Obsessive compulsive disorder (OCD)

Obsessive compulsive disorder (OCD) involves unwanted thoughts that keep coming back, and the things you feel driven to do about them. It’s treatable, and one kind of therapy has more evidence than any other. This page covers what OCD involves, why unwanted thoughts are common, how therapy and medication can help, and how to find help.

What OCD involves

OCD involves obsessions and compulsions (healthdirect). Obsessions are unwanted thoughts, images or urges that keep coming back and cause a lot of distress. Compulsions are things you feel driven to do, over and over, to ease that distress or stop something bad happening.

The themes are wide. Common ones include:

• fear of germs or illness
• fear of harming someone
• needing things to be in order or feel just right
• sexual or religious thoughts
• doubts about whether you’ve locked the door or turned something off.

Compulsions can be washing, checking, counting, putting things in order, or asking other people for reassurance. Some rituals happen in your head, with nothing anyone else can see.

OCD isn’t about liking things tidy. For many people it has nothing to do with order at all.

More than half a million Australians have OCD, and it usually starts in late childhood or the early teenage years. Many people with OCD keep it secret because of shame about the thoughts. Only a proper assessment can say whether it fits, and a diagnosis describes a pattern you’re living with, not who you are.

Unwanted thoughts are common

In a study of nearly 800 university students in 13 countries, almost all had at least one unwanted, intrusive thought in the previous three months (Radomsky and colleagues, 2014). Having a thought like this doesn’t say anything about who you are or what you want. In OCD, the thoughts come more often, cause much more distress, and lead to things you feel you have to do.

If a thought frightens you, or you’re not sure whether it’s this or something else, talk to a GPGP (general practitioner) For most people, where getting help starts. A GP can write a Mental Health Treatment Plan, prescribe medication and refer you on, and some are trained to deliver a small number of structured therapy sessions themselves. More in the jargon decoder Close. If you’re having thoughts of suicide or of hurting yourself, the numbers at the end of this page are there any time.

What helps

For OCD, the kind of therapy matters more than it does for most other problems. ExposureExposure (facing things in steps) Facing what you've been avoiding, a bit at a time, and staying long enough for the alarm to settle. For fear and anxiety, it's often the part of therapy that does most of the work. More in the jargon decoder Close and response prevention, a kind of cognitive behavioural therapy (CBT), has the most evidence for OCD, and it’s what guidelines recommend first (UK guidelines, 2005). You gradually face the things that set off your anxiety. Then you hold off on the checking, washing or asking for reassurance you might normally do to reduce your anxiety. It’s uncomfortable, and you and your therapist work out the pace together, starting with things that feel manageable.

A review of 37 trials found CBTCognitive behavioural therapy (CBT) A structured, practical form of talking therapy. It's built on a simple idea: what you think affects how you feel, and both affect what you do. More in the jargon decoder Close for OCD helped a great deal more than being on a waiting list or having a comparison treatment (Öst and colleagues, 2015). The two main kinds of CBT for OCD, exposure and response prevention and cognitive therapy, did about as well as each other. Cognitive therapy for OCD works on how you interpret the thoughts and what you believe they mean, rather than on the thoughts themselves. Therapy in a group and therapy one to one also did about as well as each other. The reviewers noted the trials had a number of weaknesses in how they were run.

Guidelines in the UK recommend CBT that includes exposure and response prevention. For milder OCD, a shorter course can be enough. For more severe OCD, they recommend CBT together with an antidepressant medication. When OCD is mostly thoughts, with rituals that happen in your head, CBT includes facing the thoughts and holding off on the mental rituals. For adults who live with family, they suggest a family member can help with the exposure work, if that suits everyone.

Many therapists say they use CBT, so ask whether they use exposure and response prevention for OCD, and how much of their work is with OCD.

Medication

Medication can be part of treatment too. A review of 54 trials found that both talking therapy and medication helped more than a dummy pill (Skapinakis and colleagues, 2016). For more severe OCD, the reviewers concluded that therapy and medication together are likely to work better than therapy alone. Most people in the therapy trials were also allowed to stay on their usual antidepressant, which makes the comparisons less certain.

Only a doctor can prescribe medication, and whether to take it is something you and your doctor decide together. Therapy and medication covers what’s known about the two together, and who can prescribe.

If you’ve had therapy that didn’t help

If you’ve had CBT or counselling for anxiety and the OCD didn’t shift, it may not have included exposure and response prevention. If you try therapy again, ask whether the therapist uses exposure and response prevention. Does therapy actually work? covers why the type of therapy matters more for OCD than for most problems.

For family and friends

Asking for reassurance can be part of OCD, so people close to you can get drawn into the rituals without meaning to. Families can be part of the treatment, and it’s reasonable to ask a therapist how to help.

Finding help and paying for it

Starting sooner helps, and a GP is the usual first step.

Online programs can help too. MindSpot is free for adults and can include support from a clinician. This Way Up is free when a GP or therapist prescribes it, with a small fee otherwise. Both have courses for OCD.

There are several ways to pay for therapy:

• Full fee. Seeing a private psychologistPsychologist Someone trained to assess mental health problems and treat them with therapy. It takes at least six years of study and supervised practice, and they're registered with Ahpra, the national regulator. Psychologists can't prescribe medication. More in the jargon decoder Close, counsellorCounsellor Someone trained to help people talk through and work on difficulties. The title isn't protected in Australia, so it's worth checking a counsellor's training and registration. Medicare doesn't give a rebate for counsellors. More in the jargon decoder Close or psychotherapistPsychotherapist Someone trained in therapy, often for longer-standing patterns. Like counsellor, the title isn't protected in Australia, and Medicare doesn't give a rebate for psychotherapists. More in the jargon decoder Close directly. MedicareMedicare Australia's public health insurance scheme. For mental health, it gives rebates on sessions with psychologists and some other professionals, usually through a Mental Health Treatment Plan. More in the jargon decoder Close doesn’t cover counsellors or psychotherapists.
• Workplace programs. Many employers pay for a few sessions for their staff.
• Community services. Non-profit organisations and local community health centres provide low-cost care.
• headspaceheadspace A national youth mental health service for anyone aged 12 to 25, with centres around Australia and support online and by phone. It's free or close to it, you don't need a referral or a parent, and you can book it yourself. More in the jargon decoder Close. headspace offers free or low-cost support for people aged 12 to 25.
• Groups. Group therapyGroup therapy A trained professional, sometimes two, working with several people at once. It's a way of running therapy, and many approaches work in groups. More in the jargon decoder Close programs, which usually cost less per session.
• A Mental Health Treatment PlanMental Health Treatment Plan A document your GP writes with you. It makes you eligible for a Medicare rebate on up to ten individual sessions a calendar year: six, then a review with your GP, then the remaining four. The plan itself isn't therapy. More in the jargon decoder Close. Your GP assesses whether a plan suits you. A plan gives you a Medicare rebateRebate The amount Medicare pays back towards a session. It comes back to you after you've paid, so what you pay yourself is the fee minus the rebate. More in the jargon decoder Close on up to ten sessions a calendar year.

Free and low-cost options has more on each of these, including the online programs.

If you’re under 18, Kids Helpline is there to talk to any time, and a GP or headspace can help you find someone to see.

If you’ve had thoughts of hurting yourself, or of suicide, the numbers below are there any time.

Kids Helpline is on 1800 55 1800, any time, for anyone aged 5 to 25. Lifeline is on 13 11 14 and, if you’re 15 or over, the Suicide Call Back Service is on 1300 659 467. In an emergency, call 000. Crisis and emergency support has the full list.

Where next

However good the treatment, how well you and your therapist work together matters a great deal. Why who you see matters more than what they do explains why.