Unwanted repetitive behaviors and thoughts afflict about 2 percent of the population, typically beginning in the teen years but often much earlier. The chronic condition, caused by a mix of neurobiologic and environmental factors, responds to both drug therapy and exposure psychotherapy.
Obsessive-compulsive disorder (OCD) is an anxiety disorder in which people have unwanted and repeated thoughts, feelings, ideas, sensations (obsessions), or behaviors that make them feel driven to do something (compulsions).Often the person carries out the behaviors to get rid of the obsessive thoughts, but this only provides temporary relief. Not performing the obsessive rituals can cause great anxiety. A person's level of OCD can be anywhere from mild to severe, but if severe and left untreated, it can destroy a person's capacity to function at work, at school or even to lead a comfortable existence in the home.
OCD affects about 2.2 million American adults, and the problem can be accompanied by eating disorders, other anxiety disorders, or depression. It strikes men and women in roughly equal numbers and usually appears in childhood, adolescence, or early adulthood. One-third of adults with OCD develop symptoms as children, and research indicates that OCD might run in families.
Although OCD symptoms typically begin during the teen years or early adulthood, research shows that some children may even develop the illness during preschool. Studies indicate that at least one-third of cases of adult OCD began in childhood. Suffering from OCD during early stages of a child's development can cause severe problems for the child. It is important that the child receive evaluation and treatment as soon as possible to prevent the child from missing important opportunities because of this disorder.
People with OCD:
• Have repeated thoughts or images about many different things, such as fear of germs, dirt, or intruders; violence; hurting loved ones; sexual acts; conflicts with religious beliefs; or being overly neat. • Do the same rituals over and over such as washing hands, locking and unlocking doors, counting, keeping unneeded items, or repeating the same steps again and again. • Have unwanted thoughts and behaviors they can't control. • Don't get pleasure from the behaviors or rituals, but get brief relief from the anxiety the thoughts cause. • Spend at least an hour a day on the thoughts and rituals, which cause distress and get in the way of daily life.
Unwanted repetitive ideas or impulses frequently well up in the mind of the person with OCD. Persistent paranoid fears, an unreasonable concern with becoming contaminated or an excessive need to do things perfectly, are common. Again and again, the individual experiences a disturbing thought, such as, "This bowl is not clean enough. I must keep washing it." "I may have left the door unlocked." Or "I know I forgot to put a stamp on that letter." These thoughts are intrusive, unpleasant and produce a high degree of anxiety. Other examples of obsessions are fear of germs, of being hurt or of hurting others, and troubling religious or sexual thoughts.
In response to their obsessions, most people with OCD resort to repetitive behaviors called compulsions. The most common of these are checking and washing. Other compulsive behaviors include repeating, hoarding, rearranging, counting (often while performing another compulsive action such as lock-checking). Mentally repeating phrases, checking or list making are also common. These behaviors generally are intended to ward off harm to the person with OCD or others. Some people with OCD have regimented rituals: Performing things the same way each time may give the person with OCD some relief from anxiety, but it is only temporary.
People with OCD show a range of insight into the uselessness of their obsessions. They can sometimes recognize that their obsessions and compulsions are unrealistic. At other times they may be unsure about their fears or even believe strongly in their validity.
Most people with OCD struggle to banish their unwanted thoughts and compulsive behaviors. Many are able to keep their obsessive-compulsive symptoms under control during the hours when they are engaged at school or work. But over time, resistance may weaken, and when this happens, OCD may become so severe that time-consuming rituals take over the sufferers' lives and make it impossible for them to have lives outside the home.
The course of the disease is quite varied. Symptoms may come and go, ease over time, or get worse. If OCD becomes severe, it can keep a person from working or carrying out normal responsibilities at home. People with OCD may try to help themselves by avoiding situations that trigger their obsessions, or they may use alcohol or drugs to calm themselves.
The old belief that OCD was the result of life experiences has become less valid with the growing focus on biological factors. The fact that OCD patients respond well to specific medications that affect the neurotransmitter serotonin suggests the disorder has a neurobiological basis. For that reason, OCD is no longer attributed only to attitudes a patient learned in childhood -- inordinate emphasis on cleanliness, or a belief that certain thoughts are dangerous or unacceptable. The search for causes now focuses on the interaction of neurobiological factors and environmental influences, as well as cognitive processes.
OCD is sometimes accompanied by depression, eating disorders, substance abuse, a personality disorder, attention deficit disorder or another of the anxiety disorders. Coexisting disorders can make OCD more difficult both to diagnose and to treat. Symptoms of OCD are seen in association with some other neurological disorders. There is an increased rate of OCD in people with Tourette's syndrome, an illness characterized by involuntary movements and vocalizations. Investigators are currently studying the hypothesis that a genetic relationship exists between OCD and the tic disorders.
Other illnesses that may be linked to OCD are trichotillomania (the repeated urge to pull out scalp hair, eyelashes, eyebrows or other body hair), body dysmorphic disorder (excessive preoccupation with imaginary or exaggerated defects in appearance) and hypochondriasis (the fear of having -- despite medical evaluation and reassurance -- a serious disease). Researchers are investigating the place of OCD within a spectrum of disorders that may share certain biological or psychological bases. It is currently unknown how closely related OCD is to other disorders such as trichotillomainia, body dysmorphic disorder and hypochondriasis.
There are also theories about OCD linking it to the interaction between behavior and the environment, which are not incompatible with biological explanations.
A person with OCD has obsessive and compulsive behaviors that are extreme enough to interfere with everyday life. People with OCD should not be confused with a much larger group of people sometimes called "compulsive" for being perfectionists and highly organized. This type of "compulsiveness" often serves a valuable purpose, contributing to a person's self-esteem and success on the job. In that respect, it differs from the life-wrecking obsessions and rituals of the person with OCD.
Clinical and animal research sponsored by NIMH and other scientific organizations has provided information leading to both pharmacological and behavioral treatments that can benefit the person with OCD. One patient may benefit significantly from behavior therapy, yet another will benefit from pharmacotherapy. And others may benefit best from both. Others may begin with medication to gain control over their symptoms and then continue with behavior therapy. Which therapy to use should be decided by the individual patient in consultation with his or her therapist.
Clinical trials in recent years have shown that drugs that affect the neurotransmitter serotonin can significantly decrease the symptoms of OCD. The first of these serotonin re-uptake inhibitors (SRIs) specifically approved for the use in the treatment of OCD was the tricyclic anti-depressant clomipramine (Anafranil). It was followed by other SRIs that are called "selective serotonin re-uptake inhibitors" (SSRIs). Those that have been approved by the Food and Drug Administration for the treatment of OCD are citalopram (Celexa), flouxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil) and sertraline (Zoloft).
Large studies have shown that more than three-quarters of patients are helped by these medications at least a little. And in more than half of patients, medications relieve symptoms of OCD by diminishing the frequency and intensity of the obsessions and compulsions. Improvement usually takes at least three weeks or longer. If a patient does not respond well to one of these medications, or has unacceptable side effects, another SRI may give a better response. For patients who are only partially responsive to these medications, research is being conducted on the use of an SRI as the primary medication and one of a variety of medications as an additional drug (an augmenter). Medications are of help in controlling the symptoms of OCD, but often, if the medication is discontinued, relapse will follow.
Cognitive behavioral therapy (CBT) has been shown to be the most effective type of psychotherapy for this disorder. The patient is exposed many times to a situation that triggers the obsessive thoughts, and learns gradually to tolerate the anxiety and resist the urge to perform the compulsion. Medication and CBT together are considered to be better than either treatment alone at reducing symptoms.
A specific behavior therapy approach called "exposure and response prevention" is effective for many people with OCD. In this approach, the patient deliberately and voluntarily confronts the feared object or idea, either directly or by imagination. At the same time the patient is strongly encouraged to refrain from ritualizing, with support and structure provided by the therapist, and possibly by others whom the patient recruits for assistance. For example, a compulsive hand washer may be encouraged to touch an object believed to be contaminated, and then urged to avoid washing for several hours until the anxiety provoked has greatly decreased. Treatment then proceeds on a step-by-step basis, guided by the patient's ability to tolerate the anxiety and control the rituals. As treatment progresses, most patients gradually experience less anxiety from the obsessive thoughts and are able to resist the compulsive urges.
Psychotherapy can also be used to provide effective ways of reducing stress, anxiety and resolving inner conflicts.
Ways to Make Treatment More Effective
Many people with anxiety disorders benefit from joining a self-help or support group and sharing their problems and achievements with others. Internet chat rooms can also be useful in this regard, but any advice received over the Internet should be used with caution, as Internet acquaintances have usually never seen each other and false identities are common. Talking with a trusted friend or member of the clergy can also provide support, but it is not a substitute for care from a mental health professional.
Stress management techniques and meditation can help people with anxiety disorders calm themselves and may enhance the effects of therapy. There is preliminary evidence that aerobic exercise may have a calming effect. Since caffeine, certain illicit drugs, and even some over-the-counter cold medications can aggravate the symptoms of anxiety disorders, they should be avoided. Check with your physician or pharmacist before taking any additional medications.
The family is very important in the recovery of a person with an anxiety disorder. Ideally, the family should be supportive but not help perpetuate their loved one's symptoms. Family members should not trivialize the disorder or demand improvement without treatment. When a family member suffers from obsessive-compulsive disorder it's helpful to be patient about their progress and acknowledge any successes, no matter how small.