatment are justified? Schools are required to extend “reasonable accommodations” for students with documented disabilities—including psychological ones—to comply with the federal Americans with Disabilities Act.

But there’s hand-wringing among university administrators and faculty about how to support college students with mental health issues while making sure young adults progress academically. One of the goals of college, after all, is to prepare students for the working world. And not every boss may be OK with a blown deadline for a critical client report, no matter the reason. Professors also want to make sure they’re being fair to all students.

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Immune Reaction Linked to OCD

Brody Kennedy was a typical sixth-grader who loved to hang out with friends and play video games. A strep-throat infection in October caused him to miss a couple of days of school, but he was eager to rejoin his classmates, recalls his mother, Tracy.
Then, a week after Brody became ill, he awoke one morning to find his world was no longer safe. Paranoid about germs and obsessed with cleanliness, he refused to touch things and showered several times a day. His fear prevented him from attending school, and he insisted on wearing nothing but a sheet or demanding that his mother microwave his clothes or heat them in the dryer before dressing.

“The whole area of mental illness caused by infections is being looked at more closely because of PANDAS,” says Dr. Michael A. Jenike, a professor of psychiatry at Harvard Medical School. “If you can prevent lifelong suffering by using antibiotics or some acute intervention, that would be huge.”
No one knows what portion of obsessive-compulsive disorder cases may be tied to PANDAS — or even how prevalent the condition may be, Jenike says.
“I used to think it was exceedingly rare,” he says. “Now I think it’s exceedingly common.”

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The Sex Addiction Epidemic

It wrecks ­marriages, ­destroys ­careers, and saps self-worth. Yet ­Americans are being ­diagnosed as sex ­addicts in ­record numbers.
Although sex addicts sometimes describe behavior akin to obsessive-compulsive disorder, research hasn’t directly correlated the two. But a growing body of research shows how hypersexual disorder can fit into other forms of addiction.

Most treatment programs are modeled on Alcoholics Anonymous, but rather than pushing cold-turkey abstinence, they advocate something called “sexual sobriety.”

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OCD and Holiday Giving

“I will never forget that feeling of being completely lost and alone, not knowing who to listen to or where to turn for help.”
 
This quote is from my first post on Connections, where I talk about my son Dan’s journey through severe OCD. Though this nightmare transpired almost four years ago, the fear I felt back then is still palpable, and is what fuels my advocacy for OCD awareness and proper treatment.

If you’re reading this, you are likely either an OCD sufferer or care about someone with OCD, and so there’s a good chance you have an idea of how I felt. Again, if you’re reading this, then you’ve also found OCD Chicago’s web site, and now there is no longer any reason to feel “lost and alone.”

OCD Chicago is an amazing organization that provides the most up-to-date information and resources not only for OCD sufferers, but for their families and mental health professionals as well. Our popular OCD Guides for all age groups offer encouraging and practical steps to improve the lives of adults and children who are affected by OCD.

Exploring the entire OCD Chicago web site could take days. In addition to facts and resources, the Expert Perspectives and Personal Stories links are informative and down-to-earth. For specific information on helping students with OCD in school, parents and educators have the option to visit our second web site, the OCD Education Station.

While the quality of this site is impressive, I believe the heart of OCD Chicago lies in the individual attention afforded those who seek our help. A “real person” who has knowledge of OCD will always answer the phone when you call and spend whatever time is needed responding to your questions and pointing you in the right direction. We offer referrals to treatment providers and support groups, and our support group is the only free one in the Chicagoland area. OCD Chicago also provides speakers to school districts, public forums and the news media for the purpose of heightening awareness and understanding of OCD. Most importantly, OCD Chicago offers hope and encouragement to those dealing with OCD.

OCD Chicago offers every one of its resources and services for free, and we rely solely on donations to keep afloat. But nonprofit organizations such as ours are often not at the top of the list when people are considering holiday giving. Even as there has been an increase in awareness of mental health disorders that has brought a request for our services to a higher level, donations have dropped. While some of this drop can be attributed to our economic times, there appear to be other reasons as well.

For one thing, when people are in the throes of OCD, they are often not in the position to help others financially. Their own therapy and related costs, coupled with coping with a crisis situation, makes holiday giving a low priority. And once things stabilize for OCD sufferers and their families, the last thing they often want to think about are their struggles with OCD, and once again, contributing to mental health groups is overlooked.

Another point to consider is that many OCD sufferers and their families are just not comfortable talking about OCD, and may even keep it a secret. Chances are you know a lot more people with OCD than you think you do. If we were all more open about discussing OCD and how it affects us, it would become a more personal cause for a lot people, who, in turn, would donate to OCD organizations. One of the main goals of groups such as OCD Chicago is to reduce the stigma of OCD and other mental health disorders. Ironically, it is this very stigma that perpetuates the silence, precludes so many people from donating, and leaves us struggling financially.

And so I am asking, during this holiday season of giving, to consider donating to OCD Chicago or another OCD organization of your choice. If you or a loved one is suffering from OCD, or has suffered in the past, there is no better way to honor this struggle than to ensure the continuation of organizations such as OCD Chicago. If you remember that feeling of being “completely lost and alone,” please donate, so that others who may feel this way will always have somewhere to turn.

OCD Treatment Through Storytelling: A Strategy for Successful Therapy

OCD Treatment Through Storytelling

OCD Challenge - Internet Treatment Program

USU researchers complete study on “religious OCD,” hope for treatment to go mainstream

Two Utah State University researchers have completed a study dealing with a specific type of obsessive compulsive disorder causing “religious obsession” - with hope that their new treatment will become mainstream in the medical field.

Although the size of the study was small, it was well-received at the Association for Behavioral and Cognitive therapies conference in Toronto two weeks ago, and the research will continue at the University of North Carolina-Chapel Hill.

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Trichotillomania/Dermatillomania Support Group

Obsessive Compulsive Disorder Support Group

Oxford Messed Up

Reese Witherspoon, OCD and a Baby in ‘Rule #1’

When you have obsessive-compulsive disorder and you immerse yourself in whatever triggers your deepest anxieties, it’s called “exposure therapy.” When you do it in a movie, it’s called “Rule #1,” and it stars Reese Witherspoon.

Witherspoon is in talks to star as Diana McBride, a woman with OCD who tries to wrangle her anxiety (and get her husband back) by, letting a young woman with a baby come live with her.
How that figures into McBride’s OCD has yet to be seen, but hopefully this won’t be played totally for laughs.

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Testimonial 31

Testimonial 30

Sensorimotor OCD & Social Anxiety

Sometimes the symptoms of social anxiety and OCD can overlap. Because avoidance maintains fear, Steven Seay, PhD recommends high level exposures that involve “broadcasting” your symptoms in order to address anxiety-related cognitions. This is a CBT technique called intentional mistake practice.

Remember, the problem here is not the behavior per se… The problem is the fear-related attributions you make regarding the behavior (i.e., the possibility that the behavior might result in an unwanted outcome.)

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Anxiety: Three Messages Parents Should Avoid

The wrong messages can push both anxiously disposed kids as well as otherwise normal kids in the direction of struggling with anxiety for the rest of their lives.If you’re a parent or someone who cares about kids, you just might want to know what type of messages instill insecurity.

Three common mistakes that parents make are:
-Invalidating or Denying Your Children’s Feelings;
-Providing Incessant Reassurance; and
-Protecting Your Kids from All Challenges and Risk Taking.

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Recognizing and Acknowledging OCD Symptoms

Let’s say you wake up one morning and your leg hurts. You hobble around on it for a few days, but the pain gets worse. You tell yourself you’ll give it “one more day” and if it’s not better, you’ll call your doctor. Most of us can relate to this scenario where we’ve had a medical issue, we’ve kept an eye on it for a little while, and then we sought help, and a diagnosis.

But what if you have symptoms of a mental health disorder such as OCD? While it would be ideal to follow the same actions as above, that is often not the case. The truth is many OCD sufferers will do the opposite of the above scenario. Instead of seeking help, they will suffer in silence and hide their symptoms as much as possible.

While we have miles to go in educating the public as to what OCD really is and isn’t, we are making some progress. Information on OCD and its symptoms is readily available on the OCD Chicago site; there are more books, web sites, and organizations than ever before dedicated to helping those with this disorder.  We know that OCD is a treatable, neurologically based anxiety disorder. But still so many sufferers avoid a diagnosis, treatment, or both. Why?

The reasons include, but are certainly not limited to, fear, embarrassment and shame. And it is never simple. OCD is an insidious disorder that does whatever it can to undermine the sufferer’s desire to get well.  At a recent conference I attended, I met a woman who had been housebound for eight years because of severe OCD. She spoke eloquently of her struggle and also talked about the never ending support of her mother. While I assumed she must not have known she had OCD and that it was treatable, she told me that was not the case. In fact, she came from a family of OCD sufferers, and while intellectually she knew that OCD was treatable, she never felt that her OCD could be beaten. She had no hope for herself.

And so even in cases where the signs and symptoms of OCD are clear to the sufferer, it does not always mean they will initiate treatment.  This is one of the reasons why it is so important that family and friends also be aware of the symptoms of OCD. If you think there is a possibility your loved one may have OCD, learn everything you can about the disorder. Again, the OCD Chicago site, which includes these guides, offers a wealth of information. If we are able to convey our thoughts and concerns to the people we care about and let them know we are on their side, that realization might just bring them one step closer to fighting their OCD.

But like I said, nothing with OCD is simple. While there are the more typical obsessions and compulsions that we commonly use to illustrate OCD (obsession with germs leading to the compulsion of hand washing, for example), not all symptoms of OCD are so obvious or clear cut. After suffering for at least a few years, my son Dan finally told me he had OCD. At the time, he had no symptoms that I would have associated with OCD.  His compulsions were mostly mental, and therefore not obvious. As I learned more about the disorder, however, it became clear that Dan did indeed have visible symptoms of OCD; they were just lesser known symptoms. He had a hard time making decisions, he was constantly apologizing for things most people wouldn’t apologize for (a type of reassurance seeking), and he avoided doing things and going to places that he used to enjoy. Granted, not everyone who exhibits these symptoms has OCD, but these behaviors should at least raise some red flags and warrant a visit to a therapist, preferably one who specializes in OCD. Trust your intuition. If you have a feeling something is wrong, you’re probably right.

The bottom line is that OCD can manifest itself in many ways. As with fingerprints, no two people with OCD will have exactly the same symptoms. A lot of people, including OCD sufferers, don’t realize this. For OCD sufferers who exhibit some of the lesser known symptoms of the disorder, it is unlikely they will even be aware that they have OCD until they see a competent therapist. The more knowledgeable we can all become as to how OCD presents itself, the more apt we are to recognize the often elusive signs and symptoms of the disorder. And once we know what we are dealing with, we will be in a much better position to fight OCD.

“Sensitivity gene” predicts whether children benefit from CBT

Research has shown that a genetic marker, called Serotonin Transporter Promoter Polymorphism (5HTPP), can be used to predict whether a child suffering from anxiety disorder will benefit from cognitive behavior therapy (CBT).

This London study is the first time that genetic analysis has been used to assess whether a psychological treatment like CBT will work for children.

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Should you take antidepressants while breast-feeding?

A new mom states:“I recently had my first baby and just learned I have OCD. My doctor put me on a very low dose of antidepressant and my symptoms are much better. I am breast-feeding my son and don’t want to use formula but am worried about side effects. What problems should I look for?”

Reactions to medications in breast-feeding babies tend to be more common under 6 months of age and are usually temporary. It is not well known, however, what long-term effects these medications might have on a child’s development. To minimize short-term problems, it may be helpful to time the dosing of medication to occur right after the baby has breast-fed or before a long stretch of sleep. Also, both mom and baby should be monitored closely by their respective physicians.The benefits of breast-feeding a baby often outweigh the risks of exposure to an antidepressant, and parents with treated medical (including mental health) problems are generally better able to care for their babies. Mothers are strongly encouraged to talk with their physicians about best medication choices.

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Outpatient Interventions Help Combat Eating Disorders

Two treatment strategies appear to be effective in the management of and recovery from eating disorders according to Dr. Harry A. Brandt, an eating disorder expert. These treatments – family-based treatment (FBT) and Cognitive Remediation Therapy (CRT) – are “really exciting and are ... helping patients a lot.” according to Dr. Brandt.

FBT leads to a shift from viewing the family as a cause of an eating disorder to, instead, evaluating family dynamics that might develop in the context of an eating disorder – perhaps functioning in a maintenance or perpetuating way,” said Dr. Brandt, director of the Center for Eating Disorders at Sheppard Pratt, Baltimore. Dr. Brandt observed that CRT is different from cognitive-behavioral therapy, or CBT, because the latter focuses on symptoms of illness rather than on the structure of the thinking. CRT uses effectively neutral material targeting the thought processes with the goal of developing new types of thinking. There isn’t a focus on bingeing/purging or weight restoration.”
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Personal Stories - My Battle with Obsessive Compulsive Disorder

ADAA Video Series - OCD, PTSD and Anxiety Disorders

Mental First Aid: How To Help In An Emotional Crisis (NPR)

Why More Americans Suffer From Mental Disorders Than Anyone Else

That mental health disorders are pervasive in the United States is no secret. Americans suffer from all sorts of psychological issues, and the evidence indicates that they’re not going anywhere despite (or because of?) an increasing number of treatment options.

But how does the U.S. compare to other nations? The World Health Organization (WHO) has spent a good amount of time and resources determining how rates of mental health disorders fluctuate across the globe.

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Attend our OCD Awareness Event October 11

Attend our one-night-only event on October 11, 2011 entitled OCD: REAL STORIES – REAL PEOPLE.

Enjoy a warm evening of friendship, connection and awareness.

OCD: REAL STORIES – REAL PEOPLE begins with three true stories that explore different aspects of Obsessive Compulsive Disorder (OCD) and are performed by ETD artistic company members. A break follows, during which refreshments will be served. The evening then resumes with three speakers who share their own experiences living with OCD.

ETD Executive Artistic Director Brighid O’Shaughnessy explains, “After having been long-time fans of one another, it is truly exciting to be partnering with OCD Chicago on this event. This is the first time Erasing the Distance is doing an entire night of stories dedicated to helping us all better understand the OCD experience.  Each of the stories presented are truly unique and shed light on how each individual finds solace, support, and recovery – some through humor, others through therapy and all through acceptance.”

Ellen Sawyer, Executive Director of OCD Chicago, adds, “We are proud to present real life stories of individuals who have triumphed over OCD, and are especially glad to share them with people who understand the specific challenge of having OCD. Speaking out in this way is a wonderful opportunity to reduce the stigma that surrounds OCD and enlighten people who suffer from the disorder.”

OCD: REAL STORIES – REAL PEOPLE
Tuesday, Oct. 11
7:00pm -10:00pm

Ann Sather Restaurant
909 W. Belmont Ave., Chicago
(Free parking is available in the lot west of Ann Sather.)

Featuring:
David Hornreich, Maura Kidwell and Craig C. Thompson (actors)
Brian, Anne and Dan (speakers)

$10 per person, $5 for students.
Click to register.
Advance registration is required.   
Call 773-880-1635 or email .(JavaScript must be enabled to view this email address) with any questions

ACTORS:
David Hornreich has been a part of the Chicago theater community for nearly five years. A native of Seattle, he graduated from Western Washington University in 2004 with a B.A. in acting and directing. In addition to “Grown Up” theater, David has been fortunate enough to work both teaching and acting in Children’s Theater and educational programs with a long list of companies - including Northlight Theater Academy, Greatworks productions, and more.

Maura Kidwell is a graduate of Beloit College and an ensemble member of Redtwist Theatre (formerly Actors Workshop), where she appeared in their Jeff-Nominated production of Equus (Jill) and Les Liaisons Dangereuses (Mme. de Tourvel). Maura is also an artistic associate of Ouroboros Theatre Company, where she performed in the world premiere of Cyrano: Translated (Doris Cooper). Other credits include Ten Cent Night with Chicago Dramatists Theatre (Dee), Amadeus with St. Louis Shakespeare (Constanze), and Mister Paradise with Dream Engine/Indefinite Theatre (Girl). Maura can also be seen and heard in many commercials, industrial films and feature films.

Originally from Kansas City, MO, Craig C. Thompson graduated from Boston University in 1998 and has been living and performing in Chicago ever since. Craig is a former member of Infamous Commonwealth Theatre and has been seen in their previous productions of The Crucible, Lewis and Clark Reach the Euphrates, My Thing of Love, The Kentucky Cycle (Jeff Citation for Outstanding Ensemble and Outstanding Production), Savage in Limbo, and Big Dreams. Craig has also acted for Backstage Theatre in Waiting for Lefty (Jeff Nomination for Outstanding Ensemble), Foreground Theatre, Lifeline Theatre, Emerald City Theatre and Real Rain Productions.

SPEAKERS:
Dan was diagnosed with OCD at age eight. He received treatment in the form of exposure and response prevention therapy. He has volunteered for OCD Chicago - he played the saxophone at a fundraiser and helped edit one of the guides. Dan recorded “The Big Whack-A-Mole Game In My Head” for Chicago Public Radio, about his experience with OCD. The program won the National Mental Health Association’s 2005 Mental Health Media Award for “Best First-Person Account.” Dan is currently a college student, studying computer science. He enjoys fencing, cooking, and reading mystery novels.
Brian has suffered with OCD since he was in college in 1979. Therapies that were conventional at the time proved remarkably unsuccessful until he was correctly diagnosed with OCD in early 1993. He underwent intensive exposure and response prevention therapy that summer, learning to manage his illness using a combination of cognitive behavioral techniques and support group therapies. In 1995, Brian started his own support group on the North Shore, and was a charter board member of OCD Chicago. He continues to serve in an advisory capacity to sufferers. Brian is President of R.F. Mau Co., a Lincolnwood-based manufacturing firm. He lives in Glenview with his wife and two daughters. 
Anne was first diagnosed with OCD more than 20 years ago and went through an intensive treatment program at the Chicago Medical School. She served three terms as a board member of OCD Chicago and as consulting editor on Obsessive-Compulsive Disorder Demystified: An Essential Guide for Understanding and Living with OCD, by Cheryl Carmin (Da Capo Press). She speaks frequently on the topic of OCD to professional groups and with the media. Anne is a graduate of Northwestern University’s Medill School of Journalism; she started her own business as a writer and communication consultant in 1995.

OCD CHICAGO:
OCD Chicago, the leading provider of consumer resources to help sufferers cope with and conquer Obsessive Compulsive Disorder (OCD), works to increase public and professional awareness of OCD, educate and support people with OCD and their families, and to encourage research into new treatments and a cure. A resource for individuals, families, mental health professionals, educators, clergy and the media across the country, we are dedicated to improving the lives of people who suffer with OCD. Founded in 1994, OCD Chicago is a registered 501(c)(3) nonprofit organization.

ERASING THE DISTANCE:
Erasing the Distance is a non-profit arts organization that uses the power of performance to disarm stigma, spark dialogue, educate, and promote healing surrounding issues of mental health.

ETD collects true stories from people whose lives have been impacted by mental health issues. We sculpt the stories into theatrical pieces for the stage, which our ensemble of actors then perform for schools, corporations, community organizations, and the general public. Founded in 2005, ETD’s shows have reached over 26,000 people throughout Illinois and beyond.

Recent ETD productions include Finding Peace in This House, a custom collaboration with The Chicago School of Psychology that is being remounted in January 2012; Stronger Than Silence: surviving our secrets, a show about sexual assault presented in collaboration with C4 Quetzal Center; and Falling Petals, a show about mental illness from Asian American perspectives that is being performed again at Governors State University in February 2012. For more information, please visit http://www.ErasingTheDistance.org.

USF study seeks to turn existing drug into new childhood OCD treatment

ST. PETERSBURG — One child feared that stepping on a crack would harm his mother, just like the old nursery rhyme warned.

Another child wouldn’t touch anything that had fallen on the floor.

For these children, and thousands like them, what at first may sound like a silly aversion can evolve into an all-consuming phobia. But obsessive-compulsive disorder is difficult to treat, particularly in children. It’s hard to find talk therapy geared to children. And many parents are reluctant to try drug treatment, fearful of the side effects or the stigma of the antidepressants used to control OCD.

Now, University of South Florida researchers are offering an unlikely alternative.

With $1.1 million from the National Institutes of Health, the university is studying a treatment for childhood OCD that uses an antibiotic traditionally prescribed for tuberculosis. The medication, D-cycloserine or DCS, appears to enhance the brain’s ability to extinguish the fears that feed into OCD.

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Fighting OCD - No More Secrets

With the help of the Internet, my son Dan diagnosed himself with OCD at the age of seventeen. He had known something was wrong for at least a few years, but never told anyone. Wanting to get help before he left for college that coming fall, Dan mustered the courage to tell me his secret. We were in the car when he anxiously announced he had something really important to tell me. But he just couldn’t seem to get the words out.

“Just say it, Dan. You’ll feel better once you do,” I urged.

“Okay. I have OCD,” Dan blurted out.

With a quizzical look, I looked over at my son. “OCD? Obsessive Compulsive Disorder? Dan, what are you talking about? You never even wash your hands.”

While my knowledge of OCD at the time was minimal at best, telling me his secret was the smartest thing Dan could have done. Though it was not easy, he now had a ready-made advocate and the support of his family. Though I was shocked at his revelation and knew next to nothing about OCD, I, like most parents out there, was willing to do whatever it took to help my son.

If you are a teen who is either suffering from OCD or isn’t sure what is going on, please tell your parents about your concerns. While their initial reaction may not be what you hope for (see above!), please remember that they are probably surprised by your admission and know little, if anything, about the disorder. A common reaction from parents is to try and minimize their children’s fears by saying something like, “Oh, I do that too,” or “I’m sure it’s not that bad.” While this lack of validation can be upsetting for an OCD sufferer, these comments are usually made out of ignorance, not malice.

And so parents, indeed entire families, need to be educated, and the first step towards this education is to be open with each other and acknowledge what is going on. You and your parents need to learn as much as possible about OCD, and visiting the OCD Chicago site is a huge step toward that goal. There is a wealth of information here, from OCD symptoms to how to deal with your family to finding the right therapist.

Another reason why you should tell your parents about your OCD is that it is very important that they be taught the proper way to respond to you while you are dealing with this disorder and undergoing treatment. It is common for family members to inadvertently enable their relative with OCD, and this only makes matters worse. Your family deserves to know what is going on with you, so that they can help you as much as possible.

Some teens are reluctant to talk with their parents about their OCD because they are embarrassed or ashamed of their obsessions. Be assured that you do not have to share any of these details with your family if you do not wish to. Whatever you talk about with your therapist in regards to your OCD remains private. While it is important for your family to know that you have OCD, discussing the details of your disorder is up to you.

For whatever reason, there are teens who feel that it is just not possible to talk with their parents about their OCD.I realize there are all kinds of families with all kinds of issues, and sometimes it is not in the sufferer’s best interests to share with their parents. In this case, I can’t stress enough how important it is to have someone advocating for you. Please confide in a close relative or one of your friend’s parents, or someone at your school or religious institution who you trust.

Anything worthwhile takes hard work, and fighting OCD is no exception. The sooner you start treatment, the sooner you can rid yourself of your symptoms and get back to the business of being a teenager. Keep the bar high for yourself and always remember that all of the hopes and dreams that you have for your future can still be yours. So get started, and if you haven’t already, include the people who love you most in your journey. Tell your parents.

Combining Cognitive Behavioral Therapy With Medication For Childhood OCD Improves Symptoms

Published this month in the Journal of the American Medical Association, a study measured different treatment approaches in 124 patients between 7 and 17 years old diagnosed with OCD, and found a combination of cognitive behavioral therapy and medication resulted in a “significantly greater response rate.”

Commonly prescribed medications for OCD—generally serotonin reuptake inhibitors (SRIs) such as Prozac or Zoloft—can cause side effects. Lead study author Martin Franklin told Reuters that often when kids don’t get better on one drug, doctors will try adding a second or switch to a new medication. Which means the risk of these side effects is compounded. Franklin and his team wanted to explore other options that wouldn’t introduce unnecessary risks, he said.
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Sudden and Severe Onset OCD - Practical Advice for Practitioners and Parents

Many thanks to the contributing clinicians and researchers, who answered our questions with great patience, and whose love for these children is not always listed on their CV, but is always their most obvious qualification: Dan Geller, MD, Tanya Murphy, MD, Eric Storch, PhD, Kyle Williams, MD, Jim Leckman, MD, Madeleine Cunningham, MD, Karen Newell, PhD, and Sue Swedo, MD. And to the moms and dads who have dedicated their lives to raising awareness about this disorder – you are the silent heroes to countless children.

“My child was fine last week, last month – and now I have lost her. This is not my child; what has happened??? What do I do??”

For every parent of a child with an illness, especially a mental illness, there is a particular story. But when you meet a parent of a child with PANDAS (typically a child between ages 3-14), you will hear the same panicked story over and over. A child who was happy at home and at school, and was social and athletic, is now walking in circles for hours, washing hands until they bleed, asking the same questions over and over – and over. A child that used to be comforted by a hug is now inconsolable. They may be begging parents for help, begging for a way to end the horror that exists only in their minds. Imagine a child screaming in terror in a corner, and a parent unable to hold them. These parents will tell you in detail about the day or week that their child changed. Here is what life looks like now – children may exhibit some or all of these symptoms:

• Acute sudden onset of OCD
• Challenges with eating, and at the extreme end, anorexia
• Sensory issues such as sensitivity to clothes, sound, and light
• Handwriting noticeably deteriorates
• Urinary frequency or bedwetting
• Small motor skills deteriorate - a craft project from yesterday is now impossible to complete
• Tics
• Inattentive, distractible, unable to focus and has difficulties with memory
• Overnight onset of anxiety or panic attacks over things that were no big deal a few days ago, such as thunderstorms or bugs
• Suddenly unable to separate from their caregiver, or to sleep aloneScreaming for hours on end
• Fear of germs and other more traditional-looking OCD symptoms

You will often find these parents on the computer every night, desperate for an explanation that makes sense. They are seeking specialists who can help – and finding no answers. They are starting to feel crazy themselves, because no one seems to believe what they are going through.

If you are a pediatrician or pediatric therapist faced with this family in your office, this may look daunting. However, let’s take a minute to walk through options that are available to parents, medical and mental health professionals, and kids suffering from this disorder. These treatment recommendations were developed from interviewing clinicians and researchers around the country, so that you can potentially stop the disease in its tracks while you referring these children for additional help if needed.

What is Pediatric Autoimmune Neuropsychiatric Disorder Associated with Strep or PANDAS?

PANDAS was defined in 1998 by Dr. Sue Swedo. Over the prior decade, Dr. Swedo had been studying Sydenham Chorea where 70% of patients exhibit sudden onset OCD symptoms before or after this classic movement disorder. She and other researchers were finding children who had sudden onset OCD symptoms without the carditis (heart inflammation) or movement disorder normally characteristic of Sydenham Chorea and acute rheumatic fever.
Auto-antibodies have been implicated in the carditis of Acute Rheumatic Fever, and Dr. Swedo theorized that perhaps a related set of antibodies were mistakenly attacking the basal ganglia (part of the brain) rather than the intended streptococcal bacteria triggering the movement disorder/sudden onset of OCD. In July 2010, researchers met at the NIH to discuss the past decade of clinical findings. Of significance, the panel found that while strep throat seems to be a trigger, it may not be the only trigger. Sudden onset OCD could be triggered by other diseases, including Lyme, Mono, Mycoplasma and the flu virus (such as H1N1). Based on this and other clinical reports, the panel modified the research definition of PANDAS.

How to Identify a PANDAS Child

Sudden dramatic onset is the most salient characteristic and differentiates PANDAS from a more frequent pediatric OCD presentation - which involves subclinical symptoms becoming gradually more severe. Incapacitating fears and anxieties seem to come on “overnight” with many parents being able to name the exact day when their child changed. In addition, while the mean age of OCD in children is between 9 and 10 years of age, PANDAS cases can start at a younger age such as 5 or 6, often corresponding with a diagnosis of strep.
Physicians are encouraged to assess for:

• A history of sore throat, fever, exudative pharyngitis, cervical adenopathy (enlarged and tender lymph nodes in the neck), enlarged or damaged tonsils
• Atypical presentations of strep, especially in young children, include abdominal pain and vomiting, vaginal or perianal redness
• In some cases of PANDAS, the strep appeared to be “hiding” in the sinuses or middle ear resulting in a negative throat culture
• It is also possible that non-strep organisms can cause a similar neuropsychiatric illness in vulnerable children. Therefore, it is important to check for mycoplasma, mono, or exposure to Lyme disease

During the meeting at NIH last year, researchers and clinicians across the country began to revise the criteria defining this illness in children. Based on that conference, because there are non-strep causes of sudden onset illness, researchers changed the name of the disease to PANS: Pediatric Acute-Onset Neuropsychiatric Syndrome.
Mental and medical professionals should look for:

• Abrupt, dramatic onset of OCD is the first diagnostic criterion for PANS. For those familiar with the CYBOCS (Childhood Yale Brown Obsessive Compulsive Scale) scores, some clinicians look for an increase in total score of more than 16 in the course of a few days. Children may have mild “quirks” or even some signs of OCD prior to this abrupt dramatic onset. In retrospect some clinicians suggest that mild micro-episodes may even have occurred in the past. However, in the space of a few days, they “fall off a cliff”, dramatically causing a significant decrease in the child’s ability to function. Impairment is significant. Parents can usually name the day that the crisis occurred and have vivid memories of the first obsessions or compulsions because of their extreme nature. As an example, a normally joyful, balanced emotionally, independent, social child may turn into a child that has extreme temper tantrums that are out of character, and can no longer leave a parent’s side without accommodation. Panic attacks and unusual anxieties are not uncommon. In addition to the typical obsessional fears and compulsive behaviors, this criterion also may be satisfied by the sudden severe onset of food avoidance, anorexia and eating restrictions. Clinically, these occur as solitary symptoms among PANS patients, as well as from complications resulting from obsessional fears of choking, vomiting or of contaminated foods.
• Although there appears to be uniformity in the acuity and severity of onset of the co-occurring symptoms, there is great variability in the nature of the symptoms accompanying the OCD. As a result, the second major criterion for PANS is the concurrent acute onset of additional symptoms from at least two of the following seven categories:
   
  1. anxiety (particularly acute separation anxiety and irrational fears)
   
  2. emotional lability and/or depression
   
  3. irritability, aggression and/or oppositional behaviors
   
  4. behavioral (developmental) regression
   
  5. sudden deterioration in school performance
   
  6. sensory or motor abnormalities (particularly dysgraphia/ trouble with handwriting)
   
  7. somatic/physical signs and symptoms

As in most of psychiatry, PANS is a clinical diagnosis, meaning that there are currently no laboratory or genetic tests that can confirm the diagnosis. As such, a second opinion to find consensus on the diagnosis of PANS between two experienced physicians may be useful.

Additional Medical Testing to Consider Prior to Onset of Treatment

Many physicians report that a throat culture appears to be key (even if there are no signs or symptoms of pharyngitis). Due to the difficulty in properly sampling these children, a two-swab sample should be taken to check for bacterial colonization. The first swab should be a rapid strep test. It is very important that the culture is obtained properly by vigorously swabbing across the entire pharynx, behind both tonsils and the uvula. If the child doesn’t gag and protest, the swab is probably inadequate. If negative, use the second swab for a 4-hour agar plate culture. If these are both negative, consider testing for Lyme disease, Mycoplasma, vitamin D, Ferritin and thyroid. Many children with recurrent upper respiratory infections have immune deficiencies and would benefit from an immune function assessment such as blood counts measuring quantitative immunoglobulins and a referral to a pediatric immunologist.

Finally, many physicians rely on antibodies to the exotoxins of streptococcus to confirm a prior infection measuring ASO and AntiDNaseB. These tests have fixed windows where the measurement may begin to be positive 1-8 weeks after initial infection. Typically two measurements are required. The first should be obtained as soon as possible after the suspected infection and the second at least six weeks later. It is currently unknown whether carrying the bacteria without an active infection alone is sufficient to cause symptoms in PANS children.

If test results are all normal, it does not rule out a diagnosis of PANS, and exposure to infections from close contacts should be considered.

Treatment Options and Strategies to Consider for PANS

While acknowledging the need for additional research, we also cannot sit idly by while children scream in terror. We have to help children suffering today. Clinicians around the country have started treating our kids. Best practices suggest that one develop a treatment plan based on interventions with the minimum effective dose, an intervention with the best cost/benefit ratio (less intrusive, minimal short term and long term side effects, good at preventing relapse, easy to administer, tolerated well) and treatments that have the most research behind them. Research can include controlled studies (better) and case reports (good but less informative). We will rate each of the following treatments currently being used as a guide for professionals and parents to consider when trying to determine the best course of action. This is said with the caveat that at this point in time PANDAS and PANS treatments are drastically under researched. Please see the end of this article for more about how to help on this front.

IVIG: The original research studies investigating possible treatment options were done by giving children IVIG (intravenous immunoglobin). Essentially, this treatment gives a child antibodies from a myriad of donors. We don’t know exactly how IVIG works, but it appears to help in a number of autoimmune illnesses.

In PANDAS, IVIG reduced the OCD symptom severity for 82% of children suspected of having PANDAS in a small study that is now being repeated at the NIH.  IVIG is offered to children in a clinical environment – but is often not covered by insurance and is expensive. While IVIG is usually considered quite safe for treating auto-immune disorders, there are several risks. Nausea, vomiting, and headache are not uncommon and in rare instances, aseptic meningitis or allergic reactions may occur. Although most side effects are not harmful in the long term, they are unpleasant and therefore IVIG therapy is generally recommended only for severe or persistent cases or as indicated for immune deficiency disorders.

Antibiotics: Dr. Swedo also did research showing that using antibiotics as a prophylaxis to prevent strep successfully reduces neuropsychiatric exacerbations. Another study will start soon as a collaboration between Harvard and the University of South Florida. They will be examining a common treatment course successfully used by clinicians: using antibiotics in children with PANDAS. Early in the disease if strep is present, this is an obvious course. But no research has yet been done on why many clinicians find that a longer term course of antibiotics often seems to offer great hope to families suffering from this disease –even after the actual triggering illness is over. As such, some physicians have found the following particularly helpful for new, sudden onset cases:

• Use antibiotics for 3-6 weeks initially. Use of augmentin has anecdotally been found to be more effective at a relatively high dose as well as the cephalosporins (cephalexin, cefdinir) and azithromycin. Consider using probiotics but not at same time of the day; allow 2-3 hour window between. If no improvement is seen after 3-4 weeks, a physician may consider an alternate class of antibiotic treatment. If symptoms completely remit, a trial off the antibiotic may be attempted. If symptoms return, additional treatment may be warranted.

However, in many cases, a physician will see a child a several weeks after the initial onset, or in a second exacerbation. In that case, some clinicians have recommended the following:

• A throat culture can still be very informative at this point as well as antibody levels. Then treat with antibiotics as above while waiting for the results. If there is a marked reduction in symptoms, gradually wean. With a recurrence, antibiotics are reintroduced and continued as needed. Try to gather retrospective information, ask for detailed pediatrician records to be forwarded and nail down the exact timing of testing and labs. Since prior testing may have been limited, a trial of antibiotics appears to be low risk.

Exposure and Response Prevention (an intervention under the broader umbrella “Cognitive Behavior Therapy or CBT): Unlike traditional onset OCD, where research clearly guides a mental health and medical professional’s decision making about how to proceed with treatment, PANS onset OCD is still under researched. As we wait for studies to be completed we still need to develop treatment strategies that can address the pain and suffering of children and families now. For many PANS children, the suddenness of onset and the migratory nature of the obsessions/compulsions can make Exposure and Response Prevention therapy or ERP challenging; however, a combination of a medical intervention and traditional ERP might be the best course of action at this point in time. For some children an initial treatment with antibiotics or IVIG results in significant relief of symptoms. For those with slow or partial remission of symptoms, ensuring that ERP is included seems to be critical. Children develop habits and fears quickly and they may use ERP treatment to teach their brain to ignore the irrational fear signals they have been receiving. ERP teaches a child concrete tools to overcome OCD thoughts on a daily basis. Many clinicians find that learning ERP allows the entire family to function more calmly during future exacerbations, while seeking medical help. Some recent but preliminary work by a group at University of South Florida found strong effects for this approach in children with PANDAS (Drs. Storch & Murphy).

SSRIs: Most clinicians experienced in treating children with PANDAS do not initially recommend SSRIs, especially given the very young age of many of the children. However, as the disease course continues, they may find relief with the use of SSRIs in much lower doses than is normally recommended for children with OCD. Close monitoring is strongly recommended, as very young children may have more adverse behavioral or neurological effects. Occasionally, mood stabilizers have been reported as helpful, as the presence of mood volatility in PANS/PANDAS is a major limitation in the use of SSRIs. Please see this link for more information about SSRIs.

Plasmapherisis: Dr. Swedos’ original study included both IVIG and plasmapherisis. Plasmapherisis was the more immediate and effective option in the original study. However, as the most expensive and invasive treatment option, this is rarely used in a clinical setting, and is beyond the scope of this article. For more information, see the original research study, or read more about plasmapherisis online.

Steroids: As with all autoimmune diseases, doctors have found that anti-inflammatory medications (such as corticosteroids) can be effective in both short and long term use. However, these can be very damaging to children in long-term use and should only be considered in careful consultation. Some parents or clinicians have found that short-term use of steroids can help auto-immune, triggered OCD once the initial infection is cleared. Behavioral side effects are sometimes seen in steroid therapies (especially mood symptoms) and can overlap with PANS symptoms. Should additional research studies come available, IOCDF will publish those findings.

Ibuprofen and NSAIDs: Some parents have reported that non-steroid anti-inflammatories (such as Ibuprofen) do seem to help symptoms. This has led some researchers to consider that perhaps it is the anti-inflammatory effects of the antibiotics, IVIG and steroids on the blood-brain barrier that is resulting in improved symptoms. While long-term use of NSAIDs carries its own issues, some pediatricians prescribe a low-dose NSAID during significant episodes. Please consult with your doctor as there are multiple other issues to consider when using this approach.

Summary, Conclusions, and Going Forward

As noted previously, in the absence of research, we cannot recommend doing nothing for these children. Their suffering is intense. And the risk of long-term damage cannot be ignored. We also do not know if some of these children remit spontaneously later in adolescence. We do not know if some of them grow into adults with the most treatment resistant OCD due to permanent basal ganglia damage. While we research those questions, offering treatment options at the local level, especially in the first few months after onset, could be critical to the long term success for these kids. One prospective study conducted in a pediatrician’s office suggests that first-onset PANDAS symptoms may remit following successful treatment of the strep infection with antibiotics. Unfortunately, there has not been a follow-up report on these children, so it is unknown if some children experience a second exacerbation following successful treatment of the initial onset of PANDAS symptoms.

Like Sydenham Chorea, PANS provides a window into a whole new way of treating mental illness as a faulty immune response. There are many researchers across the nation who have developed hypotheses about the cause, contributing factors, and treatment. They need funding to move forward with this seed research, before developing larger grant proposals. If you are interested in learning more, or in contributing towards this research, the IOCDF welcomes your call or donation. Dr. Madeleine Cunningham often ends her presentations on PANDAS with this compelling quote: “If auto-antibodies are proven to play a role in mental disorders, then it will change the way mental illness is diagnosed and treated forever.” Being a part of this change - whether you are a treating physician, a researcher, a parent or a donor – might change your life forever too.

Additional reading:
What every Psychiatrist should know about PANDAS

References:

 
1. S Swedo et al, “Obsessive-Compulsive Disorder in Children and Adolescents : Clinical Phenomenology of 70 Consecutive Cases ”, Arch Gen Psychiatry. 1989;46(4):335-341.
 
2. Giedd JN, Rapoport JL, Kruesi MJ, et al. Sydenham’s chorea: magnetic resonance imaging of the basal ganglia. Neurology 1995; 45:2199-202.
 
3. Castillo M, Kwock L, Arbelaez A. Sydenham’s chorea: MRI and proton spectroscopy. Neuroradiology 1999; 41:943-5.
 
4. Giedd JN, Rapoport JL, Garvey MA, Perlmutter S, Swedo SE. MRI assessment of children with obsessive-compulsive disorder or tics associated with streptococcal infection. Am J Psychiatry 2000; 157:281-3.
 
5. Debes NMM, Hansen A, Liselott S, Larsson H. “A functional Magnetic Resonance Imaging Stufy of a Large Clinical Cohort of Children with Tourette Syndrome.”, J Child Neurol May 2011 vol. 26 no. 5 560-569
 
6. Khurana DS, Melvin J, Kothare S, et al. “Acute Disseminated Encephalomyelitis in Children: Discordant Neurologic and Neuroimaging Abnormalities and Response to Plasmaphereisis”, Pediatrics Vol. 116 No. 2 August 1, 2005, pp 431-436.
 
7. Sahlas DJ, Miller, SP, Guerin M, et al. “Treatment of acute disseminated encephalomyelitis with intravenous immunoglobulin.”, Neurology, March 28, 2000; vol. 54. No 6. 1370-1372.
 
8. Calabrese G, Columbo C, Bonfanti A, et al, “Caudate nucleus abnormalities in obsessive-compulsive disorder: measurements of MRI signal intensity.” Psychiatry Res, 1993 Jun; 50(2):89-92.
 
9. Crespo-Facorro B, Cabranes JA, Lopez-Ibor A, et al. Regional cerebral blood flow in obsessive-compulsive patients with and without a chronic tic disorder. A SPECT study. European Archives of Psychiatry and Clinical Neuroscience, 1999, Volume 249, Number 3, Pages 156-161
 
10. Hurley R, Taber K, “Acute and Chronic Lyme Disease: Controversies for Neuropsychiatry.” J. Neuropsychiatry Clin Neurosci 20;iv-6, Feb 2008
 
11. Zomorrodi A, Wald, E. “Sydenham’s Chorea in Western Pennsylvania.” Pediatrics Vol. 117 No. 4 April 1, 2006, pp e675-e679.
 
12. Murphy T, Kurlan R, Leckman J, “The immunobiology of Tourette’s Disorder, Pedeiatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus, and Related Disorders: A way forward”. J of Child and Adolescent Psychopharmacology, Volume 20, Number 4, 2010. Pp 317-331.
 
13. Allen AJ, Leonard HL, Swedo SE. Case study: a new infection-triggered, autoimmune subtype of pediatric OCD and Tourette’s syndrome. J Am Acad Child Adolesc Psychiatry 1995; 34:307-111
 
14. Nicolson et al, “An Open Trial of Plasma Exchange in Childhood Onset Obsessive-compulsive Disorder Without Poststreptococcal Exacerbations. ” J Am Acad Child Adolesc Psychiatry 2000, 39[10]: 1313-13157
 
15. S Swedo et al, “Identification of Children With Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections by a Marker Associated With Rheumatic Fever”, Am J Psychiatry 154:1, January 1997
 
16. Swedo SE, Leonard HL, Rapoport JL.” The pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) subgroup: separating fact from fiction”, Pediatrics. 2004 Apr;113(4):907-11.
 
17. Moretti G, Pasquini M, Mandarelli G, Tarsitani L, Biondi M (2008). “What every psychiatrist should know about PANDAS: a review”. Clin Pract Epidemol Ment Health 4: 13.
 
18. Swedo SE et al., “Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections: Clinical Description of the First 50 Cases”, Am J Psychiatry 155:2, February 1998.
 
19. Shet A, Kaplan EL, Johnson DR, Cleary PP, “Immune response to group A streptococcal C5a peptidase in children: implications for vaccine development”, J Infect Dis. 2003 Sep 15;188(6):809-17.
 
20. Storch EA, Murphy TK, Geffken, G et al, “Cognitive-Behavioral Therapy for PANDAS-Related Obsessive-Compulsive Disorder: Findings From a Preliminary Waitlist Controlled Open Trial”, Journal of the American Academy of Child & Adolescent Psychiatry: October 2006 - Volume 45 - Issue 10 - pp 1171-1178
 
21. Murphy TK, Storch EA, Strawser MS, “Selective serotonin reuptake inhibitor-induce behavioral activation in the PANDAS subtype”, Primary Psychiatry, 2006;13(8):87-89
 
22. Perlmutter SJ, Leitman SF, Garvey MA, “Therapeutic plasma exchange and intravenous immunoglobulin for obsessive-compulsive disorder and tic disorders in childhood”, Lancet 1999; 354 : 1153 – 58
 
23. Snider L, Lougee L, Slattery M, Grant P, Swedo S. “Antibiotic prophylaxis with azithromycin or penicillin for childhood-onset neuropsychiatric disorders”. Biol Psychiatry 57 (7): 788–92. 2005
 
24. Schneider R., Robinson M., Levenson J., “Psychiatric presentations of non-HIV infectious diseases: Neurocysticercosis, lyme disease, and pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection”, Psychiatric Clinics of North America, Volume 25, Issue 1, Pages 1-16
 
25. Swedo S, et al. “PANS – Pediatric Acute Onset Neuropsychiatric Syndrome”, pre-publication working draft.
 
26. Chong BH and Chong JJH, “IVIg immune inhibitory activity: APC is key”, Blood March 4, 2010 vol. 115 no. 9 1663-1664

OCD Center of Los Angeles

Sexual Orientation OCD - Part 4: Challenges to Treatment of HOCD

Jon Hershfield, MA, of the OCD Center of Los Angeles discusses common challenges seen in the treatment of Sexual Orientation OCD, also known as HOCD or Gay OCD.  Part four of a four-part series.

Sexual Orientation OCD – also known as HOCD or Gay OCD – is best treated with Cognitive Behavioral Therapy.

In my previous blog on Sexual Orientation OCD (aka HOCD), I looked at some of the potential sub-types that appear in this condition.  While they are all treated with various Cognitive Behavioral Therapy (CBT) strategies, crippling fear can lead people toward beliefs that impede therapy.  Here are some thoughts about treatment issues I commonly hear from HOCD clients.

My Big Gay Secret Self

Many HOCD sufferers, regardless of sub-type, become preoccupied with the idea that other people might think that they somehow “appear” gay.  As a result, some men with HOCD may over-attend to the way they dress, opting for baggy, neutral choices rather than fitting, stylish choices that they might associate with homosexuality.  They may pay special attention to the way they speak or even the way they hold a drink, trying to eradicate any possibility that a person may mistake them for being gay.  Women with HOCD may over-attend to the length of their hair, or whether their clothes are “feminine” enough.  Both men and women with HOCD are likely to obsess about their body type and whether there is something inherently “gay” about it.

Some of this distorted thinking comes from limited or erroneous information they have collected about homosexuals, which leads them to compulsively avoid stereotypes that really have little to do with homosexuality.  Still the HOCD persists with the notion that the sufferer has some clue of what gay “looks like” and then compels them to avoid that.  For most, this appears not to be a fear of negative evaluation, but more a fear that this imagined person who may somehow identify them as gay will actually be seeing into their soul –- that if another person calls them gay, this person is seeing their “true self” and this will confirm their worst fear…gay denial!

There is no gay denial.

There is no latent homosexuality, there is no hidden self.  It’s something someone made up one day.  It does not exist.  There is no secret version of yourself waiting to be discovered (yes, I anticipate lots of angry emails from your psychoanalyst).  I think it is important to recognize that people often choose to modify their behaviors to fit with what they think society expects of them.  In some cases this results in people of one sexual preference choosing to live the lifestyle of another sexual preference as a way of avoiding what they see as the negative consequences of accepting themselves as they are.  This could be done in order to avoid professional, cultural, religious, or other consequences.  Of course, there may be a small percentage of the population that somehow is not conscious of what their preferences are, and appear surprised when they “come out” as gay.  I am assuming these people exist because I have seen them on television, but then I see a lot of rare and bizarre things on television.

In all seriousness, there are people who claim not to have known their sexual preference until they met the right person.  This concept is very disturbing to an HOCD sufferer.  Yet it cannot be referred to as “coming out” since it is really more like “waking up.”  And this real “coming out” doesn’t begin with fear, but with yearning.

Get Out of the Way

The most effective treatment for all forms of OCD is a type of Cognitive Behavioral Therapy (CBT) called “Exposure with Response Prevention” (ERP).  The most common impediment to ERP treatment for HOCD is the continued practice of compulsive behavior throughout the exposure itself.  Usually this comes in the form of self-reassurance.  For example, many HOCD sufferers may attempt to overcome their fears by exposing to gay pornography, gay neighborhoods, or other things that are likely to trigger their discomfort.  Among the most common self-ERP attempts I hear involves reading online “coming out” stories.  All of these may be good ideas for ERP work, but they can easily backfire for the following reason: trying to prove you don’t like the porn, or that you don’t belong in the gay neighborhood, or that the person in the coming out story is nothing like you will never work.

ERP only works if the person resists doing this mental ritual, and instead accepts whatever thoughts and feelings the OCD may throw at them without protest.  In more intensive ERP, you are not only accepting the thoughts, but actively agreeing with them, diving head first into the fear instead of tip-toeing around it.  Any effort to analyze the exposure for evidence of your sexual orientation results in the brain confirming once again that your sexuality is up for debate.  If instead, your behavior indicates to the brain that the presence of triggering material does not result in mental rituals, then your brain will begin to recalculate its position on the importance of knowing the certainty of your sexual orientation.  In other words, if you stop doing mental compulsions aimed at finding certainty about your sexual orientation, your brain will learn that it is not necessary to have that certainty.

A common fear related to ERP treatment is the distorted idea that accepting the presence of gay thoughts in your mind somehow leads to a likelihood of acting out gay behaviors.  This OCD logic has the sufferer in a double bind in which doing compulsions feels like a way to protect oneself from becoming gay, but at the same time actually fuels the obsession about one’s sexual orientation.  When someone with HOCD stops doing the compulsions, they often see this as dangerously opening the door to unwanted gayness.  This is not unique to sexual orientation OCD, as it is an identical frame for the harm OCD sufferer who worries that accepting harm thoughts will lead to violence, or the contamination OCD sufferer who worries that not washing will lead to contracting a terrible disease. It is important to remember, then, that ERP for OCD always feels like you are doing something wrong.  This is because what you thought was right (compulsive behavior) is actually the source of the problem.

Feeling Gay

As the ERP work intensifies, the OCD fights for its own survival by leading the sufferer to fear that they are “feeling” gay.  Feeling gay is an interesting phenomenon because it is oxymoronic.  A truly gay person does not over-attend to gay feelings, but sees them as a normal part of their existence.  It’s no more conscious than the feeling of me having brown hair.  A gay person doesn’t sit around “feeling gay” any more than a straight person sits around feeling straight.  It’s the OCD that makes someone over-attend to their feelings, and it’s that same over-attending that distorts these feelings into something to obsess about.  An HOCD sufferer is likely to report feeling gay when they do exposure work and being terrified by this.  But the fact that they report “feeling” gay actually means they don’t have any idea what it is like to actually be gay!

An additional challenge to ERP treatment often presents itself when a person starts to initially see the benefits of the treatment.  At that point, the person habituates to things that would previously have triggered a significant spike in their anxiety.  As this habituation takes place, the person’s thoughts and feelings become more congruent with those of non-HOCD sufferers.  In other words, the individual becomes less upset by the presence of the unwanted thoughts and feelings they experience related to the issue of sexual orientation.  As this juncture, some with HOCD then begin to obsess that they are not “bothered enough” by the trigger, and then use this as evidence of their homosexuality.  This is sometimes referred to as (awkwardly enough) a “backdoor spike” because the OCD goes from identifying the fear as evidence of being gay, to now identifying the lack of fear as evidence of being gay.

What often goes unnoticed in HOCD and similar obsessions is that demonstrations of disgust and terror can also be compulsions, which are essentially behavioral strategies for avoiding or reducing discomfort.  This does not mean they always feel good to do (often they do not).  By actively causing oneself to be repulsed by gay thoughts, a sufferer can then avoid the discomfort that comes from thinking that the gay thoughts are acceptable and then inferring that this makes them gay.  It’s enough to make anyone dizzy.

Whether the OCD is using fear or ambivalence as its threat, the goal of treatment needs to remain firmly focused on accepting whatever is going on inside as simply going on.  Thoughts happen, feelings happen, sensations happen, and nowhere in this does anyone have certainty as to what it means.  We guess and we tolerate whatever discomfort we imagine could come from being wrong.  Life without OCD is lived in the present, making choices based on current preferences, not predictions, and choosing labels based on patterns in those preferences.

The Fear of Not Having HOCD

One of OCD’s more sinister sneak attacks is the threat that having HOCD is just a cover for not accepting that you’re gay.  Of course, sufferers of all types of OCD obsess about not having OCD.  The “scrupulosity” OCD sufferer may see OCD as a way of denying they are sinners, while a “contamination” OCD sufferer may debate whether they are just inherently lazy about cleanliness, while someone who obsesses that they might be a pedophile or a murderer will worry that identifying their problem as being OCD is just a way to avoid accusations of being a monster.

All of these people miss the larger point, which is that non-OCD sufferers do not obsess about having OCD.  To be clear, virtually everyone has some obsessions and compulsions, but roughly 2-3% of the population has them to such an extent that it impairs functioning and is diagnosable as a disorder.  So a non-OCD sufferer may be disturbed by an intrusive thought or may engage in a pointless ritual, but they do not get so completely trapped by this cycle that their quality of life is affected, and they are unlikely to be concerned with whether or not they have OCD.

HOCD sufferers often seek reassurance from their treatment providers that they do indeed have OCD.  This is really the same reassurance-seeking compulsion that they engage in elsewhere when trying to gain certainty that they are not gay.  Just as the HOCD sufferer must learn to tolerate uncertainty related to their orientation, they must also learn to tolerate uncertainty related to their diagnosis.  If somehow they managed to be in such denial that they convinced an OCD specialist to diagnose them with a disorder they didn’t have, then they must have been obsessing over that denial to such an extent that they compulsively sought reassurance from a treatment provider who would tell them they weren’t gay.  That sounds like OCD to me.

Gay Fantasy and OCD

Some people have gay sexual fantasies.  Some people have OCD.  Some people have both and none of this has to do with one’s sexual orientation.

Sexual fantasy in itself is a healthy thing.  While there are ways in which it can be used compulsively or destructively, for the most part mindfully observing arousal thoughts is an activity we should all be able to enjoy as one of the perks of having a brain.  Most, if not all, sexual fantasy involves taboo.  It is this state of actually allowing ourselves to entertain and fully embrace and accept “wrong” thoughts that is so stimulating and freeing.  It is good because it is oh so bad.  For example, a heterosexual man may conjure up in his mind the fantasy of cheating on his wife.  This man is not necessarily interested in cheating on his wife and in all likelihood he would run awkwardly away from an opportunity to actually do so.  If he walked into a room and a beautiful stranger were laying there saying “take me,” he would probably not be comfortable.  “This is a real person,” he thinks, “someone’s sister or daughter!  Plus, are they disease free?  When was the last time they showered?  What will they think of me afterwards?  What will I think of myself?  Will my wife find out?  Would this hurt my wife?  Will I be able to live with the guilt?”  He can accept the fantasy, but not the reality, because the fantasy appears wrong and the reality to him actually is wrong.  The appearance is exciting, the reality is distressing.

For many heterosexuals, gay fantasies are not technically unwanted thoughts themselves.  They are taboo, and while the reality might be unpleasant, the fantasy is undoubtedly stimulating.  But a gay fantasy should not to be confused with an HOCD obsession, which is an intrusive, unwanted thought about the fear of being gay.  For people with actual gay fantasies who also have HOCD, the obsession is not about the existence of the gay thoughts, but about the fear that enjoying their fantasy element means they are engaging in the reality of it.

This is very painful for heterosexual men who, to put it lightly, simply have a dick thing.  They are attracted to women, choose women for their relationships, but simply happen to find masculinity, and penises in particular, to be conceptually activating.  Maybe a penis is a narcissistic reminder of one’s own beauty, or maybe it represents control, power, submission, any number of things.  Maybe it represents freedom from having to always perform as the archetypal strongman in control.  Who knows.  In any case, it is not important.  What is important is to live in the present and allow yourself to value the things that are presently in your life.  If that means today you love being with your wife, but tomorrow you will spontaneously choose to be with a man, then deal with tomorrow when tomorrow comes.  Across all forms of OCD, the energy spent trying to sort out a thought in order to preempt it from creating a catastrophic future is nothing more than a mental compulsion.

Some may note that there appears to be slightly more acceptance of lesbian fantasizing in Western culture and media (note I said fantasizing, not necessarily practicing).  This may be because our patriarchal society promotes the fantasy of men with multiple women to pleasure them, so thinking of them pleasuring each other creates the implication that a man would be happily welcomed to join them.  It’s a chauvinist cultural flaw, but it exists nonetheless.  But women with HOCD tend not to allow this patriarchal loophole to give themselves permission to enjoy gay fantasy.  The OCD mind distorts the pleasurable thought into one being grotesque, sexless, and unlovable.  So the challenge of living with HOCD is both easier and harder as a woman because this perceived acceptance for straight women having gay fantasies can equate to a greater fear that being gay is a tangible truth.

All this being said, it is normal and healthy for straight people to sometimes have gay thoughts.  Whether or not these thoughts are enjoyed or hated is somewhat beside the point.  As a therapist specializing in Cognitive Behavioral Therapy, some beliefs will always seem inherently distorted to me.  The belief that simply having a gay thought and liking it makes you a gay person is one of these beliefs.  Remember, our lives are defined not by the content of our thoughts, but by the behaviors we seek when responding to them.

Sexual Orientation OCD - Part 3: HOCD Sub-Types

Jon Hershfield of the OCD Center of Los Angeles discusses treatment of Sexual Orientation OCD, also known as HOCD or Gay OCD, using Cognitive Behavioral Therapy (CBT) and Mindfulness.  Part three of an ongoing series.

There are many variations and sub-types of Sexual Orientation OCD (HOCD).

When I initially wrote the part one and part two of my article on Sexual Orientation OCD (aka “Homosexual OCD”, aka “HOCD”, aka “Gay OCD”), it was intended solely to reflect this rather common form of the disorder as I saw it presented in several of my clients.  I had not anticipated such a significant online response, with so many additional questions and angles on the subject.

Sexual obsessions in general are under-reported because of shameful feelings associated with them.  And yet there is probably a somewhat higher prevalence of sexual obsessions in OCD than any other obsession for this same reason – the thoughts are unwanted! This seems so very evident in Sexual Orientation OCD because the feared consequence appears so tangible.  In other common OCD obsessions, such as “Harm OCD,” the idea that someone might be in denial of violent impulses is plenty terrifying.  However, there is an understanding that being violent is unacceptable in and of itself.  With Sexual Orientation OCD, the sufferer generally does not see anything wrong with being gay per se, as long as it is not themselves being gay.  This causes a lot of confusion and a lot of resistance to seeking treatment.

I’d like to use this latest installment in what has become a series of discussions on Sexual Orientation OCD to be more specific about the different ways I have seen this OCD manifestation present and the different Cognitive Behavioral Therapy (CBT) strategies that appear to work.  I have attempted to categorize them, but it’s important to remember that sufferers are likely to fall into a combination of several categories and not just one.  Also bear in mind that I will continue to use “gay” or “homosexual” to be synonymous with alternative orientations for simplicity’s sake only.  Homosexual and bisexual individuals with OCD can, and do, sometimes obsess about being straight.

All-Or-Nothing HOCD

This is perhaps both the most common and the least reported subtype of HOCD because it is easy to overlook the OCD characteristics.  In short, All-Or-Nothing HOCD describes the experience of those who have always been of one orientation, have never experimented with other orientations, and who do not have gay fantasies, but who just randomly have a “gay” thought or feeling one day and it scares them.  It is often reported as starting with a simple, “Did I find that person attractive?” and “What does it mean that I can’t be 100% certain that I did not find that person attractive?”

In All-Or-Nothing HOCD, the primary distorted belief is that straight people never have any gay thoughts, so any gay thoughts must be an indicator of latent homosexuality.  In fact straight people do have gay thoughts, but generally prefer not to apply them to gay sexual behaviors.  In actuality, it is not possible to know what the word “gay” even means on a literal level without having what can only be described as a “gay” thought.

So for the sufferer who sees gay thoughts as contaminating an otherwise purely straight mind, compulsions are going to be focused on making the gay thoughts go away through various proving rituals.  This may take the form of compulsive masturbation to straight fantasies or avoidance of anything that might trigger the presence of a gay thought.  It often involves avoiding people who the sufferer sees as even having the potential to be gay.  Just as a handwasher tries to be certain there is not contaminant on their hands, this HOCD sufferer is aiming for total eradication of the unapproved gay thought.

Cognitive Behavioral Therapy (CBT) treatment strategies for All-Or-Nothing HOCD should involve gradual exposure to things that trigger gay thoughts while the sufferer practices resisting the urge to tell themselves they are not gay.

Relationship HOCD

People are complicated.  That means relationships are twice as complicated.  Some people are lucky in love, some people are unlucky, some people are both, and some people really can’t tell because of their OCD.  This form of HOCD occurs when an OCD sufferer uses potential gayness as an explanation for what they see as failed heterosexual relationships.  Women with Relationship HOCD may identify themselves as “man-hating dykes,” while men may see themselves as “just not understanding women,” and may describe themselves as being “in denial” of their “true” sexual orientation.

Often in cases like these, the HOCD itself is a smokescreen for what is sometimes called Relationship OCD (aka ROCD) or Relationship Substantiation OCD.  Those with ROCD tend to have obsessions that revolve around fears of not “really” loving or being sexually attracted to their spouse or partner, not being involved with the right person, or not being the right person for their partner.  Those with Relationship HOCD can put off dealing with these issues if they conceptualize themselves as being incapable of having a healthy heterosexual relationship because, in their mind, they might actually be gay!

Because this form of HOCD emphasizes partnership, sufferers are likely to over-attend to how they relate to people of the same sex.  A man may notice that he feels better understood, has more in common with, and enjoys his time with another man in ways that women do not satisfy him.  The only thing missing is the sex, he thinks, and this triggers a lot of compulsive analysis about who he is “really” wired to love.

Similarly, a woman may become aware that other women share qualities their male partners seem to lack – for example, sensitivity, patience, and emotional availability.  In those who don’t have HOCD, this same-sex identification is looked at as totally normal.  “Of course my same-sex friends understand where I’m coming from.  They know what the other sex is like!  They get my interests and motivations!”  The word “gay” doesn’t enter into the equation.

CBT for Relationship HOCD is going to involve traditional Exposure and Response Prevention (ERP) for sexual orientation fears, but also exposure to behaviors that demonstrate vulnerability to a romantic partner, accepting uncertainty about the “quality” or “completeness” of heterosexual relationships, and other non-avoidance exposures.

Self-Hating HOCD

This form of HOCD generally has more to do with depression than sex or sexual orientation.  Typically (though not exclusively) this seems to occur in people who were severely mistreated, abused, or bullied.  Just as this can occur in Social Anxiety Disorder, the “bully” takes up residence in the person’s mind and any perceived failure in life triggers an internal statement of “You’re gay.”  It’s meant as an insult, more than a suggestion that one should set about finding themselves sexually.

The constant inner-abuse seen in this type of HOCD often leads to a deeper depression, which further distorts the intrusive thoughts, which in turn leads to even more depression.  In some cases this may lead to a pseudo-gay fantasy state in which the sufferer imagines themselves living out what they see as the greatest disappointment to their parents.  The line of thinking is that they are so unlovable as to be invisible to their desired orientation.  In treating those with this type of HOCD, there may be more emphasis on cognitive restructuring and learning to identify “bully” thoughts as distorted glitches in the mind which are essentially irrelevant to sexuality.  Because ERP requires significant motivation and commitment, it may also be clinically appropriate to focus on the depression first before engaging in exposures.

Experimental History HOCD

Despite the fact that same-sex exploration is common in children who are learning about the human body (i.e. playing “doctor”) and discovering how different things look and feel, people with OCD who obsess about their sexual orientation may use benign childhood experiences as “proof” of latent homosexuality.  So despite a post-pubescent life of heterosexual behavior, the presence of unwanted homosexual thoughts triggers frightening doubts.  The sufferer is likely to compulsively review childhood memories and the unknowable memories of thoughts and feelings that might have been had during any same-sex exploration.  “What exactly did I do and why?”

It is also common for teenagers throughout the course of puberty to experience confusion related to gender, orientation, and other sexual issues.  As the sexual brain develops, so too the does the sexual mind.  For people with OCD during their teens, this can be very troubling.  For those whose HOCD develops later, they may look back on this period in which their sexuality was developing and compulsively analyze anything that could be construed as inconsistent with their current sexual preference.

Another variation on this reflecting form of HOCD is compulsive analysis of any same-sex play that might have taken place in college or at some other point in life.  A big part of treatment for those with this type of HOCD is identifying mental checking as a compulsion to be resisted, instead of as a way to figure out one’s sexuality.  Curiosity is not orientation.  Whatever happened, happened.

Real Man / Real Woman HOCD

People who suffer from this form of OCD place a lot of emphasis on masculinity and femininity and the cultural expectations that come with them.  A male sufferer might notice an attractive male, and then chastise himself for being able to notice attractiveness in males.  He assumes this is a sign of femininity, something a “real man” would have no ounce of (again see the all-or-nothing thinking).  This can also present itself through a man’s affinity for the arts or other things he may have been culturally primed to see as non-masculine.

Cognitive Behavioral Therapy (CBT) for this form of HOCD may involve more exposure to material that the sufferer sees as “dainty” or weak, such as watching program with a flamboyant homosexual character or attending a ballet.  This is sometimes more triggering than exposure to gay pornography.

Similarly, a heterosexual woman may notice another woman is beautiful and then distort this through the belief that “real women” only ever think about men.  It also may involve avoidance of assertive behavior or any other cultural attribute traditionally associated with masculinity.  Exposure for this sufferer may involve images and films involving “butch” lesbians or feminist literature.

Groinal Response HOCD

The functioning paradigm here is, “I must experience sexual arousal or groinal sensations only in very specific pre-approved circumstances.”  These circumstances typically mean in the presence of an attractive, age-appropriate member of the opposite sex.  But there are a few important considerations to note here:

• all sexual thoughts (wanted or unwanted) may cause sexual arousal;
• attending to one’s groin actually causes sensations to occur there;
• there are sensations going on in your groin all the time, but unless you go out of your way to pay attention to them, you just don’t notice them;
• groinal sensations often occur for no reason.

Men don’t get headaches just because they thought of something painful and they don’t get erections just because they are feeling sexual.  In short, who knows what’s going on down there?  Yet the HOCD sufferer is going to compulsively check and analyze sensations for evidence of homosexuality.  Part of the confusion the OCD capitalizes on is the fact that groinal stimulation is generally considered a positive sensation.  Fellatio or cunnilingus is going to feel good no matter what gender is delivering it, but the HOCD mind insists it only be delivered by a person to whom we are attracted in order to accept it.  HOCD manipulates the mind into thinking that any positive groinal sensation at the “wrong” time must mean a general sexual preference to whatever is in the environment at that moment.

Cognitive Behavioral Therapy (CBT) for the treatment of this type of HOCD is going to involve identifying and challenging distorted beliefs about groinal responses and exposure to arousing material that falls outside of their traditional preferences.

Spectrum HOCD

Not everyone agrees, but many believe as Alfred Kinsey did, that sexuality exists on a scale with straight on one side, gay on the other, and people mostly somewhere in the middle.  While it will no doubt be triggering for some readers to consider, many people who identify as heterosexual sometimes have homosexual thoughts, feelings, sensations and fantasies.  Those without obsessive-compulsive tendencies allow themselves to enjoy this aspect of their reality.  These are people who prefer sexual activity with the opposite sex, but also find same-sex fantasies (and even behaviors) to be somewhat intriguing and arousing.  They are not bisexuals, who would likely say they are quite capable of sexual and romantic fulfillment with either sex, but are instead heterosexuals who simply are not dangling off either edge of the Kinsey scale.

For those people who experience themselves as somewhere within this spectrum of sexuality, but also have HOCD, this can be very upsetting.  They will want to know for sure if they are bisexual or not, how far in one direction or another they “belong”, and what the “right” term is to describe themselves.  “Am I 10% gay?  20%?  If I don’t know for sure, then I will always feel that I am harboring a secret.”  Without an appropriate label, they live in constant fear of an identity crisis.

Treatment for this type of HOCD relies heavily on Mindfulness Based CBT and resisting compulsive mental analysis.  The exposure is not aimed at homosexuality, but at uncertainty.  This can sometimes be done in the form of an imaginal exposure script in which the sufferer describes the negative consequences of never knowing what to label themselves.

(Really) Need-To-Know HOCD

These are people who identify as heterosexual but have been struggling with untreated (or mistreated) HOCD to such an extent that they have gone from mental checking, to physical checking, to actual experimental checking.  This is somewhat rare and I would imagine some people might read this and say, “OK, let’s just call it gay then,” but that’s not what is happening here.  People who suffer from OCD, regardless of the manifestation, are struggling against an intolerance for uncertainty.  People without OCD largely tolerate uncertainty by not paying much attention to it.

For any reader who does not have OCD, try thinking really hard about the fact that you are not 100% certain what will happen when you die.  Now imagine that all of the people you love will consider you hugely irresponsible for not attaining certainty on the issue.  This is how an OCD sufferer often feels.  Not only do they poorly estimate the risk posed by unwanted thoughts and feelings, but they have an exaggerated sense of responsibility for avoiding these risks.

Ultimately, for some HOCD sufferers, being gay may sound like a relief from not knowing for sure that they are straight.  So they begin to build a case for gayness.  This may involve seeking treatment from LGBT specialists, trying to train themselves to enjoy gay pornography and sometimes engaging in sexual experimentation.  The goal is not necessarily to like gay sex, but to determine once and for all – “am I gay or straight?”

Typically this backfires in one of two ways.  Either the person finds the experience somewhat satisfactory but not preferential to straight sex, or they find the experience abhorrent and resent themselves for having done it.  In either case, they are left with the same uncertainty they find intolerable, plus more ammunition for the OCD.  Just as in the other forms of HOCD, the objective has to be tolerance for not-knowing rather than proof.

These are the various subtypes and angles on HOCD that I have treated thus far, but there are certainly others.  In the next installment of this series, we will examine some additional nuances to HOCD and common impediments to effective treatment.

Sexual Orientation OCD - Part 2: CBT for HOCD

Jon Hershfield of the OCD Center of Los Angeles discusses treatment of Sexual Orientation OCD, also known as HOCD or Gay OCD, using Cognitive Behavioral Therapy (CBT) and Mindfulness.  Part two of an ongoing series.

Treatment of Sexual Orientation OCD

Sexual Orientation OCD can be successfully treated with Cognitive Behavioral Therapy and Mindfulness.

As noted in our previous post, Sexual Orientation OCD is a condition in which an individual, straight or gay, obsessively doubts their sexual orientation.  Research has consistently found that the most effective treatment for this and all types of Obsessive Compulsive Disorder (OCD) is Cognitive Behavioral Therapy (CBT), with a focus on Exposure and Response Prevention (ERP).

Over the past ten years, many OCD specialists have also begun to integrate concepts from Mindfulness-Based Cognitive Behavioral Therapy (MBCBT) into their treatment of OCD.  In MBCBT, the goal is to change one’s perspective toward one’s thoughts, as well as the behavioral responses these thoughts lead to.  Using mindfulness, it is possible to circumvent much of the OCD process and ultimately reverse it into remission.

Mindfulness is particularly helpful when treating the more obsessional variants of OCD, including Sexual Orientation OCD.  When combining MBCBT with the traditional tools of Cognitive Behavioral Therapy, the following treatment techniques are used to address the unwanted thoughts and behaviors seen in Sexual Orientation OCD.

Mindfulness – Thoughts are just thoughts.  You have them because you have a brain.  The rest is just details.

Practicing mindfulness means actively observing your own tendency to over-attend, over-value, and over-respond to thoughts.  In Sexual Orientation OCD, the sufferer is over-attending to ego-dystonic thoughts related to sexual identity.  For most people, if they have a thought about a meteor hitting them today, they quickly shrug it off with a “whatever happens, happens” approach.  Anything is possible, and being wrong would mean certain death, but it hasn’t happened so far and life is too short not to go outside just because of the highly unlikely possibility of being struck by a meteor.  But if an individual with Sexual Orientation OCD has a thought of secretly or suddenly being gay, they feel an overwhelming need to investigate, neutralize, and suppress that thought.

When you over-attend to any thought, you automatically give it increased value.  It is no longer a thought that just popped up for no apparent reason; now it is an important thought you carefully monitored until it presented itself!  And now that it has been over-valued, you desperately want to respond to it.  Of course, any response in this situation will be an over-response, because the thought has no important value in the first place.  These unnecessary responses are essentially compulsive efforts to neutralize or eliminate a thought that was meaningless and not worth more than a moment’s attention.  Compulsive behavioral responses in Sexual Orientation OCD typically involve the following:

• Avoidance of sexual orientation-related triggers (i.e. gay people, gay films and TV shows, gay neighborhoods);
• Physical rituals designed to “prove” ones sexuality (i.e. checking ones genitals for signs of arousal, increased sexual activity in an effort to prove to one’s self that they are straight, compulsive masturbation to straight pornography);
• Mental rituals aimed at forcing unwanted gay thoughts away (over-analysis of gay thoughts, trying to force straight thoughts into consciousness, mentally reviewing past sexual encounters, etc.).

Cognitive Restructuring – Thoughts about thoughts that don’t help.

Everyone has distorted thinking at times.  And people with Sexual Orientation OCD have distorted thinking about their sexuality.  In Cognitive Restructuring, the objective is to learn to identify distorted thinking, and challenge it with rational, objective, evidence-base thinking.  Identifying distorted thinking means learning the language of OCD and knowing when to call yourself out on maladaptive cognitions.

This can be a slippery slope for the obsessive-compulsive who may feel inclined to use restructuring as a mental ritual.  The trick is to be straight (no pun intended) and to the point.  A triggering situation occurs, you think something about it, and then you have one shot to modify that thought for something more rational.  It is important to remember that this is not a debate between you and the OCD.  The OCD got its chance to call you gay.  Then you get your chance to challenge the idea.  Anything else is mental ritual.

It is important to understand that mental rituals are compulsions, and that they make your OCD worse.  By spending mental energy trying to prove your sexual orientation, you are only contributing to the brain’s misconception that the thought was important, and that there is some reason to doubt your orientation.  When simple cognitive restructuring is not doing the trick, it is always a wiser choice to return to mindfulness and to accept that many thoughts happen without those thoughts having to mean something important.  Don’t get conned into an OCD contest you can never win.

Cognitive distortions in Sexual Orientation OCD typically include the following:

• All-or-nothing thinking – “If I have even a single gay thought, that must certainly mean that I am gay.”
• Catastrophizing – “Being gay would destroy my life.”
• Discounting and minimizing the positive – “Despite having had these thoughts many times, I’ve always been straight, but this time is different.”
• Comparison – “I’ll never be happy like that straight couple over there.”

This is, of course, just a sample of the trickery OCD uses with this issue.  Identifying your OCD’s thought traps and mastering the language of CBT for OCD is what you should expect in the early part of treatment.

Exposure and Response Prevention – The greatest change, in fact the only change, occurs when we change our behavior.

We would all like to feel better before actually taking the steps needed to get better.  But that’s putting the cart before the horse, and is not realistic.  We must first change behavior, and then learn patience while we wait for thoughts and feelings to catch up.  Learning to ride a bike requires exposure to the fear of falling, paired with prevention of the instinctual response of jumping off the bike to prevent falling.  Nobody with a fear of falling off a bike gets over that fear before getting on the bike.

Some OCD sufferers may be concerned that this means engaging in homosexual behavior to overcome their fear of being gay.  This is missing the mark.  The fear is not about having gay sex, but is instead about being stuck with thoughts that you think have the power to ruin your enjoyment of heterosexual sex and destroy your life.  So “testing” yourself by engaging in sexual contact outside of your historically-true sexual orientation as a means to overcome this fear will generally backfire.

Instead, a more effective approach would be exposure to thoughts of homosexuality and the fear that you are not who you thought you were.  Your OCD brain tells you that you must not think certain thoughts because they are dangerous to you.  But your rational brain has the power to stand up to this bully and burn out the OCD circuits by intentionally exposing yourself to unwanted thoughts about your sexual orientation.

This often takes a combination of visual, situational, and imaginal exposure.

• Visual exposure would typically involve looking at images or videos of things that trigger the unwanted thoughts while resisting mental rituals to explain or neutralize the thoughts.  To be done effectively, this form of exposure would start with something mildly triggering, such as a picture of an attractive same-sex celebrity.  Once this no longer elicits a fear response, the exposure would be heightened to repeatedly looking at pictures of a more sexual nature, and ultimately multiple viewings of explicit pornographic material.
• Situational exposure would typically involve visiting gay neighborhoods, bars, nightclubs, listening to “gay” music, spending time with gay acquaintances, etc.
• Imaginal exposure would typically involve writing out a short, but explicit story in which you describe yourself living a homosexual lifestyle, and the unwanted consequences that you envision would arise from this.

The objective of these exposures is to intentionally, but gradually, raise the anxiety caused by your unwanted thoughts, and to ultimately demonstrate to your brain that you can tolerate the presence of these thoughts.  Conversely, compulsions teach the opposite – that you cannot tolerate discomfort.  Exposure is the same mechanism employed any time you wish to gain strength.  You lift a weight, something heavier than you normally would lift in your everyday life.  Over time that weight becomes easier to lift.  But the weight stays constant.  What changes is your ability to accept the weight.

On the subject of consequences, it is important to remember that Sexual Orientation OCD causes suffering equal to that of other forms of OCD.  Culturally, the idea of someone worrying about being gay might trigger a sense of amusement in someone not afflicted with this form of OCD.  However, let’s not overlook what the person suffering from Sexual Orientation OCD is really afraid of:

• “My entire history as a lie.”
• “I will be rejected and abandoned by my family and friends.”
• “I will be subject to public ridicule.”
• “I will have to spend the rest of my life having sex that feels alien to who I am.”
• “I will have a lifetime of self-hatred and self-disgust.”
• “I will never truly connect to another person again.”

In short, dying alone in the dark.  Ask the right questions, and every obsessive fear arrives here.  But it’s important to point out that what the OCD sufferer fears is not accurate.  While being part of any cultural minority has unique challenges, I have never heard any genuinely gay clients describe their own homosexuality in the above terms.  Simply put, what the OCD is threatening is not true.

Sexual orientation is so wrapped up in identity that it’s an easy target for OCD.  Obsessive Compulsive Disorder spends its free time researching new and exciting ways to lock you into fear.  There really is no reason to ask why Sexual Orientation OCD happens.  The answer is obvious – because it works.

CBT and MBCBT are aimed at reversing a learned fear cycle.  Your OCD says you must not have gay thoughts.  But gay thoughts exist.  People who say they’ve never had one are lying; not because they are secretly gay, but because it requires a gay thought to even know what the word means.  So if something necessarily exists and you are trying to prevent it from existing, this is not going to work out well.  If instead, you can accept the reality that a variety of sexual thoughts occur as a function of having a brain, then you can train yourself to treat those thoughts with whatever significance that you, not your OCD, deem appropriate.

Sexual Orientation OCD - Part 1: What is HOCD?

Many people mistakenly think of Obsessive Compulsive Disorder (OCD) solely as a condition in which people wash their hands excessively or check door locks repeatedly.  There are actually many sub-types of OCD.  In this ongoing series, Jon Hershfield of the OCD Center of Los Angeles discusses Sexual Orientation OCD, also known as HOCD or Gay OCD.

So, Am I Gay or What?

I sat down to write this blog on Sexual Orientation OCD while my wife and I had started to watch a movie (It’s been suggested I work too much).  It’s either irony or personalization, but the opening scene of the movie involves a man kissing his lover… another man.  This is the second film in two weeks that I’ve rented which involve men and their male lovers, something I was not aware of when I selected the films.

Or was I?

Sexual orientation OCD is sometimes referred to as HOCD (an abbreviation for Homosexual Obsessive Compulsive Disorder) or Gay OCD.  This is an unfortunate abbreviation because it misses the true nature of this manifestation of OCD. 

Having gay thoughts is not the same as being gay.

First, it is not exclusive to heterosexuals.  Over the years, therapists here at OCD Center of Los Angeles have treated many homosexuals (male and female) who are plagued by obsessive fears of being “straight,” and who suffer equally when OCD attacks their sexual identity.  Furthermore, the fears that clients with this condition report have little to do with actually becoming gay (or straight).  At its core, Sexual Orientation OCD is the fear of not knowing for sure, paired with the fear of never being able to have a healthy, loving relationship with a partner to whom one feels genuinely attracted.

Similarly, someone with contamination fears may on the surface appear to be overly concerned with dirt, but this fear is indicative of an overwhelming fear of never feeling clean again.  “If I don’t wash my hands, I will feel this way forever and nothing will be right in the world.” For every cry of “does this mean I’m gay?”  there appears to be a louder cry of “does this mean I can’t be heterosexual anymore?”

In my experience with these clients, it also appears to have little to do with homophobia or bigotry.  On the contrary, these clients are often quite open-minded on issues related to sexual orientation.  In fact, it is their own lack of bigotry that often ends up being a fear trigger.  One notable exception is cultural bigotry in which part of their Sexual Orientation OCD is fueled by the broader societal beliefs of the sufferer’s culture of origin.  For simplicity’s sake, I will refer to “gay” throughout the rest of this article to describe any sexual orientation that is not one’s own.  For those who are homosexual but have obsessive fears of “straightness” please substitute the appropriate word.

One thing that has struck me as bizarrely consistent is that OCD sufferers who obsess about their sexual identity seem notably less “gay” than me.  Allow me to illustrate:

• Picture a man who loves the arts, has no interest in sports, admires electronic music, doesn’t “pull chicks” at the bar and feels little discomfort in the presence of naked men in the gym locker room.  Obviously gay, right?  But then, that describes me, despite the fact that I am straight.
• So what is the opposite of me?  A man who loves watching sweaty guys fight over a ball, admires music fronted by long-haired androgynous men singing about love, and showers at home to avoid naked guys… Well, this sounds pretty gay too.

So this is what happens when your OCD locks in on sexual orientation.  Whoever you are, whatever you do, suddenly seems gay.  Just as the selective abstraction found in Contamination OCD makes it appear that dirt is everywhere, so does this same distortion make gayness appear to be hunting you down.

When this form of the OCD is in full swing, sufferers tend to over-attend to any indication that their “sexual orientation of origin” may be compromised.  Since anxiety, distraction, and a lack of being “in the moment” are likely to make sexual experiences less gratifying, this often becomes a major trigger.  “If I don’t always want to have straight sex, I must be gay!” Interestingly, the idea that they might be asexual altogether doesn’t come up.  It’s the fear of the dark side, not the neutral one.  And the idea that their libido is actually compromised as a result of the anxiety and obsessions that they experience due to their OCD just sounds like an excuse, rather than a rational argument.  You simply cannot win when you play OCD’s game – OCD cheats.

Many people who suffer from Sexual Orientation OCD get stuck on the notion that they may or may not find someone attractive and that this may or may not mean something important about them sexually.  If they see a member of the same sex, they feel it is possible that the “seeing” was really intentional “looking” and that this intentional looking indicates a secret sexual desire.  They will often then attend to and monitor their genitalia to check for arousal in an attempt to prove or disprove the theory.  This often backfires since attention causes sensation.  This, by the way, is true of other body parts as well.  When you consider picking something up with your hands, the brain actually sends a priming impulse to the hand before you’ve even made a decision to move.

It is important to recognize the fundamental error in the line of thinking that pairs acknowledgment of attractiveness with sexual desire.  Attraction is a word we use to describe the feeling of being pulled into something, like a magnet.  We generally conceptualize this feeling of being pulled-in as evidence of our desire to be near someone or something.  This idea is troubling for the OCD sufferer who feels a strong need for certainty about the meaning of attraction, particularly when the false assumption is being made that all attraction is sexual attraction.

I often hear the question, “Am I attracted to this person?” from my clients.  I’m never quite sure how to answer it because it is a loaded question.  The words themselves only ask if the identified object is one they feel compelled to be near.  Furthermore, the reason for the attraction could be any number of things, positive or negative.  But the meaning my clients are hinting at is usually more along the lines of, “Do I desire to have sexual intercourse with this person?” The idea that I personally could even know what another person truly desires indicates an error in information processing.  What is more striking is the fact that their OCD does not allow them to consider the possibility of being attracted to someone, while concurrently not wanting to engage in sexual behavior with that person.

Every person is capable of identifying others as “attractive.”  This means that a person, regardless of gender, meets some set of criteria that is personally and culturally seen as attractive.  For Westerners, this may have something to do with musculature, bone structure, and/or facial symmetry.  But according to researchers, ancient Mayans apparently had a cultural preference for those who were cross-eyed and had flat foreheads.  In other words, “attractive” is not a fixed concept, and has different meaning for different people.

When we look at an attractive landscape in nature, we desire to be near it.  When we see an attractive person, this also compels us to linger.  In some cases it may be envy that draws us in.  Saying, for example, “I wish I had a body like that.”  But in many cases, it’s just giving a thumbs-up to the universe.  “Good one, Universe, you made an attractive person.”  But for the person suffering with Gay OCD, this triggers abject horror.

I often get asked the question, “Do you think I’m gay?”  After the usual therapist-speak of “Does my opinion matter?  Why do you want to know? And what would it mean to you if I thought you were?,” I suggest that my clients study the evidence with me.  The test is not very thorough.  It has one, simple question, with a few optional follow-ups:

“Do you like to have gay sex?”

That’s pretty much all we need to know in order to determine whether or not we should get busy with the work of treating their OCD.

I have seen clients with OCD who also happen to be gay.  They obsess about the same things that other OCD sufferers struggle with, except quite notably that they don’t obsess about their sexual orientation.  The only exceptions to this are gay clients who obsess about the possibility that they might actually be straight.  And I have never had a homosexual client tell me they weren’t sure if they liked homosexual sex.

On the other hand, for straight individuals with Gay OCD, their biggest fear is often that they will seek therapy for unwanted thoughts about their sexual orientation, and that the therapist will tell them that these thoughts indicate that they must actually be gay.  Unfortunately, this often happens when clients end up with ill-informed treatment providers who don’t understand what constitutes Obsessive Compulsive Disorder, and illuminates the importance of finding a therapist who thoroughly understands OCD and its appropriate treatment with Cognitive Behavioral Therapy (CBT).

To put it as simply as possible, gay thoughts are not unwanted by homosexuals.  For homosexuals, gay thoughts are what psychologists call ego-syntonic thoughts.  That’s just a fancy way of saying that their gay thoughts are in keeping with their true values and desires.  Conversely, for heterosexuals, gay thoughts are ego-dystonic, which simply means that the thoughts are in opposition to their true values and beliefs.  Furthermore, gay people like to have gay sex, while straight people with Sexual Orientation OCD are terrified of having gay sex.

OCD: Real Stories - Real People

OCD Chicago and Erasing the Distance partner for a one-night-only event on October 11, 2011 during National OCD Awareness Week entitled OCD: REAL STORIES – REAL PEOPLE.

OCD Chicago and Erasing the Distance (ETD) are thrilled to partner for OCD: REAL STORIES – REAL PEOPLE, a one-night-only Chicago event presented during National OCD Awareness Week on Tuesday, Oct. 11 from 7:00pm-10:00pm.

Enjoy a warm evening of friendship, connection and awareness. OCD: REAL STORIES – REAL PEOPLE begins with three true stories that explore different aspects of Obsessive Compulsive Disorder (OCD) and are performed by ETD artistic company members. A break follows, during which refreshments will be served. The evening then resumes with three speakers who share their own experiences living with OCD.

ETD Executive Artistic Director Brighid O’Shaughnessy explains, “After having been long-time fans of one another, it is truly exciting to be partnering with OCD Chicago on this event. This is the first time Erasing the Distance is doing an entire night of stories dedicated to helping us all better understand the OCD experience.  Each of the stories presented are truly unique and shed light on how each individual finds solace, support, and recovery – some through humor, others through therapy and all through acceptance.”

Ellen Sawyer, Executive Director of OCD Chicago, adds, “We are proud to present real life stories of individuals who have triumphed over OCD, and are especially glad to share them with people who understand the specific challenge of having OCD. Speaking out in this way is a wonderful opportunity to reduce the stigma that surrounds OCD and enlighten people who suffer from the disorder.”

OCD: REAL STORIES – REAL PEOPLE
Tuesday, Oct. 11
7:00pm -10:00pm

Ann Sather Restaurant
909 W. Belmont Ave., Chicago
(Free parking is available in the lot west of Ann Sather.)

Featuring:
David Hornreich, Maura Kidwell and Craig C. Thompson (actors)
Brian, Anne and Dan (speakers)

$10 per person, $5 for students.
Click to register.   
Call 773-880-1635 or email .(JavaScript must be enabled to view this email address) with any questions

ACTORS:
David Hornreich has been a part of the Chicago theater community for nearly five years. A native of Seattle, he graduated from Western Washington University in 2004 with a B.A. in acting and directing. In addition to “Grown Up” theater, David has been fortunate enough to work both teaching and acting in Children’s Theater and educational programs with a long list of companies - including Northlight Theater Academy, Greatworks productions, and more.

Maura Kidwell is a graduate of Beloit College and an ensemble member of Redtwist Theatre (formerly Actors Workshop), where she appeared in their Jeff-Nominated production of Equus (Jill) and Les Liaisons Dangereuses (Mme. de Tourvel). Maura is also an artistic associate of Ouroboros Theatre Company, where she performed in the world premiere of Cyrano: Translated (Doris Cooper). Other credits include Ten Cent Night with Chicago Dramatists Theatre (Dee), Amadeus with St. Louis Shakespeare (Constanze), and Mister Paradise with Dream Engine/Indefinite Theatre (Girl). Maura can also be seen and heard in many commercials, industrial films and feature films.

Originally from Kansas City, MO, Craig C. Thompson graduated from Boston University in 1998 and has been living and performing in Chicago ever since. Craig is a former member of Infamous Commonwealth Theatre and has been seen in their previous productions of The Crucible, Lewis and Clark Reach the Euphrates, My Thing of Love, The Kentucky Cycle (Jeff Citation for Outstanding Ensemble and Outstanding Production), Savage in Limbo, and Big Dreams. Craig has also acted for Backstage Theatre in Waiting for Lefty (Jeff Nomination for Outstanding Ensemble), Foreground Theatre, Lifeline Theatre, Emerald City Theatre and Real Rain Productions.

SPEAKERS:
Dan was diagnosed with OCD at age eight. He received treatment in the form of exposure and response prevention therapy. He has volunteered for OCD Chicago - he played the saxophone at a fundraiser and helped edit one of the guides. Dan recorded “The Big Whack-A-Mole Game In My Head” for Chicago Public Radio, about his experience with OCD. The program won the National Mental Health Association’s 2005 Mental Health Media Award for “Best First-Person Account.” Dan is currently a college student, studying computer science. He enjoys fencing, cooking, and reading mystery novels.
Brian has suffered with OCD since he was in college in 1979. Therapies that were conventional at the time proved remarkably unsuccessful until he was correctly diagnosed with OCD in early 1993. He underwent intensive exposure and response prevention therapy that summer, learning to manage his illness using a combination of cognitive behavioral techniques and support group therapies. In 1995, Brian started his own support group on the North Shore, and was a charter board member of OCD Chicago. He continues to serve in an advisory capacity to sufferers. Brian is President of R.F. Mau Co., a Lincolnwood-based manufacturing firm. He lives in Glenview with his wife and two daughters. 
Anne was first diagnosed with OCD more than 20 years ago and went through an intensive treatment program at the Chicago Medical School. She served three terms as a board member of OCD Chicago and as consulting editor on Obsessive-Compulsive Disorder Demystified: An Essential Guide for Understanding and Living with OCD, by Cheryl Carmin (Da Capo Press). She speaks frequently on the topic of OCD to professional groups and with the media. Anne is a graduate of Northwestern University’s Medill School of Journalism; she started her own business as a writer and communication consultant in 1995.

OCD CHICAGO:
OCD Chicago, the leading provider of consumer resources to help sufferers cope with and conquer Obsessive Compulsive Disorder (OCD), works to increase public and professional awareness of OCD, educate and support people with OCD and their families, and to encourage research into new treatments and a cure. A resource for individuals, families, mental health professionals, educators, clergy and the media across the country, we are dedicated to improving the lives of people who suffer with OCD. Founded in 1994, OCD Chicago is a registered 501(c)(3) nonprofit organization.

ERASING THE DISTANCE:
Erasing the Distance is a non-profit arts organization that uses the power of performance to disarm stigma, spark dialogue, educate, and promote healing surrounding issues of mental health.

ETD collects true stories from people whose lives have been impacted by mental health issues. We sculpt the stories into theatrical pieces for the stage, which our ensemble of actors then perform for schools, corporations, community organizations, and the general public. Founded in 2005, ETD’s shows have reached over 26,000 people throughout Illinois and beyond.

Recent ETD productions include Finding Peace in This House, a custom collaboration with The Chicago School of Psychology that is being remounted in January 2012; Stronger Than Silence: surviving our secrets, a show about sexual assault presented in collaboration with C4 Quetzal Center; and Falling Petals, a show about mental illness from Asian American perspectives that is being performed again at Governors State University in February 2012. For more information, please visit http://www.ErasingTheDistance.org.

Connections

Welcome to Connections, OCD Chicago’s new blog! My name is Janet Singer and I will be blogging about anything and everything to do with OCD. My posts will include current topics of interest to OCD sufferers and their families, and I also hope to connect with readers by sharing my own thoughts and experiences. So whether you are an OCD sufferer or you care about someone with OCD, this blog is for you.

Three and a half years ago I flew fifteen hundred miles to be with my son Dan, who was in college. I knew he had not been well, but the condition I found him in shocked me. Dan had not eaten in more than a week and was spending hours at a time sitting hunched over in one particular chair, doing absolutely nothing. My son was in the throes of severe OCD.

What followed was a year-long roller coaster ride for our family, as we floundered and then fought our way through a disorienting maze of treatments and programs, desperately trying to find the best help possible for Dan. We went from seven therapists to ten medications to a nine week stay at a world renowned residential program. Our frustrations turned to horror as it became evident that many of the drugs and therapies used to help Dan were actually hurting him. There were times I wondered if my son would ever be able to function again in society, or even worse, survive. 

I will never forget that feeling of being completely lost and alone, not knowing who to listen to or where to turn for help.  This memory is one of the reasons why I became an advocate for OCD awareness, and am now so excited to be a part of Connections. I want to share what helped and what hurt in my son’s battle against severe OCD with the hope of benefiting others.

Another reason why I am so enthusiastic about Connections is that, while there is no doubt that OCD can be a devastating disorder, there is also no doubt that OCD is treatable. We can help each other through this journey, with the knowledge that there is indeed a light at the end of the tunnel.

As for my son Dan, he has worked hard to reclaim his life. He is now a senior in college and living life to the fullest. He still has OCD, but OCD does not have him. There is a big difference. And most importantly, he is living proof that even those with the most severe OCD can not only recover, but triumph.

Heroic US filmmaker and OCD Sufferer Matthew Van Dyke free after six months in Libyan ‘hell’

THE last thing American filmmaker Matthew Van Dyke remembers was filming people in the Libyan city of Brega.
The atmosphere was jovial and relaxed. Someone asked if he wanted a coffee and he said yes. Then everything went blank.The next thing he knew he was in one of Muammar Gaddafi’s notorious prisons, hearing someone being tortured in a nearby cell. Van Dyke spent six months in solitary confinement hell until the rebels’ push into Tripoli caused the prison guards to flee, enabling him to escape. Even before the imprisonment, Van Dyke suffered from obsessive compulsive disorder, which he says was made worse by imprisonment.

Despite his ordeal, Van Dyke plans to stay in the country until “Libya is free”.
“I made that commitment to the rebels and I (will) keep it.’

Read the Article

Ruling may broaden insurance coverage for psychiatric illness

A California woman’s treatment for anorexia at a residential facility was medically necessary and must be covered by her healthcare plan. A 9th Circuit federal appeals court has so ruled in a case that could lead to more extensive benefits for those being treated for mental illnesses.

Under the California mental health parity law, insurance plans “must provide coverage of all ‘medically necessary treatment’ for nine enumerated ‘severe mental illnesses,’ ” the court said, listing eating disorders as well as obsessive-compulsive disorder, schizophrenia, schizoaffective disorder, bipolar disorder, major depression, panic disorder, autism, and serious emotional disturbances in children and adolescents.
Read the Article

Dr. Gina Glenn discusses Obsessive Compulsive Disorder

Prevention Program for Postpartum OCD

A new report describes a program that helps to reduce anxiety and obsessive compulsive disorder that may accompany childbirth. Postpartum obsessive compulsive symptoms, can be devastating to mothers and their families.

Many women experiencing these difficulties are not getting the services they need because they don’t even know that what they are experiencing has a label and can be helped.
In response to this need, researchers from the University of Miami developed a cognitive behavioral program to prevent of postpartum obsessive compulsive symptoms.
Their findings are reported online by the Journal of Psychiatric Research.

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Should OCD Be a Family Affair?

When my son, Dan, was first diagnosed with OCD, I wanted details. What was he thinking, how was he feeling, is today better or worse than yesterday? The problem was, Dan would not, or could not, share the details of his disorder with me. He was even reluctant to see a therapist because he thought everything they spoke about would be relayed to his parents. Once I explained “doctor-patient confidentiality” to him, he couldn’t get to the therapist fast enough.

I now realize that Dan was right. I was better off not knowing. Dan’s OCD dealt with mostly mental compulsions and therefore was not obvious at the time. I had no idea how much he was suffering. I think if I had known, I would have accommodated him incessantly, and my heightened anxiety levels wouldn’t have done him any good either.

People with OCD seem to benefit a great deal from interaction with others who can truly understand what they are going through: fellow sufferers. And maybe what those with OCD really need most from their families is what all of us need and deserve: acceptance, understanding, and love.

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The “Mental” in “Mental Illness” is Really a Misnomer

The illnesses we consider “mental” all have a physical aspect to them, namely the brain. Whenever we use the phrase “mental illness,” we reinforce the false dichotomy of mental vs. physical, mind vs. body, which leads many people to question whether brain dysfunctions such as obsessive compulsive disorder and depression are truly illnesses, even when they have no trouble agreeing that certain so-called mental illnesses, such as autism, epilepsy, and Alzheimer’s are also physical.

There will never be true parity in the treatment of “mental illnesses” until this misnomer is corrected. The terms “brain disorders,” “brain dysfunctions” or “neurobiological disorders” are preferable and more accurate.
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The ABC’s of OCD, Disability, and Treatment

So you have been diagnosed with a severe anxiety disorder and require more than one to two hours of therapy a week…What do you do?  What if you have no financial resources and need to apply for public benefits?  As a clinical social worker and doctor of psychology, many of my clients come to me with questions about insurance, disability benefits, income and proper treatment.  I don’t always know all of the answers but I can most always put someone in the right direction.  I would like to take some time to address “going out” on disability whether it be temporary or permanent.  I call this process “Navigating the System.” 

When “Navigating the System” of work or public benefits, disability, and insurance, one must be prepared to have patience and perseverance, as managing one’s care takes time.  NOTHING HAPPENS QUICKLY!

It is a difficult decision to leave work due to disabling anxiety.  If someone decides to take a leave, this typically indicates that they are going to receive a level of treatment that tends to the severity of the diagnosis, such as a residential or partial hospitalization program.  The guiding reasons for taking a leave are severity of illness, financial concerns, and if one’s insurance will cover the cost of a specialized treatment program.  In an ideal world, anyone whose diagnosis precludes them from functioning on a day-to-day basis would receive appropriate treatment, but this is not always the case.

Short-Term Leave

Many people who take a short term leave for OCD and other anxiety disorders are planning to go into some kind of intensive treatment, such as partial or intensive out-patient program or a residential program. If you are considering taking a short-term leave of absence from work and would like to be paid for the leave, you must talk with your human resources person to determine what kind of short-term disability you have (or not).  If you have disability insurance, you will then need your psychiatrist to put you on leave so you can attend a treatment program.  Many people are in intensive treatment and/or residential programs for about 6 weeks or longer.  Of course, this depends on whether or not insurance will cover that length of treatment.  The goal is to get the necessary treatment and return to work and have the least amount of financial burden possible.

In conjunction with a short-term leave, the Family and Medical Leave Act (FMLA) may be able to provide protection for your job…Visit http://www.employer-employee.com/fmla.html#bytopic for more information.  Not everyone is covered by FMLA!  If you are covered by FMLA, most people will be able to take 12 weeks off work but this does not mean the leave comes with a financial benefit. Of importance is the opportunity to have your job to return to once treatment is completed. It is very important to work with the human resources department at your place of employment.

If one is not able to return to work and is considered disabled on a long-term basis, it is then important to look to long-term disability and Social Security Disability.  If you are employed,  discuss your benefits with your human resources department.  If you are unemployed, you will need to consider Social Security to determine the appropriate course of action (1-800-772-1213).

Long-Term Disability

Social Security Administration (SSA)
The SSA oversees two different long-term disability programs:

• Social Security Disability Insurance (SSDI, Title 2), and
• Supplemental Security Income (SSI, Title 16).

What Social Security Means by Disability
The definition of disability under Social Security is different than other programs. Social Security pays only for total disability. No benefits are payable for partial disability or for short-term disability.

“Disability” under Social Security is based on your inability to work. Social Security considers you disabled under Social Security rules if:

• You cannot do work that you did before;
• You cannot adjust to other work because of your medical condition(s); and
• Your disability has lasted or is expected to last for at least one year or to result in death. This is a strict definition of disability. Social Security program rules assume that working families have access to other resources to provide support during periods of short-term disabilities, including workers compensation, insurance, savings and investments (http://www.socialsecurity.gov).

Requirements for Social Security Disability InsuranceThe qualifications for Social Security Disability Insurance (SSDI) are more rigorous than those for SSI. To qualify for SSDI benefits, you must meet all of the following criteria: (1) Worked in a job covered by Social Security. (2) Worked in that job for 5 of the past 10 years. (3) Have a medical condition that prevents you from working and renders you disabled (according to SSA’s definition of “disabled”).

The most common factor that disqualifies SSDI applicants is not having worked five of the last ten years. However, even if you do not meet the Social Security’s requirements for SSDI benefits, you may still be eligible to receive Supplemental Security Income (SSI) (http://www.ssa.gov/dibplan/dqualify.htm).

The above information seems so simple, yet being approved of disability is very difficult and the process is lengthy and difficult.  Many people I know have worked with attorneys to have a higher success rate of being approved for Social Security Disability.  With that being said, it is up to the individual as to whether or not an attorney should be involved.

Social Security Disability Insurance (SSDI) - Medicare
SSDI is federal long-term disability insurance. It is an entitlement program; you must have paid into Social Security through F.I.C.A. payroll taxes in order to collect your Social Security Disability. Awards vary from $1 to about $2,300 (as of 2010) per month, and are based on work history and the amount of F.I.C.A. paid. To qualify, you must meet Social Security’s definition of “disabled,” meaning your disability will keep you from doing any kind of work at all for up to one year. There is a five-month waiting period before payment begins. You may backdate your claim as far back as your medical records substantiate disability. You may collect SSDI and State Disability together. After two years on SSDI payments you will receive Medicare automatically (Medicare coverage is considered good health insurance. (http://www.socialsecurity.gov).

Supplemental Security Income (SSI) - Medicaid
SSI is the Social Security program that guarantees a standard of income to people who are age 65 or older, blind or disabled with limited income and resources. Medicaid is a state-run medical program that is federally funded and pays for medical assistance for certain low-income people.  Some of the people covered by Medicaid are certain children, the aged, the blind, the disabled and others with limited financial means.  Usually, a person receiving SSI is eligible for Medicaid.  In 32 states and the District of Columbia, Social Security makes Medicaid eligibility decisions for people receiving SSI or federally administered state supplementary payments.

In seven other states and the Commonwealth of the Northern Mariana Islands, people receiving SSI have to file a separate application with their Medicaid agency.  In those states, the agency will use the SSI rules to decide Medicaid eligibility for the aged, blind and disabled receiving federally administered cash assistance.  The seven states are: Alaska, Idaho, Kansas, Nebraska, Nevada, Oregon, and Utah.

The remaining eleven states require a separate application with the Medicaid agency and use their own Medicaid eligibility rules.  Each of these states uses at least one Medicaid eligibility requirement more restrictive than the SSI program uses.  The eleven states are: Connecticut, Hawaii, Illinois, Indiana, Minnesota, Missouri, New Hampshire, North Dakota, Ohio and Virginia (http://www.socialsecurity.gov).

As you may have figured out by now having a disabling anxiety disorder and dealing with the financial and insurance aspects is by no means an easy task.  Even with the best resources, it is not always easy to find care that is close in proximity or a therapist who will take insurance.  The trend is that many OCD/Anxiety therapists no longer will accept insurance. 

The sad reality is that there is a cost to care and not everyone can afford the care.  Some might think it better to have a system like in Canada, but it is difficult to find appropriate care in Canada and many Canadians who can afford care comes to the US for treatment of OCD and other anxiety disorders.

The key to both “Navigating the System” and success in treating OCD/Anxiety is perseverance.  Despite their complexity, Leave and Disability programs exist to help those in need, so if you and your therapist feel these programs are a viable option for allowing the delivery of treatment you need, make it your mission to understand the programs so, when it comes to choosing or qualifying for any of them, you’re well-informed.

Helping or Enabling? A Fine Line When Dealing with OCD

Family members face a confusing predicament when it comes to their child’s OCD, and often find themselves enabling the OCD symptoms. Sometimes they don’t realize that enabling makes the symptoms come back stronger the next time. The author of this article describes her own experience in deciding on helping or enabling.

“Parenting for me has often involved following my instincts and using good common sense. Whether it was telling my 15-year-old daughter that she could not go to the co-ed sleepover, or encouraging my shy child to invite a friend over, I seemed to have a pretty good handle on things.”

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Children Who Suffer from Obsessive-Compulsive Disorder Three Times More Likely to be Bullied

“One of the things we have noticed working with many kids with OCD is that peer relations are extremely impaired,” said Eric Storch, Ph.D, a U of Florida assistant professor of psychiatry and pediatrics. “Kids target kids who are different. Kids with OCD sometimes exhibit behaviors that peers simply don’t understand.” Parents should be alert to this and make it part of their discussions with school personnel about OCD.

Bullies relay messages to already-sensitive obsessive-compulsive children that they are inherently flawed. Repetitive unwanted thoughts, a core feature of OCD, magnify these false beliefs. Further, the more that an individual has a thought, the more powerful the thought becomes. For OCD victims, this creates a seemingly endless cycle of worry and anxiety.

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Don’t Grow Up with OCD

Traci Foust, age 39, has lived with OCD for 30 years. She chronicles her struggle in her book ‘Nowhere Near Normal.’ In a recent interview she said “I wonder what life would be like if I was diagnosed earlier or if I got medication earlier.” Early diagnosis and treatment can help prevent OCD from becoming a chronic condition in adulthood.

Traci advises parents: The most important thing I can tell any parent that suspects anxiety issues is that for everything that you hear from your child there is something horrific that your child isn’t telling you because they’re embarrassed by it. Parents have to say: I feel there is more you want to me tell me, and when you’re ready, know that nothing is going to make me think you’re a bad person.

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The Pregnancy & Postpartum Anxiety Workbook

The Secret Lives of Hoarders

The Case for Antidepressants

Are antidepressants nothing more than a placebo? To the contrary, a careful analysis of studies shows that they are extremely useful.

Peter D. Kramer clinical professor of psychiatry at Brown University and author of “Listening to Prozac” writes “In Defense of Antidepressants.”

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Eating disorders may become habitual patterns of coping throughout life

A study published in July’s issue of the Journal of the American Dietetic Association found that unhealthy eating patterns that start in childhood or teen years can spill over. They may even intensify with age. Data from the 10-year study that followed 2,287 teens through early adulthood showed a sharp increase with age — 8.4 percent to 20.4 percent — in the number of young women resorting to extreme measures to control their weight.

The results are not a complete surprise to those working in the field of eating disorders. Individuals afflicted with an eating disorder tend to relapse during times of stress. Food restriction becomes a habit of coping - a soothing ritual that has become embedded in the way they manage anxiety.

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Students with OCD: A Handbook for School Personnel

Obsessive Compulsive Personality Disorder

‘Underneath Every Hoarder Is a Normal Person Waiting to Be Dug Out’

It wasn’t until the 1990s that studies on compulsive hoarding were conducted. The first unexpected finding for the psychologists Randy Frost and Gail Steketee was that the problem was much more prevalent than was thought.

Frost and Steketee also found that hoarders were not driven by anxiety to acquire or collect items but by positive emotions. Anxiety enters the picture only when they try to throw anything away. Hoarders see things in things that other people don’t. They find value, comfort, solace, a buffer against loss, accumulated history in their stuff.

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What is OCD?

OCD Kids: Michelle

WHEN EPIDEMICS COLLIDE: OCD AND AIDS

Our planet is currently in the throes of a major health crisis. I am referring to AIDS. The average person’s life has been influenced in a number of ways by this modem-day plague. Unlike previous decades, individuals no longer feel as free to have unprotected or casual sex. Medical and dental facilities have become far more careful about disease control. Blood supplies must be constantly screened. Police now wear gloves when searching certain suspects, as do food workers when serving meals.

There is also a place where this epidemic unfortunately crosses paths with another, less well-known epidemic: Obsessive-Compulsive Disorder. There are those with OCD who have obsessive thoughts about contracting AIDS, and the results can be extremely punishing. These fears are actually part of a larger group of obsessions about contamination.  One of the main features of OCD is that sufferers have difficulty in determining just how risky certain things are. Sufferers often confuse possibility with probability: if something can happen, it will happen, no matter how unlikely. Unfortunately, for those with fears of AIDS, there happens to be a lot of media hysteria concerning the disease and how it can be contracted. As a result, it is not unusual for even the average individual to have unreasonable fears of people with AIDS. Even so, the average person’s worries still do not tend to be as exaggerated or illogical as those of someone with OCD.

OCD sufferers’ notions of how the disease can be contracted don’t usually stop at the three most common ways: sharing infected needles, having unprotected sex, and receiving contaminated blood transfusions (which all happen to be direct blood-to-blood contacts). For the obsessively doubtful, almost anything that anyone else has touched can become a potential source of the disease.

The following situations are quite typical of this type of OCD, and are seen as high risks for contracting AIDS:

• Touching any red specks or spots anywhere, because they could be blood from an infected person
• Being near anyone who looks unwell or is very thin, or is disheveled or homeless, or who could be an addict
• Having blood drawn or having injections, even with new, packaged needles
• Going to hospitals, doctors’ offices, dentists, medical labs, or any place where ill persons gather or medical procedures are done
• Being near people who are, or who in the sufferer’s mind appear to possibly be, homosexual
• Being near health-care workers
• Touching doorknobs, light switches, or handrails in public places
• Getting cuts or scrapes where the virus could enter
• Fearing that they may be stabbed or struck by someone carrying an infected needle, or having thoughts that they may have stepped on a discarded syringe lying on the ground (they may even have false body sensations that this has happened)

This list is by no means complete.

A common variation on the fear of getting AIDS is the fear of contracting it, giving it to someone else, and then having to live with the guilt of having caused an innocent person’s death. These sufferers may also have other problems with feeling overly responsible for others, another main theme among those with OCD. For these people, you could add this to the list above:

• Touching loved ones or touching anything else in public or in their homes (if giving AIDS to family members is the problem)

Getting and staying uncontaminated can be an excruciating 24-hour-a-day job. When sufferers are contaminated, they worry about getting perfectly clean. When clean, they worry about staying that way. They can only begin to feel comfortable when they are in control of everyone and everything around them. They wash and shower to excess when they believe they have touched something containing the AIDS virus, and they can often be spotted by their bright red, chapped hands. They will usually only touch feared things using barriers such as tissues, paper towels, or gloves. Every little cut or scratch may have to be covered with medication and a Band-Aid to keep the virus out. Anything possibly contaminated must be washed or disinfected, or else it must be thrown out. (Actually, most of these descriptions could be applied to the majority of people with contamination fears.)

To try to make this impossible task easier to manage, sufferers create “dirty” and “clean” worlds for themselves. They have places they can go and things they can do only when they are in a “contaminated state.” The same is true for when they feel “clean.” Certain rooms or locations can only be entered when sufferers themselves are “clean.” One of my patients even had a “clean” car and a “dirty” car. When family members fall under a sufferer’s control, they have to wash and change clothes whenever they enter the house, or else face a lot of upset or arguing.

Obviously, all this gets to be debilitating as the disorder takes over. Leaving the house can become extremely difficult. Some people stop socializing, or stop going to work or to school. In addition, sufferers tend to avoid or put off needed visits to physicians and dentists, and they may develop other health problems. In reality, all of the above are solutions designed to escape the doubt and anxiety, but they only end up helping in the short run. Unfortunately, in the long run, as sufferers use these methods, they only train themselves to be better avoiders who keep their fears going. Avoiding only convinces them that the fears are real, and it prevents them from actually seeing that the dreaded consequences never occur. Ironically, what starts out as a way to help control the anxiety ends up controlling and damaging their lives via a downward spiral of fear and avoidance. For those who do not suffer from these anxieties, it is difficult to appreciate just how gut-wrenching and debilitating they can be.

So, what do you do to get out of this kind of predicament? The answer (one that sufferers do not usually want to hear) is to learn to face the fearful obsessive thoughts while resisting the compulsions to escape and avoid. Behavior therapy is the key to accomplishing this. If you are a regular reader of this newsletter, you probably know that the type of behavioral therapy known as Exposure and Response Prevention (E&RP) is presently the best and most thoroughly proven way to do this. Success rates have been shown to be 75 percent or better.

E&RP is a retraining process. Basically, sufferers are encouraged to allow themselves to be more and more unclean for longer periods of time as they try to carry out a growing number of average activities when they are “contaminated.” By staying with what they fear, sufferers gradually become accustomed to acting in more normal ways in everyday situations, and they slowly begin to trust the idea that nothing catastrophic will happen. They learn that they can allow the fear to subside on its own, without taking any special actions, and that they can rely on this to happen. Double-checking, questioning, and asking others for reassurance or help in cleaning are discouraged and gradually eliminated. Friends and relatives are instructed to not participate or assist in these activities. They are shown that rather than helping or easing the sufferer’s anxiety, they are only contributing to keeping that person in a helpless state.

The therapy process can sometimes be tricky as sufferers’ obsessions work overtime to create more doubts about these issues. They ask, “How can doing the things I fear will give me AIDS help me to feel less anxious today, since it could take 10 years to find out if I will develop AIDS?” The answer, of course, is that the problem they are having doesn’t really exist in the future, but within their own faulty judgment about taking risks in the present. OCD is not just a set of biological or behavioral problems, it is also a set of information-processing problems. Learning to challenge illogical thinking is another important part of the process. I like to ask patients if there is any scientific evidence to support their self-protective actions, or any reports of AIDS contracted according to their special theories. I also question why average persons don’t live as self-destructively as the sufferer lives, yet manage to live just as long. Sometimes sufferers will answer: “Most people are ignorant. If they knew what I know, they would do as I do.” When questioned as to where they get their unique information from, they of course cannot point to anything other than the same TV shows or news articles available to the rest of the population. When pressed, some severe sufferers will even admit that having AIDS couldn’t be much worse than the personal hell they have created for themselves.

Working with a trained behavior therapist, either in an intensive daily program or in weekly sessions, you practice doing the things you fear to do. At the start of therapy, you work with the therapist to construct a list of all the places and activities that would give you difficulty if you stayed with them and didn’t avoid. Each item is rated on a scale of 0 to 100. This list is known as a hierarchy. Next, a program of behavioral assignments is laid out for you, based upon the listing you have made. No one forces you to do things or surprises you. Typical homework assignments may include the following: (these are in no special order):

• Shaking hands with others
• Eating in a restaurant and not wiping or cleaning the silverware
• Touching light switches, door knobs, mailbox handles, etc.
• Sitting on public benches, using public phones or rest rooms, taking public transportation
• Bringing home items from stores and not washing or wiping them
• Visiting a local hospital and sitting in the waiting room, using water fountains, phones, or rest rooms, or eating in the coffee shop
• Bringing such things as brochures or napkins home from a hospital and touching them to your belongings
• Touching books about AIDS in a bookstore or library and even buying or borrowing them so they can be used to “contaminate” things at home
• Allowing yourself to be near or to touch people who look as if they could possibly have AIDS
• Not washing or changing clothes immediately upon coming home from being outside, and allowing family members to do the same
• Limiting hand-washing to just a few times per day and to only 10 seconds per time
• Limiting showering to only 10 minutes per time, and to no more than once per day (even less often if this has been a serious problem)
• Listening to audio tapes several times daily telling you that you have AIDS (or will give it to others)
• Resisting putting band-aids and disinfectants on every tiny cut or scrape

This last type of assignment is gradually made more anxiety-provoking, and is designed to increase your tolerance of your obsessive thoughts to the point where you can feel free to disregard them. Not washing, wiping, or otherwise undoing assignments after they are carried out is extremely important. To do so would be to cancel out any benefit they may have.

Medication can often be important to overcoming OCD. It should not be an end in itself, but should be seen as a tool to help you take part in therapy. It can provide a level of improvement from which to begin working. Not everyone requires it, but there are many who could not carry out behavioral assignments without the symptom relief it provides. It may also reduce feelings of depression, which can then result in a person feeling energetic and having a more positive and motivated attitude about working toward a recovery. Antidepressant drugs such as Anafranil, Prozac, Paxil, Zoloft, Luvox, Celexa, Serzone, and Effexor are all currently being used to relieve the symptoms of OCD and depression. There is no best drug as everyone responds differently to them. Medication for OCD has been discussed in other articles in past issues, so I will not go into further detail here.

Recovery from this problem is possible. Many have already achieved it. Don’t feel helpless or give up hope. Find yourself a behavior therapist trained in the use of E&RP, as well as an experienced psychiatrist if you need one. Don’t assume that every practitioner is qualified to treat OCD. Be a good consumer and find out how many cases of OCD they have actually treated and if they use the most up-to-date approaches. Call the OC Foundation for names of practitioners in your area, or get names at a local OCD support group.

Is Childhood OCD an Indicator of Food Issues in Later Years?

Researchers at the South London and Maudsley NHS Foundation Trust’s (SLaM) OCD Service in collaboration with the Institute of Psychiatry (IoP) have discovered an increase in the development of eating disorders in children who were previously diagnosed with obsessive-compulsive disorder (OCD).

A new study found that nearly one in ten children who had OCD later went on to develop an eating disorder, a higher statistic than is found in those without OCD. Dr. Nadia Micali, of the IoP of King’s College in London, and colleagues tracked 126 children and their parents for as many as nine years to gather their data.

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Baltimore scientists search for cause, treatment for hoarding

Samuels, an associate professor of psychiatry at the Johns Hopkins University’s School of Medicine, is the go-to guy nationwide for researchers seeking to understand the biological basis of hoarding — an intense, irrational drive to collect items in vast quantities, coupled with an inability to discard even objects that are worthless or broken.
Samuels established that hoarding occurs in approximately 5 percent of the population — a far larger number than was previously suspected — and linked compulsive hoarding behavior in some patients to chromosome 14.

“Individuals who have obsessive-compulsive disorder and individuals who hoard are different,” Samuels says. “The age of onset is later for hoarders, and the traditional treatment for OCD works poorly for people with hoarding behavior.”
In addition, he says, the two diagnoses are associated with different personality traits. People who hoard are preoccupied with details and have difficulty making decisions. On the positive side, many are creative and artistic.

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How Brain Sees the ‘Big Picture’ May Affect Self-Image

Body dysmorphic disorder, an illness that causes people to see themselves as disfigured or ugly, is linked to an abnormality in how visual information is processed, and the image distortion extends to the world around them, according to a new study.

In their research, investigators at University of California, Los Angeles (UCLA) found that people with body dysmorphic disorder, or BDD, have less brain activity when processing images as a whole—what they call “the big picture”—than they do when looking at things in detail.

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Perinatal Mood Disorders: What You Need to Know

Prenatal depression and postpartum anxiety disorder affect one in ten. And recent studies and clinical work are now recognizing the prevalence (3-6%) of disorders like prenatal anxiety, postpartum obsessive-compulsive disorder (OCD), and postpartum post traumatic stress disorder (PTSD).

Many theories abound as to why these psychological disorders occur in relation to pregnancy. Hormonal fluctuations, increased stress and underlying, chronic inflammatory processes are all vying for attention and, thankfully, are finally receiving it. In no event, does a perinatal mood disorder represent “bad parenting,” “inadequacy for motherhood” or other judgments against the woman, herself.

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People with body-image disorders process ‘big picture’ visual information abnormally

People suffering from body dysmorphic disorder, or BDD — a severe mental illness characterized by debilitating misperceptions that one appears disfigured and ugly — process visual information abnormally, even when looking at inanimate objects, according to a new UCLA study. The study compared 14 BDD patients, both men and women, with 14 healthy controls. Researchers used a type of brain scan called functional MRI (fMRI) to scan subjects while they viewed digital photographs of houses that were either unaltered or altered in ways to parse out different elements of visual processing.

The researchers found that the BDD patients had abnormal brain activation patterns when viewing pictures of the less-detailed houses: The regions of their brains that process these visual elements showed less activation than the healthy controls. In addition, the more severe their BDD symptoms, the lower the brain activity in the areas responsible for processing the image holistically.

“The study suggests that BDD patients have general abnormalities in visual processing,” Feusner said. “But we haven’t yet determined whether abnormal visual processing contributes as a cause to developing BDD or is the effect of having BDD. So it’s the chicken-or-the-egg phenomenon.

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Postpartum Support International

CAMBRIDGE EXPLODES OCD MYTH

New scientific evidence challenges a popular conception that behaviours such as repetitive hand-washing, characteristic of obsessive-compulsive disorder (OCD), are carried out in response to disturbing obsessive fears.

The study, conducted at the University of Cambridge in collaboration with the University of Amsterdam, found that in the case of OCD the behaviours themselves (the compulsions) might be the precursors to the disorder, and that obsessions may simply be the brain’s way of justifying these behaviours.

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What if you can’t afford treatment?

If you suffer from Obsessive-Compulsive Disorder, Cognitive-Behavioral Therapy (CBT) is a highly effective form of treatment.  However, while it is a cost-effective form of treatment, the expense of therapy is daunting for many people.  In this article, I’ll outline concrete steps you can take to get the help you need if you feel you can’t afford treatment.  In identifying these steps, I kept two broad goals in mind:  helping you find resources to better understand OCD and resources that will help you reduce or eliminate OCD in your life. 

Consider the True Cost of Therapy

Before you decide that you can’t afford treatment, be sure to discuss your situation with a professional trained and experienced in treating OCD.  Ask about the fee per session and try to get a rough estimate of how many sessions you might need to achieve your goals.  This will give you an estimate of how much a course of treatment will cost.  While the individual sessions may seem expensive, progress is often rapid and long-lasting.  Unlike other forms of therapy, CBT for OCD is designed to be brief and focused.  You might be surprised to find that the total cost of a course of treatment for OCD is similar to many other unexpected life expenses (car or home repair, medical or dental procedure, vet bill) or luxury items (a new TV or a small vacation).  For some, it may simply be a matter of prioritizing treatment over other expenses. 

It may also help to compare the cost of treatment to the cost associated with having OCD.  Some call this the “OCD tax” and it comes in the form of lost jobs, damaged relationships, lost time, less productivity, and the expense of certain rituals (cleaning supplies, etc) among other penalties.  When you compare that to the cost of treatment, you might find that the true cost of therapy is less than you anticipated.

Ways to Make Therapy Less Expensive

If you’ve researched the cost of therapy, and you still feel it’s too expensive, the good news is there are several ways to reduce the cost of treatment. These include:

• Sliding Scales
• Adjusting the frequency and duration of sessions
• Training centers
• Group programs

Sliding Scales

Some therapists and treatment centers offer a sliding scale for therapy services.  This means that the fee for treatment is adjusted based on need and ability to pay.  When you’re doing your research to select a therapist to help you overcome OCD, ask if they offer a sliding scale.  This reduces the cost per session and lessens the overall cost of treatment.

Adjusting the Frequency and Duration of Sessions

When we think of therapy, we often think of a weekly 50 minute session.  However, if you’re seeking help but concerned about the expense, there are other options.  Since there’s no evidence that less frequent meetings are any less effective, many patients choose to meet every other week to lower the cost of treatment.  If you’re willing to work hard in between sessions and follow the homework your therapist assigns, this can be an excellent option to cut the expense associated with therapy.  In addition, while exposure therapy sessions often require adequate time for habituation to occur, you can discuss the possibility of shorter sessions with your therapist to reduce the fee per session.

Training Sites

Another way to reduce the expense of treatment is to seek help from a center that provides training to students interested in treating OCD.  These sites often offer reduced fees if you’re treated by a student.  If the student is being closely supervised by a professional who is an expert in OCD, the treatment you receive can be highly effective at a reduced fee. 

Group Programs

Another option to reduce the cost of treatment is to consider a group program.  These are often conducted in a more intensive format.  This means that the sessions are frequently longer (1.5-2 hours) but the overall cost may be less since it is in a group setting.

Other Options

If after researching the possibilities above you’ve decided you can’t afford treatment, there are other options to consider that meet our two goals of education about OCD and learning the techniques to overcome it.  An excellent option to consider is the use of a self-help book written by an OCD expert.  These books provide thorough information about OCD as well as walking you through the steps needed to make progress in your quest to rid yourself of this disorder. There are several excellent self-help books that offer education about OCD along with step-by-step instructions for practicing exposure and response prevention therapy.  Self-help books I recommend include:

• The OCD Workbook by Bruce Hyman, Ph.D.
• Overcoming Obsessive Thoughts, Christine Purdon and David Clark
• Stop Obsessing! by Edna Foa, Ph.D.
• Getting Over OCD: A 10 Step Workbook for Taking Back Your Life by Jonathan S. Abramowitz, Ph.D.
• Freedom From Obsessive-Compulsive Disorder:  A Personalized Recovery Program for Living with OCD,  Jonathan Grayson, Ph.D.
• Obsessive-Compulsive Disorders:  A Complete Guide to Getting Well and Staying Well, by Fred Penzel, Ph.D.

Another option to consider is a support group.  Support groups are often low-cost or free and provide education and social support if you’re struggling with OCD.  Groups led by an OCD expert can provide guidance and education about practicing exposure on your own while peers provide troubleshooting and encouragement.

Conclusion

While individual therapy for OCD can be expensive, the overall cost of treatment is often comparable to other unexpected expenses.  In addition, there are several ways to reduce the cost of treatment.  These include seeking a therapist who has a sliding scale, adjusting the frequency and duration of sessions, getting treatment at a training site, and seeking help through a group OCD treatment program.  Self-help books, such as the ones listed above, and support groups are other low-cost alternatives that will help provide education about OCD as well as guidance in overcoming this disorder.

Self-Directed Treatment for OCD: The Irony of Doing the Opposite

I remember a movie in which one of the characters went around asking people to define the word “irony.” Although most of them seemed to know what it meant, they were unable to put it into words.  Not until the end of the movie did one of them give the definition.  I’m reminded of this because the continuation and elimination of OCD symptoms are perfect examples of irony or the occurrence of outcomes that are opposite to those that were intended.  You have probably been steering clear of triggers for your obsessions and doing compulsions after contact with those you couldn’t avoid.  Ironically, instead of lessening your distress, what you have been doing is sustaining or even worsening your condition.  To get out of this quagmire, you have to start doing the opposite of your strategy up until now.  This means deliberately making contact with the triggers while refraining from doing compulsions.  With enough exposure to the triggers, and for sufficient periods of time, you will notice that they become powerless to provoke distress, and the absence of distress eliminates the need for compulsions.  See what I mean about OCD and irony? Exposure, ritual prevention, and awareness exercises are used to achieve this.

Exposure, Ritual Prevention, and Awareness Exercises

It is important that you understand how the exposure, ritual prevention, and awareness (ERPA) exercises are related to the way the symptoms work.  So let’s review the series of events that takes place during a cycle of OCD symptoms, commonly called an OCD spike.  First, there’s a trigger, something that is noticed in your physical, social or mental worlds.  Second, it instantly activates an obsession—thoughts, feelings or impulses that are distressful.  Almost simultaneously, you feel fear, guilt, apprehension, dread, anger or any number and combination of distressing emotions. These three events—exposure to a trigger, activation of an obsession, and feelings of distress—are sensed as happening together, as a single event.  Therefore, the terms, “trigger,” “obsession,” and “distress” are used interchangeably to refer to this seemingly single event—the spike.  Your natural reaction is to turn it off as quickly as possible.  Finally, by trial and error, you find out that by repeating certain actions and/or mental gyrations you get temporary relief until the next obsession hits.

ERPA exercises address each one of these events.  First, you select a trigger for a particular obsession-compulsion combination and then practice exposure to this trigger.  During the exposure, the next step is to refrain from rituals and instead practice awareness of the distress.  When this is successfully done the distress fades away. Because the obsessions that used to cause terrible anxiety no longer has that power, it becomes insignificant, making it intrusive and repetitive no more. With the absence of the obsessions, there is no need for compulsions.  The exercises have changed the brain, which in turn changes behaviors and emotions.  Desensitization has occurred.  The exposure exercise is the vehicle, the Rolls Royce of treatments, which delivers this result.

By practicing the exercises at least one to two hours per day (including weekends and holidays), you should made good progress. When this schedule is adhered to, most people desensitize themselves to the particular trigger they’re working on within five to seven days.  This success gives them a big dose of confidence that they can control their anxiety, and increases their motivation to pursue and eradicate it.  They now truly believe they will become “scared fearless.”

To put together an exposure exercise, you’ll be following these steps:
1. Select a trigger, an obsession-compulsion combination for elimination.
2. Practice exposure: by bringing on the obsession in reality and in imagination.
3. Practice ritual prevention by refraining from doing compulsions and fear blocking behaviors.
4. Practice acceptance fully experiencing the triggered thoughts, images, impulses, emotions and physical sensations they set off.

I’ll explain each of the above activities as follows:

Selecting an Obsession-Compulsion Combination for Elimination

The best obsessions-compulsion combination to target is usually the obsession-compulsion combination that is the least distressful.  Even though you may be eager to get rid of the most troublesome of your symptoms, it’s best to start with the one that provides the greatest chance for success. After all, nothing succeeds like success.  Don’t worry; we will eventually deal with all of your triggers.  As you are aware, there will be some stress associated with the exercises you are about to undertake.  So start with the easiest one first to keep the distress at a minimum.

Exposure: Bringing on the Obsessions

The exposures involve making contact with triggers for obsessions in reality, which are in the outer, physical and social world, or in imaginary situations, which are in the inner, mental world because fear is the problem and fear is the solution.  I realize that the idea of facing fear is quite scary, but it’s necessary.  In case after case, patients have reported that once they start confronting fear, they find it not to be nearly as distressful as anticipated.  More importantly, they discover that exposure works.  The obsessions stop triggering fear and become just “thoughts.” Being neutral with no emotional impact, they are insignificant and gradually fade away.

Shaping

Keep in mind that the exposure exercises are done in a most gradual way, moving toward a goal slowly. This gradual way of making progress is called shaping. Start with a situation that causes only minimal distress and stay with it until you have little or no reaction to it.  Only then do you take on another situation, one that’s only slightly more difficult than the first one, and stick with it until the distress evaporates.  This process is continued until you have been thoroughly exposed to all of your obsessions, including what you initially estimated to be the most frightening.  By the time you get to it, you will have been desensitized by the exposure exercises leading up to it, so that the final step will be no more difficult than the first one.  This process, moving toward a goal in small steps, is an important part of the recovery process.

For exposure to succeed in erasing the fear, there are two necessary conditions.  First, rituals, and any other means of dodging the exposure, must be prevented.  The use of false fear blockers will be fully discussed in the next section.  For now let’s discuss the second of these conditions, the need for prolonged exposure.  Exposure sessions must be long enough for you to experience a noticeable decline in your distress during the exposure.  This means your sessions could be for an hour or more.  What people typically feel during their sessions is a gradual rise in distress, which levels off after several minutes.  Then it starts to decline.  It is during this phase that you‘re receiving the benefits of the exercise.  Whatever the trigger, it’s losing its power to provoke fear.  With the next exposure session, and subsequent ones, you’ll find that the fear at the beginning is lower and falls away faster, until eventually you’ll feel little or no distress.  You will have neutralized the trigger, and learned that exposure alone will free you from anxiety without resorting to the use of faulty fear blockers.

Keep your exposure sessions to no more than 90 minutes by selecting triggers that are in the mild to moderate range of difficulty.  Exposure can be mentally and emotionally draining, so you don’t want to cause an unnecessary hardship by overdoing it. If you underestimate the power of a trigger and find that it’s taking more than 90 minutes for the distress to decrease, stop working on it and replace it with an easier exercise.  You can return to the one you underestimated after the easier exercises have desensitized you.

As mentioned above, exposure exercises can be in reality or in imagination.  Exposures in reality aim to eliminate obsessions triggered by situations in the real world, your physical and social environment.  Exposure activities of this kind require being physically involved with situations that trigger obsessions. Exposures in imagination aim to eliminate obsessions triggered by thoughts and images of imaged dreaded future events that are impossible and improbable.  Exposures of this kind, since they exist only in your mind’s eye, require contact with the imagined triggers. One of the best ways to do exposure in imagination is by writing down the content of your obsessions and recording this scenario on audiotape and listening to it repeatedly for as long as it takes to feel some relief. You can also practice exposure to this scenario by rewriting and rereading it for extended periods of time, again, until you feel your distressed lessening.

For both types of exposure exercises, it is of the utmost importance that you do not stop them while your anxiety is up.  If you do, desensitization is prevented and you can even be further sensitized to the situation you’re trying to neutralize.  With this in mind, schedule your exposure sessions at times when you have enough time to complete them, and know that you will not be interrupted, or distracted.  The best results are obtained when you practice every day, including weekends and holidays.  A momentum develops that makes the practice easier with faster results.  I also recommend that you do the exercises early in the day.  This way you’re less likely to put them off and the thought of doing them is not hanging over your head like the sword of Damocles for the bulk of the day.

Ritual Prevention: Refraining from False Fear-Blocking Behavior

A false fear-blocker is any action or thought immediately following an obsession that reduces the fear.  I use the term “false” because the reduced fear is only temporary and returns with the next obsession.  Its greatest harm is blocking exposure, which prevents recovery.  The most common false fear blockers are: physical and mental compulsions; distraction; avoidance; and reassurance seeking.

Physical and mental compulsions are voluntary actions that are under your control.  Just as you can control the movement of your muscles, you can control the performance of physical rituals.  The same is true for mental rituals; they are willful words that you say to yourself and images that you purposely produce. The question isn’t, “Can I prevent rituals?” but, “Am I willing to prevent them?” If you wish to overcome OCD the answer must be “yes.” The price you’ll pay for giving them up—short-term, mild anxiety—is well worth the long-term benefit of freedom from OCD.  The old saying, “it’s easier than you think”, has been found to be true by all the courageous people who have abandoned rituals and overcome their suffering.  You can be one of them.  Remember that by shaping your exposures you can control your anxiety level, which will make it easier to relinquish the rituals.

Distraction is probably one of the first false fear blockers people use to cope with obsessions.  By trying to get their minds on something else, they hope to ignore obsessions with their attendant anxiety and distress.  Really paying attention to what they’re doing, constantly being busy, and keeping on the move are ways those of a more energetic bent may use to compete with repetitive, intrusive thoughts and images.  Listening to music, chattering incessantly and mindlessly are resorted to by others attempting to dampen the impact of obsessions.  Those with the tendencies to worry may even concentrate on troublesome problems of everyday life in efforts to push their obsessions out of mind.  The most drastic and decidedly dangerous distraction is inflicting self-injury, frequently to the head, as if to drive out demons, expiate guilt, or exchange physical pain for emotional anguish. Distractions, like their fear blocker cousin, compulsions, only offer a frequently unpredictable, short term let-up from the distress of inevitably recurring obsessions.  Distractions must be abandoned so that the genuine fear blocker can’t work—exposure. Avoidance—as you know by now—is the opposite of exposure and prevents recovery.  Prior to having this knowledge, however, you did what came naturally and stayed away from triggers that activated irrational thoughts, images and impulses. Now, you need to take the path to recovery, the one that follows the fear.  If you stray from it and wander into the wasteland of avoidance, your journey will be without end.  Or, as one of my patients said, “I get it. The idea is to be like a heat seeking missile, fix on the fear, follow it, and blow it up.”

Avoided situations can be your ally when you recognize that they are actually triggers for your obsessions, and as such, targets for desensitization. When they have been neutralized, and you are able to easily approach them, you will have demonstrated the ultimate proof of a successful treatment outcome.

Reasoning is probably the most commonly used fear blocker even though the person realizes, most of the time that their fears are unreasonable.  However, during severe OCD spikes, this understanding weakens and doubts arise that the dreaded thoughts could be real.  For example, could the thoughts really mean that “I have a major character defect or that I am crazy?” Just as nature abhors a vacuum, humans abhor uncertainty.  We deal with it by rationalizing, analyzing, intellectualizing, theorizing, and using all kinds of mental manipulations attempting to achieve certainty.  This happens in OCD when the faulty fear blockers of reasoning, “thinking things through,” and challenging irrational thoughts are called into play. As you already know, these efforts at relief are futile.  We have little direct control over our emotional reactions because emotions happen to us, they’re not things we will to happen. Our rational control of fear is weak; but fear can easily hijack rational control, doing so routinely in OCD.  This is because the connections from the brain’s emotional systems to the rational systems are stronger than connections from the rational systems to the emotional systems (LeDoux, 1996).  Philosophers, poets, and other sages have expressed this understanding over the centuries, and joining them today are neuroscientists reporting discoveries about how the brain works. Remember, with fear, what you think won’t help you, but what you do will.

Reassurance is one of the most powerful and unrecognized of these fear and recovery blockers.  It’s a form of compulsion that are I’ve found in over 90 percent of the people I’ve worked with. Because so many compulsively seek reassurance to calm their OCD and anxiety, it deserves special attention.

People with OCD worry that their obsessions might come true.  To ease this distress they ask other people, usually family members or close friends, over and over again to reassure them that their fears will not materialize.  Because obsessions are always unrealistic, the family members or friends (and even therapists) tell them there is no need to worry; nothing bad is going to happen.  For instance, it is quite common for people with fears of being irresponsible or careless to seek reassurance that they are neither. Typically they get the reassurance that they want, and temporary relief, but like other compulsions, reassurance blocks recovery. This is the first paradox.  Reassurance is not helpful—it’s harmful.  However, the short-term relief it provides is rewarding enough to keep the person repeatedly seeking more, which is the second paradox.  The more reassurance received, the more reassurance wanted.  Trying to satisfy the demand is like trying to fill a bottomless pit.

In addition to hindering recovery, incessant requests for reassurance can grow to be overbearing demands that lead to interpersonal strife.  In one case, after her husband’s demands became so intense and frequent, one woman actually moved out and rented an apartment of her own. Her husband entered an intensive treatment program where both were helped and the reassurance stopped.  This is an example of the third paradox.  Once reassurance is eliminated, the reassured finds no further desire for it accompanied by a decrease in their obsessions and other compulsions.  How, then, should you handle your urges to ask for reassurance?

First. Stop asking for reassurance.  Identify your most frequent questions and do not ask them.  Avoid subtle, indirect ways of getting reassurance.  These may be unknown to the reassurers, but knowingly practiced by you. For example, one client I worked with would abruptly stop doing whatever she was doing, sit down and space out.  Her husband learned that these behaviors signaled that she was caught up in obsessions, and unbeknownst to him, they became a nonverbal request for reassurance that he would immediately provide. It was his cue to begin telling her not to worry, that her fears were irrational, that it was only her OCD.  So in addition to attending to the obvious requests, subtle, indirect ones also need to be stopped.

Second. Educate your significant others about the harmful effects of reassurance.  Have them read this passage.  Explain that providing reassurance interferes with recovery.

Third. Create a gentle refusal statement. At first, you will most likely continue to seek reassurance despite your efforts to abstain from them.  Therefore, people from whom you typically get reassurance need to work with you to create a palatable way to say no. One way of doing this is for them to say, “I think you’re asking for reassurance.  Remember, reassurance is not helpful; it’s harmful.  Therefore I’m not going to respond.”  However, if this doesn’t work, it’s possible that the agreed upon statement itself has become reassuring, or that you believe that nothing bad will happen because the reassurer would warn you.  In this case, the best way to end it is for the parties to stop talking about OCD entirely.

Awareness

I guess everybody’s heard that you must face your fears to overcome them.  That is easy to say but hard to do. Our instinctive reaction in the face of threat is fight or flight.  This reaction has survival value for dealing with true dangers, but not for the false dangers you fear with OCD.  Survival for you is overcoming OCD, which requires experiencing the fear, sticking with it, immersing yourself in it, and subduing it.  Reading this may stoke anticipatory fears, but keep in mind that you can control your fear levels by approaching the triggers gradually so that you feel only mild to moderate levels or of anxiety.  On making contact, you might notice that the fear gradually rises but then levels off, and after a while it begins to decrease.  It is during this last phase that you are getting the benefits of treatment.  You are being desensitized.

While facing the fear, your task is to pay attention to your uncomfortable thoughts, and emotional and physical sensations.  Dwell on the scary thoughts and images.  Do the opposite of what you have been doing and accept the fears as being possible.  Imagine the dreaded future events happening. Say to yourself, “So be it.”  Concentrate on the prospect of living in a world of uncertainty, of never knowing if and when something bad is going to happen, of never getting over the anxious condition, and so forth and so on.  Keep thinking about thoughts and calling up images to deliberately provoke fear.  In this way you are using fear to fight fear.  You can’t overcome fear by trying to go around it but only by going through it. Really be aware of the emotions you are experiencing.

Also notice your body’s physical reactions.  Where do you feel the anxiety in your body?  If your heart is beating faster and harder, tune in to it.  If you have muscle tension, focus on that.  If you’re breathing faster and harder notice it.  Are your stomach and chest tight? Do you feel hot? Are you sweating? If the answer is yes, it means that you are on the right track because you’re feeling the fear and letting it burn itself out.  By pursuing the fear, you are destroying it.  Exposure is to obsessions and compulsions as sunlight is to vampires. All of these bad feelings are for the good.  You’ll know this for yourself when, after several exposures, the fear no longer exists.  You won’t be able to summon it even if you try.

However, you might be concerned that the obsessions will become stronger if you give up your efforts to stop blocking them or if you deliberately bring them on.  Or you might worry that whatever you dread will happen. Paradoxically, neither of these outcomes occurs.  Instead, the exact opposite happens; you will recover as a result of re-training your brain’s fear system to stop making false alarms about harmless events. You will be desensitized to the previous fear triggers and see them as they truly are—harmless thoughts and images that are simply part of the normal flow of your stream of consciousness. In other words, OCD is erased when the unwanted thoughts, images, and impulses are faced, and embraced.

You may ask, “If exposure to fear is all that’s required to get over OCD why hasn’t this already happened? I’ve had these obsessions for many years and they just keep coming.”  The answer is that you have used futile fear-blockers to cut off distress from the obsessions. This means that your exposures to the fear haven’t been long enough for it to naturally drop, which it will, simply as a result of your feeling it. You will fully understand the truth of this after you’ve completed your first exposure exercise.

The above exercises may seem daunting. But keep in mind the benefits they offer:

• Changes in emotions from high anxiety too little or no anxiety
• Allowing rational thoughts to replace irrational ones
• Ability to maintain employment, volunteer activity, or pursue education or training goals
• Engaging in a normal interests and routines
• Enjoying satisfactory family and social activities and relationships

Good luck. You’ve got the power!

Tourette’s Support Group

Personal Stories - Dan’s Story

Mandel’s disorder no laughing matter

“It doesn’t make any sense intellectually, but at times in my life it gets to the point where it’s insurmountable. It’s more than not being able to touch that door. It would stay with me the rest of the day and I wouldn’t be able to function or concentrate. That’s what I’ve been dealing with my whole life. It gets noisy in your head.”

It would seem Mandel hasn’t become the basket case that was Howard Hughes.

“Hughes flourished, too, until the later stages of his life,” Mandel counters. “I’m not far from there. It’s always in my mind that I could end up where he ended up. I don’t look at his story and go: Oh, that’s crazy. That’s not me. I look at it and go: That could happen. I really understand how I could get there. And I’m really not that far from there.
That’s what people don’t understand…mental health is something of a stigma… something that’s not really taken care of in much of the world. Mental health care is not nearly equal to physical health care.”

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Specialty OCD Clinic - India

Students with OCD - A Handbook for School Personnel

Wayne State University Researchers Find New Way to Examine Major Depressive Disorder in Children

A landmark study by scientists at Wayne State University published in the May 6, 2011, issue of Archives of General Psychiatry, the most prestigious journal in the field, has revealed a new way to distinguish children with major depressive disorder (MDD) from not only normal children, but also from children with obsessive compulsive disorder (OCD).

Using a new technique to measure cortical thickness of 24 MDD patients, 24 OCD patients and 30 healthy control patients, the research team observed cortical thinning in five regions of the brain and greater thickness in the bilateral temporal pole in MDD patients. In OCD patients, the only significantly different region from healthy control patients was a thinner left supramarginal gyrus.

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Testimonial 25

10 Things You Should Know About Compulsive Hoarding…

Compulsive hoarding affects approximately 700,000 to 1.4 million people in the US. The OCD Collaborative Genetics Study reported that genetic linkage findings are different in OCD families with and without hoarding behavior, suggesting that a region on chromosome 14 is linked with compulsive hoarding behavior in these families and that hoarding is a distinct genetic subtype of OCD.

Hoarding often runs in families and can frequently accompany other mental health disorders, like depression, social anxiety, bipolar disorder, and impulse control problems. A majority of people with compulsive hoarding can identify another family member who has the problem.

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Exposure Therapy for OCD- Exposure Therapy is a Step-by-Step Process for Improving OCD Symptoms

Although exposure therapy works for reducing the symptoms of OCD, many people decline exposure therapy out of fear and misunderstanding. However, if you break down OCD exposure therapy step-by-step, you will discover that it is simply a tool for unlearning unhealthy associations and is a process that you are in complete control of.

Before conducting exposure therapy, the first step is to build what is referred to as an “exposure hierarchy.” This means ordering the things you are afraid of from least distressing to most distressing.

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Orthorexia: When healthy eating goes astray

What is orthorexia? The term comes from the Greek words ortho, meaning straight, right or correct, and orexis, or appetite; so orthorexia literally means “correct eating”.  Orthorexics are characterized by an obsession with healthy eating, avoiding any foods that they perceive to be unhealthy.  While the origin of the word and its meaning are easy to trace, the phenomenon itself is actually quite controversial.

Anecdotal accounts of orthorexia abound but few data exist on its true prevalence and research studies are lacking.  While some eating disorder experts suggest that this condition is nothing more than a form of anorexia, others argue that orthorexics can easily be distinguished by their focus on healthy or virtuous eating rather than on thinness or weight loss. 

In some ways, orthorexia seems more similar to OCD than to anorexia—the sense of control that comes from rigid and ritualized behaviors, the quest to protect one’s health, the belief that there is a “right” way to do things and the emphasis on virtue. The orthorexic’s preoccupation, or obsession, with food leads to meticulous and inflexible eating that looks very much like the compulsive behavior seen in OCD. 

What’s wrong with healthy eating? Just in the same way that having good hygiene is not a bad thing but showering for several hours a day is, there is nothing wrong with eating healthy foods unless this inflexibility consumes your life.  Health conscious eaters have diets based in moderation.  They can make choices that are not dictated by food, can be flexible in eating when they need to be, and don’t think about food all that much.  Sufferers of orthorexia, on the other hand:

• Have an extreme preoccupation with food and the quality of the food
• Eliminate many “unhealthy” foods and eventually only eat a few foods
• Focus on the virtuousness of eating
• Eat in a way that negatively impacts quality of life
• Are judgmental of others’ food choices
• Become socially isolated because of their eating
• Have rigid eating habits and lack moderation
• Experience guilt or self-loathing when they stray from their diet

And because orthorexics often have such a limited diet there can be serious health consequences from vitamin, mineral, and caloric deficiencies.  Ironically, the quest for perfectly healthy eating can instead result in anemia, osteopenia or other health detriments. 

What is the treatment for orthorexia? Orthorexia is such a newly named phenomenon that there are no scientific studies demonstrating what treatments may be most effective for this condition.  However, because of orthorexia’s similarities to OCD, we may be able to extrapolate methods that could be of benefit. For example, cognitive-behavioral therapy strategies that work well in OCD, such as targeting distorted beliefs and graduated exposure to feared stimuli, may also be useful in orthorexia. 

In cognitive therapy, distorted orthorexic beliefs about the need for perfection and the danger of occasionally eating unhealthy foods could be addressed.  Detailing the true benefits of eating in this manner versus the costs—social isolation, loss of spontaneity and decreased quality of life—may be useful in motivating sufferers to relax their standards to more realistic levels and to gradually reincorporate feared foods into their diets. 

What’s the bottom line? Research studies are needed to better delineate what orthorexia is and how it can be treated.  It appears that a significant number of people fall prey to this preoccupation with eating correctly.  And because this condition far exceeds simply “healthy eating”, the consequences can be serious.  Until treatment protocols specifically tailored to orthorexia can be created and studied, cognitive-behavioral strategies similar to those used in OCD may be modified to address the perfectionistic beliefs and compulsive behavior that characterize orthorexia.

Testimonial 24

Scientists Show That Anti-Inflammatory Drugs Reduce Effectiveness of SSRI Antidepressants

Scientists at the Fisher Center for Alzheimer’s Disease Research at The Rockefeller University have shown that anti-inflammatory drugs, which include ibuprofen, aspirin and naproxen, reduce the effectiveness of the most widely used class of antidepressant medications, the selective serotonin reuptake inhibitors which are used to treat OCD. This surprising discovery, published online this week in the Proceedings of the National Academy of Sciences, may explain why some depressed patients taking SSRIs do not respond to the medication and suggests that this lack of effectiveness may be preventable. However, changes in medication should not be undertaken without a doctors advice.

In the study, which focused on depression investigators treated animal models with antidepressants in the presence or absence of anti-inflammatory drugs. They then examined how the models behaved in tasks that are sensitive to antidepressant treatment. The behavioral responses to antidepressants were inhibited by anti-inflammatory/analgesic treatments. They then confirmed these effects in a human population.  Depressed individuals who reported anti-inflammatory drug use were much less likely to have their symptoms relieved by an antidepressant than depressed patients who reported no anti-inflammatory drug use.

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Experimental Radiation Treatment for OCD Hits a Snag

“We’re on hiatus now with the gamma knife,” said Steven Rasmussen of Brown University, referring to the machine that delivers the radiation. “Three of the last 20 patients have developed a brain cyst, which we never saw before. The new gamma knife delivers a slightly different distribution of radiation, and we think that caused the cysts in these patients. None of our first 36 patients developed this adverse effect.” Surgeons at the University of Pittsburgh, however, have found no cysts in their gamma knife patients in nearly five years of follow-up, and continue to perform the procedure.

A form of brain surgery that uses radiation to destroy spots of tissue in the brain gives significant relief to some people with disabling obsessive-compulsive disorder (OCD). But the surgical team with the most experience performing this technique has called a temporary halt to it until long-term side effects that have appeared recently can be studied.
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The Ray of Hope