Expert Insights: Obsessive-Compulsive Disorder
Expert Insights: Obsessive-Compulsive Disorder
In this video, Dr H. Blair Simpson gives a brief overview of the hallmarks, themes, and common comorbidities found in obsessive-compulsive disorder (OCD) and explains what to look for when treating OCD in connection with other psychiatric illnesses. Dr Simpson is Professor of Clinical Psychiatry, Columbia University, and Director of the Anxiety Disorders Clinic and the Center for OCD and Related Disorders at New York State Psychiatric Institute in New York City.
Dr Simpson is funded by the National Institute of Mental Health (NIMH). Her team is recruiting adults for an OCD treatment study. Information can be found at:
OCD is one of our most important psychiatric illnesses. People think about a lot of other disorders—schizophrenia, bipolar disorder, depression—but sometimes OCD doesn’t get as much recognition or enough awareness as it should. First, [OCD] is a very disabling illness. Many of the people who have it can be [very] impaired by it, and yet it is often hidden in the sense that it isn’t as dramatic or obvious so people often suffer in privacy.
[OCD] is relatively much more common than people thought; it is about 2% lifetime prevalence and in comparison, schizophrenia is 1%. It is more common than schizophrenia. Its onset is in adolescence or young adulthood, with about a quarter of cases starting in childhood. So again, putting it in perspective, about half of the cases of OCD will start by age 19 and in comparison, about half of the cases of depression start at age 32. So it has a much earlier age of onset. Typically, the course of it once you get it is typically chronic, waxing and waning symptoms.
Finally, the severity of it is much more than . . . other anxiety disorders. If you have the disorder, the vast majority will have moderate or severe symptoms.
If you add that all up—early onset, how common it is, chronic course, and severe symptoms—you can see that it can be very disabling. What happens is that people get the disorder relatively early in life and it can get them off track.
Hallmarks of OCD
It’s in the name—obsessions and compulsions. So what are obsessions? Intrusive thoughts, images, or impulses that someone has that they don’t want and that they find very distressing. And what are compulsions? They are behaviors or mental acts that someone does over and over again to try to reduce the stress typically that the obsession has caused.
It is very important to realize that obsessions are not just thoughts. They can be images or impulses. For example, I worked with someone who had intrusive thoughts of coffins popping into his head all day long and it generated incredible distress . . . The other part of it is that compulsions are not just behaviors. They can be something that someone does over and over again in their head all day long. For example, the person who had those intrusive images of coffins . . . the compulsion was to then call up a positive image to try to neutralize the obsession.
[The vast majority of patients who seek clinical treatment have both obsessions and compulsions], and usually they’re related to each other. What I mean by that is there are certain themes that usually go together.
People will have intrusive thoughts about illness or about germs—and often the compulsion could be washing rituals. So the theme goes together.
Fears of harm
That could be fear of harm befalling yourself or befalling someone you love. That can lead to a lot of checking behaviors or checking in your head that that harm didn’t actually occur.
Concerns about symmetry or things being “just right”
These are people who can actually either be spending hours arranging and ordering their home or office to make sure things are just aligned or it can be as they read or as they walk, making sure things are done in a certain number or a certain rhythm.
In general [hoarding] has been considered part of OCD, but the current thinking is that people who only hoard objects and have huge stashes of things and can’t get rid of things [are dealing with] a separate [issue]. But there is still a part of a hoarding behavior that can be part of OCD . . . someone who has a concern about harm (eg, don’t want to harm anyone), and they can’t let go of any of those newspapers that have medical information in them for fear that they might harm one of their extended family members or friends if they don’t send it to them. That would be an example of hoarding behavior but it is in the context of OCD.
These are sexual, religious, or aggressive thoughts. These are also very upsetting to people, such as doing things that are sacrilegious to your God, or awful sexual or aggressive images that the person doesn’t want.
Everybody with OCD has obsessions and compulsions; they need to be distressing, time consuming, and impairing. The actual content of the obsessions and compulsions can vary widely among patients, and one that most people know are the contamination and washing rituals, but this is only one of multiple themes that are common in OCD . . . there are many different contents and themes but they all have the same sort of organization of obsessions and compulsions.
Affects and insight
People can not only have different themes and types of symptoms but they can also have different types of affects. What I mean by that is some people get very anxious when they get in front of one of their OCD triggers. They can have paralyzing anxiety, including panic attacks. It is not panic disorder; it’s OCD with panic attacks. Other people can have an intense sense of . . . not so much anxiety, but disgust. Another group can have a sense of increasing tension and a sense of things not being “just right.” So there is a range of affects that people can have with OCD; it’s not only anxiety.