Perhaps you struggle with obsessive-compulsive disorder. Maybe it’s someone in your life. Either way, you know how confounding and torturous it can be. And you also know relief doesn’t come easy. That said, let’s take a look at a cutting-edge treatment…
Providing a patient with necessary insight separates them from their anxiety. Further, it allows her/him to learn that anxiety has a beginning, middle, and end.
Obsessive-compulsive disorder (OCD) is a multifaceted, heritable anxiety disorder characterized by symptoms of obsessive thoughts and compulsive behavior. It affects some 3% of the US population and is one of the top 20 causes of illness-related disability worldwide.
And you know what? My guess is it’s much more prevalent because so many stay in the shadows out of embarrassment and shame.
By the way, I’m one of that “some 3%.”
Eda Gorbis, PhD, LMFT is founder and director of the Westwood Institute for Anxiety Disorders. She’s also an adjunct clinical assistant professor of psychiatry and biobehavioral sciences at the University of Southern California Keck School of Medicine.
Most importantly, Dr. Gorbis specializes in treatment-resistant (refractory) OCD and complex comorbidities, and her work is recognized as cutting-edge worldwide.
I’m telling you, this information needs to be available to the OCD masses. And I’m glad to have it here on Chipur.
(Oh, long article alert. So read it in a couple of sittings, right?)
Dr. Gorbis’ Intensive OCD Program
As background for her work, Dr. Gorbis points-out that OCD was untreatable until British psychologist Victor Meyer developed the first modern exposure and response prevention (ERP) treatment in 1966.
Gorbis believes that when correctly used, behavioral therapy can produce a 76% rate of continuing symptom relief three months to six years after treatment cessation.
In her therapy, she uses a variation of cognitive behavioral therapy (CBT), incorporating writing techniques, which increase mindfulness and awareness of the maladaptive associations that typically reinforce OCD symptoms.
And this is really important: Patients have to realize what they’re obsessing about and/or what they’re overvaluing. That’s where writing comes into play, as according to Gorbis it utilizes the brain’s highest level of cognitive functioning. And that aids in untangling the complicated web of thoughts and emotions that exist in the brain of someone struggling with OCD.
Simply, written self-analysis results in clarity and logical understanding of one’s condition.
OCD and Cognitive Distortions
Gorbis observes that there are several cognitive distortions commonly floating around in the minds of OCD patients. Typically, the distortions involve all or nothing (“polarized”) thinking, interpreting a thought as an experience, or feeling that a failure to perform a ritual perfectly, or when mandated, will result in disastrous consequences.
Pertaining to “disastrous consequences,” those with OCD have a tendency to not only overvalue the “dangerousness” of a situation, but think that despite hundreds of positive experiences under the same circumstances, disaster looms if the ritual isn’t performed.
According to Gorbis, those dealing with OCD fail to see situations accurately. That’s why she teaches mindful awareness, which she believes can be done best by adding analytical writing to CBT. Her theory is that when spoken word is translated into written form, it requires the most complicated processing of the word and the thought.
Gorbis believes writing is max-therapeutic because it enables us to reprocess the information we’ve been “regurgitating.”
Gorbis’ “Fear-Structured Skeletons”
In Gorbis’ work, “fear-structured skeletons” are worksheet assignments designed to increase mindful awareness via identifying internal and external cues.
Here’s how it works. Patients describe the internal and external cues of their obsessions in a repetitive manner, reprocessing and re-summarizing information in their own words.
The exercise is crucial in coming to understand the triggers for obsessive thoughts, be they things that are seen or experiences and feelings that generate obsessions. Keep in mind, it’s common for patients to exhibit several triggers, and the writing process allows for an analysis of a multitude of obsession causal factors.
On top of that, patients are taught to come up with what Gorbis refers to as their Subjective Units of Distress (SUDS) levels, rating their anxiety on a 0-10 scale. This allows a patient to self-diagnose, self-treat, and prevent relapse.
Bottom-line: Providing a patient with necessary insight separates them from their anxiety. Further, it allows her/him to learn that anxiety has a beginning, middle, and end.
I can’t express how huge that is.
The Intensive OCD Program: Structure
Here are the nuts and bolts of Gorbis’ program. Psychoeducation about self-treatment, writing, and self-evaluation takes four to five days, entailing 14-15 self-administered tasks and tests.
The patient’s situation is analyzed by the therapist and a determination of the common denominators of the fear structures is made. Only then is a custom-tailored program assigned.
The program must utilize two of what Gorbis refers to as the best approaches available to OCD patients. The first step is the prolonged exposure and response prevention (ERP) program designed by Drs. Edna Foa (under whom Gorbis trained) and Michael Kozak.
From Gorbis, here are Foa/Kozak’s steps…
Patients increase their mindful awareness via training and recording of ritualized behavior
Patients are taught to stay in an OCD situation, without giving-in to compulsions until discomfort decreases
Patients receive help in concentrating on, and are guided through, targeted situations
Exposures are repeated daily using patient specific stimuli until distress significantly dissipates
To this, Gorbis adds a combination of imaginal and actual exposure, which helps to prevent relapse.
When therapy commences, Gorbis teaches the patient to “re-label,” recognizing that the intrusive thoughts and urges aren’t real, rather the result of their OCD. She then moves-on to teaching the patient to “reattribute,” realizing that the intensity and intrusiveness of the thought or urge is due to a biochemical imbalance in the brain.
Gorbis posits that when a patient learns that s/he can induce OCD, the realization hits home that the OCD itself can be significantly reduced – eliminated.
Indeed, through self-induction and overloading the brain with disturbing and distressing images, at a frequency and intensity that exceeds obsessive-compulsive intrusions, the patient gains control of her/his disorder.
Let’s Tie a Bow
Don’t know about you, but I find Dr. Gorbis’ treatment approach, and its foundation, fascinating and, yes, cutting-edge. And as a 3%’er, it hits home.
What are your thoughts?
Now, I realize embarking upon a therapy program in Los Angeles wouldn’t be practical for most of us. However, there’s still the information – the knowledge – that can be used for self-improvement and comfort. Heck, if you’re already working with a therapist, share this article or get her/him on Dr. Gorbis’ site.
Yes, it’s true, relief doesn’t come easy. But it really is an option for those who pursue knowledge and work their butts off.
You’ve dealt with tics off-and-on for years. I mean, you’ve kept your stress under control, used cognitive and behavioral techniques, and learned how to cover them. So they’ve been a minor inconvenience. Well, now they’re worse than ever. Stunned, you’re asking some serious questions about cause and how to make them go away. Yeah, “Whoa!”
PET and SPECT imaging have revealed abnormal patterns of blood flow and metabolism in the basal ganglia, thalamus, and frontal and temporal cortical areas. Also involved may be the anterior cingulate cortex.
Let’s wrap things up by learning about cause and treatment…
What Causes Tics?
You know what’s coming, right? No one knows for sure what causes tics. Why does it always have to go down that way with most anything a mood or anxiety disorder sufferer may be dealing with? Kind of goes along with no one knowing why psychotropic meds work (if and when they do).
Frustrating, isn’t it?!
There was a time when emotional issues were believed to be the primary cause of tics. But those days are gone, as it’s being discovered that biochemical and structural abnormalities may exist in the brains of those enduring tics.
In on the action are believed to be the neurotransmitters dopamine and serotonin, along with the intracellular signaling molecule (“second messenger”) cyclic AMP.
Would it surprise you that genetic factors are at play in 75% of tic disorder cases? Though no single gene has been found to be the culprit, tics are definitely a family thing.
Prescription and recreational drugs may generate and/or exacerbate tics. The most common are stimulants such as methylphenidate (Ritalin) and pemoline (Cylert), amphetamine/dextroamphetamine (Adderall), other amphetamines, and cocaine. To a smaller degree, tics may be worsened by anticonvulsants, opioids, antihistamines, and tricyclic antidepressants.
Finally, the negative impact of stress and fatigue upon tics can’t be over-emphasized.
How to Treat Tics
As we begin, it’s important to note that most children don’t require treatment for their tics. It’s thought that waiting is a good idea because of the fluctuating nature of tics. Jumping right-in to, say, meds is a dicey proposition because who would know if they’re working in the midst of the fluctuations.
If, after a comprehensive assessment (lots of overlap with OCD and ADHD to be considered), treatment is indicated, it needs to be facilitated by a multidisciplinary team to include a physician(s) and psychotherapist.
Now to the meds side of the fence. Often used are first-generation antipsychotics, such as haloperidol (Haldol), pimozide (Orap), and fluphenazine (Prolixin), as well as the newer atypical antipsychotics, such as risperidone (Risperdal), olanzapine (Zyprexa), and ziprasidone (Geodon).
A newer med, tetrabenazine (Xenazine), is showing promise as an add-on to the first-generation antipsychotics, allowing for lower doses of each. Also used are alpha-2 agonists, such as clonidine (Catapres) and guanfacine (Tenex).
It’s not uncommon to include a SSRI antidepressant, such as fluoxetine (Prozac) and sertraline (Zoloft) to address assorted mood, anxiety, and impulsivity issues, should they present.
When deciding upon, or using, any med (especially the antipsychotics), please consider, and monitor, side effects. And when it comes to the antipsychotics, keep in mind that dosing is significantly lower than that for psychotic presentations.
Now, it’s important to consider alternative therapies for tics. Though more study is indicated, interest is growing in the positive impact of dietary changes and supplements. Some theorists have suggested hidden food and chemical allergies, or nutritional deficiencies, may influence the development and maintenance of tics.
That said, recommendations include eating organic food (avoiding pesticides), using antioxidants, increasing intake of folic acid and the B-vitamins, eating foods high in zinc and magnesium, eliminating caffeine, and avoiding artificial sweeteners, as well as colors and dyes.
It’s a Wrap
Well, that’s going to do it for our three-part tic/tic disorder series. Funny, I’d intended to write just one piece, but as soon as I started digging-in I knew that wouldn’t cut it.
So why did I choose to bring you all of this information on tics? I know how miserable and self-esteem grinding they can be. And that’s because I live with a tic disorder. Yep, I’m walking the walk, so I guess I can talk the talk.
Interesting, if we spent any length of time together, you probably wouldn’t know I, well, tic (like a clock?). I mean, I’ve worked hard to manage them, but it’s taken many moons to get comfortable – emotionally, mentally, and physically. But I’m definitely there. By they way, I use a clonidine patch.
So the truth about tic disorders: at times not very much fun, incurable, but manageable.
It’s not as though dealing with OCD or tics and Tourette syndrome individually isn’t tough enough. But, go figure, they can have a very chummy and tricky coexistence. And if you’re in the midst, or care about someone who is, it’s important to connect the dots. So let’s get after it…
Though speculative, the ‘tourettic OCD’ perspective of Mansueto and Keular opens the door to treatment possibilities that ‘inside-the-box’ thinking just can’t offer.
I was blown-away by Dr. Mansueto’s insight, point-of-view, compassion, and kind writing-style. So I just had to bring the piece to you. How ’bout we do the cause and treatment piece next week?
Oh, just a quick note. Because of space constraints, there’s no way we’ll be able to get into the treatment options Dr. Mansueto details. But I’ll provide a link to his article as we close so you can indulge at-will.
OCD and Tourette Syndrome: Re-examining the Relationship
Before we get started, I want to address Tourette syndrome (TS), which is horribly misunderstood. Fact is, some of you may have a hunch you have it, but won’t pursue diagnosis and treatment. And that’s because in your mind it would confirm that it’s only a matter of time before you begin to blurt-out obscenities or socially inappropriate and derogatory remarks (coprolalia). Just so you know, it presents in only about 10% of cases. And even if you’re in that 10%, there are scads of management strategies and techniques that’ll help you move-on with your life.
So, TS diagnostic criteria? Very simply, multiple motor tics and one or more verbal (phonic) tic presenting during the course of the disorder.
Okay, Dr. Mansueto kicks-things-off by thanking the “hundreds of kids” he’s personally worked with in 25+ years of clinical practice. As he puts it, “They were as much my teachers as my patients, in that they opened my eyes to numerous insights, some of which are outlined here.”
He then moves-on to examine commonly accepted views of OCD and tic disorders. I’m recommending you check-out the International OCD Foundation’s website for the OCD scoop and the first article of this series for the lowdown on tic disorders. Both links are just above.
The OCD, Tics/Tourette Syndrome Overlap
OCD and tics/Tourette syndrome (T/TS) are independent entities – diagnosable situations, each. Ah, but according to Mansueto, that sets the table for some curious goings-on.
Mansueto posits there’s substantial evidence that the overlap of OCD and T/TS suggests a very chummy and tricky relationship between the two. What evidence?
Up to 60% of those enduring TS have been reported to have OCD symptoms.
50% of children with OCD are reported to have had tics, and 15% met criteria for TS.
Evidence from family studies and lines of genetic research suggest the disorders are etiologically (cause) linked.
Clinically, distinguishing between OCD and T/TS symptoms can not only be difficult, but at times impossible. “Are we dealing with complex tics or compulsions?”
Can you see how significant it is to identify and understand the overlap? And let’s keep in mind that it has a huge impact upon diagnosis, treatment decisions, predicted course of the disorder, and prognosis.
So why all the slicing and dicing? According to Mansueto, it’s about helping the patient thrive in the face of some pretty formidable impediments.
Tourettic OCD: The OCD and T/TS Blend
In an effort to address the shortcomings in the OCD and T/TS literature, Dr. Mansueto and his colleague, David Keuler, propose the existence of a clinical subgroup of folk, seen frequently in treatment, who present with a distinguishable cluster of symptoms that represent a blend of OCD and T/TS features.
They call the subtype “Tourettic OCD” (TOCD). And it’s distinct from “purer” forms of OCD because it’s heavily influenced by T/TS-associated features.
The distinguishing features of TOCD?
Symptoms are preceded by prodromal sensations characterized by physical discomfort in body parts or a diffuse psychological distress or tension “in my head” or “in my mind.” This, as opposed to being preceded by anxiety.
Symptoms tend to be relieved by a variety of motor responses to include “evening things up,” doing things to certain numbers, positioning items, touching and retouching things, and doing things symmetrically. And to alleviate the somatic/psychological discomfort, all has to be done “just right” or “just so.”
Patients describe a relative absence of fear or concerns about catastrophic consequences occurring if required actions aren’t performed. Instead are concerns that the discomfort might be intolerable or unending if the actions are left undone or poorly done.
TOCD symptoms can present alone or may coexist with classic OCD symptoms.
Finally, it’s not uncommon for TOCD to have been preceded by certain “historical indicators.” These may include early signs of sensory hypersensitivity (tactile-defensive reactions to clothing tags, scratchy fabrics, confining clothes, etc.), multiple comorbid disorders (particularly the attention deficit component of ADHD, learning disorders, impulsivity, and issues with emotional self-control), a weak – or no – response to SSRI (Zoloft, Celexa, Lexapro, etc.) mono-therapy, and a weak, no, or abnormal response to exposure and response prevention therapy (ERP).
Also presenting may be sexually aggressive or gruesome images.
Though speculative, the TOCD perspective of Mansueto and Keular opens the door to treatment possibilities that “inside-the-box” thinking just can’t offer. At their clinic, patients receive a mix of therapeutic approaches pulled from both OCD and T/TS “tool kits.”
The Alphabet Soup Syndrome
Mansueto shares that a good number of patients, many of whom are children, come to his clinic because OCD has been detected – in the midst of a complex of other diagnoses. He refers to this array of diagnoses as the “Alphabet Soup Syndrome.”
Tics or TS may not be in the mix; however, common co-diagnosed situations include the attention deficit component of ADHD, learning disabilities, oppositional defiant disorder, and sensory processing disorder. Sensory processing disorder is an unofficial diagnosis, which is designed to explain a child’s emotional “meltdowns” (depression or other mood disorders are typical).
According to Mansueto, a large portion of these patients have hallmark features of TOCD, along with the array of associated conditions that occur so often in conjunction with a nervous system that is prone to developing tics. However, the manifested simple tics may not be the easiest to identify.
At Mansueto’s clinic, the array of problems is viewed as the product of a “tourettic nervous system,” which is “hair-triggered,” easily aroused, and hard to settle. In these folk, the excitatory mechanisms of the nervous system, which initiate and energize actions and feelings, are working just fine. It’s the complementary inhibitory mechanisms that modulate these functions that aren’t up to the task.
That is a powerful observation.
Let’s Leave It at That (Wow!)
Gotta’ tell ya’, I’m out of breath from putting this piece together. There was just so much creative, detailed, and important info to work with. Can you see why Dr. Mansueto’s article nailed me right between the eyes?
If you or someone you care about is dealing with OCD, tics, or Tourette syndrome, understanding the potential for a very chummy and tricky coexistence is vitally important.
Please be sure to read Dr. Mansueto’s article. It’s loaded with relevant and meaningful information. Heck, I’ll go so far to say it’s a “must read.”