We all know people who are much more neat, clean and orderly than others. These traits are entirely appropriate in many situations on the job and at home. In Obsessive-Compulsive Disorder (OCD) these traits are carried to an extreme and disruptive degree. People with OCD can spend hours of each day cleaning, tidying, checking, or ordering — to the point where these activities interfere with the rest of their daily lives.
Obsessive-compulsive disorder (OCD) is a psychiatric Anxiety Disorder characterized by recurring and disturbing thoughts (called “obsessions”). Most people with OCD — about eighty percent — also engage in repetitive, ritualized behaviors that the person feels driven to perform (called “compulsions”).
An important distinction with OCD is that the person recognizes that their thoughts or behaviors are senseless or excessive. However, the drive to actively dismiss the obsessions or neutralize them by engaging in compulsions is overpowering. Most people with OCD have multiple types of obsession and compulsion. OCD can be accompanied with other mental illnesses, such as eating disorders, Anxiety Disorders, or Depression.
Please note that OCD is not the same as Obsessive-Compulsive Personality Disorder, which is an entirely different mental illness. ((1))
What is the prevalence of OCD?
The National Institute of Mental Health estimates that 2.2 million, or about one and a half percent of Americans have OCD. ((2)) Others estimate the number to be between one and three percent, with the prevalence of clinically recognized OCD being much lower. This suggests that many people with the disorder may not be diagnosed, due to many individuals not seeking treatment because of the stigma associated with OCD. Another reason is that many sufferers do not realize that they have the condition.
OCD strikes men and women equally. The Anxiety Disorders Association of America (ADDA) states that one-third of affected adults first experienced symptoms in childhood ((3)), and most have experienced symptoms by early adulthood. It is rare for the onset of OCD to be after age thirity-five. Research indicates that OCD might run in families. The ADDA further says that in 1990, OCD cost the U.S. six percent of the total $148 billion dollar mental health bill, eight billion dollars. The figure is almost certainly higher now.
What are the diagnostic criteria for OCD?
The Diagnostic and Statistical Manual of Mental Disorders (DVM-IV) ((4)) states that to be diagnosed with OCD, the individual must have either obsessions or compulsions alone, or both obsessions and compulsions. Obsessions and compulsions are described as:
- Recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress.
- The thoughts, impulses, or images are not simply excessive worries about real-life problems.
- The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action.
- The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind, and are not based in reality.
- Repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly.
- The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts are not actually connected to the issue, or they are excessive.
In addition to these criteria, at some point during the course of the disorder, the individual must realize that his/her obsessions or compulsions are unreasonable or excessive. Moreover, the obsessions or compulsions must be time-consuming (taking up more than one hour per day), cause distress, or cause impairment in social, occupational, or school functioning.
What are OCD Obsessions?
OCD obsessions are repeated, persistent, unwanted ideas, thoughts, images or impulses that are experienced involuntarily and that appear to be senseless. These obsessions typically intrude when one is trying to think of or do other things. Typical OCD obsessions include:
- Fear of contamination. This may take the form of the fear of the presence of bodily secretions, such as blood, sweat, saliva, tears, vomit, mucus, or excretions such as urine or feces. Others fear the presence of germs from themselves or others.
- Doubts that tasks or rituals have been completed satisfactorily. This may take the form of repeatedly washing the hands or taking a shower; and counting systems or counting activities, often with the obsession with numbers or types of numbers, such as odd numbers. Often these tasks are repeated over and over due to the person’s fear of making mistakes, particularly in counting.
- Excessive concern with order, arrangement, or symmetry.
- Intrusive thoughts and fears that are difficult or impossible to control. Intrusive thoughts, urges and images are of inappropriate things at inappropriate times. These may be anything from images of catastrophes to thoughts of harming others. Other categories of intrusive thoughts include inappropriate aggressive thoughts, inappropriate sexual thoughts, and blasphemous religious thoughts.
- Physical symptoms may include tics, tremors, jerking arm movements, involuntary movements of the limbs and other Parkinson’s Disease-like movements. Distinguishing between certain complex motor tics and certain compulsions, for example repetitive touching, can be a problem.
What are OCD Compulsions?
A person with OCD typically performs tasks or rituals (or compulsions) to seek relief from obsession-related anxiety. The person will have developed these over a period of time. To others, these tasks and rituals may seem strange and meaningless. But to the person with OCD, they are critically important, and must be performed exactly so to ward off dire circumstances and to stop the stress from building up. Examples of these tasks and rituals are having to exit the front door on a particular foot, or counting the number of tiles in a hallway.
It is important to remember that the person with OCD is aware of the senselessness of these rituals, but is driven to do them to prevent catastrophic consequences that they have imagined. This awareness separates OCD from a psychotic illness, such as schizophrenia. People with psychosis lose touch with reality and their perceptions become distorted. Obsessions may involve unrealistic thoughts and fears, but unlike psychotic delusions, they are not fixed, unshakeable false beliefs. The symptoms of OCD may be bizarre, but the sufferer recognizes their absurdity.
Every OCD sufferer has a different set of tasks and rituals, but the following are some common ones:
- Frequent hand washing, leading to dermatitis
- Picking at the skin, causing skin lesions
- Pulling the hair, causing hair loss or bald spots
- Impulses to shout obscenities in inappropriate situations
- Avoidance of situations that can trigger obsessions
- Replaying pornographic images in the mind
- Not shaking hands or touching objects others have touched, such as doorknobs and public phones
- Repeatedly checking whether something was done, such as locking the door, shutting off the stove, or turning off a light
- Counting steps, tiles, words in a book; counting objects in certain patterns or order
- Repeatedly touching an object, ones self, or another
- Intense distress when objects aren’t orderly, lined up properly or facing the right way
- Excessive concern about accidentally or purposefully injuring another person. Ex. Repeated thoughts that you’ve hurt somebody in a traffic accident, images of hurting your child or another person
- Fear that negative or aggressive thoughts or impulses will cause personal harm or harm to a loved one
- Feeling overly responsible for the safety of others
- Distasteful and inappropriate religious thoughts, such as blasphemous images
- Distasteful and inappropriate sexual thoughts or images
- Endless reviewing of conversations
- Repetitively calling up “good” thoughts to neutralize “bad” thoughts or obsessions
- Excessive praying and using special words or phrases to neutralize obsessions
- Difficulty throwing away useless items such as old newspapers or magazines, bottle caps, or rubber bands; hoarding
- Inability to stop repeating a name, phrase, or simple activity
- Mental repetition of words, real or nonsense, to vanquish a horrific image or thought
What is the course of OCD?
As mentioned, OCD usually begins no later than early adulthood. If left untreated, OCD almost always lasts a lifetime. Symptoms may come and go, get better for a few months or years, only to get worse again. Only five to ten percent of untreated OCD sufferers experience a spontaneous remission in which all symptoms go away for good. A similar percentage experience a progressive deterioration of their symptoms.
If OCD becomes severe, it can prevent a person from working or carrying out other normal responsibilities and actions. People with OCD may try to help themselves by avoiding situations that trigger obsessions, or they may use alcohol or drugs to calm themselves.
Stress can make OCD worse, but eliminating all stress is unlikely to reduce the obsessions. It has been found that it is better for people with OCD to keep busy, since idleness gives them time for increased obsessional thinking.
What is the cause of OCD?
In short, no one really knows. In the majority of cases, the onset of OCD is not associated with an external event. There has been quite a bit of research and some important findings, but none that can account for all aspects of OCD. Following are some findings and theories concerning the cause of OCD:
- Biology: Changes in your body’s natural chemistry may cause OCD. Women with OCD often report that their symptoms become more severe the week before their menstrual period. Presumably, this is related to the natural ebb and flow of hormones that regulate the menstrual cycle. Changes in the severity of OCD may be related to fluctuations in the body’s internal chemical environment.
- Environment: Learning theory holds that the obsessions and compulsions are the result of abnormal learned responses and actions over time. But this does not account for cases in which only compulsions are present, nor for cases where brain injuries cause OCD.
- Insufficient serotonin in the brain: When comparing the brains of people with and without OCD, researchers find that those with OCD do not have enough serotonin, the brain’s chemical messenger. In addition, people with OCD who take medications that enhance the action of serotonin often have fewer symptoms.
- Strep throat: Some studies suggest that some children develop OCD after infection with strep throat. It is possible that one of the body’s antibodies mistakenly acts like a brain enzyme. This disrupts communication between neurons in the brain and may trigger OCD.
- Brain structures: PET scans show that people with OCD have elevated brain activity in areas of the frontal lobes and the basal ganglia. OCD may turn on the basal ganglia and its connections inappropriately, resulting in the emergence of self-protective behaviors such as checking and fear of contamination.
Diet has not been shown to affect OCD. Having parents or other family members with the disorder can increase the risk of developing OCD, but researchers have not identified any genes responsible for it.
What is the treatment for OCD?
The NIMH states that OCD responds well to treatment with certain medications and/or exposure-based psychotherapy. Around eighty percent of people with OCD are helped with this combination. For those not helped, several new treatment approaches are being researched, including combination and augmentation (add-on) treatments, as well as modern techniques such as deep brain stimulation.
A behavior therapy technique referred to as exposure and response prevention works well with OCD. Exposure consists of confronting the patient with situations that evoke obsessional distress. Response prevention consists of instruction to abstain from compulsive rituals. Cognitive Behavioral Therapy (CBT) combines these with retraining one’s thought patterns and routines so that compulsive behaviors are no longer necessary.
Most people with OCD benefit from taking certain psychiatric medications. The Food and Drug Administration (FDA) has approved several medications specifically for OCD. Among them are the antidepressants clomipramine (Anafranil), paroxetine (Paxil), fluvoxamine and sertraline (Zoloft). Many other antidepressant medications on the market may also be used to treat OCD “off-label,” that is, even if they haven’t been specifically FDA approved for that use. Antidepressants may be helpful for OCD because they may help increase levels of serotonin, which may be deficient in OCD.
Since OCD is a progressive disease that feeds on itself, it is imperative that you get professional psychiatric care as soon as possible. Early treatment can relieve symptoms, prevent the spread of the disease, and provide you with the tools to control obsessions for the rest of your life.
((1)) OCD is often confused with the separate condition obsessive-compulsive personality disorder (OCPD). The two are not the same condition. With OCD, the disorder is incompatible with the person’s self-concept, causing much distress. The person is aware that their behavior is not rational and is unhappy about their obsessions, but feel compelled by them, anyway. With OCPD, the person accepts the disease’s characteristics as compatible with their self image, and therefore is not distressed. Persons with OCPD are not aware of anything abnormal about themselves. They will readily explain why their actions are rational, and it is usually impossible to convince them otherwise. They tend to derive pleasure from their obsessions and compulsions. There are many other differences, as well. For more information, visit PsychCentral.
((2)) National Institute of Mental Health (2008). Obsessive-Compulsive Disorder (OCD). Retrieved June 23, 2008, from National Institute of Mental Health. Web site: http://www.nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd/index.shtml
((3)) Anxiety Disorders Association of America (2008). Statistics and Facts About Anxiety Disorders. Retrieved June 23, 2008, from Anxiety Disorders Association of America. Web site: http://adaa.org/AboutADAA/PressRoom/Stats&Facts.asp
((4)) Quick Reference to the Diagnostic Criteria from DSM-IV-TR. Arlington, VA: American Psychiatric Association, 2000.
DVM-IV is the abbreviation for the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, which is a publication of the American Psychiatric Association. It is a primary American source for mental health professionals that lists categories of mental disorders and the criteria for diagnosing them. It is used by clinicians and researchers, insurance companies, pharmaceutical companies and policy makers. The American Psychiatric Association has more information on the DSM-IV.
Other resources used in this article are:
Bourne, Edmund J. Healing Fear: New Approaches to Overcoming Anxiety. Oakland, California: New Harbinger Publications. 1998.
Mayo Clinic (2006). Obsessive-compulsive disorder (OCD). Retrieved June 21, 2008, from Mayo Clinic. Web site: Mayo Clinic http://www.mayoclinic.com/health/obsessive-compulsive-disorder/DS00189
PsychCentral (2006). Obsessive-Compulsive. Retrieved June 22, 2008, from Psych Central. Web site: http://psychcentral.com/resources/Obsessive-Compulsive/