People with OCD face their worst fears to get better
Ms Chua, who was diagnosed with obsessive compulsive disorder in 2003, praying at a temple — something she could not do before due to her condition, which kept her housebound. The ERP therapy aided in her recovery, and she can now touch lift buttons and staircase railings without fear. PHOTO: IMH
SINGAPORE — The first time Ms Chua was asked to touch a doorknob with her bare hands, without using tissue paper, she cried.
The sales promoter, who requested that her full name not be published for privacy reasons, was diagnosed with obsessive-compulsive disorder (OCD) in 2003 when she sought medical treatment for depression. Last year, as part of what seemed like an unusual treatment approach, she was asked to confront some of her worst fears.
“That day, I went home and cried. I told my case manager I did not want to continue with the treatment.
“To you, (opening a door with your bare hands) might sound like a simple thing to do but to me, it was so difficult and scary,” she said.
OCD is among the top three mental health conditions in Singapore, affecting one in 33 people here at some point in their lifetime, but its exact cause is not known.
The Institute of Mental Health (IMH) said that in the past three years, it saw about 1,000 patients with OCD each year. It runs an OCD clinic, which sees severe and chronic cases.
Ms Chua is one of those who sought treatment at the clinic.
For more than a decade, she heard a nagging voice in her head telling her that common items — lift buttons, staircase railings — and everyday activities such as shaking hands or walking barefoot at home would expose her to potential health hazards.
Compelled by an invisible force, the 38-year-old, who disliked cleaning, spent hours — usually from midnight to dawn — cleaning and disinfecting her bathroom.
“I had to clean my surroundings thoroughly before taking a shower. I washed everything, including the toiletries and bottles of shower gel that I was supposed to bathe with, using soap,” she said.
As her condition worsened, Ms Chua became housebound. Her life, in her own words, was handicapped by her bizarre thoughts.
CONFRONTING THEIR WORST FEARS
OCD is widely known for its symptoms of obsessive and compulsive thoughts and behaviour, such as repeated handwashing, counting and checking. At its worst, it could affect sufferers’ everyday functioning.
But not many people have heard about how it is treated. An effective, albeit unusual, treatment known as exposure and response prevention (ERP) therapy is currently the gold standard in psychological treatment for OCD.
ERP is the most extensively studied psychological intervention for adults and children with this mental disorder. Unlike traditional talk therapy, which involves talking to a therapist to make sense of negative thoughts, ERP therapy places the sufferer in the pathway of their darkest fears.
Dr Jackki Yim, senior clinical psychologist at IMH, said the therapy targets the two factors that fuel and maintain the person’s OCD symptoms: Avoidance and compulsion.
During treatment sessions, patients are exposed to whatever evokes anxiety in them, and taught to resist performing their usual coping rituals.
A patient Dr Yim encountered, who had severe symptoms of being excessively concerned about upsetting people for over 10 years, was asked play the game “Cards against Humanity”, during which she read aloud mean phrases to other players.
“The patient learns that her anxiety and distress do not last forever and decrease even without escaping, avoiding or ritualising it,” explained Dr Yim.
The tactic can be overwhelming at first for a person suffering from OCD, but Dr Yim said it is “definitely worthwhile”. About seven in 10 patients at IMH’s OCD clinic undergo this ERP therapy and medication treatment.
A LIFE-CHANGER FOR SUFFERERS
When carried out properly, the ERP treatment can be a life-changer. Positive changes can typically be seen in a patient about two-thirds through a course of treatment, although this may vary depending on the complexity of each case, said Dr Yim.
She added that analyses of over 24 randomised controlled clinical trials showed that 70 per cent of OCD patients using ERP reported a significant reduction in symptoms, and its effects are mostly maintained.
But the experts stressed that the treatment has to be delivered in a structured, purposeful and gradual manner.
If not administered carefully, it can be traumatic and increase a patient’s anxiety, said clinical psychologist Vyda Chai from Think Psychological Services. Instead of throwing the patient into the “deep end” at the first attempt, most treatment sessions start with situations that are easier to handle, she added.
“Confronting the less distressing situations and progressing gradually to increasingly distressing situations will not only get a patient’s cooperation, but also increase the treatment’s chance of success,” said Dr Yim.
While ERP therapy can be an effective treatment tool for OCD, IMH experts said it does not mean that the condition can be completely reversed.
“OCD is considered a chronic condition. We can control it with the right treatment, similar to what we do with diabetes, and get the patients back to a stable level so that their OCD does not interfere with their daily lives. The longer you leave it, the harder it is for patients to get better,” said Dr Jayaraman Hariram, senior consultant at IMH’s Department of Community Psychiatry.
Ms Chai added that there is no one-size-fits-all solution. An OCD patient may also suffer from other mental conditions such as depression, and other behavioural intervention strategies may be explored, she said.
Some patients may also require medication to first stabilise their condition, added Dr Yim.
Most OCD patients are treated on an outpatient basis, but a small proportion might require hospitalisation when their symptoms become too severe and debilitating, and families and caregivers are unable to cope, said Dr Hariram.
REACHING A turning point AFTER 10 YEARS
For Ms Chua, the watershed came in 2014, when she suffered a nervous breakdown. She checked herself into IMH, where she was hospitalised for two weeks and put on medication which helped to stabilise her condition.
“That day, I felt so giddy and lay in bed from morning to night. At 12.30am, the time when I always start cleaning the toilet, I told myself I simply could not go through it again. My sister and mum were so sad to see me in that state,” she said.
Last year, ERP therapy further aided in her recovery, allowing her to get a part-time job as a sales promoter for the first time in 10 years.
Since then, with her bare hands, Ms Chua has tucked into a meal, and touched lift buttons, food trays and staircase railings. She learnt that nothing bad would happen if she walked barefoot, rode on public transport and disposed of rubbish.
“I took baby steps and became more confident with every session. For the first time in more than 10 years, I managed to visit the temple and knelt down to pray to Buddha.
“To me, that is amazing. Previously, I could not even bear the thought of walking around at home without wearing shoes,” she said. While OCD-related thoughts still pop up now and again, her fears are no longer taking over her actions.
“All I hope for is to be able to function normally, work, and maybe get a place of my own.
“To other people struggling with OCD, I would advise seeking treatment as soon as possible. It is really not as scary as you think it is,” she said.
