• Obsessions are very intrusive and distressing thoughts or images that go well beyond the content of worries. Compulsions are repetitive actions or thoughts that are done to reduce distress, to ameliorate doubt and/or to "prevent" something bad from happening.
• Who among us has not had disturbing (e.g., obscene, violent, blasphemous, racist, mean-spirited, rude, etc.)thoughts pass through our minds? For most of us, these are dismissed with a shudder as mere "brain noise." For some of us, these are the catalysts for profound doubts and alarm.
• For example, many new parents may experience obsessional thoughts of unwittingly harming their infants. Such thoughts often provoke intensely irrational alarm and shame: "Am I the next Andrea Yates? Do I not want this child? Is thinking it the first step toward doing it? If I tell anyone about this, they'll lock me up!"
• Prevalence of Obsessive-Compulsive Disorder = 2-3% Of these, many are primarily obsessional (i.e., no overt compulsions) who are tormented by disturbing thoughts and inner efforts to control or neutralize them. Reassurance seeking and efforts to neutralize thoughts may become compulsions.
• Obsessive thoughts may focus on the most inappropriate, vile, offensive, awful, dangerous or shameful thing you can imagine. Such content, coupled with the knee-jerk effort to suppress or neutralize the thought, is exactly what makes it "stick." The "jolt" your body feels when you have the thought makes the thought seem very important.
• Common obsessive thoughts:
  
  What if I hurt my baby?
  
  What if I'm gay? (in a heterosexual person, or vice versa)
  
  What if I lose control of myself and say something crazy or awful?
  
  What if I lose control of myself and do something crazy or awful? (e.g., suddenly turning the steering wheel while in traffic, jumping from a moving car, jumping from a high place, cutting off all my hair, fondling someone, having sex with an animal, running naked into the yard, doing something obscene or blasphemous in church).
  
  What if I carelessly contaminate myself/my family with germs/disease?
  
  What if I carelessly leave doors unlocked, the stove on, etc.?
• Common compulsions:
  
  Checking, repeating, washing or disinfecting, praying, counting, ordering, hoarding, reassurance-seeking, touching, neutralizing thoughts, doing something until it feels "just right.". (Notice that "compulsions" are not the same as impulse disorders like "compulsive gambling" or "compulsive spending.")
• Like with worries, the consuming desire to get rid of obsessive thoughts is not a solution. It is the major contributor to the problem.
• Those plagued by obsessions doubt their self-control of their own behavior. Yet, such individuals' profound alarm and guilt about their disturbing thoughts suggest that their brain's orbital frontal cortex is successfully doing its job: actively inhibiting untoward or dangerous actions, no matter what the thoughts. OCD is a disorder of overcontrol, not undercontrol. If you have manifestations of OCD and have never acted on such thoughts but are severely distressed by them, the inhibitory activity of your brain is entirely contrary to your fears. Check with a professional familiar with OCD to be sure.
• Like with worry, many of the same cognitive errors rule:
  
  Thoughts are over-valued.
  ("If I keep thinking this, it must be really important.")
  
  Doubt is translated into actual danger.
  ("Thinking it is dangerously close to doing it. If I keep thinking it, I must be getting closer to doing it.")
  
  Thought content must be controlled.
  ("I've got to use will power!")
  
  Total certainty is not only possible but imperative.
  ("How can I be absolutely sure I won't….")
  
  Need to avoid culpability.
  ("If I'm careful enough, I can't be held responsible for bad things.")
  
  Magical power to keep things from happening.
  ("If I can control this bad thought, my loved ones will be safe.")
  
  Wish to erase all risk.
  ("If I'm careful enough, I can control the risk.")
• Thus, effective treatment often begins with cognitive therapy and education tailored to address such errors in thinking. In some individuals, such an understanding may be enough. However, many individuals will need to use exposure (i.e., repetitive, voluntary immersion in the obsessive thought they ordinarily try to avoid or neutralize) in order to recover. If there are compulsions, special effort will be directed toward response prevention (i.e., blocking the automatic connection between the anxiety-arousing obsession and the anxiety-relieving compulsion).
• Examples of self-conducted exposure, preferably guided by a therapist familiar with OCD:
  
  "Scheduled Obsessing": Schedule several times per day when you give your full attention to your obsession and the distress that accompanies the thought. Try to postpone other intrusions of the obsession until your next scheduled time to give it your full attention. Do not allow yourself to do or think anything to lessen your distress until a set time on the clock.
  
  "Loop Tape": Your therapist can help you write a vivid transcript of your obsession that you record on a cassette tape. You can then listen to this tape for regular exposure sessions to the point of habituation (i.e., until no anxiety is aroused and you mostly feel bored listening to your own obsession).
  
  Standard Exposure: If you fear "satanic" thoughts, you might watch The Exorcist repetitively to the point of habituation. If you fear harming children, you might research the Andrea Yates case until it no longer raises your anxiety. If you fear sexual thoughts, you might repeatedly write every "dirty" word and act you can imagine. If you fear "germs" or contamination, you might deliberately touch "dirty" things. A therapist can help you tailor exposure to your particular obsessions.
  
  Change the status quo of an obsession: Don't try to make it go away, but change the obsession in some manner. For example, sing the content of your blasphemous thought. Write down everything that you can think of in five minutes related to a sexually charged obsessive thought. Make all AIDS-related obsessive thoughts "blue" in your mind (e.g., color them blue and envision the word "blue" amidst such thoughts) and remind yourself that all such "blue" thoughts are obsessions. Turn your obsessive image of a reprehensible act into an absurd slapstick comedy that "plays" in your mind.
• Examples of self-conducted cognitive therapy (see Schwartz's book, Brain Lock):
  
  1. Relabel: Clearly identify and label each obsession and compulsion for what they are (e.g., "No, I'm not about to lose control of myself-this is just an obsession creating a false alarm.")
  
  2. Reattribute: "This thought is nonsense and does not need to be examined. It's not me, it's my OCD. Just because the orbital cortex of my brain is overly active right now does not mean I have to take it seriously."
  
  3. Refocus: "My brain is not shifting gears for me, so I must do it. I know this is an obsession I'm stuck on, so I'm going to shift my attention to ______ (any pleasant behavior)." Invest yourself in this activity instead of analyzing, examining or trying to get rid of the obsessive thought. Try to let at least 15 minutes pass before you do anything about an obsessive thought. Strive not to do what your OCD "tells" you to do.
  
  4. Revalue: Become an impartial spectator of your own thoughts. Devalue the OCD feeling that has been so compelling. Anticipate obsessions-it's not a question of "if" they come-they will come. When they do come, revalue them as acceptable brain noise.
• Medications can be very useful and can sometimes be imperative for OCD:
  
  Anafranil (clomipramine) was the first "antidepressant" that also showed anti-OCD effects, too. SSRI's (e.g., Prozac, Paxil, Zoloft, Celexa, Lexapro and Luvox) and other "antidepressants" (e.g., Effexor) are the most commonly used, are generally best tolerated, and are well-studied. Higher range dosing for longer periods is the norm. Combinations of medications may augment your response. There can be remarkable individual differences in response and side effects across the various medications. Having no response or uncomfortable side effects to one drug does not predict your potential response to another drug. Consult with someone who is an expert in the psychopharmacology of OCD and be patient.
  
  
  
  
  When certainty will finally be attained.
• Further Reading: Obsessive-Compulsive Disorder
  
  Baer, L. The Imp of the Mind: Exploring the Silent Epidemic of Obsessive Bad Thoughts. New York: Dutton, 2001.
  
  Foa, E. and Wilson, R. Stop Obsessing: How to Overcome Your Obsessions and Compulsions. New York: Plume, 1991. (Especially Chapter 5, "Letting Go of Worries and Obsessions")
  
  Grayson, J. Freedom from Obsessive-Compulsive Disorder: A Personalized Recovery Program for Living with Uncertainty. Berkeley Trade, 2004.
  
  Schwartz, J. Brain Lock: Free Yourself From Obsessive-Compulsive Behavior. New York: Regan, 1996.

SS

Psychotherapy of obsessive-compulsive disorder and spectrum:
Established facts and advances, 1995-2005.
Neziroglu F, Henricksen J, Yaryura-Tobias JA.
Psychiatric Clinics of North America, 2006 Jun;29(2):585-604.

Dropout rates and refractory cases persist, for reasons that remain unexplained. There are few predictor variables and few innovative approaches to deal with them. New treatment approaches must be developed to improve treatment response even for the responders. Studies show that symptoms are reduced minimally (30%-50%). No new ways of dealing with treatment-refractory cases have been developed. Studies now include more co-morbid cases, however, and their inclusion may account for some of the lack of progress in improvement rates. It needs to be seen whether patients who have one or more comorbid conditions do as well as patients who do not have comorbidity and whether the number or type of comorbid disorders accounts for treatment response. Perhaps better results would be seen with pure OCD cases. Certainly results now are more generalizable to clinical practice. Now it is important to look for alternative treatment approaches and to apply cognitive therapy to more specific problems. Cognitive therapy seems to be helpful with the disorders of the obsessive-compulsive spectrum. The attrition rate is lower when cognitive therapy is used in the treatment of hypochondriasis, and cognitive therapy also is helpful in reducing OVI , which is more severe in body dysmorphic disorder and hypochondriasis. The role of cognitive therapy in OVI needs further exploration.

Anxiety and Stress Disorders Institute of Maryland:
Treating anxiety disorders and stress-related disorders in Towson, Maryland, since 1978.