The phrase “Obsessive Cupcake Disorder” really irritates clinical psychologists like Oliver Suendermann. The deputy director of NUS’ clinical psychology programme, Dr Suendermann is also a cognitive behavioural therapist who studies OCD and body dysmorphic disorder. These are two of the most widely misunderstood mental health conditions, he says, and making light of them does nothing to dispel the myths surrounding them.
“It’s a nightmare to have OCD,” Dr Suendermann says. “You stop [ritualising] when you feel right. And the more you ritualise, the more uncertain you feel. It’s an endless cycle. And people joke: ‘Obsessive Champagne Disorder.’ Imagine someone making fun of cancer or diabetes in the same way.”
In fact, joking that “you’re so OCD” just because you arrange your shoes by colour actively makes it harder for people suffering from OCD to recognise it in themselves, and ask for professional help.
To meet criteria for a clinical diagnosis of OCD, a person must have obsessions, which are intrusive and repetitive thoughts or images, or compulsions, repeated and ritualised physical or mental acts, or some combination of both. This behaviour—the perceived, obsessive worry or fear or the exaggerated responsive behaviour to “prevent” it—can interfere with relationships and health. It can take up hours of the day. It’s exhausting and distressing. A person suffering from OCD knows they’re being irrational, but they can’t help it. It’s not cute to say you have it because you’re a perfectionist.
“A person suffering from OCD knows they’re being irrational, but they can’t help it. It’s not cute to say you have it because you’re a perfectionist”
OCD is also, for unknown reasons, particularly endemic in Singapore. The most recent, most comprehensive mental health review in Singapore was conducted in 2016 by the Institute of Mental Health, in collaboration with the Ministry of Health and Nanyang Technological University. Updating their findings from the previous 2010 study, researchers found that one in seven people in Singapore have experienced a mental disorder in their lifetime, up from one in eight in 2010. That figure balloons to one in five for persons aged between 18 and 34 years old.
What’s more, they found that roughly one in 28 people in Singapore has obsessive-compulsive disorder. That’s just under four percent, as compared to a global rate of two percent. OCD is the third most prevalent disorder in the country, after only major depressive disorder and alcohol abuse disorder.
And especially with the coronavirus pandemic still raging around the world, those numbers may be only poised to go up. Vogue recently spoke with Dr Suendermann to get a crash course on obsessive-compulsive disorder, how it’s clinically treated, and what people without it can do to support diagnosed loved ones. Here are the most important takeaways.
1. “The thing with OCD is that it comes in so many different shapes and forms”
According to Dr Suendermann, what kind of OCD someone has depends on what exaggerated emotion drives their compulsive behaviours, and what those behaviours are. Just a few examples of “motivational dimensions” to OCD that Dr Suendermann describes are “harm avoidance” (the most common), “disgust response,” and “incompleteness.” While harm avoidance springs from anxiety, and is an exaggerated response to circumvent potentially harmful things from happening, someone with “incompleteness” is motivated by a feeling of discomfort or tension. Essentially, something will feel “not just-so,” and the person with OCD will act to try and correct that feeling.
2. OCD attacks your personal values
People with OCD sometimes describe having the disorder as like having a “bully inside your head.” The disorder hones in on what a person cares about most, and often contradicts core moral values. Obsessions are sometimes violent or aggressive in nature, and all the more terrifying for it. A person might think constantly about swearing in front of a child or harming a loved one, for example—and even though rationally they know they’d never do it, the irrational fear persists. To cope, a person with OCD intensely checks and rechecks mentally, reliving every interaction they’ve had recently with that intrusive thought. “A person with OCD might think: ‘I’m a dangerous person. Did I touch that woman on the MRT accidentally? What would that mean about me? That means I’m a bad person,’” Dr Suendermann says. “That’s what OCD is: responding to a thought that most people have, and that most would dismiss, and instead assigning it a huge, horrible meaning.”
“That’s what OCD is: responding to a thought that most people have, and that most would dismiss, and instead assigning it a huge, horrible meaning”
3. OCD can inflate your sense of responsibility to the point of dysfunction
Hyper-responsibility, as it’s known, isn’t about narcissism, power fantasies, or entitlement. Rather, in a person with OCD, it’s the irrational belief that the compulsive rituals they’re performing are the only thing preventing a bad thing from happening. Dr Suendermann often sees patients whose OCD makes them think that their “negligent behaviour”—basically, if they ignore their compulsions—will cause themselves or their loved ones harm. “It could be anything. The thinking could go: If I don’t check the door is locked two dozen times, I’ll be burgled. Or it could be: If I don’t complete a mental ritual in my head, my parents will have an accident and die,” Dr Suendermann says. Without treatment, having these thoughts—the obsession—and enacting these behaviours—the compulsion—can become overwhelming, and take up hours of a person’s day.
4. OCD and anxiety disorder are not the same thing…
… Although someone can have both. The two are often “comorbid,” meaning that they occur in the same person at the same time. But the difference between OCD and generalized anxiety disorder isn’t in the worry, but in the response to the worry. Only people with OCD will respond to anxiety with ritualistic behaviours like hand-washing or counting. People with generalized anxiety, on the other hand, don’t have the belief that such behaviours can keep a worrisome “what if” from coming true. Another comorbid diagnosis that Dr Suendermann often sees with OCD is clinical depression and suicidal ideation. “[OCD] makes people feel hopeless,” he says, “especially if they don’t get the appropriate therapy.”
5. COVID-19 has worsened OCD in people who had it prior to the pandemic
It has also manifested symptoms in some people who didn’t have it before. Many people’s OCD is marked by the persistent fear of becoming sick or spreading sickness (“contamination” OCD). With the novel coronavirus’ presence, their anxiety and stress has only gotten worse. Studies are still ongoing, but OCD researchers have already found that, especially in patients with contamination obsessions or compulsive hand-washing, COVID-19 is having a disastrous effect on mental health. Perhaps this is unsurprising, but worsening OCD symptoms in the midst of a pandemic make treatment much, much more challenging. “I believe we have seen more people calling us for obsessive problems,” Dr Suendermann says, “but many were reluctant to come in [to our clinic] last year because of their fear of catching something there. A lot of people delayed their therapy.”
6. That said, using telemedicine to treat OCD has shown great promise
“A lot of work [to treat OCD] should be done in the patient’s home, because that’s where the disorder plays out,” Dr Suendermann says. “Like, it’s their bathroom that they can’t use. Over the computer, you can work with that. I can have a patient put their computer in the bathroom, to guide them through their exposure exercises whilst being in their home with them.” A lot of therapy is more effective outside the therapy room, he adds, especially when it comes to anxiety-related therapy. This is because working to alleviate clinical obsessive thoughts requires confronting fears directly, by exposing a patient to them. “It’s been fairly effective. I think it’s here to stay.”
7. Exposure therapy is much more difficult than just being in the same room as the thing you fear
It sounds simple when you put it like that. But the treatment of choice, apart from medication, for OCD can be incredibly challenging to do, especially at first. “The main idea in exposure therapy is to help the person [with OCD] experience that they’re much safer than they think they are,” Dr Suendermann explains, “but it’s incredibly stressful work for them.” He might have a patient touch the object they believe is contaminated, and resist the compulsion to wash their hands afterwards.
8. “You can’t think yourself out of OCD. You have to experience that you’re okay without your rituals”
If someone performs mental rituals compulsively, as opposed to physical ones, Dr Suendermann has to work with the patient to identify what specifically those rituals are, and get them to agree to not enact them. Because these kinds of rituals are all in someone’s head, though, it’s sometimes difficult to tell if someone is resisting them. Someone with OCD might believe they have to walk through a doorway with “the right thought.” And when you consider the number of doorways you cross in a given day, it can quickly become exhausting to imagine you might have to repeat that action upwards of ten times because you weren’t focused on the correct thought at the time. “The mind gets so active. In a way, we’re helping patients to think less,” Dr Suendermann says. “The only way we’re going to do that is to help someone to experience their perceived threat without compulsively responding. They have to see they’re okay, that they’ve made it through alive and well.”
“I’ve heard Singapore called ‘the OCD capital of the world. The rate’s gone up from 3 percent to 3.6 percent. That’s a lot. We’re a country with nearly six million people. We’re talking hundreds of thousands of people here”
9. Extra support is needed in a patient’s life to prevent them from ritualising after the therapy session is over
Those studying OCD have identified a phenomenon they call “storing,” where someone affected by the disorder will be exposed to a perceived threat and “store” their response ritual for later. “As a therapist, you have one hour with the patient,” Dr Suendermann says. “Then you leave. If they go to the bathroom and wash after that, they undo all the gains of the session.” At this point, he and other therapists like him rely on a patient’s external support system. This is especially true given that a person with OCD is not always aware that they’re performing their rituals. If a person with OCD has a partner or a friend who understands the disorder, they can identify the response ritual and gently encourage them not to perform it.
10. OCD’s prevalence in Singapore is a specific phenomenon that still leaves a lot of unanswered questions
Dr Suendermann has theories as to why Singapore is affected by OCD at a higher rate than the rest of the world. Perfectionism, a highly valued trait here, is a risk factor that can tip the scales for someone mentally vulnerable to the disorder. Mistakes are often avoided at all costs here, too, for fear of punishment or reprimand. “I’ve heard Singapore called ‘the OCD capital of the world,’” he says. “The rate’s gone up [between 2010 and 2016], from 3 percent to 3.6 percent. That’s a lot. We’re a country with nearly six million people. We’re talking hundreds of thousands of people here.” Though mental health has seen some destigmatisation here in the last few years, treatment delays for OCD—the time someone takes between first presenting symptoms and seeking help for them—have gone up, too. Someone with depression typically seeks help after a year or two, down from four years in 2010. Someone with alcohol abuse disorder, on average, pursues treatment after four years, down from 13 previously. But someone with OCD still only gets professional help only after living with the disorder for, on average, 11 years.
If you or a loved one is suffering from obsessive-compulsive disorder, seeking treatment with a professional is the best course of action. The NUS Clinical and Health Psychology Centre is one such place for help, and can be learned about online, or by emailing or calling their team.