About this leaflet
This leaflet is for anyone who has problems
with obsessions or compulsions, their family and friends – and
anyone else who wants to find out more.
In this leaflet you can find:
- what it is like to have OCD
- how to help yourself
- what help is available
- places to get help
- other sources of information
- references to research and policy
"He's an obsessive football fan" - "she's obsessive about shoes"
- "he's a compulsive liar". We use these expressions when we talk
about people who do something again and again, even when others
can't see any reason for it. It isn't usually a problem and, in
some lines of work, can even be helpful. However, the urge to do or
think certain things repeatedly can dominate your life
- you get awful thoughts coming into your mind, even when you try
to keep them out
- you have to touch or count things or repeat the same action
like washing over and over
you could have Obsessive Compulsive Disorder (OCD).
What is it like to have OCD?
Liz "I'm afraid of
catching something from other people. I spend hours bleaching all
the surfaces in my house to stop the germs, and wash my hands many
times each day. I try not to go out of the house if possible. When
my husband and children come back home, I ask them in great detail
where they have been, in case they have visited somewhere
dangerous, like a hospital. I also make them take off all their
clothes, and wash themselves thoroughly. Part of me realises these
fears are stupid. My family are sick of it, but it has gone on for
so long now I can't stop".
John "My whole day is
spent checking that nothing will go wrong. It takes me an hour to
get out of the house in the morning, because I am never sure that
I've turned off all the electrical appliances like the cooker, and
locked all the windows. Then I check to see that the gas fire is
off five times, but if it doesn't feel right I have to do the whole
thing again. In the end, I ask my partner to check it all for me
again anyway. At work I am always behind as I go through everything
several times in case I have made a mistake. If I don't check I
feel so worried I can't bear it. Its ridiculous I know, but I think
if something awful did happen, I'd be to blame".
Dawn "I fear I will
harm my baby daughter. I know I don't want to, but bad thoughts
keep coming into my head. I can picture myself losing control and
stabbing her with a knife. The only way I can get rid of these
ideas is to say a prayer, and then have a good thought such as "I
know I love her very much". I usually feel a bit better after that,
until the next time those awful pictures come into my head. I have
hidden away all sharp objects and knives in my house. I think to
myself "you must be a horrible mother to think like this. I must be
OCD has three main parts:
- the thoughts that make you anxious (obsessions)
- the anxiety you feel
- the things you do to reduce your anxiety (compulsions).
What you think (obsessions)
- Thoughts - single words, short phrases or
rhymes that are unpleasant, shocking or blasphemous. You try not to
think about them, but they won't go away. You worry that you might
be contaminated (by germs, dirt, HIV or cancer), or that someone
might be harmed because you have been careless.
- Pictures in your mind - showing your family
dead, or seeing yourself doing something violent or sexual which is
completely out of character - stabbing or abusing someone, or being
unfaithful. We know that people with obsessions do not become
violent, or act on these thoughts.
- Doubts - you wonder for hours whether you
might have caused an accident or misfortune to someone. You may
worry that you have knocked someone over in your car, or that you
have left your doors and windows unlocked.
- Ruminations - you endlessly argue with
yourself about whether to do one thing or another so you can't make
the simplest decision.
- Perfectionism - you are bothered, in a
way that other people are not, if things are not in the exactly the
right order, not balanced or not in the right place. For example,
if books are not lined up precisely on a bookshelf.
The anxiety you feel (emotions)
- You feel tense, anxious, fearful, guilty, disgusted or
- You feel better if you carry out your compulsive behaviour, or
ritual - but it doesn't last long.
What you do (compulsions)
- Correcting obsessional thoughts - you
think alternative 'neutralising' thoughts like counting, praying or
saying a special word over and over again. It feels as though this
prevents bad things from happening. It can also be a way of getting
rid of any unpleasant thoughts or pictures that are bothering
- Rituals - you wash your hands frequently,
do things really slowly and carefully, perhaps arrange objects or
activities in a particular way. This can take up so much time that
it takes ages to go anywhere, or do anything useful.
- Checking - your body for contamination,
that appliances are switched off, that the house is locked or that
your journey route is safe.
- Avoidance - of anything that is a
reminder of worrying thoughts. You avoid touching particular
objects, going to certain places, taking risks or accepting
responsibility. For example, you may avoid the kitchen because you
know you will find sharp knives there.
- Hoarding - of useless and worn out
possessions. You just can't throw anything away.
- Reassurance - you repeatedly ask others
to tell you that everything is alright.
How common is OCD?
About 1 in every 50 people suffer from OCD at some point in
their lives, men and women equally. That adds up to over 1
million people in the U.K. Famous sufferers may have included the
biologist Charles Darwin, the pioneer nurse, Florence Nightingale,
the actress Cameron Diaz, and the soccer player David Beckham.
If you gamble, eat or drink 'compulsively', do you have
No. The words 'compulsive' and 'obsessive' are sometimes used to
describe people who gamble, drink alcohol, shop, use street drugs –
or even exercise too much. However, these behaviours can be
pleasurable. The compulsions in OCD never give pleasure – they are
always felt as an unpleasant demand or burden.
How bad can OCD get?
It varies a lot, but work, relationships and family life are all
more productive and satisfying if you are not constantly having to
cope with OCD. Severe OCD can make it impossible to work regularly,
to take part in family life – or even to get on with your family.
In particular, they may become upset if you try to involve them in
Are people with OCD 'mad'?
No - but you may be reluctant to seek
help if you think that others will think you are mad. It's common
to feel ashamed or try to hide this problem. Although you may worry
that you will lose control, we know that people with OCD don't.
Other conditions similar to OCD
- Body dysmorphic disorder, or 'the distress of imagined
ugliness'. You become convinced that part of your face or body is
the wrong shape, and spend hours in front of a mirror checking and
trying to cover it up. You may even stop going out in public.
- An urge to pull out your hair or eyebrows
- A fear of suffering from a serious physical illness, such as
cancer (Health anxiety or hypochondriasis).
- People with Tourette's syndrome (where a sufferer may shout out
suddenly, or jerk uncontrollably) often have OCD as well.
- Children and adults with some forms of autism, like
Asperger's syndrome, can appear to have OCD because they like
things to be the same, and may like to do the same thing over and
When does OCD begin?
Many children have mild compulsions. They organise their toys
very precisely, or avoid stepping on cracks in the pavement. This
usually goes away as they grow older. Adult OCD usually begins in
the teens or early twenties. Symptoms can come and go with time,
but sufferers often don't seek help until they have had OCD for
What is the outlook without help or
Many people with mild OCD improve without treatment. This does
not usually happen with moderate to severe OCD, although there may
be times when the symptoms seem to go away. Some will slowly
get worse, for others the symptoms get worse when they are stressed
or depressed. Treatment will usually help.
What causes OCD?
Genes: OCD is sometimes inherited, so can
occasionally run in the family.
Stress: Stressful life events bring it on in
about one out of three cases.
Life changes: Times where someone suddenly has
to take on more responsibility – for example, puberty, the birth of
a child or a new job.
Brain changes: We don't know for certain, but
if you have the symptoms of OCD for more than a short time,
researchers think that an imbalance of a chemical called serotonin
(also known as 5HT) develops in the brain.
Personality: If you are a neat, meticulous,
methodical person with high standards you may be more likely to
develop OCD. These qualities are normally helpful, but can slip
into OCD if they become too extreme.
Ways of thinking: Nearly all of us have odd or
distressing thoughts or pictures in our minds at times - "what if I
stepped out in front of that car?" or "I might harm my child". Most
of us quickly dismiss these ideas and get on with our lives. But,
if you have particularly high standards of morality and
responsibility, you may feel that it's terrible to even have these
thoughts. So, you are more likely to watch out for them coming back
– which makes it more likely that they will.
What keeps OCD going?
Surprisingly, some of the ways in which you help yourself can
actually keep it going:
- Trying to push unpleasant thoughts out of your mind - this
usually only makes the thoughts return. For example, try not to
think of a pink elephant for the next minute – you will probably
find it difficult to think of anything else.
- Thinking 'safe' or 'correcting' thoughts. For example, you
spend time putting right a disturbing thought with another thought
(like counting to ten) or picture (such as seeing a person alive
- Rituals, checking, avoiding and seeking reassurance will all
make you less anxious for a short time - especially if you feel
that this might prevent something dreadful from happening.
But, every time you do them, you strengthen your belief that they
stop bad things from happening. And so you feel more pressure to do
them.... and so on.
- Remember - it's not your fault and you are not going
- Expose yourself to your troubling thoughts. This sounds odd,
but it's a way of getting more control of them. You record them and
listen back to them, or write them down and re-read them. You need
to do this regularly for around half an hour every day until your
- Resist the compulsive behaviour, but not the obsessional
- Don't use alcohol or street drugs to control your
- If your thoughts involve worries about your faith or religion,
then it can sometimes be helpful to speak to a religious leader to
help you work out if this is an OCD problem.
- Contact one of the support groups or websites listed at the end
of this leaflet.
- Buy a self-help book such as one of those listed at the end of
- Cognitive Behavioural Therapy
(CBT). This is a treatment that helps you change the way
you think and behave so you can feel better and get on with your
There are two types of CBT used to treat OCD -
Exposure and Response Prevention (ERP) and
Cognitive Therapy (CT).
- Exposure and response prevention (ERP)
This is a way to stop compulsive behaviours and anxieties from
strengthening each other. We know that if you stay in a stressful
situation long enough, you gradually become used to it and your
anxiety goes away. So, you gradually face the situation you
fear (exposure) but stop yourself from doing your usual compulsive
rituals, checking or cleaning (response prevention), and wait for
your anxiety to go away.
It's usually better to do it in small steps:
- make a list of all the things you fear or avoid at the
- put the situations or thoughts you fear the least at the
bottom, the worst ones at the top;
- then start at the bottom and work up, tackling one at a time.
Don't move onto the next stage until you have overcome the last
This needs to be done every day for at least one or two weeks.
Each time, you do it for long enough for your anxiety to fall to
less than half what it is at its worst – around 30 to 60 minutes to
start with. It can help to write down a measure of how anxious you
are every 5 minutes, for example, from 0 (no fear) to 10 (extreme
fear). You will see how your anxiety rises, then falls.
You may practice some of the steps with your therapist, but most
of the time you will be doing it on your own, at a pace you feel
comfortable with. It is important to remember that you do not need
to get rid of all your anxiety, just enough to manage it better.
Remember that your anxiety:
- is unpleasant but won't do you any harm;
- will go away eventually;
- will be easier to face with regular practice.
There are two main ways of trying ERP:
You follow the guidance in a book or DVD or use a software
programme on a computer, tablet or smart phone app. You also have
occasional contact with a professional for advice and support, but
less often. This approach may be suitable if your OCD is mild, and
you have the confidence to try out ways of helping
- Direct regular contact with a
professional, on your own or in a group.
This can be face-to-face, over the phone or by video link. This
usually happens every week or two weeks to start with, and can last
for between 45 and 60 minutes at a time. Up to ten hours of contact
is recommended to start with, but you may need more.
John could not leave the house on time for work every day,
because he had to check so many things in the house. He worried
that the house might burn down, or he might be burgled if he did
not check certain things five times each. He made a list of what he
was checking, starting with the easiest to tackle. It looked like
- the cooker (least feared)
- the kettle
- the gas fire
- the windows
- the doors ( the most feared)
He began with step one. Instead of making sure that the cooker
was switched off several times, he checked it only once (exposure).
At first he felt very anxious. He stopped himself from going back
to check again. He agreed not to ask his wife to check everything
for him as well, and not to ask her for reassurance that the house
was safe (response prevention). His fear gradually lessened over
two weeks. Then he moved on to step two (the kettle) and so on.
Eventually, he was able to leave the house without any of his
checking rituals and get to work on time.
Cognitive therapy is a psychological treatment which helps you
to change your reaction to the thoughts, instead of trying to get
rid of them. This is useful if you have worrying obsessional
thoughts, but do not perform any rituals or actions to make
yourself feel better. It can also be added to exposure
treatment (ERP) to help overcome OCD.
Cognitive therapy helps you to:
Stop fighting the thoughts
We all have odd thoughts at times, but that is all they are.
They do not mean you are a bad person or that bad things are going
to happen – and trying to get rid of such thoughts just doesn't
work. Relax in their presence. Treat them with mild curiosity or
amusement. If even more unpleasant thoughts intrude, don't resist,
let them happen, and think about them in the same way. Thoughts
will often fade away when you are happy to let them stay.
Change your reaction to your
You learn to notice when you are having upsetting 'thoughts
about thoughts' such as 'I'm a bad person for thinking like this.'
You may keep a diary of these unhelpful ways of thinking, then
challenge them by asking yourself:
- What is the evidence for and against this idea being true?
- How useful is this thought? What's another way to look at
- What's the worst/best/most realistic outcome?
- How would I advise a friend who had my problems? If different
to the advice I give myself, what makes me so
Deal with responsibility and blame
You tackle unrealistic and self-critical thoughts, such as:
- placing too much importance on your thoughts (they are 'just'
- overestimating the chances of something bad happening;
- taking responsibility for bad things happening, even when they
are out of your control;
- trying to get rid of all risk in the lives of your loved
Test out unhelpful beliefs
A common fear in OCD is that 'thinking it will make it happen'.
Try looking out of the window at a building and think about it
falling down. Get a really strong picture in your mind. What
happens? Another upsetting belief is that 'having thoughts is as
bad as carrying them out'. Imagine your neighbour is unwell and
needs some shopping done. Just think about doing it. Does that make
you a good person? In order to be helpful, you have to
do the action. The same is true for 'bad'
thoughts. It is important to learn that obsessional thoughts are
not carried out in
A cognitive therapist will help you to decide which of your
ideas you want to change, and will help you to build new ideas that
are more realistic, balanced, and helpful.
Most meetings with a therapist take place at your local GP
practice, a clinic or sometimes a hospital. You might be able to
have CT over the phone, or in your own home if you can't leave your
SSRIs (Selective Serotonin Reuptake Inhibitors) can help to
reduce obsessions and compulsions, even if you are not
depressed. Examples include sertraline, fluoxetine,
paroxetine, escitalopram and fluvoxamine. They are generally safe,
but may cause side-effects in the first few days like a headache,
dry mouth or feeling sick. SSRIs can be used alone, or with
CBT, for moderate to severe OCD. Higher doses often work
better for OCD. If treatment with an SSRI has not helped at all
after 3 months, the next step is to change to a different SSRI or a
medication called Clomipramine. It is best to continue medication
for at least 12 months, if it is helping. These medications are not
addictive, but should be gradually reduced over
several weeks before stopping.
How well do these treatments work?
Exposure Response Treatment (ERP)
About 3 out of 4 people who complete ERP are helped a lot. Of
those who get better, about 1 in 4 will develop symptoms in the
future, and will need extra treatment. BUT, about 1 in 4 people
refuse to try ERP, or else do not finish it. They may be too
fearful, or too overwhelmed to do it.
About 6 out of 10 people improve with medication. On average,
their symptoms reduce by half. Anti-obsessional medication does
help to prevent OCD coming back for as long as it is taken, even
after several years. Unfortunately, about 1 in 2 of those who stop
medication will get symptoms again in the months after stopping
it. This is much less likely to happen if the medication is
combined with CBT.
Which approach is best for me – medication or talking
Exposure therapy (ERP) can be tried without professional help
(in milder cases) and is effective and has no side-effects, apart
from anxiety. On the other hand, it needs a lot of motivation and
hard work, and it does involve some extra anxiety for a short
CBT and medication are probably equally effective. If you have
only mild OCD, CBT on its own is effective.
If you have moderately severe OCD, then you could choose either
CBT (up to 10 hours of contact with a therapist) or medication (for
12 weeks) first. If you are no better, then you should try both
treatments. There may be a waiting list to see a professional
of several months in some parts of the country.
If your OCD is severe, it's probably best to try medication and
CBT together from the start. Medication alone is an option if your
OCD is more than mild, and you don't feel you can face the anxiety
of ERP and your OCD. It helps about 6 out of 10 people, but there
is more chance that the OCD will return in the future – about 1 in
2 compared with about 1 in 4 for exposure treatments (ERP). It does
have to be taken for about a year, and is obviously not ideal
during pregnancy or breastfeeding.
It's worth talking these options over with your doctor who
should be able to give you any further information you need. You
may also want to ask trusted friends or family members.
What if the treatment does not help?
Your doctor can refer you to a specialist team, which may
include psychiatrists, psychologists, nurses, social workers and
occupational therapists. They may suggest:
- adding cognitive therapy to exposure treatment or
- taking two anti-obsessional medicines at the same time, such as
clomipramine plus citalopram;
- adding antipsychotic medication, such as aripiprazole or
- treating other conditions (1 in 3 people with OCD also
have anxiety, depression or a problem with alcohol
- working with your family and carers, to support and advise
If you have difficulty living on your own, they may also suggest
finding suitable accommodation with people who can help you become
With treatment, the outlook for most people with OCD is good. If
you have very severe OCD that has not improved, you might be
offered the choice of referral for a brain operation called
'ablative neurosurgery'. This is really a last resort as there can
be serious side-effects. An alternative approach being researched
is deep brain stimulation, using electrical pulses.
Will I need to go into hospital for treatment?
Most people get better by attending a GP surgery, or a clinic
that can be attached to a hospital. Admission to a mental health
unit will only be suggested if:
- your symptoms are very severe, you cannot look after yourself
properly or you have thoughts about suicide;
- you have other serious mental health problems, such as an
eating disorder, schizophrenia, psychosis or a severe
- your OCD prevents you getting to a clinic for treatment.
Which treatments do not work for OCD?
Some of these approaches may work in other conditions – but
there is not strong evidence for them in OCD:
- Complementary or alternative therapies such as hypnosis,
homeopathy, acupuncture and herbal remedies – even though they
- Other types of antidepressant medication, unless you are
suffering from depression as well as OCD.
- Sleeping tablets and tranquillisers, (zopiclone, diazepam, and
other benzodiazepines) for more than two weeks. These drugs can be
- Couple or marital therapy – unless there are other problems in
the relationship besides the OCD. It is helpful for a partner and
family to try and find out more about OCD and how to help.
- Counselling and psychoanalytical psychotherapy. Some people
find it helpful to think about the childhood and past experiences.
However, the evidence suggests that facing our fears seems to work
better than talking about them.
Tips for family and friends
- The behaviour of someone with OCD can be quite frustrating –
try to remember that he or she is not trying to be difficult or
behave oddly - they are coping the best they can.
- It may take a while for someone to accept that they need help.
Encourage them to read about OCD and talk it over with a
- Find out more about OCD.
- You may be able to help exposure treatments by reacting
differently to your relative's compulsions:
- encourage them to tackle fearful situations;
- say 'no' to taking part in rituals or checking;
- don't reassure them that things are alright.
- Don't worry that someone with an obsessional fear of being
violent will actually do it. This is very rare.
- Ask if you can go with them to see their GP, psychiatrist or
What if there is a long wait to start
Your GP may refer you to a local service called 'Improving
Access to Psychological Therapies' (IAPT) or to a specialist mental
health team. At the moment, there is a shortage of NHS
professionals trained in CBT. In some areas, you may have to wait
several months to start treatment.Qualified therapists are often
registered with the British Association of
Behavioural and Cognitive Psychotherapies. If the measures
outlined in the "helping yourself" section don't help, you can
start antidepressant treatment in the meantime.
A charity for people with OCD, body dysmorphic disorder,
compulsive skin picking and trichotillomania. Help and
information line: 0845 390 6232; email: firstname.lastname@example.org.
National support group for children and adults with
OCD. Advice Line: 0845 120 3778 or email: email@example.com.
An organisation for people with anxiety problems including
panic, phobias, OCD and related conditions. Provides support to
sufferers, their family and carers. Live chat, email, self-help
books, CDs, DVDs and resources. Helpline: 0844 775774; email:
Information from the National Health Service on conditions,
treatments, local services and healthy living.
British Association for
Behavioural & Cognitive Psychotherapies
The main body for the different groups of professionals who
offer CBT inside and outside of the NHS. It maintains
standards of good practice, provides information, leaflets
and keeps a register of members who can be contacted for
non-NHS treatment. Tel: 0161 054 304; email: firstname.lastname@example.org.
For information on self help computer packages for anxiety,
depression, phobias, panic and OCD see our leaflet on CBT or the following
Well Agency: Books on PrescriptionReading Well Books on
Prescription helps you manage your well-being using self-help
reading. The scheme is endorsed by health professionals, including
the Royal College of Psychiatrists, and is supported by public
- NICE: Core interventions in the treatment of
obsessive-compulsive disorder and body dysmorphic disorder.
Clinical guidelines 31 (Quick reference guide), National Institute
for Health & Clinical Excellence, 2005.
Obsessive-Compulsive Disorder Evidence Update 47. National
Institute for Health & Care Excellence, 2013.
- Blenkiron P. Treatment of
obsessive compulsive disorder (review). Continuing
Professional Development Bulletin in Psychiatry, (2001), vol 2,
- Roberts A & Veale D.
Obsessive-Compulsive Disorder (review). British Medical
Journal, 2013, vol 348, pages 31-34.
This leaflet was produced by the Royal College of
Psychiatrists' Public Education Editorial Board.
Series Editor: Dr Philip Timms
Expert Review: Dr Paul Blenkiron
This leaflet reflects the best available evidence available at
the time of writing.
© October 2014. Due for review: October 2017. Royal
College of Psychiatrists. This leaflet may be downloaded,
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