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What is OCD?

Obsessive-Compulsive Disorder is the name for a wide variety of bizarre patterns of obsessive and compulsive behaviour.

Typical obsessions are with:

  • fear of shameful misbehaviour
  • death and disaster
  • contamination
  • perverted sexual thoughts
  • symmetrical arrangements
  • intrusive thoughts and images
  • lucky or unlucky numbers
  • unsatisfactory body images

Typical compulsions include:

  • cleaning
  • washing
  • checking
  • counting
  • measuring
  • repeating ritual actions
  • hoarding things
  • confessing imaginary 'sins'

A large majority of OCD cases (over 75%) involve both obsessions and compulsions, and it is easy to see why.

Mrs X was obsessed with the idea that dangerous germs were contaminating her children. She felt compelled to clean the bathroom over and over again - often dozens of times a day.

Mr Y had an obsessive fear that a dreadful accident was going to happen to his parents, but that he could somehow prevent it by touching every lamp-post as he walked by. The lamp-post touching ritual became a compulsion


OCD takes many different forms

In this leaflet we will describe some of the more typical patterns of obsession, but there are many others. In fact, the person with OCD may 'select' almost anything:

  • Mr A refused to have anything orange in the house, and refused to let his family even speak the word.
  • Whenever Mr B left the house, he always insisted on retracing his exact footsteps when he came back in - if he wasn't quite sure, he'd go out and come back again.
  • Mrs C refused to have any sound or movement in the house at certain times of day.

A minority of people with OCD indulge in ritual-type behaviour without having obsessional thoughts, and vice-versa. There is an even smaller group who perform certain actions, which do not on the face of it look like rituals, with extreme slowness. However, these actions often involve eating, cleaning or washing, and they usually follow a strict set of procedures. This suggests that they are part of the OCD group.

All of these OCD symptoms are forms of behaviour which in small doses would not be a problem. There are plenty of people around who are a bit finicky about cleanliness; or who like to double-check that the door is locked at night; or who like their possessions to be arranged 'just so'. Others may think of them as a bit odd, but that is as far as it goes.

People with OCD are in a different category. Their compulsions are so strong that ritual behaviour swallows up great chunks of their day, putting jobs at risk, relationships under strain, and generally making life a kind of living hell. OCs can also damage themselves physically, with constant washing, for example.


How common is OCD?

It used to be considered quiet a rare disorder - and there are still many GPs who have seldom if ever reported seeing a case. No-one knows for sure how many cases there are, because many OCs disguise their condition and are extremely reluctant to discuss it with anyone, but recent estimates suggested it is relatively common. Minor OCD symptoms - 'eccentric' or 'odd behaviour' - are very widespread.

The number of people in whom these symptoms are serious enough to be considered a clinical disorder is much harder to estimate. The lowest figure quoted by experts is 1 person in 2,000 (which would mean about 28,000 in Britain altogether). But some American researchers believe that there may be as many as 5 million OCD cases in the USA. If this is so, it suggests there could be as many as 1 million here. Perhaps we will never know for sure: people with OCD tend to keep silent about their condition. Typically, OCD cases live with their problem for around 10 years before they seek outside help.


Who gets it, and how?

Anyone can develop OCD, and it is impossible to predict who it will be. It affects many perfectly ordinary people but it is often surprising to learn how many talented, creative and even famous people have been affected. According to some experts they include Dr Samuel Johnson and his biographer, James Boswell; writers like John Bunyan, author of 'Pilgrim's Progress', Hans Christian Anderson, Dickens, Ibsen and Proust; composers Rossini and Stravinsky, philosophers Rousseau, Pascal and Kierkegaard, film maker Woody Allen, and many, many other cases. Most famous of all was the brilliant millionaire industrialist Howard Hughes, while in a recent interview, comedian Ben Elton also talked about his checking compulsions.

OCD usually starts in late adolescence or the early adult years. It affects men and women in roughly equal number. Around half of those who seek help are unmarried, and in most cases the disorder seems to have developed gradually over the years. Sometimes a traumatic event of some kind can trigger it off, or turn minor obsessions into the full-blown condition. This was the experience of Ken who told his story in 'The Observer' newspaper in March 1990:

KEN'S CASE
At the age of 25, Ken was going through a difficult period, and was clinically depressed. He was having problems with relationships and with his career. The 'trigger' for OCD occurred on a trip to Canada.
"There was a drought, and we couldn't often wash. I felt so dirty that I used to hold my hands away from my body. When I returned to London, suddenly I couldn't touch anything - total revulsion." Normal life rapidly became impossible. Ken ate with his fingers because he couldn't bear the idea of touching cutlery (people with OCD often have this highly illogical attitude to cleanliness). Ken's father made him a special table that no-one else was allowed to touch. He washed his hands so often that the skin peeled and the flesh split to the bone. Eventually he would spend the whole day sitting inside, an imaginary 'clean circle', only leaving it to go to the bathroom or to bed. In this way, Ken wasted six years of his life.

It is not surprising that depression and OCD often go together. Depression can help set the stage for the disorder; understandably, the disorder itself can make people depressed. OCD is not a disease, and people with OCD are not 'mentally ill' - though they may well need help from a psychologist or psychiatrist. OCD is a disorder of the way people behave, not of their minds or bodies. So those with OCD who believe they are schizophrenic (especially those who experience obsessive thoughts and images, and even 'hear' sounds or music) need not worry on that account. Schizophrenia is no more common in OCDs than in 'normal' people.

Since OCD is not a disease, people cannot 'catch' it from one another. However, the children of OCs sometimes develop similar symptoms as they get older. There may be an element of heredity in this (just as the children of athletes tend to be athletic); but it is much more likely that parents are passing on their ways of thinking and behaving to their children by example.


The main forms of OCD

OCD comes in many different forms, and we do not have space to describe them all in detail. However, the main forms fall into a number of recognisable groups.

Obsessions with Compulsive Rituals

Five main types of OCD come under the this heading: washing and cleaning; repeating sequences of actions; checking; orderliness; and hoarding.


1. Washing and Cleaning

These are the commonest kinds of OC behaviour, and they affect more women than men. OCs tend to react to things that make them anxious by performing complicated or endlessly repeated rituals of washing hands, hair, clothing, bedding, floors - almost anything may be involved. Sometimes the condition can develop very rapidly.

The rituals are a response to an obsessive fear of contamination - and the choice of what contamination to fear is often highly illogical. For instance, some OCs have a deep fear of dog faeces, but are not particularly worried about human faeces, or those of cats and other animals. For others, it is the other way round.

Washing and cleaning OCs commonly feel threatened by 'germs', asbestos, radiation and even fibreglass. Those who are obsessed with dog faeces often worry about the invisible organism called toxicara canis, which is said to infect many dogs.

It is worth noting that in all these examples, the 'real threat' is something invisible - germs, microscopic fibres, waves of radiation. OCs are of course well aware that most 'normal' people do not find these things particularly worrying.

ANNA'S CASE

Anna's OC problems started in her mid-20s, with post-natal depression. Having lost one baby in childbirth she became over-protective of the new one. "I went over the top with sterilising the baby's things. I used a bar of Sunlight soap each day till my hands were red raw."

Years later she read about asbestos fibres causing cancer and developed a strong obsession about it. She "pulled the house to pieces" looking for fragments of asbestos, and removed anything suspicious. She still feels that asbestos gets into her hair while she is at work, so when she gets home she feels compelled to change her clothes and wash her hair. But one washing is seldom enough: has she really got all the asbestos out? Has she absent-mindedly stepped outside again?

When her condition is really bad she is driven to wash again and again, just in case. The same goes for vegetables: on occasions she spends so long washing them that there isn't actually time to eat them... "It's like a devil inside me telling me to do these things or I will lose a child, or catch asbestosis."

Recently she has become obsessed with the thought of toxicara infection from dog faeces. She thinks that she has somehow touched these faeces and got them into her mouth or hair.

"I imagine that if I don't wash, the little worm in the faeces will get into my hair and then at night it will creep onto the pillow and into my mouth; eventually it eats the optic nerve."

Anna's case is quite typical, and it also shows how illogical and selective OCD can be. 'Washing' OCs are seldom bothered by their feet and shoes, which are much more likely to bring dirt into the house.

'Cleaning' OCs may keep one or two areas of the house spotlessly clean, while neglecting

others completely. As with most OC conditions, of course, the rituals take up so much time that normal life - including normal cleaning - goes by the board.


IMPORTANT: The toxicara organism really exists, and it can attack the optic nerve, BUT:
  • such cases are extremely rare
  • the toxicara 'worm' is far too small and weak to 'creep onto the pillow' etc.
  • it will only get into someone's body if they transfer it there with their own hands
  • normal personal hygiene is perfectly adequate to prevent this happening.

2. Repeating

OCs may feel compelled to repeat a series of actions many times, before doing some perfectly simple things, such as going to bed. The repeating comes in because they feel that the ritual has to be absolutely 'correct' before it is safe to proceed. It has been known for it to take two hours for a 'repeated' OC to get from the car into the house. Other cases involve number rituals - counting and touching trees or lamp posts, for example.

There is a strong element of superstition in these rituals, especially in the kind where a person feels obliged to repeat the actions they were performing at the moment when some anxious thought entered their minds, and to do so a given number of times.


3. Checking

'Checking' OCs are usually obsessed with the thought that something dreadful may happen due to their carelessness or misbehaviour. Did they switch that light off? Or the gas, or the water taps? Did they lock the doors and latch the window properly? They go and check, but after a while they start to doubt whether they did it properly. So off they go and check again ... and again: in severe cases for hour after hour.

In his book 'Obsessional Thoughts and Behaviour', Dr Frederick Toates describes how his own checking obsessions started. Though English-born, at the time he was working as a lecturer at the University of Odense, in Denmark:

DR TOATES' CASE

Dr Toates was working in a laboratory. One night he carefully checked that all the lights were turned off, then took the bus home. But half way home ... "I was overcome with the feeling that something had been left on. There was nothing for it but to wait for a bus ... to take me back."

Of course, nothing had been left on, so he set off again. And once again he was compelled to go back and check. Again, OK. When the same thing happened once more on his third attempt to go home, he took a taxi back to the lab, and had the driver wait. "That finally did settle it for the day" - after a totally wasted evening.

Dr Toates tried to figure out why he was behaving like this: "What was I afraid of during this checking? What pulled me to do it? I can't say, but using my conscious thoughts as evidence would suggest that it was the need to avoid a catastrophe, such as the university going up in flames. On the one level I knew all was well; on another level, I just doubted it."

Others are obsessed with the fear that they have dropped some tiny but dangerous thing, which may hurt someone badly. They search carpets, chairs and floors for minute fragments of glass, or needles or pins. Even human hairs may pose a threat: could they perhaps choke someone, or get into electrical equipment and cause a fire? This kind of obsession invites comparison with the 'cleaning' OCs fear of invisible contamination.

A third type of checking takes place where someone fears he or she has done something dreadful, or might do. In some cases, they repeatedly check that all knives are hidden away, in case they should stab someone. Others retrace the route they have just driven over, obsessed with the thought that they have run someone over and left them injured. Some may even repeatedly phone police or hospitals with similar worries.


4. Order and Symmetry

These are obsessions which go way beyond normal tidiness, and involve time-consuming rituals. One manager can't start work until he has sharpened all his pencils to exactly the same length and fineness, with a scalpel. This takes at least an hour each day.

  • D - a TV presenter - must have the table and all the 'props' set out exactly right before starting an interview; if anything is even slightly out of position, it has to be done all over again.
  • Mr E, a retired factory manager, insists that everything in the living room must always remain in exactly the same position. If anything has to be moved for cleaning, enormous care has to be taken to replace it exactly where it was before.

There are also many cases which involve ensuring that pairs of things match exactly: shoes and laces, even eyebrows. Everything has to be absolutely 'correct' before the person concerned can get on with his or her tasks.

OCs of this type obviously need the co-operation of those around them - especially their family - in their obsessions. Failure to co-operate can lead to arguments, rows and even in some cases violence, or at least the threat of it.


5. Hoarding

People who have this form of OCD find it next to impossible to throw anything away - including rubbish and even kitchen scraps. They may buy vast quantities of food or other things that will never be used. The consequences of this can easily be imagined.


Some less common OC problems

Slowness without visible rituals

This is where people behave normally (i.e. at normal speed) in other situations, but slip into slow-motion when they tackle certain kinds of actions. Among the commonest are taking a bath, dressing, eating and crossing roads - apparently because they feel compelled to follow very strict procedures when doing these things. Repetition may come into it, when the procedure goes slightly wrong or gets interrupted. They then have to perform part of the process (or even all of it) over and over again until it is right.


Obsessional thoughts (without obvious rituals)

Many OCs are afflicted by 'endless ruminations' - thoughts that go round and round in their heads. They often comment on how long it takes them to make decisions - and not just important or difficult ones. Dr Toates describes having enormous difficult in deciding whether to buy oranges or grapes during a trip to the supermarket.

Unfortunately, ruminations of this mild kind are not the whole story. There are many reports of OCs having dark and brooding thoughts, about things which are inevitable but not necessarily imminent: the passing of time, growing old, death and the loss of loved ones.

These thoughts can become intrusive: they suddenly enter the mind and refuse to leave. Sometimes they are not merely depressing, but frightening thoughts about:

  • harming people, especially their loved ones, contaminating people in some way, or attacking them or running them over;
  • doing something they consider wicked or disgusting: taboo sexual acts, perversions, incest, child abuse, rape, bestiality and so on.

The frequency and persistence of these intrusions can be a terrible torment, filling the person concerned with confused and guilty feelings.

A smaller group of OCs find their thoughts are 'haunted' by intrusive images or sounds which are disturbing without being particularly threatening - a cat, for example, or a ringing phone.

People in this group may start to develop rituals as a means of putting the disturbing thoughts or images out of their minds.

 

Treatment and cure

OCD is not a disease or a 'mental illness', but sometimes it is a secondary condition triggered by depression (or sometimes General Anxiety Disorder).If this is so, then treating the depression is the first priority, and the GP is the first port of call. Once the depression goes away, the OCD may well follow without much extra effort.


The underlying problem - Anxiety

However, what underlies most cases of Obsessive-Compulsive Disorder is severe anxiety - fear, in fact. Certain 'triggers' - things which may seem perfectly ordinary to other people - bring on the anxious feelings.

The person affected deals with the anxiety by developing a ritual, the purpose of which is to help them face the threatening situation. The stronger the anxiety,the longer and more complex the rituals tend to be. Thus people for whom entering a house- even their own - provokes anxiety, may perform their particular strange (and perhaps embarrassing) rituals.

DR JOHNSON'S CASE

A friend of Dr Samuel Johnson, writing 200 years ago, described the Great Man's peculiar way of crossing the threshold:

"On entering Sir Joshua's house with poor Mrs Williams, a blind lady who lived with him, he would quit her hand, or else whirl her about on the steps as he whirled and twisted about to perform his gesticulations; and as soon as he had finished, he would give a sudden spring and make such an extensive stride over the threshold, as if he were trying to wager how far he could stride...'

Rituals like these give relief from anxiety, but unfortunately they can easily go on to become a major problem in themselves. As we have seen, the ritual washing,checking, repeating etc. can make such an enormous demand on the individual's time,that normal life becomes increasingly impossible. In a way, the rituals are like anarcotic drug: people can get hooked on them.

The reasons for the anxiety may be experiences in childhood, traumas,or unpleasant events later on. In most cases the 'cause' is impossible to identify for certain, and it is not at all useful to waste time ruminating about the subject. The point is that, as with the exaggerated anxiety responses, the mind and body have learn to react in a faulty way. To recover from OCD, the person affected needs to 'unlearn' these automatic responses.


A strategy for recovery

The logical approach to treatment is therefore to help the person with OC do two things:

  • to stop using the rituals
  • and to learn to face the anxiety without them.

This is accomplished by gradual exposure to the situations which are feared, while resisting the urge to ritualise.


Exposure programmes

In the course of therapy, 'cleaners' would be helped to touch, or come close to, the contamination which they dread, and then be given support to help them resist the desire to ritualise. Those who use rituals to cancel out a dreadful thought would be helped to stop doing so, and to accept the anxiety or discomfort that will be aroused. Such a person might be encouraged to think the dreaded thoughts deliberately, perhaps for 15 minutes or more at a time, or to talk them through with the therapist (or a family member who had been instructed in how to respond). Some individuals will be able to find relief by tape recording the dreaded words and playing them back regularly, or whenever the thoughts start.


Making progress - slow but sure

Gradual steps are the answer. Thus a 'washer' might be encouraged to cut down steadily on the number of times they repeat their ritual. Once less than usually on the first occasion, then twice less, three times less, and so on. The therapist and helper can set an example by touching the feared contaminant themselves.Alternatively, time might be the key. On the first occasion, wait 5 minutes, and gradually work up to an hour, two hours, and so on

If the ritual involves checking, the checker could be encouraged to leave home for gradually increasing lengths of time without performing the checks. Or a start could be made by focusing on one particular part of the 'check-list', doors for instance. Indeed, the urges to check individual items may have to be tackled one at a time. Although anxiety problems can start with one focus and very rapidly spread to others (e.g. from doors to gas taps, water taps, windows, electricity, etc.), reversing the process can be more difficult. Fortunately, however, success with one checked object usually increases confidence and makes the next one easier to deal with.

Exposure treatment works best when the steps are carried out regularly- every day - and for at least an hour at a time. There is no need for people to be 'flooded' with long and difficult exposures involving massive amounts of fear and discomfort. Gradual exposure works just as well and is easier to manage. Also,research shows that intensive exposure imposed by a tough therapist is no more effective than relaxed self-exposure, where the OC sets his or her own targets (and limits). In any case, someone who can only make progress under strict supervision is more likely to relapse again when this support ends.

During exposure, it is nice to make steady progress, but it is not necessary to 'win' every time. If the person cannot avoid the rituals on one occasion, that stage can always be tackled again later. However, it is vitally important to keep up the pressure. Giving oneself a 'treat' by indulging in the rituals unnecessarily during the exposure programme can rapidly lead back to square one.


Professional help

It is difficult for a person with OCD to tackle this alone, and help from professionals - clinical psychologists and psychiatrists - or trained volunteer support workers may well be needed. Basically, treatment is a learning process. All OCs have to learn that:

  • the thing they dread will not actually harm them
  • anxiety may be unpleasant but it cannot cause them any physical damage
  • if they stop their rituals the urge to perform them will gradually decline.

Occasionally, the OC condition is so severe and deeply entrenched that exposure treatment fails to make any significant impact. In these cases, in-patient treatment may be needed for a number of weeks. It should be stressed that this is very uncommon, and that it is entirely voluntary.


Is there a cure?

Anyone can have an anxiety condition at any time, so talking about a cure, is like talking about a cure for the common cold. Another bout of the problem may occur in the future, and a one-time OC may never entirely shake off the urge to perform the rituals, even if he or she doesn't actually give in. The aim of treatment is not to eliminate every trace of anxiety and the OC response to it, but to get back to a more satisfactory way of life.

And although others can help - therapists, family, or volunteers -recovery remains basically the OC's own work. There is no magician with a wand to wave, no famous doctor with a miracle drug, and no powerful guru whose healing hands will take the problem away. Recovery by self-exposure is about taking back control over yourself and getting a grip on the world around you. It requires a good deal of personal effort, as well as the determination to succeed - but it works.


What to do about OCD

If you think you may have one of the many forms of OCD, your first step should be to see your GP. Most GPs will recognise the symptoms if you describe them clearly. Of course your GP will want to consider whether the source of your problem is some other kind of anxiety disorder or perhaps depression. If your GP decides you are not an OC, he or she will usually be right. But if you are convinced the diagnosis is wrong,try again.

When GPs decide a patient has OCD, they may prescribe drugs, or refer them to a clinical psychologist, or both. Either way, GPs like sensible patients who genuinely want to get better; so if it's drugs - make sure you take them. And if it's an out-patient appointment at a hospital - make sure you turn up on time!

In some parts of the country it is possible to go straight to a hospital psychologist without seeing a GP first, but except in extreme circumstances, this is a bad idea. It is far better to trust your GP and get his or her support.


Advice for helpers

In some forms of OCD the person affected demands constant reassurance from family, and even help with carrying out the rituals (as with Ken Sell's father,who made him a special 'clean' table).

Refusing this 'fix' may be painful, and may provide distress and anger, but it is of vital importance to the OC's recovery. The therapist may help you practice how to say a kind but firm 'no'. Refusal could be on the lines of"We agreed that I would not reassure you", or "We agreed that I would not take part in your rituals." 'Helping' them by giving them what they want is like handling the drug addict the key to the drug cabinet. In the long run, it is far kinder to refuse.


Understanding support

The family is not just there to say 'no', of course. People who are facing up to the difficult task of recovery from OCD need all the help they can get, and a loving, caring family is most important. Above all the family needs to understand the condition and understand how it can be ended. So if you are affected by OCD, make sure your family read this booklet too.

Over half the calls about OCD that Anxiety Care receives are not from the person affected but from a member of their family. This is often because the OC will not recognise the problem, or feels so humiliated and ashamed that he or she won't admit it. We often hear stories like this:

"My son spends 14 hours a day washing. I want him to go to a doctor, but he won't. He thinks they'll say he's mad and put him away.Whenever I mention it, he gets angry and we have a dreadful scene. What on earth can I do?"

This is a difficult problem - and all too common. You can't force someone to seek help, but neither can you just let them go on being miserable. The first step is to convince them that OCD is nothing to do with 'madness'. After this,they should be encouraged to read leaflets and books about OCD, so that they can start to understand their condition. This may take time, and it may well be difficult. Certainly it will need care and tact on the part of family and friends. But the day that the OC makes the decision to seek help will be a vital turning point in their lives: it is the first step towards recovery.


What Anxiety Care can do

Anxiety Care helps people who have a severe anxiety condition to help themselves. Many such people long for a miracle cure which will 'make it go away' - and some 'experts' claim to be able to supply this - but no such miracle cure exists. Indeed, it is unrealistic to aim for a total 'cure':anxiety is a fact of life.

But anxiety disorders can be overcome, and those affected can recover to live a satisfactory life again. The way forward is described in this booklet.Re-learning our reactions and casting off our deeply rooted ways of behaving is a tough challenge. It requires effort, determination and support, but it really works, and there are thousands of former OCs around to prove it.

 


The basic reference work on which we have drawn is Fears, Phobias and Rituals by Professor I M Marks, published by Oxford University Press (1987)

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