Obsessive compulsive disorder

While most of us have, at some time, experienced the uneasy feeling that we have left home and forgotten to do something important such as locking the door or turning off the gas, we usually manage to put these worries out of our minds. But if you have obsessive compulsive disorder, such worries can totally dominate your life.

Obsessive compulsive disorder (OCD) is a type of anxiety disorder that affects about 2 in every 100 people in Australia. People with OCD have persistent distressing thoughts that are often accompanied by repetitive acts performed over and over again to try to relieve their anxiety. OCD is sometimes called the ‘doubting’ disease, as fears and thoughts can be so strong that they fill the mind with doubt.

Symptoms of obsessive compulsive disorder

The main symptoms of OCD are obsessions and compulsions.

Obsessions

Obsessions are repeated thoughts, ideas, impulses or images that are unwanted, unpleasant and intrusive. Common obsessions include:

  • fear of contamination or dirt;
  • concern about things being orderly and symmetrical; and
  • fear of harm to self or others.

These persistent, unwanted thoughts make people with OCD feel very anxious, distressed and sometimes guilty. The obsessions are not the same for everyone, and the obsessions may change over time. People with OCD often avoid situations that trigger their obsessions.

Obsessions sometimes involve a fear that you will do something out of character, including violent behaviour or inappropriate sexual behaviour, which makes it hard to talk about. However, people with OCD never actually act on these obsessional thoughts.

Compulsions

Compulsions are repetitive behavioural rituals or mental acts. The compulsions are performed to reduce the anxiety, distress or disgust generated by the obsessions. They may or may not be obviously related to the obsessions. Examples of compulsions include:

  • repeated hand washing or cleaning (usually associated with a fear of germs);
  • ritual checking behaviours (such as checking locks, lights or appliances before leaving home - generally driven by safety worries);
  • ordering objects (often associated with an obsession with symmetry);
  • repeatedly tapping or touching objects or moving in a certain way; or
  • mental rituals, such as counting or repeating words in your head.

The compulsions usually need to be performed according to certain rules, such as doing something a certain number of times or in a certain order. People with OCD usually know that the compulsions are excessive, illogical or unreasonable. They understand that performing their compulsions will not prevent whatever they are worried about, but find it impossible to resist performing them nonetheless. So unlike ordinary habits or personal rituals, someone with OCD is unable to stop engaging in their compulsive behaviours.

OCD symptoms in children

Symptoms of OCD often develop in childhood or during teenage years, but many people are not diagnosed until they are older teenagers or adults. Use the following checklist to see if your child has symptoms that are consistent with those of obsessive-compulsive disorder (OCD).

  1. Does performing a certain ritual feel like an urgent necessity of life to your child?
  2. Do recurrent intrusive thoughts cause your child discomfort or anxiety?
  3. Does an extreme need for order and cleanliness force your child to tidy things, bathe or shower, or wash his or her hands excessively?
  4. Does your child do things over and over (such as get up and down from a chair, count or tap)?
  5. Does your child repeatedly perform certain routines to prevent ‘bad things’ from happening?
  6. Does your child have great difficulty discarding things even when they have no practical value?

Some of the repetitive things that children with OCD do include:

  • worry about germs from other people;
  • repeatedly wash their hands;
  • check things many times (such as locks on doors); and
  • have to tap or count repeatedly.

Is it OCD or not?

Being a little 'obsessional' can be quite normal and even beneficial. It is not the same as OCD, which is characterised by the presence of obsessions and compulsions, not just neatness or careful planning.

Which types of behaviours indicate OCD?
 What's OCDWhat's not OCD
Cleaning/Washing
AdultA man who washes his hands 100 times a day, until they are red and rawA woman who unfailingly washes her hands before eating
Child/
Adolescent
A 14-year-old boy who is late for school every day because he can't get out of the shower until he has lathered and rinsed exactly 41 timesA 16-year-old girl who spends 30 minutes washing and styling her hair every day before school
Counting/Repeating
AdultA university student who must tap on the doorframe of every classroom 14 times before enteringA musician who practises a difficult passage over and over again until it's perfect
Child/
Adolescent
A 7-year-old girl who can't stop skipping over cracks in the footpath until she has done it 89 times because she fears that something terrible will happen to her mother if she doesn'tA 5-year-old girl who laughs with her friends while skipping over cracks in the footpath, reciting, ‘Step on a crack; break your mother's back’
Checking/Questioning
AdultA woman who locks and relocks her door before going to work every day — for half an hourA woman who double-checks that her apartment door and windows are locked each night before she goes to bed
Child/
Adolescent
A child who checks over and over that the light switch is in the off position, even though it is obvious that the light is offA child who double-checks that the light switch is off as she leaves a room, just like her parents have asked her to do

Complications

Having OCD can be exhausting, frightening and embarrassing. It can interfere with school, work, relationships and your social life. Many people, realising that their behaviour might seem strange to others, keep it secret and develop elaborate ways to hide the disorder from parents, teachers, employers and friends.

OCD can be extremely time-consuming, with the compulsions taking up several hours every day. Some severely affected people are unable to leave their house for even a short shopping trip as they feel the need to keep going back to check things.

Untreated, OCD in adolescents can be particularly devastating because it coincides with a crucial period of social and emotional development. Schoolwork, home life and friendships can be seriously affected.

In some people, additional anxiety disorders, eating disorders, body dysmorphic disorder, tics, depression, hoarding and alcohol or substance misuse may develop. People who compulsively wash their hands or body may develop dermatitis and skin problems as a result.

Causes

The exact cause of obsessive compulsive disorder is not known, but it is thought that a combination of biological and environmental factors are involved.

Having a family member with OCD increases your risk of developing the condition. This may be because of a genetic link, although no specific genes have been identified as yet. OCD has also been linked to an imbalance of serotonin (a chemical in the brain) and differences in the function of certain areas of the brain, but more research is needed.

OCD may be more common in people who have experienced bullying, abuse or neglect.

Diagnosis of OCD

Your doctor will ask about your symptoms, including the thoughts you are experiencing and the behaviours that you engage in. Many people with OCD have symptoms for years before they are diagnosed because they are reluctant to seek help. Try not to feel embarrassed or ashamed - your thoughts and behaviours are part of a mental health disorder that is well recognised and can be treated.

A diagnosis of OCD can be made based on your history - there are no special tests needed. Your doctor may refer you to a psychologist or psychiatrist for further evaluation and treatment.

Treatments for obsessive compulsive disorder

OCD can be treated with psychological (talking) therapy, medication or both. Combination treatment with both medicines and psychological therapy seems to have the best response. Medication on its own is not usually recommended for children.

As part of your treatment, your doctor or therapist will explain the condition so that you understand how it affects you.

Psychological treatments

Cognitive behavioural therapy (CBT) is a commonly used form of counselling for anxiety disorders. A specific type of CBT, called exposure and response prevention therapy (ERP), has been found to be effective for the treatment of obsessive compulsive disorder. It involves being exposed to situations that provoke your obsessions, and learning to prevent your usual response (performing compulsions).

You start with exposure to situations or thoughts that cause the least amount of anxiety for you, and very gradually work up to situations that usually make you very anxious. You are slowly guided and supported to experience these situations and manage your anxiety without having to perform your compulsions. The aim is to show that performing your compulsions is not necessary to prevent the feared outcome.

Psychological therapy helps you to stop avoiding situations that may trigger symptoms, and tends to be better at preventing relapses than medicines.

This treatment, by its very nature, provokes anxiety because you are learning to confront your fears. But many people with OCD find that their symptoms and quality of life improve following this type of treatment. If you have severe symptoms, you may tolerate ERP better if you start medication before starting ERP.

Problems associated with ERP therapy include cost and availability. There are some internet-based psychological treatment programmes that may be a good option for people who lack access to face-to-face psychological therapy. The programmes may be guided by a therapist or self-guided.

Medicines

Medicines may be prescribed in combination with psychological therapy for people with more severe symptoms. Some people are prescribed medicines on their own to treat OCD - often when psychological therapy is not available.

Selective serotonin reuptake inhibitors (SSRIs) are a type of anti-anxiety and antidepressant medicine that have been found to effectively treat OCD symptoms.

Examples of SSRI medicines used to treat OCD include:

  • escitalopram (e.g. brand name Lexapro);
  • fluoxetine (e.g. Prozac, Lovan, Zactin) - not recommended for treatment of OCD in children;
  • fluvoxamine (e.g. Luvox, Movox);
  • paroxetine (e.g. Aropax, Roxet, Roxtine, Paxtine); and
  • sertraline (e.g. Zoloft, Eleva, Xydep).

Side effects associated with SSRIs include nausea, loss of appetite, diarrhoea, restlessness, sexual problems such as reduced libido (sex drive) and insomnia (difficulty sleeping). Children, teenagers and young people need close monitoring when these medicines are first started due to the slightly increased risk of suicidal thoughts and behaviour that can affect some people younger than 25 years when these medicines are first started.

Clomipramine (e.g. Anafranil, Placil) is another type of antidepressant medicine that can also be used in the treatment of OCD. Side effects of clomipramine can include dry mouth, blurred vision, constipation, weight gain and sleepiness.

If you experience troubling side effects see your doctor - they may suggest trying a different medicine.

You usually need to take OCD medication for several weeks to notice an effect on your symptoms. Sometimes the full effects are not felt for 3 months. If you don’t respond to the medicine your doctor has prescribed, a higher dose or a different medicine may need to be tried. Many people find that their symptoms improve with medication, but do not disappear completely.

Support groups

There are many community and online support groups for people with OCD and their families. These groups help put you in contact with others who are affected by OCD, which can help immensely.

Understanding from fellow sufferers who know what having OCD feels like can help you feel less isolated. You can also share coping strategies. Education and support for family and friends may improve their patience and understanding. Ask your doctor or search the internet for a group that suits your needs.

References

1. Obsessive compulsive disorder (published July 2013). In: eTG complete. Melbourne: Therapeutic Guidelines Limited; 2017 Nov. https://tgldcdp.tg.org.au/ (accessed Feb 2018).
2. Anxiety disorders in children and adolescents (published July 2013). In: eTG complete. Melbourne: Therapeutic Guidelines Limited; 2017 Nov. https://tgldcdp.tg.org.au/ (accessed Feb 2018).
3. SANE Australia. Obsessive compulsive disorder (updated 7 Dec 2017). https://www.sane.org/mental-health-and-illness/facts-and-guides/obsessive-compulsive-disorder (accessed Feb 2018).
4. Johnson C, Blair-West S. Obsessive-compulsive disorder: The role of the GP. Australian Family Physician 2013;42(9):606-9. https://www.racgp.org.au/afp/2013/september/ocd/ (accessed Feb 2018).
5. Crino R. Treatment guidance for common mental health disorders: Obsessive compulsive disorder. InPsych. Australian Psychological Society (APS) 2014;36(5). https://www.psychology.org.au/Content.aspx?ID=6212 (accessed Feb 2018).
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