What is Obsessive-Compulsive Disorder?

Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by intrusive thoughts that produce anxiety, by repetitive behaviors aimed at reducing anxiety, or by a combination of such thoughts (obsessions) and behaviors (compulsions). References to OCD go back as far as 14th century Europe where it was believed that people who experienced blasphemous, sexual, or other obsessive thoughts were possessed by the Devil1. Based on this reasoning, treatment involved banishing the "evil" from the "possessed" person through exorcism. In the early 1910's, Dr. Sigmund Freud attributed obsessive-compulsive behavior to unconscious conflicts. He describes the clinical history of "touching phobia" as beginning in early childhood, when the person has a strong desire to touch an item. In response, the person develops an "external prohibition" against this type of touching. However, this "prohibition does not succeed in abolishing" the desire to touch; all it does is repress the desire and "force it into the unconscious."

Symptoms of OCD may include repetitive hand-washing; aggressive impulses, or with particular religious beliefs; aversion to odd numbers; and nervous habits, such as opening a door and closing it a certain number of times before one enters or leaves a room. These symptoms can be alienating and time-consuming and often lead to severe emotional and economic loss. The acts of those who have OCD may appear paranoid and even psychotic to others not familiar with the condition. However, the person with OCD generally recognize their thoughts and subsequent actions as irrational and they may become further distressed by this realization.

OCD is the fourth-most common mental disorder and is diagnosed nearly as often as asthma and diabetes melitus. In the United States alone, it is estimated that one in 50 adults have OCD. Multiple psychological and biological factors may be involved in causing obsessive-compulsive syndrome.

What is the etiology of OCD?

It's generally agreed that both psychological and biological factors play a role in causing OCD, however, they disagree on the degree of emphasis upon either type of factor.

Psychological -

Obsessive-compulsive disorder (OCD) is a psychiatric anxiety disorder that includes distressing, intrusive thoughts (obsessions) and related compulsions (tasks or "rituals") to neutralize the obsessions. Obsessions are usually upsetting and the compulsions lead to temporary feelings of relief. To be diagnosed with OCD, the person must have either obsessions or compulsions alone, or obsessions and compulsions together, but most people with OCD have both.

Obsessions are:

Recurrent and persistent thoughts, impulses or images that are intrusive and inappropriate. These thoughts cause severe anxiety or distress.
The thoughts, impulses, or images are not just excessive worries about real-life problems. The person '" suffering from OCD '" tries to ignore or suppress the 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.

Compulsions are:

Repetitive behaviors or mental acts that the person feels they must perform in response to an obsession or according to rigid rules. The behaviors or mental acts prevent or reduce stress or prevent some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what the are supposed to neutralize or prevent or are clearly excessive. In addition, at some point during the course of the disorder, the person must realize that his/her obsessions or compulsions are unreasonable or excessive, which is why people with OCD are not considered to be detached from reality or psychotic. The obsessions or compulsions must be time-consuming, taking up more than one (1) hour per day, cause distress, or cause difficulty in social, work, or school functioning.

Biological:

OCD has been linked to abnormalities with the neurotransmitter serotonin, although it could be either a cause or effect of these abnormalities. Serotonin is thought to play a role in regulating anxiety. To transmit these chemical messages from one neuron to another, the Serotonin must bind to the receptor sites located on the neighboring nerve cell. It's hypothesized that in persons with OCD, these might be relatively under stimulated. This suggestion is consistent with the observation that many OCD sufferers benefit from the use of selective serotonin re-uptake inhibitors (SSRIs) '" a class of anti-depressant medications that allow for more serotonin to be readily available to other nerve cells3.

A possible genetic mutation could also contribute to OCD. The mutation was found in the serotonin transporter gene, hSERT, in unrelated families with OCD. Moreover, data from identical twins supports the existence of a "heritage factor for neurotic anxiety". Environmental factors also play a role in how these anxiety symptoms are expressed; various studies on this topic are currently in progress and the presence of a genetic link is not yet definitely established.

Another theory is that abnormal brain development '" and the resulting malfunction '" may contribute to the manifestation of OCD '" particularly a miscommunication between the orbitofrontal cortex (OFC), caudate nucleus, and the thalamus. The caudate nucleus lies between the OFC and thalamus and, under normal conditions, prevents signals from being returned to the thalamus; in situations where the caudate nucleus does not function normally, it may become hyperactive and create an unceasing cycle of activity between the OFC and the thalamus resulting in heightened anxiety. People with OCD show increased grey matter volumes in the bilateral lenticular nuclei, extending to the caudate nuclei, with decreased grey matter volumes in bilateral dorsal medial frontal/anterior cingulate gyri. This OFC over activity is reduced in persons who have successfully responded to SSRI medication '" possibly because on an increased stimulation of serotonin receptors 5-HT2A and 5-HT2C. Additionally, recent evidence supports the possibility of a heritable predisposition for neurological development favoring OCD.

Rapid onset of OCD in children may be caused by Group A streptococcal infection '" a condition identified by its acronym PANDAS4 It has been suggested that PANDAS should be addressed as possible cause of childhood OCD before other pharmacological remedies are attempted.

Neurotransmitters role

Researchers have yet to be able to pinpoint the exact cause of obsessive-compulsive disorder, but brain abnormalities, genetic influences, and environmental factors are being studied. Brain scans of persons with OCD show that they have different brain activity than a person without OCD and that results in abnormal functioning of circuitry in the striatum5 which might lead to OCD. Abnormalities in other parts of the brain and an imbalance of brain chemicals '" especially serotonin and dopamine '" may also contribute to the occurrence of OCD. These can be defined as dopaminergic hyper-function in the prefrontal cortex and serotonergic hypofunction in the basal ganglia.

What are the signs and symptoms of OCD?

Obsessions

A typical person with OCD performs tasks, or compulsions, seeking relief from obsession related anxiety. Within and among individuals with OCD, the initial obsession (intrusive thought) can vary both in their clarity and vividness. A relatively vague obsession might involve a general sense of disarray or tension, accompanied by a belief that that life can't proceed as normal while the imbalance remains. By comparison, a more articulable obsession could be a preoccupation with the thought or image of someone close to them dying. Another such obsession would be the thought (or image) that someone '" or something '" other than themselves will either harm the person with OCD or the person or things that they care about.

With some people suffering from OCD they dread entire concepts fearing their materialization by causes that may seem implausible or indiscriminate to others. For example, a generalized fear of contamination might entail not only a wariness of bodily secretions (or excretions), but also apprehension toward household chemicals, radioactivity, newsprint, pets, or even soap6. Others might sense that the physical world is qualified by certain immaterial conditions.

Some people with OCD experience sexual obsessions that can involve intrusive thoughts or images of "kissing, touching, fondling, oral sex, intercourse, incest, and rape" with "strangers, acquaintances, parents, children, family members, friends, co-workers, animals, and religious figures". These obsessions can be of either heterosexual or homosexual content and involve "partners" of any age. As with other intrusive, unpleasant thoughts or images, most people these same disquieting thoughts. The difference for a person with OCD might attach extraordinary significance. As an example, obsessive fears about sexual orientation can appear to a person with OCD as a crisis of sexual identity. Additionally, the doubt associated with OCD can lead to uncertainty regarding whether the person might act on troubling thoughts, resulting in self-criticism or self-loathing.

A person with OCD understands that their thoughts don't correspond with the external world; however, they feel that the must act as though their thoughts are correct. For example, an individual who engages in compulsive hoarding might be inclined to treat inorganic matter as if it had the awareness or rights of living organisms, but this same individual might find the consequent behavior irrational on a more intellectual level. With more severe cases of OCD, obsession(s) can shift into delusions when resistance to the obsession is abandoned and insight into its senselessness is lost. (Insel and Akisal [1986])

Compulsions

While some who suffer from OCD perform compulsive rituals because they inexplicably feel they must, others act compulsively to mitigate anxiety that stems from particular obsessive thoughts. They feel these action might somehow prevent a dreaded event from occurring or will push the event from their thoughts. Either way, the individual's reasoning is so idiosyncratic or distorted that it results in significant distress for the person with OCD or those around them. Behaviors such as excessive skin picking (dermatillomania), hair plucking (trichotillomatia) or nail biting (onychophagia) are all part of the Obsessive-compulsive Spectrum and, although persons with OCD know these behaviors are not rational, they feel bound to comply with them to fend off feelings of panic or dread.

Some common compulsions include counting specific items (such as footsteps) or specific ways (for instance, by intervals of two) as well as doing other repetitive actions '" often with atypical sensitivity to numbers or patterns. People (suffering OCD) might repeatedly wash their hands7 or clear their throats, making sure certain items are in a straight line, repeatedly check that their parked car has been locked before leaving it, constantly organizing in a certain way, turn lights on and off, keeping doors shut or closed at all times, touching an object a certain number of times prior to exiting a room, or walking in a certain way.

People with OCD rely on compulsions to escape from their obsessive thoughts; however, they are aware that the relief is only temporary and that the intrusive thoughts will soon return. Some people use the compulsions to avoid situations that may trigger their obsessions. Although some people do certain things over and over again, they aren't necessarily compulsions. For example, bedtime routines, learning a new skill, or religious practices are not compulsions. The determining factor of whether or not behaviors are compulsions or mere habits depends on the context in which they are performed. For example, arranging and ordering DVDs or videos for eight hours a day would be expected of a person working in a video store, but would seem abnormal under other circumstances. Put another way, if the activity helps bring efficiency to a person's life, it is probably a habit, however, if it interferes with the person's normal enjoyment of life, it is probably a compulsion. In addition to the anxiety and fear that typically accompanies OCD, some people might spend hours performing such tasks every day. In such situations, it can be difficult for the person to fulfill their work, family, or social roles. In some cases, these behaviors can also result in adverse physical symptoms. As an example, people who wash their hands obsessively with anti-bacterial soap and hot water can make their skin red and raw with dermatitis.

OCD without overt compulsions

OCD sometimes manifests without overt compulsions. Nicknamed "Pure-O", OCD without overt compulsions could '" by one estimate '" characterize as many as fifty percent (50%) to sixty percent (60%) of OCD cases. Rather than engaging in observable compulsions, a person suffering from this subtype might perform covert, mental rituals or feel driven to avoid the situations in which particular thoughts seem likely to intrude. As a result of this avoidance, people might struggle to fulfill both public and private roles '" even if they place a great value on these roles or if they have fulfilled the role successfully in the past. Moreover, this avoidance can confuse others who do not know its origin or intended purpose.

Co-morbidity

People suffering from OCD may also be diagnosed with other conditions including Major Depressive Disorder, Generalized Anxiety Disorder, Anorexia Nervosa, Social Anxiety Disorder, Bulimia Nervosa, Tourette Syndrome, Asperger Syndrome, compulsive skin picking, and Body Dysmorpic Disorder8. In addition there is some research which has demonstrated a link between drug addiction and OCD as well. It is believed that this might be a type of compulsive behavior and not just a coping mechanism.
The incidence of depression among OCD patients has also shown to be extremely high. One explanation for this was submitted by Mineka, Watson, and Clark in 1998 when they explained that "people with OCD (or any other anxiety disorder) might feel depressed because of an 'out of control' type of feeling." Lastly, individuals with OCD have also been found to be affected by delayed sleep phase syndrome.

How is OCD diagnosed?

A formal diagnosis can be performed by either a psychologist or a psychiatrist. Specifically, to be diagnosed with OCD, a person must have obsessions, compulsions, or both. The Quick Reference to the 2000 Diagnostic and Statistical Manual of Mental Disorders (DSM) suggest that several features characterize clinically significant obsessions and compulsions. Such obsessions, according to the DSM, are recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and that cause marked anxiety or distress. They are of a degree that lies outside the normal range of worries about "conventional" (quotations added) problems. A person suffering from these obsessions might attempt to ignore or suppress them or to neutralize them with other thoughts or actions (compulsions). The person will recognize the obsessions as being irrational.
Compulsions become clinically significant when the person suffering from them feels driven to perform them in response to an obsession, or according to rules that must be rigidly applied; as a result the person feels or causes significant distress. Therefore, while many people who do not suffer from OCD might perform actions often associated with the condition, the distinction for persons suffering from clinically significant OCD lies in the fact that the person must perform these actions. Otherwise, they will experience significant psychological distress. It is helpful to quantify the severity of symptoms and impairment both prior to and during treatment for OCD. In addition to the patient's estimate of the time spent each day harboring obsessive-compulsive thoughts or behaviors, Fenske and Schwenk in their 2009 article "Obsessive-Compulsive Disorder: Diagnosis and Management," contend that more concrete tools should be used to gauge the patient's condition. This could be done with rating scales such as the Yale-Brown Obsessive Compulsive Scale (Y-BOCS).

Differential diagnosis

OCD is often confused with another, separate condition known as obsessive-compulsive personality disorder. OCD is ego dystonic meaning that that the disorder is incompatible with the sufferer's self-concept9. Because such disorders '" that are ego dystonic '" go against a person's self-concept, they tend to cause much distress. OCPD '" on the other hand '" is ego syntonic meaning that it's marked by the person's acceptance that the characteristics they display are the result of the disorder and are, therefore, compatible with his/her self-image.

Ego syntonic disorders understandably cause no distress. People with OCD are often aware that their behavior is not rational and, therefore, are unhappy about their obsession(s), however, still feel compelled by them. In contrast, people with OCPD are not aware (emphasis added) of anything abnormal about themselves; they will readily explain why their actions are rational, and it is usually impossible to convince them otherwise.

People with OCD are ridden with anxiety; by contrast, however, people with OCPD tend to derive pleasure from their obsessions or compulsions10. Almost as frequently, these rationalizations do not apply to the overall behavior but to each incidence individually; for example, a person who compulsively checks the front door might argue that the time taken and stress caused by one more check of the door is much less than the time and stress associated with being robbed. In practice, following that check, the person is still not sure and deems it still better in terms of time and stress to do one more check, and that reasoning can continue as long as necessary.

Some people suffering from OCD exhibit what are known as overvalued ideas. What this means is that the person with OCD is truly unsure as to whether the fears that cause them to perform their compulsions are irrational or not. Following some discussion, it is possible to convince the person that their fears might be unfounded. Exposure Response Prevention (ERP) therapy on such patients might prove more difficult because they might be unwilling to cooperate '" at least initially. For this reason, OCD has often been compared to a disease of pathological doubt where the sufferer, though not usually delusional, is unable to fully realize which dreaded events are reasonably possible and which are not. There are severe cases where the person has an unshakeable belief '" in the context of OCD '" that is difficult to differentiate from psychosis.

OCD is different from behaviors such as an addiction to gambling or overeating. People with these disorders typically experience at least some form of pleasure from their activity; OCD sufferer's do not actively want to perform their compulsive task and, therefore, experience no pleasure from doing so. OCD can, similar to many other forms of chronic stress, lead to clinical depression over time. The constant stress brought on by the condition can cause sufferers to develop a deadening of spirit, a numbing frustration, or sense of hopelessness. Currently, there is no known cure for OCD, however, a number of successful treatment options are available.

How is OCD Managed and Treated?

According to a team of Duke University led psychiatrist, behavioral therapy (BT), cognitive behavioral therapy (CBT), and medications should be regarded as first-line treatments for persons with OCD11. Psychodynamic psychotherapy12 might also help in managing some aspects of the disorder. The American Psychiatric Association (APA), however, notes a lack of controlled demonstrations that psychoanalysis or dynamic psychotherapy is effective "in dealing with the core symptoms of OCD."

Behavioral therapy

The specific technique used in BT/CBT is called exposure and ritual prevention (also known as "exposure and response prevention") or ERP; it involves the gradual learning to tolerate (the) anxiety associated with not performing the ritual behavior. At first, as an example, the person might touch something only 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 what is known as 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). This allows the person to reasonably quickly habituate to the anxiety producing situation and discover that their anxiety level has dropped considerably; this allows them to progress to touching something more "contaminated" or not checking the lock at all.

Exposure ritual/response prevention (ERP) has a strong evidence base '" usually being the most effective treatment for OCD13. Evidence has shown that the use of ERP can lead a person to become completely symptom free. The only caveat to using ERP as the sole method of treatment is that the individual must be highly motivated and consistent.

More recent behavioral work has focused on associative splitting '" a new technique aimed at reducing obsessive thoughts. This method draws on the "fan effect" of associative priming14 where the sprouting of new associations diminishes the strength of existing ones. As an OCD patient shows marked biases (or restrictions) in OCD-related semantic network (e.g., cancer is only associated with "illness" or "death", fire is only associated with "danger" or "destruction"), they are encouraged to imagine neutral or positive associations to OCD-related cognitions (cancer = zodiac sign, animal, lobster; fire = fireflies, fireworks, candlelight-dinner). First studies using associative splitting have tentatively confirmed both the feasibility and effectiveness of this approach for a subgroup of patients.

Medication

Medications as treatment for OCD include selective serotonin re-uptake inhibitors (SSRI) such as Paroxetine, Setraline, Fluoxetine, Escitalopram, Fluvoxamine, and the tricyclic anti-depressants '" specifically Clomipramine. The SSRIs prevent excess serotonin from being pumped back into the original neuron that released it. The result is that the serotonin is allowed to bind to the receptor sites of nearby neurons and transmit messages which can help to regulate the excessive anxiety and obsessive thoughts. In some treatment-resistant cases, a combination of Clomipramine combined with an SSRI has shown to be effective either when neither drug on its own has worked.
The treatment of OCD is an area which needs significant improvement in the prescribing regiment. Benzodiazepines are sometimes used in the treatment of OCD, although they are generally thought to be ineffective for this condition; however, in one small study, effectiveness was noted. Serotonergic anti-depressants typically take longer to show benefit when used to treat OCD compared to other disorders it is used to treat. It is not uncommon for between two and three months to elapse before tangible improvement is noted. In addition, this treatment usually requires high dosages to be effective. Fluoxetine, for example, is usually prescribed in dosages of 20 Mg. per day to treat clinical depression, however, in cases of OCD, the prescribed dosage ranges from 20 Mg. to 80 Mg. per day. With most cases anti-depressant therapy alone provides only a partial reduction in symptoms '" even in cases that are not deemed treatment-resistant. Current research is devoted to the therapeutic potential of agents that affect the release of the neurotransmitter glutamate or the binding to its receptors. In addition, low dosages of newer atypical anti-psychotics such as Olanzapine, Quetiapine, Ziprasidone, and Risperidone have proven useful as adjuncts in the treatment of OCD. It should be noted, however, that the use of anti-psychotics for treatment of OCD must be undertaken carefully. This is due to the fact that, while low-dosage(s) have proven to be beneficial, higher dosages have caused dramatic obsessive-compulsive symptoms even in patients who normally do not have OCD. It is believed that this is a result of the antagonism of 5-HT2A receptors which becomes very prominent at these dosages and, therefore, outweighs the benefit of Dopamine antagonism.