New Obsessive-Compulsive Disorder: What you should know · 2012. 8. 3. · OCD is characterised by obsessions and/or compulsions, and usually both are present. Obsessions are recurrent,

Obsessive-Compulsive Disorder:

What you should know

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Obsessive-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.

Introduction

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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.


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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.

What is OCD?


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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 first-

degree 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.

Who gets OCD?


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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 germs or toxic substances

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

Self-doubt – e.g. have appliances been turned off, is the door locked, was the correct letter put in the envelope, was a mistake made at work?

Excessive checking; counting; touching and tapping.

Need for symmetry and order

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

Violence/aggression – fear that 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.

Religious – blasphemous thoughts or impulses or images.

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

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.

Common types of OCD


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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.

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


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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.

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.

Disability associated with OCD


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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).


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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).

Treatments for OCD (cont.)


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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.crufad.org

• www.adamentalhealth.asn.au • 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.

What can you expect from treatment?


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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.

• Many people find the CBT very anxiety-provoking initially, and about

25% do not go ahead with the treatment.

• Antidepressant medication can have side effects, although many of these

improve after the first week or two.

For many people, combining these two treatments seems to provide the best

of both worlds.

Treatments for OCD (cont.)


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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 other healthcare professionals can help


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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 your GP can help


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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?


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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.

How you can help a friend or loved one with OCD


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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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.

References1 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.


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Ground Floor, 1 Innovation Road

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New Obsessive-Compulsive Disorder: What you should know · 2012. 8. 3. · OCD is characterised by obsessions and/or compulsions, and usually both are present. Obsessions are recurrent,

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