Obsessive Compulsive Disorder
Obsessive-compulsive disorder (OCD) is classified as an anxiety disorder. OCD is characterized by obsessions, compulsions, or both. Obsessions are intrusive thoughts or images which recur repeatedly and which are difficult to put out of mind. Obsessions are intrusive, can be frightening or unpleasant at times, and may generate significant distress, fear, discomfort or disgust.
In attempting to suppress or eliminate the obsessions, affected individuals feel compelled to perform repetitive gestures, known as compulsions.
Obsessions and compulsions can result in pervasive and marked feelings of distress and a significant loss of free time (more than one hour per day). They may strongly impede the sufferer’s normal activities, professional (or academic) life, and regular social activities and relationships.
Compulsive rituals may take up several hours per day. Unfortunately, these compulsive behaviours bring only temporary relief before the obsession-compulsion cycle begins anew. Unlike compulsive gambling, these compulsions do not bring any pleasure to the sufferer.
Some individuals must deal with so many compulsions that they cannot leave their homes, go to work or visit family and friends. They often judge themselves very harshly; OCD sufferers will often conceal their symptoms and isolate themselves.
Obsessions and compulsions
Individuals suffering from OCD are aware of the absurdity of their thoughts and/or behaviour; however, left untreated, they cannot seem to rid themselves of these ideas/behaviours, which are uncontrollable.
Obsessive-compulsive disorder must be evaluated by a health professional (physician, psychologist) and diagnosed by a psychiatrist in accordance with predetermined criteria. The latter must recognize the specific symptoms of OCD and distinguish them from behaviours relating to a different disorder.
Thus, during a consult with a health professional, it is important to relate one’s compulsive thoughts, emotions and behaviours in detail. The latter will likely use an OCD rating scale, such as the Yale-Brown Obsessive Compulsive Scale (known as Y-BOCS), which estimates the level of distress and degree of severity of the patient’s obsessions and compulsions. The health professional will also assess the impact of obsessive symptoms on professional, family, and domestic life and on daily activities.
OCD shares a number of common characteristics with other disorders. Although these disorders are treated differently, they may easily be mistaken for OCD:
- Trichotillomania (the compulsion to pull out one’s hair, eyebrows and body hair).
- Uncontrollable habits (nail-biting, scab-picking)
- Tics, involuntary, repetitive and daily motor or vocal behaviours.
- Roughly 30% of individuals with Tourette’s Syndrome also suffer from OCD.
OCD may be distinguished from impulse-control disorders such as pathological gambling or compulsive sexual activity.
As is the case of numerous psychological conditions, it would appear that OCD results from the interaction of different biological, environmental and social factors. Consequently, the selected interventions and treatment must address these three components.
For example, some medical studies suggest that OCD would be caused by a chemical imbalance, which alters how the brain influences thoughts, emotions and behaviours. The success of certain drugs in reducing obsessions and compulsions suggest that serotonin, a neurotransmitter found in the brain, is at the centre of this imbalance.
Genetic factors may also play a role. In nearly 50% of all cases, another family member also suffers from this disorder.
For their part, studies in psychology show that the reduction in anxiety that normally arises from compulsive acts leads the individual to repeat these gestures and to use them again and again. Some thought mechanisms, like faulty logic or overvaluation of risk and responsibility, have also been identified for their involvement in sustaining obsessions.
Who is at risk?
Obsessive-compulsive disorder, or OCD, affects approximately 750,000 people in Canada. It is estimated that between 2-3% of the population suffers from OCD, with both men and women equally affected. Obsessive-compulsive disorder ranks as the fourth most common anxiety disorder; however, it is often still misunderstood, under diagnosed and undertreated, as many health practitioners are unfamiliar with OCD symptoms and have not received specialized training to provide appropriate therapies.
56-83% of individuals presenting with OCD also suffer from a second mental disorder such as depression, social phobia, etc.
OCD generally presents when patients are in their late teens or early twenties, although onset may occur during childhood or in later adult years. In half of all cases, OCD first appeared in adolescence. Onset is rare after age 35.
A combined psychological and pharmacological therapeutic course, tailored to the specific treatment of OCD, is essential. While OCD may vary in severity throughout the sufferer’s life, spontaneous remission does not occur. Stressful events, major life changes or periods of increased fatigue may all aggravate OCD symptoms.
Prevention and care
Panic disorder, social phobia and depression may also be associated with OCD. In such instances, the recommended treatment will initially target the most serious and debilitating symptoms. In the case of OCD-related depression, a single drug can sometimes lessen the symptoms of both disorders at once. Thus, a preferential treatment option must be selected based on the overall OCD assessment and may involve the concerted effort of many health professionals.
Overcoming OCD requires courage, hard work and a structured approach.
There are two forms of treatment which have proven effective in cases of obsessive-compulsive disorder:
- Cognitive-behavioural therapy (CBT)
- Specific and controlled medication therapy
These two therapies may be combined. Ideally, CBT will be offered by a licensed psychologist recognized for expertise in the treatment of OCD and belonging to the Ordre des psychologues du Québec. On the other hand, drugs therapy for the treatment of OCD may only be prescribed by a physician, preferably a psychiatry specialist. A concerted effort by health professionals will allow treatment to be structured on the basis of a full understanding of the issue, next steps in treatment, and preferential approaches to be used and encouraged.
Participation in support groups, where other affected individuals and their families gather to provide each other with mutual support and share their experiences and understanding of the problem, may also be useful.
Family or individual therapy may also be beneficial for family members. In fact, the structured therapeutic approach can address problems encountered in everyday life, find closure, and devise ways to resolve them while feeling supported and understood.
- Cognitive-behavioural therapy (CBT)
A consensus of experts has recommended cognitive-behavioural therapy (CBT) in the treatment of OCD. As the name implies, CBT addresses both cognition (thoughts) and behaviours. In other words, the therapist works to modify both the interpretation of a given situation and the ways in which the individual behaves. Thoughts and behaviours play an important role in understanding OCD.
Individuals suffering from OCD regularly experience difficulty in separating their obsessive behaviours and thoughts from the rest of their personality. For them, everything they are (their values, desires, skills, and flaws) and do (thoughts and actions) is influenced by the OCD. However, it is clear that OCD is a behavioural (or habit) issue rather than a personality disorder.
Thus, obsessions keep these individuals in a constant state of high alert (activation of emergency warning system). In order to reduce the anxiety, they perform compulsions. It is shown that these behaviours only serve to maintain anxiety and support the problem.
Cognitive-behavioural therapists help their patients recognize and control their compulsions. They work to modify behaviour and the ways in which patients perceive and interpret events through the use of self-assessment exercises. The execution of these practical exercises, as well as the gradual acquisition of new techniques, can help lessen anxiety. This approach equates the therapeutic process to a form of learning: we learn to develop new behaviours by practicing them.
- Inference-based therapy (IBT)
A new therapeutic approach, inference-based therapy (IBT) or “doubt therapy”, was developed by Kieron O’Connor, a researcher at Université de Montréal’s psychiatry department.
This therapy is characterized by the notion that OCD is anchored primary in doubt rather than obsessive phobia. In ten steps, the therapist teaches the patient to differentiate between pathological (obsessive) doubt and normal doubt. IBT also helps effectively lessen anxiety and depression in affected individuals.
Based on the majority of recent studies, IBT is effective with all OCD types and degrees of severity.
- Medication therapy
Medications such as antidepressants, which raise the concentration of chemicals produced in the brain, have proven effective in numerous cases.
Some antidepressants act on the brain’s serotoninergic system. Current studies show that selective serotonin reuptake inhibitors (SSRIs) are particularly effective to lessen obsessive symptoms.
Following assessment, a physician or psychologist will determine whether drugs should be prescribed, and will determine both the dosage and the length of treatment. The physician may also prescribe different kinds of medication or a combination of drugs. Every individual is unique and responds differently to a given drug. Thus, it is important to go to all scheduled follow-up appointments with the attending physician to ensure that an optimal dose is determined on the basis of patient comments, observations and reactions.
It is important to adhere to treatment and take all prescribed drugs in the correct dose and at the right time. A period of eight to ten weeks must pass before the drug’s effectiveness can be assessed. The dose will be adjusted until the individual can function optimally while experiencing as few undesirable side effects as possible. Before concluding that treatment has failed, affected individuals must first consult their physician and their psychologist.
Some individuals do not like to take medication regularly, or worry about the effect these drugs might have on them. If you feel the same way, do not hesitate to ask specific questions about your prescribed drug when visiting your physician:
- How does it work?
- How long before it begins to take effect?
- When should I take it?
- Must it be taken with food or between meals?
- Can I take other drugs while on this one?
- Will there be side effects, and if so, what are they?
Can family members help?
Family members can play a crucial support role, initially by accepting that a loved one suffers from a psychological disorder, and then by offering support throughout the therapeutic process. Family members often become involved in the OCD sufferer’s rituals against their will. Organizing their schedules to accommodate a loved one’s need to engage in compulsive behaviour, performing these rituals in their stead, and constantly reassure them as needed can become a heavy burden and generate tension. Individuals with OCD never perform their rituals voluntarily; rather, they consider them embarrassing, and expend a great deal of effort to suppress their need to perform them.
Helping a loved one does not mean participating in these rituals. However, care must be taken not to pressure them while they perform their rituals. In CBT treatment, sufferers learn to better control their compulsive behaviours, at their own pace. Later, they also learn to reward themselves for the incremental progress they make.
An excellent way to support loved ones is to point out their strengths and remind them of times when they were free of compulsions. OCD is a problem, not a person, and it is good to remind your loved ones of the positive traits they possess that are unrelated to OCD.
Families can also help their loved ones learn more about OCD, and negotiate with them so they continue to participate in family life and also contribute to the family’s overall quality of life.
Are support groups useful?
It can be beneficial to join a support group to share personal experiences and learn about those of others. Taking a course on OCD and learning how to face its challenges is also a possibility.
Many people have noted that participation in a support group was a key component in their therapeutic approach. Meeting others with the same problem, gaining a better understanding of the issue and receiving support and encouragement can be very healthy. Support group members take an active role in their treatment and often know a great deal about the best therapeutic programs and educational resources within their communities.
Some support groups are geared specifically to adults, children or family members. It is important to select a group in which you feel completely comfortable.
Je ne peux m'arrêter de laver, compter, vérifier, Mieux vivre avec un TOC
Dr Alain Sauteraud. Éditions Odile Jacob, Self-Help Collection, Paris, 2000.
Les ennemis intérieurs : obsessions et compulsions
Jean Cottraux. Éditions Odile Jacob, Paris, 1998.
Clinician's Handbook for Obsessive-Compulsive Disorder: Inference-Based Therapy
Kieron O'Connor, Frederick Aardema. Wiley-Blackwell, 2011
Fernand-Seguin Research Center - Hôpital Louis-H Lafontaine
OCD Studies Center
Association / Troubles Anxieux du Québec (Anxiety Troubles Association)
Revivre (Association for people suffering from anxiety, bipolar disorder or depression)
ligne d’écoute : (514) 738-4873 ou 1.866.REVIVRE
La Clé des Champs (Peer network for people living with an anxiety disorders)
Phobies-Zéro : (Help groups for youth and adults suffering from anxiety disorders – all around Quebec)
Ligne d’écoute et de soutien : (514) 276-3105 ou 1-866-0002
AMI-Québec - Alliance for mental illness
(514) 486-1448 ou 1-877-303-0264
Association québécoise de prévention du suicide (suicide prevention)
24 heures/ jour, 7 jours/7 partout au Québec
1-866 APPELLE (277-3553)