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OCD ( obsessive-compulsive disorder )OCD ( obsessive-compulsive disorder )

We all have routines and habits that we perform regularly. But sufferers of obsessive-compulsive disorder, or OCD, carry this behaviour to such extremes that they may not be able to carry out normal activities.

Almost all of us can probably remember occasions on which we've had to double check to make sure we turned off the lights before going to bed, or that we have our passports when we're off on holiday.


However, sufferers from obsessive-compulsive disorder, or OCD, take such behaviour to extremes. Some wash their hands literally hundreds of times a day until they are red, raw and chapped. Others may spend hours checking doors, locks, switches and taps in a strict order before leaving the house. And if they lose count or make a mistake, the ritual has to start again.

Some sufferers are dominated by obsessive thoughts, such as the fear that they'll kill someone. They may then resort to very complicated protective rituals, such as hiding sharp knives to remove temptation.

OCD affects one in 25 people, and it's thought that as many as one million people in the UK, and as many as five million in the US, are affected. It can strike anybody at any time. However, the most common time for this condition to develop is between the ages of around 16 to 40. OCD can run in families, but this may be because children emulate their parents and take on their anxiety and fears.

OCD usually takes two forms. First there are the obsessive thoughts. These persistent, distressing, unwanted ideas intrude into the mind even against the sufferers' will.

The second form is compulsive behaviour, repetitive actions and rituals that have to be performed again and again, even though the person knows they are ridiculous and tries to fight them.

Both of these forms tend to affect people who have conscientious, perfectionist personalities. At the same time, depressed or anxious people may also suffer from obsessional symptoms.

In moderation, these behaviours are harmless and may even be beneficial, for example tidiness and cleanliness can help people in their homes and jobs. But when taken to the point where they dominate every action, they can cause great distress, not just to the sufferer, but also to his family and friends. They can prevent the sufferer leading a normal life or working efficiently. Attempts to prevent the obsession or compulsion often result in considerable anxiety or worry that something awful may happen if the act is not performed.

There are various types of OCD. One of the most common is a fear of contamination, which results in the sufferer constantly washing, or avoiding things or places where contamination can occur.

Sufferers may feel dirty after going to the toilet or being near animals, and may have to wash for hours afterwards. Some spend hours every day doing housework. They may even have to move house or move to another town, if the one they live in is 'too dirty'.

Another common form of OCD is checking. People afflicted with this type have to repeatedly check things like doors, taps, appliances and light switches, sometimes literally hundreds of times. They may have to get up early to leave time for everything to be checked.

Some sufferers feel they have to retrace their footsteps or go back to particular places, because they become obsessed with the fear that they have harmed someone and need to check just in case.

Rituals involving counting are also quite common. Sufferers may have to work out how many words someone says when they speak to them, count the number of letters in road signs, or indulge in extremely complicated mathematical calculations such as multiplying the digits of house numbers. They may have to touch various objects a very specific number of times.

Less commonly, sufferers may be dogged by obsessional slowness. They spend hours in the bathroom cleaning their teeth or shaving. Such sufferers tend to have a strong need for symmetry, order and exactness. Everything must be done in a slow, methodical way. Even a tiny deviation means starting over again.

Hoarding is another variety of OCD. Sufferers feel compelled never to throw anything away and may keep bits of string, old bus tickets, even food. Their rooms are cluttered with old furniture, tin cans, papers and clothes that the sufferer can't bear to part with.

Apart from these rituals some sufferers are dogged by morbid preoccupations: they fear they will harm or damage someone close to them, or they imagine they have inadvertently run someone over when out in the car.

Often sufferers' families and friends get drawn into these rituals and obsessions. They may force their children to stay all day in a playpen for fear of them getting contaminated, forbid them to play with other children, or at a later age forbid them to come into the house again after going to school, without first disinfecting their shoes and washing carefully.

Underlying all these strange thoughts and bizarre rituals is anxiety, even though sufferers may not feel consciously anxious. Sometimes depression acts as a trigger which starts an obsession. Prolonged extreme stress can also cause troublesome anxiety, which goes on long after the source of stress has disappeared.

At other times, the obsession can be traced back to a particular event, such as a divorce or bereavement. The experience of anxiety - the racing heart, sweaty palms, dry mouth and trembling - is so unpleasant that the sufferer will do almost anything to avoid it, hence the development of rituals, which keeps the fear at bay.

There are various effective ways of treating OCD and overcoming anxiety. One of the most successful is called exposure therapy. This involves the sufferer gradually being exposed to the thing he fears. By deliberately entering into and staying in anxiety-provoking situations, the anxiety first increases and then decreases.

So, the OCD sufferer who fears contamination is encouraged to expose themselves gradually to 'dirt', but first they may be asked to grade feared situations on a scale of 0-10. They are then encouraged to enter any of the feared situations, starting with the easier ones. For example, they may be encouraged first to use their own toilet, then the toilet in a friend's house, then a stranger's house, and slowly work up to using a public lavatory. As the sufferer gets accustomed to doing these things, the anxiety reduces and the urge to wash afterwards becomes less intense.

The person who has to check everything numerous times may be encouraged to confront the situations linked to the checking. He will do this until the anxiety and discomfort lessens, and in turn the need to check.

Therapists may help by what is called 'modelling'. The therapist first does what the sufferer has to do, providing a concrete example. For instance, a therapist might let a sufferer watch him eat a sandwich after touching something the sufferer considered dirty, such as a pen or a newspaper. As the sufferer progresses, he might then be encouraged to share in a meal that has been prepared in someone else's kitchen.

At the same time, sufferers are asked to limit and resist obsessional behaviour. For instance, someone who continually washes after touching something 'dirty' must resist for one minute, and can then wash for 10 minutes. They work up to waiting for 10 minutes, then washing for one minute.

Sufferers must also resist the urge to ask for reassurance concerning any harm he might cause by not checking or washing. Reassurance is a form of 'reward', which tends only to keep anxiety at bay for a short time.

Learning to tolerate anxiety-provoking situations without asking for reassurance helps the sufferer realize he can cope with anxiety.

To increase their motivation, sufferers are encouraged to focus on the benefits to be gained from a change in behaviour: for example, being able to lead a normal life, visit friends, hug your children or go shopping without worrying.

Family members may be asked to get involved. Children can encourage a parent to go swimming in a public pool, which he would previously have avoided for fear of contamination. Gradually as the sufferer realizes he can cope with the anxious feelings, the feelings lessen and the obsessional behaviour and thoughts decrease.

Another technique is called cognitive therapy, in which depression and anxiety are believed to be a result of unhelpful negative thoughts.

Treatment encourages sufferers to challenge these thoughts. For example, if the thought 'I've left the back door unlocked' intrudes, sufferers are encouraged to question what the evidence is. They are asked to think, 'How many times before have I gone back to check and found it locked?' and so on. Techniques such as relaxation and breathing may be used to help cope with the anxious feelings.

If these psychological techniques don't work, a form of drug treatment may be suggested. This may be used alone or in conjunction with another approach.

Anxiety and rituals may often become worse during a period of depression. If this is an underlying problem the doctor may prescribe antidepressant drugs.

One group of antidepressants that may prove useful are called seratonin-re-uptake inhibitors. Seratonin is a brain chemical which is thought to be involved in depression. It may also be a factor in OCD. They can cause a number of side-effects, but these are not nearly as bad as the side effects you often get with older, tricyclic antidepressants. The drugs are often more effective when taken along with others, such as lithium and the amino acid L-tryptophan.



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