In obsessional-compulsive disorder, there may be recurrent ideas or images entering the mind, such as phrases, pictures and disagreeable ideas, often obscene.

There may be aggressive impulses to hit or injure someone, suicidal thoughts, a desire to swear in church or to take off one’s clothes.

With phobias, there may be extreme anxiety and an unreasonable fear of an object or a situation. These are regarded by the sufferer as groundless and irrational but he cannot control them.

Some phobias are clear-cut, and psychotherapy can often reveal the repressed anxiety that caused the fear of the phobic situation. The connection may be subtle but easy to recognise.

In other cases, there is no clear connection between what caused the repressed fear or anxiety and the resulting phobia.

In treating phobias, behavior modification and learning techniques may be required. Another method is desensitisation.

In this, the person is exposed, initially in thought, to the situation which he most fears. He starts by thinking of himself in that situation in a mild way, then mentally removes himself before the anxiety is severe. This goes on until he imagines himself in the worst possible situation, without anxiety.

Next, he is placed in the real situation, for a short time and removed as soon as he shows anxiety. Finally, he can be fully exposed and able to cope without anxiety.

Another technique is implosion, the reverse of the slow process of desensitisation.

Here the person is placed, at once, into the worst possible situation he can imagine. This creates extreme anxiety and it is believed the shock is so great that the anxiety disappears.

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A further operation is lumbar sympathectomy, which involves cutting the sympathetic nervous chain in the lower back. This chain controls the tone in the arterial wall. When the nerves are cut, the arteries permanently dilate and blood flow can increase. Sometimes both operations are combined.

The bypass operation is the same principle as in coronary bypass surgery, where atheroma blocks one of the coronary arteries and a vein is used to bypass the obstruction.

There is no doubt about the marvels of modern medicine, but how can we convince our patients to avoid the bad habits that lead to many of these problems?

Changing our diet and avoiding smoking would reduce the incidence of atheroma.

The diagnosis of intermittent claudication can be made on the history alone. When the doctor examines the legs, he may be unable to feel the pulses in the feet. This indicates obstruction to blood flow.

In the past, various drugs were used in an effort to dilate the narrowed arteries and improve the blood flow. Unfortunately, these have proved disappointing.

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