Obsessive Compulsive Disorder (OCD)
Obsessive Compulsive Disorder (OCD) affects 2 - 3% of the population - more than 500,000 Australians. OCD has been recognised as the fourth most common psychiatric disorder, after phobias, substance abuse and major depression. OCD usually begins in late childhood or early adolescence.
People with OCD experience recurrent and persistent thoughts, images or impulses that are intrusive and unwanted (obsessions), and perform repetitive and ritualistic behaviours that are excessive, time consuming and distressing (compulsions). Common obsessions include fears of contamination and fears of harm to self or others. Common compulsions include excessive handwashing, showering, checking and repeating rituals. These compulsions and obsessions may take up many hours of a person's day. OCD can cause significant interference in family and social relationships, and daily routines, and may intrude into every activity and action.
Many people with OCD experience intense fears of something terrible happening to themselves or others, they have constant doubts about their behaviour, and frequently seek reassurance from others. Prior to identification and treatment of the disorder, families may become deeply involved in the sufferer's rituals, causing significant distress and disruption to all members of the family [information for families].
People with OCD are typically aware of the irrationality and excessive nature of their compulsive behaviours and obsessive thoughts. They feel unable to control the obsessions or effectively limit their intrusiveness. Compulsions mostly develop into highly complex rituals, which cause high levels of frustration and anxiety for the sufferer. People with OCD are often acutely embarrassed about their symptoms and may keep them a secret for years, at times even from close friends and family. Those affected can live in their own private hell for years, while outwardly seeming to cope with and lead a relatively normal life. However, this seeming normality is only maintained at great cost in time, energy, stress and personal effort.
It is a distressing and debilitating condition, which tends to be chronic and deteriorate without appropriate treatment and support. OCD is often compounded by depression, and other anxiety conditions including social anxiety, panic disorder and separation anxiety. Conditions related to OCD include trichotillomania (compulsive hair pulling) and body dysmorphic disorder (excessive concern over a part of the body).
What are the symptoms of OCD?
The most common obsessions involve thoughts and fears of contamination, and fears of harm to self or others. Other obsessions include thoughts, images and impulses associated with symmetry and orderliness, illness, religious or moral issues, sexual concerns, and needs to save, collect or remember things. These obsessions can vary from time to time both in nature and severity. Obsessions do not respond to logic, and produce feelings from annoyance and discomfort to acute distress, disgust and panic.
Common compulsions include excessive hand washing, showering, cleaning and checking. Other compulsions include hoarding, repeating routine activities and actions, touching and tapping, applying rigid rules and patterns to the placement of objects, needing to constantly ask or confess, and a range of mental compulsions such as counting and repeating words. The compulsions generally are excessive and ritualised behaviours, involving constant repetitions.
For example, a person with OCD may spend 2-3 hours every day in the shower, and several more hours hand washing, or washing clothes, food and household items. Their anxiety may not only be that they are dirty themselves, but that they may infect others, contaminate foodstuffs and so forth. They may know that further washing is unnecessary, but they cannot stop the feeling of needing to wash and re-wash. Similarly, compulsions to check may involve repeatedly checking light and power switches to ensure that they are off, or checking locks to ensure that they are secure, despite knowing that they had just checked them.
These compulsions and obsessions may take up many hours of a person's day. They can intrude into many routine activities and actions - for example, walking, eating, opening a door and reading may involve complex rituals.
See the OCD Check List for common obsessions and compulsions experienced by people with OCD.
What causes OCD?
There are several theories about the causes of OCD. One theory views compulsions as learned behaviours, which become repetitive and habitual when they are associated with relief from anxiety. Another theory indicates that OCD may be associated with genetic traits - that there is a vulnerability to OCD and/or high levels of anxiety in certain families. Other research has investigated the role of chemical, structural and functional changes or abnormalities in the brain, which may be linked with OCD. It is most likely that the development of each person's OCD is the result of several interacting causes, and is affected by stressful life events, hormonal changes and personality traits.
Treatment for OCD
Empirically-validated treatments for obsessive compulsive disorder are available in the form of psychological treatments involving cognitive-behaviour therapy (CBT), and can produce marked improvement that is commonly maintained in the long term. Specific pharmacological treatments may also be helpful, however the effects of medication used on their own are generally maintained only as long as the medications are continued.
Cognitive Behaviour Therapy
Cognitive behaviour therapy emphasises education as an important strategy in promoting control over symptoms. Education includes in-depth factual information about the disorder and the nature of treatment, which helps to expose various myths about the causes of OCD - such as a 'character flaw', or 'bad parenting', which perpetuate low self-esteem and feelings of guilt and shame. Cognitive therapy focuses upon changing underlying and entrenched patterns of thinking and beliefs that are associated with, and trigger, anxiety and obsessive compulsive symptoms. A major component of behaviour therapy is exposure. Exposure allows habituation to anxiety, enables the person to redefine the 'danger/fear' aspect of the obsession, and provides opportunities to rebuild trust in their capacity to function and manage even with anxiety. Avoidance, compulsions and 'making safe' behaviours all reinforce fear and anxiety - exposure works because it reverses this effect and allows anxiety to decrease naturally. Exposure is generally graded - feared and avoided situations are ranked in a hierarchy of severity. Exposure tasks begin at the lower end of the hierarchy, and are repeated daily and consistently until anxiety decreases significantly. Behaviour therapy for obsessive compulsive disorder also includes response prevention, which involves a gradual reduction of compulsions in conjunction with exposure.
The successful outcome of cognitive behavioural therapy programs for anxiety disorders is dependent on a range of factors - including a highly trained and skilled therapist (usually a psychologist or psychiatrist), a positive therapist/client relationship, consistent and regular application of cognitive behavioural strategies and a high degree of motivation from the client. Use or abuse of alcohol and drugs during treatment will interfere with ability to process information and habituate to anxiety, and other comorbid mental health conditions, such as severe depression, may make it difficult to commit to the intensive application to the treatment program that is required.
Anxiety Management
A range of anxiety management techniques are generally included in psychological treatment approaches to assist people's ability to manage their own symptoms. Anxiety management techniques include relaxation training, slow breathing techniques, meditation, and hyperventilation control. These techniques require regular and consistent practice to be of benefit, and are most effective if used in conjunction with a cognitive behavioural treatment program.
Medication
Some medications, especially those which affect the serotonin system, have been found to alleviate symptoms of OCD. These can only be prescribed by a medical practitioner. These antidepressants are not addictive, but some people may experience side-effects so careful supervision is needed. Side effects may include nausea, headaches, dry mouth, blurred vision, dizziness and feeling sleepy. These effects often dissipate after the first few weeks of treatment. If you are concerned about side effects which are severe or last for a long time discuss this with your doctor. A change in dosage or a change of medication may solve the problem. To be effectively trialled the medication needs to be taken for an adequate amount of time and at the right dosage level. Responses to the medicine usually takes several weeks, and improvements may continue during the following months of treatment. When stopping treatment the dose should be reduced slowly.
Psychotherapy
Psychotherapy with a psychologist may assist the person with OCD to deal with a range of issues and problems that have been caused or exacerbated by the disorder.
Hospitalisation
For some people, when getting treatment started, or when they are severely affected, a period of treatment in hospital can be helpful. This may involve a hospital stay of a few days to a few weeks for assessment and treatment.
Support Groups & Education
Support Groups provide an environment in which people with OCD and their families can meet in comfort and safety, and give and receive support. The groups also provide the opportunity to learn more about the disorder and self-help and coping strategies, and to develop social networks.