Have you ever worried that you left a window open or forgot to lock the front door on your way out of the house, and felt compelled to go back and double-check? I’ve done it more than once, and for most of us these sorts of anxieties are short-lived and don’t interfere with our normal routine. But how would we feel if we started to have these thoughts every time we left the house? And that each time we got in the car ready to leave, we had to go back and check again; not just once, but two, three, four or more times?  Can you imagine how distressing that would be?

Around 2% of the population are diagnosed as having Obsessive-Compulsive Disorder (OCD), meaning that they spend at least one hour, often several hours each and every day, engaged in unwanted and upsetting obsessions and/or compulsions caused by extreme anxiety. For most of us, anxiety is an alarm system that warns us about danger and prevents us from taking risks. But for OCD sufferers, their alarm system is triggered far too easily, and its warnings are much more intense than necessary. Minor dangers, or dangers that don't even exist, can trigger an unnecessarily strong anxiety response.

Imagine that someone with OCD touches a doorknob, and becomes overwhelmed with the fear that their hand will become infected (the obsession). They immediately wash their hands - but not for 15 seconds as most people might. Instead, they wash their hands for 10 minutes (the compulsion).

The brain takes note of the serious response to touching a doorknob and confirms to itself that touching doorknobs must be dangerous. Furthermore, the brain notices that the anxiety did in fact diminish after 10 minutes of hand washing, so it must have helped. This creates a negative feedback loop where small sources of anxiety result in extreme responses, which then further reinforce the obsessions and compulsions.

What are the symptoms of OCD?

Although the specific content of obsessions and compulsions varies amongst individuals, certain symptom themes are common, and for many years it’s been considered that a person’s OCD will fall into one of these five main categories, and may sometimes overlap between them;

·        Checking

·        Contamination

·        Symmetry and ordering

·        Intrusive thoughts

·        Hoarding

The two components of OCD

Obsessions: The obsessions are the persistent, unwanted thoughts, fears, images or urges that cause anxiety, and are almost impossible to ignore. They’re usually exaggerated versions of concerns and worries that most people have at some time, such as the risk of contamination from dirt or germs, the need for excessive order or symmetry, or intrusive thoughts about acting inappropriately.

Obsessions can produce feelings ranging from frustration and discomfort to acute distress and panic. For some people, the obsessions may be constantly on their mind, or they may be triggered by physical objects, situations, smells, or something heard on television, radio or in a conversation.

Compulsions: The compulsions are the behaviours that the person does to try to satisfy the obsessions and eliminate the anxiety they cause. These behaviours involve repeatedly performing purposeful and meaningful actions in a very rigid and structured routine such as handwashing, cleaning, internal mental counting, excessive checking of locks, electrical and gas appliances, or applying rules and patterns to the placement of objects, furniture, and books.

Sometimes, these behaviours will have a clearly defined starting and endpoint. For example, ‘rub left side of the face first, and then right side of the face, then forehead’, and in many cases, if the sufferer is interrupted during the ritual, their OCD will dictate that they must start the procedure again from the beginning. Carrying out the compulsions brings some relief to the distress caused by the obsessions, but that relief is temporary - rather like scratching an itch, and it reoccurs each time the person’s obsessive thoughts are triggered again. And until they’re able to shift their focus to something else, they will keep on repeating; trapping them in a cycle of doing the same thing over and over again, unable to stop.

Who is at risk of developing OCD?

OCD affects individuals regardless of social or cultural background. Research shows that on average it’s reported by more males than females. It generally develops during adolescence, although it’s been known to be a problem for a small number of children as young as six. Onset after the age of 35 is unusual, but does occur.

Adults with the disorder are generally quite anxious, and often have a lifetime diagnosis of an anxiety disorder such as social anxiety disorder, an eating disorder, schizophrenia, Tourette’s, or a depressive or bipolar disorder. Up to 30% of individuals with OCD also have a lifetime tic disorder, particularly males with the onset of OCD in childhood, and these individuals tend to differ from those without a history of tic disorders in the themes of their OCD symptoms, comorbidity, course, and pattern of transmission. A triad of OCD, tic disorder, and attention-deficit hyperactivity disorder (ADHD) can also be seen in children.

Around the world, there is substantial similarity between cultures in the gender distribution, age at onset, comorbidity, and symptom structure of OCD, however cultural factors may shape the content of obsessions and compulsions.

Living with OCD

OCD is associated with reduced quality of life as well as high levels of social, educational, and occupational impairment. Whereas some sufferers may be able to hide the problem from family and friends by making excuses for their behaviour, others may be unable to get out of the house or manage normal daily activities; negatively affecting their personal relationships and their ability to study or work.

Avoidance: Generally, a person with OCD will find their obsessions and compulsions so mentally and physically draining, that they’ll go to great lengths to avoid the trigger that activates them. For example, individuals with hygiene concerns might avoid public places such as restaurants, cinemas, and trains to reduce exposure to feared contaminants, and those who need everything in their home to be neat and tidy will avoid inviting friends’ round who might disturb the orderliness. So sufferers may gradually exclude themselves from many everyday activities that they’d previously enjoyed, such as eating out, travelling, and socialising with friends and family.

Reassurance: Those whose anxiety is caused by a fear of, for example, developing an illness, causing an accident, or committing a crime, will seek constant reassurance that their fear isn’t a reality. This could involve hours of internet research, frequent hospital tests and investigations, or repeated demands for reassurance from a loved one.

Family relationships: It can be frustrating and exhausting to live with a person who has OCD, putting a strain on relationships, particularly when the person imposes rules and restrictions on family members, such as barring visitors to the house due to their fear of contamination. Being expected to help them with their rituals, respond to requests for reassurance, or undertake tasks that they want to avoid, are all behaviour patterns that maintain and reinforce OCD, and yet if family members refuse to help, they’ll be perceived as being mean or unsupportive. OCD is a master at manipulating the person who has the disorder, and in turn, his or her family.

Insight and awareness: People who become trapped in this cycle of obsessions and compulsions are generally aware of the irrational and excessive nature of their thoughts and behaviours, and may be acutely embarrassed about them; putting great effort into hiding them. However, insight can vary within an individual over the course of the illness, and they may start to believe that if they don’t do them, something bad will happen to them or their loved ones. Poorer insight has been linked to worse long-term outcomes.

It’s worth pointing out that although there’s often an obvious correlation between the obsession and the compulsion, such as excessive cleaning and washing by those who fear contamination, at other times there will be no logic at all between the two. For some, the original obsessive fears or worries have long ago been forgotten, and the compulsions are completed so that everything feels ‘just right’, and they can get on with their normal daily routine.

Do we know what causes OCD?

In spite of considerable research, scientists have so far been unable to identify a definitive cause for why a person develops OCD. However, there are several theories;

·        Cognitive: Some believe that compulsive behaviours occur in response to faulty beliefs about the world and the way that it works. For example, a person who thinks they’ll contract an illness if they don’t wash their hands multiple times before a meal.

·        Genetic: In 2001, a meta-analysis reported that a person with OCD is four times more likely to have another family member with OCD than a person who doesn’t have the disorder. However, as researchers have so far failed to identify any specific gene responsible for OCD, it’s possible that a family prevalence of the condition could, in some cases, be due to learned behaviour.

·        Chemical Imbalance: Other studies have focused on the neurotransmitter Serotonin, which is the chemical in the brain that sends messages between brain cells, and is thought to be involved in regulating everything from anxiety, to memory, to sleep. Researchers know that OCD is triggered by communication problems between the brain’s deeper structures and the front part of the brain. These parts of the brain primarily use serotonin to communicate. This is why increasing the levels of serotonin in the brain may help to alleviate OCD symptoms. 

·        Auto-immune reaction: Sometimes OCD can begin in childhood after the child has strep throat. In these cases, researchers believe that an autoimmune mechanism is to blame and that treatment with antibiotics may be effective in combatting OCD symptoms.

·        Environmental: Childhood abuse and other stressful or traumatic events have been associated with an increased risk for developing OCD, however, they’re not thought to cause it, but rather trigger it in someone already predisposed to the disorder.

Self-help

If obsessive thoughts and habits are becoming a problem, there are things you can do.

Anticipate urges: For instance, if you compulsively check that the doors are locked, try and lock the door with extra attention the first time. When the urge to check arises later, it will be easier to re-label that urge as ‘just an obsessive thought’.

Keep a diary:

·        Write down the content of obsessive thoughts or worries whenever you have them.

·        Make a note of the time of day or night, and what you were doing.

Tell someone you trust: Talking about how you feel is the first step towards getting better. It might be difficult to explain, but people who care about you will want to support you. Try talking to a relative, teacher, friend, or helpline.

Go to see your doctor:
It's important not to try and manage alone. OCD normally needs treatment to get better, and your doctor will be able to put you in touch with the appropriate services.

Treatments for OCD

·        Psychological treatments

·        Medications. 

·        Support groups

Exposure and Response Prevention (ERP):

Historically, OCD was thought to be untreatable, but the last few decades have seen great success in reducing symptoms, particularly through exposure and response prevention (ERP), a form of cognitive behavioural therapy (CBT) which is now considered to be the first-line psychotherapy for OCD. It works by breaking down the conditioned responses between obsessions and compulsions, whilst receiving guidance and support from a therapist. And with the development of internet-based ERP programmes, barriers to treatment, such as cost and availability, are no longer an issue.

The treatment is difficult and may sound frightening, but many people find that when they confront their obsessions, the anxiety eventually improves or goes away. People with fairly mild OCD usually need about 10 hours of therapist treatment, with exercises done at home between sessions. More severe OCD, may require a longer course of treatment.

Medications:

The following Serotonin Reuptake Inhibitor (SRI) antidepressants have been found to work well for OCD in research studies:

·        Fluvoxamine (Luvox)               Fluoxetine (Prozac)

·        Sertraline (Zoloft)                    Paroxetine (Paxil)

·        Citalopram (Celexa)                Clomipramine (Anafranil)

·        Escitalopram (Lexapro)          Venlafaxine (Effexor)

Support groups

Many people with OCD find support groups helpful, as they can reduce feelings of isolation, and provide reassurance and coping advice. The following websites have details of groups across the UK.

https://ocdaction.org.uk/i-need-support/support-groups/

http://www.ocduk.org/support-groups/

https://www.topuk.org/top-uk-groups/

https://healthunlocked.com/ocduk

Thank you for reading this blog post. I hope you’ve found it useful. If you have any thoughts to share, or ideas for future posts, please do let me know. I would love to hear from you.