Brain Lock: Free Yourself From Obsessive-Compulsive Behavior (32 page)

In the Refocus step during therapist-assisted exposure and response prevention, the person with OCD focuses his or her attention on the support of and interaction with the therapist while waiting for the anxiety from the exposure to an OCD-inducing stimulus to subside. When you work on your own, as described in Chapter Three, you can Refocus on other constructive behaviors and use the fifteen-minute rule as a rule-of-thumb time-delay period for response prevention. Of course, you should always try to lengthen each time-delay period or put together strings of fifteen-minute periods. Always remember to continue to Relabel and Reattribute during these periods. The idea is not to wait passively, but to Actively Revalue the urges as nothing but OCD symptoms that you are not going to allow to control your life anymore. As you get better control of your behavioral responses, you are also improving your own brain function. Breaking the loop that uses anxiety and fear to tightly bind obsessive thoughts to compulsive behaviors leads you to a progressive Revaluing of the obsessions and urges and results in further decreases in anxiety.

The use of a behavioral hierarchy based on the SUDS scale as a way of creating structured exercises in exposure and response prevention is an excellent approach to doing behavior therapy and applying the Four Steps.

KEY POINTS TO REMEMBER

• Create a behavioral hierarchy.

• Start working on the less anxiety-provoking symptoms and achieve successes before proceeding up the hierarchy. Don’t overwhelm yourself. Regular, steady progress is what you’re aiming for.

• Use the fifteen-minute rule and try to put sequences of time-delay periods together.

• Use the Four Steps on a consistent basis.

9

OCD and Medication

M
y research for over twenty years has largely been on the biological and medication side of psychiatry, and I remain an advocate of the proper use of psychopharmaceuticals. But what exactly is the proper use of medications in treating OCD? Well, I can tell you right now that I’m not a big fan of the “take this pill and wait to get better” school of psychiatry. It’s too passive, requires too little directed effort by the person, and puts too much of the responsibility for the success of treatment on the doctor finding the “right formula.”

Throughout this book, I have repeatedly referred to the “waterwings” approach to using medications, a term that I coined in the course of my work with people whose ability to do the Four Steps seemed enhanced by adding medication. It simply refers to the fact that in the early stages of treatment many people with OCD (typically about one-half to two-thirds) found that by making the symptoms less intense, medications made it easier to do the Refocus step. (However, it should be stressed that all the people in the behavior-therapy-brain-imaging studies we did at UCLA were totally medication-free.) Thus, the medication functions like waterwings do in helping a child to learn to swim: It reduces the fear and makes it easier to “float along” while you’re learning the strokes. The analogy seems particularly apt because just as children who are learning to
swim can function with less and less air in the waterwings and eventually do without them, people with OCD who do the Four Steps can get by with lower and lower doses of medication as the weeks go by and they keep working on their behavior therapy. Eventually, many of them end up on low doses or no medication at all. As our research has shown, doing the Four Steps alone changes brain chemistry in almost exactly the same way as medication does.

The medications studied so far that have been consistently helpful in treating OCD all interact with a chemical in the brain called serotonin. Serotonin is one of many brain neurotransmitters—chemicals that help to transmit signals from one nerve cell to another. After a neurotransmitter is released by a nerve cell, one main way in which it becomes deactivated is by being picked up by a “pump” and taken back up into the nerve cell. The complex molecules that pick up neurotransmitters to deactivate them are thus called “reuptake pumps.” One of the most widely used groups of medications prescribed by doctors today is called selective serotonin reuptake inhibitors or SSRIs, which selectively block or inhibit the reuptake pump that deactivates serotonin.

Three SSRIs that have been approved by the Food and Drug Administration (FDA) for treating OCD are fluoxetine (Prozac), paroxetine (Paxil), and flovoxamine (Luvox). The only other medication approved by the FDA at this time for the treatment of OCD is clomipramine (Anafranil), which is also a reuptake inhibitor, but is an older drug from the early days of psychopharmacology, is not selective, and acts significantly on neurotransmitters other than serotonin. One other SSRI with reasonable research support for treating OCD that has not yet been approved by the FDA for that purpose is sertraline (Zoloft). Probably the most important thing to remember to get the maximum OCD treatment effect from these medications is that they take a few months to show their full effect. The general principle is that you must take any one of these medications for three months to determine if it is effective for treating your OCD. Of course, in any particular case, you should follow your doctor’s instructions. (An interesting side point is that all these SSRIs are also effective in treating depression, generally in about half the time it takes them to treat OCD.)

Even though it takes three months to see the full effects of these medications on OCD symptoms (which generally means about a 50 percent decrease in the severity of symptoms), they
can
make it easier for you to do the Four Steps considerably faster than that. Unfortunately, no research has been conducted to show whether behavior therapy can make medications work faster, but I believe, after treating many hundreds of OCD patients with both behavior therapy and medication, that it definitely does. It certainly makes sense that it might, given that behavior therapy itself changes how the brain works in the same way that medications do. There’s no doubt that a lot of research still needs to be done in the mental health field.

One medication that the FDA approved for treating anxiety works mainly by acting on serotonin but not by acting on the reuptake pump. It’s called buspirone (BuSpar), and though it’s not particularly effective in decreasing the intensity of OCD symptoms on its own, it is quite helpful for people who get too anxious when they try to do behavior therapy. It seems particularly helpful for the cognitive part of the treatment, when people get so frightened by the OCD that they forget to Relabel and Reattribute or get so anxious that they can’t Refocus and realize, “It’s not me—it’s OCD.” BuSpar is a mild medication, is generally fairly easy to tolerate, and usually takes about two to four weeks to begin to work effectively. It also combines quite smoothly with the SSRIs and can even block some of the side effects of that group of medications, if your doctor wants to use them together.

So if you’re being overwhelmed by OCD or think that you could use some waterwings to help you learn to do the Four Steps, by all means talk to your doctor about the possibility of using medication. But please remember this: You must do the work. Whatever you sow, that you will also reap.

KEY POINTS TO REMEMBER

• Medications are like waterwings or training wheels—they can help keep things under control as you learn the Four Steps.

• Allow several months for things to reach an equilibrium.

• Lower doses of medication
slowly
.

• As the dose comes down, the OCD symptoms may well get stronger. Use the Four Steps to manage your responses in a controlled fashion.

• As your brain changes by doing the Four Steps, the need for medication almost always decreases.

10

University of Hamburg Obsession-Compulsion Inventory Screening Form

Do you wash your hands after you feel you have come too close to an animal or dirty object?

1. True False

Do you reposition tablecloths or rugs because you think they are not exactly right?

2. True False

Are there days when you have to think about certain words or images so much that you are unable to do anything else?

3. True False

Is it often impossible for you to stop repeating (if only to yourself) a sentence already spoken?

4. True False

During the day do you think several times about work you have already finished?

5. True False

Do you find that you cannot stop counting during certain activities?

6. True False

Do you sometimes try to distract yourself from a thought about your partner doing something he or she would not want you to know about?

7. True False

Are there any activities you cannot finish before having counted to a certain number?

8. True False

Do you sometimes consciously distract yourself from the thought of hurting or killing yourself?

9. True False

During the course of the day, do you often remember a certain word, picture, or sentence?

10. True False

Do you check the cleanliness of public seats, such as those in buses or taxis, before you sit down?

11. True False

Do you sometimes repeat aloud what has already been spoken, although you try to prevent yourself from doing it?

12. True False

Having left your home, do you constantly have to think about whether everything is in order there?

13. True False

Before starting to dress, do you think about exactly how to do it?

14. True False

Did you ever find yourself counting things for no reason?

15. True False

Was there ever a day when you could not think about anything else except hurting or killing yourself?

16. True False

Do you wash your hands after reading the newspaper?

17. True False

Did you ever notice that you touch things several times before or after you have used them?

18. True False

Have you ever touched switches on electric devices several times and counted despite trying not to?

19. True False

Do you check books or magazines for dog-ears and straighten them immediately?

20. True False

Do you fold newspapers back to the original way after reading them?

21. True False

Does the thought often occur to you that you might get sick or go blind or crazy?

22. True False

Are there days when you can think only about hurting or killing someone?

23. True False

After going to bed, do you get up again to check all electrical devices?

24. True False

Does counting the number of times you touch switches of electrical devices interfere with your everyday activities?

25. True False

Do you rearrange objects on your desk, in your cupboard, or other places repeatedly, even though nothing’s been touched since you last arranged them?

26. True False

Do you check the return address immediately before you mail a letter?

27. True False

SCORING

A. Calculate the total number of answers circled true for questions 3, 4, 5, 6, 7, 8, 9, 10, 13, 14, 15, 16, 22, and 23. These are obsessions.

If the
total
number of true answers circled for these questions is

1 or 2: You probably do not have clinically significant obsessions.

3, 4, 5, or 6: You probably have obsessions that are clinically significant.

7–14: You definitely have obsessions that are clinically significant.

B. Calculate the total number of answers circled true for questions 1, 2, 11, 12, 17, 18, 19, 20, 21, 24, 25, 26, and 27. These are compulsions.

If the
total
number of true answers circled for these questions is

1, 2, or 3: You probably do not have clinically significant compulsions.

4, 5, 6, or 7: You probably have clinically significant compulsions.

8–13: You definitely have compulsions that are clinically significant.

Source:
Dr. Iver Hand and Dr. Rudiger Klepsch, University of Hamburg, Germany.

If you want further information on OCD, please contact the Obsessive-Compulsive Foundation National Headquarters, P.O. Box 70, Milford, CT 06460, a nonprofit organization, at (203) 878-5669; fax (203) 874-2826.

11

An OCD Patient’s Diary of Four-Step Self-Treatment

Note: One of our patients kept these notes on how to apply the Four Steps to his own symptoms early in treatment. They are presented only as an example. Other people may organize their symptoms quite differently
.

BREAK THE ENDLESS LOOP. MONSTER ANALOGY. RECOGNIZE OCD THOUGHTS.

1. RELABEL immediately as:

A. Obsessive Thought

Obsessive Idea

Obsessive Phrase

Obsessive Word (number of letters, symmetry, associations).

Obsessive Image

Types:
Violent. Sexual. Excrement. Blasphemy. Loved one. Future-deprivation of pleasure. Self-punishment. (Scrupulosity.) Bad person. (Blaming myself. Intention. Do I mean that?)

Excuses:
False wish, hope. Subtle-twist anger. Subtle-twist half-reality. Contamination. Need to be perfect. Need to confess. What if? Bad person. Need for reassurance.

B. Anxiety—temporary. Guilt. Sad. Nervous.