by Ian Osborn
Life experiences are perceived by an individual through sensory neurons—for example, sights by the retina and spoken words by the auditory system. This information is first analyzed in primary sensory areas of the cerebral cortex, then a wave of successive brain regions are recruited.… Perception, interpretation, response, and modulation are mediated via synaptic connections among a large number of individual neurons … leading to prolonged, and sometimes relatively stable, alterations in brain function, including memories.
The changes induced at synapses are, Hyman speculates, only the initial effects of medications and behavior therapy. “Secondary messengers” subsequently carry the chemical changes to the most basic of all cell structures, the genes. It is by altering the information that is transcribed from the genes that these two therapies are able to alter many different and far-reaching aspects of brain functioning, including those generally considered to be “psychological,” such as memories, attitudes, and motivation.
The natural course of medicine in the twentieth century is this: A great discovery is made, it is implemented for a decade or two, then it is taken for granted. The first antibacterial drugs were introduced in the 1930s, and over the next decade the death rate from meningitis, pneumonia, and a number of other common infectious diseases dropped by more than 80 percent. As the discoverer of the sulfonamides, Gerhard Domagk, later noted, “We now accept as a matter of course the thousandfold miracle cures.”
In historical perspective, psychiatry is in the midst of a leap forward that started about the time I was in medical school. In the case of OCD, spectacular treatments have been developed that are now in the early stages of implementation. As of now, many OCDers still do not know about them. My hope is this book will help behavior therapy and medication become accepted as a matter of course very soon.
APPENDIX A
THE YALE-BROWN
OBSESSIVE-COMPULSIVE SCALE
The “Y-BOCS,” the most widely used of all OCD scales, is a ten-item questionnaire designed to quickly measure OCD’s severity. Although excellent for following progress in treatment, it should not be relied upon to diagnose OCD, as it does not completely assess some important aspects of the disorder, such as degree of avoidance.
The Y-BOCS consists of five questions about obsessions and five very similar inquiries regarding compulsions. The items are well researched and reliable, although numbers 4 and 9 are a bit controversial. Each item is given a rating of 0 to 4, the total score for the test being the sum of the ratings for all ten. Usually, a score of 0–7 is within the normal range; 8–15 indicates mild OCD; 16–23 moderate OCD; 24–31 severe OCD; and 32–40 extreme OCD. Most people who present for treatment of OCD have scores in the 20–30 range. Studies suggest that 2 percent of the population will score 18 or above.
Instructions
Read and answer the following questions. Don’t spend too much time trying to decide—just check the answer that seems to fit best.
1. How much of your time is occupied by obsessive thoughts? How frequently do the obsessive thoughts occur?
0 = None.
1 = Less than 1 hour per day, or occasional intrusions (occur not more than 8 times a day).
2 = 1 to 3 hours per day, or frequent intrusions (occur more than 8 times a day, but most hours of the day are free of obsessions).
3 = More than 3 and up to 8 hours per day, or very frequent intrusions.
4 = More than 8 hours per day, or near-constant intrusions.
2. How much do your obsessive thoughts interfere with your work, school, social, or other important role functioning? Is there anything 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. How much distress do your obsessions cause you?
0 = None.
1 = Not too disturbing.
2 = Disturbing but still manageable.
3 = Very disturbing.
4 = Near-constant and disabling distress.
4. How much of an effort do you make to resist the obsessive thoughts? How often do you try to turn your attention away from these thoughts as they enter your mind?
0 = Try to resist all the time (or the symptoms are so minimal that there is no need to actively resist them).
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 I do so with some reluctance.
4 = Completely and willingly give in to all obsessions.
5. How much control do you have over your obsessive thoughts? How successful are you in stopping or diverting your obsessive thinking? (Note: Do not include here obsessions stopped by doing compulsions.)
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 obsessions, can only divert attention with difficulty.
4 = Obsessions are completely involuntary, rarely able even momentarily to alter obsessive thinking.
6. 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 perform rituals?
0 = None.
1 = Less than 1 hour per day, or occasional performance of compulsive behaviors (no more than 8 times a day).
2 = From 1 to 3 hours per day, or frequent performance of compulsive behaviors (more than 8 times a day, but most hours are free of compulsions).
3 = More than 3 and up to 8 hours per day, or very frequent performance of compulsive behaviors.
4 = More than 8 hours per day, or near constant performance of compulsive behaviors.
7. 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. How would you feel if prevented from performing your compulsions)? 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. How much of an effort do you make to resist the compulsions?
0 = Always try to resist (or the symptoms are so minimal that there is no need to actively resist them).
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. 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 overpowering, rarely able to even momentarily delay activity.
APPENDIX B
THE DSM-IV DIAGNOSTIC CRITERIA FOR OCD
Published by the American Psychiatric Association, The Diagnostic and Statistical Manual of Mental Disorders is the standard guide for diagnosing mental disorders in the United States. Now published in fourteen languages, it is certainly the most authoritative and widely used manual of its type. Its diagnostic criteria are closely aligned to those of the official coding system for all medical disorders throughout the world, the International Classification of Diseases.
The DSM is an evolving document. Currently, it is in its fourth edition. New disorders are added when it becomes clear that they represent independent syndromes; old disorders are deleted if they are better included as parts others. When additional facts are learned about a particular disorder, its diagnostic criteria are modified to become more precise.
In the case of OCD, the most important recent change in diagnostic criteria has been the recognition of the importance of mental compulsions. Prior to the DSM-IV, compulsions were defined simply as behavioral, or observable, acts; now it is recognized that mental acts, or “thought compulsions,” are also very common. The next major change in the DSM, some experts think, may be requiring that both obsessions and compulsions be present in order to make the diagnosis.
The DSM-IV, in introducing the topic of OCD, starts off with a helpful overview of the disorder:
Obsessions are persistent ideas, thoughts, impulses or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress. The intrusive and inappropriate quality of the obsessions has been referred to as “ego-dystonic.” This refers to the individual’s sense that the content of the obsession is alien, not within his or her own control, and not the kind of thought that he or she would expect to have. However, the individual is able to recognize that the obsessions are the product of his or her own mind and are not imposed from without.
Compulsions are repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) the goal of which is to prevent or reduce anxiety or distress, not to provide pleasure or gratification. In most cases, the person feels driven to perform the compulsion to reduce the distress that accompanies an obsession or to prevent some dreaded event or situation.
The essential features of obsessive-compulsive disorder are recurrent obsessions or compulsions (Criterion A) that are severe enough to be time consuming (i.e., they take more than 1 hour per day) or cause marked distress or significant impairment (Criterion C). At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable (Criterion B). If another Axis 1 disorder is present, the content of the obsessions or compulsions is not restricted to it (Criterion D). The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (Criterion E).
The DSM-IV then presents the official diagnostic criteria for OCD.
Obsessive-compulsive disorder is diagnosed when criteria A, B, C, D, and E are present:
A. Either obsessions or compulsions: Obsessions as defined by (1), (2), (3), and (4)
(1) recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
(2) the thoughts, impulses, or images are not simply excessive worries about real-life problems
(3) the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action
(4) the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion) Compulsions as defined by (1) and (2)
(1) repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
(2) the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive
B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children.
C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships.
D. If another Axis 1 disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of Eating Disorder; hair pulling in the presence Trichotillomania; concern with appearance in the presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence of a Substance Use Disorder; preoccupation with having a serious illness in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in the presence of Major Depressive Disorder).
E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
APPENDIX C
SUGGESTED READINGS
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994.
(Widely used and authoritative manual for the diagnosis of psychiatric disorders. It is clearly written and simple enough for the average person to comprehend.)
Baer, Lee. Getting Control: Overcoming Your Obsessions and Compulsions. Boston: Little, Brown, 1991.
(One of the best self-help books. The most complete account of behavior modification techniques for OCD.)
Foa, Edna, and Wilson, Reid. Stop Obsessing! New York: Bantam Books, 1991.
(Another excellent self-help book. I usually recommend this one to patients suffering from mental compulsions.)
Freud, Sigmund. “Notes upon a Case of Obsessional Neurosis.” In Sigmund Freud, Collected Papers, trans. James Strachey. Vol. 3. London: Hogarth Press, 1950.
(Freud’s famous OCD case study, “Rat Man.” Absolutely enthralling, but Freud’s psychoanalytic interpretations are, of course, out of date.)
Goodwin, Donald, and Guze, Samuel. Psychiatric Diagnosis. 5th ed. New York: Oxford University Press, 1996.
(The clearest up-to-date explanation of how psychiatric disorders, including OCD, are diagnosed.)
Hollander, Erik. Obsessive-Compulsive-Related Disorders. Washington, D.C.: American Psychiatric Press, 1993.
(Best book on OCD spectrum disorders.)
Hunter, Richard, and Macalpine, Ida. Three Hundred Years of Psychiatry. Hartsdale, N.Y.: Carlisle, 1982.
(A fascinating compilation of psychiatric cases in centuries past. Of great historical interest.)
Hyman, Steven, and Nestler, Eric. The Molecular Foundations of Psychiatry. Washington, D.C.: American Psychiatric Press, 1993.
(The best overview of recent advances in the biochemistry of psychiatric disorders.
Jenike, Michael, Baer, Lee, and Minichiello, William. Obsessive-Compulsive Disorders: Theory and Management. 2d ed. Chicago: Year Book, 1990.
(Best textbook on OCD. New edition coming out soon.)
Kramer, Peter. Listening to Prozac. New York: Viking Press, 1993.
(More than just a thought-provoking book on Prozac possibilities; an interesting commentary on the entire field of biological psychiatry.)
Lewis, Aubrey. “Problems of Obsessional Neurosis.” Proceedings of the Royal Society of Medicine 29
(1935): 325–336.
(A classic article in which Lewis, the greatest English psychiatrist of the twentieth century, discusses OCD with great foresight.)
March, John. Anxiety Disorder in Children and Adolescents. New York: Guilford Press, 1995.
(Up-to-date and informative. Various experts discuss topics such as neurobiology, social development, and behavioral inhibition.)
Pato, Michele, and Zohar, Joseph. Current Treatments of Obsessive-Compulsive Disorder. Washington, D.C.: American Psychiatric Press, 1991.
(Especially good on group and family approaches to OCD. Medications chapters now out of date.)
Peschel, Enid, and Peschel, Richard. Neurobiological Disorders in Children and Adolescents. San Francisco: Jossey-Bass, 1992.
(Excellent book emphasizing the implications of OCD being a neurobiologic disorder, including insurance coverage and helping OCDers in school.)