Your Own Worst Enemy?
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
Psychotherapy can be a valuable tool for identifying, understanding and changing
self-defeating behavior. If you havent 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
*Examples are fictitious vignettes.
Is All Psychotherapy Alike?
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
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
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 patients 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 ones assigned therapist. Ideally, one should be able to
interview a prospective therapist and ask hard questions about the individuals
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.
Carol E. Watkins, MD
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
Individuals with OCD are seeking each other out.
There are support groups and web sites for individuals who are seeking support and
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 silenceand 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.
Glenn Brynes, PhD, MD
Carol E. Watkins, MD
Disorder in Children and Adolescents
Carol Watkins, MD
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:
- Recurrent and persistent thoughts, impulses or images that are experienced, at some time
during the disturbance, as intrusive and inappropriate and that cause marked anxiety or
- The thoughts, impulses, or images are not simply excessive worries about real-life
- The person attempts to ignore or suppress such thoughts, impulses, or images, or to
neutralize them with some other thought or action.
- The person recognizes that the obsessional thoughts, impulses, or images are a product
of his or her own mind (not imposed from without as in thought insertion)
The DSM-4 defines compulsions as:
- Repetitive behaviors (e.g. hand washing, ordering, checking) or mental acts (e.g.
praying, counting, repeating words silently) that the person feels driven to perform in
response to an obsession, or according to rules that must be applied rigidly.
- The behaviors or mental acts are aimed at preventing or reducing distress or preventing
some dreaded event or situation; however, these behaviors or mental acts either are not
connected in a realistic way with what they are designed to neutralize or prevent or are
The DSM-4 also requires:
- The obsessions or compulsions cause marked distress, are time consuming (take more than
1 hour per day), or significantly interfere with the person's normal routine, occupational
(or academic) functioning, or usual social activities.
- At some point during the course of the disorder, the person has recognized that the
obsessions or compulsions are excessive or unreasonable. Note: This does not apply to
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
childs cognitive development necessitates some changes in the psychotherapeutic
approach. If medications are used, the physician must consider the childs 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
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 childrens book, Blink, Blink, Clop, Clop, Why Do We Do Things We
Cant 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
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.
- Clomipramine, (Anafranil) ages 10 and up
- Fluvoxamine, (Luvox) ages 8 and up
- Sertraline, (Zoloft) ages 6 and up.
- Fluoxetine, (Prozac) approved for adults, but may soon receive approval for pediatric
- Paroxetine (brand name Paxil) 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 ones 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
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
Obsessive-Compulsive Disorder in Adults.
Brynes, Ph.D., M.D.
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
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
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
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
The most effective treatments for OCD include medication and specific
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 Obsessions and Compulsions
Carol E. Watkins, MD
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 individuals 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
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
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 individuals
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 therapyspecifically 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 individuals 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 individuals 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 individuals 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
Carol Watkins, MD and Glenn Brynes, PhD, MD
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
Types of Anxiety include:
Adjustment Disorder (reaction to life stresses)
Agoraphobia (fear of going out in public places)
Specific Phobia (such as fear of spiders)
Social Phobia (such as fear of speaking in meetings)
Generalized Anxiety Disorder (feeling anxious almost all of the time)
Anxiety Disorder Associated with a Medical Condition
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.
Carol E. Watkins, MD
Agoraphobia is the fear of going out into public places. It can occur
with or without panic attacks.
Marys* 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 Marys 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 physicians
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
Carol E. Watkins, MD
*vignettes are fictional examples
Anxiety in the
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
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
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 ones 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
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
Diagnosis and Personal Responsibility
How does morality fit in with ADHD?
Carol E. Watkins, MD
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
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
Coping Styles in ADD Adults
Carol Watkins, MD
ADD and Invertebrate Anatomy:
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.
One can take each of these analogies
further, but I leave that to your imagination. I did not cover mating practices or many
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.