What is OCD?
Does OCD affect many people?
Can’t people with OCD just pull themselves together?
What causes OCD?
Is there a cure?
Will the person with OCD develop a more serious mental illness?
What is the difference between obsession and rumination?
What is the difference between OCD and OCPD?
Which treatment is best?
How long before treatment starts to work?
Should the cared-for person be in hospital?
S/he won’t talk about getting help. Should I insist?
Why can’t s/he just stop when the rituals are done?
S/he seems quite happy to be like this. Why?
Would the problem be solved if we moved away?
S/he has really strange thoughts and beliefs – isn’t that more than OCD?
My family member with OCD is quite young: is it just a child thing?
Do people with OCD normally become aggressive?
Is it my fault?
How can I help?
Somebody said that OCD is an addiction, is this true?
Do people ever get back to normal?
Might s/he have a relapse?
Some origins of anxiety
What about me?
OCD used to be considered quite a rare disorder – and there are still many GPs
who have seldom reported seeing a case. But although no one knows for
sure how many cases there are (partly because many people with OCD conceal
their condition and are reluctant to discuss it), recent estimates suggest that
it is in fact quite common.
This booklet answers the questions most often asked at Anxiety Care groups and
online, by people who are sharing their home with somebody suffering from
obsessive/compulsive disorder. However, it is no more than an attempt to
scratch the surface, and anyone faced with the problem is recommended to read
more widely and use search engines online where possible. Nothing here
should be taken as medical advice and all interventions considered by family
and friends should be fully discussed with a doctor, psychologist or other
mental health professional first.
What is OCD?
OCD usually means that the affected person suffers from obsessions and
compulsions. Less frequently the person may experience one but no the
Obsessions are intrusive unwanted thoughts, ideas, urges, impulses or worries
that repeatedly run through a person’s mind. Almost by definition these
will be alarming or repugnant. They may include:
· vivid images of killing or in some way abusing a loved family member;
· worries about dirt, germs, infection or contamination (affecting the person
themselves or family members);
· recurrent fears that certain activities have not been completed properly
(even after countless repetitions);
· a need for certain objects (or even people) to be in ‘correct’ positions or
places before activities can be undertaken;
· blasphemous thoughts;
· a fear that important things may be lost unless extreme care is taken;
· a fear that harm has been caused accidentally (running somebody over in the
car or leaving harmful objects around);
· repetitive counting and weird or frightening visual images.
· Having lucky or unlucky numbers;
· Intrusive nonsense sounds, words or music, which the person will be aware is
produced by him- or herself, not by an outside force.
Other fears, which are sometimes on the line between a phobia and an obsession,
might concern worries about the shape, functioning or smell of body parts.
Discussion of these can be found elsewhere on this site, (see body dysmorphia a
leaflet on this site).
Children with OCD may have slightly different obsessions, which may include
fearing something terrible happening such as a family death, illness or
house-fire; and obsessions with food. These obsessions will reflect their
age and the things that are likely to frighten them most during a specific
period. Obsessions have also been known to swing between various foci,
where sometimes one thing and sometimes another is viewed as more important/dangerous/in
need of ritual countering.
Obsessional thoughts that have a basis in reality; that is, there is a very
small chance that the feared situation might occur (bankruptcy, disability,
death of a loved one etc.) might be considered part of another disorder such as
GAD, HC or SA. These obsessions will differ from OCD obsession in that the OC
sufferer will have compulsive rituals or thoughts to counter the obsessions,
which are likely to have nothing to do (in a rational way) with the actual
causing agent (i.e wearing green socks to protect a parent from illness). The
anxiety disorder sufferer who does not have OCD will not have such
responses. Having said that, there is a grey area where very excessive
worrying in an effort to ‘buy off’ the anxiety-generating thought, might be
considered more OCD than not. This whole area is discussed in the booklet
‘Obsessional Thinking’ which is available on this site.
Compulsions (often known as rituals) are repeated behaviours that are usually
performed to reduce the discomfort or anxiety generated by obsessive
thoughts. As above, this might be washing, checking, going back on
journeys or sorting things. This is invariably excessive, usually (not
invariably) having to be performed in a very precise manner, and may be
repeated many, many times until the person feels it is ‘right’.
Sometimes, as mentioned above, this behaviour does not seem to be directly
related to relieving an obsession, but those performing the ritual may still
experience an overwhelming need to perform it. The most common
compulsions described to Anxiety Care are:
· excessive hand washing, bathing or showering;
· cleaning household equipment or furniture;
· avoiding ‘contaminated’ or ‘dangerous’ objects or substances (commonly dog
faeces, knives, asbestos, etc.);
· checking water, electric and gas taps; windows, cupboards and doors;
· repeatedly checking that nothing ‘bad’ has happened or accidents have been
caused and demanding reassurance about this.
Less common ritual behaviours include:
· dressing oneself, or one’s children in a precise and predetermined fashion;
· entering or leaving the home or car in the ‘correct’ way (which may seem
bizarre to an observer), and repeating these behaviours.
Less common still are rituals concerning hoarding, including an inability to
throw things away without excessive checking; obsessive reading; and performing
certain acts like dressing, bathing or crossing roads very slowly.
If obsessions and compulsions do not take up more than an hour a day and are
not significantly interfering with life function, then this person has OC
symptoms but would not be diagnosed as having OCD.
Both obsessions and compulsions may vary greatly in duration and intensity
among individuals suffering them. They may be a mild irritant, a waxing
and waning problem or totally disabling and life consuming. Depression
can be a contributory factor to the disorder or become a problem as a response
to the level of handicap involved. Mental health professionals will usually try
to work out the ‘prime’ disorder; that is if depression is generating
obsession, or if obsession is generating depression, for example, so that this
prime disorder can be treated. Once the prime disorder is dealt with, the
other problems generated by it may well disappear.
People with OCD might also experience panic, (see symptoms of panic in ‘Panic
for no obvious cause’ on this site). This is likely to be in response to
a stimulus, e.g. seeing blood, dog faeces or a sharp knife, much as with a
phobic response. If these panics come out of nowhere, for no apparent
reason and the sufferer is afraid of the symptoms of panic rather than the
consequences of the panic-causing event, as would be true of OCD panic, it
might be worth checking with a mental health professional about the possibility
of there being co-current Panic Disorder. Having said that, some people
with OCD are loath to admit to extreme responses to a stimulus, particularly if
they are deeply ashamed of their problem, and it would probably be worth
discussing the whole ‘panic situation’ with the cared-for person before
involving the medical services.
Does OCD affect many people?
OCD seems to affect 2-3%of adults in the western world There is research that
suggests that symptoms at a sub-clinical level might be as high as 18-19%, and
mildly obsessive behaviour – even to the extent of ‘eccentricity; – is
extremely common. One study suggests that the probability of an
individual suffering from OCD at some time in his or her life is over 5%
(Bebbington, 1990). It is estimated that up to one child in two-hundred has
Can’t people with OCD just pull themselves together?
No. If they could, they undoubtedly would. OCD is not a
straight-forward condition like being pregnant, where there is a definite
progression to the situation that everyone can see and understand. The
waxing and waning content of OCD, sometimes coupled to extreme pressures or
rewards in daily life, can make it look as if the person is ‘only as bad as
they want to be’. This is invariably a false perception. Most of us
are capable of supreme effort when the situation demands it, but cannot be
expected to maintain this in every day life. This is about ‘balance’
where every effort we make is based on the desire or pressure to perform it
(e.g. getting out of a warm bed to go to a job we dislike will depend on how
badly we need the money. Visiting the hospital every day to see a sick
child might be possible for the severe agoraphobic, on a temporary basis, when
the need is extreme.)
Many people have vaguely obsessive habits of some sort. Some time ago a
charity worker was talking to a group of young mothers (members of a social
group, not anxiety suffers) and the conversation came round to cleanliness and
then lavatory rituals. All of them had what might be described as
irrational habits concerning using their own, or other people’s
lavatories. These ranged from mild anxiety about infection that involved
regular use of strong cleaning agents, to extreme anxiety requiring lengthy
rituals (undressing, ‘nest building’, several washes or showering). None
could be described as having OCD, but all were going beyond a reasonable level
of care. All of them were relieved to find that they were not alone in
their ‘odd’ behaviour.
Other situations encountered recently have included people who use slight
obsessions about ‘correctness’ to make them better at their jobs, and those who
put things in order as a calming precursor to any major activity. These
are personality traits rather than symptoms of an illness and, as far as OCD is
concerned, might be compared to the relationship between social drinking and
alcoholism. The problem is that those of us who find slightly obsessive
behaviour rather useful often find it difficult to relate to people whose lives
are dominated by obsessions.
What causes OCD?
There are several schools of thought. One is that abnormal functioning of
the brain is mainly responsible. It is suggested that a chemical
neurotransmitter or ‘brain messenger’ called serotonin (or 5-HT) is
over-functioning, leading to extremes of social concern. The brain
becomes overloaded with ‘worry messages’, which spill into consciousness.
Other clinicians related OCD to ‘hidden conflict’ or early trauma, while some
blame allergy, genetic predisposition (being born with a tendency towards it)
or learning experiences during the early years. Of these, there is no
evidence that allergy has an effect and most enquirers who have experienced
only ‘talking treatment’ of the analytical sort, aimed at exposing
psychological causes have reported little benefit.
Most likely, OCD is a response to a mix of genetic, biochemical and learning
situations that combine to make this disability more likely for the luckless
individual. However, it is important to understand that ‘knowing why’ is
of no great value. People cannot have their serotonin ‘equalized’ so that
it will work as a cure that does not involve personal work on the part of the
sufferer. The triggers and long-term responses are much more complicated
than that. Neither can people be talked or bullied out of it. This
is discussed more fully in the booklet ‘OCD Causes’, which is available for
download from this site.
Is there a cure?
Anyone can have an anxiety condition at any time. Anxiety is necessary
for the successful process of our lives. If we had no anxiety at all we would
do rash things and soon bring harm on ourselves. Having said that,
anxiety is only useful in small doses. Large doses start to work against
us and make life difficult. Medication and cognitive behavioural
treatment together seems to be the response of choice at the moment and the
majority of people with OCD recovery to a substantial degree after
therapy. However, another bout of the problem may occur in the future,
particularly if recovery-maintenance is not worked at. This is ensuring
that recovery work is maintained well beyond the ability to ‘just function’.
People need to be able to ‘get away from the edge’ in life. That is, if
you only get well enough to just get by, still walking on the edge of the cliff
so to speak, sooner or later someone or some thing will give you a nudge. The
person recovering needs to ensure that he or she is walking well away from the
edge, which means working at recovery well into the area of being able to
manage basic things.
Someone with OCD might still experience the urge to perform rituals from time
to time – this is to be expected. The body and mind has found a way to
reduce anxiety levels and does not give up on that sort of thing easily.
So, a one-time OC may never entirely shake off the urge to perform the rituals,
even if he or she doesn’t actually give in. In short, the aim of treatment
is not to eliminate every trace of anxiety and the response to it, but to get
back to a more satisfactory way of life.
Will the person with OCD develop a more serious mental illness?
The family member with OCD is no more likely to suffer severe mental illness
than anyone else. To the layman, OCD can sometimes look like the
beginnings of something more frightening like schizophrenia, but this disorder
does not lead to such illness (which itself is probably a combination of
disorders, and people with schizophrenia may also have OCD). At one time
it was not unknown for people to be wrongly diagnosed, but nowadays much more
is known about OCD; and the differences between this and the (arguably) more
serious mental disorders, such as schizophrenia, are clear and easily defined
by the clinician.
Within this question, carers sometimes become confused about various
psychiatric terms, particularly neurotic and psychotic. Many of us use one or
both of these terms to excess as general descriptive words for behaviour we
don’t approve of. In a technical sense, neurosis is a condition were the
sufferer remains in touch with reality and finds his or her symptoms
distressing and alien to his or her personality. Neurotic activity would
not tend to go against socially acceptable behaviour. With OCD this would mean
that the compulsions such as washing or checking would be recognised as
abnormal or excessive, but this wouldn’t involve an ability to stop performing
them. The personal inability to stop would not mean that the sufferer
felt it was genuinely necessary for everyone to do this as such a belief would
tend to preclude feeling anxious or very concerned about it, which is a
requirement of OCD.
Psychosis, on the other hand involves an inability to distinguish reality from
fantasy and would mean that the sufferer has a very personal, ‘internal
reality’ that has little or nothing to do with the surrounding world.
Such a person makes inaccurate links between situations and their purpose or meaning,
and will incorrectly evaluate his or her perceptions and thoughts even if all
the evidence is to the contrary. Psychotic behaviour might well be against
socially acceptable norms. A person suffering from hallucinations or
delusions would generally be considered psychotic and a hallucination might
involve any of the senses (e.g. sights, smells, noises, touch). This would
include the classic ‘voices’, where thoughts are perceived as coming from
outside the person. The neurotic, on the other hand, would be aware that
thoughts belonged to him or her and were an internal process. However,
there is a suggestion that the psychotic could recognise hallucinations as such
in some cases.
The area of delusion, however, can be difficult. Within OCD, sufferers
might be considered to be on a continuum of reality concerning their obsessions
or compulsions that could go, at one end, from being totally aware that what
they are doing is irrational and weird, through to, at the other end, at least
some of the time, believing that it is necessary. And this ‘some of the time’
might, itself, mean that the sufferer moved up and down the continuum according
to prevailing conditions within the disorder as it was affected by personal
conditions and outside problems. There is, in fact, research that suggests that
a small but significant percentage of clinically normal people are more
delusional than diagnosed psychotics (Sheringham). There is also some support
for the idea that delusions are more common in people with one obsessional
theme than in people with multiple obsessional themes, and that depression
might have an impact too on the presence, or not, of delusion in OCD, (Fear,
Sharp & Healy).
Anxiety Care has encountered people who, at times, were almost convinced that
they had committed certain acts that were always bizarre and unlikely to the
point of impossibility. This was almost invariably during very stressful
or traumatic periods when their general anxiety was high for fairly normal
reasons; and the great majority responded to rational discussion and drew back
to a more reasonable perspective. This often involved an inability to
accept the slightest chance that such activity had occurred as in “Guarantee me
that I didn’t kill someone while I was out shopping today, and hid the body so
well nobody has found it.” A response that involved explaining that the
odds were millions to one against was never enough, at least initially.
A very few once-only group, or other service, attenders have clung steadfastly
to delusional beliefs and in all but two cases the carer shared the beliefs.
None of these had responded to any kind of medical intervention. It could
be deduced that such people suffered from a more severe mental condition that
had an OC element to it.
As mentioned elsewhere, it must be clearly understood that because some mental
disorders can occur together, this does not mean that the OC person will
contract something more serious. ‘Can’ is a world away from ’will’.
So, from the above, it might be concluded that it is not realistic to worry
about the cared-for person becoming psychotic on the basis of the occasional
out-of-character response to the OC prompts; but if there are worries in this
area, a relevant medical professional should be consulted and the diagnostic
process followed through. More than one severely mentally ill person has
been sent to Anxiety Care, by professionals of various disciplines, on the
basis of having an anxiety disorder, which diagnosis charity workers perceived
as being the least of their problems.
What is the difference between obsession and rumination?
These two descriptions of thought are often used as if they mean the same
thing, technically they do not. Ruminations (or morbid preoccupations)
are usually experienced by people who are depressed. They are thoughts
that seem to ‘stick’ in the head and go round and round with no solution.
They are usually about activity in the past that the depressed person views as
having a profound meaning in terms of his or her current value as a
person. The depression makes poor interpretations of these facts and
their meaning a real problem to the sufferer. These ruminations will
almost invariably be about real happenings and mistakes in the past, albeit
with a severe discolouration caused by the depression. So they will make
sense to the ruminator even as they cause unhappiness. An outsider too
might see such thoughts as having a rational if seriously over valued basis.
Obsessional thought, on the other hand, is mostly about current or future
activity or activity in the immediate past and usually involves unrealistic
fears. These might be of having inadvertently run somebody over or
accidentally poisoning someone; or committing some grossly antisocial or illegal
offence while ‘out of control’ or distracted in some way. They too might take
up a great deal of thinking time.
Anxiety Care has encountered people with both OCD and depression where the
difference is hard, or impossible, to see. For example, endlessly
thinking about cheating on one’s income taxes ten years ago might be viewed as
depressive rumination on the subject of being a dishonest person; but when this
slips over into fears that the Inland Revenue and the police will come knocking
on the door, does this make it an irrational belief and therefore an obsession?
And if obsessional thinking requires a compulsion to neutralise it, does
reassurance-seeking by endlessly talking to one’s partner about the income tax
problem constitute obsessive behaviour or the relief of excessive worry, and
therefore make the problem more in the Generalized Anxiety Disorder (GAD)
area? A broader discussion of aspects of this can be found in the booklet
‘Obsessional Thinking’ which is available for download from this site.
What is the difference between OCD and OCPD?
After a recent Hollywood film, many people have become confused about the
differences between Obsessive/compulsive Disorder and Obsessive/compulsive
Personality Disorder. There is a lot on the net about these problems, but the
following is drawn from a very clear description by ‘University of Maryland
Medicine’. This article states that only about 15% of people with OCD meet the
criteria for OCPD. The latter seems to involve perfectionism,
preoccupation with details, indecisiveness, stinginess and excessive devotion
to productivity, which may be a symptom of workaholism, which is also common in
OCPD. He or she (the OCP) is likely to be a severe or harsh supervisor,
maybe at work and at home; displays of tenderness are unlikely to be valued,
and this person will probably demand that the family submit to his or her
will. He or she is not going to have insight into the OCPD behaviour and
is unlikely to see the need for psychiatric assistance. ‘Strictly defined’
obsessions and compulsions are not present in OCPD but hoarding might be.
Naturally, the hard working person who is attentive to detail and less than
warm emotionally, does not automatically have a disorder as these can also be
simple personality traits which are valued in some walks of life.
Which treatment is best?
Two treatments show good results for OCD. These are cognitive-behaviour
therapy with response prevention, and drug treatment.
Behaviour therapy helps people to learn how to reduce anxiety arising from
obsessions and how to reduce and then eliminate their rituals.
It is not something that is ‘done to people’. The individual involved
does it him- or herself, and is helped to devise a set of structured techniques
that can then be employed when necessary. The person is instructed:
· in ways to face up to the feared thoughts and internal responses (exposure to
· and in ways to refrain from carrying out the rituals that then usually arise
This work, which resembles the self-exposure method for overcoming anxiety
conditions such as phobias, should be practised every day.
Research evidence suggests that a huge amount of exposure or response
prevention is not essential each time – low anxiety levels are as effective as
high ones. The time and effort involved is a personal choice, bearing in
mind that opting for low levels of work should never be an excuse to play at
treatment. There is a good deal of practical information and self-help
literature available on this subject, in books and online. One of the
earliest was Professor Isaac Marks’ book, Living with Fear. Professor
Marks’ research also suggests that, for some obsessive compulsives, self-exposure
work done without a therapist present, is more effective (Marks et al. 1988;
Drug treatment: People with OCD report having been prescribed a wide
range of drugs. Tranquillizers alone have little effect, and placebos
none. Some general antidepressants are fairly effective for reducing depressive
symptoms where this is a major part of the problem. The tricyclic
clomipramine was one of the earliest drugs that was found to help and this is
still widely used, although side effects and other considerations do not make
it automatic first choice. Other antidepressants known as ‘serotonin
re-uptake inhibitors’ (SRI’s) have a beneficial effect on OCD and are usually
the medication of choice at present. These drugs affect the brain chemical
serotonin which allows certain nerve cells, called neurons, to communicate with
each other. Under the right conditions, these cells release serotonin
which then affect the neighbouring cells. After the serotonin is released, it
is taken back up into the cells so that it can be used again. The SRI’s
interfere with the serotonin being recycled once it has been released which
allows it to spend more time outside the cell so that it continue to affect
neighbouring cells. Why this helps reduce OC problems is still not fully
understood. With children, the smallest effective dose would probably be the
first attempt at treatment although, as children metabolise medications
quickly, higher doses might then be indicated, (OC Foundation). The level
of dose is something that has to be decided, and there does not seem to be full
agreement in the medical field on whether low or high doses are the best way to
There are several SRI’s and although all in the same ‘family’ they are
different enough for others to be tried if one does not work. Currently,
the SRI Seroxat is widely used by Anxiety Care service users. None of these
drugs help every case and there is research to suggest that 40% or more of
patients with OCD fail to respond to these drugs alone. In such cases one
of the major tranquillizers may be prescribed as well. It is up to the
prescribing physician to determine how and when these individual drugs should
Due to the controversy over drug prescribing in recent years, many people are
afraid of taking medication. This fear can also be part of the OC
problem. (A psychiatrist once told the charity that only one in seven or
eight patients would countenance drug treatment.) Side-effects can be
alarming. They may include tiredness, blurred vision, constipation,
nausea, difficulty in urinating, weight gain, light-headedness, sweating,
trembling, loss of interest in sex or sexual dysfunction. Monteiro et al.
(1987) found that a fair proportion of sexually active obsessive compulsives
became unable to reach orgasm while taking clomipramine.
There is research that suggests that a ‘medication holiday’ might be taken if
sexual difficulties seem to be encouraging the sufferer to give up
medication. That is, medication could be left off over a weekend, for
example. This would need to be done with the support of the prescribing
physician however, as it is not a good idea to alter dosages drastically
without expert confirmation that this is a suitable option.
A carer who finds it incomprehensible that a sufferer would rather have a full
sex life than proceed with recovery might usefully discuss this with someone
experienced in working with OCD such as an Anxiety Care counsellor. At
this point it should be understood that some men have a good deal of their
self-esteem and vision of themselves as ‘a man’ wrapped up in their
sexuality. In such a situation, a man who probably feels less than manly
because of the disorder anyway, might simply not be prepared to live with
reduced sexual function.
The newer SRI’s seem to produce fewer side-effects and these do not happen to
everyone, but it is as well to be aware of them if the cared-for person has
problems with his or her bodily reactions to outside stimulation. A
course of drug treatment might last for a few weeks or many months or years
according to the individual. These antidepressant drugs are not addictive
but withdrawal, as and when it is begun, should be done over a period of at
least four weeks (and perhaps a lot longer) by gradually reducing the
dosage. If the medication has been taken for two months or more on no
account should the dose simply be stopped. Symptoms of withdrawal might include
nausea, perhaps vomiting, loss of appetite, headache, giddiness, chills and
anxiety. There will be no means occurs for everyone and a gradual
withdrawal will minimize the problem. However, if a major tranquillizer
is prescribed to be taken with an anti-depressant, there may well be withdrawal
problems. Overdose can be a problem so the dosages should be monitored and
taken as prescribed.
Probably the optimum road to recovery lies in a mix of drug and
cognitive-behavioural treatment, with the addition of some general ‘talking
help’ and family support. Behaviour treatment requires a large commitment
in time and energy (and fear); while drug treatment requires only that the
person sticks to the right does at the right time. However, research
suggests that drug treatment alone is not as effective as behavioural treatment
for those who stay the course (50% don’t). Relapse might also occur once
the drug is given up as this type of medication controls symptoms rather than
offers a cure. Some research suggests that medication alone, without
psychological help, is unlikely to maintain recovery once it is stopped.
‘Talking treatment’ is often used as an adjunct to other support. This
‘cognitive’ therapy works by the therapist building a rapport with the person
and working through and challenging the assumptions and logic upon which this
person is operating. However, this can easily develop into deep
self-inspection and analysis of every process, treating everything very
seriously, unless performed by a fully trained person. And the
obsessive/compulsive is probably already willing to look inside him- or herself
too much. More analytical versions of talking treatment, where the
obsessive/compulsive is encouraged to view the obsessions as some deep seated
and unresolved sexual problem or the remnants of infantile feelings,
(over-severe potty training has been suggested in the past), might do more harm
than good. The obsessive/compulsive is probably very able to place
heavyweight reasons on all frightening thoughts so adding more is only likely
to reinforce the condition. (Part of the above is from Phillipson, 1991).
How long before treatment starts to work?
Response to behavioural treatment depends very much on the individual. If
a commitment is made to undertake the work involved, signs of recovery could be
apparent in the first session or within the first half dozen. Once the
person actually accepts that he or she is improving, the gains will
continue. As this simple treatment can be applied by the individual, him-
or herself whenever necessary, alone or with minimal support, such gains can
continue for a very long time, perhaps indefinitely.
With drug treatment, unfortunately, the side effects occur soon after the
medication is started and are usually at their worst before positive results
are felt. Some people respond quite quickly to medication, perhaps a week or
two; however, two months is a fairly general time lapse between first doses of
SRI’s and significant signs of improvement in many, so medication should not be
abandoned because there appears to be little initial response. This
improvement, when it does come, may continue for several more months until it
reaches a maximum point. A good doctor will work with the patient to keep
side effects down (modifying dosage, times of taking etc.), while keeping a
close watch on progress – or lack of it.
Should the cared-for person be in hospital?
Out-patient treatment is probably the best course if the care-for person:
· Is functioning fairly well in the home environment;
· Had a good record on coping at home and at work prior to the onset of OCD;
· Has support from family and/or friends;
· Is reasonably relaxed rather than severely anxious or depressed;
· Copes with any prescribed medication well:
· Is not totally and irrationally convinced of the reality of obsessive
thoughts and actions.
Hospitalisation may be the better option if:
· The person is severely depressed or extremely distressed;
· Is unable to cope with normal everyday activities such as working, eating and
drinking, hobbies, etc.;
· The family/friends support system has broken down (and this might include
violence, heated arguments, isolation from family members);
· Medication is causing unacceptable side-effects.
Having said this, we are all different. Some of us benefit from the (hopefully)
intensive support that is offered by a hospital environment. Some need a
complete change to allow the endless loop of repetitive behaviour an
opportunity to ease. Still others might respond well, once free of a
damaging or punitive family situation. However, there is little
information available that suggests that intensive and skilled care is readily
available for anti-obsessional work in a general psychiatric hospital. It
would not, therefore, be safe to assume that the obsessive/compulsive would
receive totally appropriate treatment for the disorder once hospitalised, and
will return home cured. It might be more realistic to accept that the OC
will simply be in a safe, comparatively stress-free environment while in
hospital and that, at best, medication levels (if these are prescribed) will be
S/he won’t talk about getting help. Should I insist?
It is common for a person with OCD to suffer the symptoms for eight to ten
years before seeking help. Many obsessive/compulsives are afraid of
people ‘finding out about them’ and/or fear that needing help will prove that
they are insane, so strongly resist any kind of outside help. Others
simply integrate the rituals into their lives and find it difficult to gauge
the level of handicap they are suffering. It is important for the caring
family to help the person to understand the need for help, but also for
themselves to understand how frightening and threatening such help might seem.
It is important for carers to work out whether or not the obsessive/compulsive
family member is ready to accept help. A simple assumption that this
person must be willing to try anything to be rid of such a handicap is not
necessarily correct. It is what the person does, not what the person says
they are doing that is important. And if the obsessive/compulsive doesn’t
seem to be able to keep professional appointments or disengages quickly from
new therapies then, whatever is said, it is the inability to stay with therapy
that must be accepted. Within the charity, it is sometimes suggested to
carers that they ‘turn off the volume’ and run the last few weeks through their
minds, using the pictures without the words. That is, they are advised to
think about what the OC family member has been doing with regard to the
disorder and treatment with no regard at all for what is being said. This
often gives a dramatically different picture of what is going on, compared to
what has been assumed to be going on, when justifying or dissembling dialogue is
Some people need to reach rock bottom before they are ready to commit to a
treatment regime. Others need to work through personal feelings,
immediate situations or to make tentative forays into a range of support
services, looking for an ‘instant answer’, before they can accept structured
help. And still others, a minority, are having their needs met by the
disorder and/or family collusion and are not going to accept treatment at
all. The caring family must be able to differentiate between their needs
and the needs of the person they are looking after; between reality and what
they wish was reality.
Why can’t s/he just stop when the rituals are done?
This is usually asked of people who check or wash endlessly and is invariably
based on the questioner’s own perception of ‘doneness’. We all have an
inbuilt perception of what constitutes ‘completion’ when undertaking such
things as checking that doors are locked or hands are clean. This will
vary according to prevailing conditions. That is, if your neighbour has
been burgled you check locks very carefully. Or if somebody has tracked
animal faeces into the house, or you have inadvertently touched a highly toxic
substance, washing is particularly rigorous.
With OCD, ‘closedness’ (doors, windows etc.), or the risk of contamination can
seem so hugely, even limitlessly, important that the work is never done.
Completion may then only occur when exhaustion or family anger forces a stop
and this may have little or nothing to do with the sufferer’s perception of
what is necessary. In short, the internal perception of completion is
very often at crisis level and can rarely be reached.
If the person has a specific ritual concerned with washing or checking such as
performing it a number of times or while thinking certain thoughts, there might
be a fairly definite conclusion to the actions (although this will invariably
be more than a non-sufferer would view as enough). However, if this ritual is
interrupted in any way, either physically or by irritation from a family
member, or by the person ‘making a mistake’ (which might involve a whole range
or things, all of which a non-sufferer would barely find relevant), the
‘completedness’ might never occur. Again, the carer is very unlikely to
be able to understand the logic of this process and applying the personal
yardstick that we are all tempted to use – ‘what works for me should work for
everyone’ – is never going to be a good idea.
S/he seems quite happy to be like this. Why?
This question is often asked with strong undertones of suspicion and
despair. The answer is probably to do with the definition of ‘happy’ and
the differences between the carer’s, and the obsessive/compulsive’s view of the
problem. If this person had MS or some other severe, visible, physical
disability, their calm, even cheerful demeanour would probably be viewed with
admiration. However, this would be based on the knowledge that the
handicap was permanent, or had a definite time span (like a broken leg).
With OCD the handicap can seem just as permanent to the person suffering it,
while those around them will tend to view it very differently – most often as
something against which this person should be continually struggling. In
such a situation, any apparent acceptance of the problem, let alone
good-humoured acceptance, can feel like a betrayal to the carer. Pressure
of various kinds then might be brought to bear so that the obsessive/compulsive
feels virtually obliged to be unhappy all the time in order to avoid censure or
accusations of not wanting to be well.
It might be an idea for carers in this situation to view the
obsessive/compulsive as a sort of ‘prisoner of war’. This person is not
where he or she wants to be, and may be there for a long time, but charging the
guns or the wire all the time is not the best answer. Feeling useful and
being active is at least as important for all such POW’s. None of them
spend all their time planning or attempting escape. This is not to say
that a person with OCD should be encouraged to see him- or herself as an
invalid, but forbidding them to find any kind of happiness – however subtle the
pressure, is not productive.
This does not apply to all obsessive/compulsives of course. This problem
can be filling a need and some people with OCD do use their handicap like a
club on those around them – as do many people with other types of problem.
The trick is to try to put oneself in the position of the cared-for person – to
attempt to see the situation as they do, not as the carer thinks he or she
should see it; and not to allow residual feelings of anger or doubt about the
validity of OCD as a handicap to colour responses.
Would the problem be solved if we moved away?
The cared-for person may well argue this, but as a general rule the answer is
no. Sometimes running away is the optimum solution to a problem; and some
people live such horrific, constrained lives in their current environment that
a geographical transplant away from their nearest and dearest would work better
than any drug. However, for most people, moving – more accurately running
away – would achieve nothing in the long term. For a few days or weeks
the novelty and the belief in the efficacy of change might achieve a remission,
but the odds are that reality would slip back in eventually and probably sooner
than later. The simple fact is that the OCD sufferer, as a general rule,
carries the problem within him or her. The obsessions are a faulty piece
of thought processing; they are not some infection from outside or focused
totally in the environment. Living conditions might well be aggravating
the situation, but it is extremely unlikely that a total change will induce
From Anxiety Care’s experience, sufferers who move home or job simply find
other things to obsess about very quickly. There are no examples within
the charity of a radical change in environment making a significant difference
to the OCD.
S/he has really strange thoughts and beliefs – isn’t that more than OCD?
The answer is no. Obsessional thoughts are very common. Around 90%
of the population will have them (Rackman et al. 1978; Salkovski et al.
1984). These thoughts, that most of us are subject to, don’t seem to
differ in any way from those experienced by obsessives. The differences
seem to lie with how these thoughts are appraised by the individual. (The
classic psychologist’s joke: “Are you bothered by evil thoughts?” “No, I quite
There is a non-conscious part of the brain that sets up a range of relevant
information to assist our conscious thought processes when we think; plus
offering sundry other information triggered by the particular though. Much of
this may have only the most tenuous link with the original thought, and it is
how we interpret this gratuitous information that causes most of the problems.
With this kind of information jumble, most of us have ‘evil thoughts’ at times,
to which we will respond in a variety of ways. Most people dismiss the
irrelevancies. However, if we feel generally guilty or negative about
theses thoughts and they occur over a long period, we may generate anxiety or
depression. And if we have an internal appraisal system that takes a
great deal of responsibility for such thoughts – If I think it, I must be going
to do it! If I have the slightest worry that I may have harmed somebody,
I have to do anything necessary to ensure I am not to blame! – OCD can
develop. The unconscious part of the brain will certainly link any
additional information, however tenuous to the original link, if it is ‘flagged
up’ by a major response in the thought processing such as a surge of
anxiety. Therefore it is to be expected that a frightening though linked
in this way will be competently filed with other, truly relevant information,
to be readily available next time the originating though occurs. So
The charity has encountered a number of young mothers with extreme fears
concerning the possibility of them harming their children. Most parents have
fairly murderous thoughts about their offspring from time to time.
Statements like I could have strangled him! I could have killed him! are
common enough among parents when discussing their children’s bad
behaviour. Where babies are concerned, endless night-crying and parental
exhaustion to the point of collapse, generates feelings that would alarm
If the person is fairly self-assured, or if there is somebody around later with
whom to talk such feelings through, these frightening responses usually
evaporate leaving only a small residue of guilt. However, with some
people, these linked thoughts don’t go away. A casual though about
dropping a baby (something we all rightly keep somewhere in our minds when carrying
something so vulnerable) turns into the belief that he or she wants to drop
it. So s/he will no longer pick the child up, or has to go through a
ritual of ‘good thoughts or actions’ first. A stray thought about what
might happen if one of the children caught something from a still-dirty piece
of washing leads to extensive re-washing; or watching the machine endlessly in
case it ‘makes a mistake’; or thinking ‘good’ or ‘blocking’ thoughts to counter
‘wickedness’ such as less than sunny thoughts about a loved one.
In such a situation, tenuously linked thoughts are treated too seriously.
Thereafter, it is not the thoughts themselves, or their frequency or intensity,
that make them cripplingly obsessional; it is the way the individual interprets
them and then goes on to try to neutralize them with ritual behaviour or other,
cancelling thoughts. This is similar to phobic responses, where avoidance or
escape, rather than accepting the anxiety, maintains the problem.
Some of us simply appraise thoughts wrongly. There could be many reasons
for this. Perhaps, that we were encouraged to take too much personal
responsibility for our actions when young; or perhaps we encountered the older
family member, expert in slipping an ‘internal policeman’ into our head.
This kind of person is very good at linking shame to innocent or enquiring
behaviour in the child as a method of control, or in force-feeding their own
rigid code of decency, linked to fears of abandonment, withdrawal of love, or
the child harming this person by his or ‘wickedness’ if it isn’t adhered
to. If this has happened, there is little point in the carer explaining
that thoughts can’t hurt and expecting this to work. To the cared-for
person, there is an inner certainty that thoughts do harm; or that he or she
has huge responsibility to protect others; or the power to harm them:
this is not stupidity or madness, it is OCD.
However, two points can be made by the carer, and strongly. They are,
first, that the cared-for person cannot hope to find the key thought that will
turn off the thoughts that are feared – because no such possibility
exists. Second, that one cannot stop oneself thinking about
something. The more we try to stop thought, the more likely the thought is
to come. This results in the obsessive/compulsive being so busy casting
around for signs of the evil, that he or she makes an already frightening
scenario even worse. This can be seen in the ‘religious obsessions’ that
were common when religion played a far greater part in life generally (but
which can still be found among obsessives with a strong religious
background). Such problems will usually involve obsessional thoughts
without physical rituals, where blasphemous thoughts are experienced and are
neutralized with ‘good’ thoughts of some kind. (Sexual and violent
thoughts are also usually obsessions without compulsions and are often dealt
with in the same way.)
Again, it is the interpretation of the thought, not the content or frequency,
that is the problem. Most of us, confronted by tragedy or plain evil,
might question the presence of a kindly God, without this leading to obsessions
and extreme responses. Many of us will also be faced, at least once in
our lives, with something that takes up all our thinking time. These
preoccupying ruminations may be morbid, but should not be confused with
OCD. If someone is faced with a very real problem like imminent
bankruptcy or a dying spouse, they might well think about this to the virtual
exclusion of everything else. This might well be destructive and cause
additional harm, but it is not OCD – it is a response to a rational danger.
Charity support workers and the caring families often find it difficult to work with
people who are predominantly ‘purely obsessional thinkers’ (POTs), because
there is little physical manifestation of OCD symptoms to help with in this
situation. That is, with POTs the original thought or mental question
generates much anxiety, which in turn begins the process of extreme mental
activity (ruminations) in an attempt to escape it, cancel out, or solve the
thought. But it does not result in physical responses such as washing or
checking. Behavioural treatment for this would involve building a
tolerance for such thoughts and reducing the ruminations. ‘Stopping’
techniques are sometimes suggested. Here, in response to the generating
thought, the person thinks STOP!, or makes some physical response such as
snapping a rubber band that is round a wrist, stamping a foot, or punching a
fist into the other palm.
These simple responses have had their successes, but there is a strong
suspicion that adding pain to the equation might further accentuate the
importance of the originating thought – but if it works, that’s fine. Any
treatment that increases the originating thought’s importance (such as
analysis) is likely to have the same negative effect. However, the
alternative of trivializing the thoughts and ruminations is entirely
pointless. A simple denial of importance with no associated logic will
have little impact on a well-established and feared process. Any
cognitive-behavioural approach will be aimed at finding ways to accept the
thoughts: To start the process that will gradually disengage those
‘importance thought’ markers and let the harmful responses slip back into their
rightful place among the bizarre and irrelevant links that are present in
However, it is important to understand that whatever treatment is used, it may
well increased the occurrence of the originating thought at first. The
brain does not take kindly to being redirected and, as ruminations decrease,
the originating thought may increase much as a naughty child might throw a
tantrum as a last ditch attempt to get its way. The important fact to remember
with POTs is that successful recovery techniques will reduce the time taken up
by ruminations, not the number of times the originating thought or question
occurs. This will normalize in it’s own good time.
Other techniques that have been used successfully with POTs include recording
the originating thought on cassette tape and playing it over and over.
The mind then grows used to the triggering thought, which gradually loses its
power to generate anxiety symptoms. A better way might be internal
repetition of the thought. That is, as it occurs, the person repeats it
in the mind so that eventually the brain accepts the idea that the thought is
not important – that it is in fact so unimportant that it can be happily
repeated over and over again.
Thoughts which counter the originating thought or question can also be useful –
changing or wrong-footing the ruminations. A useful response to the
question Did I put ground glass in David’s cereal? Might be Probably,
I’ll get the rest of the family tomorrow morning. To wrong-foot the
thought If I wear this shirt today, my mother will die, we might think; Maybe,
but I’ll have to take the risk or that question owns me. Again, this
process has had its successes but it does involve a great deal of confidence
and might not be something that could be attempted too early in recovery work.
Some POTs fall into a loop of twisted logic where family protection is
concerned. They feel far too responsible for the safety of one or more
family members and develop some internal ritual that ‘protects’ them.
Commonly, when it is suggested that such ‘keep them safe’ thoughts are
irrelevant and damaging, the obsessive/compulsive reacts as if it has been
suggested that they actually wish harm to fall upon this family member.
Any parent knows that lying awake at night until a child returns home is not
keeping them safe; or that worrying while they are away from home for the day
is similarly unproductive – but it is still done. Part of this is because, as a
thinking species, we are often aware of how powerless we are and tend to seek
out less than logical ways to make ourselves feel better about this.
The POT must learn to differentiate between natural concern and irrational fear
and the blocking of it, which is serving them rather than the family member
concerned. They must be prepared to take risks; even that harm will occur
that will then ‘prove’ that their thought rituals were correct. So, not
trying to escape, poking fun at one’s own dire thoughts, not trying to find
answers or the perfect thought sequence that cancels everything bad – these are
the ways through purely obsessional thinking. Whatever the treatment, the
originating thoughts or questions have to be accepted – not welcomed – but
allowed to exist. They will starve from lack of attention in time.
(Much of the above is based on an article by S.Phillipson in the American OCDI
My family member with OCD is quite young: Is it just a child thing?
Children tend to have a range of fears, of varying intensity, as part of their
natural development process and, as these are fairly normal, excessive worry by
the parent is not an automatic requirement. For example, a normal child of four
or five might be quite obsessive about arranging toys.
With anxiety, children tend to explain their obsessions as worries. The
most common obsessions, as discussed more fully below, are fear of intruders
entering the house, fear of contamination with germs and toxic substances and
worries that they might contract a serious illness. Children will tend to
obsess about many things at many different levels and fears may come and go
(altogether or in relevant importance) according to age. Adolescents who
abuse drugs or alcohol have a greater chance of developing OCD by the age of
eighteen than those who do not, (OCD in Children and Adolescents’).
Many children have phobias and anxiety conditions (see leaflet on Childrens’
Fears on this site) and most children work through the problems that are
(relatively) ‘normal’ for their age as mentioned above. There is research
that suggests that up to 13% of children between the ages of nine and seventeen
may have anxiety disorders in any one-year period. And anecdotal evidence
suggests that some anxious children may seem somewhat obsessive because of fear
surrounding separation from a parent figure or very high ‘worry’ levels that
could be in the GAD range (see leaflet on ‘Generalised Anxiety Disorder’ and
the booklet on ‘Obsessional Thinking’ on this site).
The problem is that maturity appears to have no effect on OCD, and research
indicates that about one-third of OCD cases are in place by the time the
sufferer is aged fifteen (Geist, 1989). Adolescents of both sexes
frequently go through stages of vaguely obsessive behaviour; and it is not
uncommon for both boys and girls to be alarmed at bodily changes and a growing
sexuality. This alarm might manifest itself in a multitude of ways, some
of which could present as obsessive – washing excessively, focus on body shape
or odour, extreme privacy etc. However, any parent of an OC adolescent
would be able to describe behaviour that could not, by any stretch of the
imagination, be described (as most of the above would be) as just another
slightly irritating, self-involved, phase.
The situation is this: the parent knows the child, and is probably the
only expert on this particular adolescent. If he or she detects behaviour
that is completely out of character, it doesn’t matter that a name cannot be
put on this behaviour, even by the doctor. Something must be done and
this means pressing for help even against GP resistance. Livingston and
Rasmussen (1989) provide some ‘Family Guidelines’, which are in turn adapted
from the work of Anderson et al. 1986. These have been altered slightly
for the benefit of British readers; however, it must be understood that such
lists are, at best, only a guide, and proper diagnosis requires the skills of a
Livingston and Rasmussen suggest that carers learn to recognise signals –
changes that may be gradual but significant – which indicate that the cared-for
person is having problems. These are:
· Doing things again and again (repetitive behaviour)
· Constant questioning of their own judgement (and need for constant
· Simple tasks taking longer than usual
· Becoming weary or exhausted more easily
· Perceptual tardiness
· Increased concern for minor things and details
· Severe and extreme emotional reactions to small things
· Inability to sleep properly
· Significant change in eating patterns
· Daily life becoming a struggle
The Adams and Torchia,(1996) work, discussed in ‘Overcome OCD!’ suggests that
parents should watch out for the following where fear of contamination and
washing and cleaning compulsions are concerned:
· Frequent or lengthy bathroom visits
· Hands are dry, red, chapped, cracked or bleeding
· Slovenly appearance (due to fear of touching ‘contaminated’ body parts or objects)
· Avoiding touching certain objects, using a barrier (tissue or shirt cuff to
touch things, or avoiding certain locations)
And the following where fear of harm, obsessive doubting, checking compulsions,
repeating compulsions are concerned:
· Generally anxious demeanour
· Frequent requests for reassurance from others and repetitive calls home
· Handing in homework etc., late or not at all
· Homework taking unusually long periods of time
· Repeatedly checking that books are in bag or satchel and homework is detailed
properly or present
· When writing, excessive crossing-outs, erasures, rewritings, repeating or
avoiding certain words and/or numbers
· ‘rituals’ for walking through doorways, getting up from chairs, often
involving repetitive actions or an unusual posture
· avoiding certain objects or locations
And the following where symmetry obsessions and arranging compulsions are
· preoccupation with clothing (e.g. shoelaces) being symmetrical
· ordering books or other items on desk or shelf
· arranging written elements on a page
Where compulsions such as counting internally, praying or repeating ‘good’
words or phrases is concerned, the child may appear preoccupied or inattentive
to external events, including completing homework or responding to others.
Anxiety Care has also encountered:
· ritual bowel habits, requiring specific amounts of defecation
· excessive cleaning or washing after bowel movement
· insistence on performing a bowel movement at a specific time each day
irrespective of bodily needs
· putting feet or hands in certain positions when sitting down
· placing cups/plates down in certain ways or a certain number of times
· excessive concern for ‘suffering’ strangers (e.g. vagrants or disabled
· excessive concern about family members’ happiness and/or mood changes
· willingness to subordinate personal needs to the slightest (perceived) needs
· extreme guilt, often sexual (e.g. masturbation and/or fantasy), or to do with
perceived wrongdoings which might be insignificant or clear only to the child.
· perception that casual contact in the street is deliberate and/or an attempt
to contaminate or ‘infect’ this child
The ‘Overcome OCD!’ article points out that many children will do some of these
things without having OCD; also that many children have ‘superstitious’ periods
where they may perform certain rituals to ward off bad ‘stuff’. The
difference here will be that these are playful responses to life in normal
children and disappear within weeks or months, while the child with OCD will
treat them seriously, will view them as shameful and secret and they won’t
Unfortunately, adolescents often have difficult in obtaining treatment within
the UK NHS, and not only for OCD. This is because they fall between the
Child and Adult Psychiatry services. There are some specialist adolescent
units; however, there is little information available on the experience of
adolescents with OCD in such units.
Problems with obtaining treatment sometimes result in parents considering
‘going private’. This is not the place to discuss the merits of private
as opposed to NHS treatment. However, a decision to seek private help
must be made on a rational basis. The strong emotions engendered by the
suffering of a child can result in parents thinking in terms of ‘We’ll do
anything necessary’. Unfortunately, private ‘talking treatment’ can be
very expensive and statistics show that there is no guarantee of recovery at the
end of it. The pressure on an adolescent or young adult, seeing the
family putting themselves in debt in this way, or just spending hard earned
money on them that had been earmarked for something else, can be
enormous. It could even work against the efficacy of such
treatment. So going in this direction needs to be carefully thought
out. And, of course, throwing money at a problem as a substitute for love
and care is another possible and negative side to this that needs no
Do people with OCD normally become aggressive?
This is a difficult question. Many animals respond to fear, at some
levels, with aggressive behaviour and humans could not be expected to be
different. Anyone suffering from a life consuming and very frightening
problem like OCD is likely to be irritable and defensive. Suffering from OCD
and/or depression makes an angry or simply short-tempered response to anything
more likely than a sunny smile. Also, spending far too much time ‘in
one’s head’ – thinking, worrying, feeling rejected and close to mental collapse
or exhaustion puts the focus on personal needs to the exclusion of much
else. Like a self-involved child, this person may be more likely than the
non-anxious person, to produce a furious response to being ‘thwarted’.
Clinical studies are not very clear about this. Some suggest that
compulsive washers tend towards obstinacy and being irritable, and the
psychoanalytic theory of ‘deep seated problems in the past’ claims OCD involves
hostility and controlled anger – which may escape sometimes. There is
little real evidence of this. However, people with OCD tend to be more
neurotic than most and the condition linked to personality factors does point
to the likelihood of angry or aggressive outbursts, not always resulting from
the thwarting of rituals (Marks, 1989).
The needs of other people can come a very poor second when the driving personal
focus of obsession is experienced. One sufferer explained to charity
workers that, although he loved his wife and children, when he was at his
worst, they simply became four more things that aggravated his OCD. His
enormous need to find a solution to his problem when obsession was total, meant
that they were only useful in as far as they were sources of reassurance; and
when they were not that, they were just in the way.
This question is also sometimes asked as a ‘back-door’ way of enquiring about
the likelihood of the OC person performing the acts that he or she is so
terrified of, such as harming or molesting people. The true answer to
that is, no; if the person involved has OCD, then the fears of violence or
sexual depravity are typical of a great many people wit obsessive/compulsive
disorder and mean nothing at all. In fact the OC may have thought
problems in this area because violence or sexual depravity is the thing he or
she hates most. Many sufferers link in to obsessions in regions where they have
strong feelings, as can be seen with the very religious person who becomes
obsessed by fears of scorning or reviling God or committing blasphemous
physical acts. In such cases, the hugely negative and/or horror reaction
to a vague thought that passes through the head marks this up as important and
frightening, so that next time it strikes with even greater power, and so on.
As said elsewhere, the depraved person who enjoys thoughts of violence and
molestation is the one likely to commit them, not the obsessive to whom these
may, literally, be the last things he or she would do. So violent thoughts, and
aggression because of the disorder are not in the same category. However,
if the carer feels that the sufferer is fantasising about these acts rather
than obsessing about them; or if he or she has a history of violent or
anti-social sexual behaviour, a clinician should be consulted who would be able
to diagnose the condition properly and help with therapy that would increase
Is it my fault?
Most of us like to get things straight in our minds and set out definite
reasons (and blame) for life’s problems. Many families living with
somebody suffering from OCD use tortuous logic to apportion blame – often
against themselves. Parents tend to take responsibility for their
children’s shortcomings, which is healthy in moderation. However, if
parents take total responsibility, the logical conclusion is that all of us,
except the very first set of parents in humanity’s dawn, are totally blameless
for everything. This is obviously ludicrous. A complicated mixture of genetic,
learning and environmental factors make each of us what we are. We could
all be better parents, spouses and children. Even when fairly confident
in our abilities, we all feel somewhat unequal to the task part of the time –
whether this is as a parent or simply as a human being. This keeps us on
our toes, but when it comes down to it, doing the best you can with what you’ve
got is all any of us can ask of ourselves.
The problem is that, faced with the helplessness of trying to assist somebody,
particularly one’s child, who has a serious and dreadfully handicapping
disorder of this kind, we tend to be confronted by the simple fact that we
can’t solve the problem and see this as a reflection on our value as a
person. We may worsen the response to this by harbouring nagging fears
that we ‘drove them to it’, if we are the parent. People with OCD are
usually terrified; they often become very dependent, self-involved,
manipulative and even aggressively demanding. They sometimes feel – and
state – that somebody should solve their problems or at least serve them in
such a way that their anxiety will be greatly reduced or extinguished
altogether; even though being completely free of anxiety is an impossibility.
Experiencing such a level of fear and helplessness, they may try to obtain what
they want by making their carers feel guilty. The family need to
recognise that this is only a declaration of fear and helplessness, and a need
to be free of the very unpleasant physical symptoms that accompany the drive to
ritualise, not a belief that this is really possible.
Parental guilt feelings are a powerful force, but the truth needs to be
confronted: the parent is not to blame. The parent is not required,
or able, to solve the problem. Of course many parental attempts to help
or cope were pointless or ill advised: That holds true for just about
everything in life that is attempted without the required fore- knowledge or
skill. This doesn’t mean that the parent is responsible, nor does it
prove this person’s incompetence as a parent or spouse. If the parent is
going to help with the considerable task of recovery, then he or she must get a
grip on this. If not, such help will focus more on comfort and service
than the loving, but tough, support that is essential; anything else quickly
becomes collusion. One Anxiety Care client said: ‘My mother helped me
until I couldn’t do anything for myself at all’.
If this question is asked with regard to family genetics or existing family
member OCD, rather than from an emotional standpoint, the answer can be
somewhat different. The OC Foundation has a large number of excellent
articles on the subject of OCD and their piece ‘OCD in Children’ is used here.
It suggests that the disorder does run in families but that genetics does not
account for all OCD. Even in identical twins, there is only a 13%
probability that, if one contracts the problem, the other will too. The
statistics on whether the problem in a parent will affect the child is a greyer
area with percentages ranging from two to eight. Obviously, at the lower
end, this is no greater for prevalence than in the general population.
However, the article states that if such an obsessive parent has blood
relatives with OCD there is increased risk for the child. The type of OCD
suffered by the parent will also affect the child in that, if the disorder was
contracted in childhood by the parent as opposed to in adulthood, there is a
greater chance of passing it on.
A family history of disorders in the OC Spectrum or other anxiety disorders is
also likely to increase the child’s chances of contacting OCD. And mild
or severe depression, other anxiety disorders, disruptive behaviour and
learning disorders, body dysmorphic problems, Trichotillomania (hair removal), and
Tic disorders are all known to co-occur with OCD at times. This means
co-occurrence is known, not inevitable.
Whatever the truth of inheritance, feeling guilty about this is unlikely to
help as guilt is only useful when it leads to change. Using guilt to
cloud judgment about acceptable behaviour within the family, or to generate
unreasonable expectations of other people’s tolerance of the OC child or
spouse, will help nobody.
How can I help?
Families tend to respond in a number of ways to OCD. Most commonly these
· Becoming involved in the rituals to keep the peace.
· Not becoming involved but allowing the rituals for the same reason;
· Denying the existence of OC rituals.
· Refusing to allow rituals in their presence.
(Livingstone & Rasmussen, 1989).
Even when the condition is denied, family tension is likely to be very
high. Anecdotal evidence suggests that most families swing between
assisting with rituals and attempting fairly negative or confrontational ways
to stop them. As anyone bringing up a difficult child will understand,
such a mix promises more trouble than success. This response is more to
do with the caring person’s patience, love, tolerance level and ignorance than
an acceptance that there is a genuine problem that needs to be dealt
with. Swinging between collusion and denial only proves to the person
with OCD that the problem is not seen as genuine. That is, we go along
with your little difficulties until it begins to affect us, then you have to
stop. It would be far better to acknowledge the existence of a major life
problem, but without agreeing to be involved in maintaining it.
This is easier said than done. Families want to help, but they are
confused and frightened. Often, one member, usually the mother or spouse, is
elected as ‘guardian’ by the obsessive/compulsive, who is able to press all the
required ‘emotional buttons’ in order to gain maximum support from this
person. The rest of the family frequently feels isolated, manipulated and
marginalized – the person with OCD has priority in all things.
Here everybody is having a miserable time with guilt, jealousy and helplessness
mixing to make a family approach to the problem extremely difficult. But
OCD destroy families, so it is important to work at the problem together.
Even if the obsessive/compulsive and the caring family are convinced that the
problem is based in biological or neurological dysfunction, this is not an
excuse to allow the cared-for person complete freedom of action. The
obsessive/compulsive needs to learn ways to accommodate his or her actions to
real life and family need, not to attempt to change external situations to fit
If this ‘helpless to resist’ attitude wins out, the family simply become
custodians and therefore part of the problem rather than assistants in the
process of recovery. In other words, carers should support the person and
recovery, not the symptoms and continued illness (Hurley et al. 1991).
If the person with OCD is willing to work at overcoming his or her problem, it
is essential that the family, or those members of it who are willing to become
involved, negotiate some kind of recovery ‘contract’. Simply reacting in
exasperation (with punitive restrictions such as turning off the water mains,
hiding soap, or tossing clothes in heaps) is likely only to result in rage and
a worsening of symptoms.
And if this family calls a halt because they’ve simply ‘had enough’, or if they
indirectly punish in some way for all the aggravation, the odds are that they
will relent fairly soon and fall into line again. As with the difficult
child, this simply proves to the OC person that the more troublesome one is,
the more likely one is to get one’s own way eventually. It is far better
to sit down with the cared-for person and work out how to get things started.
Many obsessive/compulsives have given up resisting their compulsions and simply
do not feel that they can do anything. This is invariably wrong.
There is always something, no matter how small. Examples of contracted
work might be:
· Writing down on a diary sheet how many times a day hand washing takes place
and committing to reduce this by one or more times each day;
· Agreeing to seek reassurance from only one person, or only once from
designated people with the family responding We agreed that I wouldn’t reassure
you, if asked beyond that level;
· Agreeing to wash clothing only once unless the family accepts that it is
Entering all work on daily dairy sheets, to be countersigned by a family
member, is very useful. This reinforces the pleasure of achievement and serves
as a proof of work done. Some families use very practical reinforcements
such as ‘treats’ (small gifts, outings) to mark a week’s positive work.
However, a treat should never be permission for extra ritualising as this can
undo all the good work.
Where practical rewards are negotiated, it is sometimes suggested that small
punishments should be an option if work is not done – perhaps giving up sweets,
cakes or TV for a day or two. However, this is very individual decision
and probably works better with children than with adults.
Contracts must always be negotiated, and never a matter of ‘take it or leave
it’. The person with OCD often feels very lacking in power and control
and may well overreact to something seen as pressure. Contracts work both
ways, of course. Carers might have to agree not to nag, punish with
silence or in other ways express their displeasure with ritualising. They
must also agree not to urge additional work or assume that once something has
been successfully completed this will happen every time. It might be
necessary for the supervising doctor or therapist to help with contract
negotiation and with practising on how to refuse reassurance if this becomes a
Where the person with OCD is not willing to undertake any recovery work, or
denies the problem, there is very little that can be done. An undertaking
within the family to ‘draw a line here’ sometimes helps. That is, the
person with OCD understands that the problem is accepted, the family will not
reduce support or insist on recovery work; but they will not increase support
any further to include new or extended rituals.
However much, or little, help the family or individual carer is able to
provide, there are a number of things to bear in mind that will make this more
useful. First, OC symptoms can vary according to the levels of stress
experienced. So the carer should not expect the same results every time
or feel that it’s all been for nothing if setbacks occur. Second, the carer
needs to become an expert audience. Small achievements are important too,
and progress by the inch or the yard is still progress. However, false
praise for work half done, or the repetition of work that is easily
accomplished, should not be given. If this is demanded, it is simply
another version of seeking too much support from the family. Third, family
needs must be kept in perspective. The fact that somebody has the loudest
voice does not mean they have the greatest need. Other family members may
not feel they have the right to complain, but they may signal their anger by
simply not being there one day. Fourth, outside help should be sought if family
work proves difficult. Professionals and skilled lay groups like Anxiety
Care are available; and telephone-based and online support groups are now
becoming more widely seen every month.
Somebody said that OCD is an addiction, is this true?
Strictly speaking, this is not true. An addict is seeking pleasure from certain
activity while the OC sufferer is seeking to reduce anxiety or perhaps
guilt. However, at a certain level the problems can be similar. If the
addict begins to use drugs or alcohol, for example, to reduce tension or the
bad physical and emotional symptoms generated by withdrawal, the
single-mindedness of seeking this relief can be very like the OC’s need for
relief from anxiety.
This addict metaphor is sometimes used when discussing structured help with
carers as it can be a graphic way to underline the sufferer’s perceived
personal need. Most of us are familiar with the idea that an addict in
withdrawal can be totally focused on the self and the need to obtain the substance
that he or she is addicted too. The picture of a drug addict stealing, mugging,
even prostituting him- or herself in the pursuit of the needed drug is familiar
to anyone who watched much TV. Linking this to the drive that makes an OC
sufferer seek reassurance, help with ritual or to perform compulsions,
sometimes helps carers to understand the dedication and single mindedness of
the sufferer when in the throes of an obsessive episode.
Looking at any anxiety disorder from a certain perspective can draw
similarities between avoidant behaviour and addictive behaviour as they are
both designed to bring relief and, at least indirectly for the anxiety
sufferer, pleasure; even if this is only the pleasure of not feeling anxious or
guilty. It would be wrong, however, to take this similarity too
far. The OC sufferer might well feel compelled to say or do almost
anything to obtain the support he or she needs when in dire trouble with ritual
behaviour, but this situation hasn’t arisen through self-indulgence or
foolishness as could be said for the alcohol or proscribed drug dependant
person. OCD is not something that has been taken up deliberately.
It is a potentially disabling disorder and one that most people wouldn’t wish
on their worst enemy.
Do people ever get back to normal?
Yes, but don’t expect an all-singing, all-dancing personality transplant.
This person has learnt some negative and damaging ways to deal with life’s
problems and has usually spent too much time inside his or her own head picking
at the sore bits. This leaves scars and the ever-present possibility that
symptoms will rise again when reality puts out a tripping foot. Spending
too much time watching life also tends to prove that it is dangerous out there;
and there is a possibility that someone who has suffered in this way is in fact
more in touch with real life after recovery. So, life can be good again
and well worth living, but the process of getting, and staying, there should
never be forgotten, or its difficulty underestimated.
Will s/he have a relapse?
The answer to this is, as mentioned earlier: yes, probably. Nobody wants
to hear this, but the fact of relapse must be faced. Once this
unpleasantness is accepted, the subtleties of degree and the work necessary to
minimise any setbacks can be faced up to. If the possibility of relapse
is not accepted and this is fairly common among the newly recovered and their
families, then the first signs of ‘it’ recurring will make everyone
concerned feel as if all that struggling, pain and work was pointless.
For many obsessive/compulsives, the problems or situations that triggered the
initial OC responses might not be the same as those that are currently
maintaining it. We can all think of situations for which this holds true;
(marriage, hobbies, smoking, drinking, etc.) The spreading nature of OCD
can also mean that the original stimulus grows and changes. A whole range
of everyday situations can trigger the highly sensitised person, over-ready to
feel contaminated by evil, whether s/he acknowledges this is not. Under
stress we all fall back into familiar, possibly negative, responses: and anyone
with OCD knows that stress aggravates the symptoms. Recovery does not
issue a guarantee that life stress will no longer occur, quite the
opposite. The newly recovered have to face a multitude of everyday
situations with which they are probably no longer well-equipped to deal. It is
also essential to understand that we respond to stress in different ways and that
whether or not changes cause stress is a very individual thing; this is
(Much of the above is based on an article by J. Grayson in the OCD Newsletter).
SOME ORIGINS OF ANXIETY
Anxiety and feelings of stress are symptoms, a response to pressure. The
more intolerable or persistent the pressure, the worse the anxiety. And
this does not necessarily mean a single, overwhelming difficulty. More
often it is an accumulation of things. This cumulative side of anxiety is
well documented in Barrie Hopson’s work on transitions, which he has related to
the Holmes and Rahe Social Readjustment Rating Scale (Griffiths 1981).
This information is nowhere near as daunting as it might sound. It can be
a particularly useful and comforting piece of knowledge. It shows, in
easily understood terms, how all manner of changes – many of which the majority
of us might barely accepts as changes at all – and an accumulation of such
changes, can have a profound effect on our lives.
Doctors Holmes and Rahe found that the adjustment that an individual needed to
deal with various changes was remarkably consistent from culture to culture
around the world, and they gave mean values to a whole range of these (see the
abbreviated list below).
They found that illness or a change in health were likely if certain totals
were met during a one-year period. These were; 0-149 no significant
change likely; 150-199 mild stress and a 35% chance of illness; 200-299,
moderate stress and a 50% chance of illness; 300+, major stress and an 80%
chance of illness. It is estimated that it takes a year to replenish the
energy expended in adjusting to any of the changes described below.
Understanding that ‘insignificant’ things (like moving house, changing jobs,
children starting school) can accumulate a solid amount of stress over a couple
of years or so, the obsessive/compulsive and the caring family can develop
skill in thinking ahead and can then be ready for possible dangers.
These are the scale ratings that apply most:
- Death of a spouse – 100
- Divorce – 73
- Marital separation – 65
- Death of a close family
member – 63
- Major personal injury
or illness – 53
- Marriage – 50
- Marital reconciliation – 45
- Retirement – 45
- Major change in health or behaviour of a family member – 44
- Pregnancy – 40
- Sexual difficulties – 39
- Gaining a new family member (birth, adoption, relative moving in) – 39
- Major change in financial status (lot better, or worse, off) – 38
- Death of a close friend – 37
- Changing to different kind of work – 36
- Major changes in number of arguments with spouse (lot more or lot less) – 38
- Taking out a mortgage – 31
- Major changes in work responsibilities – 29
- Son or daughter leaving home – 29
- Trouble with in-laws – 29
- Major change in living conditions (building or remodelling home or deterioration of home or neighbourhood) – 25
- Change in residence – 20
- Major change in type or amount of recreation – 19
- Taking out a loan – 17
- Major change in sleeping habits (more or less or different times) – 16
- Major change in number of family get – togethers (more or less) – 15
- Holiday – 13
- Christmas – 12
Many of us could go through that list and come to totals that are equivalent to
a double bereavement or more over a two-year period. This doesn’t mean
that we are then ‘entitled’ to be in deep grief or depression. It
certainly does not present an excuse for the recurrence of OCD, but it does
give reasons for symptoms if they occur during transitions. It also means
that the OC person has found another way to avoid believing that s/he feels
terrible for no reason apart from ‘natural weakness.’
Responses to such changes are not particularly simple either. Hopson
describes the ‘life cycle’ of a transition (a significant life-change), whether
it is planned, unplanned, sudden or gradual, as having seven phases.
· Immobilisation – feeling overwhelmed by the transition, unable to think or
· Minimisation – coping by reducing or trivialising the transition, perhaps
even experiencing a little euphoria in the process.
· Depression – feeling powerless in face of the gradually growing understanding
of the reality of the transition.
· Letting go – accepting that the transition has happened and cannot be
unhappened. Feelings start to rise again.
· Testing – trying out new behaviour and situations. Plenty of energy
available but a tendency to stereotype people and things – how they should or
shouldn’t be in relation to the change – and to become angry or irritable quite
· Search for meaning – trying to understand how and why things are different
now. Distancing somewhat from the transition to get a better look at it.
· Internalisation – absorbing and finally accepting the transition as part of
This is not a rigid series. Getting over a bereavement and getting over
Christmas are going to involve different time scales and different levels of
feelings. Similarly, people do not move neatly from one stage to the
next. Some may become caught up in one stage or another and progress no
further, while others may fall back into an earlier stage after a setback or
further life change that occurs whilst they are working through the
stages. People too have different responses to any kind of change such as
welcoming or resisting or fearing as mentioned earlier. Those with severe
problems, who are perhaps prone to responding in the more negative ways, will
obviously have additional difficulties.
The important point with Hopson’s work and with the Holmes/Rahe scale is that
it is another weapon in our armoury of understanding. It allows people to
anticipate difficulties, and to ensure that new situations don’t come as an
overwhelming surprise to obsessive/compulsives who are already all too liable
to react anxiously to the ‘threat’ of change.
Charity workers have talked to many people who have recounted obvious symptoms
of bereavement – loss of appetite, sadness, depression, emptiness, loneliness,
‘life is meaningless’ feelings – when discussing a lost job, a lost
relationship or even their lost youth and missed chances. The sad thing
is that they had denied themselves the right to feelings of grief, regarding
them as some kind of weakness or punishment. People are also fond of telling
themselves that they should look forward to things such as retirement, moving,
the freedom gained by the children leaving home. In reality, these
changes may be painful and start a ‘bereavement’ reaction at some level which will
be more painful if its legitimacy is denied.
The caring family must accept that the newly recovered person will have a
fairly tenuous hold on ‘real life problems’ for a while. New problems
will always be arising, some of which can be solved and some of which have to
be endured. It is vital, therefore, that the newly recovered person and
the caring family use their insight and knowledge to mark current and potential
problems in life: Builders are coming next month; her friend will be
bringing the baby round; the neighbours have a new dog. If problems are
foreseen early, small behavioural tasks can be undertaken or other
anti-obsessional preparations made. Certain practical, behavioural tasks
will almost certainly have been undertaken during the recovering process and it
is absolutely essential that such work is not given up. It can be
modified or reduced of course, but recovered obsessive/compulsives should not
be encouraged to believe that all the work is behind them and that ‘it’ will
never bother them again.
As said elsewhere, the recovering sufferer often has a faulty perception of his
or her level of recovery. That is, this person may be a hundred times
more able to cope than when in the depths of the disorder, but may still not be
ready to deal with the real world ‘head-on’. This is often seen in
Anxiety Care groups, where people (often after taking medication), suddenly
feel they have a new lease of life and decide to do everything that they
perceive they have missed out on over the preceding months or years of
restriction. This is understandable, but dangerous. The caring
family may have to help this member to take it a little at a time, making it
clear that this is not personal.
The latter can be very important as many recovering sufferers still have strong
doubts about their abilities and may tend to process any attempt to encourage
moderation in their activities as a manifestation of that paralleling doubt in
the family; and this might frighten them badly. This can then lead to a
further strain on the inter-family relationships, or even redoubled social and
physical activity on the part of the recovered or recovering person to ‘prove
you all wrong’; with, almost inevitably, negative results. As always,
communication is vital.
What about me?
Carers, notoriously, do not care for themselves adequately. This seems to
be a particular problem if the carer is female. Mothers are usually
genetically programmed to put huge amounts of effort into nurturing their
young, and nothing needs more effort and protection than a sick child.
There can then be conflict, however, when the cared-for person’s problems are
difficult to understand; and even more trouble if the carer cannot really
understand what is going on and feels lost, useless, or manipulated. This
can work as destructively for a needy partner or parent as for a child.
A natural response to perceived incompetence is to redouble effort; another is
to give up and/or look for an outside ‘expert’. The problem is that no outside
agency can give the quality and continuity of care that can be provided by a
family member, and most carers are aware of this at some level.
This can lead to the carer putting huge amounts of effort into areas that are
not yet, or never will be, things that can be countered in the
obsessive/compulsive; or areas that are actually working against this person’s
recovery as discussed earlier. For example, the carer might be struggling
mightily to impact upon some area of compulsive behaviour that is not ready for
response to intervention as in the case of a young, female Anxiety Care client.
This young woman had a range of compulsive cleaning and de-contamination
rituals of varying intensity, one of which culminated in lengthy bathroom
activity. Because this had such an effect on the rest of the family (late
for school and work, much argument), the caring mother attempted to restrict
the young woman’s bathroom usage. Unfortunately, this sufferer perceived
the bathroom rituals as fundamental to her compulsions – without it everything
else was ‘wrong’. Restriction then lead to a great deal of unhappiness
and conflict, and an increase in the other rituals to ‘make up’ for the lost
If there had been adequate communication between carer and sufferer and an
understanding of the principles of OC behaviour by the family, it would have
been clear that the bathroom was not the first place to start; or that a more
flexible restriction, based on understanding not family need, was required.
In the above case, being thwarted in an extremely important (to the OC) area
simply reinforced her belief that nobody understood and that she would be made
very anxious in the service of family need rather than recovery. It also
led to a distancing from her mother that took a good deal of time to work
This reinforces the requirement for the carer to become something of an expert
on OCD. This might not seem like part of ‘carer self-help’ at first
glance, but it can lead to a very useful reduction in family tension, which can
only help the carer. It also feeds in to the carer feeling more competent
and will almost certainly ensure that more energy goes into useful, thought
through, support rather than effort based on emotion, irritation and not
totally useful intervention drawn from the carer because of extreme need. To
this end, Anxiety Care has a number of publications on OCD and there are some
excellent web sites on the subject, notably the OC Foundation. Anxiety Care
also operates face-to-face mutual support groups and online support where
carers are welcome and catered for.
Becoming more knowledgeable can have a devastating effect however, particularly
if it comes in one, overwhelming burst. For example, some carers attending
charity groups for the first time have been appalled at the suffering that,
only then, they have realised can be involved in severe OCD. In a few cases
this has unbalanced the relationship with the cared-for person, bringing in
guilt and shame that, almost invariably, simply clouds the problem without
adding anything useful to the process of solving it. Working with others
carers or an outside therapist can help here, as can taking the time to read
about the problem in one’s own time and at one’s own pace before becoming
involved in group work – if this is a practical possibility – or in any other
activity that might bring on more information than is easily digestible in one
bite. If such a situation occurs, it is vital for the carer not to indulge in
guilt or shame. These emotions are only useful when they lead to
restricting anti-social behaviour or generating positive change in a person’s
responses to life. Nearly every other response is useless at best.
Nobody can expect the carer to understand OCD naturally. Obsessive and
compulsive problems tend to creep up on a person over time and research
suggests that people often suffer with OCD for many years before discussing it
with anyone. Occasionally OCD blooms, fully-grown and very obvious, but this
is unusual (sometimes, however, seen after strep infection in children).
When the problem occurs gradually, a heavy disability might be in place before
the carer is aware that anything is wrong beyond ‘funny habits’. Here,
there is no reason in the world why the carer should be aware that expertise
was needed. Hating oneself afterwards for one’s ‘stupidity’ or
‘blindness’ is counter-productive and, sometimes, self-indulgent.
Another area of work for carers is finding personal support. It has been the
experience of charity officers that professionals working in this field view a
support system for themselves, outside the therapeutic environment, as a vital
part of providing a good service. There is every reason for family carers
to do the same. Sometimes there are carer agencies locally that cater for
carers of all types; but a good friend to talk to (or vent to), go out with or
just have a cup of tea and a laugh with, on a regular basis, can be even
better. This might, however, involve laying down some ground rules first.
That is, support from a friend who sees the OC sufferer as selfish, lazy, ‘mad’
or ‘bad’ and insists on displaying this attitude, is not going to be much
support at all. This is not to say that such friends or acquaintances should be
avoided, just that the subject of OCD should be on these getting-together
occasions, if the benefits of contact are still worthwhile for personal
Having said that, it has been known for carers, forced to defend their family
member in face of prejudice and ignorance, from a friend, (a situation where
they are likely to be listening rather than shutting their mind and writing
this person off immediately as a bigot), to realise more fully how hard it is
to comprehend the level of suffering involved; and how hard it must be for the
cared-for person to come to terms with this genuine disability in face of
trivialising or contempt. As said before, feeling as if this knowledge and
understanding means the carer has failed the sufferer in some way is to be resisted.
Errors and omissions do occur and the Trustees of the charity apologise for any
that are found in this document. However, any author who feels that he or she
has not been adequately cited, or has been wrongly cited, should contact
Anxiety Care with the relevant corrections, which will be undertaken as soon as
possible. The charity reminds all readers that this is a non-profit
publication. Readers are also asked, again, to remember that this publication
is not suitable for medical diagnosis and that a doctor or other relevant
mental health professional should always be consulted where OCD is suspected in
a family member.
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