Welcome to Priory Bitesize. This month we spoke to Dr David Veale, Consultant Psychiatrist at The Priory Hospital North London. We discussed the mental health condition Obsessive Compulsive Disorder, otherwise known as OCD.
OCD is an anxiety disorder characterised by two parts: obsessions and compulsions. They can exist either separately or together, and the disorder is caused by a combination of genetic and developmental factors.
An obsession is a recurrent thought, image or urge and a compulsion is a repeated action carried out to avoid or reduce distress, usually in response to an obsession. Common obsessions and compulsions include:
- Fear of contamination of people or objects from germs, dirt or disease
- Fear of causing an accident, injury or misfortune
- Having unacceptable thoughts
- Excessive cleaning or hand washing
- Repeated assurance seeking
- Ritually arranging and ordering objects or activities
Obsessions and compulsions can have a detrimental effect on people's lives. Symptoms can interfere greatly with day-to-day life and can become significantly distressing for the individual if left untreated. Associated emotions with OCD include disgust, shame, and a distressing sense of ‘incompleteness’, which usually leads to 'ritualising' until things feel ‘just right’.
How to identity and diagnose OCD
Simple screening questions provided by the National Institute for Health and Care Excellence (NICE) can help to diagnose OCD and assess the need for further referral:
- Do you wash or clean a lot?
- Do you check things a lot?
- Is there any thought that keeps 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 very upset by mess?
- Do these problems trouble you?
If a person responds affirmatively to one of the above questions, a more formal diagnostic interview should be conducted. It is important to remember that while some OCD symptoms are easily observed and reported, others can be extremely difficult to pick up on without probing, especially where the rituals are covert or stigmatising.
For example, someone who has fears of being a paedophile may not even realise they have OCD, or avoid seeking help in case they are reported to social services. However, while every case needs to be assessed individually, there are no known cases of people with OCD acting on their thoughts. In this type of situation, it is important to assess the secondary risks, such as this person neglecting to bath their child or change his/her nappy.
Other signs of OCD to look out for include preoccupation and anxiousness or taking a long time to respond to questions (due to rumination). People with OCD may also present to their GP with physical symptoms as a result of their OCD, such as:
- Dermatological symptoms (from excessive washing)
- General stress (for example, from losing a job as a result of repeated lateness)
Avoidance is also an integral part of OCD, and could include:
- Taking care not to touch toilets, taps and door handles used by others
- Hiding all sharp objects
- Avoiding being left alone with children
Family involvement is also common in OCD, and therefore GPs should assess the degree to which relatives accommodate the OCD, along with attitudes to treatment and restrictions placed on the family by the sufferer (e.g. not being allowed to use certain rooms).
People with OCD can become skilled at hiding their symptoms in an attempt to carry on functioning ‘normally’. Research shows that people can often spend up to 10 years or more struggling with OCD before seeking appropriate help.
Getting the right help and support is vital to the success of one’s treatment, and can improve the outcome of the illness for most sufferers. Self-help is the first stage of treatment and sometimes a self-help book might be all that is required for mild OCD. However, the outcome is much less predictable for those with moderate to severe OCD; some may be chronically ill but find they have periods of remission, while others deteriorate progressively.
According to NICE guidelines, Cognitive Behavioural Therapy (CBT), which includes ‘Exposure and Response Prevention’ (ERP) is the most effective form of therapy for OCD. CBT is based on a psychological understanding of the patient’s OCD and what is maintaining the problem. The therapist helps to change the excessive degree of responsibility and thought processes, demands for certainty about the risks of exposure, and the criteria used for termination of a compulsion.
Exposure requires the patient to repeatedly test their fear and expectations, learning to tolerate the anxiety while not performing their rituals (response prevention).
What does this mean?
- Learning to give up control
- Resisting the compulsions
- Repeatedly tolerating the discomfort that occurs
- Planning out exposures and behavioural experiments so that patients test out whether their irrational theories actually match the results
Through consistent exposures, patients will gradually find it easier to face up to the fear and to cope with anxiety, and may then be able to generalise what is learnt through exposures in other areas of life. Despite an increase in short-term anxiety and distress, these tend gradually to decrease over time.
Anti-obsessional medication consists of anti-depressants called Selective Serotonin Reuptake Inhibitors (SSRIs). They may be used either alone or in combination with CBT and side effects tend to be minor, and fade after a few weeks. The drugs are not addictive and safe to use over time. They can be stopped at any time without withdrawal symptoms, provided the dosage is reduced slowly. About 60% of patients with OCD improve with medication, but of those, at least 75% will relapse in the months after stopping the drug. Research shows there are benefits to using SSRIs, in the short term and also in the longer term, when combined with CBT, for prevention of relapse.
A higher dose of SSRI is better for OCD than a standard dose needed for depression. Medication can help patients with their motivation, so that they are able to take advantage of a psychological treatment programme. It can also reduce excessive anxiety, which can interfere with completion of a course of CBT. For severe OCD, a combination of CBT and a SSRI is recommended. Intensive CBT for severe OCD can also be provided on a specialist inpatient unit.
To read about treatment options available, please visit our treatment page or for more detailed information about OCD please visit our specialist OCD/BDD service at The Priory Hospital North London.
To visit our dedicated GP section on the website, click here. If you would like to make a referral call: 0800 840 3219, to send an email click here, or alternatively use our secure online referral form.
Veale, D, Roberts, A. (2014) Clinical Review: Obsessive Compulsive Disorder. BMJ; 348:g2183 http://dx.doi.org/10.1136/bmj.g2183
Veale, D, Willson, R (2005) Overcoming Obsessive Compulsive Disorder. Constable Robinson publishing, London.