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Science
ALL IN THE MIND - LIVE CHAT
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Live chat about Obsessive Compulsive Disorder
Wednesday 8 December 2004, 5pm

Professor Paul Salkovskis Dr Raj Persaud and Professor Paul Salkovskis answer your questions about OCD. Please note that this webchat contains general and basic information. If you have specific concerns about OCD then please consult a doctor.



Dr Raj Persaud
We are out of time I am afraid. Many thanks to all of you for taking part and deep apologies that we only managed to get to just a small number of the hundreds of emails and queries you sent in for this particularly fascinating web chat. Please stay in touch with the 'All in the Mind' series via the website and the email address of the programme. For example, let us know what items you want covered in future series - the next one is broadcast from the end of Februrary 2005. I should like to thank particularly Professor Paul Salkovskis from the Institute of Psychiatry in London for helping us today - it is vital that sufferers from OCD avail themselves of the kind of high level scientific expertise that Paul provides and I hope you can support his vital research at his world class unit.

I should also like to thank the folk behind the scenes. Without Cathy Drysdale and Richard Hooper these webchats would not be possible, and we are trying to do at least one at the end of each series of All in the Mind. My deep gratitude also goes to Maire Devine, the producer, and Jo Coombs, researcher of All in the Mind plus Rebecca Asher our editor, all of whose tireless endeavours make me vaguely broadcastable.

But the deepest thanks of all go to all those who suffer from psychological problems who allowed us to broadcast their stories, and whose testimony provides the kind of invaluable insights, without which the brain and mind would remain, indeed, the darkest place in the universe.

Dr Raj Persaud, Gresham Professor for Public Understanding of Psychiatry, Consultant Psychiatrist, Bethlem Royal and Maudsley Hospitals, London.

Anonymous
Several people have asked what should happen if they go for CBT?

Professor Salkovskis
A really important aspect of CBT is that it starts from where the patient is and moves on from there. In practice this means that your therapist will start by finding out about you, the details of your problems, what it means to you and what else is important in your life. They will then ask you to go over a specific and recent example of how your problem has affected you and use that to help you understand how the problem works. This can be very important because it helps the person who has a washing problem to see that it's not that they are dirty but that they fear contamination because of what that might do. The person who has violent thoughts is helped to see that this happens because they are a sensitive and kind person who hates violence. The shared understanding is used to help the person to choose to change and this is the toughest part.

The therapist supports the person in trying out different ways to tackle the problem (eg: not washing and getting used to contamination, confronting situations without ritualising and so on). When the patient does this, it usually throws up a lot of upsetting thoughts which the therapist can help you to deal with often by helping you see that you are not responsible for preventing harm. The therapist also helps you find alternative to seeking reassurance. The other thing a therapist can do is help you to think about the things which you have given up. Obsessional problems prevent people from being able to achieve their dreams. It's not enough to just take the problem away; It needs to be replaced by things that really matter. After all we all need something to live for. Finally it's important to note that CBT is about helping the person to be true to themselves. For example people troubled by blasphemous thoughts are usually people with strong religious beliefs. We don't try and stop people from being religious but instead help them to see how to make it work for them. I might ask such a patient what Jesus would say if he were able to advise them about their thoughts. Would he condemn them for having these thoughts or would he see them as being like any other worry, that is, the exact opposite of what you hope for.

Overall CBT is about helping people to see things differently and then act on this perspective. It's about empowering people to break free from this horrible condition.


John
I am receiving CBT (I am lucky!) for CBT where I have to repeat phrases in my head to protect people. My therapist is making me record loop tapes which I have to listen to, which basically outline my worst fears. ie what has happened, what I have thought and what will now happen. This is obviously distressing. Is it the only way forward? or are there alternatives?

Professor Salkovskis
Strangely enough I have to confess that I invented this technique back in 1982! However things have moved on a bit and this should not be used on its own.

One of the key question is why it is that you find these thoughts so upsetting. For many people it's because they feel that having the thoughts means that they are a wicked person, may be responsible for harm or even that the thought might come true because they thought it. Dealing with those ideas is the first step and then the loop tape can help you confirm that nothing happens even if you don't 'fix' the thought. Also, you can learn that if you ignore the thought the anxiety goes away and it becomes a bit boring.


Rachel
My partner has been suffering from OCD for about three and a half years now and has greatly benefited from cognitive behaviour therapy and, for a time, taking Prozac. He is now off of the medication and no longer seeing a counsellor because he is so much better. However, my problem throughout all of this has been knowing how best to help and support him, when to reassure him and when to ignore his concerns, when to know that his worries are real and when to dismiss them as nonsense. Now that he is so much better this is a particular problem in that my tolerance levels of his concerns have been greatly reduced by the stress of coping with the disorder for so long. Do you have any tips for how people can support their loved ones through this disorder?

Dr Raj Persaud
This is a very common conundrum for relatives and friends of sufferers from OCD so I am glad you raised it. There are two key issues to consider - the first is what is your, and his, goal? Is it to maximise yours and his mental health in which case you should both have a zero tolerance of worthless ruminations or worry and he should ask you to identify the smallest sign of excessive anxiety so he can become aware of it and seek to eliminate it. Another goal might be to prevent relapse in the future and it's vital to bear in mind that this is a relapsing condition - this would lead to a similar approach as the goal oriented one I mentioned first.

The other key issue is perhaps to adopt a view which is what is liveable with - in other words what level of anxiety is not interfering with everyday life or function or your relationship? This could mean for example you calculate how many hours of reassurance or excessive worry you are willing to tolerate in your partner and stick to that timetable. So let's say you are willing to tolerate an hour of 'worry talk' from your partner every week then set the clock running to total this up whenever he starts, and let him know he has an hour and no more each week in which to ventilate his anxiety. I also think that your mental state should be of concern to him, and that partners and relatives keep back too much from letting a sufferer know how their illness affects them.
Anonymous
A family member has suffered from OCD for several years but is unwilling to seek professional help due to this appearing on his medical records and any (unfair) implications this may have for employment in the future. Instead he has bought several books on the subject and is determined to treat & resolve the issue himself. Is this at all possible or is professional help the only real option?

Professor Salkovskis
Sadly you're right about the possibility of stigma. I have been known to advise recovered sufferers to describe the problem as being stress related. This has the advantage of being true. Yes, it is possible to self-help and there are several ways of doing this including through the self help groups such as OCD Action, No Panic and so on.

Books can be helpful. However if the person is stuck when using these then it's worth contacting a professional to find out whether they can think of ways of helping whilst also minimizing stigma.


Anonymous
How does one find a therapist?

Professor Salkovskis Apart from Clinical Psychology Departments, you can search for a therapist on the 'Find a Therapist' section on http://www.babcp.com. This organisation is the main accredited group for CBT therapists although many people, myself included, are not registered with them.


Anonymous
What are the recommended methods for treating OCD and what are the recommended texts? Are there any clinical trials or OCD meeting groups?

Professor Salkovskis
CBT and anti-depressant that act on serotonin, in that order of preference. A great book is "Obsessive-compulsive disorder: The Facts" (Third Edition) by Padmal de Silva and Jack Rachman (pub: Oxford University Press - ISBN 0198520824). Also a new self help book by David Veale is due out next year from Robinson ("Overcoming OCD").


Alison
My husband tells me he has had compulsive thoughts for over twenty five years and since we got married eight years ago, his behaviour has worsened. I am not sure, but I think he has OCD but not in the sense that he has to perform rituals, rather it is thoughts that trap him and he says he lives 'in fear' most of his life. I do not know the details of his thoughts, but I do know that they are all medically related. He seems to have a fear of getting ill, or someone in his family getting ill. When he gets these thoughts, he cannot function at home and retires to his room sometimes for a whole weekend. He cannot be disturbed, or his thought patterns will be interrupted and he cannot tell me in full details exactly what he is thinking about, as he fears he will then have to start thinking about something else that is related to the problem he is thinking about.

Life with him is very difficult as we have two small sons and they are now aware that Daddy spends a lot of his time doing his 'thinking thing' and cannot be disturbed.

Do you think he does suffer from OCD and if so what do you suggest I do about it. He refuses to visit a doctor, as part of the problem is fear of doctors and medical things ie dying and illness. Do you think that if I called his doctor and asked him to visit this may help.

Things are getting desperate for him and our family. I fear that if something is not done soon to help him he may have some sort of breakdown. Please help


Dr Raj Persaud
It's difficult making a diagnosis over the web but from what you tell me I am pretty confident your husband is suffering from OCD and in particular a variant described as 'ruminative' OCD. This involves a preoccupation with worry and a fear that a particular thought will arrive in his head and he is working away to stop them. Sufferers tend to be rather intellectual because they think a lot and take thoughts very seriously - perhaps too seriously. At the heart of this disorder is a conviction that thoughts have great meaning whereas the approach from CBT is called a meta-cognitive approach which is to take a step back and consider how helpful this general approach to thinking is.

The therapeutic approach is not to take thoughts so seriously and consider the benefit of just allowing thoughts to come into and out of ones head without attaching too much significance to their presence or absence. It is also important not to assume we have too much control over our thoughts and to accept that this means we cannot be held too responsible for the precise content and nature of our thoughts. I would strongly recommend psychological treatment if this problem is causing significant suffering or impairment. One approach is to contact the British Psychological Society to find a properly qualified psychologist working locally specialising in this area. Also you may want to try the British Association of Cognitive Behavioural Therapies who have a very good website listing their therapists across the UK.


Anonymous
My sister is 32 and has suffered from OCD since her early teenage years (and before that too probably). She mainly has concerns over germs and contamination. In the past constant hand-washing has been a problem - she's still very fastidious but it's not as bad as it has been. She has recently plucked up the courage to see her GP. What sort of help can she expect to get from the NHS? Indeed what sort of help is most effective in such cases? How can I best support her in her quest for an OCD-free life?

Professor Salkovskis
CBT should be available through your local health services. She should try to be referred to your local clinical psychology department. Don't support her with her obsessional behaviour support her with her attempts to change and the anxiety that she will feel.


Anonymous
I think I may have OCD. My house is very untidy and unclean and I am unable to de-junk. Why do I hold on to the junk? Is it some some equivalent of a comfort blanket or is it OCD? Please help as I want to move on; I am 57 years old and I feel the junk is either a symptom or an indicator - which? I have been in psychotherapy for 5 1/2 years and my depression has much improved, but....

Dr Raj Persaud
This is a form of hoarding disorder and underlying it is the idea that you might throw something away which you later find would have been useful. It's the possibility of some theoretical future use which keeps you hanging on to stuff. The treatment involves learning to take the risk of throwing something away which later proved useful because of the massive benefits of decluttering your life. The paradox at the heart of the disorder is that ones life gets so cluttered that you can't find anything anyway so its theoretical future use becomes grossly compromised. There is no point keeping so much stuff that you can't get at most of it because you have kept too much in the first place. You need to start by setting aside a certain amount of time each day devoted to sorting and throwing. When in doubt adopt the policy of throwing away. Take the risk you will throw away something that later proves useful - even if it happens it may not be quite the disaster you feared. The benefits in terms of improving your quality of life by dramatically improving your environment.


Bill
I am interested in the application of Deep Brain Stimulation as a treatment for very severe cases of OCD. Does Professor Salkovskis have any experience of this technique and any other recent developments in treatment?

Professor Salkovskis
This is a technique which received lots of attention recently and is very dubious. Like other forms of psycho-surgery it is probably not effective. I don't believe anyone should receive this type of irreversible and potentially harmful treatment.


Gregory
What is the importance and impact of a person's spiritual or world view to OCD? My repetitive behaviour is worst when I am stressed or feel insecure in my life. I will repeat an action over and over again before I can escape at the 'right' moment. My situation seems to be linked to my metaphysical view of the world as I will be trying to affect the future path of events with each repetition by forcing the (for want of better description) 'random atoms-of-future-emerging' (event horizon of becoming!) into a favourable position. Basically I feel that I need to intervene at important 'fate junctions' to tip the scales in my favour. This can take a tremendous amount of mental/psychic/visualising energy.

Dr Raj Persaud
This is a very interesting question as Freud himself was struck by the link between the numerous rituals of religion and the comfort it seemed to offer to believers. There is another link which is that in my clinical experience sufferers from OCD and in particular the form manifested by rumination - where they are upset that they could even have some 'bad' thoughts and try to stop having them - tend to be more likely to be religious or at least, more conscientious, than the average person. This I think is because if you take the moral life seriously you constantly worry more about whether you are doing the right thing or not (if only politicians were more like this!) from moment to moment.

If you worry about yourself then this means you are more vigilant to signs of impending moral degradation. You then think that the very having of a 'bad' thought means you are a bad person. The problem with this reasoning is that 'thoughts' do not have the same significance as actions. Surely I can have the idle thought, lets say, of robbing my local bank which comes and goes totally innocuously, and that has a completely different moral status to me donning a balaclava and actually holding up the bank with a double-barrelled shot gun. OCD sufferers tend to think the thought is the same as the action.


Anonymous
From childhood I have felt the overwhelming need to perform symmetrical touching rituals to, in my mind, avert some catastrophe either on a personal or worldwide level! My concern now is that my ten year old son is showing exactly the same behaviours although I am extremely careful never to let anyone else see me do them. I need advice on how to deal with him because I really wish I didn't have to do what I feel I need to and I don't want him to be like it for the rest of his life! Should I try to talk to him about it and share my 'secret' with him?

Professor Salkovskis
Quite simply the best way to help your son is to help yourself. Make things asymmetrical and find out that the bad things you are afraid of don't happen! Then show him that mummy can do things differently, so he doesn't have to do them. If you can't do that then it's time to seek help yourself. By the way we are looking for sufferers with young children to help us understand the effect that OCD has. Please check out our website if think you can help us. See the All In The Mind web page where you will find the link.


Helen
I would be interested in some advice in terms of how family and friends should respond to the following... My mother has what I would describe as an obsessive compulsive condition. It manifests itself in several non-harmful but increasingly frustrating ways, as far as the rest of the family are concerned. One of these is the storing of old newspapers. These are kept for years in more and more plastic bags in the living room. She tries to hide them from us but the piles continue to grow under blankets and rugs. My mother insists that they should not be thrown away as one day she will get around to reading all the important articles in them. This is patently impossible as they accumulate by the day. The family feel they are becoming a fire hazard as well as a nuisance. Can anything be done to persuade my mother that it would be better for all concerned that the house is rid of this clutter? Can someone with this condition be "talked out of the behaviour" or are we being unfair? This is not an isolated example - there are several other examples of collecting huge quantities of items that are spreading all over the house and taking over. My mother does have a history of depression and remains on medication for it but apart from these symptoms, the depression is hugely improved and we would not want to do anything to impede her progress. Can you help?

Dr Raj Persaud
You are describing a well-known variant of OCD called hoarding disorder where patients find it very difficult to throw anything away no matter how useless or trivial it is. I have had patients suffering from hoarding who refuse to throw away even junk mail and who had to buy a series of houses and garages just to store all their stuff! In the series before last of All in the Mind you will find an interview I did with someone suffering from hoarding disorder - it might be easier to find the programme on the listen again website if you type in the word 'hoarding' and all in the mind in the search engine. May I make a few suggestions about your mother? The first is I strongly suspect her depression is being under-treated if she is on an anti-depressant - the evidence is that OCD symptoms secondary to depression often respond to much higher doses of anti-depressants than is usual for uncomplicated depression.

Two antidepressants for which there is good evidence that they might have a specific anti-OCD action include Paroxetine or Seroxat and Clomipramine or Anafranil - but bear in mind the doses of these need to be quite high and often higher than most GPs are comfortable prescribing. There is also good research evidence to support the use of these kinds of drugs in OCD. Obviously you should not change any medication without consulting with your doctor and there are many good medications for these problems besides the ones I have mentioned above.

Also you need to vigorously pursue psychological approaches like CBT or cognitive behavioural therapy. This would include the family being involved in therapy. The family should draw a boundary around their own living space where you mothers hoarding is not allowed to impinge upon. You should also sit down with your mother and work out a programme of throwing stuff away gradually in small amounts to begin with. She should have control over this but she needs to have some time - say 24 hours - before something is thrown away where she can check whether she really needs it or not. It is vital you actively seek to treat hoarding now as it will only get worse and worse if not dealt with now -so don't postpone it as your mother might prefer.


Anna
My comment is about the use of CBT, for OCD and other anxiety disorders. Yes, CBT can be a good technique BUT:

1- It certainly does not suit everybody and some of us respond better to other types of psychological interventions like those that take more time as criticised by your guest

2- We cannot have a one-fits-all approach; it is against common sense; we are all different and need different approaches; Your guest's comments are about saving money, not offering the best options (in that regards, NICE guidelines are not always spot on). We are supposed to be having service user centred services after all...

3- CBT may work better with very mild anxiety disorders

4- CBT is NOT readily available in secondary/primary mental health services already overstretched in financial and manpower terms (my local mental health trust is so deeply in the red it is cutting back services left, right and centre).

5- Going private raises issues of accountability, cost, having nowhere to go to when things go wrong and finding someone to pick up the pieces.


Professor Salkovskis
Thanks for this Anna. CBT is very far indeed from being a 'one size fits all' approach. The idea is that you listen carefully to the person's concerns and try to reach a shared understanding based on their experience. With OCD it is quite clear that no other psychological therapy has been shown to be effective.

It seems very unlikely that the explanations offered by psychoanalytic approaches have any basis in the reality of OCD. The big problem we have is that more people are offered psychodynamic treatment than are offered CBT ! This is both unfair to sufferers and a very silly way of running a health service. This doesn't mean that there is no place for therapies which focus on inter-personal issues; that place however is not on the front line.

If you look at the NICE guidelines you will see that they emphasize the idea of shared decision making. I completely agree with this and think it should be on the basis of 'evidence based patient choice', an approach which is respectful to the sufferer and makes sense for the service. My view is that the reason CBT is not available is because we are wasting money on useless treatments.

Finally people should not have to seek treatment privately. With the exception of people like Howerd Hughes most sufferers are prevented from working and therefore can't pay for treatment.


Anonymous
My ex-boyfriend had OCD. It took the form of compulsive washing after sex. He'd be fine when in bed, but as soon as he left bed he was terrified that he would touch something and "contaminate" it. He was also similarly terrified that I might do so. Once contamination of something (for example, if one of us touched something having left the bed - say a door handle) had occurred only thorough washing would remove the problem.

In the end, after about a year of living together (with lots of washing!) we split up since I couldn't cope. But I did ask him to go into therapy, and he has.

My question is, to what extent can it be dealt with? Should I feel that I'll either have to learn to live with the obsession or resign myself to not going out with him? Or should I keep hoping that something can be done? What is the timeframe within which changes might be seen as a result of therapy?


Dr Raj Persaud
OCD does lead to a lot of problems in the sexual arena and often because of embarrassment these don't get discussed with doctors. It's natural that sex should be a problematic area for the sufferer of OCD not least because for the cleanliness obsessed it can be a trifle messy but also because sexual thoughts in themselves raise troubling emotions for OCD sufferers as they are overly concerned with morals and obsess about whether they are immoral or evil for having certain sexual thoughts. Professor Paul Salkovskis emphasised in my interview with him on the programme (you can hear it again on the listen again part of the Radio 4 website) that it is vital patients make sure they are getting the right psychological therapy which should not involve a lot of talking or dwelling on the past, but instead focuses on the here and now and actions the patient must take to counteract their anxiety and which exposes them in a gradual way to their fears.


Anonymous
A friend's son has been exhibiting OCD type behaviour since the age of three. He is now six and his behaviours include having to arrange the remote controls in a particular way five or six times before going to school, having to be the last person to touch the door before going out, having to step on certain things on the way etc.(There are loads more)He refers to this as his 'Start agains' because if something is not performed properly he has to go back to re-do them. Three questions:
A) Is this inheritable? His father has said that he did the same thing, though when he was older.
B) Is this common in young children.
C) What would be the best course of action


Professor Salkovskis
A)There is a very small inherited element. What is inherited is some vulnerability to developing an anxiety problem; about 10 per cent. However many people with OCD don't have it in their family and most people with it in their family don't develop OCD.

B) OCD can start very early but reaches a peak in late teens. Most people develop it in their adolescence or later.

C) Someone needs to very gently find out what he thinks the worst thing that would happen is if he didn't do his 'start agains'. Even at this very early age, it should be possible for him to understand that his fears might be untrue and a good thing to do would be to work with a grown up to see if he could find out whether or not the bad things he fears will happen. Sometimes it's helpful to talk about the OCD as if it were a playground bully which is pushing him around. Ask him what the best way to deal with the bully is. Is it best to give in? Or is it helpful to resist?


Anonymous
I have suffered with OCD for seventeen years now, and in recent years, I've heard a rather worrying claim that has only made things worse. Many people, including doctors, therapists, and even Prof. Persaud himself in his book "Staying Sane", have referred to research that suggest long-term stress may cause damage to the brain, due to the release of cortisol. Also, a psychologist has frequently said that for every thought we have, there is a physiological correlate - I presume due to an emotional reaction to the thought. He cited this as possible proof that stress can do actual physical damage to your health. So what I want to know is, are my obsessive thoughts damaging my brain? Does each negative thought I have do damage to my brain, or even destroy cells, which we are often told can't be replaced? I can't use the method of exposure therapy for this, because brain damage is cumulative over time, e.g. punch drunk syndrome, and so I may be old before this affects me, or too brain-damaged to notice. What is the truth of these claims?

Dr Raj Persaud
There is a lot of evidence now that stress, depression and anxiety lead to shrinkage of certain brain parts. We also now know that some treatments for depression seem to lead to brain nerve cell growth so maybe all is not lost for those suffering from chronic severe psychological problems. My aim in emphasising the physical damage one might be doing to one's brain if you allow a serious psychological problem to remain untreated is to galvanise patients and doctors to treat psychological difficulties more seriously and engage in more urgent vigorous treatment.

There is a fascinating new study looking at combat stress in army veterans which finds that those on the front line seem to have brain shrinkage as a result of war stress. This is a new study which illustrates that the stress causing brain shrinkage is not as straightforward as previously thought. It's a bit complicated to get into here and now but basically it is vital to treat psychological problems early and urgently and once having done this we think it is reasonable to believe any nerve cell damage could well be reversible.

Remember that one of the key messages of my BBC Radio 4 series 'All in the Mind' is that psychological disorder is eminently treatable, it's just that patients seem to need to fight more to get the right treatment, and be more educated about the latest research, than they might need to be for physical problems where services might be a bit more reliable.



Oliver
In 2002 I was diagnosed with OCD and was only 13 at the time, the symptoms were building up before hand. It was only on the second visit to my GP, in one week that I was referred to the child and adolescent unit. The OCD was first a fear of germs, getting ill and possible death. This I learned to control with the help of me therapist, but in after a year of being diagnosed I went back to step one. This time my fears were still contamination but now also there were superstitions involved, for example I would have to remain still for a certain amount of time if I saw the number 13. In conclusion I am now in year 11 at school, and have had up to 5 months off school as a consequence of my OCD. My therapist believed that my case was one of the worst he had seen and has helped my get to where I am now.

Professor Salkovskis
Many people first have obsessional problems during their childhood. Wherever possible it should be treated at that time and we know that Cognitive Behavioural Therapy is highly effective for the younger sufferer. One of the things you need to be able to find out as part of dealing with the problem is that the things you fear don't happen if you stop your rituals and avoidance. The role of the therapist is to help you believe that it is worth taking the risk. One further thing: therapists often tell people that they are particularly severe, the worst case and so on. This is very unhelpful and you often reflect the fact that they don't specialise in this kind of problem. The fact that the problem is very severe doesn't mean that it won't improve with the right help.







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