Cycle of obsessive thoughts


REGULARLY FEATURED in films and TV programmes as neurotic and overtly quirky characters, people with obsessive compulsive disorder (OCD) are much misunderstood and often have to battle for years to be properly diagnosed, writes FIONA TYRRELL.

Mention the term obsessive compulsive and most people think of the neurotic novelist who couldn’t stand on cracks in the pavement played by Jack Nicholson in As Good as it Gets or the hygiene-obsessed surgeon played by Michael J Fox in a couple of episodes of Scrubs.

Hollywood has used the disorder to provide comic value for years and while this does help to raise awareness about the condition it does tend to trivialise the condition, rarely showing how debilitating it can be and shedding little light on treatment options. The phrase obsessive-compulsive has even worked its way into the wider English lexicon and is used to describe an individual who is meticulous, fussy or eccentric.

For people living with OCD, the reality of battling with the condition on a daily basis is a lot less glamorous than Hollywood would lead one to believe.

OCD is a neurophysiological disease which locks sufferers into a never-ending cycle of obsessive and distressing thoughts and meaningless rituals they feel compelled to perform to ward off those thoughts.

The condition is surprisingly common – it affects 2-3 per cent of the population and the World Health Organisation has named OCD among the top 10 most debilitating illnesses in terms of loss of income and quality of life, according to psychologist Leslie Shoemaker who is an adviser to OCD Ireland, which runs support groups in Dublin.

OCD is difficult to diagnose and people suffering from the disorder are often secretive about their symptoms or lack insight into their illness. It’s even difficult to describe the condition.

Many of the symptoms of OCD are normal in other contexts – checking the iron is switched off or washing hands or keeping order. The main difference is that these behaviours do not cause the average person undue stress or worry.

“Only when symptoms persist, make no sense, cause much distress or interfere with functioning should they be considered OCD,” explains US doctor and author John S March in his book Talking Back to OCD.

Hand washing is a normal behaviour but washing your hands 15 times with three different types of soap and obsessing about how germs on your hands could cause the death of someone close to you is not normal.

The causes of OCD are still uncertain, but it is now widely accepted to be a neurobiological disorder that causes problems in information processing.

Two particular parts of the brain which have been implicated in OCD are the Caudate nucleus, which controls the stop signal for habitual behaviours, and the orbital-frontal cortex, which controls emotions such as worry about harming others, guilt and disgust, according to March.

Insufficient levels of the chemical messenger serotonin have been pinpointed as a likely cause and it has been found that drugs that increase the brain concentration of serotonin can help improve OCD symptoms.

OCD is often described as “hijacking” the brain centres, forcing the mind to get stuck on a particular thought or urge. People with OCD sometimes describe the condition as having “mental hiccups that won’t go away”.

With OCD, obsessions often come in the form of frequent distressing involuntary thoughts, images or impulses, which are difficult to control. An OCD sufferer’s obsessions can range from worries abut health (germs, illnesses or disease) to excessive concerns about right and wrong.

They may have fears about acting out violent thoughts or impulses, harming others, especially loved ones, abhorrent blasphemous or sexual thoughts, unreasonable concern with order or safety.

Compulsions are the voluntary behaviours that are performed to reduce the anxiety brought on by the obsessions.

This behaviour is usually carried out according to irrationally defined rules, according to Shoemaker. Common compulsions include excessive washing and cleaning, checking, repetitive actions such as touching, counting, arranging and ordering.

Compulsions can be observable actions, like washing, but they can also be mental rituals such as repeating words or phrases, counting or saying a prayer.

Anxiety that a bump in the road was actually the sound of his/her car hitting a pedestrian could prompt the sufferer to go back repeatedly to the spot. They may go so far as to check the obituary pages or hand themselves over to the police, she says.

One client of Shoemaker overpaid his tax every year because of his anxiety just to ensure he didn’t get into trouble with the taxman.

People get stuck in the cycle of obsessions and compulsions. Carrying out a compulsion reduces the person’s anxiety and makes the urge to perform the compulsion again stronger each time. OCD is like the classroom bully, according to Shoemaker.

It promises it will go away if you do something for it, but it always comes back.

In extreme cases, sufferers are so consumed by the obsessive thoughts and compulsive rituals they are not able to work, she says.

Some of the most distressing forms of OCD involve obsessive thoughts about harming other people and fear of inappropriate sexual thoughts about children or family members, according to Shoemaker.

Because people with OCD “can’t separate themselves from their thoughts” they will often label themselves as “mad or bad”. The reality is that people suffering from OCD will “never act on those thoughts”.

Most people with OCD suffer from both obsessions and compulsions. Some, however, can just have obsessive thoughts.

Other disorders on the OCD spectrum include health anxiety (extreme form of hypochondria), body dysmorphic disorder (obsessions about physical appearance) and trichotillomania (compulsive hair pulling).

There is no cure for the disorder and treatment focuses on managing the symptoms of the disorder.

Medication, in the form of selective serotonin reuptake inhibitors (SSRIs), can be effective in reducing the obsession to a manageable level.

Cognitive behavioural therapy (CBT) is also recommended. This involves getting sufferers to face their obsessions without having to use compulsions to reduce anxiety.

American research indicates that people with OCD see three to four doctors and spend more than nine years seeking treatment before they receive a correct diagnosis.

Other studies have found that it takes an average of 17 years for people to obtain appropriate treatment from the time OCD begins. OCD has been misdiagnosed as depression, bipolar disorder, ADHD, autism and schizophrenia.

Getting proper diagnosis and appropriate treatment can take even longer in Ireland, according to Shoemaker. She recommends that people who think they may have OCD to do their own research and even take an online self test (see before approaching a medical professional. Unfortunately, not all GPs are familiar with the disorder and misdiagnosis can be a big problem, she says.

“I always encourage people to ask their GP if they are familiar with the disorder and find out whether they have treated someone with it before. Here in Ireland the idea of the patient as a consumer has not taken hold.”

  • Dr Gary O’Reilly will be giving a talk on obsessive compulsive disorder in children and adolescents on Wednesday, January 21st in St Patrick’s Hospital, Dublin 2. Leslie Shoemaker will give a talk on body dysmorphic disorder and trichotillomania on Wednesday, February 18th, also in St Patrick’s Hospital
  • For further information see
  • Talking Back to OCDby John S March. Published by Routledge