Obsessive Compulsive Disorder in Spouses and Family Members
Uncovering & Treating Conflicts
Obsessive-compulsive disorder is a psychiatric disorder that is challenging to understand and treat. It regularly causes intense psychological pain in the individual afflicted and high levels of stress spouses, parents, children and extended family members. The latter is often the result of the compulsive behaviors that are often associated with an intense tendency to control and easily triggered irritability.
OCD encompasses a broad range of symptoms that represent multiple psychological domains, including perception, behaviors, thinking, emotions and relationships.
Until recently OCD was viewed as an anxiety disorder in the DSM psychiatric diagnostic manual because high levels anxiety and fear are regularly uncovered in its treatment. Our clinical approach to these spouses and family members supports this view. As with most anxiety disorders, serious psychological conflicts usually can be uncovered from childhood and sometimes also from adult life that played a major role in its development.
Many spouses with OCD do not realize that they have a serious psychological conflict and rationalize or outright deny their compulsive, and often controlling behaviors. The first step then is identifying the symptoms that meet the criteria OCD. Please review the criteria below for making an OCD diagnosis.
To receive an OCD diagnosis, the spouse must meet these general criteria:
- The spouse must have obsessions and compulsions.
- The obsessions and compulsions must significantly impact his/her daily life
- The person may or may not realize that the obsessions and compulsions are excessive or unreasonable.
The obsessional thoughts must meet these specific criteria:
- intrusive, repetitive and persistent thoughts, urges, or images that cause distress, most often anxiety
- The thoughts do not just excessively focus on life problems
- The spouse is unsuccessful trying to suppress or ignore the disturbing thoughts, urges, or images
- The spouse may or may not know that his/her mind simply generates these thoughts and that they do not pose a true threat.
The obsessional thoughts often relate to a fear of one’s anger or of something terrible might happen to oneself or others. A 2008 study of 236 children with OCD showed that the most common obsessions were related to anger with aggressive obsessions (81%), followed by fears of contamination (79%), thoughts of symmetry (41.9%) and religious fears (40.7%) (Mataix-Cols, et al., 2008). Often, compulsive behaviors develop to decrease intrusive thoughts and the fear associated with them.
Many spouses with OCD engage in compulsive behaviors of various types to decrease the intense anxiety that can be associated with obsessional thoughts. They may also engage in the compulsive behaviors out of an unconscious need to try to control because of an unconscious fear that unless they do so their married and family life will be as stressful as was their childhood.
The compulsions must meet specific criteria:
- Excessive and repetitive ritualistic behavior that you feel you must perform, or something bad will happen. Examples include hand washing, counting, silent mental rituals, checking door locks, shopping, hoarding, controlling others, etc.
- The ritualistic compulsions take up a least one hour or more per day.
Most often a spouse has compulsive behaviors without any conscious knowledge of the obsessional thinking or unconscious emotional conflicts that drive the behaviors.
Uncovering emotional conflicts
Most spouses with OCD have very little or no self-knowledge as to their life hurts or conflicts that could have contributed to their OCD. Not only can there be a denial of their life hurts prior to or in marriage, but even more challenging, there can be a denial that obsessional thinking and compulsive and controlling behaviors are a problem for the marriage and children.
In the uncovering phase of treatment with the OCD spouse attempts are made to identify possible parental conflicts using the parental legacies article on this website. In this evaluation process the spouse is asked to identify the good qualities in parents and possible “baggage.” This article can be found on the home page of www.maritalhealing.com under Parental Legaices. In this evaluation, the spouse is asked to identify strengths and weaknesses in parents.
Spouses are also asked to complete an anger checklist (in the angry spouse chapter at www.maritalhealing.com) because the unconscious fear of one’s anger can be a conflict in OCD
OCD spouses are also asked to complete a mistrust checklist (in anxious spouse chapter at www.maritalhealing.com) that evaluates symptoms of anxiety/mistrust, as well as possible origins from childhood and adult life.
Spouses are often surprised to discover the degree of anxiety/trust weaknesses and anger in their lives.
Uncovering psychological conflicts in those with OCD
OCD had previously been diagnosed as among the anxiety disorders. Excessive anxiety is certainly frequently present symptom in OCD. Many adults can identify significant fears from their childhood that were unconscious and never addressed that influenced the development of their obsessional thinking and compulsive behaviors.
One common dynamic is the intense fear of a one’s own or a parent’s anger or rejecting or controlling behaviors that lead to an intense compulsion to control in relationships and in the home. This control compulsion is often in response to the damage to trust, that is, one’s safe feeling in childhood.
The role of anger in OCD has not been extensively described. However, emerging literature does demonstrate the prevalence of excessive anger in OCD. For example, a 2011 study revealed that 50% of those with OCD experienced anger attacks (Painuly, Grove & Mattoo, 2011). Rage attacks were also relatively common in one study of youth with OCD ( Storch, Jones & Lack, 2012).
Also, aggressive/checking and contamination/cleaning symptoms were the only dimensions significantly associated with impairment in another study of 99 youth with OCD ( Storch, Larson & Muroff, 2010). A 2008 study of 236 children with OCD showed that the most common obsessions were aggressive (81%), contamination (79%), symmetry (41.9%) and religious (40.7%) (Mataix-Cols, et al., 2008).
Mistakes the other spouse makes
The most common mistake seen in the spouse and family member of the person with OCD is the failure to identify this problem and to insist that steps be taken to address it. In attempting to understand the person with OCD, it can be helpful for the other spouse or family member to also complete the family of origin evaluation, as well as the mistrust and anger checklist on him or her.
OCD and Depression
Depression is the most frequent complication of OCD, as reported in several studies (El-Mallakh & Hollifield, 2008). OCD most often predates depression, suggesting that depressive symptoms usually occur in response to the distress and functional impairment associated with OCD (Bartz & Hollander, 2006).
Many persons with OCD report that their quality of life is very low. A number of studies have demonstrated that suicidal thoughts occur in over 50% of persons with OCD ( Torres AR, et al (2006);SaarenJ, et al. (2005); Bridge JA, et al (2007.) Subsequently, it is important to evaluate the degree of depression, despair and possible suicide risk in persons with OCD.
In a 2016 Swedish study of 36, 788 patients in the Swedish National Patient Register diagnosed with OCD between 1969 and 2013, 4297 had attempted suicide and 545 had died by suicide. The risk of dying by suicide was 9.83 times higher in people with OCD, and the rate of suicide attempts was 5.45 times higher, compared with general population controls, (de la Curz, et al., 2016).
Although serotonin reuptake inhibitors (SSRIs) are the pharmacological treatment of choice for obsessive-compulsive disorder (OCD), most OCD patients who have received an adequate SSRI trial continue to have clinically significant OCD symptoms. Augmentation of SSRI pharmacotherapy with CBT has been shown to be an effective strategy for reducing OCD symptoms (Simpson, Foa, Liebowitz, et al, 2008). Also, a substantial minority of patients fail to respond to SSRIs (Fineberg, Brown, Reghunandanan, et al., 2012). Rasmussen and Eisen (1997) have suggested that new procedures are needed for treatment-refractory clients.
Anger in OCD
A core feature that underlies obsessions and compulsions in some clients is the failure to recognize and deal adequately with excessive anger arising often from unjust hurts from angry, insensitive parents, spouses, siblings or peers. These individuals employ powerful defense mechanisms to try to control their resentment and rage toward those who have hurt them. Perfectionistic tendencies as well as guilt and fear of the possible eruption of anger may interfere with their ability to deal honestly with their emotional pain.
Subsequently, this buried anger can lead to obsessions about aggressive fantasies or to fears of becoming contaminated. To reduce their anxiety or stress or to try to prevent some dreaded event from occurring, clients engage in compulsive behaviors.
Aggressive obsessions are often seen in OCD and are included as symptoms to be evaluated in the Yale Brown Obsessive Compulsive Checklist (Goodman et al, 1989). Also, Primeau and Fontaine (1987) have reported that self-destructive behavior and OCD share some significant characteristics and that the driving force behind self-mutilation is relief from tension which is like the performance of a compulsive ritual (Jenike, Baer, & Minichiello 1990).
An old axiom is that anxiety can often lead to a tendency to flight or fight. Common causes of anxiety are due to life trauma, a lack of confidence and modeling after an anxious or a controlling parent.
A common defense mechanism used to attempt to control anxiety is that of trying to control one’s environment. While this defense mechanism can be effective for lower levels of anxiety, under intense stress it is rendered ineffective resulting in episodes of breakthrough anxiety.
The controlling behaviors can also lead to intense marital and family stress as the person with OCD is perceived as treating others with a lack of respect.
The controlling spouse/person chapter at www.maritalhealing.com can be helpful in addressing this conflict which is as important as resolving that his present, but often unconscious. The completion of the mistrust checklist in this chapter is helpful in this process.
The clinical use of forgiveness can be clinically effective in both the identification and the resolution of the excessive anger in some OCD clients. Most clients only experience their resentment after they have engaged in cognitive forgiveness exercises toward those who have disappointed them at different life stages. However, clients with OCD are so highly defended and controlling that the work of forgiveness can be quite prolonged and difficult. These individuals often comment in the uncovering phase that they found it easier to deal with their cleaning or washing compulsive behaviors than with their emerging anger, aggressive impulses, and impulses for revenge.
Ashley, a thirty-five-year-old married mother of two, sought treatment of her obsessive fears that her children might acquire terrible diseases from germs in the home. To protect her children, she spent numerous hours cleaning the home each day. Early in treatment she asked to be hospitalized after her fears of contamination became so extreme that she put her children’s wool coats into the washing machine.
Initially, Ashley denied that anyone had hurt her. After explaining the value of forgiveness in the treatment of obsessive- compulsive disorders, she was asked to think that she wanted to try to forgive anyone who had disappointed her or been insensitive to her in her childhood, adolescence, and adult life. It took months before Ashley could admit that she had been hurt by anyone. Finally, as she thought of forgiving anyone who had hurt her, her defenses diminished and her emotional pain emerged. She acknowledged that her husband, Kurt, had been extremely insensitive to her for years. In fact, he was extremely critical, and at times, he was verbally abusive. She recognized that she needed to deny her pain with him for many reasons, including fear of his anger, fear of divorce, and strong insecurities from the constant criticism that she had experienced in her youth.
Ashley also came to realize that she had been denying strong resentment from the time she was a child toward each of her parents. Her perception was that they had favored her other siblings and had treated her like a second-class citizen. She came to recognize that she had then married someone who was almost as critical as they had been. At this stage, she needed an antidepressant to deal with the sadness and strong rage she felt toward her husband and her parents. During the work process, she felt so hurt that she was unable to think about forgiving anyone, but when she realized how essential it was for her to resolve her anger to overcome her germ phobia, she decided to decide to forgive even though she did not feel like doing so.
Ashley slowly came to understand that her real fears were not of her children being harmed by germs, but of her own buried rage that was emerging and the fact that she feared hurting her husband or someone else because of it. During the struggle with her powerfully angry impulses, in frustration, Ashley responded, “I wish I was back dealing with my germ phobia - it was a lot easier than this.” Ashley could continue to forgive her husband, Kurt, because she was aware of his difficult life with an alcoholic father who continued to be a major source of stress even in their married life. She had always felt empathy for Kurt and, in the end, her compassion enabled her to decide to let go of her anger with him. Finally, her forgiveness was facilitated by his participation in therapy and acknowledgment of the mistakes he had made in their relationship.
The dynamics were explained to Kurt and he was asked to consider that he might have been misdirecting anger at Ashley meant for his alcoholic father. He apologized to Ashley and committed himself to work at forgiving his father, which helped significantly in her recovery. However, Ashley continued to have difficulty in letting go of her anger with her parents. She came to believe that they never wanted her and had always harbored a resentment against her. As she tried to tell herself that they were emotionally sick people who had no right to have a negative influence over her emotional life, she could make the cognitive decision to let go of her resentment towards them. She could not develop compassion for her parents and had great difficulty in absorbing the pain.
As Ashley’s unconscious rage with her husband and parents decreased using forgiveness, her obsessive fear concerning her children lessened also. Her husband felt guilty about his role in his wife’s illness and made major changes in the way he treated her; in addition, he decided to forgive his father and resolved not to act in a similar manner.
After three years of treatment, Ashley’s obsessive-compulsive symptoms were resolved. Given the growing literature that demonstrates the high comorbidity of excessive anger in OCD, forgiveness therapy should be considered as part of the treatment plan.
Other Interventions for OCD
- treatment of perfectionistic thinking
- growing in trust
- building confidence
- working against catastrophic thoughts by trusting more
- strengthening healthy friendships
- creating distance from negative and controlling people
- the use of serotonin reuptake inhibitors (SSRIs) for severe symptoms
- employing, when appropriate, the role of faith by meditating on trusting the Lord with one's fears
- trying to make acts of trust before giving into compulsive behaviors such as hand washing and checking
- consulting with a Catholic priest for Catholics whose OCD is the result of severe fears of illness and death.
Obstacles in the treatment of OCD include:
- a compulsive need to control and the refusal to give it up
- the refusal to attempt a course of medication
- a desire to punish others or seek revenge with a refusal to give up anger.
- withdrawal into the sick or victim role to avoid or control others.
The Prognosis in Anxiety Disorders
Although anxiety disorders resolve in many individuals, studies describe the anxiety disorders in some as insidious, with a chronic clinical course, low rates of recovery, and relatively high probabilities of recurrence. The presence of associated or co-morbid psychiatric disorders, such as depression, significantly lowered the likelihood of recovery from anxiety disorders and increased the likelihood of their recurrence, (Bruce SE, 2005).
PANDAS in Youth
Streptoccal infections have been identified as triggering sudden-onset obsessive compulsive disorders in youth. Quick treatment with antibiotics has been shown to reverse the symptoms. This pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections is referred to as PANDAS for shor). This controversial and seemingly rare diagnosis was given to children who abruptly developed obsessive compulsive disorder or tic disorders such as Tourette’s syndrome after contracting infections caused by group A streptococcus bacteria, such as strep throat or scarlet fever.
The first cases of PANDAS were described in 1998. Since then, experts have recognized that other infectious organisms besides group A streptococcus bacteria can cause sudden-onset OCD or tics.
The Role of Faith
As described in sections of chapters at maritalhealing.com, if appropriate, faith can play a beneficial role in the resolution of emotional pain and conflicts. (See healing and faith at the National Library of Medicine web site, www.ncbi.nlm.nih.gov/pubmed/.) Several spiritual interventions help in resolving anxiety and conflicts and in building deeper trust and confidence.
Pope Benedict commented on the role of faith in addressing anxiety when he stated, "In the face of the ample and diversified panorama of human fears, the word of God is clear: He who'fears' the Lord is 'not afraid.' The fear of God, which the Scriptures define as the 'beginning of true wisdom,' coincides with faith in God, with the sacred respect for his authority over life and the world. Being 'without the fear of God' is equivalent to putting ourselves in his place, feeling ourselves to be masters of good and evil, of life and death. But he who fears God feels interiorly the security of a child in the arms of his mother: He who fears God is calm even during storms, because God, as Jesus has revealed to us, is a Father who is full of mercy and goodness. He who loves God is not afraid," 6/22/2008.