Book Review: Ocd A guide For the Newly Diagnosed by Dr. Michael Tompkins

Dr. Tompkins is writing to those looking for an answer to their strange behaviours and thoughts and also to those who have just been to their doctor and have come away with an unfamiliar diagnosis:  Obsessive Compulsive Disorder or OCD. This is also a book for family members and friends of those with OCD who are looking for answers to their relative’s or friend’s odd behaviours and how to help them.
Tompkins begins with a clinical definition of OCD and how it differs from other mental illnesses and from the more common usage of the word obsession, meaning to enjoy very much.  He then very briefly lists 3 common types of obsessions: unacceptable or disgusting sexual thoughts, thoughts of harming self or others and finally blasphemously religious or morally wrong obsessions.
The compulsion or ritual part of OCD is when the sufferer feels driven to carry out a ‘deliberate and purposeful behaviour’ which is supposed to either prevent harm from occurring or to lessen their own discomfort.  Checking- anything from locked doors to calculations or emails to be sent- is done to make sure things are done correctly. The difference between a person with and without OCD is the frequency of checking each item before they feel ‘ok’ that the job is properly done.  People with cleaning and washing compulsions are worried they will be ‘contaminated’ by the item they have just touched that they feel is ‘dirty’, ‘dangerous’ or ‘disgusting’.  A problem here is that while washing to remove visible dirty is done quickly, the removal of the 'feeling of dirt’ takes much longer.  Another problem people with washing and contamination have is the amount of time or trouble they take to avoid coming into contact with ‘contaminated’ objects like door knobs or public washrooms.  It doesn’t even have to be a real item that triggers the ‘wash’ compulsion, it can also be a ‘dirty’ thought. Those with ordering and arranging compulsions will arrange their possessions in a particular way and become very upset should anyone interrupt them.  This is done to prevent a disaster (not related to a lack of organization) from occurring or for a need for everything to ‘feel right’.  Some people with OCD will repeat tasks like turning on a light switch until it ‘feels right’ or until they have done it a certain number of times.  Still others hoard items.
Not all compulsions are behavioural.  Mental acts like repeating a prayer or a mantra can also be done to prevent a feared act from occurring or to bring relief from anxiety, guilt or shame.  Seeking reassurance that something won’t happen or that it is ok to not do a compulsion is another compulsion because it is not done to acquire information but rather to lessen anxiety.  When the anxiety returns, the same question is asked again and again and again.
Once OCD begins there are certain thoughts or events that keep it reccurring. These are known as triggers, faulty thought appraisals and selective attention.  A trigger is a neutral event or thought that leads to an obsessive thought. For example, an approaching bus leads a man with OCD to obsess:  Did I push someone under that bus? A woman with OCD might obsess that somehow SHE caused the car accident that killed her mother even though she was nowhere near the scene at the time.
Faulty thought appraisals occur when an OCD sufferer decides that a random intrusive thought is in some way significant or revealing. Having a random repugnant sexual thought is interpreted to mean that they are sick or weird. Having a thought cross their mind about harming someone must mean that they are evil and disgusting. Other irrational beliefs held by people with OCD include:
-They are 100% responsible for what happens to themselves and others around them
-They can and must maintain complete and total control over all their thoughts
-It is both important and possible to be 100% certain a bad event won’t happen
-Imperfection in themselves is intolerable so tasks must be redone until they ‘feel right’.
-Things go wrong much more often than they go right, so check to make sure you did it properly.
Dr. Tompkins states that once a thought is earmarked as threatening a person pays greater attention to it.  A person on the watch for these thoughts goes actively ‘looking’ in his mind for them. Since the mind has the ability to create these feared thoughts and images, voila, you find them.
Another problem is that although the compulsion may reduce anxiety, guilt or shame, this is only temporary.  Over time this works less and less well so the person often needs to do their compulsion longer or add more features to it.
Tompkins admits that getting a correct diagnosis of OCD can be an ordeal due to lack of knowledge on the part of the professionals. However, it is the ticket to qualifying for and receiving correct treatment and/ or medications and having the insurance companies pay for some or all of this.   A formal diagnosis can also help family and friends understand the problem better.  He then walks the reader through the diagnostic process.
Then is the time to seek treatment.  Tompkins provides a list of questions to ask prospective therapists. He does not minimize the hard work the client needs to do.  It involves facing “fears and distress as well as tolerat[ing] the feelings of having to admit to yourself and others that you have OCD.”  He explains the basics of the 2 main behavioural therapies: CBT and ERP, and how long treatment lasts. Finally he shares some do’s and don’ts that will make therapy more successful:
-        share even your most shameful obsession
-        don’t try to get away with mini-compulsions
-        do your homework each week as prescribed
-        have the therapist model the exposure if it will help you decrease your fears
-        tell any new symptoms that occur   
 He then briefly discusses other forms of psychological treatments and why he does not recommend them.  He also evaluates the pros and cons of attempting other medical treatments (i.e. brain surgery) in the event that regular treatments are ineffective.
Medication is another step a person just diagnosed with OCD has to address. Tompkins discusses the types of medications, their common side effects and finally the frustrations that can occur while trying various medications until the right one is found.
One of the most important areas of this book is the section on having a recovery attitude after your therapy is over to keep OCD as minimal an intrusion in life as possible.  He reminds readers to practice healthy personal care habits: proper nutrition, exercise, enough sleep and to resist the urge to do more than their fair share at work so they have a healthy work/ life balance.  He also gets specific with advice for helping to keep OCD at bay: accept both life’s uncertainty and that personal imperfection is okay, keep practising exposures to keep the fear away and to not give OCD an opportunity by doing little compulsions.  He says to resist the urge to analyze, reassure the self or repeat phrases like ‘this is my OCD’.
It is hard to have OCD at home where everything is familiar.  It is harder still to have OCD and go to work or attend school.  Tompkins gives Americans their workplace rights and helps the newly diagnosed person decide whether accommodations are needed. He gives examples of what can be done to assist the employee or student wwith OCD in fulfilling his job or school responsibilities.
The book also provides a list of US treatment centers and organizations and websites to visit.
This book gives any adult the information and understanding necessary to be able to talk to a health practitioner, explain clearly their symptoms and get a formal diagnosis of their illness.  His step by step detailed instruction manual is easy to both understand and put into practise.  He alleviates potential fears of treatment and taking medications by explaining the therapeutic and medical offerings available and even evaluates them so readers know which ones to look for and which to avoid.  He doesn’t mince words pretending that OCD therapy will be fun or easy but reassures the reader that most do find a reduction in symptoms with some combination of therapy done well and medication.  Not too many books give advice on how to maintain your gains after therapy is over but Tompkins devotes a whole chapter to this. 
  However, as a Canadian I’d like to see some Canadian organizations in his resource section.
 I’m also not so sure that getting a proper OCD diagnosis is as difficult as Tompkins says.  The source for this is a study from 1986, over 20 years ago.  I’m hoping that except for maybe rural America that this has changed, especially after seeing all the different anxiety and OCD centers in the many American states that he lists in his book. He also downplays ACT (Acceptance & Commitment Therapy) but I found that for me, some of the ACT ideals were very useful while I had intense anxiety.  Did I want to do something positive or of value (go out for a walk) or stay at home and give in to the anxiety?  ACT can give you the motivation of why you are going through the work of practicing CBT or ERP.
While Dr. Tompkins very briefly takes the reader thru common theories of how OCD occurs,he he fails to mention Dr. Jeffrey Schwartz’s view that when the basal ganglia is over stimulated it  starts sending false messages of dread or discomfort to the brain. The brain becomes ‘stuck’ and can’t automatically delete these messages anymore.  The person with OCD must learn how to do this manually.  Schwartz also has a treatment plan a little different from, and not as anxiety-provoking as ERP which Tompkins also did not include.  This is odd since he lists the Westwood Institute in his resource section and they follow Schwartz’ program. Schwartz’ book Brain Lock is not an obscure work and should be included in Dr. Tompkins' overview of OCD for the newly diagnosed. 
This is a positive, upbeat book that would help any newbie on the start of their journey to beating ocd.