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Obsessive-compulsive disorder (OCD) is a psychiatric anxiety disorder most commonly characterized by a subject's obsessive, distressing, intrusive thoughts and related compulsions (tasks or
"rituals") which attempt to neutralize the obsessions.
The phrase "obsessive-compulsive" has worked its way into the wider English
lexicon, and is often used in an offhand manner to describe someone who is meticulous or absorbed in a cause (see also "anal-retentive"). Such
casual references should not be confused with obsessive-compulsive disorder; see clinomorphism. It is also important to distinguish OCD from other types of anxiety, including the routine tension and stress that appear throughout life. Although these signs are often present in OCD, a person who shows
signs of infatuation or fixation with a
subject/object, or displays traits such as perfectionism, does not
necessarily have OCD, a specific and well-defined condition.
To be diagnosed with obsessive-compulsive disorder, one must have either obsessions or compulsions alone, or obsessions and
compulsions, according to the DSM-IV-TR diagnostic
criteria. The Quick Reference to the diagnostic criteria from DSM-IV-TR (2000) describes these obsessions and
compulsions:[1]
Obsessions are defined by:
- Recurrent and persistent thoughts,
impulses, or images that are experienced at some time during the disturbance, as intrusive and
inappropriate and that cause marked anxiety or distress.
- The thoughts, impulses, or images are not simply excessive worries about real-life problems.
- The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought
or action.
- The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind, and are not
based in reality.
- The tendency to haggle over small details that the viewer is unable to fix or change in any way. This begins a mental
pre-occupation with that which is inevitable.
Compulsions are defined by:
- Repetitive behaviors or mental acts that the person feels driven to perform in response
to an obsession, or according to rules that must be applied rigidly.
- The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation;
however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or
prevent or are clearly excessive.
In addition to these criteria, at some point during the course of the disorder, the sufferer must realize that his/her
obsessions or compulsions are unreasonable or excessive. Moreover, the obsessions or compulsions must be time-consuming (taking
up more than one hour per day), cause distress, or cause impairment in social,
occupational, or school functioning.[1] OCD often causes feelings similar to those of depression.
Causes and related disorders
It was the general belief in the 14th, 15th, and 16th centuries that those who experienced blasphemous, sexual, or other
obsessive thoughts were possessed by the Devil. Based
on this reasoning, treatment involved banishing the "evil" from the "possessed" person through
exorcism.[2]
Today the community of scientists studying obsessive-compulsive disorder has been split into two factions by a disagreement
over the exact cause of the illness. On one side is a group who believe that obsessive-compulsive behavior is a psychological
disorder. On the other side are scientists who believe that obsessive-compulsive behavior is caused by abnormalities in the
brain. A majority of researchers now believe in this biological hypothesis of OCD.[3]
Stanford University School of Medicine OCD web page states
that:"Although the causes of the disorder still elude us, the recent identification of children with OCD caused by an autoimmune
response to Group A streptococcal infection promises to bring increased
understanding of the disorder's pathogenesis."[4]
Psychological explanations
Freud
In the early 1910s, Sigmund Freud attributed obsessive-compulsive behavior to
unconscious conflicts which manifested as symptoms.[2] Freud describes the clinical history of a typical case of 'touching phobia' as follows:
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After it has started, in early childhood, the patient shows a strong desire to
touch, the aim of which is of a far more specialized kind that one would have been inclined to expect. This desire is promptly
met with an external prohibition against carrying out that particular kind of touching. The prohibition is accepted, since
it finds support from powerful internal forces, and proves stronger than the instinct which is seeking to express itself
in the touching. In consequence, however, of the child's primitive physical constitution, the prohibition does not succeed in
abolishing the instinct. Its only result is to repress the instinct (the desire to touch) and banish it into the
unconscious. Both the prohibition and instinct persist: the instinct because it has only been repressed and not abolished, and
the prohibition because, if it ceased, the instinct would force its way through into consciousness and into actual operation. A
situation is created which remains undealt with—a psychical fixation—and everything else follows from the continuing conflict
between the prohibition and the instinct.[5] |
” |
Biological explanations
There are many different theories about the cause of obsessive-compulsive disorder. Some research has discovered a type of
size abnormality in different brain structures. The majority of researchers believe that there is some type of abnormality in the
neurotransmitter serotonin, among other possible
psychological or biological abnormalities; however, it is possible that this activity is the brain's response to OCD, and
not its cause. Serotonin is thought to have a role in regulating anxiety, though it is also thought to be involved in such
processes as sleep and memory function. This neurotransmitter
travels from one nerve cell to the next via synapses. In order
to send chemical messages, serotonin must bind to the receptor sites located on the
neighboring nerve cell. It is hypothesized that OCD sufferers may have blocked or damaged receptor sites that prevent serotonin
from functioning to its full potential. This suggestion is supported by the fact that many OCD patients benefit from the use of
selective serotonin reuptake inhibitors (SSRIs) — a class of
antidepressant medications that allow for more serotonin to be readily available to other
nerve cells.[3] (For more about this class of drugs,
see the section about potential treatments for OCD.)
Recent research has revealed a possible genetic mutation that could be the cause of OCD.
Researchers funded by the National Institutes of Health have found a
mutation in the human serotonin transporter gene, hSERT, in unrelated families with OCD. Moreover, in his study of identical twins, Rasmussen (1994)
produced data that supported the idea that there is a "heritable factor for neurotic anxiety".[6] In addition, he
noted that environmental factors also play a role in how these anxiety symptoms are expressed. However, various studies on this
topic are still being conducted and the presence of a genetic link is not yet definitely established.
Another possible genetic cause of OCD was discovered in August 2007 by scientists at Duke University Medical Center in North Carolina. They genetically engineered mice that
lacked a gene called SAPAP3. This protein is highly expressed in the striatum, an area of the
brain linked to planning and the initiation of appropriate actions. The mice spent three times as much time grooming themselves
as ordinary mice, to the point that their fur fell off.[7]
Technological advancements have allowed for the possibility of brain imaging. Using tools like positron emission tomography (PET scans), it has been shown that those with OCD tend to
have brain activity that differs from those who do not have this disorder.[8] This suggests that brain functioning in those with OCD may be impaired in some way. A popular
explanation for OCD is that offered in the book Brain Lock by Jeffrey Schwartz, which suggests that OCD is caused by the
part of the brain that is responsible for translating complex intentions (e.g., "I will pick up this cup") into fundamental
actions (e.g., "move arm forward, rotate hand 15 degrees, etc.") failing to correctly communicate the chemical message that an
action has been completed. This is perceived as a feeling of doubt and incompleteness which then leads the individual to attempt
to consciously deconstruct their own prior behavior — a process which induces anxiety in most people, even those without OCD.
It has been theorized that a miscommunication between the orbital-frontal cortex, the caudate nucleus, and the thalamus may be a factor in the explanation
of OCD. The orbitofrontal cortex (OFC) is the first part of the brain to notice
whether or not something is wrong. When the OFC notices that something is wrong, it sends an initial “worry signal” to the
thalamus. When the thalamus receives this signal, it in turn sends signals back to the OFC to interpret the worrying event. The
caudate nucleus lies between the OFC and the thalamus and it prevents the initial worry signal from being sent back to the
thalamus after it has already been received. However, it is suggested that in those with OCD, the caudate nucleus does not
function properly, and therefore does not prevent this initial signal from recurring. This causes the thalamus to become
hyperactive and creates a virtually never-ending loop of worry signals being sent back and forth between the OFC and the
thalamus. The OFC responds by increasing anxiety and engaging in compulsive behaviors in an attempt to relieve this
apprehension.[3] This over activity of the OFC is
shown to be attenuated in patients who have successfully responded to SSRI medication. The increased stimulation of the serotonin receptors
5-HT2A and 5-HT2C in the OFC is believed to cause
this inhibition. [[1]]
Symptoms and prevalence
OCD is manifested in a variety of forms.
Community studies have placed the prevalence between one and three percent, although the prevalence of clinically recognized
OCD is much lower, suggesting that many individuals with the disorder are unaccounted for clinically.[9] The fact that many individuals do not seek treatment may be due in part to
stigma associated with OCD. Another reason for not seeking treatment is because many
sufferers of OCD do not realize that what they are suffering from is OCD, mainly because the typical depiction of the disorder in
the media and elsewhere only covers a few of the many symptoms of OCD.
The typical OCD sufferer performs tasks (or compulsions) to seek relief from obsession-related anxiety. To others, these tasks
may appear odd and unnecessary. But for the sufferer, such tasks can feel critically important, and must be performed in
particular ways to ward off dire consequences and to stop the stress from building up. Examples of these tasks: repeatedly
checking that one's parked car has been locked before leaving it; turning lights on and off a set number of times before exiting
a room; repeatedly washing hands at regular intervals throughout the day.
Rearranging matters rigidly may be a sign of OCD
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Symptoms may include some, all, or perhaps none of the following:
- Repeated hand washing.
- Repeated clearing of the throat, although nothing may need to be cleared.
- Specific counting systems — e.g., counting in groups of four, arranging objects in groups of three, grouping objects in
odd/even numbered groups, etc.
- One serious symptom which stems from this is "counting" steps — e.g., feeling the necessity to take 12 steps to the car in
the morning.
- Perfectly aligning objects at complete, absolute right angles, or aligning objects perfectly parallel etc. This symptom is
shared with OCPD and can be confused with this condition
unless it is realized that in OCPD it is not stress-related.
- Having to "cancel out" bad thoughts with good thoughts. Examples of bad thoughts are:
- Imagining harming a child and having to imagine a child playing happily to cancel it out.
- Sexual obsessions or unwanted sexual thoughts. Two classic examples are fear of
being homosexual or fear of being a pedophile. In both
cases, sufferers will obsess over whether or not they are genuinely aroused by the thoughts.
- Strange and chronic worried about certain events such as sleeping, eating, leaving home, etc without proper items. An example
would be one who literally can't fall asleep without a metronome.
- A fear of contamination (see Mysophobia); some sufferers may fear the presence of human
body secretions such as saliva, sweat, tears, vomit, or mucus, or excretions such as
urine or feces. Some OCD sufferers even fear that the soap they're
using is contaminated.[10]
- A need for both sides of the body to feel even. A person with OCD might walk down a sidewalk and step on a crack with the
ball of their left foot, then feel the need to step on another crack with the ball of their right foot. If one hand gets wet, the
sufferer may feel very uncomfortable if the other is not. If the sufferer is walking and bumps into something, he/she may hit the
object or person back to feel a sense of evenness. These symptoms are also experienced in a reversed manner. Some sufferers would
rather things to be uneven, favoring the preferred side of the body.
- An obsession with numbers (be it in maths class, watching TV, or in the room). Some people are obsessed with even numbers
while loathing odd numbers (they cause them a great deal of anxiety and often make the person uncomfortable or even angry) or
vice versa.
- Twisting the head on a toy around, then twisting it all the way back exactly in the opposite direction.(see even body
section)
There are many other possible symptoms, and one need not display those above to suffer from OCD. Formal diagnosis is performed
by a mental health professional. Furthermore, possessing the symptoms above
is not an absolute diagnosis of OCD.
OCD sufferers are aware that such thoughts and behavior are not rational, but feel bound
to comply with them to fend off feelings of panic or dread. Because sufferers are consciously aware of this irrationality but
feel helpless to push it away, untreated OCD is often regarded as one of the most vexing and frustrating of the major anxiety
disorders. Due to their insight into the abnormal nature of their compulsions, most OCD sufferers will meticulously hide their
behaviors from others in order to avoid negative attention. This, combined with the fact that with some sufferers the compulsions
are purely mental, means the disease is often nicknamed "the secret illness".[citation needed]
In an attempt to further relate the immense distress that those afflicted with this condition must bear, Barlow and Durand
(2006) use the following example.[11] They
implore readers not to think of pink elephants. Their point lies in the assumption that most people will immediately create an
image of a pink elephant in their minds, even though told not to do so. The more one attempts to stop thinking of these colorful
animals, the more one will continue to generate these mental images. This phenomenon is termed the "Thought Avoidance Paradox”,
and it plagues those with OCD on a daily basis, for no matter how hard one tries to get these disturbing images and thoughts out
of one's mind, feelings of distress and anxiety inevitably prevail. Although everyone may experience unpleasant thoughts at one
time or another, these are usually warranted concerns that are short-lived and fade after an adequate time period has lapsed.
However, this is not the case for OCD sufferers.[12]
Obsessive-compulsive disorder is often confused with the separate condition obsessive compulsive personality disorder. The two are not the same condition,
however. OCD is ego dystonic, meaning that the disorder is incompatible with the sufferer's self-concept. Because
disorders that are ego dystonic go against an individual's perception of his/herself, they tend to cause much distress. OCPD, on
the other hand, is ego syntonic—marked by the individual's acceptance that the characteristics displayed as a result of
this disorder are compatible with his/her self-image. Ego syntonic disorders understandably cause no distress. Persons suffering
from OCD are often aware that their behavior is not rational and are unhappy about their obsessions but nevertheless feel
compelled by them. Persons with OCPD, by contrast, are not aware of anything abnormal about themselves; they will readily explain
why their actions are rational, and it is usually impossible to convince them otherwise. Persons with OCD are ridden with
anxiety; persons who suffer from OCPD, by contrast, tend to derive pleasure from their
obsessions or compulsions.[13] This is a significant
difference between these disorders.
Equally frequently, these rationalizations do not apply to the overall behavior, but to each instance individually; for
example, a person compulsively checking their front door may argue that the time taken and stress caused by one more check of the
front door is considerably less than the time and stress associated with being robbed, and thus the check is the better option.
In practice, after that check, the individual is still not sure, and it is still better in terms of time and stress
to do one more check, and this reasoning can continue as long as necessary.
Some OCD sufferers exhibit what is known as overvalued ideas. In such cases, the person with OCD will truly be
uncertain whether the fears that cause them to perform their compulsions are irrational or not. After some discussion, it is
possible to convince the individual that their fears may be unfounded. It may be more difficult to do ERP therapy on such patients, because they may be, at least initially, unwilling to
cooperate. For this reason OCD has often been likened to a disease of pathological doubt, in which the sufferer, while not
usually delusional, is often unable to fully realize what sorts of dreaded events are
reasonably possible and which aren't.
OCD is different from behaviors such as gambling addiction and overeating. People with these disorders typically experience at least some pleasure from their activity; OCD
sufferers do not actively want to perform their compulsive tasks, and experience no pleasure from doing so.
OCD is placed in the anxiety class of mental illness, but like many chronic stress
disorders it can lead to clinical depression over time. The constant stress of the
condition can cause sufferers to develop a deadening of spirit, a numbing frustration, or sense of hopelessness. OCD's effects on
day-to-day life—particularly its substantial consumption of time—can produce difficulties with work, finances and
relationships.
There is no known cure for OCD as of yet, but there are a number of successful treatment options available.
Related disorders
People with OCD may be diagnosed with other conditions, such as anorexia nervosa,
social anxiety disorder, bulimia nervosa,
Tourette syndrome, compulsive skin picking,
body dysmorphic disorder, and trichotillomania. There is some research demonstrating a link between drug addiction and obsessive compulsive disorder as well. Many who suffer from OCD suffer from
panic attacks. There is a higher risk of drug addiction among those with any anxiety
disorder (possibly as a way of coping with the heightened levels of anxiety), but
drug addiction among obsessive compulsive patients may serve as a type of compulsive behavior and not just as a coping mechanism.
Depression is also extremely prevalent among sufferers of OCD. One explanation for the high depression rate among OCD populations
was posited by Mineka, Watson, and Clark (1998), who explained that people with OCD (or any other
anxiety disorder) may feel depressed because of an "out of control" type of feeling.[14]
Some cases are thought to be caused at least in part by childhood streptococcal
infections and are termed PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with
Streptococcal infections). The streptococcal antibodies become involved in an autoimmune process. Though this idea is not set in stone, if it does prove to be true, there is cause to
believe that OCD can to some very small extent be "caught" via exposure to strep throat (just as one may catch a cold). However,
if OCD is caused by bacteria, this provides hope that antibiotics may eventually be used to
treat or prevent it.[15]
Demographics and other statistics
In a 1980 study of 20,000 adults from New Haven, Baltimore, St. Louis, Durham, and Los Angeles, the lifetime prevalence rate of OCD for
both sexes was recorded at 2.5%.
Education also appears to be a factor. The lifetime prevalence of OCD is lower for those who have graduated high school than
for those who have not (1.9 percent versus 3.4 percent). However, in the case of college education, lifetime prevalence is higher
for those who graduate with a degree (3.1 percent) than it is for those who have only some college background (2.4 percent). As
far as age is concerned, the onset of OCD usually ranges from the late teenage years until the mid-20s in both sexes, but the age
of onset tends to be slightly younger in males than in females.[16]
Violence is very rare among OCD sufferers, but the disorder is often debilitating to their quality of life. Also, the
psychological self-awareness of the irrationality of the disorder can be painful. For
people with severe OCD, it may take several hours a day to carry out the compulsive acts. To avoid perceived obsession triggers,
they also often avoid certain situations or places altogether.
It has been alleged that sufferers are generally of above-average intelligence, as the
very nature of the disorder necessitates complicated thinking patterns.
Treatment
OCD is typically treated with behavioral therapy (BT), cognitive therapy (CT), medications, or any
combination of the three. Psychodynamic psychotherapy may help in managing
some aspects of the disorder, but it is not commonly a primary intervention. According to the Expert Consensus Guidelines for the
Treatment of obsessive-compulsive disorder (Journal of Clinical Psychiatry, 1995, Vol. 54, supplement 4), the treatment of
choice for most OCD is behavior therapy or cognitive behavior therapy.
The specific technique used in BT/CBT is called exposure and ritual
prevention (also known as exposure and response prevention) or ERP; this involves gradually learning to tolerate the
anxiety associated with not performing the ritual behavior. At first, for example, someone might touch something only very mildly
"contaminated" (such as a tissue that has been touched by another tissue that has been touched by the end of a toothpick that has
touched a book that came from a "contaminated" location, such as a school.) That is the "exposure." The "ritual prevention" is
not washing. Another example might be leaving the house and checking the lock only once (exposure) without going back and
checking again (ritual prevention). The person fairly quickly habituates to the (formerly)
anxiety-producing situation and discovers that their anxiety level has dropped considerably; they can then progress to touching
something more "contaminated" or not checking the lock at all—again, without performing the ritual behavior of washing or
checking.
Medications as treatment include selective serotonin reuptake inhibitors (SSRIs) such as paroxetine (Paxil, Aropax), sertraline (Zoloft), fluoxetine (Prozac), and fluvoxamine (Luvox) as well as the
tricyclic antidepressants, in particular clomipramine (Anafranil). SSRIs prevent excess serotonin from being pumped back into the original neuron
that released it. Instead, the serotonin can then bind to the receptor sites of nearby neurons and send chemical messages or
signals that can help regulate the excessive anxiety and obsessive-compulsive thoughts. In some treatment resistant cases, a
combination of clomipramine and an SSRI has shown to be effective even when neither drug on its own has been efficacious.
Serotonergic antidepressants typically take longer to show benefit in OCD than with most
other disorders which they are used to treat, as it is common for 2–3 months to elapse before any tangible improvement is
noticed. In addition to this, the treatment usually requires high doses. Fluoxetine for example is usually prescribed in doses of
20 mg per day for clinical depression, whereas with OCD the dose will often range from 20 mg to 80 mg or higher,
if necessary. In most cases antidepressant therapy alone will only provide a partial reduction in symptoms, even in cases that
are not deemed treatment resistant. Other medications such as riluzole, memantine, gabapentin (Neurontin), lamotrigine (Lamictal), and low doses of the newer atypical
antipsychotics olanzapine (Zyprexa), quetiapine
(Seroquel) and risperidone (Risperdal) have also been found to be useful as adjuncts
in the treatment of OCD. The use of antipsychotics in OCD must be undertaken carefully
however, since although there is very strong evidence that at low doses they are beneficial (most likely due to their
dopamine receptor antagonism), at high doses these same antipsychotics have proven to
cause dramatic obsessive-compulsive symptoms even in those who don't normally have OCD. This is most likely due to the antagonism
of 5-HT2A receptors becoming very prominent at these doses and outweighing the benefits of dopamine antagonsim. Another point that must be noted with antipsychotic treatment is that SSRIs inhibit the
chief enzyme that is responsible for metabolising antipsychotics — CYP2D6 — so the dose will be
effectively higher than expected when these are combined with SSRIs.
The naturally occurring sugar inositol may be an effective treatment for OCD. [17] Inositol appears to modulate the actions of serotonin and
has been found to reverse desensitisation of the neurotransmitter's receptors.[18]
St John's Wort has been cl
