Obsessive-compulsive disorder (OCD) is a mental health condition that involves difficulty managing thoughts and behaviors. Severe OCD symptoms are long-term, do not respond well to treatment, and considerably limit functioning.

The usual treatment for OCD may include medications and psychotherapy. However, since these may not be effective in severe cases, there is a need for alternative interventions. One possibility may involve brain stimulation techniques.

This article explains severe OCD, including its symptoms, causes, and related conditions. It also describes treatment, prevention, outlook, support sources, and when to call a doctor.

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OCD is a mental health condition where a person has recurring thoughts and behaviors that are difficult to manage. Doctors refer to the recurring thoughts as obsessions, and the recurring behaviors as compulsions. The lifetime prevalence of OCD is 1.6 to 2.3%.

Symtpoms can range from mild to severe. According to a 2019 review, the characteristics of severe cases include:

  • long-term or chronic symptoms
  • little response to medication or behavioral therapy
  • symptoms that substantially limit function and affect a person’s quality of life

Learn more about OCD.

In children after a strep infection

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are mental health conditions that can affect a child after a streptococcal infection, such as strep throat or scarlet fever, or after receiving strep injections.

PANDAS involves a sudden, dramatic manifestation of OCD symptoms, a tic disorder, or both. A tic is an involuntary, brief, sudden, repetitive movement.

Learn more about PANDAS.

OCD symptoms can affect all aspects of life, including:

  • personal relationships
  • work
  • school

Obsessive thoughts

Below are common symptoms of obsessions a person may experience:

  • a fear of contamination or germs
  • aggressive thoughts toward themselves or others
  • unwanted thoughts regarding:
    • harm
    • religion
    • sex
  • a need to have things in a perfect order or symmetrical position

Compulsions

The following are symptoms of compulsions:

  • excessive handwashing or cleaning
  • repeatedly checking things, such as whether a door is locked
  • arranging things in a precise way
  • compulsive counting

Additionally, some individuals may have a tic disorder that manifests in movements such as:

  • eye blinking
  • shoulder shrugging
  • head jerking

They may also have vocal tics that manifest in:

  • sniffing
  • throat-clearing
  • grunting

Related conditions

Conditions related to OCD include:

  • hoarding, where an individual has difficulty disposing of possessions
  • trichotillomania, also called hair-pulling disorder, where a person has a recurring urge to pull hair from their body
  • body dysmorphia, where someone has difficulty stopping themselves from thinking about perceived flaws in their appearance
  • excoriation disorder, sometimes called a skin-picking disorder, where people compulsively pick at their skin

It is best for a person with symptoms of compulsions and obsessions to make an appointment with a mental health professional with experience in treating OCD. They may wish to ask their primary care doctor for a referral.

If someone is having thoughts of hurting themselves or others, they should not wait for an appointment but seek immediate help.

Suicide prevention

If you know someone at immediate risk of self-harm, suicide, or hurting another person:

  • Ask the tough question: “Are you considering suicide?”
  • Listen to the person without judgment.
  • Call 911 or the local emergency number, or text TALK to 741741 to communicate with a trained crisis counselor.
  • Stay with the person until professional help arrives.
  • Try to remove any weapons, medications, or other potentially harmful objects if it’s safe to do so.

If you or someone you know is having thoughts of suicide, a prevention hotline can help. The 988 Suicide and Crisis Lifeline is available 24 hours a day at 988. During a crisis, people who are hard of hearing can use their preferred relay service or dial 711 then 988.

Find more links and local resources.

Researchers do not yet know the exact cause of OCD.

Multiple factors likely play a role. These may include:

  • Genetics: People with a close relative, such as a parent or sibling, who has OCD have a higher risk of developing it.
  • Environment: Some studies suggest a link between childhood trauma and OCD. Additionally, cases of PANDAS stem from an autoimmune reaction to a Streptococcus infection. “Autoimmune” means that a person’s immune system attacks their own tissues.
  • Brain structure and function: Some research suggests an association between OCD and atypical structure and function in certain parts of the brain. However, the relationship is unclear.

Treatment of OCD usually involves:

  • Medications: Options may include the class of antidepressants called serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac). When SSRIs are ineffective, doctors may prescribe an antipsychotic, such as aripiprazole (Abilify).
  • Psychotherapy: Some types of therapy can be effective, including cognitive behavioral therapy (CBT) and exposure and response prevention (EXRP). CBT consists of working to adjust patterns of thought that may be harmful to a person or others. EXRP consists of spending time in situations that trigger compulsions but resisting the urge to engage in them.
  • A combined approach: Doctors may recommend a combination of the above.

Brain stimulation

Although further studies are necessary, some research suggests certain brain stimulation techniques may produce reversible changes in atypical brain structure and functioning in people with severe OCD. These techniques include:

  • Transcranial magnetic stimulation (TMS): This entails the application of electric currents that a head coil transmits. In 2018, the Food and Drug Administration (FDA) approved this as an add-on treatment for OCD.
  • Transcranial direct current stimulation (tDCS): This involves the application of low intensity brain stimulation of continuous electrical current over the head, which scalp electrodes transmit.
  • Deep brain stimulation: This is a last resort that consists of the implantation of electrodes deep within the brain. These electrodes provide electrical stimulation.

Because TMS and tDCS are noninvasive, these are preferable to try first rather than the more invasive procedure, DBS.

There is no clear way to prevent OCD from occurring. However, stress may trigger or worsen symptoms. Exercising regularly and connecting with others may help reduce feelings of stress.

Additional lifestyle practices may also help decrease anxiety, which can help prevent OCD symptoms. These include:

  • getting enough sleep, which promotes emotional balance
  • not smoking, as this can increase anxiety and worsen OCD symptoms
  • avoiding alcohol, which can cause anxiety as it wears off

While OCD is a chronic condition, some individuals experience a course of waxing and waning. This refers to a pattern where symptoms worsen and then ease.

Without treatment, OCD is typically chronic, with a minority experiencing a worsening course. Among people who undergo effective treatment, approximately 50% have residual symptoms. However, treatment and certain lifestyle strategies may help reduce and manage its effects.

The National Alliance on Mental Illness has a toll-free helpline people can reach at 1-800-950-NAMI (6264).

Additionally, support groups may help a person feel more understood and connected. The International OCD Foundation offers an extensive list that includes groups such as:

Severe OCD involves chronic symptoms that may affect various areas of life, including work, school, and personal relationships. It can substantially limit various functions and affect a person’s quality of life. Symptoms involve obsessions and compulsions.

Researchers do not fully understand the cause of OCD. However, genetics, the environment, and an atypical brain structure may contribute to its development. Treatment may include medications, psychotherapy, or a combination of both. Brain stimulation techniques may also be an option in severe cases that do not respond to these interventions.

Although treatment is effective in some people, OCD is a chronic condition that seldom goes away completely. Certain lifestyle measures, such as regular exercise and adequate sleep, may help. It is best for people experiencing new or worsening symptoms to contact a doctor.