Obsessive Compulsive Disorder

Obsessive Compulsive Disorder

Summary

Obsessive-compulsive disorder (OCD) is classified as an anxiety disorder. Patients with OCD have persistent thoughts they cannot control (obsessions) and/or feel they must perform certain actions repeatedly (compulsions) in order to feel safe, to stop obsessive thoughts, or to be able to go about their daily business. When obsessions and compulsions interfere with someone’s ability to work or to live their life, it becomes identified as an illness. About 2.2 million adult Americans have OCD, according to the National Institute of Mental Health(NIMH).

An example of OCD occurs when people who have obsessive thoughts about accidentally burning down their house repeatedly return home to make sure they have not left the stove on. Patients usually understand that their thoughts and behaviors are irrational and senseless, but cannot free themselves from them.

The exact cause of OCD is not known. However, a combination of psychological, biological and environmental factors may be responsible. Heredity is also believed to play a role in the development of the disorder.

Although there is no cure for OCD, certain treatments – such as a combination of psychotherapy and medications – can help control symptoms. A form of exposure therapy known as exposure and response prevention involves gradually exposing patients to stimuli that trigger obsessive thoughts and teaching new ways to deal with these thoughts. Cognitive behavior therapy (CBT) targeting obsessive and compulsive symptoms is also a proven treatment method.

About OCD

Obsessive-compulsive disorder (OCD) is an anxiety disorder in which patients experience recurrent, persistent thoughts they cannot control (obsessions) and/or an uncontrollable need to perform certain actions over and over (compulsions). Patients usually understand that their thoughts and behaviors are irrational, excessive and interfere with their ability to work and live their lives normally, but cannot free themselves from them. About 2.2 million adult Americans have OCD, according to the National Institute of Mental Health(NIMH).

There are many people with a compulsive nature, such as those determined to complete tasks early and to the best of their ability or to master a new sport or activity. Though such people may be labeled “compulsive,” this type of behavior does not qualify as a mental disorder and may in fact be a key factor in building self-esteem and contributing to success.

People with OCD take these feelings and actions a step further, repeatedly engaging in thoughts and/or behaviors until the process becomes disruptive to their lives. For example, people who have obsessive thoughts about accidentally burning down their house may feel they must repeatedly return home to make sure they have not left the stove on or the iron plugged in. These people may feel a sense of relief when they have completed the behavior they feel compelled to engage in, but it usually does not last long before the next obsessive thought arises. As the discomfort returns, the patient may feel compelled to repeat the obsessive-compulsive cycle again.

Over time, these behaviors may take over a person’s life to an increasing degree and prevent the patient from living a normal life. OCD is usually diagnosed by a physician. The typical patient is someone who has obsessions and/or compulsions for more than an hour each day, and the symptoms cause distress to the patient and are disruptive to their lives. OCD can affect people of all age groups, and tends to affect men and women equally. About one-third of adults with this condition first experienced symptoms during childhood. When the condition is diagnosed earlier in life, it tends to appear more frequently in boys than in girls.

Potential causes of OCD

The exact cause of obsessive-compulsive disorder (OCD) is unknown. However, a combination of psychological, biological and environmental factors may be responsible. Heredity is believed to play a strong role in the development of the disorder.

Growing evidence indicates that chemical imbalances may be common in the development of OCD. Various studies have indicated that low levels of the chemical serotonin (a neurotransmitter that helps nerve cells communicate) may contribute to OCD. Many patients with OCD who take medications that boost serotonin levels show improvement in symptoms. In addition, people who have brain injuries sometimes develop OCD, which further suggests that physical damage in the brain can cause the disorder.

OCD also appears to increase metabolism in the basal ganglia (a region of specialized nerve cells that is mainly involved in body movement) and frontal lobes (the upper brain area, which is mainly involved in emotions and personality) of the brain. This may cause repetitive movements, rigid thinking and lack of spontaneity. Finally, people with OCD have been shown to have higher levels of the hormone vasopressin (which raises blood pressure and reduces excretion of urine).

People with close family members (e.g., parents) with a history of OCD have a higher risk for developing the condition themselves. Researchers have identified a previously unknown gene variant that makes a person twice as likely to develop OCD. A gene variant, or allele, is an alternate form of a gene that often affects appearance. For instance, different alleles are responsible for variations in eye color. The allele is part of the human serotonin transporter gene (hSERT) that is affected by selective serotonin reuptake inhibitors (SSRIs), commonly prescribed medications for OCD, other anxiety disorders and depression. A recent study found that patients with OCD were twice as likely to have the hSERT genetic variant. In a subsequent, related study, researchers found that the newly-discovered gene variant was twice as likely to be passed down from a parent to a child with OCD. Those who are shown to have this variant are likely to respond well to medication.

Signs and symptoms of OCD

Obsessive-compulsive disorder (OCD) is characterized by two major symptoms: obsessions and compulsions. Some patients experience one component more strongly than the other.

Obsessions are recurrent persistent and unpleasant thoughts or impulses that a person cannot control. These thoughts may appear once in a while or may be almost constant, crowding the mind and preventing a person from concentrating on other tasks. Typical obsessions include fear of dirt or contamination; excessive concern with order, symmetry and exactness; constant thoughts of specific sounds, images, words or numbers; fear of harming a loved one; and fear of thoughts considered evil or sinful.

Compulsions are repetitive behaviors that a person engages in and cannot control. A patient engages in compulsions as a means of relieving obsessive thoughts, even though this action may seem irrational to the person and others. For example, people who are obsessed with a fear of germs may wash their hands compulsively to combat this fear. In other cases, the compulsive act is not as clearly associated with the obsessive thought. Many people also develop rules to follow that help control anxiety in the midst of obsessive thoughts, such as touching objects a specific number of times or counting to a certain number. In some cases, performing the compulsion does indeed relieve the anxiety, but only temporarily.

Typical compulsions include excessive washing of hands, repeatedly checking doors to make sure they are locked or checking to make sure appliances are turned off, keeping items arranged in a certain order and hoarding items such as coupons. People with OCD also may have other mental illnesses, including eating disorders, other anxiety disorders and/or depression. Children with OCD may also have learning disorders (e.g., dyslexia) or behavior disorders.

Diagnosis methods for OCD

Patients may be embarrassed about acknowledging suspected obsessive-compulsive disorder (OCD). However, people who have deeply ingrained rituals that disrupt their lives are encouraged to consider seeking psychiatric treatment. The longer these patterns continue, the more difficult they are to treat successfully.

Before diagnosing OCD, a physician should perform a complete physical examination and compile a thorough medical history. The physician should ask about the nature of a patient’s obsessions and compulsions. Consultation with family and friends may help reveal behavior patterns that will lead to a more accurate diagnosis.

The physician may ask the patient the following questions:

  • Does the patient have repeated unwanted thoughts that seem senseless?

  • Does the patient do things repeatedly in a way that seems excessive?

There is no specific laboratory test to diagnose OCD. It is usually diagnosed in patients who have obsessive thoughts and/or who perform compulsive actions, and who recognize that these feelings and actions are unreasonable. In order for the diagnosis to apply, the obsessive-compulsive thoughts should appear for more than an hour each day and cause marked distress and interruption of a patient’s lifestyle. If a physician suspects that OCD is present, the patient may be referred to a psychiatrist or other mental health professional. Referral is best for patients who do not want medication therapy, who have other psychiatric disorders along with their OCD, or whose symptoms present a risk to themselves or others.

Treatment options for OCD

Although there is no guaranteed cure for obsessive-compulsive disorder (OCD), certain treatments can help control or eliminate some symptoms. A combination of psychotherapy and medications is the approach most likely to result in improvement or remission of symptoms. Psychotherapy may take place in an individual or group setting. Cognitive behavior therapy can help patients learn to use different thought patterns and routines that will steer them away from obsessive thoughts and/or compulsive behaviors.

In addition, patients may be asked to participate in a form of exposure therapy known as exposure and response prevention. In this therapy, the patient is gradually exposed to the situation that triggers obsessive thoughts and is taught new coping skills that do not include obsessive-compulsive behavior. For example, patients with a fear of germs may be asked to dirty their hands and then to refrain from washing them for a specific period of time. This pattern is repeated over a long period of time until symptoms gradually decrease in frequency and intensity. The therapist assists the patient in managing any anxiety that is produced during this process. The treatment is sometimes difficult, but it can be a highly effective therapy for patients with OCD, particularly children and adolescents.

Some patients may also benefit from using certain types of medication. Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) or tricyclics are most often prescribed, although some newer antipsychotic medications or monoamine oxidase inhibitors (MAOIs) may also be recommended. Patients should be aware that a physician will almost certainly need to adjust the dosage and/or change medications to achieve the best results with minimal side effects. In addition, the U.S. Food and Drug Administration(FDA) has advised that antidepressants may increase the risk of suicidal thinking in some patients, particularly children and adolescents, and all people being treated with them should be monitored closely for unusual changes in behavior or dangerous new thought patterns. However, the benefits of such medications typically outweigh the potential risks.

Other medications that may be used to treat OCD include:

  • Antipsychotics. Medications used control hallucinations and delusions due to psychosis. Some of the newer antipsychotics also have an indication for treatment of anxiety. Some obsessive thoughts are closely associated with psychotic phenomena.

  • Mood stabilizers. Medications of various drug classes used to treat fluctuations of mood. For some individuals a mood stabilizer helps to stop the cycle of obsessive thoughts and compulsive behaviors.

  • Anticonvulsants. Medications used to prevent seizures. Some anticonvulsants have been shown to be effective mood stabilizers.

  • Anti-anxiety medications. Medications used to treat anxiety, tension and agitation. The benzodiazepines, one of the classes of medications used for anxiety, should only be prescribed for a relatively short period of time, usually while other medications are being started to help with a more immediate control of anxious mood.

Ongoing research on OCD

The National Institute of Mental Health (NIMH) is continuing to support research into new treatment approaches for patients whose obsessive-compulsive disorder (OCD) does not respond well to medication and/or psychotherapy. These approaches include combination and add-on treatments, as well as modern techniques such as deep brain stimulation (DBS). DBS involves implantation of microstimulators, similar to those used in heart pacemakers, in targeted brain regions to block the nerve signals believed to cause OCD symptoms. To date, about 25 OCD patients for whom traditional treatment approaches have been ineffective have received DBS implants. The OCD studies, although small, have shown dramatic reductions in symptoms for many patients. The main focus of the new NIMH-funded study is to understand the brain regions involved in OCD and to help determine the most effective pacemaker placement. More research will be necessary before DBS can be considered a usual treatment for OCD.

Questions for your doctor regarding OCD

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to obsessive-compulsive disorder (OCD):

  1. What makes you suspect that I have OCD?
  2. Do I have to see a mental health professional to confirm a diagnosis of OCD? Can you recommend one?
  3. Are there medications that may help me? Which do you recommend and why? What are the potential side effects?
  4. Are there any over-the-counter medications, foods, beverages or supplements that I should avoid?
  5. What changes in my symptoms or behavior should I immediately report to you?
  6. Do I have any other conditions often associated with OCD? How will that impact my treatment options?
  7. What forms of therapy are most likely to benefit me?
  8. How long before I start seeing results from the various treatments?
  9. Are my children more likely to develop OCD now that I have been diagnosed? Should they undergo any screening or preventive therapies?
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