Coping with Obsessive Compulsive Disorder

Kevin Gournay

• Publisher: SPCK Publishing
• Year: 2012
• eBook ISBN: 9781847092397
• Topic: Medicine
• Subtopic: Diseases & Allergies

OCD is thought to affect up to one million people in the UK, and an estimated three million in the USA. Listed among the top 10 most debilitating illnesses by the World Health Organisation, OCD can have a devastating effect on work, social life and personal relationships. Professional treatment can be hard to access, and in addition many people are too ashamed of their problem to seek help. Coping with Obsessive Compulsive Disorder offers expert advice and a thorough self-help programme based on solid scientific evidence.

Part 1

OCD: The facts

1

Defining OCD

Professionals define OCD principally through the two classification systems used in the English-speaking world: the Diagnostic and Statistical Manual, published by the American Psychiatric Association (APA) and currently in its fourth edition (DSM-IV), and the International Classification of Diseases, published by the World Health Organization, currently in version 10. Nevertheless, OCD is quite difficult to define because it can present in a number of ways. The principal manifestations of OCD are in the form of:

• Obsessions, which are also commonly known as obsessional thoughts and/or ruminations. These terms mean exactly the same thing.

• Compulsions, which are also known as compulsive actions or rituals. These terms mean exactly the same thing.

• A combination of obsessions (ruminations) and compulsions (rituals).

Obsessions (ruminations)

The NICE guidance, published in 2005, defines an obsession as ‘an unwanted or intrusive thought, image or urge that repeatedly enters the person’s mind’.

If you ask people with obsessions, they will tell you that they realize that these intrusive thoughts or images are irrational, and are, as we shall demonstrate in some of the case examples in this book, alien to their nature. Obsessions, by definition, cause considerable distress and anxiety and can severely affect day-to-day functioning.

In the vernacular we use the word ‘obsession’ to describe something someone thinks about all of the time, and it is not uncommon to hear phrases such as an obsession with football, or an obsession with Elvis Presley. Such ‘obsessions’ usually give the person a great deal of pleasure and they have at some point decided that they would rather occupy their mind with the focus of the obsession, rather than other life matters. Such obsessions are not the focus of this book. Anyone who has known someone with obsessional thoughts will recognize the enormous distress that these thoughts cause. Another defining characteristic of obsessions is that people will do, or try to do, everything that they can in order to try and resist them coming into their mind; the severity of such resistance can be very extreme.

Madeline

Madeline had always been a devout Roman Catholic; she attended Mass every Sunday, went to confession twice a month and was always present on important days in the church calendar – for example, during Holy Week. Madeline describes herself as someone with a social conscience, who has always been guided by a strong Christian philosophy. Madeline’s obsession arose following a period of prolonged stress, when she began to worry that she might ‘blurt out’ something that she did not mean to say while in church. This developed into Madeline thinking of the names of Christ, the Virgin Mary and the disciples, coupled with gross obscenities. Whenever she entered a church, she was overwhelmed by the fear that she might blurt out phrases involving a combination of holy names and gross obscenities. Very quickly, these combinations of names and obscenities came into her mind at various, random times during the day, and she soon became depressed because she thought she had sinned by having such thoughts.

We will later on describe how such patterns of thinking and fears are overcome. It is worth noting now, however, that Madeline responded to treatment and she was greatly comforted when she was told by her therapist that such thoughts are quite common in people with obsessions.

Compulsions

Compulsions are different. They are defined in the NICE guidance as ‘repetitive behaviours or mental acts that the person feels driven to perform’.

Some compulsions are often very clearly observable by others – for example, excessive washing and cleaning, or the repetitive checking of locks, switches and taps. Sometimes, however, they are only experienced by the person themselves – for example, needing to repeat to oneself a certain phrase a set number of times.

Examples of common compulsions include repetitive behaviours associated with ideas of being unclean or contaminated, or the checking of light switches, door locks or gas taps, with the fear that not checking these items will lead to some harm befalling the person or their family.

As you can see, the definitions of obsessions and compulsions have some overlap and there is often a link between thoughts and actions, although not necessarily always.

Richard

Richard, while successful in his education and career, describes himself as ‘always a worrier’. He recalls, during his school days, becoming very concerned about catching illnesses from others. This worry often caused him to lose sleep. He also developed the compulsive washing of his hands to prevent being infected with viruses and bacteria. Over time Richard began to carry antibacterial wipes wherever he went and became concerned about eating foods that might cause him ‘a stomach upset’. This led him to check the contents of his fridge and throw out foods that he thought were close to their sell-by date. Richard began to avoid social situations for fear of catching infection and stopped eating out in restaurants. Just before he attended for an assessment of his problem he was using two packets of antibacterial wipes each day, and several bars of soap a week, and his hands were red and inflamed because of excessive hand-washing. He had also just thrown out the entire contents of his fridge because he found a yogurt that was one day from reaching its sell-by date. His contamination fears were causing problems with his marriage. His wife complained that Richard’s avoidance, excessive cleaning and the restrictions he imposed on their everyday life had begun to overwhelm all other aspects of their life together. She also mentioned that their conversations were increasingly dominated by Richard’s fears.

In the second part of this book we will describe how compulsions and fears, such as Richard’s, can be overcome. Indeed, we have to say at this point that Richard’s problems are much more common in the general population than one would think.

Shelley

Shelley was 18 and had been accepted by Cambridge University to undertake a BSc in physics. She had always been a high achiever and was committed to her studies and future academic career. At the time of referral she was taking a gap year and working as a volunteer at her local university. She got on very well with her parents and siblings and had plenty of friends. Over the previous 18 months she had gradually begun developing fears that something ‘awful’ was going to happen to her family (including her grandparents). To counteract the anxiety that such thoughts caused, she developed a number of ‘rituals’, which at first she did discreetly but over time became increasingly obvious due to her need to ritualize more and more.

She had three main rituals. The first was checking that the taps in the upstairs bathroom were off and not dripping. She would turn the taps on and off seven times, and on the seventh time tighten the tap as hard as she could before trying to leave the bathroom. The second was turning her bedroom light switch on and off 14 times and then on the fourteenth time repeatedly telling herself, ‘It’s off, it’s off,’ before trying to exit the room. The third was dragging her foot across the areas in the house where two different types of carpets met. However, she would often think that her foot ‘jumped up’ or didn’t maintain perfect contact with the carpet during the dragging ritual, so she would have to repeat this until she was satisfied. This could, at worst, take up to an hour to complete before Shelley was satisfied.

Obsessions and compulsions combined

Perhaps the most common presentation of OCD is the combination of obsessions and compulsions. In the cases of Richard and Shelley, above, those around them could observe their compulsive behaviour and, at first sight, one could say that this was the central problem. Richard’s widespread compulsive behaviour, principally focused on hand-washing, checking and avoidance behaviours, was underpinned by his fears of being infected, while Shelley’s fears were focused on ‘some unknown harm’ befalling her family.

We will demonstrate in the second part of the book how to deal with problems such as Richard’s and Shelley’s, and in such cases one needs to focus on both the obsessions, and the compulsions that result. Turning back to the case of Madeline, none of her friends or family observed any changes in her behaviour apart from noticing that, as her obsessions worsened (the nature of these obsessions she kept very much to herself), she appeared more withdrawn and depressed. Such obsessions often lead to behavioural manifestations, such as avoidance, as happened with Madeline; before she came for treatment, she was avoiding attending some, though not all, of the church services that were a normal part of her religious observance, and this, therefore, fed back into her fears that she was a ‘bad’ Christian.

How common is OCD?

At one time OCD was seen as a rare disorder but it is now commonly accepted that between 1 and 2 per cent of the population have the condition to a degree that warrants treatment. The National Institute for Mental Health in the USA has collected a vast amount of evidence concerning the prevalence of OCD and information can be found on their website.¹ For the academically minded, this website provides a long list of publications describing various studies carried out to estimate prevalence.

An issue that is of great concern when one considers that there are perhaps up to one million people with OCD in the UK is the availability of treatment. Even with significant advances in the development of treatments and the training of health professionals, it seems clear that only a tiny proportion of those with OCD are likely to receive effective treatment. Apart from the scarcity of treatment resources within the NHS, people may not come forward as they are ashamed of their problem, particularly if their fears centre around harming others or entertaining thoughts that other people might find disagreeable. An individual may take the decision to endure their condition in silence because they do not see it as a solvable problem; rather, it is something they have to live with. In addition, there is the issue of approaching a professional for help within the wider context of the stigma attached to mental health problems.

Children and adolescents with OCD

OCD often begins in childhood, and it is estimated that more than 50 per cent of adults affected remember their OCD beginning during their childhood years. OCD is more common in younger boys, but by the time adolescence is reached there are equal numbers of boys and girls with the disorder. The most common forms of OCD in children concern rituals of symmetry, counting, and having things in a particular order. Sometimes they are referred to as safety and security rituals, because unless things are done in a particular way or a particular number of times, the child may fear that something dreadful will happen to them or to others. Children may simply feel very uncomfortable if things are not done in a certain way or a certain number of times.

It is important to realize that some obsessive behaviour occurs in many children, but this is not necessarily a sign that they are developing OCD. Simple superstitions, such as stepping on a crack in the pavement, are common and some children engage in harmless rituals before they go to sleep, to make them feel safe. Quite simply, most children grow out of this developmental phase. Children have a need to seek reassurance from their parents and there is, of course, a parental responsibility to provide this reassurance appropriately. However, children with OCD may develop patterns of seeking reassurance that quickly get out of hand. It is now accepted that if one can recognize OCD at an early stage, interventions can be very beneficial and prevent the problem developing to a more substantial form in later life. We advise that children showing OCD-like behaviour should be assessed, by a paediatrician or a child and adolescent mental health service professional, because this may be part of another condition, such as autistic spectrum disorder.

The line between normal and abnormal

Before going any further, we must make the point that the vast majority of us will recognize some traits common to OCD in ourselves. For example, most of us will remember, as children, some magical or superstitious thinking or ritualistic behaviour. Comfort rituals with children are a part of normal development. Many people are uneasy about walking under a ladder, or will touch wood, throw spilled salt over their shoulder, salute a magpie, and so on. One needs to remember that superstitions are so common that some hotels do not have a room 13 and some do not have a thirteenth floor!

More subtly, some individuals have a sense of responsibility that could be described as slightly disproportionate. Although not so severe that this could be deemed a problem, some people may more readily identify the responsibility they have for their actions and be concerned lest they make errors. Such individuals often worry about their work excessively and may continue to worry after they leave work and go home. On reflection, anyone might wish, of course, that a surgeon carrying out an operation should have these characteristics, because such a surgeon might check, somewhat obsessively, to ensure that no surgical instruments are left in the patient’s body after an operation. Similarly, an accountant with a meticulous approach to financial matters is someone in whom we place great reliance and trust. Some people with OCD are, like Madeline described above, guided by religious principles, and they become disproportionately concerned with matters of right and wro...

Table of contents

• Cover
• About the authors
• Foreword
• Title page
• Copyright
• Dedications
• Table of contents
• Acknowledgements
• Introduction
• Part 1 OCD: The facts
• Part 2 Treatment and self-help
• Conclusion
• Useful addresses
• Notes
• References
• Search items