Offering one to one help with Obsessive Compulsive Disorder - OCD in Bristol and Bath UK.

What is Obsessive Compulsive Disorder?

Obsessive Compulsive Disorder (often referred to simply as OCD) is a broad brush label which covers a very wide range of difficulties. Though symptoms can vary hugely, the condition is marked by either obsessive and/or compulsive thoughts and/or behaviours which usually create an enormous amount of anxiety for the sufferer. Often a compulsive thought or behaviour will be seemingly irrational, but the sufferer will nonetheless be compelled to complete the behaviour by a strong feeling of anxiety. The anxiety will usually diminish upon completion of the behaviour, thus offering, on the face of it, an antidote to anxiety. These behaviours, once begun however, often become strongly engrained as patterns of daily rituals which must be completed in order that the sufferer can go through the day with a manageable level of anxiety. Being denied the opportunity to complete the anxiety reducing ritual, the sufferer will often become very anxious indeed. Sufferers will be only too aware that the thoughts or compulsions themselves are irrational but that does not diminish the need to ritualise. It’s easy to see then how this condition can severely limit a persons’ experience of life.  

Do I have OCD?

It’s worth pointing out that obsession and compulsion are basic components of every mind. Most of us have a healthy level of obsession. We know that it might be a good idea when we’re out to check every hour or so that we still have our wallet or handbag with us. Most of us will check that the door is locked when leaving the house. Often, in absent-mindedness we’ll return just to make sure! Most people know the feeling of being half way down the motorway and thinking “You know I don’t remember….DID I turn the gas off?!” The compulsion to return to check can be overwhelming for some people, but still it can be considered “normal”, because these are real concerns which require mindfulness. Most people will also recognise that the mind has a natural tendency to repeatedly return to uncomfortable or embarrassing moments or indeed to moments where there has been conflict. There is an effort by the mind to balance difficult feelings or thoughts by re-running them in an attempt to make it right this time. Irrational as it is, we all know that feeling of watching a movie and wondering (just for a moment) whether, despite the fact that last time we saw the movie the hero’s girlfriend met an unfortunate end that “this time” she will make it through? Like it or not, there’s not a person on the planet who hasn’t had the disconcerting experience of having at some time or another a depraved or evil thought despite having no actual affinity with that thought or idea. Research has shown that difficult or destructive thoughts are experienced by approximately 80% of the population (this crosses cultures too), and it is now widely recognised that although we perhaps don’t understand quite WHY this should be so, we do know that it is a common experience and DOES NOT indicate a personality disorder. It simply seems to be part of having a brain! We think “Where did THAT come from?!” “That’s not what I feel!” Most of us will easily be able to allow those thoughts to simply come and go, rare as they are, and think no more of them. We recognize that they are not indicative of who we are. Even avoiding walking under ladders is an irrational compulsion. So, everybody can relate to the symptoms of OCD. Everybody has experienced some of the symptoms, albeit in a manageable and diluted form. With OCD however, it can become very difficult to separate oneself from those thoughts, and with over-identification and increased anxiety, those thoughts can become overwhelmingly dominant. The problems begin then, when these natural inclinations seemingly take on a life of their own, and escape the control of the intellect.

Typically speaking a person will be diagnosed as being an OCD sufferer when the obsessions and compulsions create real distress, consume over an hour a day, and/or significantly interfere with a persons’ ability to function normally in society; that is to say at work, at home, and socially. Recent figures show that approximately 2-3% of the UK population has OCD. We know that in fact a very high proportion of people will suffer from mild compulsions and obsessions. These would not necessarily be diagnosed as OCD, and often will remain private, but they can be troubling nonetheless.

What are the symptoms?

Symptoms are as varied as one can imagine. We can become obsessive or compulsive about literally anything. Common obsessions are repetitive, involuntary, unwanted, often distressing thoughts, images or impulses which include, but are not limited to: -  

·        Harming or hating – others, oneself, or loved ones.

·        Fears about contamination - germs, dirt, virus’s etc. Worry about “infecting” others.

·        Hypochondria - Excessive worry about illness, and/or death of self or others.

·        Jealousy, envy, or becoming inappropriately overly concerned with another’s life.

·        Violent or intrusive sexual thoughts.

·        Thoughts of impending doom or disaster.

·        Persistent, repetitive need to check potentially harmful elements for safety.

·        Irrational concern with form, number, or measure.

·        Extreme perfectionism/preciseness.

·        Upsetting thoughts of blasphemy.  

·        Appearance – inappropriate attention to detail.  

Compulsions are just as varied as obsessions and often complete the cycle of anxiety reduction. So a person who has obsessive thoughts about germs and contamination may feel a strong compulsion to clean and disinfect. Compulsions can also be driven by obsessional thoughts of keeping order which can manifest in odd behaviours seemingly unrelated to anything rationally apprehended. Compulsions may include, but are not limited to: -  

·        Repeated checking gas is off, windows are sealed, plugs unplugged, doors locked etc.

·        Continually showering or washing (hands usually).

·        Touching objects to make sure they are there.

·        Arranging, and ordering. Ornaments or collections. Lists and lists of lists.

·        Counting. (Teeth, tiles, flowers, wallpaper squares, anything countable).

·        Cleaning and disinfecting (both for self and others).

·        Self harming

·        Hoarding useless objects.

·        Hair pulling and eating (trichotillomania). Spot/skin picking.

·        Difficult cyclic routines which must be practiced precisely.

·        Restyling hair/clothes/makeup repeatedly before being able to leave home.

This is only a sample list of possible obsessions and compulsions. The list could be almost endless. It’s important to note though that if you do have an obsession or compulsion listed above it doesn’t necessarily mean that you have OCD. The distinction and diagnosis is one of degree, and though OCD is a serious disorder, it is still a label for an extreme form of what most of us do to one degree or another anyway. Even if you have been diagnosed as having OCD, it doesn’t always help to identify too closely with that “label”. It can be helpful to know that the condition that you are suffering with is recognised and has a name since it gives you a sense of normalisation, but in the long term it’s sometimes unhelpful to associate too closely with being a “victim” or a “sufferer”. Ultimately, you need to be able to separate yourself from the symptom which sends the message that you have the power to do something about it. Much of an OCD sufferer’s distress will be created by the mistaken belief that the thoughts or compulsions are in some way indicative of a twisted core identity. This must be challenged. Indeed, this is the first rule of treatment with OCD. You are not your OCD. Remember, at worst, your OCD is only a percentage of your life.

How do we “get” OCD?

We may less “get” OCD, than always have had it. The truth is, the exact mechanisms of OCD are still not completely understood, though we do see different patterns of activity in the brain in OCD sufferers which show the "housekeeping" areas of the brain are overheated and over active. It is believed that the part of the brain which promotes the feeling of something not being right (which of course is useful when firing appropriately) actually gets stuck in the open position making it very difficult to shake the feeling that something is wrong. The anxiety creates an extension of normal patterns of worry, concern, or interest, into an unhealthy level of obsession which results in compulsive behaviours carried out in an effort to create order, solution, and reduce anxiety. It seems that certain personality types may be more pre-disposed to OCD, and we know that in terms of recovery it’s not necessarily a case of being “cured” of OCD. It’s more realistic to think of the condition being in remission. To put it another way, if you’re a person who tends to be obsessive and/or compulsive, or are pre-disposed genetically to OCD then that may well be part of your core personality. This is no cause to lament. When properly channeled, these tendencies can be incredibly useful and productive. The correct measure of compulsion to clean the house, or drive carefully is useful and healthy! Equally of course, some of the greatest pioneering contributions to our World have been made by people with obsessive personalities. Many people manage with therapy (which can be self directed of course) to reduce their symptoms by as much as 90% (some claim even higher success than this!) and often people who take control of their OCD lead rich lives.

So, often it’s much more about creating manageable patterns than it is about being “cured”, and long term condition management is usually much easier following recovery since one learns along the way what factors contributed to both the creation and the solution of the difficulty. Thus, a measure of control is attained which was not available first time around. Perhaps a more useful question to ask then is “What do we know about OCD?” and then “What is the way out?”

Whilst we know that there is an involuntary cognitive (thinking style) distortion involved, OCD is usually classified as an anxiety disorder (as opposed to cognitive) since most sufferers (80%) will already be aware that their thoughts and compulsions are irrational. Cognitive therapies are ordinarily concerned with recognition and correction of unreasonable and irrational thoughts. Though this is certainly helpful in tackling OCD it can be of limited value when used alone, since the sufferer is already usually only too aware of the unreasonable/irrational nature of their thoughts. The disorder begins at the emotional level. Therefore, as well as the longer term cognitive and behavioural adjustments required for recovery, successful treatment should include a practical method for reducing anxiety. When emotional arousal (anxiety) is reduced, then it becomes much easier to correct thoughts and challenge behaviours. I will qualify this position. 

The science of anxiety and OCD.

Studies show that serotonin levels in the brain are erratic and unbalanced in OCD sufferers. This is also found to be the case where people are suffering with depression and anxiety so the parallels are clear. It is unsurprising therefore to note that some common anti-depressant medications (Anafranil, Prozac, Luvox, Paxil, and Zoloft) are shown to be helpful in treating OCD. We know however in the treatment of depression that anti depressant medication used alone is of limited effectiveness, because there are factors which are shown to create depression which are not purely chemical. It is arguable that the imbalance of brain chemistry we find in depression is as much a result of depressive thinking as it is the cause. If the cause of depression is in part a negative thinking style, then we will remain much more prone to depression if this is not addressed…with or without the aid of pharmacological intervention. OCD may well be the result of a combination of factors…biological, neurological, cognitive, behavioural, emotional and chemical. The truth is though it’s difficult to say which of these is the cause and which is the effect, though it appears at least at first to be primarily a neurological condition. It is helpful to think of it in these terms when setting out to overcome it since this gives substance to the assertion that the difficult thoughts or feelings are not you! They are a misfiring within the brain. It is most probably a combination of factors. What we do know though is that behavioural therapy used in conjunction with medication and an anxiety reduction plan covers all the bases and will usually create an effective combination. Medication, obviously, should be discussed with your GP.

Interestingly, brain scans in OCD sufferers have also shown that the amygdala, which is an almond sized part of the brain near the brain stem, becomes highly active when compulsive behaviour in OCD sufferers is challenged. The amygdala is a primitive, instinctively driven part of the brain which is responsible for triggering the fight or flight mechanism when we are threatened - the fear response. It is the amygdala which creates problems for us when it fires inappropriately, such as it has been shown to do in people who have irrational fears, phobias, or panic attacks. We can see that if this part of the mind is being activated as a response to having these behaviours challenged, then in a very real sense we are talking about an anxiety disorder. The thought of not carrying out the behaviour creates a fear response, and we know that when the amygdala is triggered to deliver a fear response, the resultant feelings can be experienced as being overwhelming. This is because this is the part of the mind which deals with survival, and thus it has the ability to override the intellect, as it would do in any situation where we are faced with danger. When faced with danger we respond instinctively, not intellectually. This explains why there is such a strong instinctive drive to carry out these behaviours despite their irrationality. There are many explanations as to why the mind becomes obsessive, some of which we had discussed in our earlier example but one thing that we can all recognise for certain is that we are much more likely to become obsessive when we are highly emotionally aroused. In my work here as a therapist, I see this to be the case absolutely. When we are highly stressed it becomes much more difficult to enjoy a restful mind filled with calm thoughts. The mind instead becomes emotionally aroused and overactive (obsessed). When we are highly stressed we also become hyper-vigilant which means that we start to notice and become alarmed by things which might not bother us ordinarily, adding to the already difficult mix. So, we can in this loop, become overly concerned with cleanliness, order and control. We also find when the emotional mind is overly aroused in this way, it can become all but impossible to take intellectual control and instead we begin to become almost entirely instinctively and emotionally focused. We know that the emotional mind can be very irrational (we have all been unreasonable or irrational in times of high emotional arousal), and this is a significant factor in understanding why compulsions can be so irrational. Simply put, the irrational emotional mind becomes overdriven and commands a much greater deal of control than is usual or healthy. This is a result of too much emotional arousal (stress, anxiety), coupled and compounded by the resultant belief of powerlessness, which perpetuates the cycle of poor self-esteem, shame, guilt, feelings of being out of control, exhaustion, fear etc. With all this going on, it’s hardly surprising that depression and anxiety often exist alongside OCD. 

An Example 

Obsessional behaviour is a fear response. If we feel threatened by something, then the mind moves into a  hyper-vigilant mode and invariably begins to "notice" or "pick up" on thought patterns which relate to that threat in some way. Whilst acknowledging that OCD does have a neurological factor, let's just have a look at how obsessive behaviours could begin in anyone:-

Suppose a wife loses her husband. At any given time, any one of us could have a reasonable level of concern about being burgled, but that thought process will sit comfortably at the back of the mind, in it's proper perspective. In our example however, the lady who has lost her husband becomes extremely anxious as a result of that loss. In an effort to bring order and control to a situation which has left her feeling out of control and unsafe she now starts to worry about security in a big way. She has an overwhelming need to eliminate any further threat or danger and thereby undertakes to "check" that the windows are secure, that the doors are locked, plugs are unplugged, that hands are clean (germ free) etc. "Checking" increases the strength of the response, because it sends the message (by behaviour) that we agree with the assumption that there is inherent danger in the environment. This increases the need of course for more vigilance. And then another thought crosses her mind. Having lost her husband she begins to be troubled by the thought that she might not be able to cope if anything were to happen to her daughter. What if...? What if.....? She begins to imagine scenarios. Terrible scenarios; perhaps scenarios where she herself might have some part in her daughters demise, and having such irrational ideas begins to make her wonder if she can even trust herself? Day by day the imaginings become more and more detailed, more and more vivid. Well, central to the workings of hypnotherapy is the recognition that the imagination is an extremely powerful tool. It can be used positively to create foresight and innovation which can inspire us to positive action or it can be used negatively to create worry and anxiety which can paralyse us with fear. The instinctive mind responds to what we imagine, as well as what really is. The now hyper-vigilant instinctive mind, seeing these dreadful happenings (in the imagination) day in, day out, assumes that this lady really must be living in a terrible place filled with danger, and steps up the level of vigilance and the resultant need for security to an even higher degree. Now the mind, believing that the World is such a hostile environment filled with dangers seen and unseen, switches to "Red Alert"....and begins to "notice" even more things which are a cause for concern, silly things, irrational things. Some of these things it may not be possible to actually control in any way. So in the presence of such great disorder, such a great loss of control, then perhaps there is some other way to create order? The lady now finds herself compelled to make sure that the ornaments on the mantelpiece are placed absolutely symmetrically and millimeter perfect. But there is still no rest and our lady soon finds that to enjoy any semblance of peace she needs to know that her daughter is okay and starts to phone her every hour to make sure. The daughter, seeing her mothers obvious distress agrees that it's okay for Mum to phone every hour but clearly this makes the daughter very anxious too. Occasionally her exasperation spills out into the conversation. Mum feels dreadful about worrying her daughter like this and begins to become frustrated with herself ....starts to hate herself even .....and then the depression and hopelessness sets in .....and now she worries about her relationship with her daughter. The very thing she most feared, losing her daughter, is now in danger of happening it seems. So now she's really feeling like she's losing control, so more anxiety, more attempts by the mind to "fix" it......and so on it goes......exhausting reading isn't it?! We can see how easily the mind can get itself into a bit of a twist. But the important thing to recognise is that the condition BEGINS at the emotional level. The emotional arousal created by any big life event or indeed by anxiety generally can be sufficient to set this negative process in motion. Once unleashed of course the anxiety is self perpetuating and needs no help to sustain itself. So, by this example, one can see what must happen in order to tackle OCD. Anxiety must be reduced, relationships improved, control and reason must be returned, and a new perspective must be introduced. If you read back through this example carefully, you will also be able to see how the main contributing factor to the creation of this difficulty (outside of the life event) was an overload of negative introspection. In other words, allowing the mind to have free reign as far as fantasies of negative happenings were concerned. But then the OCD sufferer didn't know at the time what the consequences of that introspection might be. Understanding is everything.  

Treatment

The good news is that OCD can be successfully treated. Treatment consists of two components. If you have followed the logic so far, you will see that the first thing that we have to achieve is to reduce that overall emotional arousal (anxiety). You will find more details on how we go about doing this on this website. See Anxiety & Depression. Essentially, we do not directly challenge the rituals or thoughts from day one of treatment. We know that initially this will be likely to simply create more anxiety. Instead, we take some time to begin to help you to relax again generally. When obsessive thoughts or compulsions are running riot, we know that it is difficult at first to have any measure of intellectual control. We can make a difference however by concentrating on relaxation generally (reducing emotional arousal) and by strengthening and improving those areas of a persons life where there IS control. As with all of this work, the importance of good mental hygiene is explained, so it becomes possible to identify areas of thinking which create and sustain excess anxiety. This will include looking at what you are and are not responsible for, challenging negative assumptions, assessing expectations, self acceptance, the okay-ness of making mistakes, improving relationships etc. Alongside this, we also address any other concerns, or areas of life which are out of balance, or where needs are not being properly met. Successfully implementing these measures goes a long way to returning a sense of comfort and control and this is in itself anxiety reduction. It translates back to the subconscious mind in a number of positive ways. It creates a space of "safety" which is necessary to reduce emotional arousal. It also reminds us that we DO have a measure of control, and that things are not perhaps as bleak as they seemed. Indeed, even simply learning to relax and decrease emotional arousal generally will usually bring about a significant reduction in the symptoms of OCD. This is stage one of treatment, which continues on alongside stage two when that is begun. Stage two of treatment can begin when we have achieved the objectives outlined above (usually three to five sessions in). Now, we know that the idea of challenging behaviours will seem at first an alarming prospect to a sufferer. As I have already explained, it will often trigger a literal (and sometimes extreme) fear response within the amygdala. Keep in mind however, that since we will have already worked to reduce emotional arousal and anxiety generally, then we find that the level of hyper-vigilance reduces too. It then becomes much more possible to begin to challenge the compulsions and behaviours successfully. The amygdala itself becomes less active and less sensitive when our anxiety levels generally are lowered; the message being that the environment at large is a safe/r place to be, which of course means that there is less need for the extreme level of protection (hyper-vigilance) the amygdala has been providing. We also have another tool at our disposal. Modern treatment allows us to de-traumatise the amygdala in a single session. This is the same process we use to treat phobias and can in some cases be very helpful in treating OCD. By de-arousing the amygdala with regards to those behaviours which are over-stimulating a response, we can significantly aid recovery by reducing the automatic fear response. We know that the brain is very capable of re-patterning over time so there is every reason to expect that as we continue to create new patterns then those new patterns can become dominant in the field of awareness and ultimately, second nature.  So stage two then involves actively challenging those thoughts, compulsions, and behaviours; beginning gently of course. So we challenge only those behaviours which are the least anxiety provoking at first, and then build on that gently over time. Once there is a sense of confidence that the behaviours can be successfully and comfortably challenged, then like everything else in life, we can go on to build greater and greater success on the foundations of those first early steps. Alongside this, you can see that each success means a reduction in that thought or behaviour-creating anxiety, and therefore a further decrease in emotional arousal. We continue then in that positive spiral out and away from the OCD and back towards intellectual control…easier patterns, calmer emotions, and a clearer mind.

In terms of the treatments I offer, dealing with OCD is invariably a longer term treatment. Recovery is not an overnight process as any sufferer will know, but do remember that solution focused therapy is “brief” therapy. So when I say longer term, I mean that we might spend ten sessions working together (more if required, but not indefinitely) as opposed to the three to six or so which other difficulties might need. It is important to note that in considering therapy for OCD, there is every chance of improvement, but one must be willing to consider the possibility of challenging the condition…that is to say, recognising that at some point, one will need to “leave the house having checked the door only once” (or not “insert behaviour here”). I do understand that initially this may seem frightening, but in the longer term it should seem less so as you discover that you can successfully challenge those behaviours, and this is the method by which success is achieved. I mention this because, here, with OCD, it is very much a team effort and it’s never as simple as having your OCD simply “hypnotised away”…although indirectly that is exactly what we do by reducing your emotional arousal and helping you to access the tools you need to deal with the condition. The real treatment with OCD is self directed behavioural therapy. In other words, you have to consistently challenge your compulsive behaviours. Continually challenging those behaviours is what disempowers OCD over time. Dr Jeffrey Schwartz's four step process of re-labeling, re-attributing, re-focusing, and re-valuing is generally recognised as THE model for self directed therapy and has been shown conclusively to yield extremely good results. His research shows that this continual behavioural adjustment actually normalises the patterns of activity in the brain, so one can think of the results as being quite literal. It is possible to actually change the way your brain works by doing things differently! We therefore use his model as the central model for behaviour modification. Remember also, that as with anything, we don't change "habits" of a lifetime overnight. Continued repetition of new patterns is what creates this change in the brain. If you’re reading this and you’re a sufferer, you will already know that recovery involves meeting those fears head on and nobody can actually do that for you, but we can certainly help to make doing that possible! It is also important to note that 100% recovery does not occur in every case, but almost everyone could expect to see a marked improvement through taking the right action. As already stated, with OCD it’s often a case of creating a comfortable reduction in symptoms and patterns. Sometimes, perhaps for reasons beyond our knowledge, some people take longer to recover completely than others. Simply put, everyone is different, but that is no reason to be doubtful. Do know that many sufferers recover to go on to lead successful happy productive lives. With treatment, there is every reason to expect a high degree of success, and almost without exception we will see a significant reduction in symptoms with the right approach. The emphasis as always is on providing understanding, so I aim to provide you with the support, the space, and as many tools as possible to ensure that you have all the leverage you need to achieve success. This includes helping you to discover who you when you are not your OCD.  Generally speaking, I am in the business of "brief therapy". That is to say that most difficulties are resolved to satisfaction well within ten sessions. With OCD we can make an enormous difference within such a timeframe, but it has been my experience that overcoming OCD is a longer term process and often my clients may decide that they would like to stay connected with me on an ongoing basis. I just wish to make clear that stopping short of creating any "dependency", this is just fine. No one says "Your ten sessions are up.....off you go!" We work for as long as you wish, but it is YOUR decision. I NEVER create dependency in people. I aim to empower you so you can go live your life with all the joy and zest you can experience!

The information provided in this article is primarily concerned with OCD but the same rationale does of course apply also to lower levels of obsession and compulsion. We know that there are three main areas of obsession -Jealousy, Hypochondria, and Fear of Death. These are very common concerns, and although perhaps not as debilitating as OCD can still be very troubling nonetheless. These concerns usually respond very readily to anxiety reduction in just the same way that OCD will and are therefore very suitable for treatment with hypnotherapy. I am a trained and certified OCD and Anxiety Disorders specialist, and I have helped many people to overcome OCD and take back control of their lives.

If you would like to book a free initial consultation to discuss your difficulty with a view to beginning treatment, then please contact me.