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“THE MIND CONNECTION”December 2013 Column: Scrupulosity Manifests Itself in Some Forms of OCD

By John Hartsock

In our capitalistic, materialistic society, there is a heavy emphasis based on the concept of “earning. “From first grade through the end of formal schooling, grades are “earned”. Starting positions on athletic teams, leading parts in school plays or musicals, and student office titles like class president are all “earned”. In the adult world, competition is even more intense, and scrutiny and judgment can become burdensome to the point of feeling intolerable.

Religious faith can offer a refuge from the ravages of the world. But the kind of distorted religious faith that takes the form of excessive scrupulosity in those afflicted with obsessive-compulsive disorder (OCD) can turn out to be much more harmful than good. Scrupulosity may or may not be part of the clinical OCD picture, but when it is, it often takes the form of an excessive preoccupation with the salvation of one’s soul, pathological doubt that one’s sins have been forgiven, a belief that one has committed the “unpardonable” sin, or compulsive requests for reassurance from clergy that one has “earned” God’s grace. It is not surprising that physical death and what happens to the soul after death can be matters of great concern for an OCD sufferer. After all, pathological doubt is the hallmark of most forms of OCD, and what happens to people after death is something that can neither be confirmed nor denied by the living. OCD is an anxiety disorder, and the most fundamental source of all anxiety can be categorized under the fear of the unknown.

Since nobody living on this planet has experienced what actually happens after the body dies, it could legitimately be argued that the mystery and fear surrounding death and its aftermath is the root problem in all forms of anxiety. Faith is the greatest buffer against the anxiety that can be caused by the problems of daily living. But faith can ebb and flow throughout the course of one’s life, and the strength of faith at any given time varies greatly not only between individuals, but within each individual. Differences of opinion concerning matters of faith and the mystery of death cannot be reconciled easily, if at all. They cannot be disputed or supported, because in fact, they are matters of faith. OCD sufferers, who crave certainty, security, and a sense of control above all else, can have great difficulty confronting their own deaths, and the deaths of those who they care about.

The prospect of separation from God and loved ones creates anxiety and distress among most people. But for OCD sufferers, this anxiety and distress can breed a type of paralyzing scrupulosity that becomes pathological. “All of us try to be good, but some of us are predisposed, for biological, neurological reasons, to develop OCD,” said Dr. David L. Kupfer, a clinical psychologist who practices in Virginia, and treats excessively scrupulous OCD sufferers. Joseph W. Ciarrochi, an associate professor of pastoral counseling at Loyola College in Maryland, has encountered many cases of excessive scrupulosity among the patients that he treats in his clinical practice as a clinical psychologist. The scrupulous often see “a sin where there is none”, according to Ciarrochi. “People with this condition lose the ability to know that they know something.” Ciarrochi, who authored the book “The Doubting Disease” that concerns the symptoms and treatment of OCD and scrupulous behavior, noted that “when we have a religious obsession, we try to do something about it.”

In this respect, scrupulosity becomes much like an itch that must be scratched, or an unpleasant, annoying sense of pain that must be alleviated. The Latin root for the word “scrupulous” is “scrupulous,” which means a “small sharp or pointed stone.” Many people living with excessive scrupulosity are like those people walking with a pebble in their shoe. The pebble may be tiny, but its effect is very annoying and burdensome.

The scrupulous often resort to bombarding their priests, rabbis, pastors or ministers with concerns about sins in attempts to gain reassurance for themselves. The Catholic who ruminates endlessly about whether he or she has made the “perfect confession,” or one who endlessly agonizes over whether a loving God will accept that confession, is suffering from excessive scrupulosity. This person will often seek endless reassurance from his confessor or religious/spiritual director that he or she will not go to hell, that he or she is a good person who is worthy of salvation.

For those who are troubled by such scrupulous concerns, the knowledge that eternal salvation is not something that is earned, like a grade in school, can be a great comfort. Instead, salvation is a free gift from God that human beings can either choose to accept or reject. Dr. Alec Pollard, Ph.D, who treats scrupulous people in his practice at St. Louis University, proposes an interesting theory about how he helps them deal with the problem. “None of us wants to go to hell -- inferno or no inferno,” said Pollard, who like Kupfer and Ciarrochi, was speaking on the subject of scrupulosity in OCD at the International Obsessive Compulsive Disorder Foundation’s seminar that was held in Washington, D.C. in 1999. “But some people become particularly preoccupied with this concern.”

“One of the things that I ask my patients to do is to think of their own goals, and the goals that they believe that their God would have for them,” Pollard added. When Pollard poses the question of whether God would desire that excessively scrupulous people spend their lives obsessing about the possibility of hell, he does so by bringing each of his patients face-to-face with the question of how they believe that the God that they worship would want each of them to spend their own individual lives.

“One of the questions that I might ask (obsessively scrupulous) patients is, “Do you believe that your God put you on this earth in order to do that behavior?” “If they believe that their God wants them to do what they are doing, then they are cured [and don't need treatment],” Pollard said. “But if they believe otherwise, they need to address the problem and change the behavior.”

The problem with excessive scrupulosity among OCD sufferers is an age-old problem. Prominent figures in Christian history -- notably, Martin Luther and St. Ignatius, founder of the Jesuits -- endured well-documented struggles with excessive scrupulosity. “If you have a problem, get some help,” said one OCD sufferer who spoke of his excessive scrupulosity at the 1999 IOCDF seminar.” Trying to [help] yourself is like trying to give yourself open-heart surgery.”

Comments, questions and suggestions about this article are welcomed and can be sent to

Ahead for the January 2014 column: Examining strategies to combat scrupulosity in OCD

“THE MIND CONNECTION”November 2013 Column: Hit and Run OCD: A Driving Nightmare

By John Hartsock

For millions of Americans, driving a motor vehicle is a privilege that is mostly taken for granted. Most people who get behind the wheel don’t spend an inordinate amount of time dwelling on concerns other than to get from one location to another.For certain individuals with anxiety disorders like obsessive-compulsive disorder, however, operating a car or other vehicle can become a personal nightmare.

Bruce Hyman, Ph.D, is a Florida clinician who treats people suffering from a form of obsessive-compulsive disorder that is known as “hit-and-run OCD.’’ Drivers with hit-and-run OCD have ungrounded fears that they may have struck, injured, or even killed a pedestrian who they’ve passed by or near on the road. “People with hit-and-run OCD may have other forms of OCD, but [in the case of] the patients who come to see me for help, driving is the main problem,’’ Hyman told an audience attending the 1999 International Obsessive-Compulsive Disorder Foundation’s national seminar held in Washington, D.C.

As with other forms of OCD, symptoms in hit-and-run OCD range from mild to incapacitating.“It ranges from having a minor reluctance to drive, to a total avoidance of driving,’’ Hyman said. “The most severe case that I’ve encountered involved nine straight hours of checking.’’People with ungrounded concerns that they’ve harmed other people, or individuals who are overly scrupulous, may be prone to such driving anxieties.

According to Hyman, drivers who suffer from hit-and-run OCD experience what are known as “spikes” of anxiety and they engage in a process to neutralize the anxiety. Drivers engaging in this neutralization process may return back to where they heard a bump in the road to determine that they have not struck a pedestrian.They may visit police stations to examine police records concerning accidents in a given area, in order to gain reassurance for themselves that they have not struck anybody. They may resort to chasing or following ambulances if they feel that their car has caused an accident, or they may watch television news broadcasts for accident information. They may repeatedly ask others for reassurance that no accident has occurred. They may also check the body of their cars for dents, damage, or even for parts of dead bodies.

Checking the rearview mirror for reassurance is a very common practice among drivers with hit-and-run OCD.Drivers with hit-and-run OCD, like people who have other forms of OCD, tend to adopt an exaggerated sense of responsibility for events on the road.“They don’t know where their responsibility ends, and [where the responsibility of others] begins,’’ Hyman said.

Anxiety spikes for people with hit-and-run OCD are triggered by events like riding over a bump, pothole or other irregularity in the road, passing pedestrians, driving by motorcyclists, a child or group of children on bicycles, or an elderly person. “These situations become extremely difficult and anxiety-provoking,’’ Hyman said. So will hearing a police or ambulance siren in the immediate area of the driver with hit-and-run OCD.

“[People with hit-and-run OCD may speculate that] what if the siren is in response to an accident that they’ve caused,’’ Hyman said. “This creates an overwhelming urge to check.’’ A report of an accident in the media originating in the area where the person has been driving, or an unexpected sound hitting a car, caused by something like a pebble or a rock, can also cause a spike in anxiety and an urge to check.

Treatment for hit-and-run OCD, like treatment for other forms of the disorder, involves a combination of medication and cognitive behavioral exposure therapy. One tool in the cognitive behavioral therapy arsenal might involve having a person with hit-and-run OCD tape-record a scenario of their worst fear – for instance, hitting a child with their vehicle and going to jail. After listening to the tape of this scenario over and over again, the anxiety gradually subsides. “They listen to the tape over and over again, and some patients get desensitized to the anxiety, while others may actually get bored,’’ Hyman said.

Exposure therapy can start with situations that cause a moderate amount of anxiety – for example, driving past a school and not going back to check. “Initially, [the patient] will get very anxious, but over time, the anxiety will go down,’’ Hyman said. Daily exposure practice, like driving over bumps in the road, is very important, Hyman said. Hyman also has his hit-and-run OCD patients drive over a 40-pound dummy or sack, in order to test reality. “There’s no doubt as to what it would be like to hit somebody,’’ he said. “There’s no doubt as to what that would feel like.’’ Hyman pointed out a realization that is bound to help anybody with hit-and-run OCD. “If you hit a person, you would know it,’’ he said.

Medications can also help alleviate some of the anxiety that can make practicing cognitive behavioral exposure techniques much more difficult.Many of these medications fall into the category known as selective serotonin reuptake inhibitors – or SSRIs. SSRIS include the medications Luvox, Prozac and Paxil. These medications will vary in both their effectiveness and tolerance, depending on the individual using them. Anafranil, which is also widely used in the treatment of various forms of OCD, may also be used in the treatment of hit-and-run OCD.

Whatever the treatment plan is for hit-and-run OCD, driving without interference from obsessions and compulsions is always the main goal. “People with OCD are generally good drivers,’’ Hyman said. “They’re slow drivers. [But they need to realize] that even when they’re involved in an accident, other factors may be involved. [For instance,] the other driver may have been drinking, or driving poorly.’’

Comments, questions and suggestions about this article are welcomed and can be sent to

Ahead for the December 2013 column: Examining the role of scrupulosity in OCD

“THE MIND CONNECTION”October 2013 Column: Washing, Cleaning Rituals Prominent in OCD

By John Hartsock

Obsessive-compulsive disorder manifests itself in a variety of forms, but probably none is more prominent or common than the form of the disorder in which repetitive washing and/or cleaning becomes a central feature. People with this form of OCD may literally spend hours daily in showering rituals, or wear the skin on their hands and fingers raw from excessive personal washing routines. Along with being time-consuming and wearisome, these rituals can cause individuals and their families’ considerable financial expense and emotional distress.

The key to overcoming washing and cleaning rituals is the same as the key to overcoming checking, counting or any other type of obsessive-compulsive ritual ---- habituation. Perhaps more than in any other form of OCD, repetitive washing and cleaning rituals are triggered by what are characterized as subjective units of distress [SUD]. People with anxieties surrounding washing are commonly distressed by things like dirt, dust, germs, and bodily secretions such as saliva, urine and feces. In a typical SUD paradigm, a person with washing anxieties may regard touching a rusty, dirty doorknob as a “50” on a scale between “O’’ and “100,’’ with “100” signifying maximum distress.

While nobody would want to sit on a toilet seat that is covered with feces or urine, people with the washing form of OCD would be unduly preoccupied with the cleanliness of the toilet seat. Such a person may become so paralyzed by the fear of sitting on even a perfectly clean public toilet seat that they may attempt to avoid using public bathroom facilities altogether, often with troublesome consequences. People with this condition may attempt to “time” their bathroom usage so that they only void their systems in the privacy, comfort, and “safety” of the bathrooms in their own homes. If circumstances force them to use a public bathroom, they may resort to practices like excessive showering or hand washing, or discarding the perfectly clean clothing that they were wearing in the public bathroom in order to deal with their anxiety.

Needless to say, such an approach is maladaptive, and results in additional emotional distress and very often, considerable financial expense, for affected individuals. At the 1999 International Obsessive Compulsive Disorder Foundation’s [ICODF] annual national seminar that was held in Washington, D.C., a middle-aged college professor related how he was able to overcome his contamination fears with the help of Philadelphia-based behavior therapist Jonathan Grayson. After teaching for nearly four decades, the professor’s OCD-related washing compulsions made it impossible for him to continue in his career, and he was forced to resign from his position. “I had an anaconda around me that was squeezing the life out of me, and was very difficult to cope with,’’ was the professor’s description of his battle with OCD. “I was washing my hands [repeatedly] every day, and I couldn’t get any work done.’’

Grayson helped the man regain control of his life by challenging and overcoming his washing compulsions. “[Grayson] asked me if I wanted to live with this my whole life, and I told him that I wanted this damn thing out of my life,’’ the professor said. Grayson initially assigned the professor the task of touching his own shoes – an exercise which caused the professor a moderate amount of distress.“I was able to do that,’’ the professor said. Using a public bathroom was much more challenging for the professor. He habituated himself to the anxiety of the situation by running his hands across the toilet seat, then rubbing his hands on his clothes and face. Eventually, the professor’s contamination concerns ceased to become an issue in his life. But only through facing his fears and “looking the devil in the eye” did the professor regain a sense of normalcy. “Avoidance will make your life miserable,’’ the professor said.

People with OCD often have many forms of the disorder, in varying degrees. Washing and cleaning rituals are a common problem, but checking compulsions, excessive hoarding, and scrupulosity – an excessive concern about religion or morality -- can also be symptoms of the disorder in the same person. It is advised that OCD sufferers with multiple symptoms of the disorder should confront and acclimate themselves to the most troublesome situations first in order of their priority.

Whether the problem is washing, checking, hoarding, or a combination of many different symptoms, progress against the disorder can only be made by the process of exposure and habituation to situations that cause distress. At the same time, it should be remembered that mastery of OCD symptoms is almost never accomplished in a perfectly straight line. “You have to focus on something small and doable,’’ said Dr. Ian Osborn, a State College area psychiatrist who treats OCD patients in his clinical practice and authored a book on OCD entitled “Tormenting Thoughts and Secret Rituals.’’

Osborn emphasized the importance of maintaining the somewhat delicate balance between confronting OCD symptoms full-force and pacing oneself during times of stress. “When you’re doing well, you must challenge the OCD and obtain one or two victories a day,’’ Osborn told an OCD support group audience. “[But] you have to give yourself a break when you’re in a slump.’’ That’s the best way to prevail in a day-to-day struggle against a disorder for which there is presently no cure, but for which treatment advances have made considerable progress. “Any kind of stress can worsen symptoms,’’ Osborn said. “OCD should be recognized as a chronic brain disorder that should be worked on daily.’’

Comments, questions and suggestions about this article are welcomed and can be sent to

Ahead for the November 2013 column: A look at the Hit and Run form of OCD

“THE MIND CONNECTION”September 2013 Column: Medication Options for OCD

By John Hartsock

Three decades ago, obsessive-compulsive disorder [OCD] was considered an extremely rare disease, and one that was also very difficult to treat. Today, clinicians know that neither is true. OCD affects millions of Americans, but advances in psychotherapy and psychopharmacology over the past 20 years have made for a much-improved outlook for OCD sufferers and their families.

OCD must usually be fought with a combination of behavior therapy and medication. Through behavior therapy, people with OCD are taught to actively challenge their obsessions and compulsions. Medications help make that path more navigable for people with OCD. “The preferred treatment for OCD is usually a combination of cognitive-behavioral therapy [CBT] and medication,” said Danielle Gibbons, who is a certified registered nurse practitioner [CRNP] at the Primary Health Network’s behavioral health center on the UPMC Altoona Regional Health System campus. Dr. Bruce Hyman, PhD, who treats people with OCD in his clinical practice in Florida, said that a combination of effective cognitive-behavioral therapy and the appropriate medication can provide a significant amount of relief from OCD symptoms. “Medication gives people somewhere between 30 to 60 percent relief, on average, in my experience,” said Hyman, who spoke to fellow clinicians, OCD sufferers, and their families at the annual International Obsessive Compulsive Foundation’s [ICOF] national seminar that was held in Washington, D.C. in 1999. “Cognitive-behavioral therapy kicks [the percentage of relief] up by another 30 to 40 percent.”

With the right treatment regimen of medication and behavioral therapy, Hyman feels that OCD sufferers can attain an average range of 50 to 60 or up to 90 percent relief from their symptoms, depending on their severity. Irregularities in serotonin -- a neurotransmitter in the brain which regulates mood, aggression, and impulsivity -- have conclusively been proven to play a role not only in obsessive-compulsive disorder, but also, in mood disorders like major depression. In fact, since OCD and major depression often occur together, some medications can be quite effective in treating both problems. A group of medications known as selective serotonin reuptake inhibitors [SSRIs] are used in the front-line treatment of OCD. Included in this class of medicines are Luvox, Prozac, Zoloft, and Paxil. “But the dosage for SSRIs in the treatment of OCD may need to be higher than the dosage that is used to treat depression,” Gibbons said. Anafranil, a tricyclic antidepressant, is also commonly used in the treatment of OCD.

Treatment with either medication, behavior therapy, or a combination of both requires patience and perseverance on the part of OCD sufferers, who may not always receive immediate relief of their symptoms. “Improvement may be seen in a couple of weeks after starting treatment, but it may also take several months to see the effects of treatment,” Gibbons said. Because of the lower incidence of troublesome side effects like dry mouth or blurred vision, SSRIs are often the first choice in medication treatment for OCD, Gibbons said. Treatment for the more severe cases of OCD may also include the use of major tranquilizers like Abilify, Seroquel, Zyprexa, or Geodon to augment the use of the SSRIs.

OCD is a challenging disorder, and one that can be worsened by stressful life events or circumstances. But the arrival of new and effective medications has given OCD sufferers, and their families, plenty of reason for hope. “It’s now a very treatable condition,” Gibbons said. There are some cases that are more resistant to treatment, cases in which complete remission is difficult to achieve. But people with OCD can benefit from treatment well enough now to participate in daily activities without [experiencing] disturbance or disruption from their symptoms. “Sometimes, it just takes people awhile to get to that point.”

Comments, questions and suggestions about this article are welcomed and can be sent to

Ahead for the October 2013 column: A Closer Look at Washing and Cleaning Compulsions in OCD

“THE MIND CONNECTION”August 2013 Column: Habituation and Exposure are Key Tools for Battling OCD

By John Hartsock

For individuals who are ensnared in the ritualistic dance that accompanies obsessive-compulsive disorder [OCD], challenging and discontinuing the rituals may be the furthest thing from their minds. Individuals with obsessive-compulsive disorder derive a sense of security from performing rituals to deal with the anxiety created by their obsessive, intrusive thoughts. But that security is a false and fleeting one.

In order to successfully cope with OCD, it is the rituals themselves that must be avoided and discontinued. People with OCD improve by exposing themselves to situations that cause them anxiety, and habituating themselves -- or getting themselves acclimated to, if not altogether comfortable with -- those situations and/or thoughts that provoke the anxiety. Through exposure and habituation, situations that previously provoked intense anxiety can become increasingly bearable and tolerable.

Therefore, people with cleaning or washing compulsions can habituate themselves to eating a sandwich after using a public restroom and not washing their hands. Another person with excessive checking compulsions can habituate himself to leaving his house in the morning without checking the locks on the doors repeatedly. A person with “hit-and-run” OCD compulsions while driving a vehicle can expose himself to situations where he hits a bump in the road or hears a noise while passing a pedestrian. Such a set of circumstances would ordinarily prompt the driver with hit-and-run OCD to retrace his or her driving route to gain reassurance that an accident has not occurred. But habituation can enable such a driver to overcome his anxiety and resist the compulsion to retrace his route.

A mother with intense fears of sexually molesting his or her son or daughter must habituate herself to the anxiety that she feels in the presence of the child, so that the mother can adequately fulfill her maternal obligations. A man plagued by obsessive fears of shouting obscenities in public places can habituate himself to what will be the initial anxiety of standing in the middle of a crowded supermarket, and, seeing that nothing of the sort will happen, experiencing the relief of his fears gradually diminishing.

Dr. David L. Kupfer, a clinical psychologist who treats OCD sufferers as part of his counseling practice in Virginia, helps who he refers to as “obsessively good people” who have irrational fears of doing harm to others. People with OCD often place an inordinate amount of significance upon the abhorrent thoughts that may enter their minds. But thoughts are only thoughts, maintains Kupfer, who spoke at the International Obsessive-Compulsive Foundation’s [ICOF] annual national seminar in Washington, D.C. back in 1999.Thoughts are vastly different from actions, and Kupfer said that OCD sufferers would do well to remember this.“Thoughts don’t mean anything,” Kupfer told the audience of OCD sufferers, their families, and other clinicians. “You can tell yourself, “That is just a thought, and a thought is OK to have.”

OCD sufferers often place intense significance on “forbidden thoughts”, and they may spend an inordinate amount of time attempting to analyze or suppress the troublesome thoughts. This strategy inevitably fails, according to Kupfer, who maintains that “what you resist- persists.”A therapeutic approach to coping with intrusive thoughts is to accept having the thoughts, not to dwell on their meaning, and not to be siphoned into a sense of emotional paralysis over the thoughts.

“The cure for these thoughts is to accept them, endure them, and habituate to them,” said Kupfer, who espouses the notion of the mind as a “personal playground.”Habituation is also an essential tool to use when trying to diminish and eventually eliminate rituals. Ideally, all rituals should be eliminated immediately and completely. Realistically, that often cannot be accomplished. The anxiety created by OCD is often so severe that the sufferer must work on a step-by-step, gradual plan to expose him or herself to uncomfortable situations and reduce rituals.

“Ideally, response prevention [eliminating rituals] shouldn’t be done cold turkey,” Hyman said at the 1999 ICOF national seminar. “A person can wait 10 minutes to check, instead of five minutes, or they can wait a full hour to check, instead of a half-hour.” During the extra time that checking is delayed the sufferer habituates, or acclimates, his or her nervous system to the situation and feels the anxiety diminish.

There are also other practices that people with OCD can implement to gain mastery over the affliction. One is to vocalize their most morbid thoughts, fears and persistent and troubling obsessions on a 30 to 60-minute cassette tape, then replay the tape and feel the anxiety created by the vocalized thoughts, until that anxiety diminishes or subsides altogether .Edna Foa and Reid Wilson, both Ph.D.’s who have specialized in the treatment of OCD, wrote an outstanding book on effective treatments for the condition entitled “Stop Obsessing”, which was copyrighted in 1991. Along with espousing the use of the tape-recorded therapeutic approach to combating OCD, Foa and Wilson also promote accepting obsessions as meaningless mind drivel, postponing obsessions for a period of time rather than attempting to fight or ignore them, writing down the obsessions on paper or singing songs about the obsessions, distracting oneself from obsessions by engaging in an activity, and letting go of tensions, worries and obsessions by practicing calming breathing techniques.

Contamination fears/cleaning rituals, checking compulsions, the fear of harming others and the need to have things in their environment in a certain order or symmetry are common symptoms experienced by people with OCD, according to Foa and Wilson. Battling OCD is a lot of hard work, and sometimes, the gains that are accomplished -- especially initially or during times of stress -- can feel as if they are only minimal victories. But hard work with therapeutic tools like delaying rituals or tape-recording, and habituating to, morbid obsessions is essential on a daily basis. “Daily practice is very important,” Hyman said. So is the use of certain medications, in combating some of the more severe forms of OCD.

Comments, questions and suggestions about this article are welcomed and can be sent to

Ahead for the September column: Medication Options for Obsessive-compulsive Disorder

“THE MIND CONNECTION”July 2013 column: Obsessive-compulsive Disorder Appears in Many Forms

By John Hartsock

A teenage girl becomes pre-occupied with contamination fears, and becomes convinced that her entire family will contract a life-threatening disease if she does not wash her hands repeatedly all day long. Eventually, the skin on her hands becomes raw before she seeks professional help.

A middle-aged professional man is plagued by the compulsion to check and re-check the lock on the front door of his house each morning before leaving for work to make sure that he has, indeed, locked the door .Initially, the checking rituals take up only 10 to 15 minutes each day. But as the man's doubt and anxiety intensify, he comes more compelled to check and re-check the lock each morning .His checking compulsion begins to take over more and more of his time. He rises earlier each morning in order to accommodate this emotional tyrant. But eventually, he begins to arrive late for work on a regular basi . Confronted by his superiors, he becomes overwhelmingly anxious and ashamed of his ritualistic checking. He fears that he is going insane. He feels too embarrassed to explain the reason for his tardiness, or to seek professional help. His checking rituals worsen until they encompass most of his waking hours. He is eventually terminated from his position.

A young woman attending college classes at a major university becomes gripped by the notion that she must read every single word in her textbooks over and over again in order to fully absorb and comprehend the material that she is required to know in order to pass her courses. Her scrupulous attention to every minor detail becomes exceedingly time-consuming and draining, and reaches the point that all aspects of her life suffer. She is eventually forced to leave college and seek professional help.

A middle-aged woman develops a habit of hoarding every material item in her home, including those that are no longer useful.As she becomes unable to discard anything for fear that it may someday be needed, the woman’s home becomes over-run by her possessions and her life becomes unmanageable.

A young man becomes imprisoned by the notion that every time his car hits a bump in the road, he may have hit a nearby pedestrian. He checks and re-checks his driving routes in an effort to reassure himself that no accident has occurred, and that nobody has been injured or killed. He may even call local police stations or newspapers to alleviate his concerns that he has been responsible for a tragic accident that, in fact, has never happened.

A middle-aged man' scrupulosity about religious matters prompts him to confess his real or imagined sins repeatedly -- either in private prayer or to a priest or minister. Better that, the man reasons, than to be responsible for an unpardonable sin that could result is his soul’s eternal damnation.

All of the people cited in the above examples are suffering from different forms of obsessive-compulsive disorder, which is also known as OCD. OCD is an anxiety disorder that is characterized by intrusive, unwanted and disturbing thoughts (known as obsessions), and ritualistic, repetitive actions (known as compulsions).The obsessions create distress and a state of anxious doubt that triggers the compulsive behavior. But performing the compulsions almost always only temporarily relieves the anxiety. Most forms of OCD involve both obsessive thoughts and compulsive rituals. A few forms of OCD involve obsessions only. But in even those forms of OCD, some associated mental rituals often also become part of the problem. Obsessive-compulsive behavior becomes a self-destructive cycle when it impacts the sufferer’s life to such a significant degree that much of his or her existence becomes consumed by the intrusive thoughts and/or subsequent rituals. Occupational and social impairment can range from mild to incapacitating. No matter what form OCD takes, the disorder is often time-consuming, emotionally draining, and self-defeating for the sufferer. The constant need for reassurance that is imposed by the disorder is akin to an itch that can never be scratched with any lasting degree of satisfaction.

Dr. Herbert Gravitz, PHD, a clinical psychologist who treats patients suffering from OCD is his practice in Santa Barbara, Calif., spoke to OCD sufferers, their family members, and other clinicians involved in the treatment of the disorder, during the International Obsessive-Compulsive Foundation’s [IOCF] annual national seminar held in Washington, D.C. back in 1999.Gravitz likened the disorder to an octopus with relentless, enslaving tentacles. “OCD is like an octopus,” Gravitz said. “It bullies the [afflicted person], and it bullies their family members.”OCD is a “shape-fitter,” according to Gravitz.

Some sufferers are not particularly bothered by contamination issues, but their lives may instead be controlled by scrupulous concerns centering on their eternal salvation. For others, religion and scrupulosity are not issues. These people may be agnostics or atheists, but they’re instead crippled by pre-occupations about dirt, germs, contamination, or contracting or spreading diseases. Other OCD sufferers are excessively concerned about harming others. Their form of the disorder causes them to go out of their way to avoid certain situations, or to perform crippling rituals in a futile effort to relieve their anxiety.

Gravitz outlined the various dilemmas presented by the disorder during his Washington, D.C. presentation. “Did I run over this person?” he asked the audience rhetorically, outlining the struggles that are endured by some OCD sufferers. “Am I contaminated?” he said, illustrating the internal battles that others with OCD face “I’ll have to check that, or I’ll go crazy,” he postured, describing the distress that is experienced by other OCD sufferers. Once believed to be an extremely rare disorder, it is now known that OCD, in one form or another, affects millions of Americans -- between two and three percent of the country’s population -- at any one time.OCD is one of the most common psychiatric disorders and, like the other major mental disorders it has a prominent biochemical basis.

Dr. Ian Osborn, a Penn State University psychiatrist, outlined the physical, biochemical causes of OCD is his book, Tormenting Thoughts and Secret Rituals, which was published in 1999.Dr. Osborn writes that “OCD is caused by a hyperactive circuit of nerve cells running from the basal ganglia to the orbital frontal area of the brain.”Since these areas of the brain govern impulse control, having OCD can be a blessing as well as a curse. Many OCD sufferers tend to be scrupulous, hard-working and conscientious individuals who are not prone to the whims of impulse. Their disorder may sometimes actually allow them to feel a heightened sense of empathy and sensitivity toward others, and inoculate them against taking rash, spur-of-the-moment actions that they later regret. Deficiencies in the brain chemical serotonin have been proven not only to play a role in OCD, but also, in mood disorders such as bipolar disorder and major depression.

People with OCD have intrusive thoughts that they have great difficulty dismissing. “In OCD, the brain doesn’t let these thoughts go,” Osborn said. Though OCD can be a difficult problem, it is also one that now responds well to treatment.

Comments, questions and suggestions about this article are welcomed and can be sent to

Ahead for the August column: Effective Treatments for Obsessive-compulsive Disorder

“THE MIND CONNECTION”June 2013 column: Treatment Options Have Improved for Schizophrenia

By John Hartsock

As arguably the most debilitating and disabling of all the mental disorders, schizophrenia was responsible for the vast majority of long-term institutional commitments that took place in this country during the first half of the 20th century. Neither the prognosis for, or treatment options available for, the disease of schizophrenia at that time were very promising. Medications used to treat schizophrenia then were non-existent, and people unfortunate enough to be afflicted with the devastating brain disorder were usually confined to dreary mental hospitals, often for the duration of their lives.

Schizophrenia is an oppressive and dastardly disease, and the outlook for individuals who were ill with schizophrenia prior to 1950 was dismal. In 2013, schizophrenia remains one of humanity’s toughest health challenges, but the options for treating it have vastly improved. “When you look at people with severe mental illness who are pushing shopping carts, a lot of that is schizophrenia”, said Dr. Joseph Antonowicz, medical director of behavioral health services for the Altoona Regional Health System. “People with schizophrenia become so non-functional. Schizophrenia puts people into another world. But we still have treatments that are effective and can help.”

To be sure, schizophrenia remains a chronic illness that usually requires lifetime treatment. But a wide variety of anti-psychotic medications that are available today, coupled with better and more diversified psychotherapeutic treatment plans, make the outlook for people presently suffering from schizophrenia much more hopeful.

The arrival of anti-psychotic medications in the 1950s provided control of what are now known as some of the “positive symptoms” of schizophrenia -- symptoms like hallucinations and delusions -- and enabled many people with schizophrenia to live independently, or at least, outside of institutions. Those initial anti-psychotic medications, known as “typical” anti-psychotics, were powerful sedating major tranquilizers like Thorazine and Mellaril that neutralized some of the worst symptoms of schizophrenia. But their effectiveness did not come without a cost. The medications often caused some disturbing side effects such as tardive dyskinesia -- a condition involving involuntary muscle movements that, when the medication was used over an extended period of time, became permanent .Moreover, the early anti-psychotics did little to address what are known as the “negative symptoms” of schizophrenia -- symptoms such as flat or emotion-less affect, disorganized speech patterns, and/or an inability to plan and carry out daily functions.“Negative symptoms” of schizophrenia have been regarded as such because they “take away” from an individual’s personality.

A new wave of anti-psychotic medications -- which became known as “atypical” anti-psychotics -- came along over 20 years ago and proved to be more effective for combating the negative symptoms of schizophrenia. “The newer anti-psychotics, like Zyprexa and Geodon, may be effective for the negative symptoms of schizophrenia -- things like low motivation, not taking good care of oneself, and an inability to plan things,” Antonowicz said. “Those kinds of symptoms seem to respond better to the newer anti-psychotics than they ever did to the older ones.”While the newer anti-psychotics tend to involve fewer problematic side effects like tardive dyskinesia, that condition still manifests itself in some instances where these newer medications are used.

While treatment with medication is imperative for people with schizophrenia, it is also important for sufferers of the disease to integrate themselves back into society. Schizophrenia often robs people -- usually at a relatively young age -- of the ability to successfully interact socially with others. Consequently, personal isolation is often a problem for people who suffer from schizophrenia. At facilities like the Home Nursing Agency at 500 East Chestnut Avenue in Altoona, individuals who are struggling with a variety of mental disorders, including schizophrenia, have the opportunity to meet and interact with others who are facing similar challenges, and to learn or re-learn coping skills. The Home Nursing Agency offers both day treatment and partial hospitalization programs and outpatient therapy programs for individuals who are referred to the agency by their doctors or therapists, as well as for other individuals who can enter the programs after being evaluated at the agency’s walk-in clinic.

Joel Zeiker, clinical services manager at the Home Nursing Agency, said that while schizophrenia can pose a difficult challenge, it is often not an insurmountable one. “Schizophrenia can be [more challenging] because of the intensity of the symptoms and psychosis, but there are people with schizophrenia who, with the help of their medication, can manage their symptoms, be able to socialize, and be able to work at some types of jobs,” Zeiker said. “The medicines are very important.”Schizophrenia is an extremely complex disorder, and some medications that are used to treat it don’t always work -- at least not immediately.

As is the case with other mental disorders, a trial-and-error process is often necessary with medication for schizophrenia.“The newer anti-psychotics, as a whole, are a lot easier to deal with than the older anti-psychotics,” Antonowicz said. “There’s a lot of hit-and-miss [involved], depending on things like family history.”“There are a lot more [medication] options, and hopefully, research will advance more [options] in the future,” Antonowicz said. “While the medications that we have now can help, and [in many cases], help a lot, we have a lot of room to get better.”

Questions, comments and suggestions regarding this article are welcome and can be sent to

Ahead for the next column: Examining the many faces of obsessive-compulsive disorder [OCD].


By John Hartsock

Schizophrenia is perhaps the most severe and disabling of all the clinical mental disorders. It is a disorder that involves psychosis -- a loss of contact with reality -- in which symptoms like hallucinations and delusions markedly distort perception. “Schizophrenia is probably the most devastating and destructive mental illness” said Dr. Joseph Antonowicz, the medical director of behavioral health services for the Altoona Regional Health System. “It takes peoples’ lives away from them, more so than a lot of the other [mental disorders], and it’s a lot harder to treat.” “Schizophrenia isn’t just hallucinations or delusions,” Antonowicz added. “It attacks many different aspects of one’s life -- how you think, what makes sense to you, what is important to you. It just distorts everything.” In any given year, 2.5 million adults suffer from schizophrenia, a biologically-based brain disorder that in all of its various forms, affects one percent of the population. The various types of schizophrenia include: 1.) Paranoid schizophrenia: A disorder characterized by delusions such as incorrect beliefs of being persecuted unfairly, or of being a famous person (Jesus Christ, for example). Paranoid schizophrenia can also include hallucinations -- seeing or hearing things that are not real. 2.) Disorganized-type schizophrenia: A type of schizophrenia characterized by disorganized, erratic speech and/or behavior. People with schizophrenia may also display inappropriate emotions such as laughing at the death of a loved one, or explosive outbursts of rage that are out of proportion to the situation at hand. 3.) Catatonic-type schizophrenia: A type of schizophrenia characterized by disturbances of movement in which people may be completely immobile for extended periods of time, or alternatively, move all over the place in a frenetic fashion. 4.) Undifferentiated-type schizophrenia: A type characterized by some symptoms that are found in all of the above forms of schizophrenia, but with not enough symptoms of any one type to classify it as a particular form of the disease. 5.) Residual-type schizophrenia: A type characterized by at least one past episode of schizophrenia, but currently showing no symptoms like delusions, hallucinations, or disorganized speech or behavior.

Along with delusions and/or hallucinations, other symptoms of schizophrenia may include social withdrawal, loss of appetite, lack of attention to personal hygiene and self-care, flat or emotionless affect, and a sense of being controlled by outside forces.

The delusions and hallucinations experienced by a person suffering from schizophrenia can be particularly troublesome, according to Denis Navarro, outpatient supervisor/clinical specialist at the Altoona Regional Health System. “Hallucinations and delusions of reference -- the idea, for example, that the television set is talking to you -- are the worst [symptoms],” Navarro said. “And command hallucinations are the scariest. That’s where people believe that they are being directed to do something and it usually isn’t good.”

The bad news about schizophrenia is that, without proper and adequate treatment, it is the most disruptive, disabling and even deadliest of mental disorders. Untreated or inadequately treated schizophrenia can leave individuals with an increased risk for suicide, homelessness, chronic disability, substance abuse, or early death stemming from poor self-care. Although most people with schizophrenia are not a danger to others, the delusions and hallucinations caused by the disorder can drive some people to violent behavior. Psychiatric treatment is essential for people with schizophrenia.

“It’s no fun being mentally ill,” Antonowicz said. “It involves a lot of heartbreak, and schizophrenia can involve somewhat more [heartbreak] than some of the other [disorders]. It’s just so much more destructive.”The good news about schizophrenia is that with adequate, appropriate treatment that often involves psychosocial rehabilitation as well as psychiatric intervention and medication, the prognosis for controlling the disease and leading an independent, functional life can be quite good.“The best outcome for the treatment of schizophrenia is with medication and certain types of psychotherapy that is really aimed at helping people with the disorder become more functional with things like social-skills training” Antonowicz said.

Comments, questions and suggestions about this article are welcomed and can be sent to

Ahead for the June column: Examining some of the treatment regimens for schizophrenia.



By John Hartsock

Proper and prompt treatment is essential in the successful management of Bipolar I and Bipolar II Disorder, but timely and accurate diagnosis of the disease is also extremely important.

While current research suggests that about four percent of the population experiences some of the characteristic symptoms of bipolar disorder at some point in their lives, the complete bipolar syndrome is rare, occurring in a percentage of between just 0.4 and 1.6 percent of the population.

It is not uncommon for an accurate diagnosis of bipolar disorder to take several years. Studies show that 40 percent of people with bipolar disorder receive another, incorrect, diagnosis first, and that some people diagnosed with major depression actually have bipolar disorder. Bipolar disorder is particularly difficult to diagnose in children and adolescents, who tend to have more erratic and rapid changes in mood, behavior, and energy levels than adults.

The prognosis for bipolar disorder can be a positive one with appropriate counseling and medications. Left untreated, misdiagnosed, or undiagnosed, bipolar disorder can worsen and become a severely disabling problem.

Lithium is one of the best medications ever developed for use in the treatment and management of bipolar disorder, according to Dr. Joseph Antonowicz, medical director of behavioral health services for the Altoona Regional Health System.

“Lithium is still used, and it is still very effective,” Antonowicz said. “It’s still the medication [for bipolar treatment] against which all others are measured. [Medications] have to be as good as Lithium. If they’re not, they may not be particularly helpful in treating bipolar disorder.”

In today’s psychopharmacological world, there are a variety of medications and combinations of different medications available for the treatment of bipolar disorder.

“It used to be just Lithium, Thorazine, and Haldol,” Antonowicz said of the early bipolar disorder medications. “Now, we have a whole lot more [medications available] than we’ve ever had.” Mood-stabilizing medications like Lithium are important in bipolar treatment, but the newer anti-psychotic and anti-depressant medications can also be vital.

“[Patients] may end up on a mood stabilizer, a second-generation anti-psychotic, and an anti-depressant,” Antonowicz said. “We have a whole bunch of seizure medications like Depakote and Tegretol that have been approved by the FDA [Federal Drug Administration].”

There are different approaches to treating bipolar disorder than there are to treating other diseases, like schizophrenia.

“Lower doses of anti-psychotics can be used,” Antonowicz said. “For example, if you’re treating bipolar disorder, you might use 300 milligrams of Seroquel; for treating schizophrenia, you might use 800 milligrams of Seroquel.”

Getting symptoms of mania--particularly acute mania--under control is equally as important as controlling depressive symptoms. While depression associated with bipolar disorder can lead to suicide attempts or completed suicides, the mania involved in bipolar disorder can also trigger erratic and very dangerous behavior. Psychotic symptoms involving delusions and in some cases, hallucinations, can manifest themselves in both the manic and depressive stages of bipolar disorder.

“Somebody who is psychotic could be running around outside without a shirt on when the temperature is 10 degrees,” Antonowicz said.

Like other mental illnesses, genetic influences and biochemical imbalances in the brain play primary roles in the development of bipolar disorder. But stressful life and interpersonal situations can be factors in the emergence and/or severity of the disorder. Minimizing and controlling stress can prevent bipolar symptoms from becoming worse. In this regard, counseling with a mental health professional can be helpful once a medication regime has been established.

Comments, questions and suggestions about this article are welcomed and can be sent to

Ahead for the next column: A look at schizophrenia.


Depression: A Serious, Misunderstood Illness

By John Hartsock

Clinical depression is a disorder that is rife with paradoxes.

Clinical depression is a serious disease, yet many of the millions of Americans who suffer from it each year do not seek treatment for it because of fear, ignorance, or unwarranted embarrassment. The disease of depression can be mild or moderate, and can sometimes be tempered or overcome by appropriate changes in lifestyle and/or behavior. Some forms of depression can be severe, necessitating treatment with medication, and in some cases, hospitalization and/or electro-convulsive therapy.

Depression can be fleeting, lifting abruptly like an early-morning fog. It can also be chronic, involving dozens of episodes over the course of a lifetime. The legendary British politician, Winston Churchill, who described the type of me

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