Obsessive compulsive disorder: why it's so hard to control

Barbara Trousdale vividly recalls the feeling of her life cycling wildly out of control when, as a child, she went back to school after being off sick - to find that everyone else had been given a homework diary, and there wasn't one left for her.

"It was first term at grammar school and I was already quite an anxious child. I remember the tone of the teacher's voice as she told me that I would have to keep my own lists. The horror of being given such a responsibility created such a sense of discomfort, a fear that I might not do everything that was expected of me and that I expected of myself."

Trousdale, now 43, began to keep long detailed lists of schoolwork. Within months, this had spilled over into everything else. "Every day, I'd have to write long lists of what needed to be done and then check them over and over again for fear that I might have crossed something off by mistake.

"When I left school, I became a medical technician and became aware of the hazards of contamination. Then my real problems started, with an obsessive need to wash my hands and clean my house several times a day."

Obsessive compulsive disorder (OCD) is the problem David Beckham owned up to last weekend. The England football captain said he couldn't control his need constantly to clean and tidy his possessions. OCD affects around three in 100 people in Britain today and - though it may seem to be on the increase, perhaps reflecting our growing desire to eliminate risk in our lives - the incidence has barely changed for centuries.

What has changed is our willingness to talk about it. "It's always been an iceberg phenomenon," says Paul Salkovskis, Professor of Clinical Psychology at the Institute of Psychiatry, who appeared in Channel 4's The House of Obsessive Compulsives last year. "It's just that the tip is getting bigger."

It was dubbed the "doubting disease" when first described as a problem distinct from other anxiety disorders by the French psychiatrist Pierre Janet in 1902. Freud believed the syndrome was a prelude to serious mental illness, the obsessive self-doubt being a maladaptive response to unacceptable sexual or violent feelings, while the compulsive acts were an attempt to neutralise the offending idea and impulses.

The result, not surprisingly, is that most sufferers feel high levels of shame, on top of the anxiety and distress - often believing they are the only ones to experience such strange, upsetting feelings.

Beckham acknowledges that it is still quite normal to scoff at sufferers: he was, he says, ruthlessly mocked by former Manchester United team-mates. "They'd come into my hotel room and I thought they were just coming in for a chat. But then they'd go out and I'm thinking, 'Something's different here.' And then all the magazines would be wonky. They'd have been in my wardrobe and all my trousers and shoes would be all over the place. It was a joke with them."

Trousdale recalls a similar lack of understanding. When she went to her GP for help, she was told to pull herself together. "As a sufferer, I was always very slow. Being OCD made me slow because I had to check everything so much. But I couldn't explain that to people at work. And I know they used to talk about me and do everything possible not to have to work with me."

Today, with greater understanding of the disorder, the stigma of OCD is diminishing and people feel more able to speak out about their experience. While OCD does run in families (brain scans show evidence of a biological susceptibility), the first episode is usually triggered by a major stress or life event at any time from childhood onwards.

"OCD often begins at a time when there has been a major shift in the amount of responsibility people have to take, perhaps because they have a baby or go to university or get promoted at work," Salkovskis says.

What happens, he says, is that unpleasant thoughts that can occur to anyone can suddenly acquire extra significance. "Most new mothers worry that their baby might stop breathing, and are fully aware that it is just a thought and no more. But a woman with OCD will have the thought and begin to worry about what it means to ignore the thought, or to feel that simply having it makes them responsible for harm that might come to their baby.

"They feel compelled to prevent that harm, or at least them being responsible for it - and they try to suppress the thought. It's the worst possible response: just tell yourself not to think of a giraffe and the image of a tall-necked spotted creature will occupy your mind."

OCD, he says, is a culture-specific problem - and the most common obsessions are often what secretly frightens a society the most. In the 16th century, it was the wrath of God: in 1691, Bishop John Moore warned of the "naughty and sometimes blasphemous thoughts which start in the mind while they are exercised in the worship of God and despite all their attempts to stifle them, the more they struggle with them, the more they increase".

Syphilis was a major worry in the 18th century, Salkovskis says, with a huge growth in obsessions about contamination resulting from the discovery of germs. Radiation became a focus after the Second World War, with obsessing about HIV, CJD and sexual abuse of children increasingly becoming a problem today.

OCD can be cured - although it's not easy, almost always requiring sufferers to face up to their worst fears (as was shown on the Channel 4 programme). Guidelines from the National Institute for Clinical Excellence, which were published in November last year, recommend cognitive behavioural therapy (CBT) as the first-line treatment, preferably used alongside medication with an antidepressant in serious cases.

"Treating OCD with CBT can be enormously successful, but it is very hands-on and requires a commitment on both sides," says Dr John Morgan, consultant psychiatrist at Leeds University. The sufferer has to trust the therapist enough to stay with them while they are exposed to the object of their obsession for long enough that their anxieties can be neutralised and gradually diminish.

"It's a very specialist therapy - I have seen people with OCD who have been nearly destroyed when they have been treated with conventional psychotherapy - which involves delving back into childhood and which increases their tendency to negative rumination."

Barbara Trousdale has engaged in treatment for her OCD several times - but, so far, never successfully. "It has never worked, for one reason or another, and at the moment I'm not working and unable even to look in the fridge when my husband is at work for fear of what I will find in there. I'm still shying away from the prospect of getting better."

In any case, effective treatment for OCD is still not widely available and, Morgan says, it could become even harder to find, with primary care trusts currently "asset-stripping mental health services" - the result of a failure to take mental health problems sufficiently seriously.

It is to be hoped that David Beckham's revelation might change that. "Who knows," says Salkovskis, "it may become fashionable to admit to OCD tendencies. Certainly men are far more reluctant to admit to being OCD, and it is to be hoped that Beckham speaking out will help more of them come forward to ask for help."

Do you have OCD?

Write down "yes" or "no" in answer to each of the following questions, based on your experiences in the past month.

1. Do you have concerns with contamination (dirt, germs, chemicals, radiation) or getting a serious illness such as Aids?

2. Are you over-concerned with keeping objects (clothing, shopping, tools) in perfect order, or arranged exactly?

3. Do you have personally unacceptable religious or sexual thoughts? Do you worry about accidentally hitting a pedestrian with your car or letting it roll down the hill?

4. Do you worry about harm coming to a loved one because you weren't careful enough?

5. Are you concerned about physically harming a loved one; pushing a stranger in front of a bus; steering your car into oncoming traffic; inappropriate sexual contact; or poisoning dinner guests?

6. Do you perform excessive or ritualised washing, cleaning or grooming rituals?

7. Do you check light switches, taps, the oven, door locks or your car's hand brake?

8. Do you collect useless objects, or inspect the rubbish before it is thrown out?

9. Do you repeat routine actions (getting in/out of a chair, going through a doorway, relighting a cigarette) a certain number of times or until it feels "just right"?

10. Do you feel a need to confess or repeatedly ask for reassurance that you said or did something correctly?

Consider your experience of repeated thoughts, images, urges or behaviours during the past 30 days. Select the most appropriate response that applies to you.

For how much of the day are you affected?

Mild (less than one hour)

Moderate (one to three hours)

Severe (three to eight hours)

Extreme

How much distress do they cause you?

None

Mild

Moderate

Severe

Extreme (disabling)

How difficult is it for you to control these thoughts? Do you have:

Complete control

Much control

Moderate control

Little control

No control

How much do they interfere with school, work or your social or family life?

None

Slight interference

Definitely interferes with functioning

Much interference

Extreme interference (disabling)

The more questions you have answered "yes" to in the first section, and the more extreme your experience as shown in the second section, the more likely it is that you have OCD. If you are experiencing psychological distress, it might be advisable to see a clinician for evaluation. Most "normal" people have some obsessive thoughts and ritualistic behaviour in their lives. It's only when their obsessions and compulsions start becoming an overwhelming primary focus in a person's life that a person has clinical OCD.

Questionnaire compiled by OCD Action (ocdaction.org. uk; helpline 0845 390 6232)