“OCD” is often used as an adjective to describe someone who enjoys cleanliness and organisation, but is that appropriate?
“OCD” is often used as an adjective to describe someone who enjoys cleanliness and organisation, but is that appropriate?
In this episode, Amelia and Jessica are joined by Dr Rebecca Anderson, an expert in Obsessive-Compulsive Disorder (OCD) research. She describes the symptoms and types of OCD, how information about OCD has been muddled during the pandemic and how new treatments might help better alleviate the symptoms of OCD in the future.
If you have OCD or know someone who has it and need advice, please visit Beyond Blue if you live in Australia, or look for your nearest OCD clinic. Dr Anderson also has a free treatment program available for adolescents.
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Dr Rebecca Anderson –Senior Lecturer, School of Population Health, and Psychology Clinic Director, Health and Wellness Centre, Curtin University.
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You can read the full transcript for the episode at https://thefutureof.simplecast.com/episodes/ocd/transcript
Jessica Morrison (00:00):
Listeners are advised that the content covered in this episode may be triggering for people with OCD.
Amelia Searson (00:06):
This is The Future Of, where experts share their vision of the future and how their work is helping to shape it for the better. I'm Amelia Searson.
Jessica Morrison (00:16):
And, I'm Jessica Morrison. Obsessive-Compulsive Disorder or OCD as it's commonly known, is often trivialised in the media and broader society as referring to a quirk that someone has if they enjoy cleanliness, being organised or have a strong attention to detail. This misconception doesn't seem to be going anywhere in the near future, now that everyone is becoming more focused with their cleaning procedures to deal with the pandemic. It's therefore important that we develop our understanding of OCD to help those with the disorder, especially if they do not know that they have it. To discuss this topic with us today is Dr. Rebecca Anderson, a senior lecturer in the School of Population Health at Curtin University, and co-founder of the OCD? Not Me! online treatment program for young people. Thanks for coming in today, Rebecca.
Dr Rebecca Anderson (01:01):
Jessica Morrison (01:02):
To start us off, what actually is OCD?
Dr Rebecca Anderson (01:05):
Well, the D part is important. So it's a disorder, and it's marked by obsessions and compulsions. So, the obsessions are repeated unwanted thoughts that we have pop into our mind, and that we seem to have trouble getting rid of. And in response to those obsessions, we then engage in compulsive behaviours, which can sometimes be quite ritualised that is designed to try and relieve the distress at the initial thought popping in creates. So an example might be, the most sort of common one we hear about and we've heard a lot about this past year, things like cleaning compulsions. We might have an image or the thought pop into your mind that, "What if I get my family sick?" And then, the anxiety starts to build and to get rid of that anxiety, we then engage in hand-washing and that brings down the anxiety. But over time, the behaviour becomes quite ritualised. And when we getting to a disorder level, it's starting to actually impact on our day-to-day life and it's causing a lot of distress.
Amelia Searson (01:57):
And obviously, we mentioned the past year, everyone's becoming more cleanly, I suppose, more aware of hygiene because of the pandemic. But, how do clinically diagnosed OCD behaviours sort of differ from the COVID-safe behaviours that we're being encouraged to practice?
Dr Rebecca Anderson (02:13):
Yeah, this is actually a fascinating question. And, it's one that's led to some interesting publications in our area. We've had to sort of shift a little bit what we do in our clinic as a result of COVID-safe practices. So typically, when we treat OCD, we use Exposure and Response Prevention techniques, and that involves us confronting feared situations. So, usually for people who are doing things like excessive hand-washing, that might involve touching things that they perceive to be dirty and then refraining from washing their hands for some time. Now, that's currently at odds with the public health messaging around being COVID safe. So, we've had to adapt to what we actually do in our clinic. And, we've had to look at what is above and beyond what you'd consider to be a normal hand wash now. So you have to look at, in the context of the public health messaging around this very real threat – it's not a perceived threat, which is what we sometimes get with OCD – There's a very real threat there around COVID.
Dr Rebecca Anderson (03:06):
And so, we have to respond and change our treatments to actually match with that. But OCD isn't just hand-washing, there's lots of other subtypes of OCD. So, we have people who engage in more checking type behaviours, so checking the stove, the locks, everything's in order. We've had people involved in treatment with us who have lined up all their kitchen appliances on a fireproof mat on their front veranda before leaving home, because then they can visually go, "Right, it's all there, I know none of that can catch alight, because they're not plugged in and I can now leave for work for the day." So, subtypes like that. We also have subtypes referred to sometimes in OCD groups as "Pure O" OCD. And, that involves people having these awful intrusions, thoughts like, "Maybe I'm a paedophile and don't know it." "Maybe I'm going to push a little old nanna over in the street." "Maybe I'm violent and don't know it."
Dr Rebecca Anderson (04:03):
And in response to that, instead of doing overt rituals, that everyone can see, they're doing a lot of mental rituals of trying to push thoughts away, or trying to just think their way out of that. And so, we get a lot of mentalised rituals, which are very, very distressing for people. And then, we also have just arranging type compulsions, where people feel driven to arrange things in particular ways, do them until they feel just right. So, it could be that you have to do them a certain number of times or until you get a visual alignment of the item. So, there's multiple subtypes of OCD that we see, presents in all sorts of different ways and sometimes can be confused with other disorders. So, we have to be really careful with how we separate it out and make sure that it is actually a diagnosis.
Jessica Morrison (04:45):
Rebecca, we've talked about misconceptions of OCD. So, how could we benefit from raising awareness of the disorder in the community and whose responsibility is that? Because you've sort of talked about some of the obsessions and compulsions there, and I don't mind sharing this, but I have a very set ritual in how I check the locks in my house, very safety conscious.
Dr Rebecca Anderson (05:05):
Jessica Morrison (05:06):
So, I don't believe I'm OCD, however, can we talk about these misconceptions and how we go about addressing them?
Amelia Searson (05:12):
It's also very common, I think, for people to say like, "Oh, you're so OCD."
Jessica Morrison (05:16):
Amelia Searson (05:16):
And, they really flippant about it. And obviously, it's not something that we should be flippant about.
Dr Rebecca Anderson (05:21):
Indeed. So, there's probably sort of two parts to that. And the first is, I guess, we need to have a good understanding of what normal behaviour is and therefore what disorder is, to be able to then tell people when, I guess, the behaviour is okay and even when a thought is okay. So, the very first part of that, that sort of normalising, we need to, I think get good public health information out there that intrusions are totally normal. So, we've got evidence from around the world that about 94% of people across all continents experience intrusive thoughts. So, you're driving car and you have a thought, "What if I just run my car off the road."
Amelia Searson (05:59):
Oh, my gosh, yes.
Jessica Morrison (06:00):
Dr Rebecca Anderson (06:00):
Okay. Yeah. And, we see there's an increased risk of OCD in the perinatal period. And so, we see a lot of new parents who have thoughts: "What if I drop the baby?" "What if I accidentally harm the baby?" And, we kind of got into that area of research, when I had my first child. I caught up with another colleague who also does OCD research. And we started talking about our intrusion, and we're like, "We know what these intrusions are, we work with these all the time; and yet, they're so distressing." I was having thoughts of what if I accidentally put my baby in the Thermomix.
Amelia Searson (06:32):
Jessica Morrison (06:32):
Dr Rebecca Anderson (06:32):
And you ... it's a horrific thought. And yet, I know what they are. And yet, they're still giving me anxiety. And, you sort of like, you almost turn your baby a little bit away from the kitchen bench as you walk past going, "Oh God, what if I didn't control myself there?" So, we need good public health information about what's normal. That intrusions are very normal, but the responses that we have to them matter. We need to be able to have those thoughts pop into our mind because we can't control that at all, and be able to not feel driven to respond to them in the ways that we do. So, that's sort of the first part. We also need to know which behaviours are normal. When do you stop washing your hands, when you wash your hands?
Jessica Morrison (07:15):
Oh, after Happy Birthday, because that's what the public health advice is.
Dr Rebecca Anderson (07:17):
There you go!
Amelia Searson (07:17):
Or Row, Row, Row Your Boat, as well.
Dr Rebecca Anderson (07:20):
Oh, yeah. But before that public health advice, what was your stop signal for that?
Amelia Searson (07:24):
I never had one. I still don't have one, to be honest.
Jessica Morrison (07:28):
That's never been a thing for me personally, but I don't know. So tell us, what is 'normal'? What's considered normal? I hate using the word normal. But what's considered-
Dr Rebecca Anderson (07:36):
Amelia Searson (07:37):
Jessica Morrison (07:38):
What's the diagnostics of–
Dr Rebecca Anderson (07:39):
Yeah. Sometimes we get a bit caught up with what that stop signals meant to be.
Jessica Morrison (07:43):
Dr Rebecca Anderson (07:43):
So for people with OCD, they might be looking for a felt sense. "It has to feel like I've got to the perfect amount", or "I have to have done it for the exact right amount of time", or "I have to have done it three times: I've got to wash my hands with soap, turn the tap off, dry them, do it again with soap, and threes the stop signal". So, we get sort of a bit muddled up with when to stop doing a behaviour as well. So, there's a few things that start to happen that sort of differs between what you might consider more normal behaviour and where we're getting more into the problematic OCD. But it all does come down to: are you feeling distressed? Is that distress impacting on you on a day-to-day basis? Is it starting to impact on your functioning?
Dr Rebecca Anderson (08:25):
So, if you're washing for so long that you can't get out of the house and we've certainly seen that, that's impacting on you're functioning and that's where you might need to start to get some help. So, coming back to your original question around whose role is it, I think it's very much the role of us in academia to be promoting what is normal and when should you get help. But knowing full well that a lot of these behaviours sit on a bit of a spectrum, and that we all engage in hand washing, we all have our own stop signals for doing that. And so, we need to know when it's actually getting excessive, and more unreasonable and when it might warrant some help. There's been some wonderful efforts in the UK, in the U.S. starting to tackle this idea of stigma around the use of terminology like, "I'm so OCD".
Dr Rebecca Anderson (09:13):
And there's been pushback, even in media campaigns. I recall there was an incident where there was a cleaning company, I think it had called itself something like the "OCD Cleaning Company" (ERROR: it was called "OCD Ltd") or something to that effect. And so, this wonderful consumer groups in the UK had pushed back on that media advertising and actually got some change. So, it got them to change the name. So, there's some really good things happening, very consumer driven. So, I think consumers, although they're often a hidden voice, they can have a really big role in actually preventing that sort of misconception from continuing.
Jessica Morrison (09:49):
I feel like maybe the portrayal of certain characters in TV shows and movies can often play a part in this wider misunderstanding. I think of Monica in Friends and her cleanliness.
Amelia Searson (09:59):
Yes. And, like Sheldon Cooper from the The Big Bang Theory.
Jessica Morrison (10:01):
Amelia Searson (10:02):
He had little rituals and quirks that he sort of got up to.
Jessica Morrison (10:05):
So, how do we get the media or these production houses to sort of change that, because I feel like that plays into it a lot?
Dr Rebecca Anderson (10:12):
Yeah. Look, I mean, I don't know the answer to that question. I think it's a big question. I think one of the things that'd be great to see is not just the cleaning and checking subtypes represented, because they make up a part of the OCD picture, but not the entire OCD picture. They're a really easy reference point though, because it's such an obvious and overt behaviour sometimes when someone is showering excessively, or redressing themselves 14 times, because that's the right number that they've got to get to. It's a very visual thing, so it presents better in a media screen. It's hard to portray those intrusive thoughts: "maybe I'm a paedophile", "maybe I'm a violent person". It's hard to portray that in a media setting, but really we see a lot of clinical cases with those types of presentations and they're having remarkable impacts on people's lives, in terms of their ability to go about their day-to-day life.
Amelia Searson (11:12):
And Rebecca, obviously a lot of your research is on the actual treatment of OCD. And, that's obviously something that we really want to discuss in this episode. So, how is OCD treated? I know there are lots of different types of OCD and everything, so it's probably a difficult question to answer, but could you give us a bit of insight into it?
Dr Rebecca Anderson (11:30):
It's a very straightforward answer.
Amelia Searson (11:31):
Dr Rebecca Anderson (11:31):
We use Exposure and Response Prevention: it's the number one treatment alongside medication as well, for the more severe cases. So Exposure and Response Prevention involves starting to gradually confront feared situations and not engaging in our regular compulsive behaviour. So for the more overt, the hand-washing example – I hate to keep going back to that after just saying we need to represent all forms – but that might involve touching things that we perceive to be more contaminated. And, refraining from washing hands until a certain point in time where it might be more naturalistic to actually wash your hands, like after going to the bathroom or patting a dog.
Dr Rebecca Anderson (12:11):
For the more covert type forms of OCD. If you're having intrusions that "maybe I'm a violent person", "I'm going to push a nanna over in the street" – that might involve letting yourself have these awful thoughts, maybe even doing that in the presence of little old nannas in the street, and not trying to do some of the things you might normally do, like push thoughts away, or avoid the nannas or walk to the other side of the street, or put your hands in your pockets, so you don't accidentally push them over or deliberately push them over, depending what your thoughts are telling you. So, we engage in this graded approach to confronting the feared situations that are being avoided. And, that is worldwide recognised as being the most useful approach for OCD.
Amelia Searson (12:55):
Those violent intrusions that you were talking about. That's really interesting to me. Do you find that there's a particular reason why people would be having violent intrusions?
Dr Rebecca Anderson (13:04):
Yeah. The most clear answer to that is that it's usually completely against the person's values. And so because of that, they get stuck on the thoughts. So, you've got new moms with a baby that they care about, and they have complete responsibility for and they love with all their heart, and you have an intrusion about putting them in the Thermomix. It's completely against your values, and therefore it gets stuck and you start to worry and ruminate about it. We've seen school teachers, love being school teachers having thoughts popping in: "Maybe I'm a paedophile." And so, they actually withdraw from their job for fear that it could come true. And so, it's usually completely at odds with their values and their personality, and their actual desires and wishes in life and that's why they get stuck on those thoughts.
Jessica Morrison (13:50):
Some clinical psychologists and researchers in this field, including yourself, have suggested that behavioural treatments should focus more on eliminating rumination or perfectionist behaviours. Do you see any of these types of suggested changes catching on in the future?
Dr Rebecca Anderson (14:04):
Yeah. So, we've done some evaluation of treating perfectionism, which often does co-present and can sometimes underlie Obsessive-Compulsive Disorder. And, we found we've had really good outcomes with that, but we have had difficulty sometimes getting people engaged who are also higher on the perfectionism. And by that, I mean that they're often very driven individuals and they've got a lot on. And so, we're saying, "Come in for treatment," and they're like, "I can't, I got so much on." And so, it can be sometimes difficult just to get the initial engagement. But when we do get people in, tackling underlying perfectionism can be quite effective. The other area that you've mentioned, rumination, is incredibly important. So, if you think about what keeps people feeling distressed, it's not that you've touched something that's perceived to be contaminated, it's that you're sitting there stewing on it and thinking about it and worrying about what that means.
Dr Rebecca Anderson (14:52):
Or you might be going back and trying to backtrack and understand: "What did I touch? Did I touch that and that, and that, and is that therefore contaminated as well?" And so, you spend all that time caught up in your mind and that's what's actually keeping you feeling distressed. And so, if we can tackle that rumination, the thinking that goes along with it, we could probably have a really good impact here in terms of in some ways making our exposure therapies that are already quite good, even more effective. So, I think that's sort of where we ought to be heading in the future. It combines a couple of areas of my research. So, I have done some research looking at repetitive negative thinking and how if we tackle that, we can actually alleviate a lot of distress for a range of different mental health disorders. So that rumination process, it really does affect not just OCD, but depression, social anxiety, a range of other disorders and tackling that is really, really critical.
Amelia Searson (15:48):
And Rebecca, you've recently proposed a trial to induce low-intensity electrical currents to help modulate the cortical activity in the brains of people with OCD. What are you hoping to accomplish and where do you hope that this will lead?
Dr Rebecca Anderson (16:03):
Yeah. What we're hoping to accomplish there is finding another avenue to get in and treat people. So, our treatments are really pretty good. So, Exposure and Response Prevention, if you look at the literature, it sort of says: "Around two-thirds, up to 80% of people respond quite well to our Exposure and Response Prevention therapies." Medications are quite effective as well. On its own, not particularly helpful when people stop the medication, because we often get a lot of relapse, up to 90% of people relapse if they just get medication. But if you add Exposure and Response Prevention, you're getting up to that in more sort of 70, 80% in terms of good treatment response. Now, that sounds amazing. That's a really good outcome, and we don't get that with a lot of other disorders, but it does leave a chunk of people for whom the treatment is not working and they're the ones that interest me.
Dr Rebecca Anderson (16:51):
We've got these great treatments we can deliver, but we've still got this big chunk of people here that we need to get help to. So this treatment trial – tDCS, we refer to it as – is looking at, is there another avenue to get into people who are getting stuck with OCD and not responding to our traditional treatments? So, around the world there's been a couple of trials, looking at tDCS in treatment refractory cases. So, those ones that didn't respond. They've had usually two trials with the best available medications. They've also had a good go at Exposure and Response Prevention, and they've not got any change in their symptoms. And so, there's been some uncontrolled trials look at tDCS to see: does that lead to symptom change? And, it looks really good. So, getting some really good treatment outcomes in terms of symptoms actually reducing, when they haven't been able to get that with our traditional therapies. But they uncontrolled and you can't hide that you're giving someone tDCS.
Dr Rebecca Anderson (17:48):
If you're sitting there with a cap on your head with electrodes on it and the saline solution, making sure you're getting this sort of gentle current. It's not something that you can feel, you might feel a little bit of tingling on the scalp as you're receiving it. So, it's not something that has been hidden to the participants: whether they've received it or not. And so, our trial is actually looking at a randomised control trial, where some people will and won't receive it, but they won't know. So, we'll actually be able to answer this question: is it just an expectancy effect? Are people expecting tDCS to work, because it's kind of the next big thing? Or is it actually ridgy didge? Does this work? So with our trial, we have a couple of different trials on the go. One is an RCT looking at a placebo versus the actual tDCS, so everyone comes in, everyone gets a cap. Not even the researcher knows, it's a blind trial. So the researcher doesn't even know; they just hit a switch and it's all pre-programmed to deliver the therapy.
Dr Rebecca Anderson (18:48):
Those who aren't receiving the proper tDCS, they get a little bit of ramp up with the electrical stimulation, but then the machine shuts off without anyone knowing. And so, we'll be able to really answer this question: does it have an effect on OCD just on its own? I mean, that would be amazing for people to be able to come in, they watch a nature video while they're receiving it. It's amazing. So, that's one of the trials we have on the go.
Amelia Searson (19:12):
Do you have – sorry to interrupt you.
Dr Rebecca Anderson (19:13):
Amelia Searson (19:13):
Do you have sort of a timeline for when you will be able to get those answers?
Dr Rebecca Anderson (19:17):
We're conducting this trial over the next year. So, we're currently recruiting people into that trial. So, we have another trial also, that's a smaller trial. And this one isn't controlled. This is just simply a ... we're tracking people over a baseline period, so we're getting some baseline measures. And then, we're combining exposure therapy and tDCS. So we get all the acronyms: ERP and tDCS for OCD.
Amelia Searson (19:40):
Dr Rebecca Anderson (19:40):
And so, we're kind of wondering whether if you stimulate the areas of the brain that are indicated in OCD, while we do Exposure and Response Prevention: does it kind of turbocharging sort of unlock something that's not being unlocked normally when we do exposure in these people. So, we're trialling that: first trial of that worldwide. So, we're excited to see what happens. We've had a few participants already go through. And I won't give away how it's progressing, but I'm excited.
Amelia Searson (20:08):
We'll talk to you in a little while by the sounds of it.
Jessica Morrison (20:11):
If the sky was the limit, Rebecca, how could life be made easier for people with OCD?
Dr Rebecca Anderson (20:17):
Yeah. I think good, you know, general population-level information about OCD is the starting point. For people to understand, what is an OCD. We all have our quirks: that's not OCD. We all have our things we like done a particular way: that's not OCD. But we need to know when do you need help? And then the next step is, where do you get that help? We do know that there's a lack of services for people with OCD. And that's problematic. There's a lot of clinicians who are trained in providing services for anxiety disorders more generally, but it's a very specific assessment and treatment process that needs to be adhered to for Obsessive-Compulsive Disorder. And, not everyone with OCD receives that even though they are accessing services. So, we've recently had a client refer to our clinic and we're the fifth psychologist they've been to, and they've never received Exposure and Response Prevention.
Dr Rebecca Anderson (21:11):
There's sometimes a reluctance on the part of clinicians to do exposure work, because it does deliberately, quite deliberately make people distressed. So, we're trying to get them to feel the things they're avoiding feeling, and process that and sit with that. And so, it's not a pleasant thing to do, but it is the right treatment. So there is some reluctance amongst clinicians, even well-versed clinicians in the treatment of mental health disorders to use the treatments that are most effective in this area.
Amelia Searson (21:43):
And, obviously we talked about the importance of raising public awareness about OCD and things like differentiating between non-diagnostic behaviours and diagnostic behaviours. What can our listeners do, and I guess, broader society, to help people with OCD, whether it's themselves, or if they've noticed symptoms or certain behaviours in their loved ones?
Dr Rebecca Anderson (22:04):
Yeah. One of the tricky things is: if your loved one has OCD, you often get pulled in to the rituals. It's got a name, it's called "Family Accommodation". So, we see this a lot with especially young children, but even with adults, that if you've got a child who's distressed and they're engaging in rituals that you tend to try and help, so you might get pulled into the ritual of arranging things a particular way, or reassurance giving. So, we get pulled into giving reassurance: "It's going to be okay, those thoughts don't mean anything". And, we get caught up in that. And so, part of the, I guess, role for family and carers is to understand that it's very normal to get pulled in to the OCD ritual. But that doesn't mean it can't be undone in a supportive and structured way, and that good therapy should involve family members and gradually reducing some of that accommodation.
Dr Rebecca Anderson (22:54):
So, I think that's just something to be aware of for anyone who has a family member: that it's very normal, just the good things we can do about that. But supporting someone to come along to actually engage in therapy and trying to help the person find therapy. There's an average wait time from the onset of significant symptoms to seeking help of about eight years. So, that's a long time for people to be suffering. And most of the time, it's not that they don't know that they need help: they're feeling ashamed. They're uncertain about what will happen when they come in for therapy. And so, there's this massive delay. And so, we'd love to see that reduce over time. So getting good information out there, alerting family members to encourage someone to come along and try and help them access support. I think they're all really important in how we get people into services earlier.
Amelia Searson (23:46):
Wow. Thank you so much, Rebecca, for coming in and sharing your extensive knowledge on this really, really important topic.
Dr Rebecca Anderson (23:53):
Amelia Searson (23:55):
And just remember, if you do have OCD or feel you need to talk with someone, there are always places to go to. Rebecca, where can people go?
Dr Rebecca Anderson (24:02):
There's a range of options for people. So, if you are feeling like you're ready to take that step to go into treatment, head to your GP, you can get a mental health care plan to head off to see a psychologist. If you're looking for a specialist treatment service, you can certainly find that information on the International OCD Foundation website. And, if you'd just like some online support and help for young people, we have a free online treatment called, OCD? Not Me! So, you can access that treatment programme from anywhere in the world and the address is ocdnotme.com.au.
Jessica Morrison (24:36):
Fantastic. Thank you, Rebecca. And, we'll make sure we put all of those links in today's shownotes. You've been listening to The Future Of, a podcast powered by Curtin University. Leave us a comment wherever you find this episode, we'd love to hear from our listeners. And, if you've got something out of the episode, please rate us. Until next time, bye for now.