OCD: how to break a compulsion

There are many forms of health anxiety, and about a third of patients in hospital outpatient departments probably have nothing wrong with them (apart from health anxiety). But Obsessional Compulsive Disorder (OCD) does need specialist psychiatric treatment and has a prevalence of between 2 and 4 per cent. OCD starts in your teens or early twenties, and often becomes a series of ingrained habits well before any treatment is sought. Repeated thoughts or fears (of germs, of causing harm, of contamination) seep into your mind. It’s an internal version of a facial twitch. The patients may know it’s “silly” or untrue but they have to deal with it because they can’t stop thinking about it.

These repeated thoughts are called obsessions, and the various checkings and washings required to counter an obsession are called compulsions. They often take the form of quite complex rituals. Hygiene is a common theme: obsessives can take two to three hours to wash themselves “correctly”. Sometimes they have to do everything five times, in the right sequence, going back to the beginning if they make a mistake. Intensive handwashing (one patient was spending £100 a week on creams, soaps and disinfectants) leads to scarring of the skin and red-raw hands.

Treatment is available in the form of behaviour therapy, and antidepressants that particularly target the serotonin system. MRI scans do seem to show up areas of abnormal brain activity, suggesting a genuine “lesion” in terms of cerebral functioning. The still commonly mentioned Freudian theory of anal fixation in childhood may have to be ditched.

However, the Sisyphean routines can be broken. Mrs P was a widow in her fifties dominated by rituals, fear of contact, and the need to have her phone ring at least 25 times before she could answer it. Her hands were red and scaly. Asked at the end of her first assessment if she might just once (as I demonstrated) touch the floor, she shrank back in horror. Not only was my NHS office floor obviously dirty, it was also potentially filthy given its public provenance. It would require a triple dose of cleaning and scrubbing once she got home. Not going out became the simplest option to avoid all this hassle.

What to do? Psychologists tried to treat her, using the standard approach known as “graded desensitisation”. After the second session she backed off, too fearful of even the slightly dirtier tasks she was confronted with. Even reducing her handwashing by one cycle (from the regular four or five) was impossible. How about answering the phone after 15 rings? She tried, but …

Like many such patients Mrs P generated in her clinicians what is termed “countertransference”– a desperate desire to do something drastic, to shout at her, to cut the Gordian knot. Oh, for an image-guided lobotomy knife to cut all those intense inner cerebral circuits, as some neurosurgeons are predicting for the future. But as yet that remains Star Trek stuff.

Luckily, Mrs P was depressed by her fears and her sore hands, so she finally agreed to take an antidepressant. We gave her one to help with sedation at quite a low dose. She didn’t get side-effects and was willing to go on taking it. After a month she had got down to 10 telephone rings. After two months she had halved her weekly cleaning bill. After three months she bought a pet dog and started going out with him, and her family. We discharged her, admiring her soft handshake.

Trevor Turner is a consultant psychiatrist working in east London. Some details have been changed to protect identity

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