Wash your hands?

Wash your hands?
Flu scare raises questions for OCD treatment
(June 2009 Issue)

By Nan Shnitzler

Wash your hands. What could be simpler? But for those suffering with obsessive-compulsive disorder, the exhortation to wash one's hands to avoid contracting the new flu might not be so simple after all.

"The safe strategy for the public I'm not sure is the safest strategy for anxiety disorders," says Jason A. Elias, Ph.D., of McLean Hospital's residential OCD Institute. He thinks an outright ban on exposure and response prevention therapy (ERP) for germphobic patients until the threat of flu has passed is an emotional response and out of proportion to the evidence of risk.

ERP exercises might involve touching bathroom surfaces and having something to eat, without the ritual response of hand washing. At first, the stress is extreme. But eventually, the body recovers and calms itself. With time, exposure therapy can break the connection between obsessive thoughts and compulsive behaviors.

"Exposure therapy helps patients recalibrate the threshold for what is life threatening and what is not. So this is a situation where a therapist, while following CDC [Centers for Disease Control and Prevention] flu prevention guidelines, can do real modeling for patients," Elias says.

Similarly, New York Mayor Michael Bloomberg did some modeling for everyone when he made a show of riding the subway to work, Elias points out. He suggests clinicians take a similar approach by keeping abreast of the available information and sharing it with patients, to make informed decisions about any therapeutic choice.

"Right now, the odds of getting killed in a car crash are much higher than getting killed by the flu," Elias says.

While acknowledging the fine line between obsessive and normal concerns, Charles H. Elliott, Ph.D., co-author of Obsessive-Compulsive Disorder for Dummies, warned people away from exposure therapy for contamination-oriented OCD in an April 28 post on Massachusetts-based psychcentral.com.

"I'm a huge proponent of exposure and response prevention therapy, but it felt to me that during a time when we're potentially facing a pandemic and the CDC is making recommendations on behaviors, it was a little bit hard to ignore that," Elliott says. "Do I feel like avoiding ERP during this period of time might be bordering on OCD?" he adds with a chuckle. "It might."

Elliott says ERP could be safely conducted if patients avoid touching mouths and faces after touching feared surfaces, but it could be "tricky" to prevent that during a two to three hour exercise. He suggests patients access reliable sources of information, such as the CDC Web site, but cautions that repeated checking could become its own obsessive behavior.

For the time being, Elliott advocates cognitive approaches to treating OCD, which while not as consistently effective as ERP, do show promise.

"Cognitive therapy teaches people to identify distortions in their thinking in order to change their actions," Elliott says. One of his favorite methods is for patients to write a narrative about their particular OCD manifestation and then make up a series of completely fictional OCD narratives.

"Creating one or two stories every day and comparing them, many of which border on illogical, to what's floating in patients' minds can convince them their OCD is a masterly created fiction," Elliott says.

At Boston University's Center for Anxiety and Related Disorders, Todd Farchione, Ph.D., doesn't think the flu risk is worth halting ERP. His students, however, told him they had reservations about ignoring CDC guidelines. As a result, they opted to review the latest data with patients to determine whether exposure was reasonable.

"By and large, we're in favor of continuing with ERP until there's pretty consistent data that suggest that people are at increased risk as a result of this recent [flu] scare," Farchione says. "With patients, I don't want to feed into this idea they should be extra careful right now because there's not enough data to suggest that."

Where to get that data can be problematic, what with the online information onslaught and scare-mongering news coverage. But people who can manage information intake can help control anxiety.

"Yes, we have up to the minute information, but it's hard to know how to digest that information," Elias says. "This flu gets so much media because of its potential, but it's not resulting in fatalities the way normal flu would."

"By gaining information, people are trying to reduce their level of anxiety to gain a sense of control," Farchione says. "The media should be more careful and take responsibility in how it presents information because it's likely to affect people's emotional state."