Obsessive Compulsive Disorder (OCD)
Once referred to as the “doubting disease”, OCD is an anxiety disorder. The hallmark feature of OCD is the presence of distressing, recurrent, and persistent obsessions and/or compulsions. OCD is diagnosed when the obsessions or compulsions take up more than one hour per day or cause significant distress or impairment.
What are obsessions?
Obsessions are recurrent and persistent thoughts, images, impulses or urges that are distressing, unwanted, and intrusive. Obsessions often revolve around themes such as contamination, religion, sexuality, safety, inappropriate social behaviour, or needing to feel “just right”. People with OCD usually report that their obsessions seem stupid, but nevertheless, they are distressed by them. Some people with OCD say they feel “paranoid” because they constantly feel suspicious and doubtful about the risk of harm to themselves or other people.
In most cases, the obsessional thoughts are associated with a feared consequence. For example, someone with obsessional thoughts about contamination may fear that they have “germs” on their hands, which will cause illness to themselves or a loved one. At one level they know that their hands are not contaminated by sinister or life-threatening germs, but this knowledge doesn’t make them feel any better due to the persistence of niggling doubt.
Someone else with an obsessional thought about whether an electrical appliance has been switched off properly may report an accompanying fear that the house will burn down. They may know intellectually that the appliance is off, but at an emotional level the doubt persists and hence so does the anxiety. In other cases, the person may not be able to identify a feared consequence, other than a vague and uncomfortable feeling of things being “Not Just Right”. For example, someone may need to line things up or order things in a particular way, count, remember unimportant words or numbers, or try to walk in a particular way, to obtain a “just right” feeling. These experiences are quite common in OCD and may or may not be associated with a clearly identifiable feared consequence.
Obsessions cause high anxiety or discomfort. Therefore the person with OCD typically develops strategies designed to reduce the anxiety or discomfort. These strategies are called “compulsions” or “rituals”.
By definition, a compulsion is a repetitive behaviour or mental act that is difficult to resist and which occurs in response to obsessions or according to rigid rules. A compulsion, which the person feels driven to perform, is aimed at preventing a feared event or reducing discomfort. The compulsions are usually recognized as being unreasonable or excessive, although this insight may be limited at the time of greatest threat.
As an example, a person with a fear of contamination (the obsession) may worry that they will become sick or spread disease to other people (feared consequence), and therefore engages in hand washing behaviour (the compulsion) in order to reduce the risk and the feeling of anxiety. The sense of relief that comes from avoiding disaster means that next time they are in a similar situation they are likely to do the same thing. Over time, lesser and lesser contact with “germs” causes doubt and fear so the washing rituals increase in frequency. If doubt then sets in about whether the washing ritual was done well enough, the washing ritual may increase in duration and stronger cleaning agents may be used.
Along with compulsions, people with OCD may develop other types of neutralising behaviours such as seeking reassurance from other people. Reassurance seeking typically takes the form of repeatedly asking whether something was done properly, or whether a particular event occurred, or is likely to occur. For example, a person with OCD might repeatedly ask a loved one whether they remember seeing him or her lock the front door or steal something from a shop. Sometimes the reassurance seeking extends to asking strangers such as the police department (e.g., “Has anyone reported a hit and run in Adams Street today?”)
Although compulsions may often bring short-term relief of anxiety, they can be very time consuming and the anxiety reduction may not be complete. Hence, people with OCD often seek to avoid situations, places or people that trigger the obsessional thoughts in the first place. For example, someone with a contamination fear may avoid touching things in public places because the obsessional thoughts may be too distressing, or the washing compulsions may be too time consuming to deal with at a particular time. Similarly, someone with a fear of the house burning down may avoid using particular electrical appliances to decrease risk, while another person with a fear of a break-in may avoid leaving the house, once again to decrease risk or because the checking compulsions are so time consuming or frustrating that it is just not worth going out in some cases.
Who gets OCD and what causes it?
OCD affects about one person in forty (2.5% of the population). For males, OCD most commonly starts in the mid to late teens, while for females it mostly starts in the early twenties. Some studies suggest that OCD may be slightly more common in women than in men. In the absence of treatment, OCD follows a fluctuating course, often worsening during times of stress and usually persisting to some degree across the lifespan. Despite the fact that OCD has been recognized in some form for hundreds of years, we still have little understanding about its causes.
The most likely scenario is that certain factors may put someone at risk of developing OCD. If enough of the factors are present, and the person is under stress, OCD may develop. Risk factors may include personality style (e.g., being cautious and responsible), a history of anxiety or depression in other family members, brain structure and functioning, and role modelling from other family members who may have OCD. In rare cases, OCD develops after a head injury.
Treatment of OCD
There are now a number of treatments that have been shown to reduce symptoms of OCD. The majority of people who receive appropriate treatment for OCD report a significant reduction in distress and disability after treatment. For most people the OCD symptoms do not disappear completely. The goal of treatment for OCD is generally to manage the disorder more effectively rather than to obtain a complete cure. Having said that, some people DO become symptom free after treatment, so anything is possible. The following section discusses the effective treatments for OCD.
This form of psychological treatment has been used for OCD for more than 40 years and remains one of the most effective strategies. The main focus is on changing the behaviours that maintain the OCD. Typically, when someone with OCD is confronted with a threatening situation they use compulsions to reduce their anxiety. They come to believe that the compulsive behaviours are necessary for anxiety reduction and hence the compulsions become stronger and more entrenched. In behaviour therapy people are encouraged to stop using compulsions and allow themselves to habituate (get used to) the anxiety over a period of time.
For example, someone with a fear of contamination may aim to tie his or her shoelaces without handwashing or put out the garbage without handwashing. This treatment is referred to as “exposure and response prevention”, or ERP. In ERP it is important to target both the obvious physical rituals (e.g., handwashing) and the less obvious mental rituals (e.g., praying or analysing).
ERP is usually done using a graded approach, starting with the least distressing steps first and gradually working up to the most distressing steps until you have conquered all the rituals on your list. Rather than taking a graded approach, some people prefer to go straight to the most difficult step, often because the most difficult step is also the one that causes them the most frustration. This approach is referred to as “flooding”. Graded exposure and flooding are equally effective strategies, although flooding is more anxiety provoking but typically brings quicker symptom relief.
Cognitions can loosely be described as your thoughts and images. In the treatment of OCD, cognitive therapy refers to the process of challenging and undermining the unhelpful thoughts and beliefs you may have about feared situations or outcomes. Typically in OCD, people report a range of beliefs such as overestimation of danger, excessive feelings of responsibility for harm to others, and the importance of controlling one’s thoughts. Simple cognitive techniques such as evidence gathering, logical reasoning, and probability assessments can sometimes help bring new perspective to your fears.
Cognitive Behaviour Therapy (CBT)
This therapy is simply a combination of behaviour therapy (Exposure & Response Prevention) and cognitive therapy. The traditional behavioural approach of graded exposure and response prevention (ERP) will generally result in better outcome if the exposure activities are conducted with a clear focus on changing underlying beliefs. That is, the behaviour therapy needs to be set up in such a way that it encourages the gathering of new information that may assist with belief change.
Many people find that antidepressant medication can significantly reduce the severity of their OCD, particularly if the OCD is severe. For severe OCD, or OCD that is accompanied by depressive illness, current research suggests that the combination of antidepressant medication with psychological treatment is likely to lead to a better treatment outcome.
In many cases, antidepressant medication can be prescribed and managed by your GP. However, effective outcome often requires higher doses of antidepressant medication than is usually needed for treatment of depression. Some GPs are less comfortable prescribing at this higher end of the dose range so prefer to hand the medication management over to a psychiatrist. A psychiatrist will also be a helpful option if you have a more complicated presentation, have other mental disorders, are pregnant or breastfeeding, have difficulty tolerating medications, or have had little success with antidepressant medication or psychological treatment to date.
How to get help for OCD
The clinical psychologists and psychiatrists at Mindcare Centre can help you tailor a treatment program that best suits your individual needs. Best practice recommends that people with OCD receive cognitive behaviour therapy for OCD, with or without antidepressant medication. The clinicians at Mindcare Centre can offer both psychological and medication treatment for OCD as part of a shared care arrangement between a clinical psychologist and psychiatrist. If the OCD is not severe, many people like to try psychological strategies first, then trial medication at a later time if needed, via a GP or a psychiatrist. Clinical psychologists and psychiatrists are both equally well equipped to assess and diagnose OCD.
Contact our friendly reception staff during business hours on (02) 9212 4445 or email us to book an appointment with one of our OCD specialists. In the absence of treatment, OCD symptoms will wax and wane in severity but do not usually go away, so don’t sit and wait – do something about it today.
Brain Lock by Jeffrey M Schwartz
Overcoming Obsessive Thoughts: How to Gain Control of your OCD by Clark and Purdon