Obsessive-Compulsive Disorder (OCD)

What Is It?

In obsessive-compulsive disorder (OCD) a person is troubled by a pattern of intrusive, distressing thoughts and repetitive behaviors.

Although the exact cause of OCD remains a mystery, doctors believe there are changes in the functioning of brain pathways that are involved with judgment, planning and body movements. Environmental influences, such as family relationships or stressful events, have an impact, too.

OCD affects an estimated 2% to 3% of people in the United States. The percentage is about the same in Canada, Korea, New Zealand and parts of Europe.

About two-thirds of people with OCD have the first symptoms before they are 25 years old, while only 15% develop symptoms after age 35. There is strong evidence that the illness has a genetic (inherited) basis, since about 35% of people with OCD have a close relative who also has the condition. Although 50% to 70% of patients first develop OCD after a stressful life event such as a pregnancy, a job loss or a death in the family scientists still do not understand exactly how or why stress seems to trigger the symptoms of this illness.

Sometimes, people with OCD manage to live with their obsessions without giving any external sign that they are suffering. Usually, however, they will try to relieve their obsessions by performing some type of compulsion: a persistent, repeated ritual that is aimed at soothing their fears. For example, a woman who has the obsession that her hands are dirty may develop the compulsion to wash them 50 times a day. A man who fears that his front door is unlocked may feel compelled to check the lock 10 or 20 times each night. Although it is also possible for a person with OCD to perform compulsive acts that are not triggered by obsessions, this is not very common.

Symptoms

Two major symptoms of OCD are obsessions and compulsive rituals.

Obsessions are persistent, repeated, anxiety-provoking thoughts that intrude into everyday life and cause feelings of distress. Although obsessions can vary from person to person, they often center on one or more of the following issues:

• Fear of contamination A person with OCD may worry constantly about having dirty hands or clothing, or about catching or spreading germs. In some cases, this fear of contamination also extends to sexual activity. The person might think that sex is dirty, even between a husband and wife.
• Fears related to accidents or acts of violence A person with OCD may have obsessive thoughts related to fears about becoming a victim of violence or suffering some other type of bodily harm. For example, he or she may worry constantly that the front door is not locked, that the oven is not turned off, or that a cigarette has not been snuffed out completely.
• Fear of committing an act of violence or sexual misconduct A person with OCD may fear losing control and doing harm to others, or committing some type of harmful or embarrassing sexual act. For example, a loving mother with OCD may suffer from obsessive thoughts about suffocating her infant, or a respectable businessman may fear that he will suddenly take off his clothes in the middle of an important meeting.
• Fears that center on disorder or asymmetry Someone with OCD can have an obsessive need to have order and precision, and may feel very anxious if even the smallest detail of his or her world is out of place. For example, the person may become upset if socks are not aligned "properly" in a drawer or if food is not arranged "correctly" on a dinner plate. Usually, an adult with OCD will recognize that these obsessive thoughts are coming from his or her own mind and will try to ignore them, suppress them or get relief by performing a compulsive ritual.

Compulsive rituals are persistent, excessive, repetitive behaviors that are aimed at reducing the fear and anxiety triggered by an obsessive thought. Examples include:

• Repeatedly washing one's hands or bathing
• Refusing to shake hands or touch doorknobs
• Repeatedly checking locks or stoves
• Compulsively counting telephone poles
• Arranging socks or items of clothing
• Eating items of food in a specific order
• Compulsively repeating a specific word or prayer

Occasionally, almost everyone feels compelled to recheck a locked door, or to make sure that his or her hands are clean. These thoughts alone are not symptoms of OCD. The obsessions and compulsions of OCD are excessive and distressing. They interfere with normal, everyday life because they are so time-consuming, sometimes eating up several hours of a person's day. They may interfere with personal relationships, as well as performance at work or school. Some compulsions may even cause physical injury. For example, compulsive hand washing can lead to chapped hands and dermatitis, while excessive tooth brushing can cause torn, bleeding gums.

Diagnosis

Many people with OCD first consult a primary care physician when a compulsion begins to affect their health or everyday life. For example, an adult with compulsive hand washing may visit a dermatologist because of cracked, bleeding fingers, or a parent may consult a pediatrician when a child with OCD begins to bathe four or five times a day.

Depressed mood is very common in OCD. In fact, a person may talk mainly about feeling depressed, because the OCD symptoms are embarrassing and more difficult to discuss.

If your doctor suspects that the problem is a psychiatric illness, he or she will likely review your medical history, and ask you to describe current anxieties and recent stresses. The doctor may then refer you to a psychiatrist for treatment.

Your psychiatrist will diagnose OCD based on an evaluation that should include:

• Asking questions about your obsessive thoughts and compulsive behaviors
• Assessing your level of psychological distress
• Determining the impact of obsessions and compulsions on your everyday life and relationships
• Checking for symptoms of other forms of psychiatric illness

Expected Duration

OCD rarely disappears on its own, and its symptoms may last for years if they are not treated properly. In fact, it is common for a person with OCD to have the problem for 5 to 10 years before seeing a psychiatrist.

Prevention

There is no way to prevent OCD.

Treatment

OCD usually is treated with a combination of psychotherapy and medications.

Medications

The most common medications used to treat OCD are antidepressants, particularly those called selective serotonin reuptake inhibitors (SSRIs). This class of medications includes fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), paroxetine (Paxil) and citalopram (Celexa). To treat OCD, the dose of medication usually has to be higher than when treating depression.

Tricyclic antidepressants also may be effective. The one most used for OCD is clomipramine (Anafranil). Although this drug may be slightly more effective than the SSRIs for treating OCD, it also tends to have more troublesome side effects, including drowsiness, constipation and dry mouth.

Psychotherapy

A number of psychotherapy techniques may be helpful, depending on the person's preference, the events that may have contributed to the problem, and availability of family and other social support. It's important to get education about OCD and to get support from friends, family or support groups. Cognitive behavioral therapy is designed to help you recognize the unreasonableness of the thoughts and teach you techniques for controlling your compulsions. Psychodynamic, insight-oriented or interpersonal psychotherapy can help a person sort out conflicts in important relationships or explore the history behind the symptoms, though insight itself is not likely to have an impact on severe symptoms.

In behavior therapy, treatments are aimed at eliminating the patient's compulsive actions by examining and evaluating the distorted, fearful thinking and considering alternative ways of dealing with anxiety. Some specialized approaches for the treatment of OCD are:

• Exposure and response prevention (ERP) In this therapy, a person is exposed to situations that provoke obsessive thoughts but is prevented from performing the usual compulsive ritual. For example, a person may be asked to touch a "dirty" shoe, then be told to wait before washing his or her hands. The person will practice this behavior daily, gradually increasing the waiting time and keeping a diary of his or her efforts. Therapy sessions usually are scheduled weekly for a period of three to 12 months.
• Habit reversal In this therapy, the person is asked to substitute a different response, such as deep breathing or fist clenching, for the usual compulsive ritual.
• Thought stopping This technique involves some form of distraction whenever an obsessive thought occurs. One common method is to instruct the person to say the word, "Stop," and snap a rubber band at the wrist.
• Saturation This approach asks the patient to concentrate intensely on the obsessive thought until the thought loses its impact and becomes meaningless.

Family therapy and group therapy also have been used successfully to treat some people with OCD. Because this disorder can be very disruptive to family life, family therapy often is recommended. In addition, therapy can identify ways that family members unwittingly perpetuate or promote symptoms.

When To Call A Professional

Since the symptoms of OCD seldom disappear without treatment, you should contact your primary care doctor whenever obsessive thoughts or compulsions cause you significant distress or discomfort, interfere with your ability to have a normal life at home or work, or cause you injury. Your primary care doctor will refer you to a psychiatrist for appropriate and effective treatment.

Prognosis

Since OCD can be a chronic (long-lasting) condition, ongoing treatment may be necessary and the outlook is usually good. After the initial phase, maintenance can be straightforward and may require appointments only once in a while.

About 50% of patients improve and about 10% recover completely. Only 10% get worse in spite of therapy.

Additional Info

American Psychiatric Association

1400 K St., NW

Washington, DC 20005

Toll-Free: (888) 357-7924

Fax: (202) 682-6850

E-Mail: apa@psych.org

http://www.psych.org/