A Guide to Obsessive Compulsive Disorder

Obsessive compulsive disorder (OCD) is a common mental health problem. Symptoms typically include recurring obsessive thoughts, and repetitive compulsions in response to the obsession. A common example is recurring obsessive thoughts about germs and dirt, with a compulsion to wash your hands repeatedly to “clean off the germs”. However, there are many other examples. The usual treatments are cognitive behaviour therapy, a selective serotonin reuptake inhibitor (SSRI) antidepressant medicine, or both. Treatment often works well to reduce the symptoms and distress of OCD greatly.

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What is obsessive compulsive disorder?OCD is a condition where you have recurring obsessions, compulsions, or both.

What are obsessions?Obsessions are unpleasant thoughts, images, or urges that keep coming into your mind. Obsessions are not simply worries about your life problems. Common obsessions include:

•Fearsaboutcontaminationwithdirt, germs, viruses (eg HIV), etc.

•Worriesaboutdoorsbeingunlocked, fires left on, causing harm to someone, etc.

•Intrusivethoughtsorimagesofswearing, blasphemy, sex, someone harmed, etc.

•Fearofmakingamistakeorbehaving badly.

•Aneedforexactnessinhowyouorder or arrange things.

These are examples. Obsessions can be about all sorts of things. Obsessive thoughts can make you feel anxious or disgusted. You normally try to ignore orsuppressobsessivethoughts.Forexample, you may try to think other thoughts to ‘neutralise’ the obsession.

What are compulsions?Compulsions are thoughts or actions that you feel you must do or repeat. Usually the compulsive act is in response to an obsession.Acompulsionisawayoftryingto deal with the distress or anxiety caused by an obsession.

Forexample,youmaywashyourhandsevery few minutes in response to an obsessionalfearaboutgerms.Anotherexample is you may keep on checking that doors are locked in response to the obsession about doors being unlocked. Other compulsions include repeated cleaning, counting, touching, saying words silently, arranging and organising - but there are others.

How does obsessive compulsive disorder affect your life?The obsessions that you have with OCD can make you feel really anxious and distressed. The compulsions that you have may help to relieve this distress temporarily but obsessions soon return and the cycle begins again.

The severity of OCD can range from mildly inconvenient, to causing severe distress. You know that the obsessions and compulsions are excessive or unreasonable. However, you find it difficult or impossible to resist them.

OCD affects people in different ways. Forexample,somepeoplespendhours carrying out compulsions and, as a consequence, cannot get on with normal activities. Some people do their compulsions over and over again in secret (like ‘rituals’). Other people may seem to cope with normal activities, but are distressed by their recurring obsessive thoughts. OCD can affect your work (or school-work in children), relationships, social life, and your quality of life.

Many people with OCD do not tell their doctor or anyone else about their symptoms. They fear that other people might think they are crazy. Some people with OCD may feel ashamed of their symptoms, especially if they contain ideas of harming others, or have a sexual element.Asaresult,manypeoplewithOCD also become depressed. However, if you have OCD, you are not crazy or mad. It is not your fault and treatment often works. If you are concerned that you may be depressed (for example if you have been feeling very down and you no longer take pleasure in the things that you used to enjoy) you should see your doctor.

What causes obsessive compulsive disorder?The cause of OCD is not clear. Slight changes in the balance of some brain chemicals (neurotransmitters) such as serotonin may play a role. This is why medication is thought to help (see below).

Also,thechanceofdevelopingOCDishigher than average in first-degree relatives of affected people (mother, father, brother, sister, child). So, there may be some

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genetic element to OCD. However, so far, no genes have been found to be linked with OCD.

Other theories about the cause of OCD have been suggested, but none proved.

Who gets obsessive compulsive disorder?It is thought that between 1 to 3 in 100 adultshaveOCD.Anyoneatanyagecandevelop OCD but it usually first develops betweentheagesof18and30.About2in100 children are also thought to have OCD.

OCD is usually a chronic (persistent) condition.

How is obsessive compulsive disorder diagnosed?If you are concerned that you may have obsessive compulsive disorder, you should see your doctor and explain your concerns. They may start by asking some of the following questions. These questions can act as a ‘screen’ for possible OCD:

•Doyouwashorcleanalot?

•Doyoucheckthingsalot?

•Isthereanythoughtthatkeepsbothering you that you would like to get rid of, butcannot?

•Doyourdailyactivitiestakealongtime tofinish?•Areyouconcernedaboutputtingthings in a special order, or are you upset bymess?

•Dotheseproblemstroubleyou?

Amoredetailedassessmentisthenneeded for obsessive compulsive disorder to be diagnosed. This may either be carried out by your doctor or by a specialist mental health team. The assessment will look at any obsessional thoughts and compulsions that you have and how they affect you and your daily life. Children with OCD may be referred to a specialist mental health team which is experienced in assessing and treating children with OCD.

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What is the treatment for obsessive compulsive disorder?The usual treatment for OCD is:Cognitive behaviour therapy (CBT), orMedication, usually with an SSRI antidepressant medicine, orAcombinationofCBTplusanSSRIantidepressant medicine.

Cognitive behaviour therapyWhat is CBT?CBT is a type of specialist ‘talking’ treatment (a specialist psychological therapy). It is probably the most effective treatment for OCD.

Cognitive therapy is based on the idea that certain ways of thinking can trigger, or ‘fuel’, certain mental health problems such as OCD. The therapist helps you to understand your current thought patterns. In particular, to identify any harmful, unhelpful, and ‘false’ ideasorthoughtswhichyouhave.Alsoto help your thought patterns to be more realisticandhelpful.Forexample,ifyouhave OCD it may be helpful to understand that thoughts or obsessions in themselves do no harm, and you do not have to counter them with compulsive acts. The therapist suggests ways in which you can achieve these changes in thinking.

Behaviour therapy aims to change behaviours which are harmful or not helpful.Forexample,compulsions.Thetherapist also teaches you how to control anxiety when you face up to any feared situations.Forexample,byusingbreathingtechniques.

Cognitive behaviour therapy (CBT) is a mixture of the two where you may benefit from changing both thoughts and behaviours. This is the most common treatmentforOCD.Aparticularvariationof CBT called ‘exposure and response prevention’isoftenusedforOCD.Forexample, say you have a compulsion to keep washing your hands in response to an obsessional fear about ‘contamination’ with germs. In this situation the therapist may gradually ‘expose’ you to ‘contaminated’ objects. But, the therapist prevents you from doing your usual compulsion (repeated hand washing) to ease your anxiety about contamination. Instead, the therapist teaches you how to control any anxiety in other ways. Forexample,byusingdeepbreathingtechniques. In time, you should become less anxious about ‘contamination’ and feel less need to wash your hands so much.

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How can I get CBT?Your doctor may refer you to a therapist who has been trained in CBT. This may be a psychologist, psychiatrist, psychiatric nurse, or other healthcare professional. There is a limited number of CBT therapists available on the NHS and there may be waiting lists for therapists in some areas. However, government policy is to make CBT more widely available on the NHS.

Therapy is usually weekly sessions of about 50-60 minutes each, for several weeks. Sometimes this is done in a group setting or sometimes ‘one-to-one’, depending on various factors such as the severity of the problem. Sometimes, CBT is done by telephone conversations with a therapist.

How effective is CBT for OCD?Of those who complete a course of CBT, there is a marked improvement in more than 3 in 4 cases. Symptoms may not go completely, but usually the obsessions and compulsions becomemuchlessofaproblem.About1in4 people with OCD finds CBT too stressful and ‘not for them’. However, cognitive therapy alone may help some people who find the full CBT too stressful.

Do-it-yourself CBTCBT with the help of a trained therapist is best. However, some people prefer to tackle their problems themselves. There is a range of self-help books and leaflets on self-directed CBT. More recently, interactive CDs and websites are being developed and evaluated for self-directed CBT. See the resources below for further details.

Medicines used to treat obsessive compulsive disorderSSRI antidepressantsAlthoughtheyareoftenusedtotreatdepression, SSRI antidepressant medicines can also reduce the symptoms of OCD, even if you are not depressed. They work by interfering with brain chemicals (neurotransmitters) such as serotonin, which may be involved in causing symptoms of OCD. SSRI antidepressants include: citalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline.

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Note: •SSRIantidepressantsdonotwork straightaway.Ittakes2-4weeksbefore their effect builds up and start to work. Theymaytakeupto12weekstowork fully.Acommonproblemisthatsome people stop the medicine after a week or so as they feel that it is doing no good. You need to give them time to work.

•SSRIantidepressantsarenot tranquillisers, and are not usually addictive.

•ThedosesneededtotreatOCD are often higher than those needed for depression.

•Ifitworks,itisusualtotakeanSSRI antidepressant for at least a year to treat OCD.

What about side-effects with SSRIs?Most people who take an SSRI have either minor, or no, side-effects. Possible side-effects vary between different preparations. The most common ones include: diarrhoea, feeling sick, vomiting, and headaches. Some people develop a feeling of restlessness or anxiety (see below). Sexual problems sometimes occur.

It is worth keeping on with treatment if side-effects are mild at first. Minor side-effects may wear off after a week or so.

The leaflet that comes in the medicine packet gives a full list of possible side-effects. Tell your doctor if a side-effect persistsoristroublesome.Aswitchtoa different preparation may then suit you better. Drowsiness is an uncommon side-effect with SSRI antidepressants, but do not drive or operate machinery if you become drowsy whilst taking one.

SSRI antidepressants and suicidal behaviourIn recent years there have been some case reports which claim a link between taking SSRI antidepressants and feeling suicidal. The Committee on Safety of Medicines has recently reviewed the evidence on whether there is such a link. They were unable to find any convincing evidence of this link. The Committee on Safety of Medicines has stated that it will continue to monitor this issue.

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Because of this possible link, see your doctor promptly if you become restless, anxious or agitated, or if you have any suicidal thoughts. In particular, if these develop in the early stages of treatment with an SSRI, or following an increase in dose.

Are SSRI antidepressants addictive?SSRIs are not tranquillisers, and are not thought to be addictive. (This is disputed by some people, and so this is controversial. If addiction does occur, it is only in a minority of cases.) Most people can stop an SSRI without any problem. Attheendofacourseoftreatmentyoushould reduce the dose gradually over about four weeks before stopping. This is because some people develop ‘withdrawal’ symptoms if the SSRI is stopped abruptly.

Withdrawalsymptomsthatmayoccurinclude: dizziness, anxiety and agitation, sleep disturbance, ‘flu-like’ symptoms, diarrhoea, abdominal cramps, pins and needles, mood swings, feeling sick, and low mood. These symptoms are unlikely

to occur if you reduce the dose gradually. If withdrawal symptoms do occur, they will usuallylastlessthantwoweeks.Anoptionif they do occur is to restart the medicine, and then reduce the dose even more slowly before stopping. You should see your doctor if you are worried that you are developing withdrawal symptoms.Some other points about SSRIs and OCDSymptoms can improve by up to 70% if you take an SSRI. So, although symptoms may not go completely, they usually greatly improve so the obsessions and compulsions are much less of a problem. This can make a big difference to your quality of life.

You should not stop SSRI antidepressants suddenly. You should gradually reduce the dose as advised by a doctor at the end of treatment. In some people the symptoms return when medication is stopped.AnoptionthenistotakeanSSRI antidepressant long-term. However, symptoms are less likely to return once you stop an SSRI antidepressant if you have had a course of CBT (described earlier).

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Reasons why medication may not work so well in some people include:

•Thedoseisnothighenoughandneeds to be increased.

•Medicationwasnottakenforlong enough-itmaytakeupto12weeks to work.

•Side-effectsbecameaproblemandso you may stop the medication. Tell a doctor if side-effects are troublesome.

Other medicines that are used to treat obsessive compulsive disorderIf SSRIs do not help much, or cannot be taken, then another type of antidepressant called clomipramine is sometimes used. This is classed as a ‘tricyclic antidepressant’ and used to be the main medication treatment for OCD before SSRIs became available. Occasionally, other medicines that are used to treat mental health disorders are used.

Cognitive behaviour therapy plus selective serotonin reuptake inhibitor antidepressantsIn some situations, a combination of CBT plus an SSRI antidepressant is advised. This may be better than either used alone when OCD is severe.

What is the prognosis (outlook) for obsessive compulsive disorder?If OCD is not treated, obsessive thoughts and compulsions may not improve and may get worse in some people. However, with treatment many people’s symptoms can be brought under control and some people may be completely cured.

If you have OCD, there is a risk that it can return even after successful treatment and recovery. If your symptoms do come back, be sure to see a doctor for further treatment.

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Further help and informationOCD ActionSuite 506-509 Davina House 137-149 Goswell Road, London EC1V 7ETTelephone08453906232/02072532664www.ocdaction.org.uk

Anationalcharitywhichprovidesinformation, advice, and support to people with OCD.

OCD-UKPOBox8955,NottinghamNG109AUTelephone08451203778www.ocduk.org

Anationalcharityforpeoplewhoare affected by OCD.

NO PANIC (National Organisation For Phobias,Anxiety,Neuroses,Info&Care)93BrandsFarmWay,TelfordShropshireTF32JQHelpline 0808 808 0545www.nopanic.org.uk

Forpeoplewithpanicattacks,phobias,OCD, anxiety and related disorders.

Triumph Over Phobia (TOP UK)POBox3760,BathBA23WYTelephone 0845 600 9601www.triumphoverphobia.com

Runs a national network of structured, self-help groups for adults (16 ) suffering from recognisable phobia, or obsessive compulsive disorder.

Anxiety UK (Formerly The National Phobics Society)Zion Community Resource Centre 339 Stretford Road, Hulme Manchester M15 4ZYHelpline 08444 775 774 www.anxietyuk.org.uk

AleadingUKcharityforanxietydisorders such as OCD, etc.

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©EMIS2010,asdistributedonhttp://www.patient.co.uk/health/Obsessive-Compulsive-Disorder.htm Used with permission.

British Association of Behavioural and Cognitive Psychotherapies (BABCP)Victoria Buildings, 9 - 13 Silver Street Bury BL9 0EUTelephone 0161 797 4484 www.babcp.com

Maintain a register of practitioners so thatyoucanfindaCognitive/BehaviouralTherapist in your area. They also have information about frequently encountered problemsincludingAnxiety,Depressionand OCD.

Oxford Cognitive Therapy Centre (OCTC)Based in the Oxford Psychology Dept, part of Oxfordshire and Buckinghamshire MentalHealthNHSFoundationTrust.www.octc.co.uk

Their website gives details of how to order a number of educational and self-help booklets with a CBT approach for conditions including Obsessive-Compulsive Disorder.

ReferencesObsessive-compulsive disorder, ClinicalKnowledgeSummaries(November2008)

Obsessive Compulsive Disorder, NICE(2005);(Coreinterventionsinthetreatment of obsessive compulsive disorder and body dysmorphic disorder)

Report of the CSM Expert Working Group on the Safety of Selective Serotonin ReuptakeInhibitorAntidepressants.Dec2004

Greenberg WM; Obsessive-Compulsive Disorder.eMedicine.Updated:May31,2009

Northern IrelandAssociation for Mental Health80 University StreetBelfast BT7 1HE

Niamh is a company limited by guarantee Charity Reference Number XN47885Company Number NI 25428

Telephone 028 9032 8474Fax 028 9023 4940info@niamhwellbeing.orgniamhwellbeing.org