Obsessive-compulsive disorder (OCD) is a chronic, debilitating mental health condition characterized by distressing, intrusive, obsessive thoughts and repetitive, compulsive physical or mental acts.
OCD is a distinct condition but falls within the category of "obsessive-compulsive and related disorders."
OCD is relatively common in both children and adults, is associated with a wide range of functional impairments, and has a significant impact on social and occupational life.
Contents of this article:
Fast facts on obsessive-compulsive disorder
- Common compulsions include washing, cleaning, checking, and repeating
- OCD occurs roughly equally in men and women and affects people of all races and socioeconomic backgrounds
- The first symptoms of OCD often begin during childhood or adolescence, however, the average age of onset is 19
- OCD could be triggered by a combination of genetic, neurological, behavioral, cognitive, and environmental factors
- Some people suffering OCD successfully hide their symptoms in fear of embarrassment or stigma
What is obsessive-compulsive disorder?
According to a 2001 World Health Organization (WHO) mental health report, it is estimated that, in the year 2000, OCD was among the top 20 causes of illness-related disability worldwide for people aged 15-44, and that OCD was the fourth most common mental illness after phobias, substance abuse, and major depression.
OCD that begins in childhood is more common in boys than girls, with the usual time of onset of OCD later for females than males; the disorder is equally common among adult men and women.
The presence of obsessions or compulsions, or both, are what distinguishes obsessive-compulsive disorder from other conditions. The obsessions or compulsions cause marked distress, are time-consuming, and interfere with a person's normal functioning.
Causes of OCD
Constant hand-washing and washing and cleaning in a specific way are common OCD compulsions.
Despite a wealth of research, the exact causes of OCD have not been identified.
OCD is, however, considered to have a neurobiological basis, with neuroimaging studies showing that the brain functions differently in people with the disorder.
Abnormalities, or an imbalance in neurotransmitters, including serotonin, dopamine, or glutamine are thought to be involved in OCD.
In certain individuals, OCD could be triggered by a combination of genetic, neurological, behavioral, cognitive, and environmental factors.
Genetic causes of OCD
Studies have shown that OCD runs in families and can be considered a "familial disorder." The disease may span generations with close relatives of people with OCD significantly more likely to develop OCD themselves.
Twin studies of adults suggest that obsessive-compulsive symptoms are moderately heritable, with genetic factors contributing 27-47 percent of variance in scores on measures of obsessive-compulsive symptoms. However, no single gene has been identified as the "cause" of OCD.
Some rapid onset cases of obsessive-compulsive disorder in children might be a consequence of Group A streptococcal infections, which cause inflammation and dysfunction in the basal ganglia.
These cases are grouped together and referred to as pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).In recent years, however, other pathogens, such as the bacteria responsible for Lyme disease, and H1N1 (the flu virus), have also been associated with rapid onset of OCD in children. As such, clinicians have altered the acronym to PANS - Pediatric Acute-Onset Neuropsychiatric Syndrome.
Behavioral causes of OCD
The behavioral theory suggests that people with OCD associate certain objects or situations with fear and learn to avoid those things or learn to perform "rituals" in order to help reduce the fear.
This fear and avoidance/ritual cycle may begin during a period of intense stress, such as when starting a new job or when a relationship comes to an end.
Once the connection between and object and the feeling of fear becomes established, people with OCD begin to avoid that object and the fear it generates, rather than confronting or tolerating the fear.
Cognitive causes of OCD
The behavioral theory outlined above focuses on how people with OCD make an association between an object and fear, whereas, the cognitive theory focuses on how people with OCD misinterpret their thoughts.
Most people have unwelcome or intrusive thoughts at some time or other, but for those with OCD the importance of those thoughts are exaggerated.
For example, a person who is caring for an infant and who is under intense pressure may have an intrusive thought of harming the infant. Most people can shrug off and disregard the thought, but a person suffering from OCD may exaggerate the importance of the thought and respond as though it signifies a threat.
As long as the sufferer interprets these intrusive thoughts as cataclysmic and true, they will continue the avoidance and ritual behaviors.
Neurological causes of OCD
Brain scans have shown abnormal activity in patients with OCD.
Brain imaging techniques have allowed researchers to study the activity of specific areas of the brain, leading to the discovery that some parts of the brain are different in OCD sufferers compared with non-sufferers.
Despite this revelation, it is not known exactly how these differences relate to the development of OCD.
Imbalances in serotonin, or glutamate may play a part in OCD.
Environmental causes of OCD
Environmental stressors may be a trigger for OCD in people with a tendency toward developing the condition.
Traumatic brain injury (TBI) in adolescents and children has also been associated with an increased risk of onset of obsessive-compulsions, with one study finding that 30 percent of children aged 6-18 who experienced a TBI developed symptoms of OCD within 12 months of the injury.
Overall, studies indicate that patients with OCD frequently report stressful and traumatic life events before the illness begins.
Diagnosis of OCD obsessions
Obsessions are more than the everyday worries experienced by most healthy people when thinking about real-life problems. Instead, people with OCD experience excessive thoughts and worries that prompt them to engage in particular actions or thoughts in an attempt to relieve or suppress the fear and anxiety. A person with OCD typically:
- Has repetitive thoughts, images or urges that they do not feel able to control
- Is aware of these intrusive thoughts and feelings and does not want to have these ideas
- Finds these thoughts disturbing, unwanted and (in the case of older children and adults) is aware that they do not make sense
- Has uncomfortable feelings, such as fear, disgust, doubt, or a feeling that things have to be done in a way that is "just right"
- Spends an unwarranted amount of time on these obsessions, which interferes with personal, social, and professional activities.
Common OCD obsessions include:
- Contamination - including body fluids, germs, and dirt
- Losing control - including a fear of acting on an urge to harm oneself or others
- Perfectionism - including concerns about exactness, needing to remember things, and fear of losing things
- Harm - including a fear of being responsible for something terrible happening
- Unwanted sexual thoughts - including obsessions about homosexuality or incest
- Religious obsessions - including concerns about offending god
Perfectionism and concern about evenness or exactness are obsessions apparent in OCD.
Not all "rituals" or forms of repetitive behavior are compulsions.
Normal and welcome repetitive behaviors that feature in everyday life may include bedtime routines, religious practices, and learning a new skill.
Behavior also depends on the context, for example, a person who works in a video store arranging DVDs for 8 hours a day is probably not acting out of compulsion.
Common OCD compulsions include:
- Washing and cleaning - including constant hand-washing
- Checking - including checking body parts or checking that nothing terrible happened
- Repeating - including rereading and repeating routine activities like getting up from a chair
- Mental compulsions - including praying to prevent harm and mentally reviewing events
Common Symptoms of OCD
Early indications of OCD often present in children and teenagers, with the disease usually beginning gradually and worsening with age. Symptoms of OCD can be mild or severe. Some people experience obsessive thoughts only, without engaging in compulsive behavior.
Some people suffering from OCD successfully hide their symptoms in fear of embarrassment or stigma. Friends and family may, however, notice some of the more physical signs above.
Tests and diagnosis
According to the American Psychiatric Association, the diagnostic criteria of OCD includes:
- The presence of obsessions, compulsions or both
- The obsessions and compulsions are time-consuming or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
- The obsessive-compulsive symptoms are not due to the physiological effects of a substance, for example, drug abuse or medication for another condition
- The disturbance is not better explained by another mental disorder
If the above criteria are met, a diagnosis of OCD may be given.
A number of other psychiatric and neurological disorders such as depression and anxiety have similar features to OCD and can occur alongside OCD.
Treatments for OCD
CBT may help a high percentage of people via two types of treatment.
Left untreated, OCD usually develops into a chronic condition with episodes where symptoms seem to improve.
Without treatment, remission rates are low, at around 20 percent.
However, around 40 percent of people who develop OCD in childhood or adolescence experience remission by early adulthood.
Treatment for OCD will depend on how much the condition affects the person's ability to function.
First-line treatments for OCD will often include:
- CBT (cognitive behavioral therapy)
- SSRI (selective serotonin reuptake inhibitors)
- Combination of SSRI plus CBT.
Cognitive behavioral therapy
CBT is an effective method of treating OCD. CBT is a type of psychotherapy (talking therapy) that aims to help the patient change the way they think, feel, and behave and refers to two distinct treatments:
- Exposure and response prevention (ERP)
- Cognitive therapy
Research has shown that 75 percent of people with OCD are significantly helped by cognitive behavioral therapy.
Exposure and response prevention (ERP)
Exposure: Part of this treatment involves exposure to situations and objects that trigger fear and anxiety. Over time, the anxiety generated by these obsessional cues decreases and, eventually, the obsessional cues cause little or no anxiety. This is called habituation.
Response: Response prevention refers to the ritual behaviors that people with OCD engage in to reduce anxiety. This treatment helps patients learn to resist the compulsion to perform these rituals.
Cognitive therapy (CT)
People participating in CT work toward eliminating compulsive behavior by identifying and re-evaluating their beliefs about the consequences of engaging or not engaging in the compulsive behavior.
Once these intrusive thoughts and the meanings the person applies to them are acknowledged, the therapist will then encourage the person to:
- Examine the evidence that supports and does not support the obsession
- Identify cognitive distortions in the appraisals of the obsession
- Develop a less threatening and alternative response to the intrusive thought, image, or idea
Only a small number of studies have tested the effectiveness of CT for OCD. These studies have, however, found CT to be effective.
Selective serotonin reuptake inhibitors (SSRIs)
There are a number of drugs available for treating OCD, with the development of SSRIs expanding the range of treatment options. SSRIs that may be prescribed to help people manage OCD include:
- Paroxetine hydrochloride
SSRIs are generally used in higher doses for OCD than for depression and for at least 3 months. About half of all patients with OCD do not respond to SSRI treatment alone, with atypical antipsychotic medications often added to the treatment.