You wouldn't suspect that teacher Stephen Chow Wai-kit suffers from a mental illness. The 34-year-old is confident, successful and handsome, with a broad smile.
Chow's attitude towards his illness is unusual: he's frank and free of the fear of stigma that silences many others in Hong Kong, where threats of being sent to the Castle Peak Asylum raise more laughter than sympathy.
Despite his traditional upbringing, Chow scorns old-fashioned cultural values that advise 'it's better to bleed than to cry' (lau huet but lau loi) and has become a role model for the successful management of his illness.
'I realised [I had] some abnormal behaviour three years ago,' Chow says. 'After going to the toilet, I had to wash my hands again and again. But I still thought they weren't clean. Then [further] odd behaviour started. After I had locked my car, I'd go back and relock it - sometimes up to 10 or 15 times. I felt terrible.'
Chow immediately shared his concerns with his friends and family - he is very close to his mother - before he went to see a psychiatrist. He was diagnosed with obsessive-compulsive disorder (OCD), which could have been triggered by the stress he was under: he was studying for a master's degree while still teaching in a secondary school.
But Chow's upfront attitude is not the norm and experts are concerned Hong Kong has more cases of undiagnosed OCD.
Emily Cheung Siu-wan, clinical psychologist of the Hong Kong Mood Disorders Centre, says management of OCD in Hong Kong is suffering due to a lack of proper treatment, ignorance, and social stigma about mental illnesses. Also, many sufferers are not being diagnosed, she says.
'Symptoms of OCD are embarrassing to report,' Cheung says. She recalls one male OCD sufferer who showered for eight hours a day. His showering ritual began at 11pm and he would shower and wash all night, often waking his wife up for help in opening more liquid soap containers. He finished washing in the morning when the rest of the family awoke and would then sleep for much of the day. He and his family endured this routine for 20 years before he finally sought professional help.
'Often, people with OCD are very nice, thoughtful and kind people,' Cheung says. 'Many of them are too concerned about doing harm to others by contaminating them, so when the intrusive thought comes in, they think it is absolutely their responsibility not to harm people, so they wash and wash again.'
OCD is an anxiety disorder characterised by an obsessive need to do certain things repeatedly - such as washing or cleaning, compulsive checking or arranging, and less commonly, hoarding or ritual behaviours. Ideas, images, impulses or intrusive thoughts enter the individual's mind again and again - even though they know they are being irrational.
The exact cause of OCD is unknown, but is thought to be caused by genetics, low serotonin levels and lifestyle changes - such as abuse, stress or the arrival of a new baby. Certain psychological tendencies - such as being a perfectionist - are also linked to OCD. Chow, for example, says he's a perfectionist. 'I suspect my mother had very high standards. She was very hygienic and this may have forced me to be a perfectionist.'
OCD sufferers interpret anxiety differently, experts say. They see anxiety as a direct threat or as a sign of impending danger to themselves or others, and they believe they are responsible for any harm (even if there is none) if they don't take preventative action.
Cheung says some people can wash their hands up to 70 times a day; the obsession is caused by the thought of germs and the compulsion is hand-washing.
However, up-to-date research is needed. The last major mental illness survey, the Sha Tin community mental health survey in Hong Kong, was published in 1993 and was confined to people living in the then-developing new town and so not representative of the whole of Hong Kong.
'Times have dramatically changed since then,' says Professor Sing Lee, director of the Hong Kong Mood Disorders Centre. 'We've been through massive social and economic changes, as well as health changes like Sars - which some believe may have been a trigger for increased OCD symptoms among people at risk.
'Without an accurate epidemiological profile of OCD in our community today, we are poorly prepared to plan services to help silent sufferers whose lives have been handicapped by this severely debilitating illness.'
The 1993 report found 0.9 per cent of males and 1.2 of females aged between 18 and 64 living in Sha Tin suffered from OCD. These results were incorporated into a 2000 World Health Organisation report, the Global Burden of Obsessive-Compulsive Disorder.
At the time, the WHO reported OCD rates in South Korea were 2.2 per cent for men and 2.4 per cent for women. In the US, 2 per cent were male and 3 per cent female.
Psychiatrist Lee Wing-king says OCD incidence is greater than records suggest. He says Sars was an 'astonishing trigger' for many OCD problems. 'People became scared of catching the virus, so they started to repeatedly wash their hands,' he says. 'Some of them kept these habits, which later developed into a disorder.'
Lee, programme director of the Hong Kong Primary Care Foundation, has treated Chow for the past three years. 'The fact that he was able to seek help shows he is very well educated,' the psychiatrist says. 'Many men think that if they show their stress, they'll be considered losers.'
Chow is receiving a combination of medication and cognitive behavioural therapy, which helps patients understand that their problem is caused by anxiety rather than danger, and teaches them to think rationally about common difficulties. Chow's obsessive thoughts and actions have been reduced by about 70 per cent.
The treatment may take many years, although early diagnosis can improve its efficacy, Lee says. Patients undergoing treatment may still have residual symptoms, such as repeated thoughts and actions, but they can resume normal functioning.
'These patients may have OCD traits in their character, like being a perfectionist, so this part cannot be relinquished completely,' Lee says.
'I've learnt I can live with the remaining 30 per cent of symptoms. During Sars, with everyone washing their hands, I felt OK,' says Chow. 'The worst thing is knowing you have a mental problem when you're still rational and conscious.
'When you have a physical problem, you know where to go and what medication will help you. When it's mental, you just don't think people will understand.'