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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CHECK UP 5. - Obsessive Compulsive Disorder
RADIO 4
THURSDAY 24/03/05 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
DR DAVID VEALE
PRODUCER:
HELENA SELBY
NOT CHECKED AS BROADCAST
MYERS
Okay, so we all get a bit set in our ways with those rituals and routines that we feel compelled to follow and oddly uncomfortable if we have to change but there are people with such powerful obsessions, involving intrusive thoughts and anxious feelings, coupled with overwhelming compulsions to act in bizarre and worrying ways that they fall outside the range of what's deemed normal or acceptable, in fact they're ill - they suffer from obsessive compulsive disorder, OCD, our topic today.
An estimated one person in a hundred fits the criteria for OCD. In some people it might take the form of morbid fear of contamination leading to excessive and repeated hand washing. For others it might be a fear of chaos, which leads them to arrange and rearrange things in carefully prescribed patterns. And those are just two examples, there are many more. If you're worried that you or someone in the family is behaving in an obsessive compulsive way please call us now - 08700 - is the number - 100 044. Or you can e-mail checkup@bbc.co.uk and put your questions about causes, prevention and most importantly treatment of OCD.
Well my guest today is an expert in treating patients using psychological techniques for this condition, he's Dr David Veale, a consultant psychiatrist at the Priory Hospital in North London. We have a lot of callers, we'll go to our first. Genevieve Bliss is in Southampton and has a son with an obsession. A very particular obsession, Genevieve?
BLISS
Yes it all centres round the number 13. And about the thirteenth day of the month he comes home a couple of days before and stays in one room only and won't go out and stays here until about the 15th actually, and then returns to where he's living.
MYERS
So he's a grown up person but he comes home to avoid being on his own, away from home, on the 13th of every month?
BLISS
Yes, every month, regularly.
MYERS
And how do you deal with that?
BLISS
Oh I have a very bad time because I'm not supposed to go anywhere either, I'm restrained, I'm kept here on a lead so to speak. I can go just short distances but I mustn't go anywhere on a train or a bus because I'm connected with him.
MYERS
David, have you heard of an obsession of this kind before?
VEALE
Yes it certainly can become an obsession. I think the key thing here is concerned about the meaning that your son's attaching to it - what does he think is going to happen if he does something on a 13?
BLISS
I don't know, he just says he's very frightened. It's also the number he was born on the 13th and on the 13th at the 13th hour and the letter M of his name was the 13th.
MYERS
Of course a lot of people have superstitions about the number 13, so in a way ...
VEALE
Of course for someone else the 13 may be lucky. So it's crucial really to understand the meaning that he attaches to it. And it's probably likely to be something to do with preventing harm from occurring that he has, he thinks, some sort of magical or god like powers to prevent bad things from happening around the 13 and so therefore he's acting just in case something bad happens.
MYERS
And is that the pattern then David you're saying in obsessive compulsive disorder?
VEALE
Yes, you've sort of got doubts about it and just in case you're going to act that particular way to prevent bad things from happening but of course you never then find out whether anything bad happens. And the main approach, if your son was in therapy, would be to really try to help him test out that particular theory because obviously the problem is that worrying about bad things from happening and the more he tries to in a magical way prevent bad things from happening it just reinforces the worry and it just keeps it going.
MYERS
Genevieve, has he tried any sort of treatment?
BLISS
Oh I've tried lots of things. He gets into a completely different outfit - shoes and shirts and everything - and then he takes them all off and leaves them here on the 15th, like a sort of shell left behind him.
MYERS
So David if he came to see you what would be the way of breaking into this vicious cycle that he seems to be in?
VEALE
Well ultimately we want him to do lots of things on the 13, repeatedly, to really try to make bad things happen and it may happen but only by coincidence. And probably the thing that's going to really help him is whether how much his life is affected by it because it sounds like he's adapted to life and everyone around him so as to make things fit in. So at the moment he can cope and life carries on, he doesn't have to change it seems.
MYERS
... would be very challenging indeed though to try and break, if you like, in this case the habit of a lifetime, feeling that something dreadful is going to happen.
VEALE
It would probably for many listeners like asking him to do a bungee jump, you know, it's going to be very scary and that's the difficulty and trying to help patients to face up to their fears and to test it out.
MYERS
But I mean some of these therapies that you use David, I hope we'll hear a little bit more about them in a moment, I mean they clearly are trying to break into this cycle of false belief if you like. Stay with us Genevieve, if you will, and I hope that David will have something else to add to what he's already said on behalf of your son. But we'll go, if we may, to another call, we have Hazel, I think, waiting to speak to us in North Wales. Hazel who is worrying that she may have the start of OCD, what makes you think that Hazel?
HAZEL
Because I spell everything in my head that I'm saying, as I'm saying it I'm spelling it. And this has happened once before when I lost my first husband and now that I'm living alone again - I don't know if it is anything or not, I'm just wondering if it could be. I am taking dothiepin antidepressants, which aren't really helping a great deal. I have tried a couple of others. But I just want to know really what I can do to stop myself doing it.
MYERS
And what do you think would happen if you didn't spell things?
HAZEL
Nothing, I don't feel any terror of it, I just can't stop myself doing it.
MYERS
Bit tedious really.
HAZEL
It is.
MYERS
What - I mean is it the start of OCD, that was sort of the basis of this?
VEALE
Well we don't know, we'd need to do a lot more detailed discussion with you. Tell us a little bit more about what - do you feel any control over it, for example could you spell it incorrectly?
HAZEL
I don't - I don't think I could no, I would have to look it up I think if I couldn't spell it.
VEALE
So it is perhaps something to do about getting it absolutely right in some way, to do it - the right spelling?
HAZEL
I don't know, but as I'm talking to you I'm spelling what you're saying as well as what I'm saying.
VEALE
Yes.
HAZEL
And I can't keep up with the words, which makes me quite tense really.
MYERS
Is this something to do with trying to take control over the words that you're using, if you're spelling them out and you've got to spell them correctly?
HAZEL
I don't know, I don't know why I do it and I wish I didn't do it.
VEALE
Well I don't know whether what you're trying to avoid in life at the moment ...
HAZEL
Well I've recently had a divorce and being disabled I live alone.
VEALE
Yes, so it may be just one way of coping at the moment, I don't think it's necessarily a very helpful way of coping in the long term, because obviously some of the problems that might be occurring as a result of the divorce, the things that you may not be facing up to or dealing with at the moment.
HAZEL
Is there anything you can suggest that I could stop myself doing it?
VEALE
It probably needs to be done in the context of seeing a therapist or reading suitable self-help books or getting information, because there's a lot of information out there in terms of books and charities like OCD Action or going to see a therapist. There is help available.
MYERS
And maybe you've done the first right thing Hazel to raise it, to be conscious it and to ask the question. Thank you for that. We've got an e-mail from Colin De Souza in Norwich. He asks very particularly: Is there a link between OCD sufferers and anal rententives? Is there?
VEALE
Well anal retentive is a very old fashioned term for an obsessive compulsive personality and in general OCD doesn't - is not particularly associated with the personality as such, there's a whole range of different personalities with OCD, so it's not particularly connected at all.
MYERS
Okay, and in fact it sounds a bit of a pejorative term to call someone anal retentive. Let's go on to the phones again and we've got Tony in Yorkshire with obsessive compulsive disorder, what's your question about it Tony?
TONY
Good afternoon. I'm in my late 50s and can say without doubt I've suffered at least 30 years and probably longer. Mine involves compulsive checking rituals - I find that probably over the past 10 years the situation has got worse and I'm now in a sort of pattern with it. I find each day I have to do certain things and certain rooms every single day before I can move on to the rest of my day and do whatever I have to do. Things involving checking taps, checking plugs, checking say if I leave the house - checking the front door, it could take five minutes to actually get off the front door step, that sort of thing. I did see a therapist about two years ago and went for several visits to her and at the end of the day really believe that nobody can help but yourself. The guidance given then was more or less along the lines well if you find that you're going to check a particular thing walk away and mentally count numbers to yourself until the feeling of the desire to check has passed. Well it sometimes works but I have to say more often than not it doesn't and you go back and have another look again. And I really just wonder if there is any sort of format you can recommend where you can break yourself from this endless pattern of going round doing the same things quite unnecessarily each day.
MYERS
Which you've described very clearly for us Tony. What's the answer David?
VEALE
Well what I think your therapist was using was something called cognitive behaviour therapy and obviously there are different levels of experience and you may not have been so ready for help at that particular stage, so it's always worth going to seek a further opinion or going one step up the chains, because there are more specialist centres that deal with OCD. Now in general when you're overcoming these types of problems it's very important to try to combine it with the principles of what we call exposure, that is facing up to your fears, and so if we take an example like one of the things you might be for checking light switches then it's important to try to combine that in some way with deliberately leaving a light on, rather than having to check that it's switched off for example. But this needs to be obviously done in the context of understanding what the problem is in terms of trying to worry about preventing bad things from happening, just trying too hard because your solutions have become your problem. And even if a more expertise level of CBT is not working then you may wish to combine it with other medication, so that there's always treatments and therapies that can help, there's very few people who can't be helped.
MYERS
So you're talking then David there about a kind of distorted thinking about what will happen if you don't make sure the house is properly locked up and then you have to obviously make sure the house is locked up because you think something awful is going to happen and not to do that though is extremely risky. Presumably that's the problem Tony, it's just a big risk isn't it not to do what you feel you have to do.
TONY
That's right. There's a certain amount of logic so far as the house is concerned obviously for security but you know yourself there's no logic in repeatedly going back to check you've turned the kitchen taps off when you know absolutely you turned the kitchen taps off or turned the lamp off in the bedroom or whatever else.
VEALE
But one of the problems that's happening at the moment is probably that you're finishing your check when you feel right, when you feel comfortable ...
TONY
That's right.
VEALE
... and a healthy person will only finish checking when they can see that the tap is switched off or the gas cooker is switched off. And it's going to be important to change the criteria you use to finish the check, so you just use more external or objective information, rather than feeling comfortable, you have to do these things feeling uncomfortable I'm afraid, in order to change.
MYERS
And someone made the comment to me that what had really helped him with his OCD was that he'd learnt the mantra, actually within a therapy setting, which is - take the risk, take the risk that you actually have left the tap on. I suppose if you can do that you really have made enormous strides, that seemed to help him enormously.
VEALE
And because if you don't the consequences of having OCD for the rest of your life are much worse.
MYERS
So it's quite a tough message but are you saying David, in your practice with your patients, that when people will expose themselves to what they call risky behaviour ...
VEALE
It's not actually risky.
MYERS
... but it's not really risky but they perceive it to be, that they actually do do well?
VEALE
Yes and if you do that repeatedly and really test it out, as if something - this is a problem of worrying about bad things happening as opposed to actually bad things happening.
MYERS
And is it a little bit analogous to the desensitisation technique used to help people overcome phobias?
VEALE
Yes absolutely, it's entirely related to that.
MYERS
Tony, thank you for that. We will move to another caller, stay listening I hope you'll learn some more. Phyllis is in Devon, has a son-in-law probably with OCD and is about to start his family. So Phyllis is there a concern there about whether this is something that perhaps is inherited, I don't know if it is?
PHYLLIS
Yes, my son-in-law and daughter have been married for about three years I think and he's 40 and they were first sharing a flat with other people and he did find it very difficult to cope with other people's sort of mess and belongings around. So now they have a flat of their own and - but my daughter still has - they have to follow quite a lot of rules and procedures. For instance, if they book a holiday they have to be absolutely sure that the sheets are washed and all that sort of thing and the kitchen has to be ordered in a certain way. And they quite openly talk about it, I think they must have had some sort of counselling, I'm not quite sure really at exactly what stage because I don't want to interfere but they seem to be coping quite well with it at present. But I was just wondering what happens when babies come along and how it could affect you. And I was just talking to someone recently whose mother has an obsessive compulsive disorder - things in threes - and they had quite a miserable childhood having to cope with it and I was wondering how things may develop that way, I don't want - I'd like them to be prepared for that.
VEALE
Okay, well the genetic risks are generally quite low, in the sense that in the population as a whole only about 1% or a little bit more of the population has OCD. But if you have a relative with OCD, in this case perhaps a baby, then the chances are increased to about 5%, so it's a very small increase and I don't think that by itself should stop someone having a family as such. It is possible when a baby comes along that your OCD may be worse because of course all your sense of responsibility and so on is focused on the baby ...
PHYLLIS
Right and there's a lot of mess around.
VEALE
Yeah absolutely, it's more common perhaps in women with babies but it does also happen in men and when the baby comes along they become very preoccupied about preventing harm to the baby whether it's contamination or thinking they might stab the baby or all sorts of things like that. So it is common but it's something that can be predicted and dealt with if the person is in therapy.
MYERS
I imagine Phyllis it's quite interesting for you or difficult for you, I should say really, because you said you don't want to - it's not your place, as it were, but then again you see what's happening. How do you - perhaps David can answer this - how might family members best deal with it, do you collude with it or do you challenge it? I mean we've actually had that question come in from another listener, Mary Elliott, she's saying what support is available to partners or friends or family because she, for example in her case, is never sure when she should keep quiet or whether she should challenge this sort of disturbed behaviour, so David what would your advice be?
VEALE
Well it's a most difficult course of all is if you're living with someone with OCD, with severe OCD, and there are lots of different ways that family members cope. Some family member might cope by accommodating it and participating in the avoidance and the rituals, another family member might try to - or might end up being aggressive or sarcastic and sort of not be very supportive at all. Someone else might be trying to cope by just denying it's a problem and trying to work excessively hard outside. So there's no right way of coping. And in the long term we want to try to help people for family and friends not to accommodate it, sometimes you may need to compromise in the short term to provide more emotional support to help them to change. But it's a very difficult balance and one of the key things about OCD is that it is in the top ten of the most disabling conditions [indistinct words] in the World Health Organisation, it causes enormous - can cause enormous difficulties in family life, social life and make difficulties in employment and all sorts of things and you have to bang on that it has to be taken seriously.
MYERS
I'll leave you there Phyllis, thank you for your call. We'll go to Fife in Scotland because I think we're picking up that theme a little bit. Susan wants to talk to us about her son with OCD and that idea of being a little bit worried about a stigma perhaps surrounding this illness and therefore stopping people going forward for treatment. What's your particular question please Susan?
SUSAN
Well my son is 16 and he washes his hands and he runs up and down stairs and flicks on and off light switches. And we've read about it and we gave him a mantra but he didn't want to take that on, he seems - he doesn't seem to want to sort of help himself that way.
MYERS
What was the mantra you were offering?
SUSAN
I know it's not easy but I'm doing fine - I got it out of a book. And we thought about taking him to the doctor's but with this thing that employers perhaps are allowed to see your health records if it came up that he'd been treated for this it might not be a good thing for him.
MYERS
Well it is an important point for people, if you get a diagnosis of OCD and are referred for treatment you will have on your medical record that you have a psychiatric illness ...
VEALE
At the same time if you don't go and get help you won't be going to get a job. So shame is an enormous problem and stigma, I appreciate that, but in general an employer may request a medical report by a doctor as such but if it's not an active problem they're not really interested. I mean the key thing is really can - for an employer - is can this person do this job at this time, and is not going to be taking off lots of time off work. And it's more important I think for your son to actually get help now because otherwise it will persist and get worse. And unfortunately saying a mantra like that is not by itself going to work.
MYERS
So even at the age of 16 isn't it something you might hope perhaps as he goes through puberty and ...
VEALE
I don't know how long it's been going on for or how disabling it is.
SUSAN
Well he was sitting his standard grades last year and he nearly stop writing because he was trying to form a particular letter but he forced himself through it, so he could finish the exam. So he's coming up to his highers, which are sort of university entrance.
VEALE
And it may well then interfere in his ability to study and concentrate ...
SUSAN
Well I think it might do yes.
VEALE
And so I really would strongly urge him to seek help, it's unlikely just to go away by itself.
SUSAN
Is that just through the local GP?
VEALE
Yeah, just go to your GP and tell them about the symptoms and say that you believe this to be an obsessive compulsive disorder and you may wish to take along some leaflets and so on, there is lots of information available from self-help books, and we have one out, there's OCD Action the charity, all sorts of things, so that you can arm yourself with a lot of information and just say look I would like to get an assessment and we would like to get some behaviour therapy or possibly a medication and so on and so on. But do seek help.
MYERS
Thank you Susan. You might take some comfort in hearing from Margaret who joins us from London, also with a son with OCD, who's had treatment and is back to normal, so that's good news isn't it Margaret, but there's a question arising.
MARGARET
Yes, yes hello. Yes my son was twelve and a half when he out of the blue the symptoms arrived and as I spoke to your colleague explained he's had treatment and he's worked hard at it and he seems - well he's had lots of prayer actually and he seems to be a whole different person. But obviously worried, he's now nearly 14, what's the likelihood of a recurrence in later life or can we just say that it's great it's over?
VEALE
I'm afraid it is unpredictable and it is possible that at times of stress and a lot of stress it may reappear but at least he'll know what it is and be able to get help at an early stage.
MARGARET
And is there much research done into ex-child OCDs, if you know what I mean, somebody who's had OCD as a child or is it kind of all so new?
VEALE
There's not enough research done into OCD at all full stop. And in any particular individual it's difficult to tell whether it will recur. But if he has relatively short lasting and he's managed to get better quite quickly then I think that's a good sign. It's just that it's something he needs to be aware of that at times of stress it may revert again.
MARGARET
Yes. I mean I felt in one sense we were lucky that it had happened when - horrible it happened at all - but lucky it happened when it did because he had to come along with me to the counsellor and as he was a minor he kind of did that, whereas I know people who've had older children who obviously have chosen not to and can't be made to.
MYERS
Because it's actually tough isn't it, as we were saying earlier, you're being asked to do something that's really quite challenging and risky and threatening and rather hard. So Margaret this was a therapist - a psychologist of some kind I take it?
MARGARET
Yes behaviour therapist.
MYERS
Yes and that's exactly of course what you practise Dr Veale is it not?
VEALE
Yes.
MYERS
There is talk however of a medication also being used, either instead of or in conjunction with behavioural therapy, but that raises a question from Michael Ryan, who's e-mailed us, and he's saying that the problem is some of these medications are often SSRIs, these are the serotonin drugs, and the trouble is with those they may have serious side effects. In fact they're often offered, it seems to me, for a lot of conditions these days - we were talking only last week about premenstrual syndrome and seroxat, for example, is one of those that's offered and yet there are possible dangers. So what's your own view and what do you recommend patients should do with the suggestion that medication could be the answer?
VEALE
Well the draft NICE guidelines on OCD will at present say and most likely to say that they are an effective treatment and they can be used for OCD safely. The controversy in the past has been when they've been used inappropriately for patients with mild depression and that's when they perhaps shouldn't be used. So the problem is not in OCD and they're usually very effectively tolerated but the main problem is really there's a high risk of relapse, that when you stop taking it that very often the symptoms of OCD may return. And so that's why it's very important, if you are taking medication, to try to combine it with the therapy at the same time. But in general you'd normally use them if the therapy isn't working.
MYERS
Let's take a very quick call finally I think from Susan in Lancashire who's had OCD for a long time, most of her life, is doing well now though - is that the case Susan?
SUSAN
Yes I think so. I've managed to get to this stage now in my life by three different things really. Firstly, by taking medication, I've been taking medication for 13 years, not a great deal, it's an antidepressant but it is supposed to help with my obsessive compulsive behaviour and I think it does. Also by some excellent behaviour therapy which I've had from a clinical psychologist at the local hospital. It's been hard work and I've been seeing her for a long time now but together we've put together a number of strategies and they have helped me in the house considerably because my obsessive compulsive disorder is to do with cleaning and obsessive housework ...
MYERS
Okay, I'm sorry I know you wanted to list three - those are two very good ones - we will have to stop you there because we've run out of time as we always do. If you'd like to hear the programme again though, find it on our website or you can ring 0800 044 044 for more information. Thanks to David Veale. Next week: urinary tract infections.
ENDS
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