Obsessions and Compulsions audio transcript

Obsessions and Compulsions – An NHS self help guide
This written version of this guide was Highly Commended at the British Medical Association Patient Information Awards 2012.

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 may harm someone… This is often worst when I am out driving. I sometimes think I have hit someone and have to go back and check again and again. Recently I have started avoiding driving altogether.”

“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, and water and locked the windows. No matter how often I check, my partner has to check them all for me again. 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…”

“I sometimes have really bad thoughts go through my mind. I wonder if this makes me a really bad person but I know I would never hurt anyone. I try to push the thoughts away by thinking good things, but sometimes it seems the harder I try the worse things get.”

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 these are becoming a major part of your daily life then you may be suffering from Obsessive Compulsive Disorder (OCD). OCD also occurs in children. If you think your child may have OCD it is really important you seek professional help, as outcomes are better the sooner treatment is begun. Your GP should be able to advise and refer your child for specialist help where they can receive a full assessment of what is going on.

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 or thought 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 or tapping a set number of times. 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 (although not all) know that their compulsions are unreasonable or over the top but they feel unable to control their thoughts or change their behaviour.

Some people experience obsessional thoughts and behaviours and are able to live with this without too many problems. They may have learned ways to cope, although things can change with time, often getting better or worse depending on stress or mood levels.

It is estimated that around three quarters of a million people in the UK (1.2% of the population) are living with severe, hugely distressing OCD, which has a big impact on their life. Fortunately treatments are very effective and if your life is being disrupted by unwanted thoughts and actions it is really worth seeking help.

What more do we know about OCD?

There are many theories about what causes OCD, including neurological, biological, genetic, psychological and social. As yet there is no one theory that has been proven to be the root cause, and it is likely that OCD comes from a complex mixture of all of these. But whatever the cause, OCD affects us in a number of ways:

• What we think:
  – obsessional thoughts and images (i.e. can’t get them out of our mind)
  – guilty thoughts
  – thoughts that we are responsible for everything
• How we feel:
  – tense
  – anxious
  – agitated
  – disgusted
• What we do:
  – compulsions – (something we must do, sometimes described as rituals)
  – avoidance
  – seeking reassurance

What are the symptoms of OCD?

Some of the symptoms of OCD are described here. Most people don’t experience all of these. You may want write down any symptoms you experience regularly.

What we think – the obsession
Fearful thoughts or pictures in your mind about being contaminated by dangerous substances. e.g. germs, dirt, AIDS.

What we do – the compulsion
Check body for signs of contamination.
Wash/disinfect frequently.
Avoid going to places or touching objects that you fear may contaminate you.

What we think – the obsession
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.

What we do – the compulsion
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 alright.

What we think – the obsession
Unwanted thoughts of a violent or sexual nature that you find repulsive or frightening for example involving children.

What we do – the compulsion
Avoid being alone with children.
Avoid going out alone.
Confess thoughts and seek reassurance.

What we think – the obsession
Pictures or words in your head that suggest you will harm or have harmed 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.

What we do – the compulsion
Avoid situations which you feel put you at risk of harming others, e.g. hide kitchen knives.
Going over and over situations in your mind to convince yourself you have done nothing wrong.
Think something to yourself to put right the frightening thoughts – these are sometimes called ‘neutralising’ thoughts because they seem to take away the power of the thoughts.

What we think – the obsession
Pictures come into your mind of your loved ones dead.

What we do – the compulsion
Carry out some task that will ‘neutralise’ the thought e.g. counting or saying a special word.
Seek reassurance from others.

What we think – the obsession
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.

What we do – the compulsion
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.

What we think – the obsession
Blasphemous or unpleasant thoughts/pictures and doubts about your faith come into your head.

What we do – the compulsion
You pray, seek forgiveness frequently.
Consult religious leader/seek reassurance.

Do you feel any of the following when you experience some of these obsessions?

• fearful/anxious
• agitated
• ashamed
• guilty
• depressed
• disgusted
• tense

How do you feel when you have then carried out the compulsive behaviour or thoughts?

• relieved
• cleansed
• calm
• relaxed
• less anxious
• disappointed

If you recognise 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.

It is estimated that over 50% of OCD sufferers experience aggressive, sexual or blasphemous (religious) thoughts, which go totally against someone’s beliefs and values. So it is hardly surprising that many OCD sufferers feel guilty and think 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. Repeatedly going over upsetting thoughts has also been shown to make them seem more believable to the person.

Research tells us that most people experience odd or distressing thoughts and pictures going through their mind at some time, for example ‘what if I was just to drive the wrong way up the motorway’. Most people easily dismiss such thoughts from their mind as meaningless.

Those who feel most guilty, distressed or disturbed by the thoughts, however, may get upset by them, and find it hard to get them out of their mind. The pattern can be something like this:

• Obsessive, unpleasant thoughts can lead to anxious, tense or guilty feelings which can cause compulsive behaviour, or thoughts to ‘neutralise’ the obsession.
• This can bring relief but it’s short lived and leads to negative thoughts such as “you must be terrible to think like that”

This all strengthens obsessions.

Can OCD be treated?

In the last 30 years the treatment of OCD has greatly improved and most people do make a good recovery. The most important treatments are medication and Cognitive Behavioural Therapy (CBT), which will be described later in this guide.

Medication and Cognitive Behavioural Therapy often work really well together.

Medication
This may be prescribed by your General Practitioner or by a Psychiatrist who specialises in such disorders. The medicines 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 Behavioural Therapy
Your GP may recommend this therapy for you. This approach helps you to tackle what you think (cognition) and what you do (behaviour). Your doctor may suggest you try some of the approaches we describe in this guide but if you require further help you may be referred to a specialist therapist. Usually this will be a Psychological Therapist or a Clinical Psychologist.

What can I do to help myself?

Research tells us that the most successful way to tackle OCD is by exposure with response prevention (ERP). 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 behaviours (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. There is some evidence that online resources can be useful to support this. Most of these have a cost, but some are available free of charge.

Because OCD is such an individual thing, not all the examples in this guide 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:

Washing and cleaning
Mary has a fear of being contaminated by germs which she believes 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 an anxiety ladder with her least feared thought or situation at the bottom and her most feared at the top.

Mary’s least feared thought, step 1, is touching her own waste bin with rubber gloves on.
Step 2 is touching her own waste bin without rubber gloves on
Step 3 is touching objects at a friend’s house
Step 4 is eating at a friend’s house
Step 5 is going to the toilet at a friend’s house
Step 6 is is touching doors and objects outside her home, for example at the supermarket
Step 7 is going to eat outside the home.
Her most feared, step 8, is going to the toilet in public toilets

Mary will begin her exposure therapy at step 1 (i.e. by touching her own waste bin with gloves on) and gradually work towards step 8 (going to the toilet in public toilets). She will prevent herself from frequent hand washing at these times – (the following section on Response Prevention will help with this).

Are you able to make your own anxiety ladder?

Put your least feared thought at the bottom and most feared at the top.

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”. People with OCD also often feel high levels of guilt without good reason. These thoughts lead to low mood and unhappiness. 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;
• write 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;
• try to challenge feelings of guilt.

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:

The least difficult, Step 1, – the taps.
Step 2 – the lights
Step 3 – the gas cooker
Step 4 –  the windows
The most difficult, step 5, – the doors

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:
• “This is only a thought, it is only upsetting if I give it too much importance. The more frightened of it I am the more it will come to mind so just let it go.”
• “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 get rid of the thought and usually has 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.

Can mindfulness help OCD?

Recent studies have shown that CBT involving mindfulness can be really useful to people who have OCD.

It can be helpful to become more mindful of how your OCD affects you and how you typically react. It is important to focus on the here and now and notice if your thoughts are frequently moving to pictures of future negative events, notice how this makes you feel. Try to bring your thoughts back to the here and now. You can accept that you tend to have these worrying thoughts and compulsions but that this does not mean these worries will come true or that you have to act on the compulsions. Acceptance and Commitment Therapy (ACT) is a type of CBT that combines acceptance and mindfulness. ACT is not about getting rid of obsessive thoughts, but about learning to be more at peace with them and accepting them for what they are. Another really important part of ACT is deciding what is most important to you in life, what really matters, and then setting yourself small goals in line with this. If you see a therapist for your OCD they may be able to offer an Act based approach.

Mindfulness mediation courses are now widely available and can further help you learn to cope with the distress of OCD.  Becoming serene, relaxed and gaining a state of inner peace can be helped by mindfulness and relaxation training.  This can in turn help you to reduce obsessions and compulsions and reduce distress.  (Visit the Mental Health Foundation’s website for an online mindfulness course or details of mindfulness teacher in your area.)  Further online resources can be found in the written version of this guide.

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.
• Consider using mindfulness to help to reduce the impact of OCD.

Where can I get further help?

• We hope you will use the advice suggested in this guide. This 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 GP is the best person to talk to first. Your GP may suggest a talking treatment or tablets or both. They 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 them how you are feeling.

A list of useful contacts, books and references are available in the written version of this guide.

Written by Dr Lesley Maunder and Lorna Cameron, Consultant Clinical Psychologists.

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust has developed this resource with the support of NHS healthcare staff, service users and local voluntary sector groups.