Fighting Fear

Confronting phobias and other fears

Why Is OCD So Hard To Treat?

Why do people refuse a treatment that works?

(It is my practice when writing these blog posts to make sure the patients referred to cannot be identified. I will go to the extent of changing age and sex, along with any other identifying features. If making these changes does damage to the point of the story, I refrain from telling it.)

Obsessive-compulsive disorder (OCD) is a condition that expresses itself to a greatly varying degree in different individuals. At its least severe, it can seem only a minor quirk in people who are otherwise untroubled. They may seem to be overly attentive to orderliness or cleanliness, but are otherwise spontaneous and able to enjoy life. They may adhere too closely to various routines, like making the bed first thing after eating breakfast, but they do not seem to others, or to themselves, to be suffering from an emotional disorder. At the other extreme are people who seem to be defined by their illness. It is the most important thing in their lives. More than one person has said to me, “If I didn’t have all these things I think about over and over, what would be left of me?” One man who made a similar remark to me was a lawyer, a husband, and a father. Despite these accomplishments, he thought he would be emptied out, a cipher, if he were no longer preoccupied by thoughts that he himself recognized were irrational.

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The response to treatment of patients with OCD is also varied and, I think, unpredictable. At one extreme are people who were suffering from OCD growing up, but who overcame it on their own without thinking they were treating it in any particular way. I know because I take a history when someone comes to me for any sort of emotional problem and a number of people report that they had OCD which lasted sometimes for years and then went away. When I ask how they overcame this problem, usually they say they don’t know.

“It just seemed to me like a waste of time, checking all the time, so I stopped.”

“But you had been wasting time all those years. How come you stopped when you did? Did you do anything different? Had anything changed in your life?”

“I don’t know. It just seemed like I was wasting time.”

About a year ago, during the same week, I saw two patients who complained of the same obsession. Each had the idea that if he, or she, chose the “wrong” clothes in the morning, something bad would happen to someone in his/her family. Although each recognized this was a superstition, each could remember a time when something bad, in one case a car accident, had, indeed, happened.  The problem was that they did not know which clothes were “right,” and which were “wrong”!  It might depend on color or style. They hovered over the clothes until they could choose something that “felt” right. And sometimes a moment later, the same clothes would “feel “wrong. Getting dressed could take an hour or more.

I told them both: “What you need to do is to purposely choose the wrong clothes. You have to defy your superstition. If you do this for as little as one or two weeks, these superstitious thoughts will no longer come to mind.”

One patient, a young man, agreed. A week later, his clothes obsession was gone. The other patient, a middle-aged woman, was able to attack other obsessions and compulsions she had, but she would not, or could not, defy fate and purposely pick the wrong clothes. A year later she was better in a number of ways, but getting dressed in the morning was still a prolonged and painful task.

I don’t know why one patient consented to this uncomfortable prescription and the other did not. I would not have been able to predict ahead of time whether either or both, or neither, would comply with my recommendation.

Treatment:  The psychological treatment of OCD is called “exposure and response prevention.” The compulsive person has to be exposed repeatedly to just those usually arbitrary and irrational situations they fear until, over time, those circumstances no longer can inspire dread or disgust.

Some examples: Someone who checks the front door repeatedly has to walk away from the door without checking. Someone afraid of touching “contaminated” objects must touch them. A person who is driven to touch and count objects must refrain from doing so. In general, checking must be prevented. And so must repetitive acts such as washing.

Washing represents a special problem. Compulsions are treated most effectively by stopping them altogether, rather than by cutting down on them a little at a time. Engaging in a compulsion even every once in a while keeps the underlying fears alive. Each time someone checks the front door, for example, the idea of something untoward is once again brought briefly to mind. It is hard to put aside the thought of an intruder if the possibility of an unlocked door is brought to mind repeatedly by checking, even if only a relatively small number of times. Washing, however, is not amenable to stopping altogether because people need to wash sometimes.

Compulsive washers have taken to heart every admonition to wash. So, they wash before meals, after, and sometimes before, going to the bathroom, on coming home from work, getting ready to cook, and so on. Many of these customs are simply social rules that have little to do with health. It is not necessary to wash usually unless one’s hands are dirty. (Of course, there are exceptions, such as when working in a restaurant or a hospital.)

The drug treatment of OCD includes the use of Prozac, or other serotinergic drugs, and/or clomipramine (Anafranil), a tricyclic anti-depressant. When these drugs do not work, as is often the case, any one of a dozen or so anti-depressants or anti-psychotic agents can be added. There are psychiatrists who specialize in choosing one or another of these agents, none of which work very well, but may work every once in a while—to a greater or lesser extent. Also, there is probably a place for the use of the minor tranquilizers, such as Klonopin, in lowering the general level of anxiety.

I cannot judge from my practice, except in general terms, how effective these drugs are. By the time patients have come to me, they have usually failed at most treatments. There may be some patients who respond to these drugs and, therefore, never come to my attention.  I know a very few patients who have responded dramatically to medication, but they are in danger of relapsing when the drugs are stopped. A complicating factor in the use of drugs is the fact that many patients with OCD are loath to take them. They are commonly afraid of ingesting any strange food or other substance. When I use these drugs, I think of them as enabling the patient to engage in exposure therapy, which is more likely to produce a lasting benefit.

There is a major problem, also, with the psychological treatment of OCD. Very many patients cannot, or will not, engage in exposure therapy—at least not systematically, not to the point where the condition goes away. It is a hard treatment.

About 15 years ago I had an encounter with a patient that was demoralizing, certainly to me, and I’m sure to him also.  This 28 year old man had a variety of obsessional concerns, including an overwhelming attentativeness to symmetry. Everything in his room had to rest at right angles. More important, he could not be near someone who was sick or had been sick recently. He could not be in the same room as a person sneezed or coughed. Consequently, he could not be in the company of other people. As a result, he had not gone to college, he had not worked, and he had never dated.

A few years before, seeing the desolation of his life, he had made a serious suicide attempt. He was hospitalized. Once he had recovered from his drug overdose, the doctors began to treat his OCD. They exposed him to a graduated level of “contaminated” objects and to disarranging his possessions a little at a time. And he got better, only to relapse again when he went home. When I saw him he was years past that time and, despite being on a number of different medications, he had not improved.

I reminded him that there was a treatment for his condition that was likely to succeed—as he knew from his own experience.  Also, I pointed out that he was not getting better, and not likely to get better, without proper treatment. I did not have to remind him how miserable his life was. He understood that very well.

“What I propose,” I told him “is to start with your room. I’ll send one of our trained aides to work with you. Going slowly, we will start spoiling the symmetry in your room. You will be uncomfortable, but after a while living in a disordered room, as everyone else does, will not bother you. Then, we can work on your fear of germs. Can you do that?”

He thought for a moment or two and then told me, “No.”

How can that be? How come someone so unhappy that he wants to die not be willing to put up with the discomfort he needs to endure to get better? After all, all we required him to do was what everyone else does effortlessly.

I think there are two reasons:  Confronting disorder and the possibility of disease must be really, really unpleasant, In a way I cannot even imagine. But, secondly, I think this young man was also experiencing a failure of imagination. I don’t think he could conceive of living comfortably in an ordinary way. The real world was just a theoretical possibility to him. The world he inhabited was hedged around with disease and disorder; and he was striving endlessly to survive.

I don’t know what happened to him in the following years. I only saw him that one time. He might have made a second suicide attempt at some point. More likely, he probably continued to live as he had been living for years, hiding more or less in his room, away from the imagined dangers of being around other people, and engaged endlessly in lining up his possessions at right angles.

My failures to help people stick out more in my mind than my successes—but the reader should know that there have been successes. There are a number of people who used to have OCD who are no longer symptomatic. I still know some of them years later, and their obsessions and compulsions are gone, despite, for instance, sometimes confronting real threats of disease. They no longer worry about incomprehensible dangers. They have been reduced, then, simply to coping with all the ordinary struggles of  life, as is true for the rest of us. (c) Fredric Neuman 2012 Follow Dr. Neuman's blog at fredricneumanmd.com/blog

Fredric Neuman, M.D. is the Director of the Anxiety and Phobia Center at White Plains Hospital.

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