Obsessions and Compulsions

These are the experiences of three people who suffer obsessive compulsive disorder...

“I’m afraid of catching something from other people, I fear that the germs that they carry may get on to me and I will become infected. I’m afraid I may also contaminate my family by passing these germs on to them. I know it is silly but I feel so tense and anxious if I do touch anyone else or any surfaces – such as door handles that they have touched, that I have to come home and wash my hands many times, then wash my clothes. That makes me feel a lot better until the next contact with others. All of my own surfaces at home are washed many times each day with bleach to stop the germs. I avoid contact with other people when at all possible. Part of me realises that these fears are daft, but it's gone on for so long now I don’t know how to stop... my family are sick of it...”

“I fear that I may harm someone… This is often worst when I am out driving. I sometimes think I have hit someone and have to go back and check again and again. Recently I have started avoiding driving altogether.”

“My whole day is spent checking that nothing will go wrong in the house... I can’t get out because I’m never quite sure that I’ve turned off the gas, electric appliances, water and locked the windows. No matter how often I check, my partner has to check them all for me again. I check to see if the gas fire is off, I do this five times and then can sometimes go upstairs, at other times it doesn’t feel right and I go through the whole ritual again. If I don’t check I feel so worried I can’t bear it. I know it's silly, but I keep thinking if something awful did happen I’d be to blame for being so careless...”

“I sometimes have really bad thoughts go through my mind. I wonder if this makes me a really bad person but I know I would never hurt anyone. I try to push the thoughts away by thinking good things, but sometimes it seems the harder I try the worse things get.”

You may have had similar experiences yourself. 

It is quite common for people to have such thoughts and to carry out checking actions, but if these are becoming a major part of your daily life then you may be suffering from Obsessive Compulsive Disorder (OCD). OCD also occurs in children. If you think your child may have OCD it is really important you seek professional help, as outcomes are better the sooner treatment is begun. Your GP should be able to advise and refer your child for specialist help where they can receive a full assessment of what is going on. 
 

Each person who suffers from OCD describes slightly different problems. In general people with OCD experience obsessions. These are thoughts, pictures or impulses which are usually unpleasant and come into mind when we don’t want them. Many things can trigger these obsessions, and they usually leave the person feeling very anxious, uncomfortable or frightened. The compulsion is the behaviour or thought performed in order to put right the obsession. Sometimes the behaviour performed is quite irrational (and the OCD sufferer recognises this) such as counting up in sevens or tapping a set number of times. Sometimes the behaviour is more closely related to the obsessional thought, such as washing hands many times to avoid thoughts of contamination or trying to replace one picture in their mind with a different and less upsetting one. Most people with OCD (although not all) know that their compulsions are unreasonable or over the top but they feel unable to control their thoughts or change their behaviour.

Some people experience obsessional thoughts and behaviours and are able to live with this without too many problems. They may have learned ways to cope, although things can change with time, often getting better or worse depending on stress or mood levels. It is estimated that around three quarters of a million people in the UK (1.2% of the population) are living with severe, hugely distressing OCD, which has a big impact on their life. Fortunately treatments are very effective and if your life is being disrupted by unwanted thoughts and actions it is really worth seeking help.

There are many theories about what causes OCD, including neurological, biological, genetic, psychological and social. As yet there is no one theory that has been proven to be the root cause, and it is likely that OCD comes from a complex mixture of all of these. But whatever the cause, OCD affects us in a number of ways:

• What we think:
  • obsessional thoughts and images (i.e. can’t get them out of our mind)
  • guilty thoughts
  • thoughts that we are responsible for everything
• How we feel:
  • tense
  • anxious
  • agitated
  • disgusted
• What we do:
  • compulsions - (something we must do, sometimes described as rituals)
  • avoidance
  • seeking reassurance

Some of the symptoms of OCD are listed here. Most people don’t experience all of these. You may want to tick any symptoms you experience regularly. 

How do you feel when you experience some of these obsessions?

How do you feel when you have then carried out the compulsive behaviour or thoughts?

If you have ticked several of these thoughts, feelings and actions then you may have OCD.

Most people who have OCD find that there is a pattern in their thoughts, feelings and actions. They feel anxiety or discomfort at having the obsession and relief once they have carried out the compulsive act. This becomes a vicious cycle which strengthens itself and becomes more likely to happen again.

It is estimated that over 50% of OCD sufferers experience aggressive, sexual or blasphemous (religious) thoughts, which go totally against someone’s beliefs and values. So it is hardly surprising that many OCD sufferers feel guilty and think that they must be a terrible person to have such thoughts. This in turn makes the thoughts more likely to return because they are given such negative importance in the person’s mind. Repeatedly going over upsetting thoughts has also been shown to make them seem more believable to the person.

Research tells us that most people experience odd or distressing thoughts and pictures going through their mind at some time, for example ‘what if I was just to drive the wrong way up the motorway’. Most people easily dismiss such thoughts from their mind as meaningless. Those who feel most guilty, distressed or disturbed by the thoughts, however, may get upset by them, and find it hard to get them out of their mind. The pattern often looks something like this. 

The cycle illustrates that obsessive, unpleasant thoughts can lead to anxious, tense or guilty feelings which can cause compulsive behaviour, or thoughts to ‘neutralise’ the obsession. This can bring relief but it’s short lived and leads to negative thoughts such as  “you must be terrible to think like that”. This all strengthens obsessions.

In the last 40 years the treatment of OCD has greatly improved and most people do make a good recovery. The most important treatments are medication and Cognitive Behavioural Therapy (CBT), which will be described later in this guide.  Medication and Cognitive Behavioural Therapy often work really well together.

Medication 
This will usually be prescribed by your General Practitioner or occasionally by a Psychiatrist who specialises in such disorders. The medicines most commonly prescribed by doctors for OCD are antidepressant tablets, which can be very effective in the treatment of OCD even if you have no symptoms of depression. These tablets are not addictive and have few side effects. They do take a few weeks to begin to work, so if you are offered this type of treatment it will be a little time until you begin to feel the benefit. 

It is important to continue with the treatment in these early weeks and to stay on the treatment as long as your doctor suggests in order to maintain full benefit.

Cognitive Behavioural Therapy 
Your GP may recommend this therapy for you. This approach helps you to tackle what you think (cognition) and what you do (behaviour). Your doctor may suggest you try some of the approaches we describe in this guide but if you require further help you may be referred to a specialist therapist.  Every area in England has an NHS Talking Therapies service that works with people with OCD and you can also refer yourself to them. Search online for ‘Find an NHS talking therapies service’ in your local area.
 

Research tells us that the most successful way to tackle OCD is by exposure with response prevention (ERP). This literally means that you must gradually face or expose yourself to the things or situations you fear, whilst at the same time preventing yourself from carrying out your usual compulsive behaviours (checking, cleaning etc). This gradual approach means that with each stage you become less afraid of what used to trouble you and you learn by experience that no disaster occurs if you stop your compulsive behaviour. There is some evidence that online resources can be useful to support this. Most of these have a cost, but some are available free of charge.

Because OCD is such an individual thing, not all the examples in this guide will be exactly like your experience. Use the parts that you think apply to you.

Exposure
We know that if we can stay in a situation where we feel anxious, gradually the anxiety will reduce – our body becomes used to the situation and we no longer feel fearful. This is called exposure and it will help us overcome our obsessions. For the person with OCD however, facing things we fear may seem very difficult, if not impossible.

Because of this it may be helpful to break down into smaller steps the exposure to situations or thoughts we find difficult. Begin by making a list of all situations or thoughts you find difficult. Next make an anxiety ladder where those situations that you only fear a little are at the bottom and your worst feared situations are at the top. It may help to look at this example:

Washing and cleaning
Mary has a fear of being contaminated by germs which she believes she may pass on to her family. This has resulted in her restricting her lifestyle and spending many hours washing herself and disinfecting her home. She has made up the following anxiety ladder.

Mary’s least feared thought, step 1, is touching her own waste bin with rubber gloves on.
Step 2 is touching her own waste bin without rubber gloves on
Step 3 is touching objects at a friend’s house
Step 4 is eating at a friend’s house
Step 5 is going to the toilet at a friend’s house
Step 6 is is touching doors and objects outside her home, for example at the supermarket
Step 7 is going to eat outside the home.
Her most feared, step 8, is going to the toilet in public toilets
Mary will begin her exposure therapy at step 1 (i.e. by touching her own waste bin with gloves on) and gradually work towards step 8. She will prevent herself from frequent hand washing at these times – (see Response Prevention in the section ‘How do I stop myself from carrying out the compulsive act’). 

Most people will at first feel greater anxiety when they begin to face the things they fear and feel an urge to perform their compulsion or ritual. The next section may help you deal with this.

It is important to break the cycle of carrying out the compulsive act or thought following exposure to the thing(s) you fear. This is called Response Prevention. There are some tips in attempting this.

1. Ask your family to help you by not reassuring you e.g. checking for you or by telling you that you are not contaminated. Reassurance can stop you from confronting what you really fear.  However, the emotional support of loved ones can be very helpful.
2. Praise yourself for not carrying out the compulsion or neutralising activity. This is an important step forward.
3. Keep a note as you are carrying out the exposure therapy to show how your anxiety begins to drop. For example, touching the bin with no gloves on and without washing hands. 
4. Don’t substitute new compulsions for old ones. For example substituting rubbing hands continually for hand washing.
5. If stopping all compulsive behaviours at once seems impossible, try to reduce gradually the time you spend on the behaviour or the number of times it happens.

If you use this approach then gradually your anxiety will reduce.

Sometimes people get gloomy thoughts when they have OCD especially when they begin to try and break the cycle of obsessions and compulsions by Response Prevention. 

Typically these thoughts are criticisms of yourself, for example, “I’m not a caring mother if I don’t check things fully” or “I’m letting things get out of control, I’m a failure”. People with OCD also often feel high levels of guilt without good reason. These thoughts lead to low mood and unhappiness. It is important that you do not just accept these thoughts. You need to find a more balanced view. Try to:

• identify these thoughts and low mood;
• jot down the unpleasant thoughts you are having at the time;
• try and counter these thoughts by writing down arguments against them. Imagine what you would say to a friend if they had such negative thoughts about themselves;
• concentrate on and remember the good things about yourself and your life, not the bad things;
• try to challenge feelings of guilt.

Mark had difficulty in leaving the house each day. He would check all appliances at least 15 times. Perhaps you have a similar problem with checking things all the time. The following example may help you understand how to tackle this kind of problem:

• write down all the things you check;
• decide which is most difficult – make an anxiety ladder;
• starting with step 1 on your ladder (least difficult) decide how many times you will check – try the minimum you can;
• begin with step 1 one day;
• when your anxiety about that stage is down to a low level move on to step 2.

Mark’s anxiety ladder looked like this:

Mark's anxiety ladder has the least difficult, Step 1, as the taps.
Step 2 - the lights
Step 3 - the gas cooker
Step 4 -  the windows
The most difficult, step 5, - the doors.

He began with step 1. He would check the taps only once before he left the house. At first he felt very anxious about this but gradually his fear lessened. He then moved on to step 2, the lights ... and so on.

Jean used to get a picture in her mind of her daughter and the words “your daughter is dead” would run into her head. She was so disturbed by this that she would ‘neutralise’ the thought in her mind by saying “she is alive and well” and would picture her daughter looking fit and healthy. She would then feel relief. This began to take up hours of Jean’s time each day and made her very unhappy. She felt she must be a terrible person. The picture seemed to get stronger and stronger. Perhaps you have a similar disturbing thought that you spend time putting right with another thought?

The most important thing when tackling this problem is to break the cycle of having an obsessional thought and putting it right with another thought, i.e. neutralising. Here are some tips!

• Don’t try and get rid of the obsessional thought, just accept it. We all have odd thoughts at times. Think to yourself that it’s just an odd thought, it doesn’t mean anything, it doesn’t mean you are a bad person.
• Do not neutralise to put the thought right – break that cycle. 
•  Jean tackled this by telling herself:
  • “This is only a thought, it is only upsetting if I give it too much importance. The more frightened of it I am the more it will come to mind so just let it go.”
  • “Stop trying to put the thought out of my mind – just let it fade – don’t be afraid of it.”
  • “Never put the thought right by neutralising (that is saying in my head “she’s alive and well”) – this will just strengthen the cycle.”
• Remember trying not to think a thought will not help get rid of the thought and usually has the opposite effect. 

Test this out now - try not to think of a blue giraffe! As you can see for yourself this just brings the thought of a blue giraffe to mind! The same goes for your intrusive thoughts. Trying not to think of them may well bring them into your mind.

Recent studies have shown that CBT involving mindfulness can sometimes be helpful to people who have OCD.   However, this is not the treatment which has most evidence for it so should not be a replacement for the most effective treatments such as medication and CBT.

It can be helpful to become more aware of how your OCD affects you and how you typically react. It is important to focus on the here and now and notice if your thoughts are frequently moving to pictures of future negative events, notice how this makes you feel. Try to bring your thoughts back to the here and now. You can accept that you tend to have these worrying thoughts and compulsions but that this does not mean these worries will come true or that you have to act on the compulsions.

Mindfulness meditation courses are now widely available and can further help you to learn to cope with the distress of OCD. Becoming serene, relaxed and gaining a state of inner peace can be helped by mindfulness and relaxation training. For some people this can help them to reduce obsessions and compulsions and reduce distress. Further online resources can be found at the end of this guide.
 

• Carefully recognise your unwanted thoughts (obsessions) and the actions you take to put them right (compulsions).
• Gradually face some of the things you fear. Work out an anxiety ladder to help you do this. Begin with the easiest step.
• Do not carry out any compulsions to reduce or neutralise your anxiety when you are facing the feared situation.
• Break the obsession compulsion cycle.
• Challenge any gloomy or critical thoughts you may have about yourself.

• We hope you will use the advice suggested in this guide. This may help you overcome OCD and return to normal life.
• If you feel you are making little progress or the problem is getting worse then seek help in overcoming your problem.
• Your GP is the best person to talk to first. Your GP may suggest a talking treatment or tablets or both. They may suggest you see a mental health practitioner who can offer expert help with your problems.

• Anxiety UK
  Infoline: 03444 775 774
  Text service: 07537 416 905
  Email: support@anxietyuk.org.uk
  www.anxietyuk.org.uk
  Provides information and support to people suffering from anxiety disorders.
• British Association for Behavioural and Cognitive Psychotherapies
  Email: babcp@babcp.com
  www.babcp.com
  Information and advice for people about behavioural and cognitive psychotherapy (CBT).
• Carers UK
  Tel: 0808 808 7777
  www.carersuk.org
  Email: advice@carersuk.org
  Provides information, advice, and support to carers and their families.
• Healthwatch
  www.healthwatch.co.uk
  If you use GPs and hospitals, dentists, pharmacies, care homes or other support services, we want to hear about your experiences. As an independent statutory body, we have the power to make sure NHS leaders and other decision makers listen to your feedback and improve standards of care.
• Mental Health Matters
  Tel: 0191 516 3500
  Email: info@mhm.org.uk
  www.mhm.org.uk
  A national organisation which provides support and information on employment, housing, community support and psychological services.
• Mind Infoline
  Tel: 0300 123 3393
  Email: info@mind.org.uk
  www.mind.org.uk
  Provides information on a range of topics including types of mental distress, where to get help, drug and alternative treatments and advocacy. Also provides details of help and support for people in their own area. 
  Helpline available Mon - Fri, 9am - 6pm.
• NHS Talking Therapies
  www.nhs.uk/mental-health/talking-therapies-medicine-treatments/talking-therapies-and-counselling/nhs-talking-therapies/
  Provides details on how to access local talking therapies services
• No Panic 
  Helpline: 0300 772 9844 (10am – 10pm everyday)
  www.nopanic.org.uk
  Support for sufferers of panic attacks, phobias, obsessive compulsive disorder, general anxiety disorder and tranquilliser withdrawal.
• OCD Action
  Tel: 0845 390 6232
  www.ocdaction.org.uk
  Email: support@ocdaction.org.uk
  Provides support and information to anybody affected by OCD and works to raise awareness of the disorder.
• OCD-UK
  www.ocduk.org
  Advice line: 0333 212 7890
  Email: support@ocduk.org
  ​​​​​​​Provides advice, information and support services for those affected by OCD adult or child, including free discussion forums. Lists support groups run to approved standards.
• Rethink
  Advice service: 0808 810 0525
  Email: advice@rethink.org
  www.rethink.org
  Provides information and a helpline for anyone affected by mental health problems.
• Samaritans
  Tel: 116 123
  www.samaritans.org
  Email: jo@samaritans.org
  Post: Freepost SAMARITANS LETTERS
  Confidential support for anyone in a crisis.
• Triumph over Phobia
  Tel: 01225 571 740
  Email: info@topuk.org
  www.topuk.org 
  ​​​​​​​Provides national network of self help groups for people with phobias or OCD. 

• Break free from OCD: Overcoming Obsessive Compulsive Disorder with CBT
  Dr Fiona Challacombe, Dr Victoria Bream Oldfield and Professor Paul Salkovskis
  Vermillion 2011
  Contains detailed information on the many forms of OCD and information on how to treat your individual problem.
• Living with fear (2nd revised edition)
  Isaac Marks 
  McGraw-Hill 2005
  This self-help guide gives practical advice to people who are suffering from phobias, panic, obsessions, rituals or traumatic distress.
• Mindfulness Workbook for OCD: A Guide to Overcoming Obsessions and Compulsions Using Mindfulness and Cognitive Behavioural Therapy
  Jon Hershfield and Tom Corboy 
  New Harbinger Self-Help Workbook 2014 
  Combining mindfulness practices with cognitive behavioural therapy (CBT), The Mindfulness Workbook for OCD offers practical and accessible tools for managing the unwanted thoughts and compulsive urges that are associated with OCD.
• NICE guidance
  Information for people with OCD or body dysmorphic disorder, their families and carers. 
  Available from www.nice.org.uk/guidance/CG31/informationforpublic
• Obsessive compulsive disorder: the facts (4th revised edition)
  Padmal De Silva and Stanley Rachman 
  Oxford University Press 2009
  In this book, the authors draw on their extensive clinical experience to give a lucid account of the nature of obsessive-compulsive behaviour. The book is intended both for those who have this disorder and for their families and friends.
• Overcoming obsessive compulsive disorder
  David Veale and Rob Willson
  Constable and Robinson 2009 
  With this step by step approach you can learn how to break free from the destructive cycle of obsessive behavior and regain control of your life. 
• Overcoming Obsessive Thoughts: How to gain control of your OCD
  Christine Purdon and David Clark
  New Harbinger 2005
  This book is particularly useful for people who struggle with obsessive thoughts they view as violent, disgusting or blasphemous (religious). 
• Understanding obsessions and compulsions
  Frank Tallis 
  Sheldon Press 1992
  This book attempts to provide a comprehensive guide to self-help, explaining the principles of anxiety reduction, giving treatment instructions in easy-to-understand language. It covers compulsive checking, washing, hoarding, obsessional thoughts and worry, obsessional personality and depression.
• Overcoming unwanted intrusive thoughts: a CBT-based guide to getting over frightening, obsessive, or disturbing thoughts
  Sally M. Winston and Martin N. Seif
  New Harbinger 2017
  In this guide, you'll discover the different kinds of disturbing thoughts, myths that surround your thoughts, and how your brain has a tendency to get "stuck" in a cycle of unwanted rumination. You'll also learn why common techniques to get rid of these thoughts can backfire and powerful cognitive behavioural skills to help you cope with and move beyond your thoughts, so you can focus on living the life you want. 

• www.franticworld.com – Mindfulness: Finding Peace in a Frantic World. Free meditations and mindfulness resources.
• www.headspace.com – A free taster of mindfulness, with an opt-in to buy further sessions.
• www.freemindfulness.org – A collection of free to download meditations.
   

• www.cntw.nhs.uk/relaxation
• www.wellbeing-glasgow.org.uk/relaxation 
   

OCD-UK recommend a free online CBT programme run by an American charity, Peace of Mind Foundation, set up by an OCD sufferer. This is called OCD Challenge, and is available at: www.ocdchallenge.com

A full list of references is available on request by emailing pic@cntw.nhs.uk
 

Share your thoughts with other people and let them know what you think of this guide. 

Written by Dr Lesley Maunder and Lorna Cameron, Consultant Clinical Psychologists.

Many thanks to Richard Thwaites, Lead Consultant Clinical Psychologist, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, who has contributed to the review of this guide.

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust has developed this resource with the support of NHS healthcare staff, service users and local voluntary sector groups.

Published by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

2024 Copyright PIC/96/0324 March 2024 V5

Review date 2027