By Professor Kevin Gournay.
Obsessive/Compulsive Disorder was at one time thought to be a rare problem. However, like many anxiety states, people who suffer from Obsessive/Compulsive Disorder (O.C.D.) keep their problems much to themselves. It is because of the very irrational nature of many obsessions that many sufferers are frightened and embarrassed about revealing their problems. Thus, until the last few years, the true incidence of the problem was unknown, there are varying estimates of the numbers of people suffering from O.C.D. but there is an agreement that probably more than one million people in the United Kingdom have one form or other of the problem.
O.C.D. of course comprises both obsessive thoughts and compulsive behaviour and sufferers may exhibit either obsessions or compulsions alone or, more commonly, a mixture. There is no doubt, that O.C.D. affects people across all cultures, occupations and radical groups. Before describing some of the current approaches, it is worth underlining that obsessions and compulsions per se are part of our lives. There is not one person who has not been preoccupied with an irrational idea, compelled to give in to a superstitious behaviour or who has not been troubled by thoughts relating to guilt, perfectionism, or some aspect of conscience. O.C.D. sufferers have these traits but some or all of them are magnified many times over.
What causes O.C.D?
Many years ago obsessions were thought to be caused by development factors and during much of this century most treatment approaches centred around psychoanalytic theories. However, in the last few years, it has become clear that the basis of O.C.D. is to be found in slight differences in the structure and chemistry of the brain. These differences in themselves do not actually result in any other abnormalities but do seem to provide the basis for O.C.D.
Our knowledge of these brain differences is expanding with the recent advances in brain imaging. We are now able to scan the brain using some of the more recent developments, for example, magnetic resonance imaging and positron emission tomography, also known as MRI and pet scans. However, despite the recognition that certain parts of the brain are different in O.C.D. sufferers, we still do not know how these structural differences relate to the precise mechanisms of O.C.D. Neither are we absolutely sure how the brain chemistry of O.C.D. sufferers vary from the so-called norm.
Another interesting line of research is in the area of genetics and recent work carried out in several parts of the world has indicated that there may be a considerable genetic basis for O.C.D. However, the more the picture unfolds, the more complex O.C.D. becomes and it is probable that O.C.D. comprises a number of different problems with some commonalities, it is also clear that the structural and chemical causes are not the entire answer.
Obsessive and compulsive thinking and behaviour can also be learned from a range of experiences for example, during childhood, following traumatic events of one kind or another and, by exposure to a mother, father or significant other relative with O.C.D. Thus, people may be born with a biological disposition to O.C.D. but never develop the full problem, while others are born with the same predisposition but, when subject to sufficient learning experiences, develop the problem in a full-blown form.
All this might sound rather complex and, indeed, as most of you know many GPs and even some mental health professionals are surprisingly ignorant about O.C.D. but it is important to see that the condition is not caused by one simple factor.
I will now look at some of the common treatments for O.C.D. and give a conclusion based on research findings rather than give a personal opinion.
Traditional psychoanalytic and psychodynamic psychotherapy was, for many years, the only psychological approach used in this problem and, indeed, many patients with O.C.D. still have experiences of receiving this sort of treatment. While some patients may report receiving some benefit from these modes of treatment, the benefit is rarely reflected in change in the obsessional thoughts or ritualistic behaviour.
Psychodynamic and psychoanalytic therapies are talking treatments which aim to resolve predominantly subconscious or unconscious conflicts and thus, in the light of research findings on the nature of O.C.D. it is obvious that chasing supposed unresolved conflicts is unlikely to achieve anything over a placebo effect. Gradually mental health professionals are accepting that these treatments are ineffective and fortunately most services have abandoned these methods as a way of helping people with O.C.D. Although, unfortunately, in some areas of the country there are still psychiatrists, psychologists and others who continue to use these out of date ineffective methods.
While relaxation training can be quite helpful for certain types of anxiety; there is no evidence that it is helpful in the treatment of obsessional thoughts or compulsive rituals although, being relaxed helps us all. Indeed, it is so ineffective that many researchers choose to use relaxation as a placebo treatment when trying to evaluate other treatments. Relaxation may, of course, be helpful in reducing general anxiety but anyone with O.C.D. is wasting their time putting effort into using relaxation methods as anything more than a secondary supplement to other forms of treatment.
Patients still ask for hypnosis and it is easy to see that sufferers think that their obsessional thoughts could be susceptible to this method. However, sadly this is not the case and hypnosis treatment represents the sort of magic wand which has no place in the treatment armoury against O.C.D. My advice to anyone contemplating spending their money on this method, (it is not available on the NHS for the treatment of such problems), is that this is truly a waste of money and the only person benefiting will be the hypnotist and his or her bank manager.
Behaviour therapy revolutionised the treatment of obsessional rituals at the beginning of the 1970s and brought the first real hope for sufferers. Treatments were based on the simple idea that if you helped people delay their responses to the compulsion to carry out a ritual such as handwashing or cleaning, they would experience a decline in their response and thus are able to “break the habit”. Response prevention is linked to exposure, whereby the patient is asked, in graduated doses of difficulty, to face up to the primary source of their compulsion, i.e. the thing which they feel is contaminating them. Much of the time patients realise that their contamination fears are irrational but nevertheless any exposure to anything resembling the source of the fear produces huge anxiety which is only temporarily reduced by the ritual.
Early treatment programmes were carried out while the patient was in hospital and the method often involved having the assistance of a nurse 24 hours a day to enable the patient to be able to resist the urge. The treatments were very successful although, as one can imagine, in-patient care with 24-hour nursing cover is very expensive. However, one reason for changing this mode of treatment was that patients often thought they could hand over the responsibility to a hospital or nurse or the therapist involved in the treatment.
Thus, during the 1970s treatment became much more outpatient focused, and therapists transferred their treatment efforts to the home setting. Indeed, when I worked with Professor Marks at the Maudsley Hospital in the 1970s, I spent a considerable amount of my time in patient’s homes, helping them to deal with their obsessive fears.
These response prevention treatments remain the main approach for people with obsessional rituals and the outcome of these methods is still excellent, with approximately 70% of patients who complete treatment reporting 70% or greater improvement in their symptoms. Nevertheless, behaviour therapy has never proved to be dramatically effective for obsessional thoughts although, there are some cases, which do respond to pure behavioural methods.
In the last few years, better results have been obtained by using cognitive therapy in conjunction with behaviour therapy with obsessive thoughts. Cognitive therapy involves helping the patient to rationally change their thinking and therapists have developed a number of strategies to help patients deal with their obsessional worries. Commonly, cognitive behavioural procedures can help people with obsessional thoughts in between 10 and 20 sessions of treatment. However, good quality research on the cognitive approaches to obsessional thoughts is still in its infancy and we await larger studies.
Drug treatments have been used with O.C.D. Antidepressants such as Annaframil (chlomipramine) may be helpful in some cases, particularly where depression is prominent. However, antidepressants only seem to confer truly long-term gains when combined with behaviour therapy. Newer compounds such as Prozac are currently being researched but, as yet, there is no evidence that they are useful in O.C.D. Further, all drugs have side effects thus, and one must balance these against benefits.
O.C.D. can be a crippling syndrome but behavioural methods may provide substantial benefits. No Panic and similar self-help organisations may provide benefits via not only the dissemination of behavioural advice but by collective support that professional treatments rarely provide. Sufferers should however take heart and the treatment outcome continues to improve. The future recovery prospects for people with O.C.D. is bright but as yet sufferers still need to work hard at getting better. The No Panic help-line will provide details of self-help materials and useful books.
Professor Kevin Gournay is an Emeritus Professor at the Institute of Psychiatry. He has more than 35 years of experience and is the author of more than 130 articles and books. He is based in Cheshunt Hertfordshire.
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