Obsessive compulsive disorder

Obsessive compulsive disorder (OCD) is a mental health condition where a person has obsessive thoughts and compulsive behaviour.

Introduction

Obsessive compulsive disorder (OCD) is a mental health condition where a person has obsessive thoughts and compulsive behaviour.

An obsession is an unwanted, unpleasant thought, image or urge that repeatedly enters a person's mind, causing them [anxiety].

The word "obsession" usually describes something enjoyable, but in OCD the obsession is unpleasant and frightening.

A compulsion is a repetitive behaviour or mental act that someone feels they need to carry out to try to prevent an obsession coming true. For example, someone who is obsessively scared they will catch a disease may feel the need to have a shower every time they use a toilet.

OCD symptoms

OCD symptoms can range from mild to severe. For example, some people with OCD may spend an hour or so a day engaged in obsessive-compulsive thinking and behaviour. For others, the condition can completely take over their life.

Although OCD affects individuals differently, most people with the condition fall into a set pattern of thought and behaviour. The pattern has four main steps:

  • obsession – your mind is overwhelmed by a constant obsessive fear or concern, such as the fear your house will be burgled
  • anxiety – this obsession provokes a feeling of intense anxiety and distress
  • compulsion – you adopt a pattern of compulsive behaviour to reduce your anxiety and distress, such as checking all your windows and doors are locked at least three times before leaving the house
  • temporary relief – the compulsive behaviour brings temporary relief from anxiety but the obsession and anxiety soon return, causing the cycle to begin again

Read more about the symptoms of OCD.

What causes OCD?

A number of factors are thought to play a part in OCD. Evidence suggests that in some cases the condition may run in families and is linked to certain inherited genes that affect the brain's development.

Brain imaging studies have also shown that people with OCD have abnormalities, such as increased blood flow and activity, in some parts of their brain. The areas of the brain affected deal with strong emotions and the response to them.

Studies have also shown that people with OCD have an imbalance of serotonin in their brain. Serotonin is a neurotransmitter that the brain uses to transmit information from one brain cell to another.

Read more about the causes of OCD.

Seeing your doctor

People with OCD are often reluctant to report their symptoms to their doctor because they feel ashamed or embarrassed. They may also try to disguise their symptoms from family and friends.

However, if you have OCD, there is nothing to feel ashamed or embarrassed about. OCD is a long-term health condition like diabetes or asthma and it is not your fault you have it.

You should visit your doctor if you have OCD. Initially, they will probably ask a number of questions such as how often you clean and whether you are concerned about putting things in a particular order.

If your doctor suspects OCD, you may need to be assessed by a specialist.

Read more about how OCD is diagnosed.

Treating OCD

If you are diagnosed with OCD, your treatment plan will depend on how much the condition affects your ability to function.

Your treatment is likely to involve behavioural therapy to change your behaviour and reduce your anxiety, and medication to help control your symptoms.

OCD is usually treated with cognitive behavioural therapy (CBT) or antidepressants called selective seretonin reuptake inhibitors (SSRIs). CBT is a talking therapy that can help you manage your problems by changing the way you think and behave.

Depending on how severe your OCD is, you may need to be referred to a specialist mental health service.

Read more about how OCD is treated.

Complications

Some people with OCD also develop depression. You should not ignore feelings of depression because they can become more severe if they are left untreated. Untreated depression will also make it more difficult for you to cope with the symptoms of OCD.

You may be depressed if you have been feeling very down during the past month and things you used to enjoy no longer give you pleasure. If this is the case, you should visit your doctor.

People with OCD and severe depression may sometimes have suicidal feelings.

Contact your doctor or care team immediately if you are depressed and feeling suicidal.

Outlook

If you have OCD, seeking help is the most important thing you can do. Left untreated, it is unlikely your OCD symptoms will improve, and they may get worse. Without treatment, nearly half of people with OCD still have symptoms 30 years later.

With treatment, the outlook for OCD is good and many people will achieve a complete cure, or at least reduce symptoms enough to be able to enjoy a good quality of life.

Symptoms

Obsessive compulsive disorder (OCD) affects people differently, but usually causes a particular pattern of thought and behaviour.

Most people with OCD tend to follow a set pattern of thought and behaviour. This pattern has four main steps:

  • obsession – where your mind is overwhelmed by a constant obsessive fear or concern, such as the fear your house will be burgled
  • anxiety – the obsession provokes a feeling of intense anxiety and distress
  • compulsion – you then adopt a pattern of compulsive behaviour to reduce your anxiety and distress, such as checking all the windows and doors are locked at least three times before you leave your house
  • temporary relief – the compulsive behaviour brings temporary relief from anxiety, but the obsession and anxiety soon return, causing the pattern or cycle to begin again

Obsessive thoughts

Almost everyone has unpleasant or unwanted thoughts at some point in their life, such as a nagging worry that their job may not be secure, or a brief suspicion their partner has been unfaithful.

Most people are able to put these types of thoughts and concerns into context, and they can carry on with their day-to-day life. They do not repeatedly think about worries they know have little substance.

However, if you have a persistent, unwanted and unpleasant thought that dominates your thinking to the extent it interrupts other thoughts, you may have developed an obsession.

Some common obsessions that affect people with OCD include:

  • fear of deliberately harming yourself or others – for example, fear you may attack someone else, even though this type of behaviour disgusts you
  • fear of harming yourself or others by mistake or accident – for example, fear you may set the house on fire by accidentally leaving the cooker on, which leads you to repeatedly check kitchen appliances are off
  • fear of contamination by disease, infection or an unpleasant substance
  • a need for symmetry or orderliness – for example, you may feel the need to ensure all the labels on the tins in your cupboard face the same way
  • fear of committing an act that would seriously offend your religious beliefs

Compulsive behaviour

Compulsions arise as a way of trying to reduce or prevent the harm of the obsessive thought. However, this behaviour is either excessive or not realistically connected at all.

For example, a person who fears becoming contaminated with dirt and germs may wash their hands 50 times a day, or someone with a fear of causing harm to their family may have the urge to repeat an action multiple times to try to "neutralise" the thought of harm. This latter type of compulsive behaviour is particularly common in children with OCD.

Most people with OCD realise that such compulsive behaviour is irrational and makes no logical sense, but they cannot stop acting on their compulsion.

Some common types of compulsive behaviour that affect people with OCD include:

  • cleaning
  • handwashing
  • checking (such as checking doors are locked, or that the gas or a tap is off)
  • counting
  • ordering and arranging
  • hoarding
  • asking for reassurance
  • needing to confess
  • repeating words silently
  • prolonged thoughts about the same subject
  • "neutralising" thoughts (to counter the obsessive thoughts)

Causes

Despite much research being carried out into obsessive compulsive disorder (OCD), the exact cause of the condition has not yet been identified.

However, in certain individuals OCD is thought to be triggered by a combination of genetic, neurological, behavioural and environmental factors.

Genetics

Genetics is thought to play a part in some cases of OCD. Research suggests OCD may be the result of certain inherited genes (units of genetic material) that affect the development of the brain.

Although no specific genes have been linked to OCD, there is some evidence that suggests the condition runs in families. A person with OCD is four times more likely to have another family member with the condition compared with someone who does not have OCD.

Genetic and family studies have also shown OCD may be related to other conditions such as:

  • tics – rapid, repeated, involuntary contractions of a group of muscles
  • Tourette's syndrome – a condition that causes a person to make repetitive movements or sounds

Some people with OCD may also have tics or Tourette's syndrome.

Brain abnormalities

Brain imaging studies have shown that people with OCD have abnormalities in some parts of their brain, including increased activity and blood flow, and a lack of the brain chemical serotonin.

The areas of the brain affected deal with strong emotions and how we respond to those emotions. In the studies, brain activity returned to normal after successful treatment with cognitive behavioural therapy (CBT) or selective serotonin reuptake inhibitors (SSRIs).

Serotonin

Serotonin also seems to play a part in OCD. It is a chemical in the brain (neurotransmitter) that transmits information from one brain cell to another. Serotonin is responsible for regulating a number of the body's functions, including mood, anxiety, memory and sleep.

It is not known for sure how serotonin contributes to OCD, but people with the condition appear to have decreased levels of the chemical in their brain.

Medication that increases the levels of serotonin in the brain, such as certain types of antidepressant, have proven effective in treating the symptoms of OCD.

Life events

An important life event such as a bereavement or family break-up may trigger OCD in people who already have a tendency to develop the condition (for example, due to genetic factors).

A life event can also affect the course of your condition. For example, the death of a loved one may trigger a fear that someone in your family will be harmed.

Stress, which can also be caused by life events, seems to make the symptoms of OCD worse. However, stress does not cause OCD on its own.

Parenting and family

OCD is not thought to be linked to upbringing, but certain factors such as having overprotective parents could increase your chances of developing OCD.

Sometimes it can be unhelpful if a family member of someone with OCD intervenes. For example, a person with OCD may ask a member of their family for constant reassurance about one of their fears, such as whether they have locked the door.

If the family member continually reassures them that they have done something in order to make them feel better, it may prevent them seeking the help and treatment they need.

Infection

There have been reports of some children and young people developing OCD after having a severe infection caused by streptococcal bacteria.

One theory is that antibodies (infection-fighting proteins) produced by the body react with part of the brain, leading to OCD. The infection itself does not cause OCD, but triggers symptoms in children who are genetically predisposed to the condition.

Symptoms of OCD that occur as a result of an infection will usually start quickly (within one to two weeks).

Diagnosis

It is very important you visit your doctor if you have symptoms of obsessive compulsive disorder (OCD).

The impact of OCD on your day-to-day life can be reduced if the condition is diagnosed and effectively treated.

Many people with OCD do not report their symptoms to their doctor because they feel ashamed or embarrassed. They may also try to disguise their symptoms from family and friends.

However, if you have OCD, you should not feel ashamed or embarrassed. Like diabetes or asthma, OCD is a chronic (long-term) health condition, and it is not your fault you have it.

Initial screening

When visiting your doctor, they will probably ask a series of questions.

The questions, which are part of the Fineberg-Zohar screening questionnaire, will help determine whether you are likely to have OCD. But like all screening questionnaires, people who do not have OCD may score positively.

The questions you will be asked may be similar to those listed below:

  • do you wash or clean a lot?
  • do you check things a lot?
  • do you have thoughts that keep bothering you that you would like to get rid of but cannot?
  • do your daily activities take a long time to finish?
  • are you concerned about putting things in a special order or are you upset by mess?
  • do these problems trouble you?

Assessment

If the results of the initial screening questions suggest you have OCD, the severity of your symptoms will be assessed either by your doctor or a mental health professional.

There are several different methods of assessment. All involve asking detailed questions to find out how much of your day-to-day life is affected by obsessive-compulsive thoughts and behaviour.

During the assessment, it is important you are open and honest, as accurate and truthful responses will ensure you receive the most appropriate treatment.

Severity of OCD

The severity of OCD can be determined by how much your symptoms affect your ability to function normally on a day-to-day basis.

Healthcare professionals refer to the disruption of daily function as functional impairment. OCD is classified into three levels of severity. They are:

  • mild functional impairment – obsessive thinking and compulsive behaviour that occupies less than one hour of your day
  • moderate functional impairment – obsessive thinking and compulsive behaviour that occupies one to three hours of your day
  • severe functional impairment – obsessive thinking and compulsive behaviour that occupies more than three hours of your day

Getting help for others

The friends and relatives of a person with OCD sometimes "play along" with their strange behaviour to avoid upsetting them.

However, this is not recommended because it can reinforce the person's obsessive-compulsive behaviour. It is better to confront them with the reality of their unusual behaviour and suggest they seek medical advice.

Treatment

If you have obsessive compulsive disorder (OCD), your treatment will depend on the how much the condition is affecting your ability to function.

As OCD develops, the unwelcome and obsessive fears that can be overwhelming vary from person to person. This is also the case for the compulsive behaviour people use to try to control their fears.

How much impact OCD has on a person's life depends on:

  • the amount of time spent on a compulsive behaviour or ritual
  • the intensity of the behaviour
  • how much of it happens in their mind, rather than in their actions

Your treatment plan

Your treatment programme is likely to involve:

  • behavioural therapy – to change the way you behave and reduce your [anxiety]
  • medication – to control your symptoms

Healthcare professionals refer to the disruption of daily function as functional impairment.

OCD that causes mild functional impairment is usually treated with a short course of cognitive behavioural therapy (CBT). CBT is a talking therapy that can help you manage your problems by changing the way you think and behave.

If you have OCD that causes moderate functional impairment, it may be recommended that you have a more intensive course of CBT, or a type of antidepressant medication known as selective seretonin reuptake inhibitors (SSRIs). You may also be referred to a specialist mental health service.

If your OCD causes severe functional impairment, you will be referred to a specialist mental health service for a combination of intensive CBT and a course of SSRIs.

Children with OCD are usually referred to a healthcare professional with experience of treating OCD in children.

Behavioural therapy

CBT that involves graded exposure and response prevention (ERP) has been shown to be an effective treatment for OCD.

Exposure and response prevention (ERP)

ERP involves identifying a number of situations that cause you [anxiety]. These are placed in order from the situations that cause you the most to the least anxiety.

You and your therapist will identify tasks that will expose you to the situations that cause anxiety, but at a level you can cope with. You need to do the exposure tasks without carrying out your anxiety-relieving compulsions (the actions you usually take to help you cope with the situation).

Although this sounds frightening, people with OCD find that when they confront their anxiety without carrying out their compulsion, the anxiety disappears completely in one to two hours.

The same exposure task should be repeated two to three times a day. Each time, the anxiety is likely to be less and last for a shorter period of time. Once you have conquered one exposure task, you can move onto a more difficult task, until you have overcome all of the situations that make you anxious.

People with mild to moderate OCD usually need about 10 hours of therapist treatment, combined with self-treatment exposure exercises between sessions. Those with moderate to severe OCD may need a more intensive course of CBT that lasts longer than 10 hours.

Medication

You may need medication if CBT fails to treat mild OCD, or if you have moderate or severe OCD. The different types of medication you may be prescribed are discussed below.

Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are a type of antidepressant that increase the levels of a chemical called serotonin in your brain. Serotonin is a neurotransmitter that the brain uses to transmit information from one brain cell to another.

Possible SSRIs that you may be prescribed include:

  • fluoxetine
  • fluvoxamine
  • paroxetine
  • sertraline
  • citalopram
  • escitalopram

You will usually need to take an SSRI for 12 weeks before you notice any benefit. Most people with moderate to severe OCD need to take SSRIs for at least 12 months. After this time, your condition will be reviewed and if it causes few or no troublesome symptoms, you may be able to stop taking the medication.

Possible side effects of SSRIs include headaches and feeling sick. However, these should pass within a few weeks.

There is a small chance SSRIs will increase your anxiety, which may cause you to have suicidal thoughts or a desire to self-harm.

Contact your doctor immediately or go to your nearest hospital if you are taking an SSRI and have suicidal thoughts or want to self-harm.

It may be helpful to tell a close friend or relative you are taking SSRIs. Ask them to tell you if they notice changes in your behaviour, or if they are worried about the way you are acting.

You may also have side effects when you stop taking SSRIs, so you shouldn't stop taking your medicine suddenly. If you no longer need the medicine, your doctor will gradually reduce your dose.

To find out more about possible side effects, see the patient information leaflet that comes with your medicine or the [medicines information] tab above.

Some people respond better to one SSRI than another. If you have been taking full recommended doses of an SSRI for three months without any benefit, you may be prescribed a different type of SSRI.

The doses of SSRI recommended for OCD are higher than those usually used for depression. There is evidence that low doses of SSRIs are ineffective.

Clomipramine

Clomipramine is a tricyclic antidepressant (TCA) that can be used as an alternative to SSRIs for treating OCD. TCAs are not as commonly used as SSRIs because they cause more side effects. However, they can be effective in treating people with OCD who cannot tolerate SSRIs.

Possible side effects of clomipramine include:

Clomipramine is not suitable for people who have:

  • low blood pressure
  • arrhythmia (an irregular heartbeat)
  • recently had a heart attack

If you are at risk of cardiovascular disease (conditions that affect the heart or blood vessels), your doctor may recommend you have a blood pressure test and an electrocardiogram (ECG) before starting your treatment. An ECG measures the electrical activity of your heart.

As with SSRIs, a 12-month course of clomipramine is usually recommended, after which time your symptoms will be reviewed.

To find out more about the possible side effects, see the patient information leaflet that comes with your medicine or the [medicines information] tab above.

If SSRIs or clomipramine prove ineffective, you will be referred to a specialist mental health service.

Support groups

Many people with OCD find support groups helpful, as they can:

  • give you reassurance
  • reduce feelings of isolation you may have
  • give you a chance to socialise with others

Support groups can also provide information and advice for family members and friends who may be affected by your condition.

Surgery

Surgery is the very last resort for treating severe OCD when all other forms of treatment have failed. It should not be considered at all until someone has:

  • received at least two full trials of different SSRIs or clomipramine at recommended doses
  • had treatment for refractory OCD (OCD that does not respond to treatment) as well as antipsychotic medication or higher doses of SSRIs or mood stabilisers
  • received unsuccessful CBT treatments both in a clinic and at home.

Ablation neurosurgery

A very small number of people with OCD will need neurosurgery. During ablation neurosurgery, a neurosurgeon (a surgeon who specialises in surgery of the brain and nervous system) uses an electric current or a pulse of radiation to burn away a small part of the limbic system. The limbic system is a structure in the brain responsible for some of the most important brain functions, such as higher emotions, memory and behaviour.

Neurosurgery for OCD has never been subjected to controlled clinical trials. However, a survey conducted by the Royal College of Psychiatrists found that out of 478 people who had surgery for OCD, more than half felt they had improved. However, up to 15% felt unchanged or worse.

In addition, surgery for OCD carries the risks of both short- and long-term side effects, such as memory loss and mental confusion, which can be serious and irreversible.

Deep brain stimulation

Deep brain stimulation is an alternative surgical technique that may be used more frequently to treat OCD in the future. Currently, it is only used as part of medical research.

Deep brain stimulation involves implanting an electrical generator into your chest and electrodes (small metal discs) into your brain. An electrical signal is sent from the device in your chest to the electrodes in your brain.

Some small studies looking at deep brain stimulation for OCD have reported an improvement in symptoms. However, there are some possible serious side effects associated with the technique, including infection and bleeding inside the brain.

Family friends

Many people with obsessive compulsive disorder (OCD) can trace some of their anxieties and compulsions back to their childhood.

On average, compulsions start to interfere significantly with a person's life when they are 17-20 years of age. However, it can be as early as five years of age or as late as 70.

The unwelcome and obsessive fears that threaten to become overwhelming as the condition develops vary from person to person. So too does the compulsive behaviour that the person uses to try to control the fears.

How much impact OCD has on a person's life depends on:

  • the amount of time spent on a compulsive behaviour or ritual
  • the intensity of the behaviour
  • how much of it happens in their mind rather than in their actions

Rituals that involve checking can affect different people in different ways. For example, when leaving the house, a person with OCD might shut the door behind them and then think about it again and again for much of the day.

Their worry about the door being properly locked is constant, and so is the misery and depression that goes with it. Despite this, some people with OCD are able to hold down demanding jobs.

For others, the behaviour can take up all of their focus. When they try to leave the house they get stuck in the hallway, repeatedly checking the lock. In the most extreme cases, the [anxiety] and the thought of carrying out these rituals can prevent a person from moving for hours.

Supporting family members with OCD

Naturally, family members of someone who is openly affected by these behaviours will want to help. For a person who has not had mental health training and is unaware of the treatment options, this usually means trying to share the load. For instance, they may take on some of the rituals of a compulsive cleaner or checker.

This might seem the natural thing to do, but the whole family may end up constantly trying to protect the person with OCD from their own fears. However, this is counter-productive because the problem is not resolved and there is no hope of moving on. In this way, the whole family 'suffers from OCD'.

The best approach is to help the person with OCD to seek treatment and to support them as they change and recover. Once therapy has begun, the contribution and support of a partner is invaluable.

Sometimes, the person with OCD can feel embarrassed or ashamed and they will try to hide their rituals from others. When this involves a physical activity, such as hand washing, the first sign that something is wrong may be the appearance of their hands, or the length of time they spend in the bathroom. Mental rituals are often more difficult to notice.

Fortunately, when someone with OCD decides to get help, a good doctor will be able to recognise the signs and seek further advice and support from specialists.

Real stories

Diana had obsessive compulsive disorder (OCD) for 26 years. Now working for OCD-UK, she shares her story here about how she finally overcame the disorder.

"My earliest memory of the illness was when I was about eight years old. The symptoms were a fear of stepping on the pavement cracks. I don't know why, but it made me feel physically uncomfortable if I did it.

"That was one ritual. Another ritual, which was a compulsion, was the fear that if I didn't say my prayers respectfully and sincerely, my mother might be killed in a car accident. I took on this huge responsibility as a child for another person's life.

"A lot of people know about the hand washing and the checking of things, but many people are unaware that OCD can also take a sinister angle, where you have a fear that you may harm your own children very violently.

"When I had my fourth child I had intrusive thoughts at bedtime that I would go to the children's bedrooms in my sleep, take out their dressing gown cords and strangle each one. This was horrendous to go through, because I didn't know whether I was going to do it or not.

"People with OCD are not dangerous and they do not harm, but I was permanently exhausted.

"That was the obsession: the compulsion was to try to relieve some of the pain and terror that came from those thoughts. I would get out of bed, find their dressing gowns, take the cords out of the dressing gowns and tie them into as many knots as possible, so that I wouldn't be able to put the cords around their necks.

"Then I'd go back to bed, but I still couldn't sleep. I would get out of bed again, get the cords, put them in a bag, seal the bag, and put the bag in a high cupboard. This would give a little relief, but it was still terrifying.

"After I saw my doctor, I saw a consultant psychiatrist. I was put on antidepressants, which helped me enormously. Medication gave me the strength to sleep and eat well, so I could then have cognitive behavioural therapy (CBT), which is a psychological treatment that deals with the present. I was able to put my heart and soul into my own recovery.

"I often used to ask myself what was wrong with my memory and why I couldn't remember whether the gas has been turned off, even though I'd checked it 13 times and I only checked 10 seconds ago. In fact, people with OCD have a perfectly accurate memory, but what we don't have is a confident memory. CBT can help to restore that."

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