Obsessive-Compulsive Disorder (OCD) is a serious anxiety-related condition. OCD can take many forms, but, in general, sufferers have repetitive, intrusive and unwelcome thoughts, images, impulses and doubts which they find hard to ignore. These thoughts usually cause sufferers to perform the same tasks (e.g. washing hands) over and over again in a vain attempt to relieve themselves of the obsessions.

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Obsessive Compulsive Disorder (OCD) can be a very disabling illness, especially if untreated. Some of the symptoms include:

• frequent and intrusive thoughts about the need to check things e.g. doors locked, electric off, hands washed

• rituals e.g. getting dressed in a particular order

• daily activities take a long time e.g. washing or cleaning

• Trying to resist these urges is very stressful

The person can become unable to lead a normal life as the thoughts and need to do things repetitively or in a certain way or order take over.

About 1 in 40 people get some symptoms at some time in their lives. It usually starts in adolescence or early adulthood. The person usually knows what they do isn’t normal or right, but can’t stop themselves doing it.

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Because everyone is unique, everyone's symptoms are different. So, it's not always clear what the right diagnosis is. Here is a list of some other possible causes for the symptoms of OCD. This is not meant to be a textbook list, just some ideas. Some of these can be very rare indeed. Sometimes it doesn't matter anyway as the symptoms need to be treated anyway, no matter what causes them.

• Schizophrenia - which has more bizarre or odd symptoms, especially in younger people  

• Phobias - which don't have obsessive thoughts or compulsions

• Depression

• Hypochondria e.g. fear of an illness such as cancer

• Body dysmorphic disorder (the "distress of imagined ugliness")

• Trichotillomania (the urge to pluck hair)

• Prescribed medicine-induced - some antipsychotics such as clozapine and risperidone, although this is rare

• Gambling or alcohol dependence - these cause the person pleasure sometimes, whereas the symptoms of OCD never gives the person any pleasure

• Tourette's syndrome

• Autism and Asperger's syndrome - can look like OCD as the person likes sameness, and routine or repetition

• Eating disorders

• Panic disorder

Just to confuse matters further, sometimes people have more than one illness (sometimes called "co-morbidity"). For example, if 1 in 10 people get depressed and 1 in 10 people get anxiety, then just by chance 1 in 10 of the depressed people get anxiety as well. However, if you're depressed, you're more likely to be anxious. Co-morbidity means what else the person is more likely to have at the same time. This can make diagnosis more difficult.

• Schizophrenia - about 1 in 4 (5-45%) people with schizophrenia also have OCD symptoms

• Depression - often caused by the OCD

• ADHD (Attention Deficit Hyperactivity Disorder)

• Bipolar mood disorder

• Social anxiety - quite common

• Seasonal Affective Disorder

• Tourette's syndrome and tics (usually little facial movements)

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Basically, anyone can get OCD. However, there are some "risk factors" that make it more likely that someone will get the symptoms of OCD. This is not a complete list but some of the main risk factors include:

• A life event - OCD often has a sudden onset after life event e.g. pregnancy, loss, sexual problem but can have a slower onset

• Brain injury e.g. head injury, encephalitis, syphilis

• Having an orderly, rigid, punctual or stubborn personality when younger

• Some medicines (such as clozapine and some other antipsychotics)

• Had depression (even mild) as a youngster (double the chance of getting OCD)

Serotonin is a chemical messenger in the brain that in some parts of the brain seems to control many things, including thoughts, obsessions and mood. The only medicines that seem to help OCD are those that boost serotonin, so it seems low serotonin could be a major cause of the symptoms.

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The list here includes most of the main options but does not say what works and doesn't. Many may be used in combination. Most herbal and alternative therapies have not really been tested in the same rigorous way that medicines have.

Our aim is to try to help people who are taking medication (or should be) get the right medicine, dose and take it regularly for as long as is right. Any medicines should usually be part of the overall treatment, although some people are quite happy just to stick with drugs or talking treatments. If your medicines are right, then everything else can fall into place. If the medicines are wrong, then they may make the symptoms worse and self-help will not be as useful.

Self-help

• Information and self-help – for milder symptoms. There are many self-help books around.
• Taking any medicines regularly and reliably
• Eating healthily and taking exercise or being active
• Putting help from others into practice e.g. repeated checking leads to you not trusting your memory so check once then don't check again. And yes, that is easier to write than to do.  

Help from others

• Cognitive Behavioural Therapy (CBT), especially if combined with medicines. Group CBT is effective. Other therapies can include exposure and response prevention, repetitive transcranial magnetic stimulation, deep brain stimulation, or even neurosurgery. The NICE guidelines for the adults with OCD and body dysmorphic disorder (BDD) recommend CBT. Having both CBT and medication may be more useful with more severe problems. CBT is a talking therapy that helps people to first understand their problems, gives them new ways of looking at it and then teaches the person the skills to overcome their problems. The therapist and client work together in finding out the most powerful or unhelpful thoughts and behaviours and then finds ways of challenging them. Exposure Response Prevention (ERP) is where the person with OCD agrees to "expose" themselves to their fear without then carrying out the compulsive ritual. This helps the person know it can be done.
• Family therapy
• Alternative therapies such as aromatherapy, hypnosis or hypnotherapy, homeopathy (treating like with like) can be used with (but not instead of) conventional treatments. Acupuncture is used extensively in many countries and may help anxiety, stress and insomnia. The evidence for these treatments is not very good, especially in OCD. All of these can be used in conjunction with other therapies. If they work then that is fine and we wouldn’t knock them. Click here for a balanced review of complementary and alternative therapies from the Royal College of Psychiatrists (e.g. Ginkgo, Sage, vitamins, other herbals etc, and some useful links).

Medicines

• Medicines that boost serotonin, such as SSRIs (such as citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline), or the tricyclic clomipramine. They can be useful especially when used at the right dose and for long enough. Whilst they may often be only partly effective, even a bit of improvement can often make a real difference and reduce the symptoms enough to help other treatments to work.

NICE recommends a "Stepped care pathway" depending on how bad the symptoms are:

• If mild OCD, general support and perhaps ERP up to 10 hours per person can help. Sometimes this can be done by telephone. 
• If this doesn't help, or the person doesn't want to or can't cope with general support and ERP, an SSRI can be tried.
• If the OCD is between mild and severe, the person should be offered either an SSRI (at a higher dose) or more intensive CBT (more than 10 hours). These seem to be equally effective. Or more effective if used together.
• If the OCD is severe, and seriously affecting the person's lifestyle, then CBT (including ERP) and an SSRI (often at quite a high dose) should be offered. If this doesn't help, it may need a specialist team to get involved. 

^{Updated 10.11}

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If you are prescribed a medicine, then there may be many reasons why that one has been chosen. These might include:

• side effects (which ones are important to you)
• local policies or agreements (such as what your GP surgery uses or agreements in your area)
• national policies (e.g. NICE, SIGN - see last question)
• familiarity (it may be better for prescribers to use medicines they are familiar with)
• relative costs for similar medicines (if two medicines are very similar, why waste money on the more expensive one?)
• personal preference (either yours or your prescriber)
• how bad your symptoms are
• any medicine you might have done well with in the past (as it's more likely to work again)

The main medicine treatment options are listed below. They are divided into "Main medicines" and "Others".

For convenience, the "Main medicines” are those medicines that are officially "approved" to treat the condition or symptoms (www.bnf.org/bnf/) and which are listed in the British National Formulary (BNF). To be listed in the BNF there needs to be good evidence that the medicine works and that the manufacturers have applied for a license (a long and costly exercise). "Others" are those medicines where there is some evidence that they help, but either not enough for a license or that no license has been applied for. These should usually only be used where other standard treatments have failed.

Main medicines

• SSRIs (e.g. escitalopram 20mg each day, fluoxetine 60-80mg each day, paroxetine 40-60mg each day, sertraline 200mg each day)

• Clomipramine (up to 250-300mg a day), the only tricyclic to be shown to work. The other tricyclics do not help OCD

Others:

• Other SSRIs (e.g. citalopram 60mg each day)

• Venlafaxine (at up to 225mg each day)

• Antipsychotics (such as quetiapine, risperidone, olanzapine), usually with an SSRI in difficult-to-treat symptoms

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Download a handy summary chart (PDF format) comparing the main medicines for OCD e.g. names, how they work, doses, how long they take to work, some side effects, how long to take and how to stop.

Alternatively you can read the chart now in the window below. Use the controls at the bottom of the window to navigate through the chart and magnify the information. The 'Download', 'Print' and 'Fullscreen' links at the top of the window are particularly helpful.

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You should think carefully about taking any chemical that affects the brain. So think carefully before your next cup of tea or coffee!

Well, that may be partly true in OCD, but sometimes people may be so ill with OCD that they are unable to cope with talking theapies. Medicines may help reduce the symptoms enough to help start the recovery process.

For an appeal for everyone to have a sense of balance about medicines and talking therapies please click here for our take on it.

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If your symptoms have improved, you probably should think about at least 1-2 years at the dose that got you better. This will much reduce your chances of getting symptoms back. It is highly likely that if you stop, the symptoms will return, but if they are working, they are helping you get on with your life.

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Before going onto another medicine, it is worth trying to get the best out of the first one. There is a risk that switching medicines too quickly means you don’t get the best out of one medicine. Then perhaps you start to search for the “magic bullet”, expecting the drugs to work quicker and having less patience. There are of course no “magic bullets”. Most symptoms have started to happen over a few weeks, months or years, not a few days, so it is perhaps unfair to expect them to go over a few days. The symptoms are more likely to go gradually over weeks or months. If side effects are the main problem with a medicine, try to cope with these by e.g. changing times, splitting the dose, manage side effects etc.

The best thing to do is set out your aims of success of any treatment in advance and be realistic. If you decide to stop, then that’s your decision, but make sure you consider the chances of becoming unwell again (and consequences of that to yourself and the people close to you).

In OCD, the symptoms might take quite a while to start to improve with medicines but given enough time can work. You need to get to the full therapeutic dose first (and this may take several weeks and give quite a few side effects to start with) and then stick with it for around three months for the full effect to build up. It will not be a “cure” as such but may be enough of a reduction for you to manage your symptoms and help with other strategies. The symptoms will not have started suddenly so don’t expect to sudden get better.

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There are no easy answers to this and it is a very individual choice.

Generally only one is the aim but the important thing is to get the most out of that drug (e.g. getting the dose as high as possible) before trying to add anything else. Sometimes low doses of antipsychotics such as risperidone can be helpful in combination with the antidepressant type medicines.  It is rarely any use to combine drugs with similar ways of working. Below are some of the combinations that are used with the reasons. This is not a complete list but you might want to talk to your prescriber about any not on this list.

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If you want to read up a bit more on the best treatments, there are many guidelines that you can look at. Probably the most important of these for England and Wales are those produced by NICE (the National Institute for Health and Clinical Excellence). NICE is an independent body that is asked to produce advice about preventing and treating illnesses and promoting good health. Scotland and Northern Ireland have their own similar bodies.

Each set of NICE Guidelines is written by an independent and carefully chosen group of specialists and experts (including service users and carers). They carefully review the available evidence and base their guidelines on this.

There are two main types of NICE guidance:

• "Technology appraisal". These look at an "intervention" (i.e. a medicine, a surgical operation etc) and decide if they think the evidence is good enough to make this intervention a standard and/or if it is cost-effective compared to other treatments

• "Clinical guidelines", which look at a particular condition (e.g. hypertension, lung cancer, depression, Parkinson's disease, bipolar disorder etc) and give guidelines covering medicines, services, support etc.

The guidelines are well intentioned and give generally sound guidance (although these are sometimes controversial). They are, however, only "guidelines", so are not rigid instructions.

When NICE issues a guideline, it produces a full set, and all of these are available on the NICE website:

• Full guideline (very long and detailed, often several hundred pages, for anorak healthcare professionals only)

• Official guideline (usually 10-30 pages, the summary version for healthcare professionals)

• Quick reference guideline for healthcare professionals (usually only a couple of pages)

• User-friendly summary for service users, carers and the general public

These should then be reviewed, usually about 4-5 years or sooner if more information becomes available.

As a general rule, you should start with treatments recommended by NICE as these are the ones with most evidence that they work. However, if these do not help you, it may be useful to try other treatments. 

• NICE: click here for the OCD guidelines. There is also a guideline for Common mental health disorders, Identification and pathways to care, and this includes OCD.

• Scottish Intercollegiate Guidelines Network (SIGN)

• Northern Ireland

There are plenty of other guidelines and so-called "consensus statements" (where a group of experts and specialists pool their ideas, based on their own experiences as well as what the published papers say, rather than just what the published studies say). These will have been produced for healthcare professionals by such bodies as BAP (British Association for Psychopharmacology).

^{Updated 10.11}

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Use the resources below to find out more information about Obsessive Compulsive Disorder. Please note that this is not an exhaustive list. We welcome your feedback on resources that you think should be listed here.

If you want a more in-depth read, you could no better than visit the BAP (British Association for Psychopharmacology) public web pages, where there are some fairly scientific articles, including about anxiety disorders so click here, to get there.

Mental Health Ireland has a great links page on this extensive site

Your Mental Health Ireland, with a young person’s page as well

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