Despite his treatment success, Marc's therapist wondered if he might have an unusual case of obsessive-compulsive disorder (OCD). This concern arose because Marc's therapeutic progress had inexplicably stalled. Marc's therapist suggested he would benefit from a second opinion with an OCD treatment specialist.
After carefully listening to Marc, the specialist concluded Marc was correctly diagnosed with OCD. The specialist further determined that Marc had received the appropriate treatment for his OCD. Marc's therapist had used a highly effective treatment for OCD called exposure and response prevention (ERP). Simply stated, ERP prepares the person to confront the feared situations that trigger their obsessions (exposure). Simultaneously, the person prevents themselves from engaging their usual compulsive response (response prevention). Overtime, with repeated gradual practice, the person's anxiety diminishes when obsessions are triggered, and/or their beliefs change about the situation.
For Marc, his primary obsessions surrounded his fear of germs. As a result, he tried to avoid anything he believed to be contaminated. If he encountered something he deemed dirty and/or unsafe, he felt compelled to perform vigorous hand-washing. The specialist noticed Marc spoke with ease about his OCD. Indeed, a deserved sense of pride was evident as Marc described the progress he had made in therapy. Marc explained,
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"When I first started therapy I didn't know what to expect. Suzy, my therapist, explained to me that I suffered from obsessive-compulsive disorder. She was great. She understood exactly what I was going through, why I did what I did. More importantly, she explained that I could learn to stop. Together we set up a treatment plan. Who would have ever thought I would be able to touch the things I now can, without washing? Gradually over time I learned not to avoid the things I was scared of, and I was slowly able to let go of my washing."
However, the conversation took a discouraging turn as Marc began to describe his more "complex" obsessions and compulsions.
"Well, ever since I was about 16 I started to become concerned about, or should I say obsessed with, my "terrible" acne. I can't explain why but it is constantly on my mind, no matter what I am doing. I feel like I have no control over it. As soon as I think about my acne, I need to look in a mirror. Believe me, if I can't find a mirror I'll find some reflective surface so I can check my face. The thing is though, I don't even know what I am checking for. It's like I think somehow my acne may have changed, or I just need to check my face. If I cannot look in a mirror, I become extremely anxious. The irony is, sometimes when I do look in the mirror, I get even more upset by what I see. Then I actually start compulsively avoiding mirrors just so I don't feel badly. It's become very embarrassing. I know my colleagues at the school where I teach know something is up, and even the kids have commented how I am always looking at myself. I swear sometimes I feel like if I didn't have a job I wouldn't leave the house for days."
Interestingly, to look at Marc, one would immediately conclude his skin is nearly flawless. In fact, by most standards, he would be considered quite attractive with proportionate, symmetrical facial features. Thus, it appeared his reactions were not based on any real evidence of flaws or imperfections. Sensing Marc's change in demeanor, the specialist gently probed more deeply about Marc's difficulties. Specifically, the specialist wanted to know what treatments he and his therapist had attempted so far. Marc responded:
"My therapist said this acne thing is just like any other compulsion. I felt encouraged when she reminded me I had successfully managed my OCD and germ fears with ERP. So, we began doing the same type of ERP we had done for my germ fear. However, this time it wasn't working. And 'Doc,' it's not that I wasn't trying- I was! It's just it became so hard not to look in the mirror. I started coming late to sessions or not at all. Truth is, I was afraid to do the exposures. Not only was I afraid, but afterwards, I felt upset. This was much different from how the ERP was before with my hand washing. And ya know, I don't really believe treatment will work this time. I mean this is my appearance, and appearance matters. I can understand why my other compulsions were irrational. It made sense to me to learn to give up my hand-washing. But, I think my concerns…okay obsessions, about my appearance, make perfect sense. I don't think there's anything wrong with caring about my appearance. Sure, it's a little embarrassing to keep checking a mirror, but it just makes me feel better to keep checking my skin. It figures, I would have the OCD that's not normal."
After completing Marc's evaluation, the specialist met with Marc and his therapist to discuss treatment recommendations. Marc was subsequently referred to our clinic as a result of those recommendations. We assured Marc his OCD was not unusual or peculiar. However, there did appear to be a reason for his current difficulty in treatment.
We explained to Marc that although his symptoms were quite similar to OCD they were, in fact, the symptoms of a different disorder. We told Marc his symptoms were better explained by what is called body dysmorphic disorder (BDD). We helped him to understand the similarities and differences between OCD and BDD. Both disorders are characterized by excessive, repetitive, thoughts and behaviors. However, in BDD these thoughts and behaviors center around a perceived and/or exaggerated defect in appearance. In contrast, the repetitive thoughts and behaviors in OCD are focused on irrational fears. We explained to Marc that these differences could account for why he was having trouble in treatment. We recommended a treatment specifically suited to BDD. This specialized treatment had some things in common with his previously successful ERP treatment. However, it is sufficiently different and specifically tailored to BDD.
Bewildered and understandably overwhelmed, we saw a gradual shift in Marc's expression as he realized he is not "unusual." He had not "failed" at treatment. It was evident he felt a sense of relief as he learned there are others out there just like him. Although skeptical there was anything that could be done about his appearance concerns, he sensed for the first time a glimmer of hope.
For people unfamiliar with obsessive-compulsive problems, Marc's story may seem unusual. Nonetheless, it depicts a fairly common scenario that arises when someone seeks treatment for OCD. In fact, Marc's situation is a good example of the obsessive-compulsive spectrum. The obsessive-compulsive spectrum refers to a group of disorders that are presumed to be similar to OCD, yet distinct enough to be considered separate disorders. As a group, these disorders fall into a diagnostic category called obsessive-compulsive and related disorders. The idea that these disorders have similarities, yet also unique differences, has important implications. These considerations affect both the identification (diagnosis) and treatment of these disorders.