Obsessive Compulsive Disorder

Around 2.5% of the population suffer from obsessive compulsive disorder (OCD), and as such this represents a significant mental health problem. The average age of onset of the disorder ranges from between early adolescence to the mid 20's and tends to appear earlier in males. Onset may be acute or gradual, and the condition is generally long term, although symptoms may vary in severity across time. Individuals may suffer significant symptoms for some years before seeking treatment.

Sufferers of obsessive compulsive disorder typically experience distressing and intrusive thoughts and ideas, and carry out repetitive unwanted behaviours in a compulsive manner. Obsessive impulses, images and thoughts provoke high levels of anxiety. Behavioural and mental actions - the compulsions - are carried out in a ritualistic manner in an attempt to alleviate this distress and anxiety. Behavioural actions such as hand washing may be performed if the individual has a fear of germs and of being contaminated. Mental acts such as praying silently or reciting sequences of numbers may be carried out in an attempt to avert some dreaded event or situation. Whatever the response, the compulsions are unrealistic or excessive, as the sufferer is usually all too well aware.

In OCD, the obsessions and compulsions are severe enough to cause considerable distress, and take up unreasonable amounts of the sufferer's time to the extent that they interfere with daily living. Occupational functioning may be impaired, and marital and other interpersonal relationships may be disrupted as a consequence. Marital distress is thought to occur in approximately 50% of couples where one partner is seeking treatment for OCD.

Obsessions

  • fear of germs, and of becoming contaminated
  • fear of causing harm or accidents to self or others
  • fear of losing control over one's environment
  • an excessive need for objects to be ordered, constant tidying
  • intrusive, unwanted thoughts or images
  • recognition that the unwanted thoughts and impulses originate within the self, and that they are excessive or unreasonable

Compulsions

  • phobic avoidance of situations that evoke the obsessions (such as avoiding public toilets if there is a fear of germs)
  • continual checking of things to make sure that they are safe, such as safety of electrical appliances, and locking of doors
  • repetitive hand washing, arranging of objects, and other ritualistic behaviours in an attempt to suppress unwanted thoughts and impulses
  • hoarding of possessions, even when items are no longer realistically useful

Social Impact

  • symptoms cause distress, are time consuming, and interrupt daily functioning
  • impairment of occupational functioning
  • disruption of marital and other interpersonal relationships
  • over-structuring of the individual or his or her life

Diagnosis

For a diagnosis of OCD to be made, both obsessions and compulsions must be present. Responsibility and self-blame are key attributes of the belief system accompanying this disorder. There are often mistaken beliefs about the harm related to different objects and situations, and when threat is perceived, the person will typically act in repetitive ritualistic ways to try to reduce the associated fear (such as hand washing after touching a dog that is believed to be germ-infested). A diagnostic interview will ascertain the presence of OCD, and the severity of the symptoms will be determined, usually via questionnaires. The three areas assessed are anxiety and distress, avoidance behaviour, and rituals. It will also be determined to what extent the symptoms of OCD interfere with daily living for an individual.

Medication Treatment

In some cases of obsessive compulsive disorder, medication may be prescribed. Serotonergic medication, such as the tricyclic antidepressant - fluvoxamine, has been found to be helpful for this condition. Similarly, fluoxetine (Prozac), another serotonin reuptake inhibitor, has been shown to be effective in reducing obsessive compulsive symptoms, with up to 60% of patients benefitting. However, relapse has been found to occur on discontinuation of these medications. For this reason, it is likely that psychological treatments will be offered in addition to, or instead of medication. Behaviour therapy in combination with medication has been found to result in longer-term success outcomes, than medication alone.

Psychological Treatment - Exposure and Response Prevention

Exposure and response prevention is a behavioural treatment used specifically with people with OCD, and this approach has a high success rate in reducing symptoms for sufferers (about 8 out of 10 people find it helpful). Patients are given a programme of repeated, prolonged exposures to situations that provoke anxiety or discomfort, and are instructed to refrain from the ritual (i.e. compulsive) behaviours that they would normally engage in to reduce this anxiety. Exposures are normally graded, so that the least anxiety-provoking situations are encountered first, before approaching more difficult tasks or situations later on. Typically patients will be encouraged to experience situations both in their imagination, as well as in the real-life context. Although initially distressing for some patients, with the support and encouragement of the therapist, the anxiety associated with these different tasks is likely to diminish over time, and the fear be overcome. Between 10 and 20 sessions may be required.