You may remember the popular song “can’t get you out of my head” by Kylie Minogue in 2001 that reached number 1 status in 40 countries worldwide. The song is about thinking day and night about a romantic obsession, something many people may find pleasurable. However, what if the obsession was not pleasurable, but more catastrophic, like thinking you left the stove on and it will burn down the house and potentially the next-door neighbor’s house, where young children live? Having a thought like this running through your head day and night would create significant distress and anguish, especially if the obsession is intrusive (e.g., not wanted).
It is not uncommon for people to have thoughts like “did I turn my stove off” or “did I lock the door behind me when leaving the house this morning”. Typical behaviors may be to double or even triple check the stove or front door when leaving the house. Some people may even leave their house and find themselves driving back home minutes later if they have a thought “did I leave the stove on”. However, when these thoughts are constant, time consuming (e.g., > 1 hour per day), distressful, hard to get out of your head (like the song) and require certain behaviors to be performed to reduce distress, then this may reflect symptoms aligning with obsessive compulsive disorder (OCD).
OCD is often confused for perfectionism or striving for order (e.g., being extremely clean, or tidy), and while these may be related to OCD, the main underlying concern for individuals suffering OCD is persistent and unwanted obsessions (intrusive thoughts) that produce daily significant distress. The key here is “unwanted obsessions”, where compulsions (e.g., repetitive behaviors) are usually performed to reduce distress of obsessions. Importantly, most compulsions are discretely performed where people try to conceal the fact they are constantly checking or undertaking rituals to ease distress.
Clinical OCD has a lifetime prevalence of around 2% in adult populations, meaning in 1 in 50 Australian’s may suffer OCD at one point in time. OCD often goes undiagnosed and untreated, where people can suffer in "silence" from symptoms for up to ten years before seeking assistance. Delayed professional assistance may be due to emotions like shame or embarrassment that are associated with obsessions and rituals. OCD symptoms may also go unrecognized in mental health settings, leading to delays in diagnosis and treatment.
People with OCD usually recognize that the fears and behavior's are illogical (ego dystonic), and the intrusive thoughts or images are not who they are (e.g., self-concept), and usually something they judge morally wrong. This may help explain why people with OCD get so distressed from their obsessions. For example, some people may think that they have run someone over while driving home for work. This obsession can be so stressful that some OCD suffers attend police stations to make sure no one was hurt. Moreover, because other people find it difficult to understand the aspects of OCD (e.g., ritualistic behavior's), those with OCD do their best to conceal their symptoms so they don’t experience stigma or be judged as ridiculous or “crazy,” possibly leading to lengthy delays in diagnosis and treatment.
Common obsessions and compulsions in OCD cluster around four specific themes: (1) harm and checking compulsions; (2) symmetry and ordering rituals; (3) contamination and washing rituals; and (4) sex, violence, and religion, accompanied by mental checking rituals. Obsessions and compulsions are time consuming, from anywhere between one to eight hours per day in more severe cases. While compulsions give temporary relief from distress (constantly washing hands) in the long term they maintain and increase the hold OCD has on individuals. Notably for children and adolescents it may also be distressing for family members who often get involved in the person rituals or providing constant reassurance.
OCD often begins in childhood or adolescence, though it can occur in adults as well. The symptoms may gradually develop or emerge suddenly, as seen in Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS). It is a rare condition in which certain infections, particularly streptococcal infections like strep throat, can trigger or exacerbate neuropsychiatric symptoms, including obsessive-compulsive disorder (OCD) and tics, in children.
The connection between PANDAS and OCD involves an autoimmune response, where the immune system mistakenly attacks the child's own tissues, including the brain. In the case of PANDAS, the antibodies produced in response to a streptococcal infection mistakenly target certain parts of the brain, leading to the sudden onset or worsening of OCD symptoms and/or tics. Noteworthy, PANDAS is still being thoroughly investigated, where a PANDAS diagnosis is debated within the medical communities. Some researchers believe in its validity and significance, while others are more skeptical. The relationship between streptococcal infections and neuropsychiatric symptoms in children is an area of ongoing research. If a child is suspected of having PANDAS, it is crucial to consult with a healthcare professional, preferably one with expertise in pediatric neurology or immunology. They can conduct a thorough evaluation, consider the child's medical history, and determine an appropriate course of treatment based on the individual's specific needs.
Children and adolescents with OCD may experience a variety of obsessions and compulsions. Common themes include fears of contamination, fears of harm coming to oneself or others (e.g., parents), or fears which produce shame (e.g., sexual themes). Compulsions might involve rituals like handwashing, checking, counting, or repeating actions. Children may have difficulty expressing their obsessive thoughts or understanding that their behaviors are excessive or irrational. They may be embarrassed or afraid to talk about their obsessions and compulsions.
Children with OCD may struggle with social interactions due to their preoccupations and rituals. They may fear being judged or misunderstood, leading to social isolation. Early intervention is crucial to managing symptoms effectively.
OCD is often comorbid with other mental illness like Generalised Anxiety Disorder, Eating Disorders, Autism and Major Depressive Disorder (MDD), so it is important to ensure a full diagnostic assessment is undertaken. Assessments for OCD consists of structured interviews, but a critical step in identifying and assessing the severity of OCD symptoms in the clinic is to use valid and reliable measures specific to OCD (Rapp, 2016). The Yale Brown Obsessive Compulsive Scale (YBOCS) is considered the gold standard in detecting and assessing OCD symptoms, and versions exist for both children and adults (Frost et al., 1995).
Treatment for OCD consists of psycho-education where information about the disorder is explained to help provide a better understanding of what are contributing to these distressful symptoms. Firstline treatments for OCD are CBT and medication. While CBT has shown efficacy in treating OCD, over the past four decades Exposure Response Prevention (ERP) has been the treatment of choice. ERP focuses on a collaborative approach to introduce clients to confronting objects and thoughts that bring distress, versus avoidance, so they learn over time that anxiety is not permanent and will reduce or cease. For example, a person who touches a doorknob may have intrusive thoughts of being contaminated and becoming ill, resulting in extensive washing to help remove the perceived contamination from their hands. ERP would expose the person to touch the doorknob and then prevent hand washing to learn to sit with the anxiety, and over a period of time learn that touching door knobs does not lead to illness.
However, some people struggle with ERP and stop seeking treatment. There are also a few misconceptions in the psychology arena that ERP works by lowering anxiety over time, and other efficacy-based treatments are not comparable to ERP’s superior efficacy. Unfortunately, current research (meta-analyses and randomised controlled trails) over the past 10 years shows there are suitable alternatives to ERP that show comparable efficacy that can be added or used as alternatives in treatment. Lastly, the premises of ERP being based on anxiety reduction over time is also debatable, meaning clinicians should be investing in the latest research (e.g., Inhibitory learning Theory) to help maximise the therapeutic effects of ERP and treatment for people suffering OCD.
At Cerebral Psychology we recognise that treatment can be challenging, and in Australia around 30% of clinicians offer ERP therapy. We also recognise there is no Australian clinical treatment guidelines. Possible treatments depending on the individual, course of OCD and age may see the following treatments being offered at Cerebral Psychology:
