An overview of obsessive compulsive disorder

Written by a sufferer

Last updated, 22nd September 2012

What is the mental health condition OCD?

"OCD makes you believe that you've violated your closest-held values and you battle with this distress every day.", a sufferer.

Obsessive compulsive disorder (or OCD for short) is an anxiety condition made up of two parts - obsessions and compulsions. The obsession part is the experience of anxiety due to an unresolved sense of doubt or fear which a sufferer cannot dismiss easily. An obsession can focus on virtually anything, but the subject of an obsession often falls into certain categories, which are listed in the page, "Common obsessions and compulsions and feared consequences". The compulsion part is a sufferer's action in response to the obsession in a vain attempt to eliminate the anxiety. A compulsion is difficult to resist as failing to perform a compulsion feels to a sufferer as if an unacceptable risk is being taken. Each part of OCD is very unpleasant - a sufferer does not choose to have obsessions and would not otherwise perform the compulsions.

Unfortunately obsessions and compulsions 'feed' on each other and enhance the hold that OCD has on a sufferer, making it a difficult condition to overcome without treatment. In OCD obsessions and compulsions 'conspire' with each other to leave a sufferer with a seemingly endless cycle of anxieties and rituals.

OCD obsessions and compulsions are best illustrated with an example. A common obsession is the fear of contamination. The belief that one's hands might be dirty or contaminated, for instance, can give a sufferer a high level of fear even when there is no evidence of contamination. The fear can be so intense that they may believe that there could be a dangerous - even life threatening - consequence of the 'contamination' unless it is dealt with immediately. This obsession then leads to the compulsion of hand washing, which may continue until the sufferer 'feels clean'. In OCD this act of washing wrongly reinforces the sufferer's belief that their hands were contaminated in the first place and that the 'danger' was actually removed by the act of washing. Unfortunately, it is not long before the sufferer once again succumbs to the sense of being dirty and the OCD cycle continues.

This is a vicious circle. Contamination fears and washing are by no means the only OCD symptoms (see the page, "Common obsessions and compulsions and feared consequences"). Each OCD sufferer's own experience of the illness (the fears, beliefs and rituals) are different and are shaped uniquely by the sufferer's personal concerns. Sometimes obsessions and compulsions are difficult to separate as the compulsions themselves can have the form of purely mental (rather than physical) rituals. This is known as "Pure-O".  A few other common obsessions and compulsions are given below.

To a non-sufferer of OCD such behaviour appears strange, unnecessary and excessive, and in most OCD cases a sufferer would agree with this assessment on a logical level. The problem is that OCD behaviour is driven largely on an emotional level, and these emotions are thought to originate from primitive parts of the brain which are difficult to control. In other words the obsessions and compulsions are forced by strong feelings rather than by evidence.

What is it like to have OCD?

To the outside world the sufferer in the above example is continually and unnecessarily washing their hands. To the sufferer the compulsion to wash is urgent and necessary to remove the uncomfortable feeling brought on by the contamination obsession. Some sufferers might describe having OCD with the following analogy. Imagine that a stranger approaches you and places a gun to your head and tells you he might pull the trigger, but does not tell you when, or if the gun is loaded or not. You would experience anxiety and doubts akin to an OCD sufferer's daily battle with their illness.

This gun scenario can be a useful analogy for OCD. OCD is the constant presence of a metaphorical loaded gun to your head, while you remain powerless to escape the situation, despite trying very hard.  This is a useful analogue that can be used to explain OCD to a non-sufferer who doesn't understand the disease - as illustrated by this light-hearted cartoon.

What OCD is not

OCD is not the transitory worry of everyday life even though the subjects of some 'normal' worries that people have can have things in common with those of OCD. If the anxiety is not chronic and extreme, or there is no associated ritualistic behaviour, then it may not necessarily be OCD (although many of the treatments used for OCD may well be effective at relieving these worries).

OCD is a label often mistakenly given to meticulous behaviour such as the act of arranging objects into a precise order. Being meticulous itself is not an illness, it may be instead a harmless part of an individual's personality, even though it may be referred to as a 'compulsive behaviour'. If such actions are not driven by the need to reduce anxiety then, again, it may not necessarily be OCD.

Why the specific worries with OCD?

The irony of OCD is that the form of the anxiety can mould itself to a sufferer's own values. For instance:

• • the person who cares passionately about being clean may feel dirty and is driven to perform cleaning rituals,

  • the person who is overly responsible may feel reckless and has to be sure that they will not be (or have been) responsible for a bad event,

  • the person who is overly concerned with safety and protection may feel dangerous and has to be sure everything is safe, and

  • the person who has strong religious or moral beliefs may feel that they have been unscrupulous.

Some specific examples of these points are given in the page, "Common obsessions and compulsions and feared consequences". The strong link between the specific form of OCD and the sufferer's personal values are thought to be an important reason why OCD can hold such strong power over an individual. The illness is 'conning' the sufferer into thinking that they have potentially violated their values and the OCD behaviour is a vain and desperate reaction to this.  In short, OCD can make a sufferer think of themselves as an extremely bad person just by the way that they interpret intrusive thoughts and feelings that the vast majority of people have.

How can OCD affect a sufferer?

OCD is a significant, distressing, disabling and all-consuming illness which can seriously affect many aspects of a sufferer's life. Although its symptoms can sometimes outwardly appear quite strange, sufferers are not 'crazy'. It is a 'neurotic' rather than a 'psychotic' condition.

There is a misunderstanding amongst some people that OCD is a trivial condition to live with. OCD can genuinely devastate a person's life leaving them feel exhausted, lonely and helpless.  It can lead to depression, unemployment, hospitalization, becoming house bound or even suicide.  OCD can also significantly affect a sufferer's family, and their friends and colleagues.

Do you have OCD?

Only a doctor or clinical psychologist can diagnose OCD, but the process of diagnosis (and the onset of treatment) can be hastened if the sufferer is aware of the symptoms of OCD so that it can be suggested to the clinician.  Here is an on-line test on the BBC web site, which may be helpful at suggesting a diagnosis.

What are the treatments for OCD?

It is often said that OCD, in one form or another, is a life-long condition. However, evidence shows that OCD can be treated so that in time the worrisome thoughts no longer have such a strong hold on a sufferer. This is a very important fact to bear in mind, especially when OCD is at its worst, when there are often very frightening feelings of hopelessness and fears that nothing can be done to relieve the anxiety.  Here are the main treatments used for OCD.

Cognitive Behaviour Therapy (CBT)

The main recommended form of treatment for OCD is cognitive behaviour therapy (CBT). OCD sufferers tend to interpret their troublesome thoughts in negative, unrealistic and catastrophic ways, which lead to the strong urge to perform the compulsions. CBT offers a way out of this. The cognitive part of CBT, teaches a sufferer, e.g., that intrusive bad thoughts are a universal human experience, and it is the mistaken interpretation of these (normal) thoughts by the sufferer that has lead to their OCD. This helps a sufferer think about their worries in ways that are more realistic and compassionate. The behavioural part of CBT helps the sufferer retrain their mind to tolerate the anxiety and doubt. This may be done in a number of ways, such as seeking to refocus on more rewarding tasks, or by actively performing exposure tasks. The latter, sometimes called exposure and response prevention (ERP), encourages a sufferer to seek anxiety on purpose, but without performing compulsions. The aim is to allow their brain to get used to the anxiety so that it no longer troubles them (a processes called habituation). ERP requires the sufferer to confront their fears head-on, which is a very difficult task to do initially (remember the gun analogy above).

A good programme of CBT should be tailored to the specific fears and concerns of each sufferer. Excellent introductions to the use of CBT in the treatment of OCD are given in many publications on-line and in books.  My page here provides a list of some useful sources of information (other publications are available - check the websites of the OCD charities, given also on this page).

Mindfulness Meditation

An upcoming therapy that is sometimes used to treat a whole range of physical and mental illnesses, including OCD is mindfulness meditation.  Mindfulness is a means of living wholely in the present moment without any reflection of the past or future and without making any judgements.  While it has not yet been subject to formal clinical trials for the treatment of OCD, it is viewed with promise among leading psychologists.

Medication

It is common for a doctor to prescribe medication for OCD, which is a useful complement to psychological therapies. The medications most commonly prescribed are so-called selective serotonin reuptake inhibitors (SSRI). This is a family of drugs that includes Prozac and Seroxat (trade names for fluoxetine and paroxetine respectively), but there are many others available. There are other families of drugs available, but an SSRI is usually a doctor's first choice. SSRIs are probably best known as anti-depressants, but they also effective at combating OCD.  Bear in mind that SSRI medication is unlikely to start helping immediately, and may take several weeks for its theraputic effect to become evident.  Often users report side effects that mostly wear off in time.  SSRI medication on its own is unlikely to remove OCD symptoms completely, but should provide relieve to the point where therapy is easier and more effective.

If you believe that you are suffering with OCD, your first port of call is your general practitioner (GP) who will advise on the treatments that are available to you.  Most GPs will be very sympathetic to OCD sufferers.  If you are unlucky to find that your GP does not know about the condition, or is not eager to help immediately you should consider seeing another GP.  OCD is a genuine, frightening and disabling medical condition for which you are entitled to treatment.  In any case, you may find it helpful to approach your GP with one of the OCD summary sheets produced by OCD charities in the UK for GPs. OCD Action's sheet is available via this page, and OCD-UK's sheet is available via this page.  It is likely that you will be offered an SSRI medication to help you in the short-to-medium term and/or referral to psychological therapy (usually CBT) for longer term help.  In the UK, expect a waiting list of a few months for access to NHS funded CBT.  Private therapists are available, although the advice is to see someone who is competent with treating OCD as it sometimes requires an approach that is slightly different to those treatments for other conditions such as depression (see the"useful references" section of this site for link to the BABCP).