OCD is a neuropsychiatric illness:
* Neuro: originates in the brain
* Psychiatric: affects thoughts, feelings and behaviours
It is predominantly biological. Obsessions sometimes develop after a major stressful experience, but that does not mean the obsession is caused by the experience, or is a natural reaction to it. Mostly, OCD starts insidiously, without rhyme or reason.
Although it is not caused by stress in the environment, it can be triggered or made worse by environmental factors, and stress makes OCD more difficult to resist.
Typically, people with OCD have insight (at least some of the time) into how irrational their thinking is. They may be secretive and shameful about their obsessive thoughts, and may conceal the condition for years. “OCD tricks you into thinking what it wants you to do makes sense, but nothing about OCD is real”. Intrusive thoughts bring feelings of shame and guilt, “Just because OCD makes you feel bad, that doesn’t mean you are bad”.
People with OCD frequently also suffer from depression.
* Obsessions and/or compulsions that are time consuming, distressing and/or interfere with normal routines, relationships and daily functioning
* Persistent impulses, ideas images, or thoughts that intrude into a person’s thinking and cause excessive worry and anxiety
* Mental states or repetitive behaviours performed in response to obsessions to relieve or prevent worry and anxiety
* Often have the intent to magically prevent some dreaded event
OCD is not the person, it is an illness; a misfiring of the system that in other people turns off our alarm system once a worrying thought has registered and been assessed. A feedback loop is established and the person feels the only escape from the worry is to perform magic rituals.
What OCD is saying to the child may not be obvious, but obsessions are so intrusive that they interfere with many parts of life. Sometimes it is possible to know the trigger for an OCD attack, but not always. Knowing the trigger can help us be more empathetic, but changing the behaviour that keeps OCD going is the key to stopping the sequence of events that is OCD. Performing the compulsions feeds the OCD, which demands more and more from the child. Left untreated, obsessions expand, morph and multiply.
* Pure Obsessionals
* People with scrupulosity (religious, moral, ethical)
Working with OCD
Gradually learning to resist the same compulsions reduces the obsessive thoughts. By taking control of how they respond to OCD, the young person can change the brain so that OCD brain responses are replaced by normal ones.
Important conversation: taking risks
“If I don’t do my rituals, what will I do to feel safe?”
By taking a chance and dealing with discomfort by not doing rituals, you open up other ways of handling discomfort.
“If I confront my fear of germs, how can I guarantee that the catastrophe I fear will not happen?” You cannot guarantee a life free of risk, pain loss, etc. The problem is your brain has made the mistaken connection between your compulsions and feelings of comfort and safety. Exposure-Response Prevention (ERP) can help break the stranglehold they have on your life.
NICE guideline for treating OCD
The main treatments for children and young people:
* Talking to someone and getting help with anxious feeling from thoughts or actions
* Mild symptoms - given a self-help book to help thoughts and actions. Healthcare professional should help to follow some of the exercises in the book. Family or carers may be given information about OCD and the treatments
* If the exercises do not help, or person does not want to try them, they should be offered a Cognitive Behavioural therapy including exposure and response prevention (CBT with ERP)
* Family or carers should be involved in the treatment
* Offered the choice treatment alone, or with a group
* For more severe symptoms CBT with ERP should be offered.
* Medication can help children and young people with OCD but they should be offered therapy before medication
* Medication offered also dependent on age. It is less likely to be offered to very young children
* Usually person should be having CBT withy ERP while taking medicine
* SSRIs (antidepressants) often work best for people with OCD
* Only offered medicines being seen by a child and adolescent psychiatrist
Evidence from research
There is a growing body of research that indicates that CBT with ERP is an effective treatment for pediatric OCD. A meta-analysis of research by Barnet et al (2008) found that remission rates varied between 40% and 85% for exposure based CBT. O’Kearney (2007) compared the research on expose based CBT interventions with medication only and with no treatment and found a 37% improvement in remission rates in the treatment groups. There was no significant difference between CBT and medication. CBT combined with medication offered potential for best health outcomes.
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. For example, a negative thought can lead to negative behaviour, which can affect feelings. CBT helps people to reassess the meaning of their thoughts and actions.
ERP consists of two parts: exposure to feared situations, thoughts or images, and response prevention, the voluntary blocking of compulsive behaviors. ERP requires the supervised or self-controlled blocking of compulsive rituals. This needs willingness to tolerate high levels of discomfort and it involves purposefully allowing anxiety to be present
Exposure relies on two related learning processes: habituation and extinction. It an be thought of as a behavioural experiment, a way of the individual gathering evidence from their own experience that the way hey currently understand the world is distorted.
Habituation harnesses the nervous system’s natural tendency to numb out to repeated and prolong contact with a stimulus. Extinction uses the way behaviour is governed by its consequences. Because the ritual brings relief from the anxiety that accompanies the obsession, the obsession is reinforced. When the ritual response is prevented, it no longer reinforces the obsession.
Exposure can be in therapy, but can also be in vivo, the prolonged, face-to-face confrontation in real-life with anxiety provoking situations, objects, thoughts or images.Once the response is blocked, the brain has the opportunity to provide the natural habituation to the fear-provoking situation, and more realistic and adaptive interpretations can replace the fearful ones. For response prevention to be effective it is necessary to eliminate, block or contain all the behaviours that neutralize or lessen the feelings of anxiety and discomfort brought on by the obsessions, and purposefully allowing the anxiety to be present.
Obsessive thoughts without obvious compulsions can still be treated with CBT with ERP. However the ERP will focus on mental rituals and any methods used to deal with obsessive thoughts.
Cognitive therapy for OCD
Most psychological treatment for OCD consists of CBT with ERP, but if someone does not feel comfortable starting ERP they may be offered 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.
CBT involves actively challenging and confronting the distorted thinking and beliefs that drive and maintain the obsessions and compulsions. Table 1 lists the key cognitive errors of people with OCD.
Black-and-White or All-or Nothing Thinking
If I’m not completely safe, then I’m in overwhelming danger
If I think bad thoughts, bad things will happen
If I take eve a slight risk, I will come to great harm
I’ve got to do everything perfectly
I’ll be punished for every mistake
Over-responsibility for Others
I must always guard against making mistakes that even remotely harm an innocent person
Over-importance of Thought
If I think about a terrible event occurring, it is much more likely to happen
Bad things are much more likely to happen to me than to other people
Suffering and sacrificing my life by doing endless rituals is a small price to pay to protect those I love. Since no harm has come to them, I must be doing something right
“What If” Thinking
In the future, what if I get it wrong
Intolerance of uncertainty
I can’t relax until I am 100% certain of everything, and know everything will be OK
Other than the treatments described above, there is no evidence that other psychological treatments or therapies can help improve OCD.
These include psychoanalysis, transactional analysis, and hypnosis.
CBT is a time limited intervention. Typically, a client may see the therapist for anything from six weeks to three months. It is also very hard work. It is a challenging approach, and may involve homework, for example keeping a journal. More recently, CBT has begun to emphasise the therapeutic alliance more, acknowledging that therapy proceeds within a relationship, and therefore, in common with other psychotherapies, in order for CBT to be effective, the client must feel able to invest in the therapist. It is not enough to be referred and just turn up.
* Realize that a person with OCD cannot control the powerful urges they experience. A chemical imbalance is ruling their thoughts and behaviours
* Never force or impose treatment or help
* Do not criticise or scold if they cannot meet expectations
* Encourage, guide, monitor, help and support
* Do not judge the person with OCD by their progress
* Expect relapses
* Reward progress with praise
* Expect the symptoms to make no sense
* Do not expect the symptoms to have symbolic meaning; they are just OCD
Warning: “enabling” OCD
It is important to avoid enabling the OCD by colluding with the rituals by offering reassurance, and by accommodating the OCD.
A thorough assessment of OCD obsessions and compulsions is the first step to breaking free. This is usually conducted through as self-report questionnaire that identifies an individual’s obsessions and compulsions and assigns a past and present disruption score to each.
It can be overwhelming to think of making improvements to each symptom at once, but the road to recovery is taken one step at a time, singling out one or two symptoms that are casing the most disruption to everyday life.