OCD

OBSESSIVE COMPULSIVE DISORDER
These are the experiences of three people who suffer obsessive-compulsive disorder

"I'm afraid of catching something from other people, I fear that the germs that they carry may get on to me and I will become infected. I'm afraid I may also 'contaminate' my family by passing these germs on to them. I know it is silly but I feel so tense and anxious if I do touch anyone else or any surfaces - such as door handles that they have touched that I have to come home and wash my hands many times, then wash my clothes. That makes me feel a lot better until the next contact with others. All of my own surfaces at home are washed many times each day with bleach to stop the germs. I avoid contact with other people when at all possible. Part of me realises that these fears are daft, but it's gone on for so long now I don't know how to stop ... my family are sick of it..."

"I fear that I will harm my partner. I know that I don't want to and I love her but thoughts often come into my head where I can picture myself harming her in some way, with a knife or by strangling her. I am so upset when I have these thoughts that I have to bring into my mind other 'good thoughts' such as 'I know I love her very much' and I say these to myself many times to get rid of the bad thoughts. I usually feel a bit better after that, until the next time the awful thoughts come into my head. I have hidden away all sharp objects and knives so that there is no risk of me doing it and also seeing these objects brings the horrible thoughts to my mind. I spend hours each day in this mental battle ... I think to myself you must be a horrible person to have those thoughts ..."

"My whole day is spent checking that nothing will go wrong in the house ... I can't get out because I'm never quite sure that I've turned off the gas, electric appliances, water and locked the windows. However often I check my partner has to check them all for me again before going to bed. I check to see if the gas fire is off, I do this five times and then can sometimes go upstairs, at other times it doesn't feel right and I go through the whole 'ritual' again. If I don't check I feel so worried I can't bear it. I know it's silly, but I keep thinking if something awful did happen I'd be to blame for being so careless..."

You may have had similar experiences yourself, it is quite common for people to have such thoughts and to carry out checking actions, but if it is becoming a major part of your daily life then you may be suffering from Obsessive Compulsive Disorder. We will call it OCD in this leaflet

What is OCD?
Each person who suffers from OCD describes slightly different problems. In general people with OCD experience obsessions. These are thoughts, pictures or impulses which are usually unpleasant and come into mind when we don't want them. Many things can trigger these obsessions, and they usually leave the person feeling very anxious, uncomfortable or frightened. The compulsion is the behaviour performed in order to 'put right' the obsession. Sometimes the behaviour performed is quite irrational (and the OCD sufferer recognises this) such as counting up in sevens for seven minutes, sometimes the behaviour is more closely related to the obsessional thought such as washing hands many times to avoid thoughts of contamination. Most people with OCD know that their compulsions are unreasonable or 'over the top' but they feel unable to control their thoughts or change their behaviour

Many people experience obsessions and compulsions and are able to live with this without problems. People may think about seeking help when their lives are becoming disrupted by these unwanted thoughts and actions

What more do we know about OCD?
OCD affects us in a number of way: What we think: obsessions; guilty thoughts. How we feel: tension; anxiety; agitation. What we do: compulsion - (sometimes described as rituals); avoidance; seeking reassurance

What are the symptoms of OCD?
Some of the signs of OCD are listed here. Most people don't experience all of these. You may want to tick any symptoms you experience regularly

What we think - obsessions	What we do - compulsions
Fearful thoughts or pictures in your mind about being contaminated by dangerous substances, e.g. germs, dirt, AIDS	Check body for signs of contamination Wash/disinfect frequently Avoid going to places or touching objects that you fear may contaminate you
Frightening thoughts/images that some serious harmful events will occur because of your carelessness, for example a gas explosion in the house because the cooker is left on, that the house will be burgled because of doors or windows left unlocked or that you may have knocked someone over in your car	Check feared situations/appliances or journey route many times Avoid being the last person to leave the house Avoid responsibility Seek reassurance regularly from another person that everything is okay
Pictures or words in your head that suggest you will harm others, especially those you care for and would never want to harm. For example that you may hurt your own child, that you may be unfaithful to your partner	Avoid situations which you feel put you at risk of harming, e.g. hide kitchen knives Think something to yourself to 'put right' the frightening thoughts - neutralising thoughts
Pictures come into your mind of your loved ones dead	Think neutralising thoughts to counteract the frightening images Carry out some task which will neutralise the thought, e.g. counting or saying a special word Seek reassurance from others
Things in your life are not in the correct order or not symmetrical enough or in the right place, e.g. ornaments are out of alignment and you feel distressed by this	You put things right or make them symmetrical many times until they 'feel' right You avoid contact with things that make you feel like this
Blasphemous or unpleasant thoughts/pictures and doubts about your faith come into your head	You pray, seek forgiveness over frequently Consult religious leader/seek reassurance

How do you feel when you experience some of these obsessions?
Fearful
Agitated
Anxious
Guilty
Depressed
Disgusted
Tense
Other

How do you feel when you have then carried out the compulsive behaviour or thoughts?
Cleansed
Calm
Less anxious
Disappointed
Relieved
Relaxed
Other
If you have ticked several of these thoughts, feelings and actions then you may have OCD

Most people who have OCD find that there is a pattern in their thoughts, feelings and actions. They feel anxiety or discomfort at having the obsession and relief once they have carried out the compulsive act. This becomes a vicious cycle which strengthens itself and becomes more likely to happen again. In addition to this the person who experiences OCD will often feel guilty and that they must be a terrible person to have such thoughts. This in turn makes the thoughts more likely to return because they are given such negative importance in the person's mind. Research tells us that everyone has odd or distressing thoughts and pictures going through their minds at some times. Most people dismiss this from their mind as meaningless. Those who feel most guilty, distressed or disturbed by the thoughts, however, may involuntarily bring them back into their mind because of this distress. The pattern sometimes look something like this

1. Obsessive unpleasant thoughts

2. Feels anxious/tense (life is disrupted)

3. Compulsive behaviour or thoughts to 'neutralise' obsession

4. Feels relieved (this is short lived)

5. Negative thoughts "you must be terrible to think like that" Strengthens obsession

Can you identify a vicious cycle that applies to your thoughts, feelings and behaviour? Try to draw it out here

Can OCD be treated?
In the last 20 years the treatment of OCD has greatly improved and most people do make a good recovery. The most important treatments are cognitive and behavioural approaches to treatment, which will be described later in this booklet, and drug treatment
Drug treatment - This may be prescribed by your General Practitioner or you may be offered the opportunity to see a Psychiatrist who specialises in such disorders. The drugs most commonly prescribed by doctors for OCD are antidepressant tablets, which can be very effective in the treatment of OCD even if you have no symptoms of depression. These tablets are not addictive and have few side effects. They do take a few weeks to begin to work, so if you are offered this type of treatment it will be a little time until you begin to feel the benefit. It is important to continue with the treatment in these early weeks and to stay on the treatment as long as your doctor suggests in order to maintain full benefit.
Cognitive and behavioural therapy - Your GP may recommend this therapy for you. This approach helps you to tackle what you think (cognition) and what to do (behaviour). Your doctor may suggest you try some of the approaches we describe in this booklet but it you require further help you may be referred to a specialist therapist, usually this will be a Community Nurse, Nurse Therapist or a Clinical Psychologist

What can I do to help myself?
Research has told us that the most successful way to tackle OCD is by exposure with response prevention. This literally means that you must gradually face or expose yourself to the things or situations you fear, whilst at the same time preventing yourself from carrying out your usual compulsive behaviour (checking, cleaning etc.). This gradual approach means that with each stage you become less afraid of what used to trouble you and you learn by experience that no disaster occurs if you stop your compulsive behaviour. Not all the examples in this booklet will be exactly like your experience. Use the parts that you think apply to you

How can I make facing what I fear easier?
Exposure - We know that if we can stay in a situation where we feel anxious, gradually the anxiety will reduce - our body becomes used to the situation and we no longer feel fearful. This is called exposure and it will help us overcome our obsessions. For the person with OCD, however facing things we fear may seem very difficult if not impossible. Because of this it may be helpful to break down into smaller steps the exposure to situations or thoughts we find difficult

Begin by making a list of all situations or thoughts you find difficult. Next make an 'anxiety ladder' where those situations that you only fear a little are at the bottom and your worst feared situations are at the top. It may help to look at this example: Mary has a fear of being contaminated by germs which she fears she may pass on to her family. This has resulted in her restricting her lifestyle and spending many hours washing herself and disinfecting her home. She has made up the following anxiety ladder

Least feared

1. Putting rubbish into kitchen bin, wearing gloves

2. Emptying rubbish from inside bin to outside bin

3. Touching rubbish without gloves

4. Washing the outside of the bin

5. Washing the inside of the bin

Most feared

Mary will begin her exposure therapy at step 1 and gradually work towards step 5. She will prevent herself from frequent hand washing at these times - (see Response Prevention below). Are you able to list your own anxiety ladder?

Most people will at first feel greater anxiety when they begin to face the things they fear and feel an urge to perform their compulsion or ritual. The next section may help you deal with this

How do I stop myself from carrying out the compulsive act?
It is important to break the cycle of carrying out the compulsive act or thought following exposure to the thing(s) you fear. This is called Response Prevention. There are some tips in attempting this. Ask your family to help you by not offering to reassure you by checking for you or by telling you that you are not contaminated. Reassurance can stop you from confronting what you really fear. Praise yourself for not carrying out the compulsion or neutralising activity. This is an important step forward. Keep a note as you are carrying out the exposure therapy to show how your anxiety begins to drop. For example, touching the bin with no gloves on and without washing hands. Don't substitute new compulsions for old ones. For example substituting rubbing hands continually for hand washing. If stopping all compulsive behaviours at once seems impossible, try to reduce gradually the time you spend on the behaviour or the number of times it happens. If you use this approach then gradually your anxiety will reduce

How can I tackle negative thinking in OCD?
Sometimes people get gloomy thoughts when they have OCD especially when they begin to try and break the cycle of obsessions and compulsions by response
prevention. Typically these thoughts are criticisms of yourself, for example, "I'm not a caring mother if I don't check things fully" or "I'm letting things get out of control I'm a failure". These thoughts lead to low mood and you start to feel unhappy. It is important that you do not just accept these thoughts. You need to find a more balanced view, try to: identify these thoughts and low mood; jot down the unpleasant thoughts you are having at the time; try and counter these thoughts by writing down arguments against them. Imagine what you would say to a friend if they had such negative thoughts about themselves; Concentrate on and remember the good things about yourself and your life, not the bad things.

How can I tackle compulsive checking?
Mark had difficulty in leaving the house each day. He would check all appliances at least 15 times. Perhaps you have a similar problem with checking things all the time. The following example may help you understand how to tackle this kind of problem: write down all the things you check; decide which is most difficult - make an 'anxiety ladder'; starting with step 1 on your ladder (least difficult) decide how many times you will check - try the minimum you can; begin with step 1 one day; when your anxiety about that stage is down to a low level move on to step 2. Mark's anxiety ladder looked like this:

Least feared

1. The water taps

2. The lights

3. The gas cooker

4. The windows

5. The doors

Most feared

He began with step 1. He would check the taps only once before he left the house. At first he felt very anxious about this but gradually his fear lessened. He then moved on to step 2, the lights ...and so on

How can I tackle obsessional thoughts where the compulsion is another thought?
Jean used to get a picture in her mind of her daughter and the words "your daughter is dead" would run into her head. She was so disturbed by this that she would 'neutralise' the thought in her mind by saying "she is alive and well" and would picture her daughter looking fit and healthy. She would then feel relief. This began to take up hours of Jean's time each day and made her very unhappy. She felt she must be a terrible person. The picture seemed to get stronger and stronger. Perhaps you have a similar disturbing thought that you spend time 'putting right' with another thought. The most important thing when tackling this problem is to break the cycle of having an obsessional thought and 'putting it right' with another thought, i.e. neutralising. Here are some tips! Don't try and get rid of the obsessional thought, just accept it. We all have odd thoughts at times. Think to yourself that it's just an odd thought, it doesn't mean anything, it doesn't mean you are a bad person. Do not neutralise to put the thought right - break that cycle. Jean tackled this by telling herself: recognising that this is only a thought, it is only so upsetting if I give it too much importance. The more frightened of it I am the more it will come to mind; stop trying to put the thought out of my mind - just let it fade - don't be afraid of it; never 'put the thought right' by 'neutralising' (that is saying in my head "she's alive and well") this will just strengthen the cycle. Remember trying not to think a thought will not help this, and can just have the opposite effect. Test this out - now try not to think of a blue giraffe! As you can see for yourself this just brings the thought of a blue giraffe to mind!. The same goes for your intrusive thoughts. Trying not to think of them may well bring them into your mind

In summary, how can I help myself overcome OCD?
Carefully recognise your unwanted thoughts: obsessions and the actions you take to put them right - compulsions. Gradually face some of the things you fear. Work out an anxiety ladder to help you do this. Begin with the easiest step. Do not carry out any compulsions to reduce or neutralise your anxiety when you are facing the feared situation. Break the obsession compulsion cycle. Challenge any gloomy or critical thoughts you may have about yourself

Where can I get further help?
We hope you will use the exercises suggested in this booklet. They may help you overcome OCD and return to normal life. If you feel you are making little progress or the problem is getting worse then seek help in overcoming your problem. Your family doctor is the best person to talk to first. Your GP may suggest a talking treatment of tablets or both. He or she may suggest you see a mental health worker who can offer expert help with your problems. If you feel so distressed that you have thoughts of harming yourself then visit your doctor as soon as possible and explain to him or her how you are feeling

Source: Northumberland Mental Health NHS Trust

NHS Direct 0845 46 47 www.nhsdirect.nhs.uk