Obsessive-Compulsive Disorder

Unwanted intrusive thoughts and repetitive behaviors afflict about 2 percent of the population, typically beginning in the teen years but often much earlier. The chronic condition, caused by a mix of neurobiologic, genetic, and environmental factors, responds to both drug therapy and exposure psychotherapy.

Definition

Obsessive-compulsive disorder (OCD) is an anxiety disorder in which people have unwanted and repeated thoughts, feelings, images, and sensations (obsessions) and engage in behaviors or mental acts in response to these thoughts or obsessions.Often the person carries out the behaviors to reduce the impact or get rid of the obsessive thoughts, but this only brings temporary relief. Not performing the obsessive rituals can cause great anxiety. A person's level of OCD can be anywhere from mild to severe, but if left untreated, it can limit his or her ability to function at work or school or even to lead a comfortable existence at home or around others.

OCD affects about 2.2 million American adults, and the problem can be accompanied by other anxiety disorders, depression, and eating disorders. It strikes men and women in roughly equal numbers and usually appears in childhood, adolescence, or early adulthood. One-third of adults with OCD developed symptoms as children, and research indicates that OCD might run in families.

Although OCD symptoms typically develop during the teen years or early adulthood, research shows that at least one-third of adult cases began in childhood. Suffering from OCD during the early stages of development can cause severe problems for a child. It is important that children receive evaluation and treatment as soon as possible to prevent their missing important opportunities because of this disorder.

Symptoms

People with OCD:

  • Have repeated thoughts, images, and urges about diverse issues, including being compulsively neat and organized; fearing germs, dirt, contamination, intruders, or violence; or imagining hurting loved ones or committing sexual acts or behaving in a way that conflicts with religious beliefs.
  • Engage in repetitive behaviors or mental acts such as washing hands, locking and unlocking doors, counting, keeping unneeded items (hoarding), or repeating the same steps to any task again and again.
  • Have obsessions that are intrusive and compulsions that often feel out of the person's control but dictated by a rule that must be applied rigidly.
  • Get no pleasure from engaging in the behaviors or rituals but do receive some relief from the anxiety the thoughts cause.
  • Spend at least an hour a day on the thoughts and rituals, which cause distress and get in the way of daily life.

Obsessions

Unwanted, repetitive and intrusive ideas, urges or images frequently well up in the mind of the person with OCD. Persistent paranoid fears, an unreasonable concern with becoming contaminated, or an excessive need to do things perfectly, are common. The individual experiences a disturbing thought, such as, This bowl is contaminated; it's not clean, and responds by repeatedly washing it. Or, he or she thinks: I may have left the door unlocked, or I know I forgot to put a stamp on that letter. These thoughts are intrusive and unpleasant and produce a high degree of anxiety. Other examples of obsessions include fear of being hurt or of hurting others, and troubling religious or sexual thoughts.

Compulsions

In response to their obsessions, most people with OCD resort to repetitive behaviors, or compulsions. The most common of these are putting things in order, checking, and washing. Other compulsive behaviors include rearranging, counting (often while performing another compulsive action such as lock-checking), mentally repeating phrases, list making, and avoiding. These behaviors generally are intended to ward off harm to the person with OCD or to others. Some people with OCD have regimented rituals. Performing the rituals in the same manner provides the person some relief from anxiety and a sense of control, but this is only temporary.

People with OCD vary in terms of their insight into their illness. Sometimes they are able to recognize that their obsessions and compulsions are unrealistic or illogical. At other times, however, they may be unsure about their fears or even believe strongly in their validity.

Most people with OCD struggle to banish their unwanted thoughts and compulsive behaviors. Many are able to keep their obsessive-compulsive symptoms under control during the hours when they are engaged at school or work. But over time, resistance may weaken, and when this happens, OCD may become so severe that time-consuming rituals make it impossible for them to have outside relationships and cause them to lose their autonomy and financial independence.

The course of the disease is quite varied. Symptoms may come and go, ease over time, or get worse. If OCD becomes severe, it can keep a person from working or carrying out normal responsibilities at home. People with OCD may try to help themselves by avoiding situations that trigger their obsessions, or they may use alcohol or drugs to deal with their mood, anxieties, and fears.

Causes

Biological factors are implicated in the risk of OCD. The fact that OCD patients respond well to specific medications that affect the neurotransmitter serotonin suggests the disorder has a neurobiological basis. There is also a higher rate of OCD among first-degree relatives of adults with the disorder. OCD is no longer attributed only to attitudes a patient learned in childhood—inordinate emphasis on cleanliness, say, or a belief that certain thoughts are dangerous or unacceptable. The search for causes now focuses on the interaction of neurobiological factors and environmental influences, as well as on cognitive processes. Physical or sexual abuse in childhood or other traumatic events are associated with a risk of developing OCD. There are also theories that link OCD to the interaction between behavior and the environment, which are not incompatible with biological explanations.

OCD is often accompanied by depression, eating disorders, substance abuse, a personality disorder, attention deficit disorder, or another of the anxiety disorders. Coexisting disorders can make OCD more difficult both to diagnose and to treat. Symptoms of OCD are seen in association with some other neurological disorders. There is an increased rate of OCD in people with Tourette's syndrome, an illness characterized by involuntary movements and vocalizations. Investigators are currently studying the hypothesis that a genetic relationship exists between OCD and the tic disorders.

Other illnesses that may be linked to OCD are hoarding behaviors (difficulty parting with possessions), trichotillomania (the repeated urge to pull out scalp hair, eyelashes, eyebrows, or other body hair), body dysmorphic disorder (excessive preoccupation with imaginary or exaggerated defects in appearance), and hypochondriasis (the fear of having—despite medical evaluation and reassurance—a serious disease). Researchers are investigating the place of OCD on a spectrum of disorders that may share certain biological or psychological bases. It is currently unknown how closely related OCD is to other disorders, such as trichotillomania, body dysmorphic disorder, and hypochondriasis.

A person with OCD has obsessive and compulsive behaviors that are extreme enough to interfere with everyday life. People with OCD should not be confused with a much larger group of people who are sometimes called "compulsive" for being perfectionists and highly organized. This other type of compulsiveness, however, is more in line with a pattern of excessive perfectionism and rigid control as personality traits. In OCD, the compulsive behaviors are performed in reaction to the intrusive thoughts, images, and obsessions.

Treatments

Clinical and animal research sponsored by NIMH and other scientific organizations has provided information leading to both pharmacological and behavioral treatments that can benefit the person with OCD. While some benefit significantly from behavior therapy and others are helped by pharmacotherapy, research indicates that a robust treatment of OCD includes both medication and therapy. Patients may begin with medication to gain control over their symptoms and then continue with behavior therapy. Which therapy to use should be decided by the individual patient in consultation with his or her therapist.

Medication

Clinical trials in recent years have shown that drugs that affect the neurotransmitter serotonin can significantly decrease the symptoms of OCD. The first of these serotonin re-uptake inhibitors (SRIs) specifically approved for the use in the treatment of OCD was the tricyclic antidepressant clomipramine (Anafranil). It was followed by "selective" serotonin re-uptake inhibitors (SSRIs). Those that have been approved by the Food and Drug Administration for the treatment of OCD are citalopram (Celexa), flouxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft).

Large studies have shown that more than three-quarters of patients are helped by these medications at least a little. And in more than half of patients, medications relieve symptoms of OCD by diminishing the frequency and intensity of the obsessions and compulsions. Improvement usually takes at least three weeks or longer. If a patient does not respond well to one of these medications, or has unacceptable side effects, another SRI may give a better response. For patients who are only partially responsive to these medications, research is being conducted on the use of an SRI as the primary medication and one of a variety of medications as an additional drug (an augmenter). Medications are of help in controlling the symptoms of OCD, but often, if the medication is discontinued, relapse will follow.

Behavior Therapy

Cognitive behavior therapy (CBT) has been shown to be the most effective type of psychotherapy for this disorder. CBT aims to diminish thoughts and beliefs in order to help modify behaviors and vice versa. Medication and CBT together are considered to be better than either treatment alone at reducing symptoms.

A specific behavior therapy approach called "exposure and response prevention" is effective for many people with OCD. In this approach, the patient deliberately and voluntarily confronts the feared object or idea, either directly or by imagination. At the same time, the therapist, and possibly others the patient has recruited for assistance, offer support and structure, strongly encouraging the patient to refrain from using rituals or avoidance. For example, a compulsive hand washer may be encouraged to touch an object believed to be contaminated and then urged to avoid washing for several hours, until the anxiety provoked has greatly decreased. Treatment then proceeds on a step-by-step basis, guided by the patient's ability to tolerate the anxiety and control the rituals. As treatment progresses, most patients gradually experience less anxiety from the obsessive thoughts and are able to resist the compulsive urges.

Other forms of therapy can also provide effective ways of reducing stress or anxiety by helping the patient become aware of and resolve inner conflicts.

Ways to Make Treatment More Effective

Many people with anxiety disorders benefit from joining a self-help or support group and sharing their problems and achievements with others. Internet chat rooms can also be useful in this regard, but any advice received over the Internet should be used with caution as Internet acquaintances have usually never seen each other and false identities are common. Talking with a trusted friend or member of the clergy can also provide support but is not a substitute for care from a mental health professional.

Stress management techniques and meditation can help people with anxiety disorders calm themselves and may enhance the effects of therapy. There is preliminary evidence that aerobic exercise may have a calming effect. Since caffeine, certain illicit drugs, and even some over-the-counter cold medications can aggravate the symptoms of anxiety disorders, they should be avoided. Check with your physician or pharmacist before taking any additional medications.

The family is very important in the recovery of a person with an anxiety disorder. Ideally, the family should be supportive and avoid perpetuating their loved one's symptoms. Relatives should not trivialize the disorder or demand improvement without treatment. When a family member suffers from obsessive-compulsive disorder, it's helpful to be patient about any progress and acknowledge successes, no matter how small.

References

  • Archives of General Psychiatry
  • British Journal of Psychiatry Supplement
  • Diagnostic and Statistical Manual, Fifth Edition
  • National Institutes of Mental Health
  • National Library of Medicine
  • Psychiatric disorders in America: the Epidemiologic Catchment Area Study
  • Psychopharmacology Bulletin

Last reviewed 03/23/2017