Obsessive Compulsive Disorder (OCD)
Obsessive Compulsive Disorder is an anxiety disorder characterised by unwanted, intrusive thoughts (called obsessions) and behavioural or mental rituals (called compulsions).
What are obsessions?
Obsessions are thoughts, images or impulses which come into your head no-matter how hard you try to block them out. They are always about something dangerous or upsetting and they make you feel anxious, guilty or scared in case the thought is true. Examples include thoughts like "did I turn off the stove?" (maybe the house will burn down), or "my hands are contaminated" (I might get sick). Obsessions can also be images of frightening or upsetting things, like stabbing someone or running someone over, or they may be urges to do something you don't want to do. Obsessions are always disturbing and unpleasant because they focus on things which are important to you and which you don't want to be true. Most people try to cope with their obsessions by reassuring themselves that the thought is not true or by doing something to lessen the risk of danger (e.g. checking the stove, washing your hands).
What are compulsions?
Compulsions can be anything you do in response to an obsession in order to prevent it from coming true or to take away the fear created by your intrusive thoughts. They can be visible behaviours, like checking or washing, or they can be things you do in your mind that no-one can see, like praying, counting, or repeating words silently. Compulsions are also called "rituals" because most people feel like they have to do them in a very precise way, and they cannot rest until they've been done properly. So instead of performing compulsions just once, people with OCD repeat these behaviours over and over until they are satisfied that danger has been averted, or until the anxiety and distress is reduced.
Common Obsession and Compulsion Pairings
Sometimes there will be an obvious connection between the obsession and the compulsion (e.g. contamination and washing), but in other cases the connection may be more personal, depending on the individual's beliefs and superstitions (e.g. counting to a certain number to avoid harm befalling a loved one). Some examples of common symptom pairings are given below.
Contamination obsessions and washing rituals
These obsessions typically occur in situations where the person with OCD comes into contact with objects that may have been touched by other people (e.g. toilets, phones, money, groceries, letters, etc). The particular concern varies from person to person but may involve a fear of contamination with germs, dirt, faeces, saliva, dust mites, asbestos or HIV, to name a few. Contact with potentially "contaminated" items is generally avoided because it causes anxiety, but if contact occurs most persons with OCD will wash and clean excessively in order to get some relief from their anxiety and reduce the possibility of danger. Washing rituals can also be associated with obsessional doubts that pieces of glass or poisons may have gotten onto crockery or into food.
In some cases the person with OCD may fear that they themselves could inadvertently poison or harm their loved ones. In order to reduce the fear associated with these thoughts, the person is likely to rewash any items they touch, and avoid handling food that will be eaten by others.
Pathological doubts and checking compulsions
Checking compulsions most commonly arise in the context of leaving the house when no one else is home, or when going to bed for the night. At these times the individual is tormented with recurring doubts that doors and windows may not be locked and appliances may not be switched off, and as a consequence they fear that there may be a burglary or a fire. Unlike others who are satisfied by one quick glance, the person with OCD will have to check over and over again in order to be satisfied that everything is safe. Other obsessions about harm frequently linked to checking rituals include: ·
- doubts that a shadow or a pothole on the road might have been a person, causing the person with OCD to go back repeatedly to check that no one has been hurt.
- doubts that twigs, cracks or shadows on the ground might be syringes or other potentially dangerous objects, causing the person to go back repeatedly to check that the ground was safe to walk on.
Magical thoughts and neutralising rituals
These symptoms typically involve an intrusive thought or image of a loved one being harmed. If this thought intrudes into the person's mind while they are performing some activity (e.g. walking through a door), then the person may have a compulsion to go back through the door again whilst thinking to themselves that their loved one will be safe. This is called mental 'neutralising' or 'undoing', as the unpleasant thought is reversed and replaced with a good thought. These symptoms may be associated with a wide variety of everyday activities, including dressing, eating, drinking, reading, sitting and walking.
Violent thoughts and associated rituals
In these cases the person experiences unwanted images or thoughts of harming themselves or others. Common examples include violent images involving family or doubts that you may be responsible for hurting strangers as you pass them by. These obsessions are terrifying and result in a variety of complex avoidance and reassurance rituals. Many people with OCD end up locking sharp objects away out of sight and respond to the thoughts by checking that no-one is hurt and telling themselves that they could never do such a thing. Since the thoughts are completely inconsistent with the person's true values and beliefs, many people are also very critical of themselves about why such thoughts occur and what they might mean.
Sexual outrage and associated rituals
Sexual obsessions in OCD are unwanted thoughts, images or impulses which make you anxious or distressed every time they come into your mind. The are completely inconsistent with a person's true values and desires, and as a result they are often associated with high levels of shame and embarrassment in addition to anxiety or fear. Common examples include thoughts of molesting children, unwanted homosexual images, and impulses to inappropriately touch or stare at breasts or genital areas. Most people with this type of OCD respond to their thoughts by reminding themselves that they would never do such a thing, and by trying to avoid situations where the thoughts are likely to occur.
How common is OCD?
OCD can occur in both adults and children, with most people developing their first symptoms before the age of thirty. Boys usually show their first symptoms at a younger age than girls, so OCD is twice as common in boy children than girls. In adults the number of men and women with OCD is equal. Since mild obsessional symptoms are common in the general population, you don't get a diagnosis of OCD unless your obsessions and compulsions interfere with your life or stop you from doing some of the things you want to do. Population surveys have shown that approximately one in two hundred adult person with OCD each year. Once you have OCD it is rare for it to go away without proper treatment, so if the symptoms described above sound familiar you should seek help from a professional who is familiar with the treatment of OCD.
What treatments have proven benefits?
Two treatments have been proven to help people with OCD. One is Behaviour Therapy and the other is medication with one of the serotonin selective re-uptake inhibitors (SSRIs).
What is behaviour therapy?
Behaviour therapy for OCD consists of graded exposure and response prevention. This means learning to confront your fears without washing, checking, reassuring yourself, or doing any other compulsions that temporarily take away your fear and make you feel better. The first step involves recognising the link between obsessions, compulsions and anxiety. Most people feel anxious, scared or uncomfortable whenever they have an obsessional thought, and reassured or relieved after they perform their compulsion (even if they also feel frustrated because they're tired of performing compulsions). Human beings don't like to feel anxious, scared, or uncomfortable, and so when something is making you anxious it makes sense to try and do something to take that feeling away. In this context it is easy to see why you wash your hands if you doubt they are dirty, or why you keep checking the stove if you doubt it might be on. But when you have OCD these behaviours help to keep your fears alive, because the doubts always come back again, bringing more anxiety, and so you have to keep repeating your compulsions in order to get any relief. A good general rule is that when you have OCD the doubts gets stronger the more you give in to them, and weaker the more you resist them.
The next step is to understand what happens when you resist your compulsions. Most people have tried to resist their compulsions at some stage, but they usually try to resist too many compulsions all at once, or a compulsion which is too strong to start with, and so they feel overwhelmed very quickly and end up giving in. However, when you continue to resist a compulsion over a period of hours, you will notice that the strong anxiety you have at the start does not last, nor does the strong urge you have at first to give in to your compulsion. If you are truly confronting your fear, then these feelings will gradually weaken and fade away. After two or three hours you might still feel a little uncomfortable, but you will be nowhere near as anxious as you were immediately after you resisted the compulsion.
For instance, if you are afraid of contamination and you decide to confront your fears by touching money or doorhandles without washing your hands, you will initially feel anxious and have a strong urge to wash. But after a while it will get easier and your anxiety will fade. Then next time you touch the same thing and you resist washing your hands it will not be so scary, and the time after that it will be easier still. Repeating exposure tasks in this way is very important because doing something once will not get you better. You have to do it over and over again until there is no more anxiety associated with that activity.
Planning Graded Exposure and Response Prevention
For most people, some compulsions will be easier to resist than others. Below is a list of steps for developing a graded exposure plan that allows you to gradually start confronting your fears in a structured and systematic way. However, exposure can be scary and difficult to do on your own, so if you need help don't hesitate to seek advice from a professional Clinical Psychologist or Psychiatrist who is experienced in the use of behaviour therapy for OCD.
- Make a list of situations where your symptoms occur. (e.g. when leaving the house, or after touching an item you think is "dirty").
- Next list all the thoughts, images or impulses which come in to your mind in each situation (obsessions) (e.g. "the stove might be on", "my hands are dirty").
- Write down all the things you do in these situations to avoid danger or to take away the thoughts (compulsions) (e.g. checking the stove, washing your hands).
- Finally, list any activities or situations you avoid because of your obsessions.
- Go through these lists and rate how anxious you think you would be if you tried to resist each of the compulsions in each different situation. Use a rating scale of 0 to 10, where 10 means you would be extremely anxious, 8 means highly anxious, 5 means moderately anxious, and 3 means mildly anxious.
- Choose one thing on the list which you think you could resist with only mild to moderate anxiety. Next time you are in that situation try as hard as you can to resist that compulsion without giving in. Pay attention to how anxious you feel at the start and to the way this anxiety fades over time.
- Repeat this same activity, resisting the compulsion, every time you are in that situation (at least once every day). You should notice that with practice it gets easier and easier to resist because your anxiety is fading.
- Once you are comfortable with this activity, choose another, slightly harder compulsion and repeat step 7. Continue in this way until you've worked though all compulsions on your list. Be careful that you don't start giving in to new compulsions once you've stopped the old ones.
Remember that when you have OCD the doubts gets stronger the more you give in to them, and weaker the more you resist them.
Although medication using Serotonin Specific Re-uptake Inhibitors (SSRIs) may be of great benefit to some people, the amount of improvement varies from person to person. Most people who benefit from medication usually find that the obsessions and compulsions are still there but they are less frequent and distressing. In general the SSRIs help people to manage the symptoms of OCD, but they are not a cure, so the symptoms worsen again after a few weeks of stopping drug therapy. On average medication is not as effective as combining medication with behaviour therapy, or doing behaviour therapy on its own.
Examples of medications that have been proven to help with OCD include Fluoxetine (also called Prozac or Lovan), Sertraline (Zoloft), and Clomipramine (Anafranil). These drugs may be marketed under different names outside of Australia.
How successful are the standard treatments?
Treatment studies have consistently shown that about 70% of people with OCD respond very well to Behaviour Therapy and say that their symptoms are greatly improved. The average reduction in severity of symptoms with medication is about 50%.