WHAT IS IT?
Obsessive Compulsive Disorder (OCD) is a trying, frustrating condition; and one which can seem mysterious to friends, family and colleagues of the sufferer. Although each person's OCD takes a somewhat different form, there are some patterns which crop up time and time again. One of these is a horror of contamination, which often shows itself as desperate attempts to avoid contact with anything dirty. People with OCD may associate an object, action or place with threat, danger or the possibility of contamination. Their response is to avoid that object, action or place, or carry out a specific action (known as a ritual) because they firmly believe that by doing so they avert the danger or de-contaminate the object or place. Another pattern involves bolstering their sense of security by repeatedly checking some aspect of their behaviour or environment. And these two patterns frequently co-incide - for example a person may need to check over and over again that they have carried out a particular ritual to do with avoiding dirt.
I expect most people have the experience, from time to time, of being unsure whether they had remembered to do something important, such as lock their car or front door; or turned off lights or the cooker. Generally, when this happens, it is because we have turned our attention away from the routine task (of locking doors and turning off lights and so on) and, instead, are preoccupied with some other matter. It could be that our attention is drawn to something a companion is telling us; or something that catches our eye - or perhaps we are simply mulling over thoughts about the previous day or daydreaming about an event in the future. Whatever it is that has hijacked our attention, the result is similar: we cannot be sure that our car or home is secure or that we really did feed the cat or turn on the washing machine or whatever it was that we were carrying out at the time, while we were distracted. Instead, we go onto autopilot and often feel a pressure to retrace our steps and check that the job was indeed done.
For someone with OCD that sense of pressure - an overwhelming feeling of needing to check - is enormous. This is where the "Compulsive" part of the name comes in. Whereas someone who has been distracted as they left their car and needs to go back to check whether they did lock it, can then be satisfied with the answer and walk away from the car, a person who has OCD cannot do so. For them, the need to check is much more than just a greater sense of pressure. They cannot get rid of the feeling quickly and simply, by going back, checking that all is well and continuing with the day's activities. Instead, they experience an extraordinary level of inner tension until they have checked many times. For example, they may need to switch a light on and off half a dozen times before they feel they can believe that it is off. Often, the person with OCD will look to others for reassurance - and in many cases it is the growing irritation of their family, who are getting tired of being asked to check that something has been done (and done thoroughly) that motivates the person with OCD to seek help.
Most people can think of examples from their own lives in which they have chosen to avoid something because it carries negative associations. I can give a personal example here: after a friend's mother was killed while crossing a road near our home, I disliked driving along that particular stretch of road and would prefer to take a different route, rather than be reminded of that terrible event. As I say, most people can relate to this and, while the restriction on one's life may be less than desirable, the level of disruption is not normally great and therefore an isolated "symptom" of this kind is not sufficient for the avoidance to be considered a "disorder".
But there is an important difference that sets a person with OCD apart from the average person, (who, it can safely be said, is also usually quite keen to avoid the dangers which can come from germs and dirt of certain kinds, or in certain places). The situation for people with OCD is very different in that they tend to display multiple obsessions and compulsions: that is to say, typically, they avoid a long list of things, rather than just one; or feel compelled to carry out not just one but a number of rituals which they believe will save them (or others) from some catastrophe.
And, what is more, that number seems to grow and grow. For people with OCD, the danger or fear of contamination spreads to other objects, places and actions by a process of association. So, a person may feel that a particular object that has been in their home is "dirty" or has brought with it some kind of contamination. He or she is likely to feel that the object has now made a particular area of a room, such as a specific chair, "dirty". This demonstrates why many people who have OCD feel as if their symptoms have "crept up" on them. In psychological parlance this process is known as generalisation. So, in OCD, the avoidance spreads or "generalises" and comes to encompass things, actions, or places to which other people would not ascribe the label: "dirty".
Continuing the example of an object that had been deemed "dirty" after something else that was considered "dirty" had touched it: as time goes by, anyone sitting in the chair or anything placed upon that chair also becomes "dirty", in the eyes of the person with OCD. The usual pattern is that the person will avoid not only the original object, or the piece of furniture on which it was placed, but, due to the process of generalisation, he or she will experience a gradual expansion of the perceived threat and so start avoiding the room in which the piece of furniture is placed and, by association, go on to avoid yet more and more objects as they, too, are brought into the net of "dirty" things.
An aspect of OCD which the sufferer's family, friends and colleagues can find particularly difficult to understand is how seemingly unrelated objects or actions, can, over time, be encompassed within the bounds of things that are deemed "dirty". In a way, this mystifies people with OCD almost as much as the people around them! In terms of therapy, though, these gradations can provide a useful "way in" as the person with OCD can usually bear the idea of giving up those ideas or actions which have the most tenuous association with the original trigger for their obsession. Once that is achieved, and we have established rapport and therapy is underway, he or she can begin to tackle the objects and behaviours which have a rather closer association to the origins of the problem.
When thinking of this, I am sometimes reminded of those pen and paper games in children's puzzle books, in which several threads or strings (of, say, fishing rods) have become entangled and the task is to work out which strings lead where (or who has caught the fish). In those puzzles, some of the lines lead nowhere, and it is the equivalent of those lines that lead nowhere that we seek to address first in therapy, before moving on to those which have the equivalent of a fish on the end!
WHAT CAN BE DONE?
BREAKING NEWS: A review has just been published (October 2006) which has brought together research findings from many different studies from across the world into effective treatment for OCD in children and young people. The results back up what has already been established in research into effective treatment for adults with OCD, in that Cognitive Behavioural Therapy (CBT) was found to be as effective as medication and that, when CBT is combined with medication, the effects are better still. You can read more on this here.
Many people, both therapists and those who struggle with the effects of OCD, are likely to find that their intuitive sense of what works is reinforced by these reviews. For people whose OCD is severe and interferes with many aspects of their lives, medication is often a hugely important lifeline. But for some of them, and - perhaps, even more so for those whose OCD is less all-encompassing - combining medication with therapy is perceived as a more thorough approach to their difficulties. An important factor in this is often that therapy has a vital, enabling effect on the person with OCD, in that it restores their sense of having some control which is a very important change for the person who, until then, is likely to have felt strongly that it was the OCD that controlled his or her life, rather than them controlling it.
Using CBT in therapy, I seek to help people challenge their own behaviours, beliefs (about sources of threat, for example), and avoidances and to gradually push back the restrictive boundaries that OCD has placed around their lives so that they claim back the control that the OCD had stolen. Indeed, some people, don't so much claim back control as claim back their very lives: OCD can place such an enormous burden on a person, couple or family that I have heard it said more than once that living with OCD (whether the speaker's own or that of a loved one) is like being imprisoned with an impossibly demanding tyrant who is always ready to criticise and terrify.
Since dirt and contamination or the threat of them are often centre-stage for people with OCD, it is not surprising that their fears often involve body products and lavatories. When people are considering having therapy to help with the challenge of their OCD, they sometimes ask, very apprehensively, whether the treatment would involve "putting my hand down the toilet and then eating my dinner without washing my hands". My reply is always the same: a resounding "No!". I see no value in or justification for expecting anyone to overshoot the usual cultural boundaries and carry out tasks that most people would find repugnant still less to ask them to do anything that flies in the face of normal standards of hygiene and common sense.
Instead, what I do do is encourage people to face the belief systems which form the scaffolding that is supporting their OCD. By gradually testing out their thought processes and finding them to be erroneous people find they can test out new ways of doing things perhaps delaying carrying out the "rituals" (such as compulsive hand washing) which tend to form an important part of life for someone with OCD. When, contrary to the propaganda put about by Chicken Little, the sky doesn't fall in, people gain confidence and resolve to tackle the next belief or pattern of avoidance. As the saying goes, "Success breeds success" and so each time a ritual is delayed or compulsion thwarted, the previous pattern is weakened and the new, more life-enhancing pattern is strengthened. And, what's more, there are solid scientific findings that back up this claim that "Success breeds success" in that it is the repeated patterns of specific brain cells firing in sequence that increases the likelihood that those same sequences will occur again in future.
So every time a person withstands the compulsion to behave in a particular way, the likelihood that he or she will give in to the compulsion in future is reduced. Instead, the person's brain is laying down new patterns of cell-firing that make non-compliance with the compulsion more likely on future occasions. And that has to be good!
Very often, by the time a person who has OCD comes to see me, he or she has tried desperately hard to overcome the compulsions and obsessions. Indeed, it is often people with OCD who have tried the hardest to bring about change in their lives before they finally seek professional help. Perhaps this is because the very nature of their difficulty gives them enormous self-discipline and so they may feel that they "should" be able to help themselves. Frequently, they have also consulted a counsellor for help in overcoming their symptoms, but, sadly, have not found the freedom they so desire. This can mean that, by the time I see the person, their sense of hope is dwindling. To my unceasing delight, I find, time and again, that the person soon starts to get their symptoms under control. Indeed, beginning the process of change can start to show fruit very quickly. But, repeating again that maxim, "success breeds success" and so, once we are "on a roll", the momentum increases and the person finds that they are able, more and more, to challenge the beliefs and overcome the behaviours that had imprisoned them.
When someone has had OCD severely or for a long time, the number and range of behaviours they want to change can be many. Usually, they tell me the most inconvenient or disabling ones early on, so our initial focus is on these. As therapy proceeds, they often experience an improvement in symptoms they had never mentioned - perhaps out of embarrassment (if, for example, the symptoms related to bodily functions) or simply because, compared with their symptoms that made life particularly difficult, these caused far less inconvenience. I then find myself in the rather odd but lovely position of celebrating with them the demise of yet another symptom - even though it is one I had been unaware of!
Depression is a wretched illness and one that often goes unrecognised. The public's understanding of "depression" is probably of a person (usually a woman) languishing alone in a corner, crying and unable to cope with day-to-day life. Naturally, this description is partly accurate as depression can certainly result in a sufferer having no option but to drop her (or his!) normal activities and, without a doubt, depressed people often find that tearfulness is a major indicator that something is definitely "wrong". But for many people the over-riding symptoms - rather than tearfulness - can be a melancholic, dull flatness of mood they just can't seem to shake off, or an exaggerated tendency to be snappy and irritable. This variety of ways that depression can affect different individuals is, presumably, one important reason why much depression is not identified or treated. In some cases, the person does make it to the GP surgery - but without any inkling that what they are suffering from is depression - and they can be taken aback and horrified - or relieved - when the doctor gives the diagnosis. Furthermore, although it is generally thought that depression is equally common in men as in women, it is more often diagnosed in women.
Another misconception is that depression amounts to little more than a weakness and that all that is required is for the person to "snap out of it", "look on the bright side" or "think of all the people in the world who are worse off". I am quite sure that, were release from depression so straightforward to achieve, then the majority of sufferers would gladly follow the advice and feel their depression magically lift. Instead, true depression, as distinct from feelings of lowness which most people experience from time to time and which are usually fairly simple to shrug off, is a distressing illness which can sap the will of the sufferer and of those close to him or her.
When people have consulted their GP and been told they have a depressive illness they can be alarmed to hear the term "major depression" which somehow smacks of a long-term disorder from which they fear they will never recover. In fact doctors and other healthcare professionals use a method of diagnosing depression which requires a duration of symptoms of only two weeks for the label "major depression" to be applied. Among the symptoms that "count" towards that diagnosis, low mood is (not surprisingly) crucial and both this and other symptoms such as sleeping problems; feelings of hopelessness or worthlessness; difficulty concentrating; reduced appetite; reduced interest in things a person had previously enjoyed can occur on a continuum and therefore it is perfectly possible to be given a diagnosis of "major depression" while continuing to meet one's obligations and fulfil one's roles.
When depression is more severe though, i.e. at the more serious end of the continuum, people can be completely unable to work or carry on with their normal tasks or in their usual roles and some people do indeed sit, blankfaced and silent - or sobbing - or take to their beds: with even framing a sentence or two requiring an inordinate effort.
As with so many conditions there are varieties of depression including "smiling depression" in which the person is able to cover up his or her inner bleakness so that virtually no one knows that they are ill; "atypical depression" in which pleasant experiences have the effect of temporarily easing symptoms and the person eats more, rather than less than usual and experiences an overwhelming heaviness in their limbs. A further form of depression occurs in bipolar disorder, which is still sometimes referred to as "manic depression", and which is typified by enormous lows but also times of being "high", when everything seems to quicken up and the person talks and thinks quickly, needs very little sleep and may engage in activities that he or she would normally avoid, such as promiscuity or running up debts by booking expensive holidays or spending money extravagantly.
In the last few years, depression has been recognised as a recurrent disorder. If a person has had three or more episodes of depression, then the likelihood is that they will remain vulnerable to further episodes. Therefore, it is important for people who have been depressed to do all that they can to prevent relapse. It has now been established, by the use of brain scans, that the same areas of the brain that change with antidepressants are changed with cognitive psychotherapy. While treatment with antidepressants can certainly deal effectively with a person's symptoms, more thorough healing and relapse prevention tend to come with therapy - alone or in combination with antidepressant medication - as people gain the skills that help them recognise the negative patterns of thought that tend to make them spiral down into depression.
Post-Traumatic Stress Disorder (PTSD)
We have all had things that have startled us - perhaps when a person or an animal has popped up, apparently from nowhere. Typically, we jump and gasp; we may close our eyes very briefly or slap one hand to our chest in a gesture that says: "You frightened the life out of me!" In the main, we make a quick, a full recovery from being startled like that: our heartbeat soon returns to normal and we can laugh at our own jumpiness.
People differ, of course, in their responses: one person has the ability to shrug off experiencing or witnessing things that most of us could never imagine facing - let alone surviving. Members of the Armed Forces, or of the Emergency Services, for example, may have dealt with situations that would floor most of us. On the other hand, some people seem especially sensitive to the effects of ordinary day-to-day events which others of us hardly notice.
If you imagine a continuum of "shock" or "trauma" stretching from experiences that are common to most of us at one end, such as being startled by someone coming through a door as we are going in the other direction, to inescapable, overwhelming terror of being caught in crossfire or swept up in a tsunami at the other, you will realise that trauma and shock need not be alien concepts denoting something we hope never to experience but commonplace, referring to everyday events.
Naturally, people react differently to events and something that would scare one person might provide a needed "buzz" for someone else. But there are, undoubtedly, events which would upset almost anyone. Some examples are witnessing a murder or other traumatic death; being the subject of a vicious attack; suffering rape or other sexual crime; living in a war zone or being involved in a road traffic collision. The list could go on and on and is not meant to be exhaustive.
When people have experienced events like these - that are not part of what most people expect to encounter in their lives, they often carry emotional "scars". In many cases, the persons or personality seemed to change, so someone who had been outgoing and confident becomes timid and rarely socialises. They may avoid activities or places that could remind them of what happened; or suffer nightmares or they may develop "flashbacks", when it feels as if they are transported back into the terrible incident.
Quite often they become moody, tearful, irritable or develop sleep problems such as difficulty in getting to sleep or staying asleep; or they may find it hard to stay in their normal bed, or in their home, unless someone stays with them.
If the trauma happened to others - such as other passengers dying while they escaped, they will sometimes develop what is known as "survivor guilt" which means that, on top of all that has happened, they are burdened with guilt that they are still alive while the others died. Not surprisingly, some people lose the sense that life has any meaning or that there is any point in making plans for the future and instead become apathetic.
For young people, this can be especially catastrophic and they may drop out of university; give up their job; end what had been a fulfilling relationship or start misusing alcohol or street drugs.
I am passionate about a technique I use, called Rewind, that helps people with PTSD reclaim their lives. I love it because it is quick, straightforward and free of any side-effects. I also love it because the person does not need to go over every detail of the incident, so it is non-intrusive, and also because it is extremely powerful and works beautifully just about every time.
After the technique, the person still remembers the dramatic incident but the difference is that there is now a sense of distance between themselves and the event, with the result that the horrifying images are no longer "in their face".
In fact, I have such faith in Rewind and have been so delighted to see a selection of people pick up the threads of their lives after some terrible event, such as a mugging or witnessing a violent crime, that I offer up to two free sessions for people who are suffering the after-effects of a recent traumatic incident. (This is conditional on my satisfying myself that there are no contra-indications, such as serious psychiatric illness). In many cases these two sessions are all they need to help them get their lives back on track and save them from slipping into a grey world of nervousness, nightmares and dashed hopes. So, if you have changed since enduring an ordeal that was beyond the experience of most people, why not get in touch and arrange up to two free sessions of Rewind?