Contributed by Kristen Fuller, M.D., Sovereign Health
In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), obsessive-compulsive disorder (OCD) was separated from the anxiety disorders (which are suggested to be emotional processing problems) and placed in the category of the obsessive-compulsive and related disorders (OCRDs), which include OCD, hoarding disorder, body dysmorphic disorder, excoriation disorder and trichotillomania. The OCRDs share distressing emotions, including anxiety, compulsive behavior, repetitive thoughts and dysfunctional beliefs, which vary with each disorder, thus defining their unique qualities and characteristics. OCRDs also share neurochemistry, malfunctioning frontal striatal pathways including connecting the caudate and putamen nuclei to the cerebral cortex, which is an important pathway supporting executive functioning (EF).
A meta-analysis evaluating EF in 110 previous studies revealed that “individuals with OCD are impaired on tasks measuring most aspects of EF,” which include inhibition, cognitive flexibility and the ability to shift between tasks. Many OCD features may result in EF impairment including intrusive and persistent thoughts, which the individual usually experiences as irrational and excessive (i.e., which vary with the degree of insight) as well as repetitive behaviors like checking and counting, washing and cleaning, and organizing and praying.
Nevertheless, the term “OCD” is often used in casual conversations between individuals to describe someone who may be extremely detailed with specific tasks or in general daily routines. We all may have strange idiosyncrasies such as avoiding bath sponges, organizing our closet by color and pattern or refusing to touch the restroom door in public, but these habits should not to be confused with obsessive-compulsive disorder. OCD is often misunderstood as a disorder that simply means being overly detailed or perfectionistic, when in fact this disorder can be debilitating for individuals who are affected, such as those who have to repeatedly wash their hands until they bleed and continue to do so without understanding why.
OCD symptoms usually begin presenting in individuals before 25 years of age and this disorder affects approximately 1 to 3 percent of the general population. Characterized by obsessive thoughts often, but not always, directly associated with compulsive actions except in timing, this condition is more than just excessive hand-washing or cleaning. These obsessive thoughts are intrusive, ego-dystonic and distressing to the individual by interfering drastically with his or her daily activities. Examples of obsessive thoughts are centered on orderliness, cleanliness, symmetry, safety, doubting one’s own thoughts and perceptions, and aggression or unwanted sexual ideas. People with this disorder may not be able to stop these thoughts or move on to the next thought, until the obsessive thoughts are diminished or stopped by their compulsions, which are actions that may be repeated over and over like a needle stuck in an old vinyl record.
Individuals with OCD who prepared a meal may not be able to eat their food because of thoughts that the stove might be on. These thoughts are so intrusive that they must continue to check the stove (compulsion) until they come to terms that the stove is actually off. In contrast, people without this disorder may wonder whether they have forgotten to turn the stove off and will quickly confirm and resolve this by checking the stove. Depending on the individual and the seriousness of the thought, a person with OCD could spend minutes to hours tormented by these thoughts and subsequent or associated compulsions, thus taking hours, as an example, preparing to go to work or to leave home.
OCD can be accompanied by other mental health conditions. I have had many patients with three or more symptoms including panic disorder, social anxiety, generalized anxiety, bipolar disorder, drug use disorders, ADHD, and more. I am prone to say, “God never said you would only have one problem.”
OCD can clinically be confused with bipolar disorder, since the racing thoughts often seen in bipolar disorder are actually the rapidly recurring thoughts of OCD. The “mood swings” into depression of bipolar disorder, are OCD patients' desperate depressive response to not having control over their OCD thoughts, feeling that they are going crazy or “losing it.” Many OCD individuals will not tell anyone, including their physicians, about their plight, since they know what is happening is abnormal and they fear they will lose their job or relationship, or end up in a psychiatry unit. Tics, hair pulling (trichotillomania), body dysmorphic disorder, depression and other mental health disorders sometimes accompany OCD.
Obsessive-compulsive personality disorder (OCPD) is often confused with OCD, but there are major differences that may be unknown to the general public. Nevertheless, OCPD is characterized by ego-syntonic thoughts and habits, meaning that the person is not bothered by these thoughts and actions. The person doesn't think these thoughts are irrational or abnormal, but rather likes them. An individual with OCPD may be described as a perfectionist, paying excessive attention to detail, resulting in a poor work-life balance, rigidity, stubbornness and preoccupation with lists and tasks that cause the person to lose sight of the big picture and often prevents the task at hand from being completed. In general, individuals with OCPD may think they do not have a problem, when in contrast individuals with OCD are aware that their thoughts and actions are abnormal or irrational.
Personality disorders are known to be abnormal, ingrained patterns of behavior that deviate from society’s norms. Difficulty with interpersonal skills, impulse control and cognition are the specific underlying traits in an individual with a personality disorder. OCPD is no different.
Treatment for both OCD and OCPD is similar in a sense that they both require psychotherapy. OCD can also be treated with antidepressants, specifically selective serotonin reuptake inhibitors (SSRIs). Other medications may be required, since between 40 to 60 percent of patients with OCD do not respond adequately (i.e., less than a 35 percent decrease in The Yale-Brown Obsessive Compulsive Scale after 10 weeks of treatment) to SSRI treatment or clomipramine trials, with or without cognitive behavioral therapy, and are considered treatment resistant, according to A. Ozcubukcuoglu and colleagues in the study, “Resistance and biological treatment algorithm for treatment of obsessive-compulsive disorder,” published in the May 1995 Bulletin of Clinical Psychopharmacology.
Adding dopaminergic atypical antipsychotic medication such as risperidone and aripiprazole can improve the outcome. Studies with aripiprazole suggest that OCD may be the result of an imbalance between dopaminergic and serotonergic pathways, where aripiprazole not only inhibits dopamine release, but modulates or regulates serotonin, according to studies published in Psychopharmacology and The Journal of Clinical Psychopharmacology.
I learned, personally, years ago that all systems of the body are interrelated. A pertinent example here is that CBT can change activation in the caudate nucleus, among other things, in OCD patients who improve.
Exposure and response prevention is the first-line behavioral therapy used to treat OCD. This therapy is carried out by exposing an unwanted idea or trigger of gradually increasing intensity in an effort to reduce the response. This is generally extremely distressing to the individual, but over time symptoms are shown to improve. In contrast, treatment for OCPD is aimed at providing individuals with tools to express their feelings to replace intellectualizing their emotions. CBT is one therapeutic approach for OCPD.
The next time you overhear people say that they are “OCD about planning an event or keeping their house clean,” make a mental note of how their description differs with the clinical definition of OCD. In communication, vocabulary counts.