MAINTENANCE TREATMENT

Once OCD symptoms are eliminated or much reduced, a goal which is practical for the majority of those with OCD, then maintenance of treatment gains becomes the goal.

Maintaining treatment gains

When patients have completed a successful course of treatment for OCD, most experts recommend monthly follow-up visits for at least 6 months and continued treatment for at least 1 year before trying to stop medications or CBT.

Relapse is very common when medication is withdrawn, particularly if the person has not had the benefit of CBT. Therefore, many experts recommend that patients continue medication if they do not have access to CBT.

Individuals who have repeated episodes of OCD may need to receive long-term or even lifelong prophylactic medication. The experts recommend such long-term treatment after 2 to 4 severe relapses or 3 to 4 milder relapses.

Discontinuing treatment

When someone has done well with maintenance treatment and does not need long-term medication, most experts suggest discontinuing medication only very gradually, while giving CBT booster sessions to prevent relapse. Gradual medication withdrawal usually involves lowering the dose by 25% and then waiting 2 months before lowering it again, depending on how the person responds.

Because OCD is a lifetime waxing and waning condition, you should always feel comfortable returning to your clinician if your OCD symptoms come back.

http://www.psychguides.com/node/75

Factsheet: Obsessive-compulsive Disorder (OCD)

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Anxiety Disorders

People with obsessive-compulsive disorder (OCD) suffer intensely from recurrent unwanted thoughts (obsessions) or rituals (compulsions), which they feel they cannot control. Rituals, such as handwashing, counting, checking or cleaning, are often performed in hope of preventing obsessive thoughts or making them go away. Performing these rituals, however, provides only temporary relief, and not performing them increases anxiety. Left untreated, obsessions and the need to perform rituals can take over a person's life. OCD is often a chronic, relapsing illness.

Characteristics

Obsessions are thoughts, images or impulses that occur repeatedly. The person does not want to have these ideas, finds them disturbing and intrusive and, usually, recognizes that they really don't make sense. Obsessions are accompanied by uncomfortable feelings, such as fear, disgust or doubt. Common obsessions include contamination fears, imagining having harmed self or others, imagining losing control of aggressive urges, intrusive sexual thoughts or urges, excessive religious or moral doubt, or a need to tell, ask or confess.

People with OCD typically try to make their obsessions go away by performing compulsions. Compulsions are acts the person repeatedly performs, often according to certain “rules.” These rituals are performed to obtain relief from the discomfort caused by the obsessions. Examples of compulsions are washing, repeating, checking, touching, counting, ordering/arranging, hoarding or saving, and praying.

In some instances, a person may suffer from only obsessions or only compulsions.

OCD symptoms cause distress, take up a lot of time (more than an hour a day), or significantly interfere with the person's work, social life or relationships.

Most individuals with OCD recognize that their obsessions are not just excessive worries about real problems and that the compulsions they perform are excessive or unreasonable. The extent to which a person with OCD realizes that his or her beliefs and actions are unreasonable is called his or her “insight.”

Causes

There is growing evidence that OCD has a biological basis. OCD is no longer attributed to family problems or to attitudes learned in childhood. Instead, the search for causes now focuses on the interaction between biological factors and environmental influences.

Research suggests that OCD involves problems in communication between parts of the brain. These problems may be caused by insufficient levels of certain brain chemicals, called neurotransmitters. Drugs that increase the brain concentration of these chemicals often help improve OCD symptoms.

Treatments

The most common treatment for OCD is a combination of cognitive-behavioral psychotherapy (CBT) and medication.

A type of behavioral therapy known as “exposure and response prevention” (E/RP) is very useful for treating OCD. In this approach, a person is deliberately and voluntarily exposed to whatever triggers the obsessive thoughts (exposure) and is then taught techniques to avoid performing the compulsive rituals (response prevention). The cognitive portion of CBT is often added to E/RP to help challenge the irrational beliefs associated with OCD.

Co-occurring Illnesses

OCD is sometimes accompanied by depression, eating disorders, substance abuse, attention deficit/hyperactivity disorder or other anxiety disorders. When a person also has other disorders, OCD is often more difficult to diagnose and treat. Appropriate diagnosis and treatment of other disorders are important to successful treatment of OCD.1 On average, people with OCD see three to four doctors and spend over nine years seeking treatment before they receive a correct diagnosis. Studies have also found that it takes an average of 17 years from the time OCD begins for people to obtain appropriate treatment.

http://www.mentalhealthamerica.net/go/ocd

About OCD and How it is Diagnosed

Current Facts About Obsessive-Compulsive Disorder

Symptoms of OCD

OCD involves ongoing obsessions and compulsions that interfere with daily life. Obsessions are unwanted ideas, thoughts, impulses, or images cause anxiety or distress. Obsessions are usually in one or more of six areas including: aggression, contamination, sex, hoarding/saving, religion, and symmetry/exactness.

However, the content alone is not enough for an OCD diagnosis. In fact, nearly 90% of the general population experiences similar obsessions. What distinguishes OCD obsessions from non-clinical obsessions are the greater frequency, intensity, and discomfort. OCD sufferers attach much greater meaning and threat to these thoughts than most people. What separates OCD patients from people with a delusional or thought disorder is that they usually realize the obsessions are unrealistic and a product of their own minds. Only 4% of OCD patients believe with absolute certainty that their feared consequences will actually occur, and most realize that their reactions to the thoughts are excessive. OCD thoughts, impulses, or images are not simply excessive worries about real-life problems and are not consistent with the individual's self-perception.

In addition to frequent obsessions, most individuals with OCD engage in actions, called compulsions or rituals, to reduce the anxiety from the obsessions. As in the case of obsessions, compulsions are also often categorized into six categories including: cleaning, checking, repeating, counting, ordering/arranging, and hoarding/collecting. The most common compulsion reported by people with OCD is checking. See the Table for other common obsessions and compulsions.

It is usually the case that at some point the compulsions were logically linked to the obsessions. For example, a person with a fear of contamination may resort to washing their hands excessively or use antibacterial gels to the point of skin irritation. Another frequent compulsion is excessive checking. Interestingly, these patients often report memory problems driving them to re-check tasks. However, research suggests this low confidence in memory is not associated with actual memory impairment.

Who Gets OCD

It is estimated that between 2 and 3 million people are suffering from OCD in the United States. The National Comorbidity Survey Replication (NCS-R) showed that about 1.6% of the United States population reported obsessive-compulsive disorder at some point in their lives, with 1% of the sample experiencing obsessive-compulsive disorder within the last year. The prevalence of OCD appears to be about the same among ethnic and national groups across the US and internationally. For example, a recent study of African Americans showed an OCD lifetime prevalence of 1.6%. Interestingly, while prevalence rates of OCD among African Americans were identical to the overall prevalence in the NCS-R, age of onset was later (about 32 years old), and use of mental health services was much lower, resulting in greater disability.

Unlike many other anxiety disorders, males and females get OCD in equal numbers. However, age of onset is often earlier in males (13-15) than females (20-24). Age of OCD onset can be as young as 2 years old but usually occurs in early adolescence or young adulthood.

What Causes OCD

The exact cause of OCD is uncertain. Some behavioral scientists believe that overprotective or unusually rigid childhood family relationships may be a factor, but there is not yet adequate research to support his theory. As is the case of several mental disorders, OCD often appears to coincide with major stressors. Approximately 60% of OCD cases follow a stressful experience, traumatic life experience, or pregnancy and childbirth. But there is increasing evidence that genetic and biological factors are significant causes of OCD as well. OCD tends to run in families, and OCD patients have been shown to have deficits of the brain chemical serotonin, which regulates our sense of emotional and psychological well-being. Brain scans of persons with OCD clearly show differences in brain circuit activity versus those without OCD. Most likely, persons with OCD are best understood as having inherited a genetic biological vulnerability to the disorder which may be triggered often during times of stress and transition such as a job change, going off to college, childbirth, or divorce.

Unfortunately, research suggests that without treatment the natural course of OCD is chronic. A notable exception is among some children with OCD, whose symptoms appear abruptly with the onset of strep or other infections. These OCD manifestations are known as pediatric autoimmune neuropsychiatric disorders or PANDAS. OCD symptoms in these cases decrease with treatment of the infection and may increase upon recurrence of infection.

Impact of OCD

OCD results in severe personal distress and interferes with employment, relationships, and the daily activities of living in adults, children, and adolescents. Between 80 and 100 percent of people with severe OCD report major difficulties at home (100%), work (80%), relationships (87%), and social life (87%). One study showed that 22% of treatment-seeking participants with OCD were unemployed compared to the 6% unemployment rate for the US general population at the time. Another study showed an even higher unemployment rate (40%) among patients with OCD. OCD patients are also overrepresented in health care populations. One survey showed that OCD patients saw dermatologists and cardiologists more often than the general public and even more than individuals with panic disorder or generalized anxiety. Such high medical use, unemployment, and lost productivity due to OCD cost the US economy billions of dollars each year. It is estimated that in 1990 the direct and indirect cost of OCD to the US economy was $8.4 billion. OCD is considered one the top ten causes of disability worldwide.

Individuals with OCD may suffer with obsessions and compulsions for up to 17 hours a day or more. Not surprisingly, this time commitment and distress often interferes with interpersonal relationships. Half of OCD sufferers report losing friends and a quarter say that OCD caused the end of an intimate relationship. This is consistent with other findings that about 60% of OCD patients report difficulty maintaining relationships. Celibacy rates are also higher in OCD populations even relative to other anxiety disorders, and approximately half of married patients with OCD report marital distress.

OCD with Other Mental Disorders

Comorbidity (having more than one mental disorder) among patients with OCD is more the rule than the exception. The most recent finding is that a full 90% of people with OCD have at least one additional psychiatric disorder. See table for lifetime comorbidity of OCD with other psychiatric disorders.

Anxiety disorders were the most common additional diagnosis (76%) followed by mood disorders (63%), impulse-control disorders (56%), and substance use disorders (39%). Eating disorders are also common among women with OCD. Ten percent of women with OCD have a history of anorexia. Likewise, 33% of women with bulimia have a history of OCD. Although effective treatment improves the quality of life among individuals with OCD, it is common for people with OCD to suffer many years before receiving adequate treatment. For example, one study showed OCD patients suffered for an average of 8 years before seeking treatment. Also, only a minority of patients (29%) receive treatment specifically for OCD.

http://www.ocdhope.com/obsessive-compulsive-disorder.php

Obsessive-Compulsive Disorder in Kids

For Families With Children Who Have OCD

About 1 percent of children, that is, some 200,000 American children and teenagers have OCD. In childhood OCD, a family history of OCD is more frequent than in adult onset OCD, leading us to believe that genetic factors may play more of a role in childhood OCD.

Months or years may pass before parents become aware that their child has a problem because children often hide their obsessions and compulsive behaviors. They try to suppress symptoms until they are alone, or at least until they get home from school. Children have a very strong need to feel accepted by others, to fit into their peer group. The strange behaviors and senseless compulsions are embarrassing to them so they hide them.

It is best to treat OCD early. The longer it goes untreated, the more generalized the symptoms become. They invade more and more of the child's life and make OCD more difficult to treat . With treatment, OCD may or may not follow the child into adulthood. Some children may have minimal symptoms as adults or no symptoms at all. Others go into remission their symptoms disappear, but return during adulthood. OCD often changes over time. Symptoms experienced as an adult may be different from those experienced as a child. Why do symptoms sometimes disappear with treatment, and then reappear later in life? No one knows for sure, but hormones and stress may cause changes in a person's biological makeup, and thus affect the expression of OCD symptoms.

Children and Rituals - Could It Be OCD?

At some point during the course of the disorder, adults with OCD recognize that their obsessions and compulsions are excessive or unreasonable. This requirement for diagnosis does not apply to children. They may lack adequate cognitive awareness to make this judgment. When they are anxious and obsessing, even adults with OCD may not realize they are being unreasonable.

Most children go through developmental stages characterized by compulsive behaviors and rituals that are quite normal. These behaviors are common between the ages of two and eight, and seem to be a response to children's needs to control their environment and master childhood fears and anxieties. Dr. Henrietta Leonard, who studied the relationship between children's developmental rituals, superstitions, and OCD, wrote that between the ages of four and eight the developmental rituals are usually most intense. Boys express their belief that girls have "cooties," a form of imagined contamination where boys may vehemently avoid being touched by girls. By age seven collecting things (hoarding in OCD) becomes common. sports cards, comic books, toy figures, jewelry and dolls are among the popular collectibles. Between the ages of seven and eleven children's play becomes highly ritualized and rule-bound. Breaking the rules of a game is likely to be met with cries of "No fair!" In adolescence rituals may subside but obsessive preoccupation with an activity or a music or sports idol is common.

Superstitions are ritual-like behaviors often seen in normal children. These are forms of "magical thinking" in which children believe in the power of their thoughts or actions to control events in the world. "Lucky" numbers and rhymes, such as "step on a crack, break your Momma's back," helps to bring about a sense of control and mastery. These normal childhood rituals advance development, enhance socialization, and help children deal with separation anxiety. Young children's' rituals help them develop new abilities and define their environment. As they mature and develop into adulthood, most of these ritualistic behaviors disappear on their own. In contrast, rituals of the child with OCD persist well into adulthood. They are painful, disabling, and result in feelings of shame and isolation. Attempts to stop doing the rituals result in extreme anxiety.

Parents of a child with OCD are frequently frightened, confused, and frustrated by their child's persistence and preoccupation with cleanliness, orderliness, or checking rituals. Often, parents react at the extremes of either intimidation or passive enabling. If parents overreact and attempt to interrupt the behaviors, the child may become hostile and extremely anxious. If parents give in to the rituals, the child never learns to confront his or her fears. Out of frustration, many parents give in to the child and may even reluctantly assist in the rituals, for example, doing repeated loads of the child's laundry because he insists his clothes are "contaminated."

Cleaning, Checking, Counting, and Children

Obsessions that focus on contamination are the most commonly reported obsessions in children. Fears of contamination by dirt and germs lead to avoidance of suspected contaminates and excessive washing. They may wash in a self-prescribed manner, more frequently, or for excessive lengths of time.

An obsession with contamination sometimes produces the opposite effect. In these cases, fear of contamination of body parts, personal objects, or both, leads to a reluctance or outright refusal to touch them. Observe for untied shoes, un-brushed teeth, sloppy clothing, and uncombed, dirty hair - especially in a child known previously to be neat and well-groomed.

Checking compulsions are also common in children and adolescents with OCD. They are often precipitated by fear of harm to self or others, or the child may be troubled by extreme doubt. Checking such things as doors, light switches, windows, electrical outlets, and appliances may take up hours every day. The child may spend hours on an assignment that should take only an hour or feel compelled to check and recheck answers on assignments - to the point that it interferes with the completion of homework.

Some children with OCD have obsessions with numbers. They may have "safe" and "unsafe" numbers, repeat actions a certain number of times, or repeatedly count to a given number. Children may also repeat actions, such as walking through a doorway, until it "feels right" or in a self-prescribed manner. Look for repetitious questioning, reading sentences over and over, and numerous eraser marks on papers from erasing and rewriting words or numbers.

Symmetry rituals may be manifested by tying and retying shoes or constantly rearranging objects until they are even. Items must be arranged in such a way that they appear symmetrical to the child. Many children with OCD have difficulty wearing certain clothes. Hypersensitivities to touch, taste, smell, and sound are common.

Fear of harming others or self, excessive moralization, and religiosity are often seen in children with OCD. Children and teenagers with OCD frequently have a tendency toward perfectionism and rigidity or stubbornness. They are likely to have above normal intelligence, have a more adult-like moral code, have more anger and guilt, be disruptive, and have a more active fantasy life.

Below is a list of signs of OCD in children to look for. Keep in mind when reading them that, by definition, OCD symptoms must be time consuming, cause marked distress, or significantly interfere with one's life. These are simply signs that there may be a

problem. If you notice them, discuss them with your child in a nonthreatening way. If OCD is suspected, consult a psychiatrist that specializes in treating OCD.

Signs of Obsessive-Compulsive Disorder in Children (Adapted and expanded from Detecting Obsessive-Compulsive Disorder in Children and Teens, by Cherlene Pedrick RN in Teachers in Focus, February 1999)

• Being overly concerned with dirt and germs.
• Frequent hand washing or grooming, often in a ritualistic manner - red, chapped hands from excessive washing.
• Long and frequent trips to the bathroom.
• Avoiding playgrounds and messy art projects, especially stickiness.
• Untied shoes, since they may be "contaminated."
• Avoiding touching certain "unclean" things.
• Excessive concern with bodily wastes or secretions.
•  Insistence on having things in a certain order.
•  Having to count or repeat things a certain number of times, having "safe"  or "bad" numbers.
• Repeating rituals, such as going in and out of doors a certain way, getting in and out of chairs in a certain way, or touching certain things a fixed number of times. This may be disguised as forgetfulness or boredom.
• Excessive checking of such things as doors, lights, locks, windows, and homework.
• Taking excessive time to perform tasks. You may find a lot of eraser marks on school work.
• Going over and over letters and numbers with pencil or pen.
• Excessive fear of harm to self or others, especially parents.
• Fear of doing wrong or having done wrong.
• Excessive hoarding or collecting.
• Staying home from school to complete assignments, checking work over and over.
• Withdrawal from usual activities and friends
• Excessive anxiety and irritability if usual routines are interrupted.
• Daydreaming - the child may be obsessing.
• Inattentiveness, inability to concentrate or focus (often mistaken as ADD).
• Getting easily, even violently upset over minor, trivial issues.
• Repetitive behaviors including aimlessly walking back and forth in the halls.
• Unexplained absences from school.
• Persistent lateness to school and for appointments.
• Excessive, repetitive need for reassurance for having done, thought, or said something objectionable.
• Asking for reassurance, when the answer has already been given.
• Rereading and re-writing, repetitively erasing.

Help for Children with OCD

Adults usually seek treatment because OCD is interfering with their lives. Children don't always recognize that they have a problem. They are often brought to the doctor when they exhibit unacceptable behavior and difficulty in school. Young people and their parents need to know there is hope and help for children with OCD.

As with adults, the combined use of medication and cognitive-behavior therapy is widely recognized as the best treatment for childhood OCD (March, 1998). Discuss your options with your child's medical team. You may want to try CBT alone first, or combine CBT with medication. In severe cases, you will probably want to start medication before beginning CBT. Together, CBT and medication are powerful tools in the struggle against OCD.

First, let's summarize medication treatment for children. A detailed discussion of medication treatment of obsessive-compulsive disorder is beyond the scope of this book. This is only a review.

Medication

As with adults, five medications make up the first line of defense in medication therapy for children with OCD: Anafranil, Prozac, Zoloft, Paxil, Luvox, and Celexa. It takes up to 12 weeks at the proper dose to determine if a medication is going to work. If one medication doesn't work, there is a good chance that another will. It is necessary for the child to make an attempt at resisting OCD symptoms while the medication is being tried. This is where cognitive-behavior therapy can be very helpful by training the child in the techniques of confronting obsessive worries and resisting compulsions.

Cognitive-Behavior Therapy

Children can benefit greatly from cognitive-behavior therapy (CBT) for OCD using exposure and ritual prevention. Developed in the 1960's this "action-oriented" approach to treatment helps children confront their OCD fears and learn new, more appropriate responses to fear provoking situations, rather than doing rituals. For example, a child who fears contamination by dirt or germs learns would be asked to touch an feared object bit by bit until the child learns that the object is not harmful or dangerous. At the same time, the therapist works with the child to limit or even stop the compulsive handwashing and excessive showering behaviors. Wherever the fears and avoidances occur in real live, the CBT therapist assists the child to face those very situations. Eventually, through practice and persistence, the child learns to tolerate increasing degrees of "contamination" without having to resort to compulsive behaviors. To conduct CBT properly requires a high degree of therapist training and skill in gearing the treatment for the individual child's OCD problem.

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS)

Childhood onset OCD has been linked to group A beta hemolytic streptococci (GABHS), the bacteria behind strep throat. It is thought that the body forms antineuronal antibodies against the bacteria. These antibodies interact with basal ganglia neural tissue. This leads to OCD symptoms or intensifying of existing symptoms. Read more in-depth information on PANDAS by Dr. Marc Reitman.

Children whose OCD is the result of this relatively rare autoimmune reaction of the body have significant improvement or elimination of OCD symptoms when the strep infection is treated with antibiotics (March, 1998). It is important to get prompt treatment for strep infections. A sudden onset or worsening of OCD symptoms accompanied by upper respiratory distress warrants a trip to the doctor to check for signs of strep infection.

OCD and Related Disorders

Children and teenagers with OCD often have one or more other disorders. Tourette Syndrome, tic disorders, ADHD, learning disorders, disruptive disorders, depression, and other anxiety disorders are the most frequently seen disorders in children and teens with OCD. Depression tends to begin after OCD has made its home. Possibly, it is in response to the OCD (Piacentini, 1997; March, 1998).

When children have one or more other disorders, it is important to coordinate cognitive-behavior therapy for OCD with the treatments for the other disorders. Doctors, therapists, teachers, counselors, and parents need to work as a team with the child to gain the upper hand over OCD and its team of disorders.