Obsessive Compulsive Disorders

What is obsessive-compulsive disorder (OCD)?

(taken from NICE clinical Guidelines WWW.NICE.ORG.UK/GUIDELINES/CG31)

Obsessive-compulsive disorder (or OCD for short) is the name given to a condition in which a person has obsessions and/or compulsions, but usually both. An obsession is a thought, image or impulse that keeps coming into a person’s mind and is difficult to get rid of. There are lots of different obsessions that can affect someone with OCD, but a few examples are:

1. being afraid of contamination by dirt and germs
2. worrying that something is not safe, such as an electrical appliance
3. thoughts and fears of harming someone else
4. wanting to have things in a particular order or arrangement (such as in a symmetrical fashion).

A compulsion is a feeling that a person has that they must repeat physical actions or mental acts. Usually people do this in response to an obsessive thought (for example, if a person is worried about dirt they might clean something repeatedly). People with OCD may use these actions to help deal with an obsessive thought or ‘neutralise’ it. There are lots of different compulsions that can affect someone with OCD (sometimes called ‘rituals’), but a few examples are:

1. excessive washing and cleaning
2. checking things repeatedly (for example, that a door is locked or that an electrical appliance is switched off)
3. keeping objects that other people might throw away (called ‘hoarding’)
4. repeating acts
5. repeating words or numbers in a pattern

From time to time, almost everyone has a disturbing thought or checks more than once they have locked the door. For most people these thoughts and actions can be forgotten. But if a person has OCD, the thoughts and feelings of discomfort can take over and they will feel anxious until they have done something to help them to deal with the thought. People with OCD may realise that their thoughts and actions are irrational or excessive, but they will not be able to help themselves from thinking the obsessive thoughts and carrying out compulsions. OCD can affect people in different ways. Some people may spend much of their day carrying out various compulsions and be unable to get out of the house or manage normal activities. Others may appear to be coping with day-to-day life while still suffering a huge amount of distress from obsessive thoughts. Some people with OCD may carry out their rituals and compulsions in secret or make excuses about why they are doing something. People with OCD may not realise that repeated thoughts, such as a fear of harming other people, are common symptoms of OCD and do not mean that they will carry out these thoughts.

When someone seeks help for their OWhen someone seeks help for their OCD, healthcare professionals will consider how distressing the symptoms are for that person and how much their life is affected. This will help them work out whether someone has mild OCD (symptoms are distressing but manageable and the person seems able to carry on with everyday life) or more severe or very severe OCD (symptoms are very distressing and seriously restrict the person’s everyday life). It will also help the healthcare professional work with the person with OCD to identify the most suitable treatment. It is thought that about 1–2% of the population in the UK may have OCD and it can affect people of any age, from young children to older adults. Some people with OCD also have depression

What is body dysmorphic disorder (BDD)?

Body dysmorphic disorder (BDD) is the name given to a condition in which a person spends a lot of time concerned about their appearance. They may compare their looks with other people’s, worry that they are physically flawed and spend a long time in front of a mirror concealing what they believe is a defect. At some time or another, almost everybody feels unhappy about the way they look, but these thoughts usually come and go and can be forgotten. However, for a person with BDD, the thought of a flaw is very distressing and does not go away, even though other people may think that there is nothing wrong with the way that person looks. Although BDD is not exactly the same as OCD, there are similarities. For instance, a person with BDD may feel that they have to repeat certain acts. A few examples are:

1. checking how they look
2. repeatedly combing their hair or applying make-up
3. picking their skin to make it ‘smooth’.

A person with BDD may feel that they cannot go out in public unless they have hidden the problem area in some way, with clothing or make-up. This can seriously affect the person’s daily life. Some people with BDD occasionally also have depression. When someone seeks help for their BDD, healthcare professionals will consider how distressing the symptoms are for that person and how much their life is affected. This will help them work out whether someone has mild BDD (symptoms are distressing but manageable and the person seems able to carry on with everyday life) or more severe or very severe BDD (symptoms are very distressing and Treatingseriously restrict the person’s everyday life). It will also help the healthcare professional work with the person with BDD to identify the most suitable treatment. The treatments for BDD are very similar to those for OCD and are explained in the sections on treatment for OCD. It is not known exactly how many people in the UK have BDD because people who have it often hide it from others, but it could be around 0.5%. The condition can affect all age groups from adults to young people and children

What treatments are helpful for adults with OCD or BDD?

There are a number of treatments for adults with OCD or BDD that are helpful, including psychological therapies and medication. These are outlined below.

Psychological treatments

The main psychological treatment for OCD or BDD is cognitive behavioural therapy (CBT) including exposure and response prevention (ERP). In this booklet it is called 'CBT with ERP' for short. But if you have OCD, another treatment called cognitive therapy may be used
Cognitive behavioural therapy with exposure and response prevention (CBT with ERP)
CBT is a psychological treatment based on the idea that the way we feel is affected by our thoughts (or ‘cognitions’) and beliefs, and by how we behave. If we have a negative thought, for example, this can lead to negative behaviour, which can affect the way we feel. CBT helps people to reassess the meaning of their thoughts and actions. ERP helps people deal with situations or things that make them anxious or frightened. With the support of the therapist, the patient is ‘exposed’ to whatever makes them frightened or anxious (for example, dirt or germs). Rather than avoiding the situation or repeating a compulsion, the patient is taught other ways of coping with the anxiety or fear. This process is repeated until the patient no longer feels as anxious or afraid.
If you have obsessive thoughts but do not have any obvious compulsions, you can still have CBT with ERP. However the ERP will focus on mental rituals and any methods you may use to deal with obsessive thoughts.
Cognitive therapy for OCD
Most psychological treatment for OCD consists of CBT with ERP, but if you do not feel comfortable starting ERP, or it has not helped you, then your healthcare professional may offer you cognitive therapy that has been adapted for people with OCD. Cognitive therapy can help people change their beliefs about things they may find distressing, but it does not usually involve being ‘exposed’ to what makes them frightened or anxious as in ERP.
But if you are having ERP, your healthcare professional may consider offering you cognitive therapy in addition to your current treatment because this can help you to stay well in the future. General information about psychological treatments If you agree, your family or carer can help you with some of the treatment exercises in ERP.
Towards the end of psychological treatment, healthcare professionals should advise you about how you can carry on using the techniques you have learnt if symptoms come back. Are there any other psychological treatments than can help me? You should be advised by your healthcare professional that other than the treatments described above, there is no evidence that other psychological treatments or therapies can help improve your OCD. These include psychoanalysis, transactional analysis, hypnosis and marital or couple therapy.

Medication

Research has shown that medication used for treating depression (called ‘antidepressants’) can also help people with OCD or BDD. Antidepressants work by increasing the activity and amount of certain chemicals in the brain that affect mood (such as one called serotonin). There are different types of antidepressants, but ones called selective serotonin re-uptake inhibitors (or SSRIs for short) often work best for people with OCD or BDD.

Choice of SSRIs

If you are an adult with OCD, you should be offered one of the following SSRIs first:

1. fluoxetine
2. fluvoxamine
3. paroxetine
4. sertraline
5. citalopram1

If you are an adult with BDD you should first be offered fluoxetine2, because research has shown that this works better for people with BDD than other SSRIs.
Because some medicines can react badly with other medicines, your healthcare professional should ask you about any other medication that you are taking. If you have significant and/or persistent side effects while taking an SSRI, your healthcare professional may offer you a different SSRI.
If an SSRI has not helped you after 4–6 weeks and you have not experienced a lot of side effects, your healthcare professional may discuss with you the need to increase your dose. He or she should tell you about possible side effects and should check for these when the dose is increased.
If treatment with an SSRI has not helped you at all, your healthcare professional should make sure that you took the medication regularly, that you took the correct amount, and check if any alcohol or other drugs you were taking at the time affected your treatment. If treatment with an SSRI has helped you, you should continue to take the medication for at least 12 months because this will help your symptoms to improve and help to prevent you becoming unwell again. Your healthcare professional should see you again after the 12 months to see whether you should continue to take the medication (this usually depends on how severe your OCD or BDD symptoms were, how long you had the condition and whether you still have any symptoms or have any other problems). If you continue to take an SSRI, your healthcare professional should arrange to see you regularly. This arrangement should be agreed by you both and written in your medical notes. When reducing your dose or stopping the medication altogether, your healthcare professional should make sure that this is done gradually over several weeks and to suit your needs. When you stop treatment with an SSRI, your healthcare professional should encourage you to go back and see him or her if you have severe symptoms caused by stopping the medication
(taken from NICE clinical Guidelines WWW.NICE.ORG.UK/GUIDELINES/CG31)


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