What is Obsessive Compulsive Disorder?
Obsessive Compulsive Disorder is an anxiety disorder characterised by:
a) recurrent, unwelcome thoughts, images, ideas or doubts, (obsessions)
b) related behavioural or mental acts (compulsive rituals) to suppress or neutralise the distress or prevent a feared outcome
c) significant functional impairment in a number of domains
Although the specific content of obsessions and compulsions may vary from patient to patient, a common underlying factor is high levels of responsibility for preventing harm or mistakes.
Examples of intrusive thoughts might be “I could push someone in front of a train”; “What if I dropped the baby?” “Is that toilet seat contaminated?” “Did I turn the oven off”, images of something bad happening to a loved one, or an urge to do something impulsive like shout in church.
Intrusive thoughts are common and normal and almost everyone experiences them at times. The cognitive-behavioural model of OCD emphasises that it is the meaning given to the content or occurrence of intrusions, rather than the thoughts themselves that is key to OCD (Salkovskis, 1985). People with OCD interpret the fact that the thought has occurred at all as meaning something terrible about them, or that not to act to prevent harm once they have the idea in their mind would mean something terrible.
OCD is a very common problem in adults and children. According to some studies, OCD is the fourth most common mental disorder after depression, alcohol and substance misuse, and social phobia with a lifetime prevalence in community surveys of about 1-2% (Torres et al., 2006).
Statistics regarding OCD are often thought to be an underestimate, as the disorder is often kept secret or hidden from all but the sufferer. They often find it embarrassing or distressing to talk about, and feel guilty or ashamed for having such thoughts and rituals.
Perinatal OCD
Until recently OCD in pregnancy and after having a baby had received very little research attention. However recent studies suggest that OCD is more common at this time than other times in life. Some people develop OCD for the first time either during pregnancy or afterwards, whilst others find that pre-existing symptoms worsen. This increase in the incidence of OCD is likely to be related to the fact that pregnancy and early parenthood is a time when mums are naturally focused on the safety of their developing child and feel particularly responsible for them. The normal stress and uncertainties of becoming a parent can also play a role.
Perinatal and postpartum OCD usually (but not always) revolves around significant fear of harm coming to the infant, with worries frequently focused on accidentally or deliberately harming the child or the child becoming ill. It is important to note that the occasional experience of all of these worries is absolutely normal and indeed very common in mums and mums to be. However, some people find themselves so distressed that they will take measures to manage their anxiety or prevent their fears coming true. Depending on the worries, this could involve compulsive behaviours such as cleaning, praying, rumination or avoidance of activities or even of spending time with the baby. In this way the thoughts and behaviours can interfere significantly with their wellbeing and their experiences of pregnancy and parenting. It is the extent of and response to the worries, rather than just having them that becomes the problem.
Fairbrother and Abramowitz 2007 proposed that the perinatal period lowers the threshold for OCD development/exacerbation by bringing with it a sudden increase in responsibility for a vulnerable and highly cherished infant; but it can also cause the misinterpretation of normal intrusive infant-related thoughts, overestimation of apparent threat and evoke a range of responses including avoidance, concealment, attempts to suppress the upsetting thought, over checking, and safety-seeking behaviour that function to reduce obsessional distress as well as the perceived risk associated with the intrusive thought(Fairbrother & Abramowitz, 2007).
The conclusion of this study is that women have increased risk of OCD or obsessive compulsive symptoms in the postpartum period. Consideration must also be given to the barriers to treatment seeking and treatment provision. For this reason all women, particularly women with previous psychiatric history, somatic disease, or with complications in pregnancy or at the birth should be carefully screened for OCD in the postpartum period.
Common obsessions
Obsessions can be focused on anything from germs to symmetry. When OCD presents itself during motherhood, the responsibilities for the life and well-being of a helpless infant may be experienced as a chronic stress. This stress could result in exacerbation of OCD since fear of being responsible for harm coming to others is a theme to many OCD symptoms. (Journal of Clinical Psychiatry 1997).
Obsessions i.e. intrusive thoughts will enter into all of our minds, most of us will either not even notice or not attach any significance to them, a little like a train that passes through a station and doesn’t stop. A mother with OCD will attach so much importance to any intrusive thought which suggests a perceived risk of harm coming to her child, that her train stops at the brightest station. I.e. she will give it an unhealthy amount of attention.
Examples include:
– Fear of contamination to the mother, child or anyone in contact with the child e.g. perceived risk of HIV, food poisoning
– Intrusive thoughts, images, doubts of harm e.g. risk of abuse/aggression if not careful
– Doubts that harm could come to child e.g. bottle steriliser not working
– Perfectionism e.g. everything around the house has to be a certain way.
Of course this list could continue, however it illustrates the breadth of the various obsessions mothers could have.
Overcoming OCD
OCD varies widely in terms of its severity, but for some people it can be a very disabling condition, which has a major impact on not only their life but also the lives of those closest to them. Fortunately, OCD is also a very treatable condition and you should therefore see your GP as soon as possible if you think you have OCD and are not already receiving treatment.
Cognitive Behaviour Therapy – What is it?
The most effective treatment by far for OCD is cognitive behaviour therapy (CBT), and this should always be the first line treatment, as there is much evidence to support its use (see https://www.nice.org.uk/guidance/cg31). This is safe for mothers and mothers to be to receive. Many people are offered other psychological treatments but, other than behaviour therapy and cognitive behaviour therapy, there is no evidence that such treatments are effective. CBT is a short term, structured, problem focused and goal directed form of therapy.
It helps identify and understand how certain patterns of thinking and behaviour can maintain OCD. OCD makes people believe that something terrifying will happen if they do not carry out their rituals or do not avoid certain situations. In CBT, these frightening thoughts are tested in a safe, planned and structured way, so that an alternative, less threatening explanation is identified.
‘Exposure and Response Prevention’ has been found to be an important part of CBT. This involves confronting the situations that are anxiety driven without avoiding, checking or carrying out other rituals. UK therapists usually term this a ‘behavioural experiment’ to find out what truly happens if you do things in a different way and test out what you fear. This can seem a frightening prospect, but it is usually done in a gradual way, with the support of the therapist and is an important part of getting over OCD. A CBT therapist will help you prepare to choose to take these steps for yourself.
Towards the end of a course of CBT, the therapist should help you identify methods to best stop the problems returning in the future. This is known as ‘relapse prevention’ and is another important aspect of treatment. The general idea is that, by the end of therapy, sufficient understanding, skills and knowledge of OCD and OCD prevention will have been gained so that the patient can act as their own therapist. Some people also find it helpful to have occasional ‘booster’ sessions at a later date.
According to the NICE Guidelines if for some reason, after being treated successfully for OCD the OCD returns, access to therapy should be given straight away – instead of being put on a waiting list. However, in practice few NHS services are able to offer this.
CBT can be delivered by appropriately trained therapists who are sometimes located in GP surgeries and sometimes in dedicated buildings of the local mental health team. The amount of therapy sessions will depend on the severity of the disorder and it may vary locally as to whether the therapy will be one-to-one or group.
Some people choose not to wait for a CBT trained therapist on the National Health Service. If that is the case make sure that the therapist is accredited by the British Association of Behavioural and Cognitive Psychotherapies (BABCP). This can be checked by using the ‘Find a Therapist’ register on their website (www.babcp.com).
Medication
Coupled with CBT, some sufferers may require medication. According to the National Institute for Health and Care Excellence (NICE) during conception, pregnancy and the breastfeeding stage, mothers suffering from OCD may be offered psychological treatment instead of, or before, medication. If they are already taking medication they should be offered one of the medications known to be safe during pregnancy and for breastfeeding mothers.
Please note if they wish to breastfeed they should not usually be offered a combination of drugs called clomipramine and citalopram.
More information is available on : http://www.medicinesinpregnancy.org/About-Us/
Thank you to our patron Dr Fiona Challacombe for her support in writing this part of the site.
References in this section
Fairbrother, N., & Abramowitz, J. S. (2007). New parenthood as a risk factor for the development of obsessional problems. Behaviour Research and Therapy, 45(9), 2155-2163. doi:http://dx.doi.org/10.1016/j.brat.2006.09.019
Torres, A. R., Prince, M. J., Bebbington, P. E., Bhugra, D., Brugha, T. S., Farrell, M., . . . Singleton, N. (2006). Obsessive-compulsive disorder: Prevalence, comorbidity, impact, and help-seeking in the British National Psychiatric Morbidity survey of 2000. American Journal of Psychiatry, 163(11), 1978-1985.