Obsessive compulsive disorder (OCD) is an anxiety disorder that is characterized by the sufferer experiencing repeated obsessions and/or compulsions that interfere with the person’s ability to function socially, occupationally, or educationally, either as a result of the amount of time that is consumed by the symptoms or the marked fear or other distress suffered by the person. Conventional knowledge is that there are four types of OCD: obsessions that are aggressive, sexual, religious or harm-related with checking compulsions; obsessions about symmetry that are accompanied by arranging or repeating compulsions; obsessions of contamination are associated with cleaning compulsions; and symptoms of hoarding.
An obsession is defined as a thought, impulse, or image that either recurs or persists and causes severe anxiety. These thoughts are irresistible to the OCD sufferer despite the person’s realizing that these thoughts are irrational. Examples of obsessions include worries about germs/cleanliness or about safety or order. A compulsion is a ritual/behavior that the individual with OCD engages in repeatedly, either because of their obsessions or according to a rigid set of rules. The aforementioned obsessions may result in compulsions like excessive hand washing, skin picking, lock checking, or repeatedly arranging items. Different than compulsions, habits are behaviors that occur with little to no thought, are repeated routinely, are not done in response to an obsession, are not particularly time-consuming, and do not cause stress. Examples of habits include cracking knuckles or storing car keys in a coat pocket.
The diagnosis of OCD has been described in medicine for at least the past 100 years. Statistics on the number of people in the United States who have OCD range from 1%-2%, or more than 2-3 million adults. Interestingly, the frequency with which it occurs and the symptoms with which it presents are remarkably similar, regardless of the culture of the sufferer. The average age of onset of the disorder is 19 years, although it often begins during the childhood or the teenage years and usually develops by 30 years of age. It tends to afflict more males than females.
Individuals with OCD are more likely to also develop chronic hair pulling (trichotillomania), muscle or vocal tics (Tourette’s disorder), or an eating disorder like anorexia or bulimia. OCD sufferers are also predisposed to developing other mood problems, like depression, generalized anxiety disorder, and panic disorder. OCD puts its sufferers at a higher risk of having excessive concerns about their bodies (somatoform disorders) likehypochondriasis, which is excessive worry about having a serious illness. People with OCD are more vulnerable to having bipolar disorder, also called manic depression.
Although sometimes confused with OCD, obsessive compulsive personality disorder (OCPD) is defined by perfectionism and an unbending expectation that the individual and others will keep a specific set of rules. OCPD sufferers do not tend to engage in ritualized behaviors (compulsions). However, OCPD tends to occur more often in people with OCD than in those without and therefore can be considered another risk factor for the development of obsessive compulsive disorder.
What causes OCD?
While there is no known specific cause for OCD, family history and chemical imbalances in the brain are thought to contribute to the development of the illness. Generally, while people who have relatives with OCD are at a higher risk of developing the disorder, most people with the illness have no such family history. A specific chromosome/gene variation has been found to possibly double the likelihood of a person developing OCD. It is thought that an imbalance of the chemical serotonin in the brain may also contribute to the development of OCD. Some life stressors, like being the victim of sexual abuse as a child, can increase the chance of developing OCD as an adult.
How is OCD diagnosed?
Some practitioners will administer a self-test of screening questions to individuals whom they suspect may be suffering from OCD. In addition to looking for symptoms of obsessions and compulsions by conducting a mental-status examination, mental-health professionals will explore the possibility that the individual’s symptoms are caused by another emotional illness instead of or in addition to OCD. For example, people with an addiction often have obsessions or compulsions, but those symptom characteristics generally only involve the object of the addiction. The practitioner will also likely ensure that a physical examination and any other appropriate tests have been done recently to explore whether there is any medical problem that could be contributing to the signs or symptoms of OCD.
What are the treatments for OCD?
Most individuals with OCD experience some symptoms of the disorder indefinitely, with times of improvement alternating with times of difficulty. However, the prognosis is most favorable for OCD sufferers who have milder symptoms that last for less time and who have no other problems before developing this illness.
Treatments include cognitive behavioral psychotherapy, behavioral therapies, and medications. Behavioral therapies for OCD include ritual prevention and exposure therapy. Prevention of rituals involves a mental-health professional helping the OCD sufferer to endure longer and longer periods of resisting the urge to engage in compulsive behaviors. Exposure therapy is the process by which the individual with OCD is put in touch with situations that tend to increase the OCD sufferer’s urge to engage in compulsions, then helping him or her resist that urge. Cognitive/behavioral therapists help patients change the negative styles of thinking and behaving that are often associated with the anxiety involved with obsessive compulsive disorder.
Selective serotonin reuptake inhibitors (SSRIs) are the medications that are most commonly used to treat OCD. These medications increase the amount of the neurochemical serotonin in the brain. (Remember that brain serotonin levels are thought to be low in OCD.) As their name implies, the SSRIs work by selectively inhibiting (blocking) serotonin reuptake in the brain. This block occurs at the synapse, the place where brain cells (neurons) are connected to each other. Serotonin is one of the chemicals in the brain that carries messages across these connections (synapses) from one neuron to another.
The SSRIs work by keeping serotonin present in high concentrations in the synapses. These drugs do this by preventing the reuptake of serotonin back into the nerve cell that is transmitting an impulse. The reuptake of serotonin is responsible for turning off the production of new serotonin. Therefore, the serotonin message keeps on coming through. It is thought that this, in turn, helps arouse (activate) cells that have been deactivated by OCD, thereby relieving the symptoms of the condition.
SSRIs have fewer side effects than clomipramine, an older medication that is actually thought to be somewhat more effective in treating OCD. SSRIs do not cause orthostatic hypotension (a sudden drop in blood pressure when sitting up or standing) and heart-rhythm disturbances, like clomipramine can. Therefore, SSRIs are often the first-line treatment for this illness. Examples of SSRIs include fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft),citalopram (Celexa), fluvoxamine (Luvox), and escitalopram (Lexapro). When the improvement that people with OCD experience is not optimal when an SSRI is the only medication prescribed, the addition of a neuroleptic medication like risperidone (Risperdal), olanzapine (Zyprexa), or aripiprazole(Abilify) can sometimes be helpful.
SSRIs are generally well tolerated, and side effects are usually mild. The most common side effects are nausea, diarrhea, agitation, insomnia, andheadache. However, these side effects generally go away within the first month of SSRI use. Some patients experience sexual side effects, such as decreased sexual desire (decreased libido), delayed orgasm, or an inability to have an orgasm. Some patients experience tremors with SSRIs. The so-called serotonergic (meaning caused by serotonin) syndrome is a serious neurologic condition associated with the use of SSRIs. It is characterized by high fevers, seizures, and heart-rhythm disturbances. This condition is very rare and has been reported only in very ill psychiatric patients taking multiple psychiatric medications.
Newer, often called atypical, neuroleptic medications like the ones named above tend to cause fewer side effects than many of the older medications in this class. The most common side effects of atypical neuroleptics include sleepiness, dizziness, dry mouth, and weight gain. Sometimes, people can be more sensitive to the effects of the sun while taking these medications and therefore should take care to wear adequate sunblock whenever exposed to the sun. Less commonly, side effects of atypical neuroleptic medications can result in painless, although abnormal, muscle movements like tremors, stiffness, and very rarely permanent muscle twitches called tardive dyskinesia.
Studies on the effectiveness of treatment of OCD in adults have variable results. Some indicate that medications, response prevention, and CBT are equally, although only mildly to moderately, effective in treating this problem. Cognitive behavioral group therapy (CBGT) has also been found to be an effective treatment for OCD.
Research on treating OCD in children and adolescents suggests that while medications are clearly effective in treating this disorder, the improvement that is experienced as a result is quite mild. However, clomipramine tends to be more effective than the SSRIs, and the individual SSRIs tend to be equally effective. As in adults, people under 18 years of age tend to improve more significantly when treated with a combination of medication and CBT. There is increasing evidence that deep brain stimulation may be effective in treating severe OCD that has not responded to other treatments. There is also increasing research about whether or not hallucinogens have a role in treating OCD.
What happens if OCD is not treated?
Without treatment, the symptoms of OCD can progress to the point that the sufferer’s life becomes consumed, inhibiting their ability to keep a job and maintain important relationships. Many people with OCD have thoughts of killing themselves, and about 1% complete suicide.
In terms of the prognosis for the specific symptoms, it is rare for any to progress to a physically debilitating level. However, problems like compulsive hand washing can eventually cause skin to become dry and even to break down. Repeated trichotillomania can result in unsightly scabs on the person’s scalp.