Obsessive-Compulsive Disorder: What you should know

Obsessive-Compulsive Disorder: What you should know Introduction O bsessive-Compulsive Disorder (OCD) is a relatively common illness in the commu...
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Obsessive-Compulsive Disorder:

What you should know

Introduction

O

bsessive-Compulsive Disorder (OCD) is a relatively common illness in the community, yet often a hidden one. One to two per cent of the population experience OCD in any twelve month period. Men and women are affected almost equally. Some people with OCD do not realise that the symptoms that trouble them are a recognised illness, and others are too embarrassed to seek help. Yet highly effective treatments are available.

This booklet provides information about OCD and its treatment. Knowing more about the illness and how it can be treated is the first step in controlling it. Sharing the information with your family and friends can help them to understand what you experience, and how they can best help you to beat your OCD.



What is OCD? OCD is characterised by obsessions and/or compulsions, and usually both are present. Obsessions are recurrent, intrusive thoughts, images or impulses that are usually experienced as out of character or unreasonable, but difficult to control. The obsessions are usually fears about some bad outcome that might happen to the individual or others. For example, that the house will be robbed or burn down, or that someone will be injured. Obsessions cause a person to feel very anxious or uncomfortable and this leads the person to try to suppress the thoughts, images or impulses, or to try to “neutralise” them with some other thought or action1. The actions carried out in an attempt to neutralise the obsessions are referred to as compulsions. They are also often referred to as rituals. They can be physical actions, such as handwashing or checking a doorknob, or they can be mental actions, such as saying a word or phrase to oneself or mentally counting. The obsessions and compulsions can be intensely distressing. They may be time consuming, with obsessions recurring throughout the day and compulsions taking hours a day to complete. There is interference with relationships, work or study. A normal routine may be difficult or impossible. A person often feels tired and loses confidence in themselves.



In calmer moments, individuals with OCD know that their concerns are unrealistic or exaggerated. When they are in a highly anxious state, however, their concerns may seem only too likely and awful. In addition to compulsions a person with OCD typically also starts to avoid any situations that may trigger their obsessions and in turn cause unpleasant anxiety and the urge to engage in compulsions, which may then be very time consuming. Many people with OCD also seek excessive reassurance from others, such as family, friends and colleagues. They are hoping that reassurance from others, hearing that they have nothing to fear or that everything is all right, will relieve their anxiety. The problem is that it never relieves it for long.

What OCD is not OCD is not a character flaw. People with OCD do not engage in the rituals to annoy others or get their own way. If they knew how to overcome the symptoms, they would do so readily. People with OCD are not “crazy” and do not have a psychosis.



Common types of OCD Common types of OCD Below is a table that summarises the most common themes in obsessions, and the compulsions that typically accompany them. Obsessions

Compulsions

Contamination – often a fear of

Repeated, excessive washing (e.g. hands, clothes)

germs or toxic substances

Self-doubt – e.g. have appliances

Excessive checking; counting; touching and tapping.

been turned off, is the door locked, was the correct letter put in the envelope, was a mistake made at work? Need for symmetry and

Rearranging things, ordering things (e.g. by colour) until it feels “right”

order Violence/aggression – fear that

Various compulsions may arise, e.g. praying, saying some phrase over and over, taking extreme care by paying attention to every movement.

they will harm someone else e.g. run over them, attack them.

Sexual – e.g. fear of being of a different sexual orientation, fears of inappropriate sexual behaviour.

Who gets OCD? It is estimated that genetic factors account for between 26% and 47% of the risk of developing OCD2. The risk of developing OCD for someone with a firstdegree relative with the disorder has been estimated at around 10%3. However, environmental and personality factors may also have a role. Women and men are almost equally affected. OCD often starts in childhood or early adulthood. Behaviours such as counting, touching, tapping or repeating behaviours are also common in childhood, but often go away and do not become OCD. The causes of OCD remain largely unknown. A very small number of cases may arise as a result of medical illness or medications, but in the vast majority of cases the cause is not known. Current theories suggest that there may be a relative reduction of a neurotransmitter called serotonin in certain areas of the brain. OCD tends to be a life-long problem. Without treatment about two thirds of people will experience symptoms of varying severity over many decades, although the illness does tend to become less severe over time4. In addition some people with untreated OCD will develop a secondary depression as the symptoms and loss of self-esteem wear them down.

Religious – blasphemous thoughts or impulses or images.

It will be apparent from the table how the compulsions develop as an attempt to reduce or remove (or “neutralise”) the feared outcome of the obsessional thought. For example, someone who fears contamination from germs washes their hands to reduce the risk of getting or passing on an infection. It will also be evident why obsessions can be so upsetting for people, since they may include thoughts that are very foreign to their moral principles or character.





Disability associated with OCD

Treatments for OCD

Research has shown that OCD is as disabling as many common physical disorders. In fact, in one study it was demonstrated to cause more “disability days” – days on which a person was unable to participate in their usual activities – than kidney disease, chronic bronchitis, diabetes or asthma5.

The National Survey of Mental Health and Wellbeing, in which more than ten thousand adult Australians were interviewed, revealed that persons with OCD were less likely than those with other anxiety disorders or depression to seek help6. Yet effective treatments are available for this condition.

It is important to realise that OCD is more than just normal worry about things from time to time. In OCD the obsessional thoughts are experienced as difficult or impossible to control. By their nature they are also often very distressing. They may go around and around in a person’s mind with little relief. It can be very tiring and make it difficult to focus attention on anything else. Interestingly, it has been shown that everyone experiences intrusive thoughts from time to time, but it seems that people with OCD have trouble in dismissing such thoughts and forgetting about them.

Only 42% of those who might have benefited from treatment sought help, although many more recognised that they needed help. Common reasons given by persons for whom any type of anxiety was a principal problem included, “I preferred to manage myself”; “I didn’t think anything could help”; and, “I was afraid to ask for help”. Many, perhaps most, people with OCD are embarrassed or even ashamed of their symptoms. They often try hard to hide their symptoms from the world. This erodes self-esteem over time as they feel like they have a “guilty secret”. There are two types of treatment, cognitive behaviour therapy (CBT) and antidepressant medication.





Treatments for OCD (cont.) Cognitive Behaviour Therapy (CBT) CBT helps a person learn how to confront and overcome their fears, and resist the compulsions of OCD. The first step is always to help the individual to understand their OCD and why it persists. A number of psychological factors are commonly identified. These include:



Excessive levels of doubt and uncertainty. People with OCD often have trouble when they don’t know for sure that something will turn out okay. This tends to lead them to do whatever they feel will make things right, even when they know it’s probably not realistic (e.g. counting to seven with every action because they feel it will stop a loved one getting ill).



A heightened sense of responsibility – people with OCD often feel unreasonably responsible for things that happen not only to themselves but to others and often the world in general. This tends to make it harder for them to take any level of perceived risk (e.g. not driving at all in case they accidentally run into someone).



Beliefs that a thought can make something happen in reality (e.g. believing that having experienced an intrusive thought or image of harming a loved one must make them a bad or violent person, even though such behaviour has never been in their nature).



A tendency to over-estimate the real risk of something bad happening (e.g. walking past a red spot on the ground, thinking that it could be blood and that it would somehow get on them and give them a disease).



Completing the rituals will relieve anxiety in the short term, but the problem is that the person never develops any real confidence and becomes locked in a vicious cycle of repeating the compulsions every time they feel anxious. Many people are frightened that if they did resist the urge to neutralise the obsession, their anxiety would get out of control or never end, or that something bad would actually happen. CBT helps a person to be more realistic about the real risks they face and to begin to confront the obsessions. This involves resisting the urge to engage in the rituals that help to reduce anxiety. The process always starts with the least anxiety-provoking concerns. In fact, although anxiety levels will rise, they do not “go through the roof”. When the person sees that their anxiety does not get out of control, and nothing bad happens, it makes it easier to continue to confront other obsessions and compulsions. CBT helps the person learn to take the ordinary everyday risks that other people take and start to get back to a normal life. In turn the individual’s confidence and trust in themselves will start to return. CBT is usually offered as a course of treatment involving 10–20 sessions. Typically 80–90% of people who complete a course of CBT will report improvement, and most of these can be expected to maintain this improvement over at least several years (and possibly longer, but research has not yet covered longer periods of time).



What can you expect from treatment?

Treatments for OCD (cont.) Medication Only antidepressant medication has been found to be effective in relieving OCD, and antidepressants which increase serotonin levels have been shown to be most effective. The response to medication is usually slow – it can take eight to twelve weeks to see a benefit. After this time, gradual improvements may continue to be seen over many months. Hence it is particularly important to allow enough time to see if medication is going to help. About 40–60% of people who take serotonergic antidepressants for OCD will show improvement. Antidepressants need to be taken every day to be effective. Unfortunately, symptoms commonly return if the medication is stopped. For this reason, it is usually recommended that CBT is also part of the treatment.

Comparing treatments Both medication and CBT may be effective in treating OCD, alone or in combination with each other. Your GP can discuss with you what treatment is likely to be best for you. Some general points can be considered:



The benefits of CBT have been shown to persist even after treatment finishes.

• •

Symptoms of OCD tend to return if antidepressants are stopped.



Antidepressant medication can have side effects, although many of these improve after the first week or two.

Many people find the CBT very anxiety-provoking initially, and about 25% do not go ahead with the treatment.

For many people, combining these two treatments seems to provide the best of both worlds.

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CBT can help weaken the power of the obsessions and the urge to complete the compulsions. Some obsessional concerns may go away completely, but others will remain in a weaker, less intrusive and distressing form that allows you to get on with your life. Medication tends to help by making the obsessions easier to ignore and less intrusive. For most people OCD will remain a long term tendency, but one that can be well controlled by taking advantage of available treatments.

What you can do to help yourself If you have OCD there are a number of ways you can help yourself. Firstly, finding out more about OCD so that you understand the illness better. In addition to this booklet there are a number of websites that you may find helpful. These include:

• •

www.beyondblue.org.au www.adamentalhealth.asn.au

• •

www.crufad.org www.adavic.org

The more you can resist the compulsions and tolerate the discomfort (and the sense of heightened risk), the weaker they will become over time, and the easier resistance will eventually become. Try and have some faith in yourself – if you’ve never actually harmed anyone deliberately, it isn’t really likely that you’ll start now. If every time you check the door you find you did lock it – why not trust yourself and don’t check? Try and learn to accept some level of risk the way you see others seem to be able to do – it really isn’t possible to have any guarantees about safety in life. Similarly, trying to resist the urge to ask for reassurance will help you learn to tolerate doubt without it causing unbearable anxiety. These things may be very difficult to do without the support of a therapist, so another way you can help yourself is by seeing someone to assess your problem and advise about treatment. Your GP is a good place to start, as he or she is knowledgeable about both psychological and medication treatments for OCD. As you can see from the sections above, treatments can be very effective in OCD. 

How your GP can help Your GP is trained to recognise the symptoms of OCD, but you will have to tell him or her what you have been experiencing. Although you may feel that your GP will find your symptoms strange or worrying, chances are they have heard these things before from other patients who have OCD. You may also worry that they will somehow think less of you for having these symptoms, but it is more likely that they will be glad you have decided to seek help and simply want to assist you as much as possible with this problem. It may help to tell your GP that you think you have OCD.



How other healthcare professionals can help CBT for OCD requires specialised training. Your GP may recommend referral to a clinical psychologist for CBT. Clinical psychologists have a basic psychology degree and then do further study during which they get experience in clinical treatments, to gain their masters degree in clinical psychology. Your GP may also suggest referral to a psychiatrist for a recommendation about medication. As OCD is a specialised area, ask your GP to send you to a psychologist and/or psychiatrist who has experience in treating OCD.



How you can help a friend or loved one with OCD If you think someone you care about might have OCD, you can help by encouraging them to see their GP to discuss the problems they’ve been having. They may need encouragement to tell their GP about the symptoms they may have been hiding from the world for years. They may need reassurance that their GP will not think any less of them. You can help by learning more about OCD and by realising that the person finds it almost impossible to resist the compulsions because of overwhelming anxiety. Understanding that even though their concerns may seem overrated or even silly to you, to the person with OCD they are very real and cause severe anxiety. They may find it impossible to see any other point of view, or to take what they consider to be an unacceptable risk that you or others they care about may come to harm if they don’t carry out the ritual. You can help by understanding more about the effects that OCD can have on the person you care about and on those they live with. OCD is exhausting and so they may seem as though they never have any energy for you or the family. The constant battle with anxiety can also cause irritability, and unfortunately, like most of us, the family home is often where the irritability is more likely to be manifest. OCD tends to reduce self-esteem and self-confidence. The anxieties about being responsible for causing harm to others may mean that the person tries to avoid any responsibility around the home – this often leaves the family or partner with an extra burden.



Once the person you care about is in treatment, it can be tremendously useful for you to understand what the treatment involves. Most therapists will be happy for you to be involved in the treatment if the person in treatment gives their permission. The therapist will be asking the person with OCD to gradually give up their rituals, take more responsibility and stop asking for reassurance. You may be asked to support them by not giving reassurance or taking over responsibility if there are times where their resolve weakens. This can be difficult when you see someone you care about in distress, and ultimately it is up to them to learn how to overcome their OCD through their own efforts – you can’t do it for them even if you wish you could. It’s also important to look after yourself. OCD can put a strain on relationships. You may have had to take on more of the load in looking after the family and household, and this can add to your stress level. It’s never easy seeing someone you care about in distress. At the same time, OCD-related behaviours can be irritating and frustrating, especially when the concerns seem overrated to you, and when it may have been going on for years.

Self-help and patient support groups There are a number of support groups in the community. Members are usually people who themselves have had OCD and usually have also had treatment for it. Some people find such groups to be helpful sources of information and support both for themselves and those close to them. However, the perceived usefulness of groups does vary, and you will need to make a judgement about whether they seem to be giving sensible and helpful advice – does it accord with other reputable sources of information such as your GP or reputable websites?



Summary OCD is a common illness, affecting 1–2% of the population. It can include excessive doubt, fears of harm to oneself or others, or unrealistic concerns about acting in a harmful way. OCD can be distressing and disabling, and difficult to overcome without professional help. Effective treatments are available, and may include medication and/or cognitive behaviour therapy. These treatments can help control OCD so that it no longer interferes with a person’s relationships and activities, and they can lead a normal life. A GP is a good person to see in the first instance to give advice about the best treatment for the individual with OCD, since everyone’s circumstances will be different. The more you can tell them about your experiences the better they will be able to help you to get the most appropriate treatment for your needs. A team approach is often helpful, and those close to the person with OCD often also have an important role. Treatments may take 6–12 weeks to show effect, but may have long-lasting benefits.

References 1 American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text revision. Washington, DC, American Psychiatric Association. 2 Hill MK, Sahhar M (2006). Genetic counselling for psychiatric disorders. Medical Journal of Australia, 185(9): 507–510. 3 Andrews G, Creamer M, Crino R, Hunt C, Lampe L, Page A (2004). The Treatment of Anxiety Disorders. 2nd Edition. Pp. 341–342. Cambridge: Cambridge University Press. 4 Starcevic V (2005). Anxiety Disorders in Adults. Pp.245–246. New York: Oxford University Press. 5 Andrews G, Sanderson K, Beard J (1998). Burden of disease: Methods of calculating disability from mental disorder. British Journal of Psychiatry, 173: 123–131. 6 Issakidis C, Andrews G (2002). Service utilization for anxiety in an Australian community sample. Soc Psychiatry Psychiatr Epidemiol, 37: 153–163. 

This patient information leaflet is published with the support of The Lundbeck Institute, Taastrup, Denmark. Lundbeck would like to thank Dr Lisa Lampe for her input in developing this booklet. ©2007 Lundbeck. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form by any means, electronic, mechanical, photocopying, recording or otherwise without written permission from Lundbeck. November 2007

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