Obsessive Compulsive Disorder

Written by Kate Southwell on 8th of July 2015
I’ve noticed recently that the number of clients I see with OCD is increasing and many of these say they have gone years before having their difficulties accurately identified. Indeed, OCD is often misunderstood and as a nation, we often use words like “I’m a bit OCD”; but what does it look like to have OCD? How does it present? And how does the treatment work?

What is OCD?
OCD is an incredibly debilitating condition, and in essence involves people suffering with obsessions, which they ultimately ‘neutralise’ with ‘compulsions’. When we consider OCD, we normally think about people needing to have things in order, or to be clean from germs or contamination and whilst these behaviours represent types of OCD, the condition is much broader than this. I have detailed below the main types of OCD I tend to see in practice, very often people present in more than one of these areas, as the content tends to overlap, or they find themselves switching between the ‘types’ throughout their OCD history.

Some people suffering with OCD do have fears about things being clean with the feared outcome of infection or contamination if they are not ‘properly’ cleansed. There is a difference between people liking things to be ‘just right’ or ‘perfect’ and those who have OCD, in that the OCD sufferer will be specifically anxious about something bad happening if things aren’t properly clean. These fears (or obsessions) are often around making themselves or their loved ones unwell, and lead to compulsions such as cleaning or avoiding food, clothes, or indeed anything that is perceived to be contaminated. People with this form of OCD can spend hours a day cleaning, or avoiding things that appear ‘dirty’, they can also just ‘feel dirty’ despite cleaning to excess, which in itself leads to more cleaning.

People who suffer from this form of OCD often doubt if things have been done. This might involve an obsession that the oven has been left on, that work hasn’t been completed properly, or that they have done something like send an email or text to the wrong person. The doubt can cause extreme distress and leads people to ‘check’ things multiple, even hundreds, of times. Most of us will doubt ourselves at some points, and I have often returned upstairs before leaving my house to check my straighteners are off and unplugged. Someone with OCD however would find this debilitating due to the severity of the obsession and the frequency of the compulsion, they may, for example, go upstairs to check, immediately doubt themselves and go back upstairs again. Some people have numerical requirements of themselves, for example “I must check everything 5 times, and if I get distracted half way through, I have to start at the beginning of my checks again”.

Magical Thinking/Responsibility
This type of OCD is very common in the people I see day to day, and involves believing that there is a link between thoughts and the physical world . This link is often arbitrary and hard to define, for example: “if I step on this paving stone in the right way, my family will be safe” or “if I don’t do this task correctly, I will injure myself when walking to work tomorrow”. The obsession in this case then clearly leads to the compulsion of ‘obeying’ the magical thinking, which can often seem unusual to people who are close to the sufferer. Magical thinking often applies purely to negative consequences, so is rarely linked to things such as “if I use this pen to select my numbers on the lottery ticket, I will win”. Magical thinking can also involve believing our thoughts have some kind of consequence in the real world, for example: “if I think badly about my mother, she might be harmed in some way”, which can lead to the desire to neutralise the ‘bad thought’ to ensure it doesn’t happen; such as by telling my mother I love her, or by giving her a hug every time such a thought enters my mind. Although sufferers can often understand that the link is arbitrary or difficulty to quantify, the risk of not undergoing the rituals or compulsions often feels too high before treatment is commenced.

OCD related to intrusive and unwanted thoughts is what I see the most of both in my previous NHS work and now privately. It is incredibly debilitating and often a hidden illness which I suspect many people don’t present to services with, for fear of incrimination, or embarrassment. As a species, we regularly generate unwanted and unpleasant thoughts in our minds, which we tend to dismiss, or not notice at all when not suffering with OCD. These thoughts are quantified as being ‘ego-dystonic’ in nature, which means they are not in keeping with who we are as people. When, for example, I have my guinea pigs out on the sofa, I, on occasion experience the image or thought of hitting them over the head with my remote control. I love my guinea pigs very much and so this thought is unpleasant to me, and not in keeping with who I am (my girls live in the lap of luxury), so I notice it briefly, and then carry on as normal. I am aware that this thought means nothing, it is a randomly generated thought, and often pops up as I use it as an example so much when treating people with OCD. I do not however alter my behaviour as a result. I do not move the remote control; I do not remove the guinea pig; I do not change what I am doing.

Someone with OCD however, would be more prone to notice this thought if this was the area they were concerned about. They would obey the compulsion to get the guinea pigs out of danger, perhaps initially by removing the remote control “just in case”, or by putting the guinea pigs back in their home, or by stopping going near them completely as they perceive that “having this thought means I might/will act on it”. The key point in OCD related to intrusions is not that the intrusions happen (which is a normal part of being a human being), but that they are noticed and feared, resulting in compulsive behaviour perceived to stop the feared outcome. People suffering with this type of OCD are often hounded from morning to night with images, thoughts or intrusions which are highly distressing to them and which they perceive to mean something about them and what they might be capable of. Their rituals, avoidance and anxiety related to these images makes them occur more than they would normally, thereby increasing the overall fear.

The most common forms of intrusions (although by no means an exclusive list) tend to revolve around inappropriate sexual images (including those of children making people terrified that they are a pedophile, despite the fact that they find these intrusions repulsive), images or intrusive thoughts about harming others, and spiritual or religious intrusions.

People's behaviour can change dramatically as a result of these intrusions and the interpretation they place on them. They may, for example not leave the house for fear of murdering someone, or sexually harming someone, or they may constantly review their past to make sure they “haven’t done something wrong”.

Treatment of OCD varies depending on the specifics of what my patient is presenting with. However, in general, it revolves around understanding that obsessions trigger off compulsive behaviour, which in turn, strengthens the obsessions. For example, I might start avoiding my guinea pigs if I interpret my obsessions as meaning I could hurt them. To combat this, I initially need to question if my thought is valid. Am I actually the kind of person who would hurt animals (I rescue worms and snails from the path when I go running)? Have I ever hurt them before (never!)? I need to understand that other people have unpleasant thoughts that aren’t acted on, and I can look at research studies that show this. I also need to understand that trying to push the thought away isn’t helpful as the more I try to ‘block it out’, the more it will come. Ultimately, what I need to do is challenge my behaviour and start to hang out with the guinea pigs, making sure the remote control is near, so I can prove to myself that my thoughts are just that...thoughts.

I treat magical thinking similarly; if my patient believes thoughts affect the world around them, I encourage them to challenge this belief in various ways. For example, I might say to someone that I will die in my sleep that night if they don’t touch the kettle in my house before leaving. We then test this by asking them not to touch the kettle and analyse the results…I do these kind of experiments on a regular basis and am still alive! If this feels too challenging, I might suggest they think (really hard) about me winning the jackpot on the lottery, and I buy a lottery ticket to see what happens; sadly, this one still hasn’t worked! The link between thoughts and reality is then challenged, and we can work together on dropping other neutralising behaviours or rituals.

Equally, with checking behaviours, my patients and I work together on resisting their urges to ‘go back and check’, which in turn weakens the strength of the next obsession when they return to the house and realise it hasn’t burnt down, or that their front door was locked. Contamination fears work similarly in that I will encourage people to reduce their cleaning behaviours and observe the results. If this feels too intense, I might, for example, model touching the work surface they perceive to be ‘dirty’, and then prepare myself some food, so they can see that I survive and am not hurt in any way.

There are also many other methods I use with people who have OCD, and as the condition varies so much from person to person, a lot of the treatments are designed specifically for the individual, however the overall aim is to help people understand obsessions and ultimately reduce their compulsions.

Although CBT treatment for OCD is incredibly effective, it is also hard for clients and, as always, I have ultimate respect for the people I see and their trust that my knowledge of their obsessions is accurate. Clients often feel like they are taking huge risks when engaging with the treatment, but I aim to help them feel safe enough in the therapeutic environment to feel confident when taking steps forward. If you live in the Lincoln area, have related to the symptoms above, and find this affects you day to day, please do not hesitate to contact me for a free telephone consultation to see if CBT might be for you. Thank you for reading.

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