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Ten tips on obsessive compulsive disorder

Clinical psychologists Dr Victoria Bream Oldfield and Dr Fiona Challacombe advise on obsessive compulsive disorder

Clinical psychologists Dr Victoria Bream Oldfield and Dr Fiona Challacombe advise on obsessive compulsive disorder

1 It's important to know exactly what constitutes OCD. The disorder is characterised by the presence of obsessions: repeated, unwanted and intrusive thoughts, images or urges. These are experienced as distressing, unreasonable or excessive. People with OCD believe that these thoughts are significant, dangerous or immoral and that it is their responsibility to act on the thoughts or harm will come to themselves or others. This belief leads to compulsions: the strong desire to perform repetitive behaviours or mental acts with the aim of preventing the feared outcome and to alleviate the associated anxiety.

2 Many compulsions are obvious but some are covert. Compulsions in OCD can be obvious and observable such as excessive handwashing or repeated checks of doors, appliances and so on. Covert compulsions are the mental equivalent, including ‘cancelling out' intrusive thoughts with other thoughts, counting, praying or trying to remember.

3 Always bear in mind that OCD is highly idiosyncratic and can change in presentation over time. It is important to ask sensitive questions about presenting problems. OCD may present with symptoms consistent with other psychological or physical disorders. For example, restricted eating may be related to obsessions regarding food and ritualised eating. Genito-urinary or other infections could result from obsessional rules regarding washing or avoidance of fluid because of contamination fears.

4 Comorbid depression needs to be recognised and treated before specific OCD treatment can start. It's common for OCD to present with concurrent depression and careful assessment of associated risk is essential. Depression is often secondary to OCD, but severe depression should be treated in its own right before initiating treatment for OCD.

5 Check for the impact on families. Studies have indicated levels of burden in family members comparable to relatives of sufferers of psychosis. Relationships can be strained and family members can be co-opted into assisting with rituals and giving constant reassurance. Sensitive enquiry about this may help with motivation to change.

6 Tell your patient that everyone has intrusive thoughts – it's not the thoughts that are the problem, it's the meaning attached to them. Everyone has experienced some version of an intrusive thought. It might be an image of jumping in front of the train while standing on the platform (or pushing someone else), or a sudden doubt about whether you locked your front door as you depart on holiday. Most people, most of the time, are able to dismiss these thoughts. In OCD, because of strong beliefs about being responsible for preventing harm, these thoughts are unignorable. Consequently people feel compelled to respond, taking action such as avoiding train platforms or driving back to check the door.

7 Acknowledging the effort a patient has made in discussing their difficulties can be extremely helpful. Suffering in OCD is often prolonged by embarrassment, guilt and shame. People are unwilling to discuss the nature of their problem as they may believe that their concerns will be dismissed as trivial, or because they think they will not be understood. Note that people with OCD frequently miss or are late for appointments because of compulsive behaviours. Making the step to discuss their problems with you will have taken courage and resolve.

8 Treatment for OCD can be very effective. NICE (2006) guidelines recommend that the initial treatment for OCD is brief individual or group CBT. Adults with mild functional impairment, or whom low intensity treatment has not been effective, should be offered an SSRI or more intensive CBT.

9 There is hopefully a widening range of options for accessing CBT. From October 2008, treatment may be available through new Improving Access to Psychological Therapies (IAPT) services. If local services are unavailable or have not been successful, referral to specialist services should be made – usually via the CMHT. A National Commissioning Group (NCG) service takes referrals from across the country for ‘treatment resistant' patients.

10 Having good information on the disorder can help people make sense of their symptoms and begin to recover. A number of books are available to help sufferers learn to help themselves including 'Overcoming Obsessive Compulsive Disorder' by David Veale and Rob Willson. Several service user-led charities and websites such as OCD-UK provide information and support for sufferers and their families.

Dr Victoria Bream Oldfield is clinical psychologist at the centre for anxiety disorders and trauma at South London and Maudsley NHS Trust

Dr Fiona Challacombe is clinical psychologist and psychiatry research trust research fellow at the Institute of Psychiatry, King's College London

Competing interests None declared

OCD-UK is the leading national charity, independently working with and for people with obsessive compulsive disorder (OCD). It also facilitates a safe environment for people affected by OCD to communicate with each other and provide mutual understanding and support.

Some OCD behaviours may be obvious - like handwashing - though others may be covert Some OCD behaviours may be obvious - like handwashing - though others may be covert

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