Ray (not his real name and he gave permission to use case to assist others) was an office worker whose role entailed some travel nation-wide. He struggled with the bright light reflected from the clouds. He had noticed floaters in his eyes and became obsessed with estimating whether they were multiplying and estimating the percentage of his vision was obscured by the floaters. Ray even went as far as having risky surgery in the hope of removing the floaters. He was assiduous in pursuing therapy even through a major life crisis. We employed Acceptance and Commitment Therapy. Therapy spanned a few years with intermittent series of sessions. Ray persisted through “thick and thin” and was finally free from his symptoms of obsessive-compulsive disorder (OCD).
Whilst Ray’s major obsession (he had several others over the years) was uncommon, his experience wasn’t. Many millions of people throughout the world experience OCD. Some research suggests that the average timespan those with OCD wait before seeking treatment is thirteen years (Ziegler et al, 2021). OCD can have serious consequences. People with OCD have a higher suicide rate and a higher rate of premature death (Fernandez de la Cruz, et al, 2024). Thus, treatment takes on even greater urgency.
People with OCD can be trapped in automatic, persistent, negative thoughts, urges or images. These cause distress and anxiety, and doubt. To get relief they perform unrelated repetitive compulsions to relieve doubt and gain certainty. These are often time—consuming and can cause significant distress. Sometimes the intrusive thoughts are the same, sometimes they are on the same theme but vary.
Whilst onset can be at any age, it is usually between seven to twelve or between late teen and early adulthood about twenty. The severity can range from mild and manageable to severe and debilitating.
Compulsions (aka “rituals” may be external behavioural (e.g. checking locks) or internal – thinking - rituals. Internal compulsions can include rumination, silent counting or replacing a thought with a different one. Rituals might give temporary relief but ultimately strengthen obsessions. OCD is not formally divided into sub-types, but common presentations include germ phobia with excessive washing and cleaning, fear of harm to self or others or even the experience that things are uneven or unsettling, sexual taboos, or anxiety re religious transgressions. Diagnostic focus should be on the function of the compulsion – to reduce distress or neutralise unwanted thoughts and obsessional fears.
OCD can be missed in a diagnosis as it can appear as several other conditions. Anxiety (GAD) may be commonly diagnosed because it presents with OCD as well as PTSD and autistic symptoms. The DSM-5 lists related conditions including body dysmorphic disorder, illness anxiety disorder, hoarding disorder and Tourette Syndrome.
First line treatment of OCD is exposure and response prevention (ERP). Between sixty-five and eighty per cent of people respond well (Ong et al, 2016). Interference-based CBT (I-CBT. Aardema, 2022) can also be used when a person does not respond to ERP. Medications may also be prescribed.
REFERENCES:
Aardema, F. et al. (2022). Psychotherapy and Psychosomatics. Vol 91. No 5.
Fernandez de la Cruz, et al, (2024). BMJ. Vol 384.
Ong et al, (2016). J. Anxiety Disorders. Vol. 40.
Ziegler et al, (2021). PLOS One. Vol 16. No. 12