OCD (OBSESSIVE COMPULSIVE DISORDER)
Is an internal manifestation of anxiety. A person feels disrupted or is in a state of flux or turbulence and this state creates a mental framework that something in the present is not right and, therefore, as a consequence harm will come to the individual or the individual by his or her actions will indirectly create harm to another person. OCD is a neurotic, and it is always an ethical dilemma for the patient (or client) because the person feels compelled to CORRECT the problem (or flaw) and thereby stop the harm even through the linkage between the persons behavior and the harm can be very indirect.
Here is an example: “If you step on a crack you will break your mother’s back.” This childhood rhyme is packed with information about psychopathology. The causative link between stepping on a crack in the cement and your mother’s back breaking is non-existent. There is no reasonable connection between these two, but when a person says it, the person makes the link, however fallacious in the mind. Therefore, it becomes a possibility even though it is not a realistic one. This is how OCD reasoning works.
A more commonly used OCD reasoning that I heard recently was as follows:
“Doctor, I have this strange worry. If I’m driving a car and I see the light turns from green to yellow, I’m terrified to enter the intersection when the light is yellow. Why? Because I realize that if I don’t make it through the intersection before the light turns to red, someone I know will die. Therefore, I’m terrified of driving and when I do I take every precaution to slow down before the intersection when the light turns yellow, so that I can avoid failing to make it through before the light turns red. Not because I fear for myself, because I know someone I care about will die.
JACK
Jack is your typical successful computer programmer. His area of work is complex and interfaces with cyber-security systems. Jack grew up in a fractured, high-conflict home, divorced parents, 3 siblings, one with severe psychiatric issues, one with alcohol problems later in life. He is the most successful of the four children, but Jack is estranged from his siblings, close with his mother, distant from father.
Jack’s style is adaptive, non-conforming. By this I mean he recognized early on he needed certain social milestones high school diploma, college, working for a large security company which pays well to adapt to the world. But, he despises regularity, 8 to 5pm job hours, meetings of any kind. He values autonomy and has passed up promotions when it meant involvement in management. When it comes to programming, his skill is superior, in part he has a capacity to focus, and his programming is described by his co-workers and others as art, both in content and form.
He came to me because he was suffering for the past three years from a disorder which has now infiltrated his day-to-day world. The constant fear that he has forgotten to do things: locking the front door, locking windows, turning off the stove, feeding his cat. Jack lives in a large city and although he owns a car, he sometimes takes the bus. When he walks to the bus stop, the thought keeps going through his mind that he has forgotten to do something, lock a window, lock the back door of his house, turn off the water in the bathroom (and this could flood his whole house), feed the cat (and the cat will suffer). Jack lives alone, never married and never wanted a partner, and has no one to follow-up on his home. Inevitably, when he does return, he is relieved to see that he has not missed any detail.
JACK’S SOLUTION
To address the symptom Jack programmed Alexa to provide assurances that he has accomplished a home security task. For example, Alexa records every security action that Jack could think of taking, backed up with camera evidence, that, once performed, Alexa is ready to re-assure Jack it is done. So, each day before work, Jack locks the door, turns off the stove, shuts off the water (he prefers shutting the water off to the whole house because he fears a burst pipe) and so on. Then, Jack can ask:
Jack, “Alexa, Is the front door locked?”
Alexa, “Yes, Jack, the front door is locked.
Alexa, “Jack, do you want to see a picture of the front door?” (this is because Jack has a camera view of his front door).
Jack, “Alexa, Is the stove off?”
Alexa, “Yes, Jack, the stove is off.
Alexa, “Jack, Do you want to see the gas valve?”
Jack, was enthusiastic about this idea. I suggested the back-up camera and the second question to assess whether his compulsion would diminish after just verbal reassurance, or whether that addition of visual evidence would be needed. Then, we could evaluate which compulsions were stronger or weaker. Which were amenable to one versus two levels of reassurance.
Just like all neurotic disorders, the problem found its way around Jacks’ solution.
In my next entry I will describe how Jack defeated his technologically creative strategy to solve his OCD. In doing so, I will describe why the “constant reminder” strategy will likely never solve the Checking OCD disorder.
The figure above describes a typical OCD pattern. There is the initial thought that then generates a state of anxiety which then causes a person to look for an escape or a way to control the anxious state. What follows is a compulsive behavior the person generates that the person “thinks” will mitigate the anxiet. Engaging in the behavior lowers the anxiety and creates a state of temporary relief. Then, the thought intrudes and they cycle repeats.
Assessing OCD
There are quite a few paper-and-pencil assessments for Obsessive Compulsive Disorder. This is probably due to the fact that OCD is a behavioral disorder which makes it amenable to quantification and observation. A commonly used instrument is the: YALE-BROWN OBSESSIVE COMPULSIVE SCALE. I’ve copied it below:
Obsessions are unwanted ideas, images or impulses that intrude on thinking against your wishes and efforts to resist them. They usually involve themes of harm, risk and danger. Common obsessions are excessive fears of contamination; recurring doubts about danger, extreme concern with order, symmetry, or exactness; fear of losing important things.
Please answer each question by circling the appropriate number.
1. TIME OCCUPIED BY OBSESSIVE THOUGHTS SCORE __________
How much of your time is occupied by obsessive thoughts?
0 = None
1 = Less than 1 hr/day or occasional occurrence
2 = 1 to 3 hrs/day or frequent
3 = Greater than 3 and up to 8 hrs/day or very frequent occurrence
4 = Greater than 8 hrs/day or nearly constant occurrence
2. INTERFERENCE DUE TO OBSESSIVE THOUGHTS SCORE __________
How much do your obsessive thoughts interfere with your work, school, social, or other important role functioning? Is there anything that you don’t do because of them?
0 = None
1 = Slight interference with social or other activities, but overall performance not impaired
2 = Definite interference with social or occupational performance, but still manageable
3 = Causes substantial impairment in social or occupational performance
4 = Incapacitating
3. DISTRESS ASSOCIATED WITH OBSESSIVE THOUGHTS SCORE __________
How much distress do your obsessive thoughts cause you?
0 = None
1 = Not too disturbing
2 = Disturbing, but still manageable
3 = Very disturbing
4 = Near constant and disabling distress
4. RESISTANCE AGAINST OBSESSIONS SCORE __________
How much of an effort do you make to resist the obsessive thoughts? How often do you try to disregard or turn your attention away from these thoughts as they enter your mind?
0 = Try to resist all the time
1 = Try to resist most of the time
2 = Make some effort to resist
3 = Yield to all obsessions without attempting to control them, but with some reluctance
4 = Completely and willingly yield to all obsessions 23.
5. DEGREE OF CONTROL OVER OBSESSIVE THOUGHTS SCORE __________
How much control do you have over your obsessive thoughts? How successful are you in stopping or diverting your obsessive thinking? Can you dismiss them?
0 = Complete control
1 = Usually able to stop or divert obsessions with some effort and concentration
2 = Sometimes able to stop or divert obsessions
3 = Rarely successful in stopping or dismissing obsessions, can only divert attention with difficulty
4 = Obsessions are completely involuntary, rarely able to even momentarily alter obsessive thinking.
The next several questions are about your compulsive behaviors. Compulsions are urges that people have to do something to lessen feelings of anxiety or other discomfort. Often they do repetitive, purposeful, intentional behaviors called rituals. The behavior itself may seem appropriate but it becomes a ritual when done to excess. Washing, checking, repeating, straightening, hoarding and many other behaviors can be rituals. Some rituals are mental. For example, thinking or saying things over and over under your breath.
6. TIME SPENT PERFORMING COMPULSIVE BEHAVIORS SCORE __________
How much time do you spend performing compulsive behaviors? How much longer than most people does it take to complete routine activities because of your rituals? How frequently do you do rituals?
0 = None
1 = Less than 1 hr/day or occasional performance of compulsive behaviors
2 = From 1 to 3 hrs/day, or frequent performance of compulsive behaviors
3 = More than 3 and up to 8 hrs/day, or very frequent performance of compulsive behaviors
4 = More than 8 hrs/day, or near constant performance of compulsive behaviors (too numerous to count)
7. INTERFERENCE DUE TO COMPULSIVE BEHAVIORS SCORE __________
How much do your compulsive behaviors interfere with your work, school, social, or other important role functioning? Is there anything that you don’t do because of the compulsions?
0 = None
1 = Slight interference with social or other activities, but overall performance not impaired
2 = Definite interference with social or occupational performance, but still manageable
3 = Causes substantial impairment in social or occupational performance
4 = Incapacitating
8. DISTRESS ASSOCIATED WITH COMPULSIVE BEHAVIOR SCORE __________
How would you feel if prevented from performing your compulsion(s)? How anxious would you become?
0 = None
1 = Only slightly anxious if compulsions prevented
2 = Anxiety would mount but remain manageable if compulsions prevented
3 = Prominent and very disturbing increase in anxiety if compulsions interrupted
4 = Incapacitating anxiety from any intervention aimed at modifying activity
9. RESISTANCE AGAINST COMPULSIONS SCORE __________
How much of an effort do you make to resist the compulsions?
0 = Always try to resist
1 = Try to resist most of the time
2 = Make some effort to resist
3 = Yield to almost all compulsions without attempting to control them, but with some reluctance
4 = Completely and willingly yield to all compulsions
10. DEGREE OF CONTROL OVER COMPULSIVE BEHAVIOR SCORE __________
How strong is the drive to perform the compulsive behavior? How much control do you have over the compulsions?
0 = Complete control
1 = Pressure to perform the behavior but usually able to exercise voluntary control over it
2 = Strong pressure to perform behavior, can control it only with difficulty
3 = Very strong drive to perform behavior, must be carried to completion, can only delay with difficulty
4 = Drive to perform behavior experienced as completely involuntary and over- powering, rarely able to even momentarily delay activity.
TOTAL SCORE_________
Items 1-10 are used to determine the total score. The total CY-BOCS score is the sum of items 1-10; the obsession and compulsion subtotals are the sums of items 1-5 and 6-10, respectively.
Total Y-BOCS scores range from 0 to 40, with higher scores indicating greater severity of OCD symptoms.
Under 7 are likely to be subclinical,
8-15 are likely to have a mild case of OCD,
16-23 are likely to have a moderate case of OCD,
24-31 are likely to have a severe case of OCD,
32-40 are likely to have an extreme case of OCD.
TREATING OBSESSIVE COMPULSIVE DISORDER
This blog entry is ongoing