Pages 271-276 from the Management of Mental Disorders, published by World Health Organization, Sydney. Editions in Australia, Canada, China, Italy, New Zealand and the United Kingdom.

4.7 Obsessive Compulsive Disorder

People with obsessive compulsive disorder complain of repetitive and irrational worrying thoughts and of having to gain ease by carrying out behaviors to nullify the risk that the thoughts might come true. The key to treatment is to have them face their fears and by not carrying out the nullifying behavior, find that the obsession has no substance. Drugs reduce the power of the obsession and so makes them easier to resist, but recovery really means being able to think about the obsession without anxiety and drugs do not achieve this

4.7.1 Description and diagnosis

Description
Obsessive compulsive disorder (OCD) is characterised by persistent, intrusive, unwanted thoughts that the individual finds difficult to control. These obsessional thoughts are usually concerned with contamination, harm to self or others, disasters, blasphemy, violence, sex, or other distressing topics. These thoughts are recognised as being generated within the individual's own mind and not inserted from without (as in `thought insertion' in schizophrenia). The thoughts may also involve images or scenes that enter the individual's head. Such thoughts and images are very distressing and may result in extreme discomfort.

Many individuals with OCD also experience persistent and uncontrollable compulsions or urges to perform certain behaviours (rituals). If the compulsions are strong the individual may experience anxiety and extreme discomfort. This discomfort can be temporarily relieved by the performance of the specific rituals. The rituals are usually associated with obsessional thoughts. For example, an individual may have the thought "my hands are dirty" thus triggering washing rituals. Or another individual may repeatedly imagine his or her house burning down thus triggering checking rituals of all electrical or gas appliances. While the most common rituals are washing or checking, other rituals may include such things as counting, arranging, or doing things in a specific and rigid order.

Although rituals are performed so as to alleviate anxiety or discomfort, the anxiety relief is usually short-lived. Also, unless the ritual has been performed perfectly, the individual may find it necessary to keep repeating the ritual many times over. Since many individuals with OCD have more than one type of obsession and associated ritual, much of the day may be taken up by the performance of such rituals. Additionally, OCD may lead to avoidance of certain objects or situations (e.g., dirt, leaving the house so as to avoid locking doors), thereby adding to life disruption. The symptoms of OCD are thus controlling, frustrating, and irritating to the individual, family, friends, and workmates.

Individuals may present with:

Diagnosis
According to the World Health Organization's (WHO) International Classification of Diseases (ICD)-10th Edition, for a diagnosis of OCD, obsessions or compulsions (or both) must be present on most days for at least two successive weeks. These symptoms:

• Are distressing to the individual
  
  
• Interfere with life activities

• Are recognised as the individual's own thoughts or urges

Additionally:

• There must be at least one thought or act that cannot be resisted
  
  
• Thinking about or carrying out the ritual should not be pleasurable
  
  
• The obsessions or rituals are unpleasantly repetitive

Differential diagnosis
Excessively repeated behaviours which are inherently pleasurable, such as gambling, drinking, or smoking, are not considered to be compulsions. Compulsions involve performing behaviours that are unpleasantly repetitive.

Depressive disorders often involve extensive rumination or brooding over specific thoughts. However, in depressive disorders the thoughts are not usually recognised as being senseless as they generally are in OCD. Co-occurring depression is common among individuals with OCD and will require separate specific treatment.

The obsessional thoughts in OCD may sometimes be mistaken for delusions in disorders such as schizophrenia . However, in OCD the individual usually has some insight and can acknowledge that the obsession is unrealistic, while in schizophrenic disorders the delusions are unshakeable.

Epidemiology
Until recently OCD was regarded as being quite rare, however, it now appears that OCD may be more common than previously believed. Men and women are equally likely to be affected. OCD usually develops during childhood or early adolescence. Without treatment the symptoms of OCD may fluctuate over time, with periods of improvement and worsening. For some individuals the symptoms may remain static while others may find that their OCD becomes worse over time. With treatment involving behaviour therapy or a combination of behaviour therapy and medication, most individuals experience an improvement in symptoms or learn to manage their symptoms more effectively.

Assessment
The rationale for assessment is described in the section on panic disorder. The Hopkins Symptoms Checklist which is discussed in that section can also be used to obtain a measure of generalised anxiety that is associated with obsessive compulsive disorder. There are also a number of self-report instruments specific to OCD that may be useful for assessing symptom levels and measuring improvement.

4.7.2 Management plan for OCD
OCD can be a severe disorder requiring specialist treatment with strategies based on behavioural principles. Effective treatment involves helping individuals to systematically expose themselves to the specific fears underlying their obsessions while encouraging them not to respond to the obsessions with compulsive behaviours or neutralising thoughts. Cure of OCD is not the primary treatment goal - rather, the primary goal is for individuals to gain control over the disorder.

Some individuals with OCD find that their symptoms improve with the use of serotonin re-uptake inhibiting anti-depressants (such as clomipramine or fluoxetine). These drugs can be a useful adjunct to treatment and are sometimes a substitute therapy if behavioural treatment is not available.

Treatment when obsessions are prominent
In some cases of OCD, intrusive and distressing thoughts are prominent and do not appear to be associated with any particular ritual or compulsion. Examples of such obsessions include parents who think they might kill their child, frequent blasphemous thoughts, or the fear that one has contracted AIDS.

In these cases the treatment principles will need to be applied to the obsessive thoughts (as well as to any associated rituals). Special expertise is required in these difficult cases since it is possible that a less experienced clinician may inadvertently worsen the situation. Therefore, referral to a clinician with specialised training and skills is recommended if such obsessions are prominent.

Treatment when compulsions are prominent
Exposure with response prevention is the treatment of choice for cases of OCD in which compulsions or rituals are prominent. Examples include the person who washes frequently in response to the thought "My hands are dirty" or who repeatedly checks electrical or gas appliances in response to the thought or image that his or her house might burn down.

The steps involved in treatment are:

1. Ongoing assessment of the disorder.
   
   
2. Education. It is important that the individual has an active role in implementing the treatment strategies. Therefore, a good grasp of the rationale of treatment is essential. The information contained in Section 4.14.9 forms a large part of this rationale.
   • Graded exposure to the cues or triggers of the compulsions or rituals.
   • Prevention of the compulsion or ritual (response prevention). (See Section 4.7.3).
     
     
3. Referral to an expert if progress is not being made.

4.7.3 Graded exposure and response prevention in OCD
The treatment strategy involves exposing the individual to stimuli that trigger anxiety or discomfort, and then having the individual voluntarily refrain from performing his or her ritual or compulsion. See Section 4.14.9 for the rationale of treatment to be discussed with the individual.

The first step is to help the individual plan a graded programme of exposure tasks that can be attempted in a systematic way. For each ritual the individual will be required to list a range of activities or situations that cause anxiety and which trigger the urge to perform that ritual. The individual would then rate each of these activities or situations according to the amount of anxiety or distress that would arise if he or she did not perform the particular ritual. These activities are then arranged in order according to those activities that generate the least anxiety or discomfort to those activities that generate the most anxiety or discomfort. The first task in the list would be an activity that is mildly discomforting but not too difficult, while the last task in the list would be the most difficult task the individual can imagine. For example, a person who had obsessional fears that unless everything was perfectly clean the family might be harmed by germs and who dealt with this by compulsive handwashing might set up the following plan:

1. Unpack a clean dishwasher without hand washing (anxiety rating 5/10)
   
   
2. Hang the washing on the clothesline outside without hand washing (anxiety rating 6/10)
   
   
3. Use the telephone without hand washing (anxiety rating 7/10)
   
   
4. Collect letters from the mailbox without hand washing (anxiety rating 8/10)
   
   
5. Do the grocery shopping at the supermarket then put food away in the cupboard and fridge without hand washing (anxiety rating 9/10)
   
   
6. Empty the household garbage bins, put them in the garbage bin outside, then put the garbage bin out for collection, without hand washing (anxiety rating 10/10)

In each case the individual is instructed to resist handwashing and to continue with the activity regularly until his or her anxiety or discomfort is significantly decreased. When the urge to wash is restricted, the anxiety associated with feeling dirty in that situation will gradually fade, and with repeated practice the anxiety and the urge will be extinguished. In the above example the first step in therapy would be to resist handwashing before unpacking the dishwasher. Once this is accomplished the next step in the hierarchy is attempted, and so on.

The principles of goal planning will be helpful when setting up a graded exposure programme (see, for example, the discussion of goal planning in Chapter 1: Core Management Skills).

Develop some ground rules
It is also important that certain `rules' are put strictly into place to cover times other than during the exposure tasks, for example in the above example, one quick hand-wash only, no washing or rinsing taps.

Maintain new behaviours
Once an individual has achieved a specific step on the graded exposure hierarchy, he or she is instructed to maintain the new behaviour in all situations. For example, when an exposure task has been successfully completed in a graded exposure exercise (e.g., unpacking a clean dishwasher without hand-washing), the individual is expected from this point forward to continue to unpack the clean dishwasher without hand-washing.

Encourage regular practice
It will be important to ensure that the individual undertakes exposure tasks on a daily basis. It will be useful to get individuals to monitor levels of anxiety during home tasks to ensure that progress is being made.

Avoid giving reassurance about the risk of danger
While it is important for the clinician to acknowledge that a task may be difficult for an individual and that he or she may have doubts about whether the task is safe, it is important that the clinician does not provide reassurance to the individual regarding the possibility of danger or harm. For example, the clinician would avoid saying things like, "It really is very unlikely that you will poison your family if you serve dinner without washing your hands. You're not going to poison them - you'll be OK." Rather, the individual needs to confront his/her fears and live with the doubt in order for the fears to subside.

Duration and setting of exposure tasks
Exposure sessions are best carried out whenever the obsessional symptoms naturally arise. Washing and checking rituals most commonly take place in the home or at work, so exposure tasks are usually discussed in therapy but practiced at home. Whenever possible exposure sessions should be prolonged (45 minutes to 2 hours) to ensure that there is enough time for anxiety or discomfort to be reduced without engaging in rituals (compulsions).

4.7.4 OCD Case Study
Michael Dunn is a 30 year old father of two children who presents with a nine year history of obsessions and compulsions. He engages in extensive checking behaviour which occupies up to two hours each day and significantly interferes with his life.

Psychiatrict History

Presenting Problem
Whenever Michael leaves his house, and before he goes to bed at night, he is plagued with doubts that he has switched off electrical appliances and locked the doors and windows. Michael is terrified that if something was left on accidentally, there could be a fire and something terrible might happen. He does not want to be inadvertently responsible for harm befalling his loved ones, neighbours, or other people, and so he checks "dangerous" items repeatedly to be certain that they are safely turned off. This checking is performed in a ritualised manner because over the years the doubt that he has turned things off properly has gradually strengthened, and now just looking at the stove is not reassuring enough. He must stare at each knob on the stove to be sure it is aligned in the "off" position, and say to himself "its off" over and over again. Then he must place his hand on each hotplate and count to ten to be sure that each hotplate is cold. If this ritual is interrupted, or if he loses his concentration, he has to start all over again, so it can take up to fifteen minutes just to check the stove. Then he has to check the kettle, the toaster, the microwave, and the iron to be sure that they are all turned off and unplugged at the wall. He also checks repeatedly to be sure that all the doors and windows are locked. Getting out of the house can take up to an hour, and the rituals leave him feeling anxious and exhausted. He is constantly running late and he was once asked to resign from his .job as a result of his frequent tardiness.

History of Present Illness
Michael reports that he has always been a worrier and that as a teenager, he would occasionally phone home to ask his family to ensure that he had switched off appliances. When he commenced work at age 18, he would sometimes have to return to work from the train station to check that he had switched off the coffee machine and locked his filing cabinet. At the age of 21 he left the family home to get married, and around this time Michael noticed a dramatic increase in his checking behaviour. He attributes this to the increased responsibility of having his own home, and the fact that there was no one there to turn things off or protect the house from intruders after he and his wife left for work each morning. Although initially he was satisfied with a quick glance at all appliances, doors and windows before leaving the house, over time his checking behaviour became more complex and time consuming. With the birth of his children his fears worsened again, so that whenever he tried to sleep he had images of his young children being caught in a fire, or being stolen from their beds. And so he returned to check the stove and the windows for a second, third or fourth time, until gradually he felt he had no control over his checking behaviour at all.

Previous Psychiatric History
When Michael lost his job three years ago because of his checking and constant tardiness, he remained unemployed for a period of four months. During this time Michael became increasingly depressed and withdrawn, and was referred to a psychiatrist for treatment. The psychiatrist commenced him on a trial of Clomipramine, both for his obsessional symptoms and his secondary depression, but after four weeks he ceased the medication due to side effects and so never achieved the therapeutic dosage. He continued to see his psychiatrist on a fortnightly basis over a period of six months for supportive counselling. He terminated the sessions at this time because he felt that although his mood had improved there was still no change in his compulsive behaviours. He has received no further psychiatric interventions until now.

Management
Treatment involved graded exposure to obsessional cues with self-imposed prevention of compulsive responses, as described below.

1. Michael was educated about the nature of OCD and the rationale for exposure and response prevention (see Section 4.14.9).
2. A list was made of all his checking rituals along with associated thoughts, images or impulses.
3. Michael was asked to rate how anxious he thought he would be if he did not check each item individually (SUDS rating 0-100).
4. Response prevention was implemented to a mildly anxious item (no checking the microwave), and the reduction in his anxiety and his urge to check was monitored across time.
5. The next exposure goal was set slightly harder than the last (no checking the toaster) and Michael monitored his anxiety and his urge to check across time.
6. Exposure goals of increasing difficulty were gradually targeted for response prevention (the kettle, windows, doors, iron, and finally the stove).
7. Basic rules were established to apply to all appliances and doors (e.g., turning things off quickly after use and never looking back to check, not even once; leaving the microwave and toaster plugged in and turned on at the wall).

Outcome
By the end of treatment Michael was consistently resisting checking all items around the home both before bed and before leaving his house. By consistently resisting the urge to check in response to obsessional fears, he noticed a gradual reduction in both the intensity of doubts about doors and appliances, and in the frequency of urges to check. His score on the Maudesley Obsessive Compulsive Inventory (MOCI) dropped from 19 (pre-treatment) to 6 (post-treatment). At a six month follow-up session Michael reported that although occasionally he will still have a passing urge to check the stove, he can easily resist it and most of the time he doesn't even think of checking things twice anymore.

Edited by Gavin Andrews MD, UNSW,2007
©2007 CRUfAD