Obsessive-Compulsive Disorder (OCD)
OVERVIEW
Obsessive-Compulsive Disorder (OCD) is a mental health disorder which emerges in how a person tolerates uncertainty in certain areas of their life. Sufferers experience uncontrollable, reoccurring thoughts, impulses or images (i.e. obsessions) and repetitive behaviors or thoughts; further, they experience urges to engage in (i.e. compulsions) in order to neutralize the obsession. For example, people with OCD may experience persistent doubt that creates an urge to check specific things repeatedly or perform routines/rituals for at least one hour per day. Performing these routines or rituals may provide temporary relief from the anxiety. However, left untreated, the unending cycle of obsessions and compulsions can cause someone great distress and interfere with all aspects of one’s life.[1]
It is important to note that OCD is an actual psychological disorder and not an obsessive personality trait. While research has shown that most people have occasional unwanted intrusive thoughts, in cases of OCD, these intrusive thoughts occur frequently and trigger extreme anxiety that impedes a person’s daily functioning.[2]
Without utilizing psychotherapeutic help, one may try to ignore or simply stop their obsessions. However, these attempts only lead to increased distress and anxiety. The vicious cycle of OCD includes ritualistic behaviors (including ritualized thoughts) that to temporarily relieve distress – these acts, in themselves, unfortunately serve to perpetuate the anxiety long-term.[3]
Signs and Symptoms
OCD, usually considered a lifelong disorder, often presents itself in one’s teen or young adult years; however, it can start in childhood. Symptoms and manifestations of OCD range from mild to debilitating. The onset of symptoms is usually gradual and tends to vary in severity throughout one’s life. Stress is one factor which usually perpetuates and worsens symptoms.[4]
The types (or themes) of obsessions and compulsions experienced by people with OCD can change over time. One often tries to ignore obsessions or attempt to get rid of them by performing a compulsive behavior or ritual. Intrusive, these obsessions typically arise when trying to think of or do other things. OCD compulsions are the repetitive behaviors that one feels driven to perform. These repetitive behaviors or mental acts are performed in an attempt to reduce anxiety related to one’s obsessions or to try prevent something bad from happening. Rules or rituals are often used to try and control anxiety when experiencing obsessive thoughts. These compulsions are usually excessive and may appear to an observer to not be related to the problem/issue the person with OCD is intending to quell; the connection, to the sufferer of OCD, is usually apparent. Further, engaging in compulsions often brings no pleasure and may offer only a temporary relief from anxiety.[5] In most cases, those with OCD feel driven to engage in compulsive behavioral acts and would rather not have to do these time-consuming and many times torturous acts. The compulsive behavior is done solely with the intention of trying to escape one’s obsession or reduce the anxiety produced by it.[6]
According to the National Institute of Mental Health and the International OCD Foundation, common obsessions and compulsions may include the following:[7,8]
Obsessions
Fear of germs or contamination (e.g. a virus, bodily fluids, chemicals or environmental contaminants such as radiation or asbestos)
Fear of losing or misplacing something
Fear of losing control and acting on a harmful impulse
Worries about harm coming towards oneself or others
Unwanted and taboo thoughts involving sex, religion, or others people
Compulsions
Excessively cleaning or washing (e.g. a body part, household item or other objects)
Keeping or hoarding unnecessary objects
Ordering or arranging items in a particular, precise way
Repeatedly checking on things (e.g. making sure that the door is locked or the oven is off)
Repeating (e.g. repeating body movements, counting items in multiples)
Constantly seeking reassurance
Some people with OCD (especially if the OCD onset occurs during childhood) can also present with a tic disorder. Motor tics are sudden, brief, repetitive movements, such as eye blinking, facial grimacing, shoulder shrugging, or head or shoulder jerking. Common vocal tics in OCD include repetitive throat-clearing, sniffing, or grunting sounds.[9]
Diagnosis
Common steps undertaken to diagnose obsessive-compulsive disorder may include:
Psychological evaluation. During an evaluation with a mental health professional, one discusses their thoughts, feelings, symptoms and behavior patterns to determine if there are obsessions or compulsive behaviors that interfere with their quality of life. With permission, the mental health professional may speak with the patient’s family or friends. The mental health professional may administer the Y-BOCS and/or Y-BOCS symptom checklist to help with diagnosis and treatment planning.
Diagnostic criteria for OCD. Doctors utilize criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5),[10] published by the American Psychiatric Association.
Physical exam. Exams may be performed to help rule out other problems and conditions that could be causing OCD symptoms as well as check for any related complications.
As per the last bullet above, OCD may be difficult to diagnose as symptoms of this disorder present similar to other conditions, such as: obsessive-compulsive personality disorder, anxiety disorders, depression, schizophrenia or other mental health disorders. Further, it is not uncommon to have both OCD and another mental health disorder. It is therefore important to work with medical and mental health professionals to properly diagnose Obsessive-Compulsive Disorder.[11]
Causes
Currently, the causes of OCD are not fully understood and several theories suggest differing factors contributing to this disorder.
OCD may have a genetic component. It sometimes runs in families, but the specific genes have yet to be identified. Additionally, it is suggested that there may be a modeling in families of certainty-seeking patterns of behavior.[12]
Biologic factors are also considered in the development of OCD. The disorder usually begins in adolescence or young adulthood, and tends to appear at a younger age in males than in females. Several parts of the brain, as well as biological processes, have been found to play a key role in obsessive thoughts and compulsive behavior, as well as the fear and anxiety related to them.[13]
Moreover, both trauma and certain illness are linked to increased risk of OCD. Additionally, following a streptococcal infection, it has been found that some children have developed a sudden onset or worsening of OCD symptoms; this post-infectious autoimmune syndrome is referred to as Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS).[14]
While prevention of OCD is currently not possible, prompt treatment upon the arrival of initial symptoms is key to helping prevent the disorder from worsening, disrupting activities and one’s overall life.[15]
Risk Factors
The Mayo Clinic notes the following factors that may increase the risk of developing or trigger OCD:[16]
Family history. Having parents or other family members with the disorder can increase one’s risk of developing OCD either due to a genetic component or via learned transmission.
Stressful life events. Traumatic or stressful events may increase one’s risk of developing OCD. Reactions to traumatic or stressful events may lead to the triggering of intrusive thoughts, rituals and emotional distresses characteristic of OCD.
Other mental health disorders. OCD may be related to other mental health disorders (such as anxiety disorders, depression, substance abuse or tic disorders.)
Complications
Problems resulting from Obsessive-Compulsive Disorder may include:[17]
Excessive time spent engaging in ritualistic behaviors
Health issues (e.g. contact dermatitis from frequent hand-washing)
Difficulty attending work, school or social activities
Troubled relationships
Overall poor quality of life
Treatment and Therapeutic Options
The first step to diagnose and treat OCD is to speak with a doctor or health care provider about presenting symptoms. The clinician performs an exam and asks about health history to make sure that a physical problem is not causing the symptoms. A mental health specialist, such as a psychiatrist, psychologist, social worker, or counselor is usually sought for further evaluation and/or treatment.
OCD is generally treated with cognitive behavioral therapy, medication, or both.
Cognitive Behavioral Therapy (CBT)
CBT is a type of psychotherapy that is effective in managing OCD in that this modality teaches different ways of thinking, behaving, and reacting to one’s obsessions and compulsions. Exposure and Response Prevention (ERP) is a specific form of CBT which has been shown to help many patients recover from OCD. ERP involves gradually exposing someone to their fears or obsessions while supporting them in blocking the use of compulsions. Instead, the client is encouraged and supported in remaining mindfully present with the emotions experienced when triggered, without using avoidance strategies. Habit Reversal Training is another such therapy that can help someone overcome their compulsions.[18]
Medication
There are several different types of medications used to help control the obsessions and compulsions of OCD. Such pharmacological options include selective serotonin reuptake inhibitors (SSRIs) and a type of serotonin reuptake inhibitor (SRI) called Clomipramine. While SSRIs and SRIs are commonly used to treat depression, they are also beneficial to manage the symptoms of OCD.[19]
Antidepressants approved by the U.S. Food and Drug Administration (FDA) to treat OCD include:[20]
Clomipramine (Anafranil) for adults and children 10 years and older
Fluoxetine (Prozac) for adults and children 7 years and older
Fluvoxamine for adults and children 8 years and older
Paroxetine (Paxil, Pexeva) for adults only
Sertraline (Zoloft) for adults and children 6 years and older
It is important to note that SSRIs and SRIs may take 10-12 weeks to start working, which is longer than is required for the treatment of depression. Further, these medications may cause side effects, such as headaches, nausea, or difficulty sleeping. Specifically, the drug Clomipramine may cause dry mouth, constipation, rapid heartbeat, and dizziness upon standing. However, these side effects are usually not severe for most people and improve as treatment continues, especially if the dose initiates low and is increased slowly over time. If unpleasant side effects are experienced upon the consumption of OCD medications, it is important not to stop the prescription without first speaking with the prescribing physician.
It is important to note that both psychotherapy and medication can take time to become effective. While there is no cure for OCD, current treatments enable most people with this disorder to control their symptoms in which they are able to lead fuller, more productive lives. Lifestyle adaptations that can lead to greater management of Obsessive-Compulsive Disorder include a lifestyle that includes: relaxation and stress management, sufficient sleep, exercise, following a healthy diet, and maintaining an active support system.[21]
Other Treatment Options
In the case of treatment-resistant OCD, psychotherapy and medications aren't effective enough to manage OCD symptoms. The Mayo Clinic lists several other therapeutic options, which include:[22]
Intensive outpatient and residential treatment programs. Comprehensive treatment programs over the course of several weeks, emphasizing ERP therapy principles.
Deep brain stimulation (DBS). DBS is approved by the FDA to treat OCD in adults age 18 years and older who don't respond to traditional treatment approaches. DBS involves implanting electrodes within certain areas of your brain to produce electrical impulses which may help regulate abnormal impulses.
Transcranial magnetic stimulation (TMS). This FDA approved device (BrainsWay Deep Transcranial Magnetic Stimulation) is used to treat OCD in adults ages 22 to 68 years, when traditional treatment approaches have not been effective. TMS is a noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of OCD. During TMS sessions, an electromagnetic coil is placed against one’s scalp near the forehead. The electromagnet delivers a magnetic pulse that stimulates nerve cells in your brain, which may regulate abnormal impulses one is experiencing.
If you find you are experiencing obsessions and compulsions that affect your quality of life, reach out to your doctor or licensed mental health professional regarding a formal diagnosis and treatment options.
Contributed by: Jennifer (Ghahari) Smith, Ph.D.
References
1 “Obsessive Compulsive Disorder,” National Institute of Mental Health. (accessed 9-17-2020). www.nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd/index.shtml
2 “About OCD,” International OCD Foundation. (accessed 9-16-2020). iocdf.org/about-ocd/
3 “Obsessive-Compulsive Disorder,” Mayo Clinic. (accessed 9-17-2020) www.mayoclinic.org/diseases-conditions/obsessive-compulsive-disorder/symptoms-causes/syc-20354432
4 Ibid.
5 Ibid.
6 “About OCD,” International OCD Foundation.
7 Ibid.
8 “Obsessive Compulsive Disorder,” National Institute of Mental Health.
9 Ibid.
10 Substance Abuse and Mental Health Services Administration. Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2016 Jun. Table 3.13, DSM-IV to DSM-5 Obsessive-Compulsive Disorder Comparison. (accessed 9-18-2020) www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t13/
11 “Obsessive-Compulsive Disorder: Diagnosis,” Mayo Clinic. (accessed 9-17-2020) www.mayoclinic.org/diseases-conditions/obsessive-compulsive-disorder/diagnosis-treatment/drc-20354438
12 “Obsessive-Compulsive Disorder,” Mayo Clinic.
13 Ibid.
14 “Obsessive Compulsive Disorder,” National Institute of Mental Health.
15 “Obsessive-Compulsive Disorder,” Mayo Clinic.
16 Ibid.
17 Ibid.
18 “Obsessive Compulsive Disorder,” National Institute of Mental Health.
19 Ibid.
20 “Obsessive-Compulsive Disorder: Diagnosis,” Mayo Clinic.
21 “Obsessive Compulsive Disorder,” National Institute of Mental Health.
22 “Obsessive-Compulsive Disorder: Diagnosis,” Mayo Clinic.