Obsessive Compulsive Disorder

This information is taken from our book Overcoming Obsessive Compulsive Disorder

Obsessive Compulsive Disorder (OCD) is a condition consisting of obsessions or compulsions, or, more commonly, both.

What are Obsessions?

Obsessions are recurrent thoughts, images or urges that you may regard at least initially as intrusive and senseless. But you find them distressing and feel anxious or guilty. You cannot distract yourself from them or ignore them.

Obsessions vary. The most common one is that objects or other people are “contaminated”. This might be from germs, dirt, disease, or radiation. Sufferers usually feel compelled to decontaminate themselves by excessive hand washing or cleaning.

The next most common obsession is fear of causing accident, injury, or misfortune. You may believe that you left the doors or windows unlocked, or left the gas taps on. You feel compelled to check them repeatedly.

Obsessions can also be concerned with violence, murder, blasphemy or sex. Some sufferers find it difficult to put their obsession into words, but whenever it is, they usually avoid a wide range of situations or activities in order to prevent discomfort and the risk of causing harm.

What are compulsions?

Compulsions are actions which sufferers repeat purposefully to avoid or reduce discomfort. They are also called rituals. Although mainly voluntary, you feel driven to perform them. The most common compulsions are:

* Checking to prevent a feared danger such as gas taps left on
* Excessive cleaning or hand washing
* Repeated seeking of reassurance that a feared event will not in fact happen
* Counting or repeated touching of objects to prevent a feared disaster
* Arranging or ordering of objects or activities in a particular way leading to slowness
* Repeated questioning of or confessing to others
* Hoarding of useless or worn-out possessions

You may also experience obsessions as thoughts for which you feel compelled to perform rituals in your mind. These are called ruminations or mental rituals  and serve to neutralise unpleasant thoughts or images. An example is mentally repeating a phrase to prevent a specific catastrophe.

You may find that you experience just a few of these symptoms during the course of the illness, or many.

How common is OCD?

About 2% of the population suffer from OCD at some point in their lives. That would be about one million people in the UK, although not everybody has the full syndrome. OCD is slightly more common in women than in men. Famous sufferers include:

* Howard Hughes, the reclusive millionaire who was preoccupied by contamination
* Martin Luther, the religious reformer
* John Bunyan, author of the Pilgrim’s Progress

When does OCD begin?

OCD can develop in childhood but usually appears in adolescence or the twenties. However many individuals with OCD leave it for years before seeking treatment.

What causes OCD?

Psychological explanations emphasize the way a sufferer has learnt to avoid certain situations and carry out compulsions that perpetuates the condition. Individuals typically have an over-inflated sense of responsibility, that is they over-estimate the degree to which they believe they can influence or prevent bad events from happening. This is often combined with a tendency to catastrophise and demand certainty or a guarantee that a bad event will not happen.

Biological explanations emphasize that some families have a genetic predisposition to anxiety which may make it more likely that another member of the family will inherit OCD. Certain stresses or life events may precipitate the onset. Once the disorder has developed, the brain tries too hard to regulate the system. Changes in serotonin function may occur in the brain which are probably consequences rather than a cause of the disorder.

What are the other symptoms of OCD?

Sufferers are often demoralized and ashamed by their symptoms and some are clinically depressed.

There are several related conditions which are often go with OCD. These include:

* Trichotillomania, an urge to pluck your hair or eyebrows
* Hypochondriasis, fear of suffering from a serious illness
* Body Dysmorphic Disorder, a preoccupation with being ugly or having a defect in your appearance.
* Tourette’s syndrome which consists of multiple vocal and motor tics.

How Disabling is OCD?

It varies from a bit to a lot. Severe OCD can make regular employment or family life impossible. Those who are in regular employment or who have family responsibilities would almost certainly find life more productive and satisfying if they did not have the symptoms. The families of sufferers of OCD may also become involved in the rituals and suffer greatly.

Are people with OCD mad?

No. The rituals may seem mad, but the person performing them is not. OCD sufferers are usually very aware of the absurdity of their behaviour, but have difficulty controlling it. They tend to be very secretive and reluctant to seek help because they are afraid that others will think them mad.

Do people who gamble or drink “compulsively” have OCD?

No. The terms “compulsive” or “obsessive” are sometimes used to describe addictions to gambling, alcohol, exercise or eating, for example, but these problems are quite different from OCD. The compulsions in OCD are never pleasurable and are usually concerned with preventing harm to sufferers or those around them.

How is the illness likely to progress?

Treatment can improve the outcome of the illness for most sufferers. Many people with mild OCD will improve over time without treatment. The outcome is much less predictable for those with moderate to severe OCD. Some may be chronically ill but find they have periods of remission. Others deteriorate progressively.

What treatments are available?

There are two main treatments that have been shown to be of benefit – Cognitive Behaviour therapy and anti-depressant medication. The former is the treatment of choice.

Cognitive Behaviour Therapy

There are two main approaches described and recommended by the NICE guidelines on OCD. The first is cognitive behaviour therapy that includes exposure and response prevention. It is based on a psychological understanding of your OCD of what keeps the problem going. The therapist may try to help you change the excessive degree of responsibility and magical thinking you feel, your demand for guarantees about the risks of exposure and the criteria you use for termination of a compulsion. When ready to test out which theory best fits the facts, people with OCD may confront whatever they fear (a process called “exposure” or a “behavioural experiment”) without performing a ritual (“response prevention”). This means learning to give up control, to resist the compulsion and to tolerate repeatedly the discomfort that occurs. Facing up to the fear gets easier and it gradually easier to cope with the anxiety. You begin by confronting easier situations and then gradually work up to more difficult ones. The side effects are the anxiety and distress in the short-term, but these tend to gradually decrease. Of those that do adhere to the programme, about 75% are helped significantly. The risk of relapse after treatment is about 25% when you may require additional treatment.

There is no evidence that psychodynamic or analytical therapy or hypnotherapy is of any benefit in OCD.

Anti-Obsessional Medication

The second type of treatment is anti-obsessional medication – anti-depressants which are strongly “serotonergic”. They may be used either alone or in combination with behavioural psychotherapy. Your general practitioner or family doctor may refer you to a psychiatrist who will be more aware of the doses required.

Clomipramine (trade name “Anafranil”) was the first anti-obsessional drug in the UK. The dose required may be quite high (250mg or more) and this can lead to some side-effects including:

* dry-mouth
* blurred vision
* constipation
* drowsiness
* dizziness on standing
* inability to reach orgasm

The newer serotonergic anti-depressant drugs are therefore more widely prescribed. These include:

* fluoxetine (trade name “Prozac”)
* fluvoxamine(“Faverin”)
* sertraline(“Lustral”)
* paroxetine (“Seroxat”)
* citalopram (“Cipramil”).

They tend to produce fewer or different side effects to clomipramine. With these drugs a minority of people may experience:

* nausea
* diarrhoea
* headache
* difficulty in sleeping
* restlessness
* difficulties in reaching orgasm

Most people find the side effects are minor irritations and usually decrease after a few weeks. The drugs are not addictive and you may stop them whenever you wish without experiencing withdrawal symptoms. If and when you do stop taking them, it is however sensible to reduce them slowly.

About 60% of patients with OCD improve with medication. In order to know whether you respond, you may have to take a high dose of the drug for at least 12 weeks. Those people who do respond may find that there is about 50% reduction in symptoms though additional drugs to improve the response. Of those patients that do respond, at least 75% will relapse in the months after stopping the drug. The risk of relapse can be minimised by combining the medication with behaviour or cognitive therapy. Medication is usually helpful when you are depressed as it may help in improving your motivation to take advantage of a psychological treatment programme. Medication may also be more useful for those who drop out or fail to comply with a programme because of excessive anxiety.

Finding help

If you feel that you, a friend or relative would like help for OCD, you might wish to discuss this with your GP, who can arrange a referral for an assessment. Alternatively you may be able to refer yourself direct in England to a local Increasing Access to Psychological Therapies (IAPT) centre for CBT.

You may find it helpful to arm yourself with a copy of the NICE guidelines on OCD. IF you are having difficulty seeking a referral to a specialist in OCD, you may find it helpful to speak first to an advocacy worker at OCD Action.

Websites on OCD  

There are various websites and bulletin boards where people with OCD and their carers are likely to get information from.

OCD Action is national charity in the UK for people with OCD.  Please join as a member and support it. There is an excellent Advocacy service. For example here is a list of examples of letters to obtain support to obtain a referral to a specialist service.

Many links on OCD are here

Understanding OCD from mainly an American perspective

The NICE treatment guidelines on BDD can be downloaded from here 

Support Groups in OCD

There are many support groups for OCD in the UK which will be listed on the OCD Action website. There is one such group that meets at the Priory North London from  7-9pm on the first Sunday of every month.

NHS services

Our specialist clinics for OCD are at the Maudsley Hospital  for out-patients and a residential unit at the Bethlem Royal Hospital, Beckenham, Kent.  A specialist service for adolescents is at the Maudsley Hospital, London

Accredited cognitive behaviour therapists (mainly private) can be searched on CBT UK register but difficult to know their experience in OCD

Recommended Books

Overcoming Obsessive Compulsive Disorder by David Veale, Rob Willson published by Robinson. Please consider adding a review on www.amazon.co.uk !

Taking Control of OCD. Inspirational Stories on OCD. Edited by David Veale and Rob Willson

Break Free from OCD by Fiona Challacombe, Visitoria Oldfield and Paul Salkovskis