New Harbinger Publications: Let’s ask the most obvious question first, why was there a need for a second edition of this book? What’s changed in our understanding and treatment of obsessive-compulsive disorder?

Bruce M. Hyman: Several factors were involved in the decision to write a second edition of The OCD Workbook. First, feedback from our readers, mostly patients and family members, gave us the impetus to revise and make what we think is a good book even better. Without a doubt, the scientific understanding of OCD and its treatment has advanced since 1999. New medications have hit the market, refinements in psychological treatment are being advanced, and with the release of major films and TV shows such as The Aviator and Monk, the media focus upon OCD has increased enormously. More people becoming aware of and accessing quality treatment for OCD than ever before.

NHP: OCD has been covered extensively in the media and, with the show Monk, has even become fodder for pop culture. The average person may know that OCD can cause some pretty extreme behavior but probably doesn’t have a strong understanding of the who, how, and what of this condition. What are a few things you think the general public should know about OCD?

BMH: I think that OCD is not just something that makes good TV and interesting movie characters, but a very real, very debilitating disease that results in great suffering to patients and family members alike. Its sufferers include people of all ages, including children as young as four years old, the elderly, and people from every walk of life, rich and poor. People with OCD are not “crazy” in any way, but suffer from a neuro-chemical “glitch” that results in persistent, unwanted irrational ideas that make no sense even to the sufferer. The thoughts compel excessive checking and washing, ordering, hoarding, and worrying behaviors that are shame-inducing and embarrassing. Sufferers have little control over these thoughts, but with effective treatment, they can certainly gain considerable control over them. Despite the potentially disabling nature of OCD, sufferers do not have to settle for a life compromised by OCD; effective treatment is certainly available.

NHP: What does the latest research tell us about the causes of OCD?

BMH: The latest research has revealed just how complicated and varied the disease of OCD really is, and that it is a mistake to ascribe a singular cause, either biological or environmental, to the whole spectrum of OCD and its related disorders. Within each subtype of OCD, for example washers and checkers, the specific genetic/neurochemical abnormality that accounts for the symptoms, may be different for different types of OCD. Research into the neurochemistry of OCD has implicated such neurochemical subsystems as the glutamate system, as playing a part in OCD. Genetic research is revealing more and more about the factors involved with the genetic transmission of OCD from one generation to the next.

NHP: Most of us know that OCD can drive someone to wash obsessively or check the settings on their appliances, yet there’s a variant of it that involves only mental rituals, like having to think “good” thoughts repeatedly. Can you tell us a little about this?

BMH: Once thought to be “untreatable” by the OCD clinician community, patients with mental rituals can be treated successfully. The key is the same as for more “overt” rituals—exposure and response prevention. The patient must be willing to fully experience the discomfort of the obsessive thought and refrain from any mental activity, such as counting, repeating, or self-reassurance. With persistence and practice, habituation can occur, lessening the severity of the symptoms.

NHP: What is the most common course of action for treating someone with OCD?

BMH: First, a thorough evaluation by a mental health professional knowledgeable about OCD and related disorders should be obtained. He or she will then prescribe a particular form of treatment—medicine, therapy, or both. Which route the patient follows is often based upon the availability of treatment. For example, in more rural areas where there are few psychologists, medication might be the first available choice since there are more medical doctors than psychologists or therapists in those areas. Some patients who want a “quick fix” may resort to medication first. Those who find medication repugnant may choose cognitive-behavioral therapy first. In more severe, debilitating cases, medication probably should be started first. However, in milder, moderately severe cases, cognitive-behavior therapy using exposure and response prevention is probably the best first choice.

NHP: You talk about neurosurgery in the second edition of The OCD Workbook. What kind of surgical procedures are done to treat OCD, and who would be a candidate for them?

BMH: Also called cingulotomy or capsulotomy, neurosurgery for OCD may be considered as an option only in the most severe, treatment resistant cases. Severely disabled patients must have documented several failed trials of CBT and failed trials of all available medications for OCD. Done at only a few neurosurgical facilities in the US, response to surgery, while often moderately successful, is not guaranteed. The vast majority of readers of The OCD Workbook are either not appropriate candidates for neurosurgery or have little need for such radical treatment.

NHP: What is ERP?

BMH: Exposure and response prevention (ERP) is the principal behavioral technique for treating OCD. The purpose of exposure is to reduce the anxiety and discomfort associated with obsessions through a process called habituation. Habituation is a natural process by which our nervous system “gets used to” or “bored by” stimuli through repeated, prolonged contact. This is accomplished through prolonged exposure to the real-life anxiety and ritual-evoking situations. This is called in vivo, or “real-life,” exposure. For example, the person may be asked to actually touch or otherwise directly contact some feared object, such as an empty garbage pail or other “contaminated” object, without relieving the anxiety by hand washing. Through repeated practice, the patient realizes that the feared disastrous consequences do not occur and the severe anxiety initially associated with that situation decreases. This is the process of habituation at work.

Exposure is best done in stages, in “baby steps” toward the ultimate goal of complete habituation to the feared object or situation. For example, exposure to a “contaminated” garbage pail may begin by having the patient touch a “safe” corner of the pail with only a fingernail. Eventually, exposure progresses to touching the pail with a finger, and waiting as long as it takes for habituation to occur. Then several fingers are used, then the front of the hand, then the back of the hand. With each step, fear is confronted, anxiety aroused, then habituation is allowed to take place gradually and naturally.

NHP: What are few specific fears OCD sufferers typically have when they begin a program of treatment and how do you counter them?

BMH: There are a number of fears that patients enter treatment with. First, there typically is great reluctance to reveal to a doctor/therapist the shame and embarrassment regarding the patient’s life with OCD and the symptoms he/she must endure. There is great fear that once the veil of secrecy is lifted, that the patient will be rejected/committed or shamed by the therapist/doctor. Once those fears are alleviated and an initial modicum of trust in the therapist is established, fears of the actual treatment involve the dreaded idea that the therapist may require that the patient challenge his/her automatically held beliefs. These include beliefs in the “danger” inherent in certain thoughts, objects or situations, and the compulsive habits, e.g., checking or washing, that the patient deems necessary to escape or mitigate harm or danger. The patient will be required to “do what is most uncomfortable” as the case in exposure and response prevention procedures. Accompanying such fears is the idea of losing one’s mind, of going crazy, or, even worse, that they will fail to benefit from treatment, leaving them with few options but to live eternally with the pain of the OCD. With regard to medications, typically patients fear the worst—unmanageable side effects, or, in light of unflattering, sensationalistic publicity surrounding the use of selective serotonin reuptake inhibitors (SSRIs), losing their mind and going crazy.

NHP: A section of your book is dedicated to the family members of those with OCD. You offer suggestions for being a “coach” for the family member who’s trying to recover. What role does the family have in recovery?

BMH: OCD symptoms, which most frequently involve persistent checking, washing or ordering behaviors, frequently have a profound impact upon the normal functioning of the family. Often, patients will require that other family members participate in compulsive checking, washing behaviors, or reassure them repetitively. As a result, considerable tension may be generated among family members, resulting in anger, hostility, avoidance, resentment and in rare cases, even violence. Effective treatment of OCD requires, first and foremost, that family members be educated about the nature of the disease of OCD. They must realize that what their family member suffers from is not a defect of character, or will power, or some attempt to bully the family. OCD is a powerful, biologically rooted disease of brain chemistry and circuitry that renders the patient powerless over the relentless obsessive thoughts and compulsive urges. The sufferer cannot help it, despite being well aware of the senselessness of their own behavior. Family members must realize that the patient and the OCD are NOT one in the same. Therefore, it is vital that family members direct their anger and frustration NOT at the patient, but at the OCD. Patients with OCD do not need lectures, scolding, more faith, or “tough love.” They need effective medical treatment, and the support, patience and encouragement that only a loving family can provide in times of great need. Family members, often desperately, need guidance from trained professionals as to how to best respond to the demands of the OCD within the family.

I do not recommend, except in rather rare circumstances, that family members act as a “coach” or therapist. They are neither trained for this role, nor do they usually have the emotional temperament to do so. Family members, however, must relearn new patterns of responding to the OCD so as to minimize their participation in the compulsive rituals. This should not be done unilaterally, but rather is best accomplished with the help and guidance of a trained mental health professional.

NHP: The last chapter of your book is dedicated to hoarding. How can you tell if you’re just a “pack rat” or if you’re hoarding is really and OCD behavior?

BMH: The difference is dramatic. The world is filled with “pack rats,” who enjoy collecting all sorts of things of interest to them, and whose homes occasionally become cluttered and disorganized as a result. In most of these cases, if they had to for reasons related to health, safety, or finances, will take the time to reorganize the clutter and get their homes in some semblance of order. If they need to make tough choices about what to keep and throw away, they do it without too much discomfort. In hoarding OCD, the person’s home becomes so cluttered and disorganized that a true health hazard can occur. One of the main differences in hoarding OCD and being a “normal” pack rat is that the OC hoarder will use a dysfunctional form of reasoning to justify not throwing something away, or accumulating more of it. It mostly takes the form of “what if I need it in the future” (when they already have five of the same thing they have little chance of needing in the future). What is often striking in hoarding OCD is the level of emotional attachment to superfluous objects most people would consider junk or even trash or refuse like milk containers, and old newspapers. The OC hoarder feels highly anxious and overwhelmed at the very thought of throwing something away, and is reluctant to allow anyone to have physical contact with the hoarded objects. These individuals are often held “captive” by their possessions. They don’t possess these objects; rather they are possessed by them! Very frequently, OC hoarders are compulsive shoppers and accumulators of “stuff.” They cannot resist purchases even at the risk of creating severe credit card and debt problems. Often the “stuff” purchased is not even opened—it can sit in a cluttered closet in its original packaging for literally years.