Features

OCD: the unwelcome takeover

04 July 2018

There is far more to obsessive compulsive disorder than straightening ornaments and checking light switches. Thankfully, awareness is growing. Journalist Georgina Wintersgill reports.

A recent storyline in ITV’s Coronation Street saw teenager Craig Tinker barricading himself in a flat to continue the rituals he believed necessary to keep his loved ones safe, including counting knives and turning the oven on and off. He goes on to be diagnosed with obsessive compulsive disorder (OCD).

The storyline has helped raise awareness of the distressing and disabling nature of OCD, which can mean people are unable to lead normal lives.

However, OCD is still seen by many as nothing more than an eccentric quirk. The expression ‘a bit OCD’ is sometimes used as a jokey synonym for perfectionist.

‘A lot of people think OCD is cleaning and checking light switches, and it can be,’ says Dr Fiona Challacombe, clinical lecturer and psychologist at the Centre for Anxiety Disorders and Trauma, King’s College London. ‘But people aren’t so aware that intrusive thoughts can be a huge thing. It’s helpful to make the patient aware that this could be what’s going on, and understand that it’s treatable.’

 

What exactly is OCD?

OCD is characterised by the presence of obsessions or compulsions – commonly both.

Obsessions are frequent and involuntary thoughts, doubts, images or urges that are unwanted, unpleasant and difficult to control. They are combined with a chronic feeling of doubt or danger.

Compulsions are repetitive behaviours or mental acts that a person feels forced to perform, usually in response to an obsession, and that are not intrinsically pleasurable for them. The motivation may be to suppress obsessional thoughts, reduce anxiety, lessen the chances of carrying out the obsession (such as hiding sharp objects) or avoid harm through rituals such as avoiding cracks in the pavement.

The most common obsessions in OCD are contamination (37.8%) and fear of harm (23.6%). Others include concerns with order or symmetry, the body or physical symptoms, unwanted blasphemous or sexual thoughts, the urge to hoard and thoughts of violence (NICE, 2005).

The most common compulsions are checking; cleaning or washing; repeating actions; or mental compulsions, such as silently repeating certain phrases (NICE, 2005).

Symptoms are similar in children and adults. The differences reflect developmental stages, so magical obsessions are common in children, and sexual obsessions are common in adolescents. Children and adolescents often involve family members in their obsessions by seeking reassurance.

When a person has OCD it’s likely that their obsessions and compulsions will disrupt day-to-day life, and impact on relationships and even on physical health. In fact, obsessions and compulsions can take over a person’s life and leave them feeling helpless (Mind, 2013).

OCD during pregnancy or in the year after giving birth is called perinatal OCD. Common obsessions are fears that the baby will be harmed, either accidentally or deliberately. Common compulsions include excessive sterilising, excessive checking on the baby, or mental actions. Women with perinatal OCD may avoid situations that could trigger obsessions, so women who fear they may harm their baby may avoid spending time alone with them, for instance.

The causes of OCD are not well understood, although studies show that it runs in families and that this is because, in part, of genetic factors (Pauls, 2008.) Although life events do not necessarily cause OCD, in people vulnerable to the condition they can be a triggering factor (NICE, 2005).

 

How you can help

If you suspect OCD, the NICE guideline (2005) suggests the following screening questions for children and adults: ‘Do you wash or clean a lot? Do you check things a lot? Is there any thought that keeps bothering you that you’d like to get rid of but can’t? Do your daily activities take a long time to finish? Are you concerned about putting things in a special order/very upset by mess?’ If a person answers ‘yes’ to one or more of the questions, it may indicate a need for onward referral.

If you suspect OCD in children, speak to the family, recommends Dr Amita Jassi, consultant clinical psychologist at the national specialist OCD service for young people at the Maudsley Hospital in London. She says: ‘The child might take longer to do homework or get really anxious in class, or they might not be able to go to bed straightaway because they take so long to do their rituals.’

OCD sufferers may be reluctant to talk about their symptoms, particularly the intrusive thoughts. But you don’t necessarily need to know the content of the thoughts in order to refer. Dr Jassi says: ‘Look out for the hallmarks of the trait. Just by listing examples [to the client] it normalises it, and the person may feel relieved.’

In some areas, it’s possible to refer clients to a mental health service; in others, GPs are the gatekeepers, so it’s helpful to familiarise yourself with local referral pathways. In some areas, adults can also self-refer via their local Improving Access to Psychological Therapies (IAPT) service.

Progress in extending the reach of specialist community perinatal mental health teams, especially outside England, is patchy (Gregoire, 2018).

If healthcare professionals are uncertain about the risks associated with the client’s intrusive sexual or death-related thoughts, they should consult mental health professionals with specific expertise in OCD. According to the NICE guideline (2005), these themes are common in people with OCD at any age, and are often misinterpreted as indicating risk. In fact, people with OCD are very unlikely to act on their thoughts because they find them so distressing and repugnant, and there are no recorded cases of a person with OCD actually carrying out their obsession (Mind, 2013).

Healthcare professionals should assess the risk of self-harm and suicide in people diagnosed with OCD, especially if the person has also been diagnosed with depression.

 

Seeking solutions

With the right treatment, 60% to 70% of OCD sufferers will improve (OCD Action, 2015). People with OCD should initially be offered cognitive behavioural therapy (CBT), which helps people change how they react to intrusive thoughts. CBT with exposure response prevention (ERP) is an effective treatment for OCD and significantly helps about 70% of those who complete the course (OCD Action, 2015). It involves helping patients to face situations they fear while refraining from performing any compulsions.

For moderate to severe OCD, selective serotonin re-uptake inhibitors (SSRIs) may also be offered; they can take up to 12 weeks to work. Around 60% of sufferers improve with medication (OCD Action, 2013).

The same treatments are used for children and adults. However, as the long-term effects of the medication on children’s brains are little understood, the child and their parents, together with the prescriber, need to decide whether the potential benefits of medication outweigh any possible risks.

Some people with mild OCD find self-help, often based on CBT, allows them to develop coping strategies (Mind, 2013). For children and adolescents with mild OCD, guided self-help is effective (OCD Action, 2015).

 

Recovering from OCD

Mums-to-be and new mums requiring psychological interventions should normally be seen for treatment within one month of assessment, and no longer than three months (NICE, 2011). Treatment should initially be accompanied by psychological therapy. CBT alone is often highly effective, but for some people a combination of CBT and medication is more effective. Mums-to-be and breastfeeding mums should discuss options with their doctor to decide if the potential benefits of medication outweigh any possible risks.

Maria Bavetta, co-founder of the charity Maternal OCD, believes that one of the best things community practitioners can do to help people diagnosed with OCD is to encourage them to become an expert on the condition. Maria says: ‘People need to be signposted to resources, such as relevant books and success stories, because it’s of great comfort to know that other people have recovered,’ she says. ‘I’d also like to see support given to the family. If the family understands how best to support the person, that will really help recovery.’ Maria shares her own story on page 21.

Dr Jassi agrees: ‘I think it’s really helpful to have parents involved in treatment, especially in younger children. It’s important to give them lots of information, instil some hope and make sure they realise it’s a common and treatable condition.’


 

Beyond indecisiveness

A new Canadian study found that fear of guilt evokes feelings of doubt in decision-making and may be implicated in OCD indecisiveness (Chiang and Purdon, 2018).

Lead researcher Brenda Chiang says: ‘People with OCD have generally been shown…to have this inflated feeling of responsibility. So they naturally have slightly higher levels of fear of guilt, making them more susceptible to indecisiveness.

‘This leads to difficulty terminating an action and evokes doubt as to whether an action was done properly, which leads to repetition.’


 

A new mother’s story

Maria Bavetta began compulsively cleaning and washing when her daughter was three months old. ‘It began when I started to bottle-feed,’ says Maria. ‘I became very aware that I had to make sure the bottles were clean. It quickly escalated to obsessive cleaning and washing – before long I was doubling my water bill. I thought: “If I don’t clean this well enough, my child will die.”

‘I realised something was the matter when I was in the bathroom washing my hands so much, my hands were bleeding. My husband saw and said: “Maria, what are you doing?” and I said: “I just can’t stop washing my hands.” We realised then that I needed to see someone.’

Maria went to her GP and was initially misdiagnosed with postnatal depression. She was later diagnosed with OCD when her second child was six months. He's now nine, and her daughter is 14.

Maria recovered after a course of CBT, including exposure response prevention, created specifically for mums (12 hours over two weeks, then three one-hour sessions over the next three months).


 

Fast facts on OCD

  • OCD is the 4th most common mental disorder after depression, alcohol/substance misuse, and social phobia.
  • OCD is 1 of 10 conditions ranked most disabling by WHO through lost income and decreased quality of life.
  • Studies have found a prevalence of 0.25-4% among children and adolescents.
  • The mean age of onset is late adolescence for mena dn early 20s for women.
  • OCD is thought to affect about 1% of women in pregnancy and about 2% to 3% of women in the year after giving birth.

Royal College of Psychiatrists, 2015; Krebs and Heyman, 2014; Veale and Roberts, 2014; NICE, 2005


 

Resources

  • OCD Action is the national charity focusing on OCD. Their helpline is 0845 390 6232/020 7253 2664 and their website is ocdaction.org.uk
  • OCD-UK is a charity run by sufferers, for sufferers. Call 03332 127 890 or visit ocduk.org
  • Maternal OCD is a charity founded by two mums who have experienced and recovered from perinatal OCD, visit maternalocd.org

 

References

Chiang B and Purdon C. (2018) Have I done enough to avoid blame? Fear of guilt evokes OCD-like indecisiveness. See: sciencedirect.com/science/article/pii/S2211364917301550 (accessed 5 June 2018).

Gregoire A. (2018) Turning the map green. Community Practitioner 91(5): 48-9.

Krebs G, Heyman I. (2014) Obsessive-compulsive disorder in children and adolescents. Archives of Disease in Childhood 100(5): 495-9.

Mind. (2013) Obsessive-compulsive disorder (OCD). See: https://www.mind.org.uk/media/4703394/understanding-ocd_2016.pdf (accessed 6 June 2018).

NICE. (2011) Common mental health problems: identification and pathways to care. See: https://www.nice.org.uk/guidance/cg123/chapter/1-guidance#step-1-identification-and-assessment (accessed 18 June 2018).

NICE. (2005) Obsessive-compulsive disorder and body dysmorphic disorder: treatment. See: nice.org.uk/guidance/cg31/evidence/cg31-obsessivecompulsive-disorder-full-guideline2 (accessed 21 June 2018).

OCD Action. (2015) OCC & BDD. See: https://www.ocdaction.org.uk/sites/default/files/pdf-precompiled/ocdbdd_gp_card.pdf (accessed 20 June 2018).

OCD Action. (2013) Medication for OCD. See: ocdaction.org.uk/resource/medication-ocd (accessed 5 June 2018).

Pauls DL. (2008) The genetics of obsessive compulsive disorder: a review of the evidence. See: onlinelibrary.wiley.com/doi/pdf/10.1002/ajmg.c.30168 (accessed 18 June 2018).

Royal College of Psychiatrists. (2015) Perinatal obsessive compulsive disorder. See: rcpsych.ac.uk/healthadvice/problemsdisorders/perinatalocd.aspx (accessed 5 June 2018).

Veale D, Roberts A. (2014) Obsessive-compulsive disorder. BMJ 348:g2183.

 

 

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