Even though they are aware that their behaviour is strange, people who suffer from Obsessive-Compulsive Disorder (OCD) have an overwhelming urge to repeat certain rituals to reduce their anxiety. What do we know about this stressful condition?
Before Alice (57) leaves the kitchen, she goes through a complicated process of checking and rechecking that all the appliances and switches are off. John (28) can’t get out of bed unless the numbers on his digital clock add up to a ‘safe’ total; he also has to tap the table a set number of times to make sure that bad things don’t happen to his family. Megan (12) washes her hands repeatedly and if anyone touches her soap it must be thrown away.
They all have OCD, a condition that causes untold stress and shame to the sufferers who can’t stop their behaviour, even though they know it’s not normal. In the past, bizarre rituals associated with OCD have at times been misdiagnosed as schizophrenia.The difference, however, is that the schizophrenic sees nothing odd about his actions, whereas the person with OCD is painfully aware of them.
‘It can take years for OCD sufferers to seek help, as they tend to hide their problems,’ says Dr Peter Crafford, a psychiatrist at the specialised mental health unit at Life Hunterscraig Private Hospital in Port Elizabeth. ‘OCD is all about struggling for control over obsessional thoughts and the impulse to perform compulsive behaviours. People with the disorder are reluctant to give over control to a drug or a doctor. Many never get treated. Those that do come to a facility like ours are often seeking help for depression. As 50% of depressions are bipolar, it’s imperative that patients are properly assessed so that they can receive the right treatment. If there is an underlying psychiatric illness, the drugs that are usually used to treat OCD can make that illness worse.’
Obsessions and compulsions
A person with OCD is obsessed with a thought, image, impulse or phrase that is intrusive, involuntary and anxiety-producing, explains Kevin Bolon, a Johannesburg clinical psychologist with a special interest in the disorder. The compulsion is the action, performed voluntarily, that reduces the anxiety associated with the obsession. The trouble is that the obsessive thought keeps reoccurring, so the activity that brings momentary relief has to be repeated, over and over again.
Sixty percent of OCD patients have a washing compulsion says Bolon. Other common compulsions are to symmetrise objects, check or touch something a set number of times. Sometimes compulsions can’t be observed – they may be repetitive sayings – and sometimes they take the form of avoidance of words, images or places. They are often associated with ‘magical thinking’, as in, ‘if I switch the light on and off 10 times the children will be safe today, but if I get it wrong, there may be an accident.’
When is it a habit and when is it OCD?
If you live a frenetic life, it’s not surprising that you are occasionally distracted or forgetful. Running late for work you leave the house on autopilot, your head already buzzing with what must be done later. As you drive off you realise you don’t remember locking the door, or switching off the iron after you pressed your shirt … you’re pretty sure you did but you feel compelled to go back to check anyway, berating yourself for being neurotic and wasting more precious time.
This kind of anxiety is not unnatural, once in a while, neither are the quirks and habitual behaviours that most people have. The key question in deciding whether you have OCD is to ask how much time your rituals take up and how much they interfere with your ability to function normally. Do you spend more than an hour each day performing some activity that soothes your anxiety? Does this habit impact significantly on your relationships, you ability to study, work, or do your chores?
‘Obsessionality is a personality trait,’ explains Dr Crafford. ‘It only becomes a psychiatric disorder when it results in dysfunction and distress.’
What causes OCD?
OCD is a neurobiological disorder that manifests as a conditioned thought, linked to soothing compensatory action. It’s not known what causes it ,but there is evidence that genetics play a part.
‘Children of an OCD parent have an increased but modest risk of developing the disorder,’ says Professor Christine Lochner, a clinical psychologist who heads research into OCD at the MRC Unit on Anxiety and Stress Disorder at the Department of Psychiatry, Stellenbosch University.’ And there are other contributing factors, including emotional trauma, head trauma, and immunological influences. For example, research over the last few years shows that patients with an active or prior history of rheumatic fever often present with OCD and related disorders.’
The earlier OCD occurs, the more likely it is genetically influenced, explains Bolon. Although the disorder can appear after a traumatic event or serious infection, it seems that these influences trigger rather than cause OCD. The underlying propensity for the condition must be there first; the trauma then tips the scales so that the disorder kicks in. It follows, therefore, that the more stressed we become as a society, the more we will see of OCD and related disorders.
Can it becured?
OCD can’t be cured, but it can and should be controlled, as it becomes worse if it is left untreated. Obsessive negative thinking leads to more anxiety, which leads to more and more compensatory compulsive behaviour, which consumes more hours in the day.
Digging in the past for an emotional explanation for OCD doesn’t help, seeing that it probably triggered rather than caused the problem.’ We know from experience and research evidence that types of therapy, like psycho-dynamic therapy, aimed at going back in history to find an original cause of the OCD aren’t helpful,’ says Prof Lochner. ‘The compulsion is easier to tackle, since the time spent doing it or the places it occurs are measurable and can be monitored and controlled.’
What is the treatment?
People with OCD generally need more of the neurotransmitter serotonin. Selective Serotonin Reuptake Inhibitors (SSRIs) boost serotonin levels and reduce anxiety and the frequency of the obsessional thought. Cognitive behaviour therapy, meanwhile, focuses on how the thought drives the action. The person is exposed to stimuli that trigger the obsession (the intrusive thoughts) which then presents the urge to do the compulsive activity that will relieve the anxiety. Then the person is encouraged to resist the behaviour. In this way, new habits are formed and the brain becomes reprogrammed.
‘The optimum treatment for OCD seems to be medication – the right SSRIs in the right dose, for a long enough period – combined with cognitive behaviour therapy,’ says Prof Lochner. ‘However, OCD patients are often treatment-resistant (only 40-60% respond to the first line of treatment) so other options must often be tried – the individual might need a different drug, a higher dose, or augmentation with other medication.’
‘I’d recommend a psychiatric assessment first,’ says D rCrafford, ‘to identify what the patient is dealing with. Treatment can then be tailored to the individual, targeting the most pressing issue.’
Is there hope?
Absolutely, say the experts. People with OCD can learn to manage their condition and live healthy and productive lives. ‘They need not fear that they are giving up control by seeking help,’ says Dr Crafford. ‘Treatment empowers them to cope.’ By talking about the disorder rather than hiding it, they can also educate others, who may be inclined to bandy the term about indiscriminately.
Good family relations play an important role, so those closest to the person with OCD should not be ashamed to ask for information and support.
Contact SADAG (South African Depression and AnxietyGroup) at 0800708090 or visit www.sadag.co.za
For information about free evaluations, referrals and a support group in Cape Town, contact Prof Lochner at 0219389179. See also www.ownocd.ning.com
Do shopaholics have OCD?
No. Compulsive shopping is an impulse-control disorder, like excessive gambling. People with impulse-control disorders may also have severe anxiety and avoidance issues, but their behaviour gives them a high – a sense of gratification – whereas the compulsive behaviour associated with OCD is to reduce anxiety around a negative situation o rthought.
What is Obsessive-Compulsive Personality Disorder?
Unlike people with OCD who suffer from their problem and want to be rid of it, people with OCPD feel that they are doing things right and that others are wrong. OCPD is not about obsessive thoughts, but rigid rules. ‘This personality disorder is characterised by a preoccupation with details, lists, orderliness, perfectionism and mental and interpersonal control at the expense of flexibility and openness,’ explains Prof Lochner. ‘These people are obsessed with being perfect in their professional and personal lives and they aren’t keen to change, even if their ways have a negative impact on their partners or house mates. They often don’t realise they have a problem until it causes conflict in relationships or they get “burnt out” from their attempts to control every aspect of their lives.’