Psychotherapy: Issues, Forms and Controversies
Obsessive-Compulsive Disorder: A Psychiatric Success Story
Vicious Cycles, Self-Fulfilling Prophecies and Bad Habits
Treatment of Obsessive-Compulsive Disorder in Children and Adolescents
Specific Treatment for Specific Types of Anxiety
Depression in Children and Adolescents
ADHD and Personal Responsibility
How Computers Can Help Individuals with ADD
Sometimes, conflicts with people are unavoidable. Problems with a coworker or family member leave you feeling angry or frustrated. It may feel like it is the other person’s fault. But what if you keep getting into similar conflicts with other people? What if there seems to be a pattern of recurring problems?
One woman* believed that her superiors were ‘stupid’ or didn’t appreciate her. She found herself subtly undermining their authority and bringing on their criticism. She had been told she “had an attitude”. She quit a number of jobs and was fired from several others.
A man is chronically late for appointments. He has angered and lost several friends. His remaining friends don’t depend on him. Even though he is otherwise competent at his job, he has been passed over for promotions that have been awarded to less creative and less intelligent colleagues.
Surprisingly people often handle situations in ways that work against their best interests. When you have a consistent pattern of dysfunctional behavior, there is a reason for it.
Psychotherapy can be a valuable tool for identifying, understanding and changing self-defeating behavior. If you haven’t recognized your destructive habits and found healthier ways to handle these situations, there is little chance you can keep yourself from repeating them.
In psychotherapy, the patient and therapist explore a territory where the patient is both the expert and a wary stranger. The therapist helps guide the patient as the patient examines his or her assumptions and attitudes. The therapist should understand how you see yourself and help you learn the role that the maladaptive behaviors play in your own inner world. Generally the problems are related to erroneous assumptions that you make about yourself and your relationships with other people. When your assumptions are faulty, your reactions may be inappropriate to the real situation. Once you understand why you have been behaving in personally destructive ways, you become free to change your behavior. Psychotherapy is about choice. It is about freedom from dysfunctional patterns.
Glenn Brynes, PhD, MD
When an individual has a family problem, or feels emotional distress, he or she is often referred to a “psychotherapist” for “therapy.” Psychotherapy can be a powerful force for change. However, like any other medical procedure, it can have its own risks as well as benefits. Some therapeutic techniques may work better than others . Anyone may call himself a psychotherapist, whether or not he is licensed. Some therapists have more training than others in making diagnoses and performing specific types of psychotherapy.
Many therapists describe their technique as intuitive or eclectic. What does this mean? Sometimes, spending time with any warm, empathic person can be a healing experience. All therapists should have the capacity for empathy. In many cases, though, empathy may not be enough.
For therapy to be effective, it should be individualized. Some therapists reject the idea of specific diagnoses without understanding current diagnostic standards or the rationale for their use. Modern psychiatric diagnoses are based on observations of huge numbers of people in a wide range of cultural situations. Vague or incorrect diagnoses can lead to inappropriate treatment or delay of the most effective specific treatment. A diagnosis is not meant to be rigid, nor does it entirely define the whole individual. It gives the therapist a framework to understand a patient’s problems and to formulate a specific plan of treatment.
An internist would not treat all of his or her patients with penicillin. Choosing the right type of psychotherapy involves more than making the correct diagnosis. In recent years, several studies have shown the efficacy of specific forms of psychotherapy in treating depression, anxiety, and other disorders. Some individuals improved with therapy alone and others did better with a combination of medication and psychotherapy.
Many insurance plans are making it more difficult to choose a therapist intelligently. All too often, instead of getting a referral from a primary care physician or other trusted confidant, one must call an 800 number, speak to an anonymous individual and receive the name of one’s assigned therapist. Ideally, one should be able to interview a prospective therapist and ask hard questions about the individual’s experience, education and repertoire of specific techniques. If it is difficult to be this assertive when one is in distress, ask a trusted friend or relative for assistance.
Psychodrama: The Art of Healing
Rita Preller, LCSW-C
Everyone who has ever participated in a psychodrama is both fascinated and stunned by the impact of the spontaneous play. J.L Moreno was the founder of psychodrama, an approach in group therapy. He was educated at the University of Vienna Medical School where Sigmund Freud lectured and both met in 1912. Moreno believed that he started where Freud left off. Freud interpreted his patients’ dreams and Moreno, “gives them the courage to dream again.”
As a student of Greek and Latin philosophy, Moreno observed that the actors in the plays were possibly experiencing a “catharsis” from playing their parts. Moreno wondered whether actors allowed to perform their own concerns and troubles, and allowed to show real tears, real laughter, and genuinely personal emotions could experience a valid, life changing emotional experience. The participants could learn new responses to old situations. The idea behind psychodrama is that we are all improvisational actors on life’s own stage.
Psychodrama offers great flexibility for participants to try out multiple ways to deal with serious life situations. It allows individuals to enact personal issues or life events with active help and feedback from the group. Other group members may stand near the protagonist and act out different sides of his dilemma. It is appealing to active individuals and those who are put off by the predominantly verbal nature of many therapies.
Moreno believed that the capacity to engage joyously with life was due to spontaneity and creativity. Psychodrama taps deeply into the healing power of the individual’s own creativity.
Obsessive-Compulsive Disorder: A Psychiatric Success Story
Over the past fifteen years, there have been dramatic changes in the approach to Obsessive-Compulsive Disorder. In the past, treatment for Obsessive-Compulsive Disorder (OCD) was less specific, and the results were not as good.
When we were in training, there was only one really effective medication for OCD, and it was only available for individuals who were in a research study or who got medication from Canada. Today, we have several readily available medications with fewer side effects.
The more traditional supportive or psychoanalytic therapies, while effective for certain other conditions, did not work well for OCD. Several research groups have worked to refine and test specific cognitive-behavioral techniques. We now have good outcome studies demonstrating its effectiveness for both children and adults with OCD. Cognitive-Behavioral Therapy empowers the individual to learn to deal with the OCD himself.
Individuals with OCD are seeking each other out. There are support groups and web sites for individuals who are seeking support and sharing.
OCD was once considered a rare condition. Community based studies have made us aware that OCD is, in fact, relatively common. Adults, adolescents and young children can be affected.
Many individuals with OCD suffered in silence—and they still do. The time interval between first symptoms and getting effective help is often well over seven years. Now that effective treatment is available, these individuals should look beyond their shame and secrecy and take back control of their lives.
Obsessive-Compulsive Disorder in Children and Adolescents
At one time, Obsessive Compulsive Disorder (OCD) was believed to be fairly rare. When it was diagnosed, it seemed resistant to treatment. In the past decade, we have learned that it is much more prevalent. Community surveys of adolescents have suggested that at any given time, 1% to over 3% are experiencing symptoms of OCD. Children as young as 5 or 6 can show full-blown OCD. Between 30% and 50 % of adults with OCD reported that their symptoms started during or before mid-adolescence. Fortunately, there are now more effective treatments for OCD. In many ways the symptoms and treatments of OCD in both children and adults follow the same general principles. However, children differ from adults cognitively, developmentally and physiologically. Because of this, we modify techniques based on the particular stage of childhood or adolescence.
Symptoms and Features of OCD
In order to meet DSM-4 criteria for OCD, the individual must have either obsessions or compulsions. In actuality, most children and adolescents have both.
The Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-4) defines obsessions as follows:
The DSM-4 defines compulsions as:
The DSM-4 also requires:
When a clinician is evaluating a child or adolescent for possible OCD, it is important to do a thorough work up. The clinician should meet with the child and ask specific questions about obsessions and compulsions. He or she should also meet with parents or other primary caregivers. Information from school and other outside sources is also useful. If there are obsessions or rituals that occur only at school, it is important to know about them, so that they can be addressed too. The parents and usually the child may also fill out checklists such as the YBOCS (Yale-Brown Obsessive Compulsive Scale) These help to determine the baseline number and severity of the symptoms. Since OCD can be associated with other disorders, the clinician should look other childhood psychiatric disorders. Most individuals with OCD, even young ones, are at least intermittently aware that their symptoms do not make logical sense. However, young children are less capable of abstract thought, so their degree of insight may not be as good.
There have been several theories about the cause of OCD. These include psychodynamic, learning theories, and neuro-biological. When we discuss cause, it is important to make it clear that we are looking at Obsessive Compulsive Disorder, not an obsessive, perfectionistic personality style. An obsessive-compulsive personality disorder is different from true Obsessive-Compulsive Disorder. There may be some overlap or it may have a different origin.
Psychodynamic: Freud classified Obsessive Compulsive Disorder as a psychoneurosis. The roots of the illness lay in a disturbance in the sexual life or development of the child. Freud did recognize that one’s heredity and innate constitution contributed to the development of the disorder. In Freud’s theory of infantile sexuality, the child goes through the stages of oral, anal and oedipal sexual interest. If the child does not successfully progress through each phase, he may develop later difficulties. During early childhood, sometimes during or just before the oedipal phase, there might be a conflict between the ego (the mediating and observing entity) and the id (the source of sexual and destructive energy). The ego solves the conflict by setting up a way of reducing the effect of the id. In some cases, the solution is an unstable one. Part of the unstable compromise might be regression to the earlier anal level of development. Such an individual might have a tendency to hoard and a horror of throwing things away. Other obsessive symptoms such as checking might be seen as a way of dealing with the unwanted intrusion of hostile oedipal wishes. (Such as a boy wishing his father dead so he could marry his mother.) If one needed to repeatedly check faucets, it might be a defense against a childhood wish to flood the house and thus kill the father. The symptoms may start to express themselves years later when something happens to weaken the ego and its shakier defenses. It is possible that these psychodynamic formulations are more relevant to individuals with obsessive or compulsive personality traits rather than to individuals with true OCD.
Biological: Most recent research studies point toward a biological basis for OCD. However, there may be subtypes of OCD. Different subtypes may have distinct biological mechanisms. As research continues, the understanding of the neurological and related biochemical mechanisms will improve. PET Scans (a kind of brain scan that shows levels of brain activity in specific areas.) have shown abnormalities in the sub-orbital cortex (the underside of the front part of the brain) and the basal ganglia. A striking abnormality was increased activity in the sub-orbital cortex. When patients were successfully treated, whether with psychotherapy or medication, the brain scan studies resembled those individuals without OCD. Serotonin seems to be involved in mediating the interaction between these two parts of the brain.
Some cases of OCD may be associated with Tourette’s Disorder. Tourette’s is characterized by multiple tics. (involuntary rapid movement or vocalization) Individuals with Tourette’s may also have OCD symptoms, and Attention Deficit Disorder. Tourette’s is often inherited. Relatives of individuals with Tourette’s may have OCD without the tics. Finally, recent research has suggested that some cases of OCD may be related to the bacteria, B-hemolytic streptococcus. This syndrome is referred to as PANDAs. Antibodies may attack segments of the brain to produce an acute onset of OCD symptoms. Similar antibodies may cause rheumatic heart disease. More research is needed in this area. However, if the OCD starts suddenly, around the same time as an upper respiratory illness, one might consider a throat swab to check for the presence of B-hemolytic streptococcus infection. If the bacteria are present, further tests, treatment with an antibiotic and a referral to a specialized center might be considered.
Tourette’s Disorder is more likely to be present in boys and in children who develop OCD at a younger age. It is important to identify this disorder because treatment may need to be modified. Children and adolescents with OCD are more likely to have Attention Deficit Disorder, learning disorders oppositional behavior, separation anxiety disorder and other anxiety disorders. Some of the anxiety disorders have similarities to OCD and are called obsessive-compulsive spectrum disorders. These include tricotillomania, (compulsive hair pulling and twirling, ) body dysmorphic disorder (the obsession that part of one’s body is unattractive or misshapen) and habit disorders such as nail biting and scab picking. The exact relationship between these two spectrum disorders and true OCD is not yet entirely clear.
Consequences of OCD
If not treated, OCD tends to be a long-term disorder. Some individuals experience waxing and waning symptoms over the years. Others experience progressive worsening of their OCD until they are housebound and spend much of their days involved in obsessions and rituals. Chronic anxiety disorders may lead to depression. If a child spends a great deal of time obsessing or engaging in mental rituals, he or she may have trouble focusing on the school lessons. Individuals who need to repeatedly erase and rewrite assignments may need to spend hours of time of homework and lose time for friends and family. This same individual may not be able to finish projects because the work is never “just right.” Some children and teens may become oppositional if others attempt to interrupt their rituals. For the large number of individuals who manage to hide their symptoms, the cost may simply be years of anxiety and low self-esteem.
Children and Adolescents are Different from Adults
The DSM-4 criteria for children and adults differ for the criterion on insight. An adult generally is at least intermittently aware that the obsessions or compulsions are unrealistic. Most of the time, this is also true for children and adolescents. However some children, particularly young ones, may not have the cognitive capacity to understand the nature of the obsessions or compulsions. Oppositional children or adolescents may not want to admit that there is something awry with their behavior. In that case, a therapeutic alliance with a clinician may enable him or her to discuss his or her real feelings about the symptoms. Family issues are different for children. The child’s cognitive development necessitates some changes in the psychotherapeutic approach. If medications are used, the physician must consider the child’s smaller size and different metabolism.
In this article, we will focus on medication and cognitive-behavioral psychotherapy. There are other psychodynamic, play therapy and family therapy approaches to the treatment of OCD.
Once a child has been diagnosed with OCD, we need to decide which treatment or treatments to use first. Many clinicians prefer to start off with cognitive-behavioral psychotherapy. If there is no response or only a partial response, medication may then be added. There circumstances in which it is appropriate to start medication and psychotherapy simultaneously or even to start with medication alone. Moderate to severe OCD may merit starting with a combined approach. If a child or adolescent is extremely resistant to the idea of psychotherapy, one might consider starting with medication alone.
It would be difficult to discuss this topic without giving a great deal of credit to John March MD and his collaborators. They have developed, tested, and disseminated specific information that includes a detailed protocol for treatment of childhood OCD.
Near the beginning of this type of therapy, the child and family are educated about the biological basis of OCD. Even young children can gain some understanding of this concept if it is presented in an age-appropriate manner. For young children, I often draw an outline of the brain and let them color round and round to signify the repetitive thoughts and actions. Older children and adolescents may appreciate pictures of brain imaging studies. I have used the pictures in the introduction section of the book, Brain Lock by Jeffrey Schwartz, MD. These pictures vividly show the differences in brain activity between affected and unaffected individuals.
When the child and family realize the biological basis of the disorder, they find it easier to externalize the symptoms. The symptoms are the fault of the disease, not the individual or family. Children continue to need more concrete models and concepts throughout the therapy. Often one may help them conceptualize the OCD or OCD symptoms as an unpleasant or silly creature. The child may also want to give this creature a name. In the illustrated children’s book, Blink, Blink, Clop, Clop, Why Do We Do Things We Can’t Stop? The OCD is named “OC Flea”, and is drawn as an unattractive, silly but non-threatening creature. Subsequent therapy helps the child shrink, squash, boss or drive away the OCD.
As the therapy progresses, the child should begin to expose himself to the anxiety-provoking object or situation and then try to avoid performing the usual compulsion. This is called exposure and response prevention. It may have to be done gradually because it can cause the child to experience significant anxiety. The child himself should have an important role in determining how quickly he wants to move through these steps. The parents can help with this too by reducing and then eliminating reassurances when a child asks obsessive questions. At the same time, they should be supportive and avoid blaming the child if he is unable to avoid performing some of the compulsions.
The child may benefit from learning relaxation techniques and learning mental self-monitoring. Other specific techniques may help individual children tolerate the anxiety engendered by the exposure and response prevention.
When the symptoms are eliminated or at least reduced to a tolerable level, the therapist should talk to the child and parents about the future. Symptoms may start to come back at a later date. They should review the symptoms and discuss how to deal with them. Some individuals come in for intermittent refresher sessions.
Recent advances in medication have added to our treatment options. In the past few years there have been more studies testing these medications specifically on children. In general, children who need medication respond to the same medications used for adults with OCD. The FDA has approved some of these medications for use in children with OCD. However, a physician may, after discussion with the family, elect to use a medication that technically is only approved for adults.
The main medications used for OCD are Clomipramine (brand name Anafranil) and the Selective Serotonin Reuptake Inhibitors. There are several other medications that may be added if those medications produce only a partial response.
Clomipramine is chemically similar to the older tricyclic antidepressants. Its efficacy in OCD seems to be related to its ability to decrease serotonin reuptake. It used to be the only effective drug for OCD. At this point, it is usually not the first line drug for children with OCD. This is because of several potential side effects. It can be sedating. It can also cause dry mouth and eyes. It has been associated with some changes in EKGs. (A measure of the heart rate and the electrical conduction within the heart.) Because children may be more sensitive to this cardiac effect, we usually monitor EKGs and heart rate in children on Clomipramine. Despite this, when used carefully, it has helped many children and adolescents with OCD.
There are now several SSRI medications. They include Fluoxetine (brand name Prozac) Fluvoxamine (brand name Luvox) Paroxetine (brand name Paxil) and Sertraline (brand name Zoloft). All seem to be effective at reducing the symptoms of OCD, but different ones may be best for individual patients. Fluoxetine has the advantage of being available in liquid form. Using the liquid, one can start at very small doses and titrate the dose gradually. Common side effects include headache, GI complaints, tremor, agitation, drowsiness and insomnia. These medications may affect how other drugs are broken down in the liver. One must use caution when mixing medications. If a child taking an SSRI, it is a good idea to consult one’s physician or pharmacist before taking other prescription or even non-prescription medications. Many children take a long time to achieve a good response to medication. 10 to 12 weeks is not uncommon. Some children will respond to one medication but not to another.
Dealing with Recurrences
Education about OCD often an early part of the therapy. Both parents and child are included. It is important for them to continue the education process. A good understanding of the disorder can help the child and family feel a greater sense of mastery and control.
The process of education should extend on after the end of the therapy. It can occur through reading age-appropriate books, attending support groups or having group therapy with peers. I have listed some recommended books and support groups at the end of the article. Secrecy and shame are common in individuals with OCD. Education and the support of others can help the individual keep the disorder in perspective.
Children and families should be aware that OCD can be chronic and that symptoms may return months or years later. Some children will schedule “check up” sessions every six months or each year. If symptoms reoccur, they may return to therapy for a shortened version of their previous treatment.
Suggested readings and Internet Links
Brain Lock: Free Yourself from Obsessive-Compulsive Behavior by Jeffrey M. Schwartz 1996, Regan Books. This book is primarily aimed at adults. However, I have found it useful for adolescents and for relatives of the child or adolescent with OCD. Dr. Schwartz discusses both the causes and symptoms of OCD. He then suggests a four-step self-help approach to help the individual deal with the symptoms of OCD. For those who do not want to read the entire book, he provides a summary of the basics of the four steps near the end of the book. Some individuals may be able to use the book to deal with the OCD by themselves. I prefer to use it with patients as an adjunct to therapy and as a reminder between sessions.
Blink, Blink, Clop, Clop: Why Do We Do Things We Can’t Stop? by Moritz and Jablonsky, ChildsWork, ChildsPlay (1998) This illustrated book explains OCD to elementary-aged children. It uses the metaphor of farm animals who are tormented by “O.C.Flea.” It can be a useful story early on in the child’s therapy. This book is probably best read with or to a child. Some of the concepts and vocabulary are more advanced and should be explained.
OCD in Children and Adolescents: A Cognitive-Behavioral Manual by John March and Karen Mulle1998, The Guilford Press. This book is fairly technical and is aimed at psychiatrists and other mental health professionals. This book contains the excellent cognitive-behavioral protocol that Dr. March has been using successfully with children and adolescents with OCD. The book also discusses in more depth special considerations in treating OCD as it occurs in children.
AACAP, (1998) Practice Parameters for the Assessment and Treatment of Children and Adolescents with Obsessive-Compulsive Disorder, Journal of the American Academy of Child & Adolescent Psychiatry, 37:10;27s-45s.
American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) Washington, D.C. American Psychiatric Association.
Treatment of Obsessive-Compulsive Disorder in Adults.
An adult suffering from Obsessive Compulsive Disorder lives in a world filled with frightening thoughts and uncertainty. While he may recognize that the fears are irrational, the intense anxiety drives him to perform repeated compulsive acts to prevent some terrible thing from happening. The individual spends much time and energy in thoughts or actions intended to reduce fears and to reassure himself.
Obsessions are recurrent thoughts or impulses that make the person very anxious (such as the fear that bacterial contamination from using a public toilet will make one’s family sick) The obsessions persist despite efforts to control or suppress them. They feel intrusive and disturbing even though the person is aware that they come from his own mind. The anxiety is out of proportion to rational worry about actual problems. Obsessions often include fears of harming someone, of contamination or of doing something embarrassing.
Compulsions are repetitive behaviors or mental acts the person feels driven to perform, often with ritualistic rigidity, to prevent the anxiety connected with the obsessions. These may include urges to wash, count, check or repeat phrases to oneself.
OCD appears to be a biologically based disorder with severe psychological consequences. The disorder occurs in 2-3% of the population (5-7 million sufferers in the U.S.). About 10% of the first-degree relatives of affected persons also have OCD.
The most effective treatments for OCD include medication and specific behavioral techniques.
Several medications in the same family as Prozac (such as Zoloft, Paxil, Luvox and Celexa) as well as Anafranil, have been shown to reduce symptoms. However, once the medication is stopped, the symptoms usually recur.
Cognitive-Behavioral Psychotherapy for OCD makes use of Exposure and Response Prevention. (ERP) This therapy works because compulsive behaviors provide only partial and temporary relief from the anxiety associated with obsessions. More complete relief can be achieved by the patient becoming “used to” the anxiety and recognizing that it can be tolerated without his becoming overwhelmed. If a person is able to endure the anxiety and not perform the compulsive behavior, he can experience mastery over the obsession. In time, the anxiety which drives the compulsive behavior is reduced and the symptoms are gradually extinguished. Many clinicians feel that the benefits of ERP can persist long after the active treatment is stopped. Often, medication and therapy are used together.
If not treated, OCD tends to be a long-term disorder. Some individuals experience waxing and waning symptoms over the years. Others experience progressive worsening of their OCD until they are housebound and spend much of their days involved in obsessions and rituals. Now with modern medication and psychotherapy, most individuals can have excellent improvement.
Glenn Brynes, PhD, MD
What is Scrupulosity?
Religious belief, and membership in a faith community are important factors in the lives of many individuals. In addition to moral and spiritual guidance, they can provide a sense of purpose, structure and community. For a certain individuals, religious beliefs become compulsive, joyless behaviors. The individual may constantly worry that he or she might say or do something blasphemous. He may fear that he has committed sin, forgotten it and then neglected to repent for the sin. He may spend long hours searching his mind to try to ferret out evidence of un-confessed sins. He is unable to feel forgiven. Specific obsessions and compulsions vary according to the individual’s religion. An Orthodox Jew might worry that he did not perform a particular ritual correctly. He might obsess about this for hours. A Roman Catholic might go to confession several times a day. Another individual could believe that anything he does might be sinful. This individual might become so paralyzed with doubt, that he or she becomes afraid to do or say anything at all.
Scrupulosity and OCD
Religious faith and religious education are not generally the causes of Scrupulosity. Actually, Scrupulosity is a form of Obsessive-Compulsive Disorder. (OCD) OCD appears to be a biologically based disorder with severe psychological consequences. The disorder occurs in 2-3% of the population (5-7 million sufferers in the U.S.). About 10% of the first-degree relatives of affected persons also have OCD.
Obsessions are recurrent thoughts or impulses that make the person anxious (such as the fear that using a public toilet will make one sick) The obsessions persist despite efforts to control or suppress them. They feel intrusive and disturbing even though the person knows that they come from his own mind. Obsessions may include fear of harming someone, contamination or of doing something embarrassing.
Compulsions are repetitive behaviors or mental acts the person feels driven to perform, often with ritualistic rigidity, to prevent the anxiety connected with the obsessions. These may include urges to wash, count, check or repeat phrases to oneself.
OCD can occur in different forms. There are a variety of different types of obsessions and compulsions. The nature of intensity of these symptoms may vary over time. Aggressive, sexual and religious obsessions sometimes occur together in the same individual.
Differentiating Scrupulosity from Devout Religious Faith and Practice
Because these obsessions and compulsions are intertwined in the individual’s religious life, it may be difficult for him or her to recognize that he or she has a psychiatric condition. An individual with religious obsessions often may focus excessively on one particular concern about sin while neglecting other aspects of his or her religion. Most religions place a high priority on compassion and being a good neighbor. The scrupulous individual while focusing excessively on a few specific rules may neglect this more general dictum.
Religious leaders within the Roman Catholic and Jewish community have addressed these issues. Commentators in both of these groups have writings that label scrupulosity as a sin. One rabbi called it idolatry because the excessive devotion to a specific ritual (to the detriment of good acts toward other people) elevated the ritual to a god-like status. In his book, The Doubting Disease, JW Ciarrocchi reviews Roman Catholic pastoral writings over past centuries. He feels that some of the things that priests did to help scrupulous individuals anticipated current treatments for OCD.
Treatment of Scrupulosity
Like other forms of OCD, scrupulosity responds to medication and cognitive-behavioral therapy. Prior to studies in the 1980’s, the usual view of OCD was that it was a relatively rare disorder with a poor prognosis. However, in addition to it being now recognized as much more common (2-3% prevalence rate), it is generally considered treatable. About 60%–80% of patients show some degree of response to treatment.
The serotonin system in the brain seems to be involved in the pathology of OCD, since the medications that have been shown to be help treat OCD increase the availability of this neurotransmitter. These medications include the serotonin re-uptake inhibitors: clomipramine, fluoxetine, sertraline, paroxetine, fluvoxamine, and citalopram.
Cognitive-Behavioral therapy—specifically ERP [Exposure and Response Prevention]—has been successfully used for the treatment of OCD. The idea behind ERP is that compulsions provide only a temporary reduction of the anxiety produced by obsessions. Furthermore, the only way to experience more permanent relief is to habituate (grow tolerant of…”get used to”) the anxiety caused by the obsession–without performing the compulsion. Habituation is the key factor, and clinicians start by identifying triggers that bring on obsessional thoughts and compulsive behaviors. Then they develop a graduated hierarchy of anxiety based on the patient’s report. The patient “challenges” him or herself by gradually moving up the hierarchy. In addition to exposure, the patient is instructed to refrain from carrying out the associated rituals or at least to delay the rituals by several minutes. .
This treatment can be adapted to religious obsessions and compulsions. However, the therapist must proceed with sensitivity to the individual’s cultural and religious beliefs. If this is not done, the therapy may actually increase anxiety and resistance.
Coordination Between Psychiatrist and Clergy
It is often useful for the psychiatrist and the individual’s religious leader to work together. In some cases, with permission, the psychiatrist and the religious leader may speak directly. In many other cases, the individual in treatment can be the communication bridge. The religious leader can help the individual distinguish legitimate concerns about faith and guilt from stereotyped religious obsessions. As the person with scrupulosity begins to face his fears, he may experience a temporary increase in anxiety. The religious leader can then be a source of support and encouragement. In some cases, clergy will give the individual permission to visualize things that would usually be considered sinful thoughts if it is part of the treatment for this condition. If an individual is compulsively repeating a ritual until it is perfect, the clergy may need to give the individual special permission to perform a ritual in a less than perfect manner.
Although the psychiatrist may coordinate with clergy, the psychiatrist usually remains neutral about the individual’s particular religious beliefs. Psychotherapy and religious conversion are different things. However, within the context of psychiatric treatment, the individual is often able to gain control of his or her OCD and Scrupulosity. This can lead to freedom from excessive guilt and stereotyped religious obsessions. Ultimately, the individual is freed to experience a richer life in his or her family and faith community.
Specific Help For Specific Forms of Anxiety Disorders
For many people, anxiety is more than a few passing worries. It may invade many aspects of their lives; interfering with relationships, work and physical health. Anxious people get sick more often and miss more work and school than individuals who are not anxious. The costs to the individual and to society are tremendous.
Today we have a better understanding of causes, subtypes and treatments.
Types of Anxiety include:
Mild anxiety reactions often respond well to support and reassurance from family, friends or clergy. In other cases, therapy or medication is needed. Many types of anxiety respond best to specific types of treatment.
Some individuals benefit from short-term cognitive-behavioral therapy. Others, may need a longer-term exploration of the reasons for their anxiety.
Agoraphobia is the fear of going out into public places. It can occur with or without panic attacks.
Mary’s* problems started one day when she was pumping gas. Some rough young men came over and made rude remarks. She was frightened and began avoiding gas stations. The fear increased, and she became unable to do the grocery shopping without her husband. She spent much of her day worrying about anticipated trips out of the house. Within two years, she was housebound. Her husband consulted a psychiatrist who gave him advice on how to persuade Mary to come in for a consultation. The psychiatrist saw them together, educated them about agoraphobia, and prescribed medication. At Mary’s next session, she was calm enough to begin the therapeutic work of enlarging her “perimeter of safety.” Her husband attended all of the sessions. Between sessions, he helped her with her homework. He would accompany her as she gradually went further from home. When she began to go places on her own, he was coach and cheerleader. She was eventually able to deal with her fears on her own. Mary elected to remain on her medications for a year after her symptoms had gone away.
In milder forms, agoraphobia may cause an individual to avoid certain situations and jobs. However, in some cases, the fear increases until the individual becomes depressed and housebound. Occasionally one may be too fearful to come in for treatment. This may be a reason for resurrecting the old concept of the physician’s house call.
Individuals with severe agoraphobia should usually start both medication and therapy as soon as possible. Without the medication, such an individual might not be able to make full use of the therapeutic process. People with mild to moderate symptoms might chose a combination approach or therapy alone. Homework between situations, and coaching from family members or therapists help one gradually face the feared situations.
Carol E. Watkins, MD
While anxiety disorders occur throughout the life-span, there are important differences in anxiety disorders occurring in older patients. Interestingly, most anxiety disorders are somewhat less common and often less severe in persons over 65 years of age; for example social phobia, agoraphobia, panic disorder, post-traumatic stress disorder and the more severe forms of obsessive compulsive disorder.
Nonetheless, about 20% of all elderly persons report some symptoms of anxiety. In addition, anxiety symptoms arising from physical problems or medication side effects are more frequent among the elderly. For example breathing problems, irregular heart beats and tremors can simulate symptoms of anxiety. Anxiety can occur along with other psychiatric problems too; over half of elderly persons with severe depression also meet the criteria for generalized anxiety disorder.
I am often struck by the fact that many elderly people must deal with significant changes, with threats to their independent functioning and with major losses at a time in their lives when they are often least equipped to deal with them. It is not surprising that this often leads to anxiety.
Fortunately, there are many good treatments for anxiety disorders. These may include the use of relaxation techniques, psychotherapy and medications. Frequently with effective treatment, the person can then handle the challenges of their life.
Glenn Brynes, PhD, MD
Mr. A* has turned down several promotions in the past two years. He has come up with many new ideas to help the company, and knows that he could do much more. He even has a sympathetic boss who wants Mr. A to get credit for the innovations. But there a problem. If Mr. A is promoted, he will have to present his ideas to teams of management and peers. The idea makes him feel petrified.
Ms. B* worries that she might blush in social situations. Because of this, she avoids going out with friends and co-workers. After a conversation, she often pulls out her pocket mirror to see whether she is blushing.
Social phobia (or social anxiety) is the fear of becoming embarrassed or humiliated in social or performance situations. If the individual is put in the situation he fears, he may have the symptoms of a panic attack. More commonly, he rearranges his life to avoid the anxiety-provoking situation.
This disorder is fairly common and can be quite disabling. Fear of public speaking may affect up to 20% of the population in America. As long as one is not required to speak in public, it is not a problem. 3% to 13% of individuals report having had symptoms severe enough to be considered social phobia.
Some individuals have a generalized fear of all social situations. Others fear specific situations such as using a public restroom, eating in public, or making eye contact with others. The symptoms often starts in adolescence and persist throughout one’s life.
Avoidance of the feared situations often causes the individual to restrict his social life and occupational choices. Many will self-medicate with alcohol or other substances.
When properly diagnosed, social phobias are treatable. The treatment may vary, depending on severity and whether the phobia is generalized of specific to one type of situation. We usually use psychotherapy alone or in combination with medication. Medication as the sole treatment is not as effective as a combined approach.
Carol E. Watkins, MD
*vignettes are fictional examples
Neurobiological Diagnosis and Personal Responsibility
Some commentators have linked the increased awareness of ADHD to a decline in personal responsibility and traditional morals. They feel that the medical community, in bestowing the diagnosis of ADHD or other mental illness, is giving the affected individual permission to continue objectionable behavior. The patient seeks medical absolution in the therapy room, abandoning the traditional values of church or temple. Some individuals who seek special accommodations in school or in the workplace are held up to public ridicule. Such individuals are said to be lazy or are trying to style themselves as victims. Some will point to themselves as good examples. They were impulsive “bad boys” in school. Once they got out of school and met the realities of having to make a living, they “straightened up” and overcame their moral shortcomings.
While these charges may make one’s blood start to boil, we need to take such criticisms seriously. Often a little self-examination can be useful. This raises several important questions. What is the meaning of “being diagnosed”? Are you still the same person? If one has a neurobiological condition that predisposes one to impulsivity, where does personal responsibility fit in? Where does reasonable accommodation end and “making excuses or being prickly” begin?
I feel that there is no conflict between the need for personal responsibility and the need to understand one’s diagnosis. Most moral systems value the concept of self-knowledge. Understanding one’s strengths and weaknesses is necessary for one to function as a moral being. Once one becomes aware that one has ADHD, it becomes a responsibility to learn more about the condition. Then, one can try, through increased self-knowledge, to avoid impulsive acts that might offend or injure others. The same principle holds for parents of a child with ADHD. When to punish, when to accommodate and when to try to gradually shape behavior?
When dealing with individuals with long-standing, severe ADHD, I sometimes encounter those who have become so used to their own impulsivity and failure that they have ceased to care about the rights of others. They have learned to associate with impulsive, antisocial peers. At their worst, they can function as predators. Such an individual might use his or her diagnosis as an “excuse” but this is usually part of an over-all antisocial pattern. I have treated a number of such individuals. For them, the road to recovery is longer and more agonizing. Some regain their self-esteem, and with extensive academic, medical and social help, achieve successful lives. Others end up in the juvenile or adult penal system.
There are some individuals who seek a specific psychiatric diagnosis to try to explain long-term life problems. Whether or not they actually have the ADHD, the diagnostic and process does not satisfy them. Each professional who does not deliver the expected miracle is eventually devalued. Such an individual might be one of the rare people who will ask for unreasonable accommodations. This person might swing from the pole of extreme guilt to the pole of feeling of constantly victimized. Such an individual would benefit from long term individual psychotherapy with a therapist who can tolerate being both idealized and devalued.
In my experience, the majority of those diagnosed with ADHD do not misuse their diagnoses to get undeserved accommodations. Indeed, the individual may be wracked with shame and anxiety about their inability to contain their disorganization and impulsivity. This sense of shame and secrecy can paralyze an individual and make him or her unable to ask for reasonable assistance. This person, hearing public criticism of ADHD, may retreat further into shame and secrecy. In particular, I have found that deeply religious individuals can be much harder on themselves than their elders or clergy.
Since the increasing diagnosis of ADHD has been criticized as a move away from traditional morality, it might be interesting to consider various religious perspectives on the subject of psychiatric diagnosis, religious communities, and personal responsibility. (For this discussion, I will be excluding the tiny minority of mentally ill individuals who truly cannot understand the nature of their actions).
Over the years, I have worked with many deeply religious people from a variety of faiths. They have often been gracious enough to bring in literature to educate me about their beliefs. When appropriate, I have involved their clergy or religious community in the treatment. This collaboration between clergy and psychiatry has almost always been positive. Once there is a climate of mutual trust and respect, a particular religious community can be an invaluable source of structure and support. In my experience, most clergy are more accepting of the diagnosis of ADHD than their more conservative parishioners. A few clergy needed education about ADHD, but almost all were eventually supportive.
For certain individuals with ADHD, daily prayers and other religious rituals provide a good way to handle transitions, and to frame the experiences of the day. The church, temple or mosque is a source of interpersonal support and a ready place for structured social activities. Religious communities can have all of the same foibles as can individuals. Like other social institutions, they can be prone to cliques, and petty prejudices. However, good clergy and lay leaders function to remind the community to look beyond prejudices and to constantly strive to imitate God.
Some Christians have used Jesus’ dealings with the Apostle Peter as a model for how one might deal with a child or an adult with ADHD. Some have wondered whether Peter himself had some of the characteristics of ADHD. He loved Jesus and desperately wanted to be more like him. However, on several occasions, he acted impulsively and was unable to follow through. For example, on the night Jesus was betrayed, Peter cut off a soldier’s ear. He also promised to stick with Jesus no matter what happened. However, by the morning cockcrow, he had betrayed Jesus three times. In other situations, Jesus called Peter by name, gently pointed out the mistake and suggested a correction. In the case of the three denials, a piercing look was enough to remind Peter of his error. The later books of the Christian scriptures, written about the time after Jesus, give hope in that they show a more mature, confident man who has clearly learned from Jesus’ encouragement and gentle setting of limits.
Some contemporary Christian ministers suggest that faith can relate to individuals with psychiatric diagnoses. Once one becomes aware of a psychiatric diagnosis, it becomes one’s responsibility to learn more about the condition. Through knowledge, one might be able to minimize impulsive acts that might offend or injure others. Prayer can lead to a sense of forgiveness and freedom from shame. Even if one feels forgiven, there is still the obligation to attempt to make amends to other people who might have been hurt by one’s impulsive acts. When one is freed from shame and secrecy, it is often easier to make meaningful amends to others. Prayer or meditation can be a source of quieting and centering. Some distractible individuals may not be able to sustain a lengthy, focused prayer. However, in the Screwtape Letters, C.S. Lewis indicates that the most powerful prayer is a simple brief prayer for the grace to manage the daily challenges.
The Jewish celebration of Pesach, (Passover) commemorates the deliverance out of bondage in Egypt. It is one of the earliest examples of interactive learning. The participants should experience the deliverance from slavery as if it were happening to them that evening. There is particular attention to teaching the children. There are stories, breath-holding contests, hunting for a hidden object and songs to keep children and other distractible folk involved. The Haggadah, (order of service), describes four types of children and commands the adults to teach each type of child in a way that he will learn best. The four children are the wise child, the simple child, the wicked child and the child who is too young to ask questions. The Haggadah describes specific teaching techniques for each child so that each will understand the experience of the Exodus.
At one Seder meal it suddenly struck me that these commandments were the Divine blueprint for the special education laws; 94-142 and subsequently IDEA. Over two millennia ago, there was a commandment to give each individual instruction that he or she could understand and apply! Particularly interesting is the instruction for dealing with the wicked child. One might see him as the distractible, impulsive defiant child. He says, “What mean ye by these commandments?” The teachings command one to point out that he has, by his language and attitude, excluded himself. This gentle rebuke is interpreted as pointing out his self-exclusion. The eventual goal of this is to encourage him to rejoin the family group and participate in the miraculous deliverance. Much of the subsequent games and playful contests also function to draw in such an individual.
The Jewish rituals cover a wide variety of every day and unusual events. These prayers and rituals can be very centering and can help structure the day. The Bar and Bat Mitzvah, coming of age ceremonies, welcome young people into the community. The preparation can be academically intense. The Jewish community recognizes this and there a number of tutorials and other accommodations so that a broader range of individuals are able to join the adult Jewish community.
The Suni Moslem believes that at birth, one is assigned two angels who record all of one’s good and bad deeds. However the “pen is lifted” in three circumstances. These are youth, sleep and insanity. Individuals with mental illness who can distinguish right from wrong are not exempt from the recording of their deeds. However, Islam tends to be understanding about an individual’s limitations, and will accept a sincere effort to obey the laws of Islam. If one Moslem does something offensive to another Moslem, the recipient may shun the offending individual for only three days. After that one must forgive.
If an individual commits an impulsive negative act, he or she must make a sincere prayer of repentance to Allah, and then ask the offended individual for forgiveness. Muhammad said that one must then follow the offensive action with a good deed. Islam is often quite specific about expected behaviors and responses. For instance, if one is unable to fast during Rammadan because of one’s psychiatric medications, one could instead feed a hungry person each day during the fast.
Most often, I find that individual believers of many faiths are harder on themselves than would be their clergy. For example, several religious groups have special fast days. Certain medications and medical conditions make fasting impractical or actually dangerous. Most clergy feel that it would be a sin to endanger one’s health for the sake of a fast day. Frequently, the patient needs to hear this directly from the clergy or lay elders. In the case of most medications for ADHD, one can stop them for a day or rearrange the dosing to facilitate a one-day religious fast. The month long, dawn-to-dusk Moslem observance of Rammadan is more challenging. However, I have managed, with community help and some pharmacological maneuvering, to see patients through this important religious observance.
Individuals who have the diagnosis of ADHD are often relieved that there is an explanation for their fogginess, fidgetiness, and impulsivity. However, when they attempt to get accommodations, they are often accused of laziness or making excuses. Some commentators have seen the diagnosis of ADHD as the medicalization of morality. However it is appropriate to consider psychiatric treatment as responsible stewardship of one’s body and mind. Those with ADHD, like everyone else, should always try to take responsibility for their actions, and make amends for any offenses. However, those who condemn this diagnosis are not representative of most liberal or conservative religious leaders.
Coping Styles in ADD Adults
Whenever I go hiking in the State Park near my home, I am struck by the variety and tenacity of the forms of life around me. There are the familiar denizens, such as the white-tailed deer, the fox and the box turtle. Often, though I am most fascinated by the smaller plants and animals that have found a tiny, unique niche suited to their own particular needs and vulnerabilities. The creatures that live under a rock or at the mouth of a small cave have often worked hard to establish and defend their special place.
One sunny afternoon, after looking under a particularly interesting rock, I began thinking about coping skills. Many of us, like these invertebrates, have developed creative and clever ways of coping with a harsh environment.
The vertebrates are an order of animals that have an internal skeleton (endoskeleton) and a central vertebral column. Vertebrates include reptiles, mammals and others. Invertebrates are all the other animals. The larger invertebrates have had to develop an external armor of find another means of support and defense.
Most individuals have the internalized ability to focus and stay organized. This ability is like the internal skeleton of the vertebrates. The internal skeleton is invisible and grows as the individual grows. It prevents the soft parts of the body from collapsing and allows the body to move smoothly through the environment.
Those with the disorganization and impulsivity of ADD are the invertebrates. Lacking the vertebrates’ endoskeleton, they devise different types of coping. See if you recognize yourself:
The Blue Crab (Callinectes sapidus Rathbun): The blue crab protects itself with a rigid outer shell and with its sharp claws. The shell cannot grow with the crab, so it must periodically molt. It is vulnerable until it grows a new, hard shell. Those who go crabbing know the other time of vulnerability. To the casual observer, the Blue crab person often does not appear to have ADD. This is because she has set up an elaborate and rigid structure around herself. The car is always parked in the same place so she will not lose it. She hires extra office staff who, on pain of her extreme displeasure, keep things running exactly on time. She becomes annoyed and a little anxious if her schedule is altered. A job or family change is akin to molting. She is quite disorganized and vulnerable in such times, and may resort to the equivalent of hiding in the mud. Eventually she grows a new shell to fit her new situation.
The Jellyfish (Polyorchus pencillatus) In most cases, this creature does not develop a rigid covering. Instead, it allows the ocean tides to carry it along. Although its movements are passive, it has formidable stingers. In its own element, the jellyfish is breathtakingly beautiful. If the tides happen to wash it up on shore, it is helpless and loses its beauty. These charming people tend to “move with the changing tides.” In many ways, they are the opposite of the blue crab people. While some might label them as insincere, they have actually just lost sight of the previous topic and moved on to another situation. Their capacity for verbal stingers is only used defensively. When they are washed out of their element, they can become helpless unless an external force helps them get back into their element.
The Earthworm (Lumbricus terrestis): These creatures spend much of their time underground. While they may not appear glamorous, they perform the useful task of enriching the soil and breaking garbage down into rich compost. Many predators value worms as a food source, so the earthworm has become adept at feeling the vibrations made by predators. Over the years, these individuals have internalized others’ negative views. They have learned to flee criticism and aggression. They may be performing valuable functions as a mother or in a job, but do not seek proper credit for this.
The Cricket (Orthoptera: Gryllidae) These small creatures have compound eyes that allow them a wide range of vision. Although they sometimes eat plants, they can also be hunters. They are able to jump rapidly in different directions. This ability for unexpected, rapid movement helps them hunt and helps them get away from their own predators. This type of person takes advantage of her high activity level and ability to think flexibly. However, the lack of stingers or hard, external armor makes her vulnerable to certain predators.
I am in awe of the kingdom of nature. So many living organisms have found their own unique ways to thrive in often forbidding niches. In the same way, I am humbled when I see how people have found creative ways of coping with difficult situations. As with these animals, when one looks deeper, one often finds that the sharp or unattractive parts are there for a reason. A person’s coping style is often unique. Some people decide that their coping style has become too rigid or no longer fits their situation. One should not try to jettison all defenses without first attempting to understand why they are in place to begin with. At this point, an individual can begin to actively choose both internal and external structuring techniques.
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Monkton Office16829 York Road/PO Box 544/Monkton, MD 21111
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Email: [email protected]
Please use telephone for appointments or medical questions.
Carol Watkins, M.D.
Glenn Brynes, Ph.D., M.D.
Rita Preller, LCSW-C