As some of you may know, I suffer from mental illness which unfortunately has made it difficult for me to work or study throughout my life. One of the illnesses I suffer from is obsessive-compulsive disorder or OCD and I want to talk about it because it occurs to me that whilst many of us are familiar with depression or social anxiety, OCD is a disorder that I often find people know the least about and it is actually quite a common disease. In fact, chances are many people you know have it in some form.
Firstly some definitions: Obsessive-compulsive disorder comes in two parts, obsessions and compulsions. Obsessions, also known as intrusive thoughts, in this context are unpleasant thoughts, images or impulses that will persistently recur and resist any attempts to ignore them or confront them. Compulsions are ritual behaviours taken by an individual often either as an attempt to drive away the unpleasant obsession, to cleanse themselves of it or to prevent the thought form becoming reality.
Obsessions and Intrusive Thoughts:
The nature of an intrusive thought or obsession varies in its content, nature or clarity. What unites them is that they always generate considerable anxiety, panic and/or feelings of self-loathing, self-disgust or mental contamination. The severity of this response varies from mild feelings of anxiety or unease to total panic inducing revulsion.
At the root of OCD type thoughts is a fallacy in the mind’s conception of the connection between thought and reality. All people have bad thoughts or images and most people will recognise that they are unimportant and will dismiss them as they occur, experiencing maybe some mild discomfort that passes quickly. However, for people like myself with OCD, our minds overreact to these kinds of thoughts, treating them as though thinking them makes them real or imminent.
Even though intellectually I know my thoughts are just inside my head and that thinking them won’t make them happen, emotionally and psychologically my mind won’t accept this and overreacts producing a powerful fear response. My overreaction reinforces the thought/image and turns it into an obsession whereby my mind is inundated with these thoughts over and over, each time producing more fear, anxiety or disgust that only serves to strengthen it further. It is hard to describe to someone else, the best I can say is that it feels like my mind is no longer my own, that it is attacking me. The more I try to enforce my conscious will and block the thoughts, the more powerful they become. To demonstrate, try not to think of a pink elephant now. Most of you will think of one and the more you try not to the more you will. This is probably as close as you can get to OCD if you don’t have it.
Typically obsessions/intrusive thoughts fall into three or four different themes. Firstly, there are violent or aggressive thoughts. These range from simple thoughts of shouting abuse or insults at someone else to impulses or thoughts of violently harming or even killing loved ones, strangers, children or even animals. They may also include having images of extreme or fantastic violent acts or acts of self-violence like jumping from a bridge or stabbing oneself. These kinds of thoughts will usually be uncharacteristic to the person and cause distress because the person would never normally act this way but, as part of the condition, they fear that by thinking about these things they will happen. For example you might be married with kids and yet are inundated by impulses to hurt them despite the fact the very idea is abhorrent to you, naturally you might start thinking that you are a bad person or have somehow been contaminated by the thoughts even if you would never act upon them.
Another, very common, type of intrusive thought would be sexual thoughts. Sexual obsessions are intrusive thoughts or images of things such as kissing, intercourse, oral sex or rape involving strangers, acquaintances, family members, children, friends, animals or even religious figures and can be of a heterosexual or homosexual nature regardless of and sometimes in opposition to the person’s actual sexual orientation. As before these are thoughts, impulses or images are not things that the person would ever act upon but the OCD person places unwarranted importance upon them causing anxiety and distress. This may lead to feelings of self-loathing, disgust, shame and self-doubt that can profoundly destroy a person’s quality of life. For example, a person with OCD might experience persistent unwanted images of child sexual abuse. They are not a paedophile and the images and thoughts disgust them, however, because OCD people often equate thought with reality they may start to fear that by having the images they might ‘lose control’ and act upon them, or that by having the images they are somehow made dirty, unclean or immoral by them.
Perhaps the archetypal theme or type of intrusive thought that is often stereotypically used in the media as what OCD looks like are intrusive thoughts concerning disease, hygiene or health. These can be thoughts concerning one’s own health, fears of catching diseases or thoughts of the imminent death of a loved one or yourself. It is these thoughts that can produce the stereotypical handwashing behaviour that is often seen in media depictions of OCD, something I will come back to later. As before these are often thoughts that ‘normal’ people might have but dismiss but for OCD person become very real and can cause feelings of distress, anxiety or contamination.
The above are just generic categories – in truth, an intrusive thought or obsession can be anything, I’ve had them about horror movies before now. Many religious people, for example, have intrusive thoughts concerning their religion or the supernatural, fears of being possessed, of acting out acts they deem blasphemous or that God or the Devil may harm them or loved ones. Ultimately anything that produces the overreaction can become an obsession.
Obsessions sometimes lead to OCD’s other half, compulsions; however this is not always the case. In fact, recent studies have shown that despite the popular association of OCD people with compulsive ritual behaviours such as hand-washing between 50-60% of OCD sufferers either do not have compulsions at all or exhibit them infrequently or internally. Such individuals suffer from what is now known as Primarily Obsessional Obsessive-Compulsive Disorder or Pure O OCD. When compulsions take place they usually take place internally in the form of rumination or mental avoidance.
This form of OCD is perhaps more insidious than the more well-known form because people can suffer from it without others being aware of it, it is entirely internal. Thus many sufferers of Pure O can go much of their lives without diagnosis, fearing that they are alone in what they experience. Indeed, there may be millions of people worldwide who may suffer from this disease and not realise it. This is the type of OCD that I suffer from and like most people with Pure O I was not diagnosed until I was an adult though mercifully I was diagnosed, for an undiagnosed Pure O sufferer it becomes an altogether even more terrifying and isolating condition, indeed before I was diagnosed I was terrified I was going mad.
Interestingly Pure O suffers report far more varied intrusive thoughts than other OCD sufferers and whilst traditional OCD sufferers often only ever have one particular obsession, people like me can pick up new obsessions all the time. Furthermore, the intrusive thoughts or images are typically far more personal and terrifying than those of traditional sufferers and often involve self-destructive scenarios, things that the sufferer fears would ruin their lives or the lives of others if they became real. For example, a Pure O sufferer might fear that they’ve undergone a radical change in sexuality and become a paedophile, or they might fear they might become a murderer and cause harm to a loved one, or that they might simply go insane. They subsequently spend large amounts of time either trying to avoid things they fear will bring the intrusive thoughts on or will spend lots of energy on ruminating on the thoughts as a futile attempt to internally resolve them.
What are Compulsions?
Compulsions are the expression of OCD that is perhaps most familiar to the public. They can take a multitude of forms and can be just as destructive to one’s quality of life as the obsessions. Typically people who suffer compulsions will feel driven to carry out certain actions or behaviours. This can either be out of a desire to somehow prevent the dreaded thought from becoming reality or can be a way of relieving the anxiety and fear the obsessions create. Some people with OCD are fully aware how irrational their compulsions are but feel compelled to do them anyway whilst others may genuinely be convinced that the compulsion works. Either way, the compulsions typically only serve to reinforce the obsessions creating them.
Common compulsions include the familiar handwashing, compulsive checking things (for example checking locks on doors, a compulsion my father often had), repeating actions, ordering things in a certain way, requesting reassurance from a loved one, hoarding behaviours or acts of self-damage such as nail biting, hair pulling or skin picking to the point of dermatillomania (compulsively picking at the skin until it bleeds or scars). As I have said it can also be internal in the form of avoidance or rumination.
Sufferers often rely on their compulsions as a way of managing their condition, a way to escape from the thoughts in their head. However any relief offered is only temporary and the thoughts always return eventually, often stronger than before.
What distinguishes compulsions from habits is the context in which they occur. Habitually checking locks if your job is a security guard is understandable, but doing so constantly regardless of situation and often numerous times can be disruptive. As a general rule, a habit improves the efficacy of your life whilst a compulsion only disrupts it. Indeed some OCD sufferers can spend several hours a day performing their compulsions or may be doing it all the time throughout the day.
Causes and Mechanisms:
The precise cause of OCD is sadly not known, indeed we know shockingly little about what triggers it though both genetic and environmental factors are believed to be involved. Typically it will manifest from early childhood onwards though it may not be recognised until much later. Looking back at my childhood now I can see how I have always had OCD but it was not recognised at the time.
Studies have suggested there is a likely genetic link at least with giving a predisposition to developing the disease. People with OCD will often have a near ancestor with the condition as well and certainly in my case there is evidence to suggest my father may have suffered from it as well (though, alas, he was never diagnosed).
As for the mechanism within the brain for how it works, this too is not completely understood and – like neuro-science itself – is an emerging area of study. Scans of the brains of people with OCD do show marked differences in brain activity to people without the condition. In particular, the striatum – the area of the brain associated with the reward system and functions like action planning, motivation, behaviour reinforcement and decision-making – shows distinctive differences in circuitry compared to ‘normal’ brains. Furthermore, people with OCD have unusual dopamine and serotonin activity in numerous regions of the brain. They also show signs of having excess grey matter in a part of the brain called the basal ganglia.
Unfortunately, there is no known cure for OCD. People who suffer from it will potentially have it for the entirety of their lives. There are ways to reduce symptoms, however, such as receiving psychological therapies to learn ways of coping and living with the anxiety and distress obsessions cause, or taking medication designed to treat anxiety. As ever, knowledge is power and simply learning about your condition can be a massive relief.
No mental illness is easy to live with and all have potential to destroy lives. OCD is an insidious disease with hundreds of millions of sufferers worldwide. Untreated and undiagnosed it can leave you trapped, a prisoner in your own mind, isolated from others by the overwhelming sense of shame and stigma that the condition can create. This is why diagnosis is so important: once you identify your enemy you can start to work on fighting it and you can also be assured that you aren’t going mad.
It is also important that as a society we talk about OCD more, that we are more aware of it because it is every bit as destructive as more well-known neurotic conditions like depression or anxiety disorder. Furthermore, it affects as much as 2.3% of the populace worldwide, that’s more than schizophrenia, bipolar disorder and panic disorders. Hopefully the more aware society is the more it can support people with OCD and understand the daily struggle we go through. Furthermore we can dispel the myths that still pervade public conceptions of OCD, such as the myth that it only involves handwashing and cleanliness obsessions.
If you recognise any of the symptoms I’ve discussed in this article in yourself please don’t be afraid to seek psychiatric help, I know from experience that they will always try to help you and will not judge you no matter how ashamed you may feel of your thoughts. Equally, if you think someone you know may be experiencing these symptoms talk to them, try to understand what they’re going through and if they aren’t diagnosed please encourage them to seek help.