Contamination in OCD

Are you a germophobe? People have phobias of all sorts of things -- heights, insects, blood, needles, dogs, you name it. However, people with a fear of germs typically do not have a phobia. Often, this is the contamination subtype of OCD. This will often manifest in tendencies to avoid people, places, or things that are thought to be contaminated. Sometimes the contamination is of a specific disease like HIV or hepatitis, or just general "germs." Other times the contamination can be more vaguely defined. In its extreme forms, contamination OCD can result in people feeling that their homes are too contaminated to continue living in. How do you know if your fear of contamination is a big problem, or just a quirk? Here are some tips -- you should consider seeking help if:

• the contamination can spread from one thing to another and then another
• attempts to rid yourself or your surroundings of contamination of caused you to be late to work, school, or other engagements
• contamination fears have affected your sex life or your romantic relationship(s)
• efforts to prevent/contain contamination have significantly lengthened your daily routines
• time spent washing, disinfecting, or otherwise cleaning has become excessive, or is thought to be excessive by others

OCD research update

This past week saw the annual meeting of the Association of Behavioral and Cognitive Therapies, or ABCT. This is the largest American organization of cognitive-behavioral researchers and therapists. Every year, the latest research is presented on cognitive-behavioral therapies for various types of problems, ranging from anxiety to depression to psychosis. This year one of the important projects discussed was the Brown Longitudinal OCD Study. This research study focused on the long-term changes seen in people with OCD who sought help for their symptoms. The study is one of the largest of its kind.

One of the interesting findings to come from this study are estimates of how many people with OCD have tried various forms of treatment. Of the people studied, 86% had been prescribed SSRI's like Paxil, Prozac, or Zoloft. 54% of the people had received cognitive-behavioral therapy (CBT). That means that the medications were tried more than 50% more frequently than CBT. This may have occurred for several reasons. People may be more interested in a treatment that doesn't require weekly visits, or at-home exercises. Perhaps people tended to visit a physician about their symptoms instead of a therapist. Perhaps CBT was not readily available in the places the study participants lived. Perhaps they were not aware of CBT, but were aware of medications that can help OCD symptoms. Whatever the reasons, the Brown Longitudinal OCD study showed that among people who were taking an SSRI at the time they started the study, 62% described themselves as experiencing significant improvement. Of those people who had received CBT in the past year, 67% rated themselves as experiencing significant improvement. These two numbers (62% vs. 67%) are close enough that we can describe SSRIs and CBT as comparably helpful in this study. Other studies have shown similar results.

Since CBT and medications for OCD work about equally well in many research studies, why are medications used more widely? Perhaps part of the answer lies in people's personal preference. But perhaps part lies in the media's messages about the topic. Here I am referring to advertising. While the pharmaceutical industry only allocates 14% of its advertising moneys on television, radio, and other advertising directly to consumers, this amounts to approximately $8 billion per year (using 2004 figures as described in a January 2008 study published in the Public Library of Science - Medicine). When one considers the essentially negligible amount of funds dedicated to the advertising of CBT, the we can begin to make sense of the disparity between how often each treatment is given.

A future post will be devoted to other ways in which the pharmaceutical industry affects the practice of healthcare in the U.S., and some of the reasons why this happens (see also http://www.sciencedaily.com/releases/2008/01/080105140107.htm).

Mental health parity law

With the recent passage of the federal bailout of the financial industry, a groundbreaking piece of legislation was passed that will significantly affect mental healthcare in the U.S. This bill stipulates that mental health conditions must receive the same insurance coverage as physical health conditions. Thus, treatment for schizophrenia or OCD will not be covered with different annual limits, co-payments, and deductibles than those for, say, arthritis.

This legislation became necessary because health insurance companies in the past 15 years have found it profitable to limit coverage for mental health services, and because existing laws did not prohibit such a practice. Individual states had passed legislation in recent years to prohibit this practice on a statewide basis. Timothy's law in New York is one example, but other states have passed similar laws, including Massachusetts, Oklahoma, and California.

The states' parity laws have varied, to this point, on which mental health disorders would be covered. The federal law does not specify which disorders must have parity. Some states' laws state that only "biologically based" conditions would be covered. What these are, however, varies from state to state. Most typically, OCD, schizophrenia, major depressive disorder, and schizoaffective disorder are considered to be "biologically based." However, the notion that some mental disturbances (and not others) are rooted in physiological problems is a dubious one. The brain contains billions of neurons connected through trillions of synapses, each of which has relevance for how we understand, perceive, move, think, or behave. Learning occurs by reconnecting neurons to one another in different patterns. So, by reading this paragraph, e.g., your brain cells are physically affected. Similarly, anytime that organisms learn to fear something, changes in neurophysiology occur. This means that if you develop a fear of elevators, water, or flying, brain changes occur. Someone who suffers a traumatic event like an assault or an accident and then avoids reminders of the event can also say their neurons were "rewired." The notion that some disorders have "neuronal correlates" in the brain and some do not is oversimplified. However, out of this oversimplification, millions of Americans have the beginnings of fair access to mental health coverage.

David Shern, the president and CEO of Mental Health America, was quoted in the New York Times as saying "this is a historic day and a great civil rights victory for millions of Americans who have been unable to access mental health treatment... With approval of this bill we will tear down the walls of stigma and discrimination and open the doors to the power and promise of treatment and recovery." History may prove this to be more hyperbole than prophetic, but the years-long efforts of legislators and mental health advocates should be recognized in getting this bill passed.

September 11th and Anxiety

For those of us who were living in New York or Washington on September 11th, 2001, and for those of us who were otherwise affected by the events of that day, each anniversary of that date can bring its own difficult memories. It is not uncommon for those who were affected by 9/11 to experience an increase in certain unpleasant symptoms on anniversaries of 9/11/01. These can include troubling memories, dreams or nightmares, anxiety, avoidance of reminders of 9/11, feeling emotionally “numb,” depression, or increased alertness (sometimes described as feeling overly “on guard”). These are symptoms of posttraumatic anxiety. For some people, these symptoms get worse over time, but for others they improve. For many, drug and alcohol use emerge as a way to cope with the symptoms.

The New York City Health Department is sponsoring a program to help people suffering from these symptoms. This program (see http://www.nyc.gov/9-11mentalhealth) pays for psychotherapy for persons who were affected by 9/11, even if only indirectly. This program is only for current residents of New York City. If you have some of the symptoms described above and have not already sought help, consider this program. While seeking help can sometimes be a hard step to take, it’s never too late to address posttraumatic anxiety.

Handwashing - how much is too much?

Many people with OCD I have worked with have described compulsively washing their hands. This habit can become excessive, at times resulting in raw and broken skin. There are two ways that handwashing can get out of control: 1) time spent washing, and 2) frequency of washing.

Excessive handwashing may be the single most common observable symptom of OCD, and is probably the behavior most commonly associated with OCD. But how much is too much? Many people with OCD become quite comfortable washing their hands several times per day. However, the frequency of handwashing can sometimes escalate, becoming a real impediment to living a "normal" life. By the time someone with compulsive handwashing seeks help, they often say that they have forgotten how often a "normal" person will wash their hands.

A good guideline for typical handwashing situations is as follows: after using the restroom, before inserting contact lenses, and before eating. A good guideline for the typical length of time it takes to wash one's hands is fifteen seconds, including time to wet hands and apply soap. If you or someone you know is washing your hands in excess of this, it may be helpful to get a consultation with a professional. This is especially true if handwashing is getting in the way of leading your (or their) life.