What is Obsessive-Compulsive Disorder? Fact Sheet for Teenagers Anxious thoughts are common and they can influence our behaviour in a helpful way. For example, the thought; “Did I leave the front door open?” may lead you to go back and check, to prevent the house from being burgled. It is also normal to have certain routines (e.g. a bedtime routine consisting of having a bath, reading a book and ending with a milky drink). However, if these thoughts and behaviours become obsessive (recurring), they can lead you to engage in unhelpful behaviours (e.g. repeatedly checking the door), which can interfere with your daily functioning (e.g. frequently being late for school). Obsessive-‐compulsive disorder is an anxiety disorder consisting of recurring obsessive thoughts and/or compulsive behaviours. What are Obsessions? Obsessions are intrusive and irrational thoughts, ideas, urges or images that are unpleasant and repeatedly pop into your mind. They are very difficult to get rid of and often cause anxiety, distress and feelings of embarrassment. You may realise that these obsessions are irrational or don’t make any sense but you still find them difficult to ignore, as there is a part of you that continues to worry that these thoughts may be true.
Common Obsessions: • Thoughts/images of harming oneself or others. • Fear of contamination (e.g. catching germs/diseases or getting sick). • Believing that certain numbers are good and others are bad. • Constantly doubting (is the door locked?) • Feeling that things have to be ‘just right’, symmetrical or in order. • Preoccupations with religious images or fear of showing contempt for religious persons or things. • Fear of blurting out offensive words in public or doing something embarrassing. • Unwanted/improper thoughts, images or urges about sex.
What are Compulsions? Compulsions (or rituals) are behaviours that you feel compelled to perform repeatedly in order to stop something bad from happening. They help to alleviate the anxiety triggered by your obsessive thoughts (e.g. having to excessively wash your hands in order to reduce your worries about catching germs). Performing these rituals may initially reduce your anxiety and distress but this is a short-‐lived feeling. You are likely to find that you have to repeat these rituals several times throughout the day. You may have tried to stop yourself from performing your compulsions but have found them too hard to resist.
Common Compulsions: • Constantly arranging and ordering things (e.g. putting books in a certain order). • Repeatedly checking things (e.g. for mistakes in homework) and starting things over again (e.g. rewriting homework). • Excessive cleaning or washing (e.g. washing hands too often). • Hoarding items (e.g. collecting junk mail, magazines, clothes). • Mental rituals such as praying a certain number of times, counting or repeating words; having ‘safe/bad’ numbers. • Constantly seeking reassurance (e.g. repeatedly asking the same questions over and over again).
Additional Feelings & Effects: • Feeling highly anxious or stressed. • Worry that you are going mad. • Feelings of low mood/depression. • Exhausted – from time it is taking to complete rituals. • Feeling embarrassed or ashamed about your need to carry out your compulsions. • Secrecy -‐ trying to hide OCD from others. • Feeling angry or frustrated. • Interference with daily activities/functioning. • Tension and arguments within family. • Friendships – less time to socialise due to time spent on rituals. • Reduced concentration.
OCD Diagnosis To receive a diagnosis of OCD you must have either obsessions or compulsions or both. These behaviours must be time-‐consuming (e.g. take up more than one hour a day); cause a lot of distress and significantly interfere with your daily life and functioning (e.g. schoolwork, family life, hobbies and friendships).
How Common? OCD affects about 12 in every 1000 people of the population in the UK (OCD-‐UK) and more specifically about 2 out of every 100 children are thought to be affected (patient.co.uk). It can occur at any time in life, affecting both young children and adults.
What Causes OCD? It is not fully clear why people get OCD but it appears to be caused by a combination of genetic, biological and environmental factors.
Biological Causes: Scientific evidence suggests that OCD is linked to neurological factors. For example, there appears to be reduced levels of serotonin (a chemical in the brain that helps us to control our mood, sleep, appetite, impulse control, body temperature and pain) in people with OCD. People with OCD also seem to have increased activity in certain areas of the brain that are thought to be involved in controlling feelings and actions. An episode of depression can trigger or worsen OCD. There may also be a link between an infection caused by the streptococcus bacteria and OCD if the infection is recurrent and left untreated, but this is very rare.
Genetic causes -‐ Is OCD Inherited? OCD seems to run in families. If your parent or sibling has OCD, there is a slightly increased chance that you will develop OCD.
Environmental Causes: OCD may develop as a result of learned behaviour e.g. watching the behaviour of a parent. Stressful events (e.g. bereavement, on-‐going bullying, changing schools, illness or exam stress) can also trigger or worsen OCD. What Keeps OCD Going? Compulsive behaviour: OCD is maintained when you carry out compulsions to reduce your anxiety and obsessive thoughts, as this reinforces your belief that your worrying thoughts may be true. You never get the opportunity to learn that your anxiety will gradually go away without performing your compulsions. As you can see from the diagram below, OCD is kept going by a vicious cycle of obsessive thoughts, anxiety and compulsive behaviour. Gaining an understanding of what maintains your OCD (e.g. what are your obsessive thoughts and what do you do to reduce your anxiety?) is the first step of gaining control of your OCD. For example, you have an obsessive OCD Vicious Cycle thought (e.g. “I will catch germs if I touch that door handle”), which causes you to feel anxious and distressed. You perform your compulsion to reduce your anxiety. (e.g. you wash your hands excessively). This helps to alleviate your anxiety for a short time. However, your worrying thoughts soon creep back into your mind and you become trapped in a vicious cycle of obsessive thoughts and unhelpful behaviours (e.g. you continue to wash hands and you avoid touching door handles).
Faulty thinking: Some people with OCD have a certain way of thinking, e.g. they tend to feel very responsible for causing or preventing harm from happening to themselves or others; they overestimate the chance of something bad happening and underestimate their ability to cope with it. ‘Magical thinking’ which is the fear that by simply thinking that something terrible is going to happen (e.g. a plane crash) it will increase the chances of it happening, is also common. The repeated misinterpretation of your obsessive thoughts often leads you to engage in unhelpful behaviour (e.g. avoidance, reassurance seeking and carrying out compulsions) which only serve to keep your OCD going. Avoidance: People with OCD tend to avoid things, such as going to places or doing things which they believe will trigger their obsessive thinking. However, by avoiding things that are likely to trigger your obsessive thoughts, you never find out that your fears are unfounded. Some people also try to push their thoughts away (thought suppression) but find that their thoughts just keep coming back. Avoidance only makes you more fearful and anxious because it fuels your obsessive thinking. Reassurance Seeking: Some people with OCD engage in reassurance seeking behaviour by asking others lots of questions or asking the same question over and over again, in order to make sure that everything is okay with respect to their obsessive worry. They may repeatedly ask questions such as; “Are you sure something terrible won’t happen?” “Are you sure I locked the door?” Are you sure you washed your hands? Are you sure I haven’t made any mistakes?” It is natural for others to want to alleviate your anxiety by giving you reassurance but it does more harm than good. It makes your worry stronger. Reassurance seeking is addictive as your worries and doubts will soon return and your desire to seek further reassurance will follow. Constant reassurance seeking is a type of compulsive behaviour. It only serves to reinforce the belief you that you have in your obsessive thought and it does not let you learn that you can cope with the anxiety and discomfort that you are experiencing. Family Involvement: When family members try to help you with your OCD, they are likely to offer you reassurance; they may help you to perform your rituals (e.g. checking that the door is locked for you) or they may give you items (e.g. anti-‐bacterial hand gel) to help you to carry out your compulsions. Although these behaviours are done with the best intention, they are likely to worsen your OCD symptoms. Treatment for OCD
The good news is that OCD can be effectively treated, although there is no actual cure. Cognitive Behavioural Therapy (CBT) and medication are the two main types of treatment for managing OCD symptoms. Medication (usually anti-‐depressant medication or in some cases anti-‐anxiety medication) is usually only prescribed when OCD symptoms are moderate to severe. It is recommended, however, that CBT should be tried first with young people before medication is considered. Making sure that you get enough sleep, take regular exercise and eating healthily will also assist with your recovery. Cognitive Behavioural Therapy (CBT): CBT is an effective and clinically proven treatment for managing the symptoms of OCD. It will help you to challenge your irrational thoughts and beliefs and learn new ways of thinking (cognitive) and to find new ways of doing things (behavioural), so that you develop more effective coping strategies. CBT strategies for OCD include cognitive restructuring, exposure and response prevention and relaxation techniques to control anxious bodily symptoms. Please keep in mind that these strategies may not work straight away. They will need to be practiced in order for you to see the benefits. Treatment is a gradual and ongoing process and continuing to practice the techniques that you have learnt, even when your symptoms have improved, can prevent you from having a relapse and help you to maintain the good progress that you have made. Cognitive Restructuring/Challenging your Thoughts: It is important to learn to challenge the negative thoughts and beliefs that keep your OCD going. Cognitive restructuring aims to increase your awareness of the thoughts and beliefs that are maintaining or triggering your OCD. Our thoughts play a big part in affecting the way we feel, so thinking in unhelpful ways (e.g. “I can’t cope with this”) only serves to increase our anxiety. OCD is like a bully in your head, it tries to boss you around and gets you to do things that you would rather not be doing. It makes sense then, that thinking in more realistic and helpful ways will help you to feel better and more in control of your OCD (e.g. “I can cope with this….my anxiety won’t last forever”).
A thought diary (see link below) can help you to spot thinking errors (e.g. are you overestimating the chances of something bad happening or assuming that you can’t cope with it?). It is a useful way of identifying how your thoughts and beliefs are triggering and fuelling your OCD. It is much easier to control your thoughts if you know what triggers them.
Once thinking errors (see ‘unhelpful thinking styles’ link below) have been identified you can then learn to challenge them and replace them with more realistic/alternative thoughts. This can be achieved by asking yourself the following questions:
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What am I thinking right now? What is the evidence for and against my anxious thoughts? Are my thoughts realistic? Is there another way of looking at this? What am I worried will happen? Am I underestimating my ability to cope?
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What are the advantages and disadvantages of thinking in this way? What other outcomes are possible?
It is helpful to write your realistic thoughts down and keep them with you, as it can be hard to recall them when you are feeling anxious. Challenging your negative thoughts is not an easy skill to learn; it requires practice and patience to get it right but it is worth persevering with if you want to gain control over your anxiety. So, we know that everyone has intrusive or unpleasant thoughts at times and the best way to deal with them is to ignore them or to challenge them. If you try to push these thoughts away (thought suppression) they will just keep popping into your head. It is important to remember, that you are unable to make things happen by just thinking about it (e.g. thinking that your dad will have a car crash on his way home from work does not mean it will happen). In the same way, thinking unpleasant thoughts does not mean that you want something bad to happen. All these thoughts are normal. It is how you chose to deal with them, that is important.
Links: Realistic thinking www.anxietybc.com OCD thought diary: www.getselfhelp.co.uk Unhelpful Thinking Styles www.psychologytool.org; Finding Alternative Thoughts & Fact or Opinion www.getselfhelp.co.uk Developing & Using Coping Cognitive Cards www.anxietybc.com Exposure and Response prevention (ERP) Exposure and Response Prevention helps you to feel more in control of your OCD by helping you to face your fears (exposure) without giving into your compulsions (response prevention). It provides you with the evidence that your fears won’t come true and you learn to cope with the uncomfortable feelings of your anxiety. Research has demonstrated that if you stay in a situation that makes you feel anxious for long enough (without completing a compulsion), gradually your anxiety will ease off and you will feel better (see graph below). Exposure & Response Prevention High Anxiety
Low Anxiety
The graph shows that during the first ERP trial (e.g. exposing yourself to touching a door handle you fear to be contaminated) the anxiety experienced was high but by the time the seventh trial was completed, there was very little anxiety.
When you first start to face up to your fears you are likely to find it challenging and your symptoms may initially feel worse but if you if you stick with it, you will soon start to take control of your OCD. It is best to start with the least anxiety-‐provoking situations and
then move on to the most anxiety-‐provoking situations (graded exposure). Exposure needs to be repeated several times until your anxiety diminishes. So it is important to remember, that to break the vicious cycle of OCD you must resist the urge to carry out your compulsions. This way you are able to test out what really happens if you don’t perform a compulsion (i.e. that your anxiety will pass) rather than what you fear will happen (e.g. “I will cause harm to someone I love”). Links: Facing Your Fears: Exposure www.anxietybc.com; Exposure homework sheet www.getselfhelp.co.uk Reducing Bodily Symptoms of Anxiety Relaxation: You are likely to feel very anxious when you first start to fight your OCD. Learning to control your anxious bodily symptoms will make it much easier for you to tackle your obsessive thoughts and to face your fears when you undertake exposure and response prevention. Relaxation allows you to reduce the unpleasant feelings (e.g. fast breathing, butterflies, sweating and feeling sick) that you feel when you experience anxiety and it helps the body return to a calmer state. Relaxation can include everyday things such as reading, yoga, exercise, or listening to music. More specific relaxation techniques include progressive muscle relaxation (tensing and releasing muscles), meditation and guided imagery or visualisation. Relaxation is a skill that has to be learnt, so it is important to practice regularly. Relaxation techniques are an effective way of allowing our physical and mental tension to be released and gaining control of our anxiety.
Links: A first Steps Guide to improving Relaxation: www.firststeps-‐surrey.nhs.uk How to do Progressive Muscle Relaxation: www.anxietybc.comm Guided Visualisation & Imagery for Self-‐Help: www.getselfhelp.co.uk Calm Breathing: Calm breathing can also help you to control the anxiety symptoms of over breathing or hyperventilating by slowing down your breathing. Try the following: • Place one hand on your upper chest and the other on your stomach. • Take a deep breath through your nose while counting to five. • The hand on your chest should remain still while you breathe in and the one on your stomach should rise with your breath. • When you reach the count of five, breathe out slowly through your mouth. • Focus your thinking on the word ‘calm.’
Links: Calm Breathing: www.anxietybc.com Mindful breathing: www.getselfhelp.co.uk Tackling Excessive Reassurance Seeking • Stop asking for reassurance! This will be hard at first but the more you try to resist, your OCD will eventually give up and stop bossing you about.
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Inform your family and friends that they need to stop giving you reassurance. Educate them that reassurance keeps your OCD going and will not aid your recovery. If you ask them for reassurance, they can remind you that your OCD is trying to bully you and the best way to deal with bullies is to ignore them or to talk back (e.g. with more helpful realistic thoughts). It is important that your family remain consistent and don’t give into your OCD by giving you reassurance, otherwise they will give more power to your OCD and you will not learn to use other strategies to manage your anxiety. The more that you are able to reassure yourself independently, the more confident you will feel about your ability to control your OCD.
Link: How to address excessive reassurance seeking www.anxietybc.com Praise: Your family can help to support you by giving you lots of praise for your efforts in fighting your OCD (e.g.” I’m so proud of you….you are doing a great job!”). Don’t forget to praise yourself and to reward yourself for fighting your OCD (e.g. after completing exposure tasks).
Self Help Resources for OCD
Websites:
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Obsessions & Compulsions: A Self Help Guide. www.ntw.nhs.uk Obsessions & Compulsions: Self Help Guide www.moodjuice.scot.nhs.uk Obsessive Compulsive Disorder: www.teenmentalhealth.org Obsessive-‐Compulsive disorder www.mind.org.uk Obsessive Compulsive Disorder. Booklet, Arlene Watts. www.GlasgowSTEPS.com
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Obsessive Compulsive Disorder. An Information Guide for Parents of Children & Teenagers
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with OCD. www.ocduk.org
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www.nopanic.org.uk -‐ recovery program for OCD. www.ocdfoundation.org – information & resources. www.anxietybc.com -‐ information & resources.
Books: • Talking back to OCD. John March & Christine Benton, 2007. • Obsessive Compulsive Disorder. Cognitive Behaviour Therapy with Children & Young People. Edited by Polly Waite & Tim Williams, 2009. • Free From OCD: A Workbook for Teens with Obsessive-‐Compulsive Disorder. Timothy Sisemore, 2010.
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Touch and Go Joe: An Adolescent’s Experience of OCD. Joe Wells, March 2006 Breaking Free from OCD: A CBT guide for Young People and Their Families. Jo Derisley, Isobel Heyman, Sarah Robinson & Cynthia Turner, May 2008.
Written by Susan Campbell (May, 2015)
