Obsessive-Compulsive Disorder (OCD)

Obsessive–compulsive disorder (OCD) is a mental disorder where people feel the need to

  • check things repeatedly
  • perform certain routines repeatedly (called “rituals”), or
  • have certain thoughts repeatedly.

Patients are unable to control either the thoughts or the activities for more than a short period of time. If one tries to suppress the urge to do or think something, nervousness, anxiety and uneasiness ocuur.

Common activities include hand washing, counting of things, and checking to see if a door is locked. But they can be virtually anything, from cleaning things to walking in a certain pattern when approaching the office. Some may have difficulty throwing things out. The activities interfere with one’s quality of life and can take more than an hour a day.

Most adults realize that the behaviors do not make sense. [1] The condition is associated with tics, anxiety disorder, and an increased risk of suicide. [2][3] However, often the rituals have common themes, that can frequently by traced to a patient’s individual history or current situation. This is then the task of psychotherapy.

The cause of OCD is unknown. [1] There appear to be some genetic components with both identical twins more often affected than both non-identical twins. Risk factors include a history of child abuse or other stress inducing event, but it is more the subjective perception of a life event that matters, than the actual facts.

Some cases of OCD have been documented to occur following infections, and then frequently in a more severe form.

The diagnosis is based on the symptoms and requires ruling out other drug related or medical causes. [2] Rating scales such as the Yale–Brown Obsessive Compulsive Scale can be used to assess the severity. [4] Other disorders with similar symptoms include anxiety disorder, major depressive disorder, eating disorders, tic disorders, and obsessive–compulsive personality disorder. [2]

Treatment involves psychotherapy and counselling, such as psychodynamic (psychoanalytic) psychotherapy and cognitive behavioral therapy (CBT) and, and sometimes medication, typically selective serotonin reuptake inhibitors (SSRIs). [5][6]

Psychodynamic (psychoanalytic) psychotherapy looks at possible causes for the OCD. Often, there are intrapsychic processes that maintain the rituals and obsessive thoughts. In most cases, people are not aware of repressed emotions or inner conflicts that maintain the OCD. In therapy they can be made aware, which often leads to a substantial or full collapse of the OCD.

CBT for OCD involves increasing exposure to what causes the problems while not allowing the repetitive behavior to occur. [5]

On the medication side, the selective serotonin reuptake inhibitors (SSRIs) should be considered first line of treatment. The tricyclic antidepressant clomipramine appears to work as well as the SSRIs, but it has greater side effects than the SSRIs [5], probably because it is less selective than these, and there are no real reasons anymore for using it. Atypical antipsychotics may be useful when used in addition to an SSRI in treatment-resistant cases but are also associated with an increased risk of side effects. [6][7]

Without treatment, the condition often lasts decades. [2]

Obsessive–compulsive disorder affects about 2.3% of people at some point in their life. [8] Rates during a given year are about 1.2% and it occurs worldwide. [2] Half of people develop problems before twenty, and it is rare to occur for the first time after age thirty-five. [1][2] Males and females are affected about equally. [1]

Obsessions are thoughts that recur and persist despite efforts to ignore or confront them.[10] People with OCD frequently perform tasks, or compulsions, to seek relief from obsession-related anxiety. Within and among individuals, the initial obsessions, or intrusive thoughts, vary in their clarity and vividness. A relatively vague obsession could involve a general sense of disarray or tension accompanied by a belief that life cannot proceed as normal while the imbalance remains. A more intense obsession could be a preoccupation with the thought or image of someone close to them dying[10][11] or intrusions related to “relationship rightness.”[12] Often people with OCD feel overly responsible for the well-being of other people and themselves. They may have fears to contaminate objects, so that others may contract a severe disease, or attempt to make things ‘undone’ that to other people do not seem dangerous or even risky. A person with OCD builds a personal scaffolding to hold the own emotions in check. In therapy, once people get in touch with their emotions and can describe and explain them, the fears, anxieties, and thus the OCD itself, often subside considerably.

Some people with OCD experience sexual obsessions that may involve intrusive thoughts or images of “kissing, touching, fondling, oral sex, anal sex, intercourse, incest and rape” with “strangers, acquaintances, parents, children, family members, friends, coworkers, animals and religious figures”, and can include “heterosexual or homosexual content” with persons of any age.[13] As with other intrusive, unpleasant thoughts or images, some disquieting sexual thoughts at times are normal, but people with OCD may attach extraordinary significance to the thoughts. For example, obsessive fears about sexual orientation can appear to the person with OCD, and even to those around them, as a crisis of sexual identity.[14][15] Furthermore, the doubt that accompanies OCD leads to uncertainty regarding whether one might act on the troubling thoughts, resulting in self-criticism or self-loathing.[13] Often, in therapy the patient discovers that there are some other fears or themes below these disquieting thoughts that might only be very superficially connected to them. This can lead to a great sense of relief and a decrease in the anxieties and fears.

People with OCD understand that their notions do not correspond with reality; however, they feel that they must act as though their notions are correct. For example, an individual who engages in compulsive hoarding might be inclined to treat inorganic matter as if it had the sentience or rights of living organisms, while accepting that such behavior is irrational on a more intellectual level.

Someone exhibiting OCD signs does not necessarily have OCD. Behaviors that present as (or seem to be) obsessive or compulsive can also be found in a number of other conditions as well, including obsessive–compulsive personality disorder (OCPD), autism, disorders where perseveration is a possible feature (ADHD, PTSD, bodily disorders or habit problems). [16] or sub-clinically.

Some with OCD present with features typically associated with Tourette’s syndrome, such as compulsions that may appear to resemble motor tics; this has been termed “tic-related OCD” or “Tourettic OCD”. [17][18]

There is tentative evidence that OCD may be associated with above-average intelligence or at least a small increase in intelligence.[19][20]

Obsessions

OCD sometimes manifests without overt compulsions [21] and is referred to as Primarily Obsessional OCD, OCD without overt compulsions could, by one estimate, characterize as many as 50 percent to 60 percent of OCD cases. [22] People with this form of OCD have distressing and unwanted thoughts emerging frequently, and these thoughts typically center on a fear that one may do something totally uncharacteristic of oneself, possibly something potentially fatal to oneself or others. [23] The thoughts may be of an aggressive or sexual nature. [23]

Rather than engaging in observable compulsions, the person with this subtype might perform more covert, mental rituals, or might feel driven to avoid the situations in which particular thoughts seem likely to intrude. [24] As a result of this avoidance, people can struggle to fulfill their roles at home and in the workplace, even if they place great value on these roles and even if they had fulfilled the roles successfully in the past. [24] The covert mental rituals can take up a great deal of a person’s time during the day.

Compulsions

Some people with OCD perform compulsive rituals because they inexplicably feel they have to, others act compulsively so as to mitigate the anxiety that stems from particular obsessive thoughts. The person might feel that these actions somehow either will prevent a dreaded event from occurring, or will push the event from their thoughts. In any case, the individual’s reasoning is so idiosyncratic or distorted that it results in significant distress for the individual with OCD or for those around them. Excessive skin picking, hair-pulling, nail biting, and other body-focused repetitive behavior disorders are all on the obsessive–compulsive spectrum. [2] Some individuals with OCD are aware that their behaviors are not rational, but feel compelled to follow through with them to fend off feelings of panic or dread. [2][25]

Some common compulsions include hand washing, cleaning, checking things (e.g., locks on doors), repeating actions (e.g., turning on and off switches), ordering items in a certain way, and requesting reassurance. Compulsions are different than tics (such as touching, tapping, rubbing, or blinking) and stereotyped movements (such as head banging, body rocking, or self-biting), which usually aren’t as complex as compulsions and aren’t precipitated by obsessions. It can sometimes it may be difficult to tell the difference between compulsions and complex tics. [2] About 10% to 40% of individuals with OCD also have a lifetime tic disorder. [26]

Associated Diagnoses

People with OCD may be diagnosed with other conditions, as well or instead of OCD, such as the aforementioned obsessive–compulsive personality disorder, major depressive disorder, bipolar disorder, [27] generalized anxiety disorder, anorexia nervosa, social anxiety disorder, bulimia nervosa, Tourette syndrome, Asperger syndrome, attention deficit hyperactivity disorder, dermatillomania (compulsive skin picking), body dysmorphic disorder, and trichotillomania (hair pulling). 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. [28]

Individuals with OCD have been found to be affected by delayed sleep phase syndrome at a substantially higher rate than the general public. [29] Moreover, severe OCD symptoms are consistently associated with greater sleep disturbance. Reduced total sleep time and sleep efficiency have been observed in people with OCD, with delayed sleep onset and offset and an increased prevalence of delayed sleep phase disorder. [30]

Causes

As in many other mental health condition three factors play a role also in OCD:

  • biology (e.g. genetics)
  • psychology (e.g. individual life experiences and coping strategies)
  • social (e.g. communication at the workplace and at home and one’s social network)

There appears to a heritable quality. In general, genetic factors account for 45–65% of the variability in OCD symptoms in children diagnosed with the disorder. [31] Recent evidence supports the possibility of a heritable predisposition for neurological development favoring OCD. [32]

Identical twins are more often affected than non-identical twins, which also supports the hypothesis of a genetic predisposition. [2] Further, individuals with OCD are more likely to have first-degree family members exhibiting the same disorders than do matched controls. In cases where OCD develops during childhood, there is a much stronger familial link in the disorder than cases in which OCD develops later in adulthood.

A mutation has been found in the human serotonin transporter gene, hSERT, in unrelated families with OCD. [33]

There may be an evolutionary benefit to moderate versions of compulsive behavior. These individuals might have had an advantage over their peers and were so able to pass on these traits. Examples would be moderate constant checking of hygiene, the hearth, or the environment for enemies, or the hoarding of supplies.

Brain scans of people with OCD have shown that they have different patterns of brain activity than people without OCD and that different functioning of circuitry within a certain part of the brain, the striatum, may cause the disorder. Differences in other parts of the brain and neurotransmitter dysregulation, especially serotonin and dopamine, may also contribute to OCD. [34] Independent studies have consistently found unusual dopamine and serotonin activity in various regions of the brain in people with OCD. These can be defined as dopaminergic hyperfunction in the prefrontal cortex (mesocortical dopamine pathway) and serotonergic hypofunction in the basal ganglia. [35] Dysregulation of glutamate, a cotransmitter with dopamine in dopamine pathways that project out of the ventral tegmental area, has also been the subject of recent research, [36] although the role of glutamate in the disorder’s etiology is not yet clear.

People with OCD have shown a greater probability for increased grey matter volumes in bilateral lenticular nuclei, extending to the caudate nuclei, with decreased grey matter volumes in bilateral dorsal medial frontal/anterior cingulate gyri. These findings contrast with those in people with other anxiety disorders, who have shown decreases in grey matter volumes in bilateral lenticular / caudate nuclei, while also decreased grey matter volumes in bilateral dorsal medial frontal/anterior cingulate gyri. Orbitofrontal cortex overactivity is attenuated in people who have successfully responded to SSRI medication, a result believed to be caused by increased stimulation of serotonin receptors 5-HT2Aand 5-HT2C. [37] The striatum, linked to planning and the initiation of appropriate actions, has also been implicated; mice genetically engineered with a striatal abnormality exhibit OCD-like behavior, grooming themselves three times as frequently as ordinary mice.

In any case, no matter what the specific peculiarities in OCD are, the vast majority of cases can be treated, often with a combination of psychotherapy/counselling and medication.

Obsessive-compulsive personality disorder (OCPD)

OCD is egodystonic, meaning that the disorder is incompatible with the sufferer’s self-concept. [38] Because ego dystonic disorders go against a person’s self-concept, they tend to cause much distress. OCPD, on the other hand, is egosyntonic—marked by the person’s acceptance that the characteristics and behaviours displayed as a result are compatible with their self-image, or are otherwise appropriate, correct or reasonable. By contrast people for people with OCPD their actions seem to them normal and there is no motivation to change anything because they feel it is just the way things ought to be done.

 

Therapy

Psychotherapy has been shown repeatedly to be an effective approach in treating OCD. In OCD a combination of psychodynamic and cognitive-behavioral approaches seems especially valuable. Medication can be added to speed up the recovery process.

References

[1] The National Institute of Mental Health (NIMH) (January 2016). “What is Obsessive-Compulsive Disorder (OCD)?”. U.S. National Institutes of Health (NIH).

[2] Diagnostic and statistical manual of mental disorders : DSM-5 (5 ed.). Washington: American Psychiatric Publishing. 2013. pp. 237–242. ISBN 9780890425558.

[3] Angelakis, I; Gooding, P; Tarrier, N; Panagioti, M (25 March 2015). “Suicidality in obsessive compulsive disorder (OCD): A systematic review and meta-analysis.”. Clinical Psychology Review. 39: 1–15. doi:10.1016/j.cpr.2015.03.002PMID 25875222.

[4] Fenske JN, Schwenk TL (August 2009). “Obsessive compulsive disorder: diagnosis and management”. Am Fam Physician. 80 (3): 239–45. PMID 19621834.

[5] Grant JE (14 August 2014). “Clinical practice: Obsessive-compulsive disorder.”. The New England Journal of Medicine. 371 (7): 646–53. doi:10.1056/NEJMcp1402176PMID 25119610.

[6] Veale, D; Miles, S; Smallcombe, N; Ghezai, H; Goldacre, B; Hodsoll, J (29 November 2014). “Atypical antipsychotic augmentation in SSRI treatment refractory obsessive-compulsive disorder: a systematic review and meta-analysis.”. BMC Psychiatry. 14: 317. doi:10.1186/s12888-014-0317-5.

[7] Decloedt EH, Stein DJ (2010). “Current trends in drug treatment of obsessive-compulsive disorder”. Neuropsychiatr Dis Treat. 6: 233–42. doi:10.2147/NDT.S3149PMC 2877605. PMID 20520787.

[8] Goodman, WK; Grice, DE; Lapidus, KA; Coffey, BJ (September 2014). “Obsessive-compulsive disorder.”. The Psychiatric clinics of North America. 37 (3): 257–67. doi:10.1016/j.psc.2014.06.004. PMID 25150561.

[9] Markarian Y, Larson MJ, Aldea MA, Baldwin SA, Good D, Berkeljon A, Murphy TK, Storch EA, McKay D (February 2010). “Multiple pathways to functional impairment in obsessive-compulsive disorder”. Clin Psychol Rev. 30 (1): 78–88. doi:10.1016/j.cpr.2009.09.005. PMID 19853982.

[10] Baer (2001), p. 33, 78

[11] Baer (2001), p. xiv.

[12] Doron G, Szepsenwol O, Karp E, Gal N (2013). “Obsessing About Intimate-Relationships: Testing the Double Relationship-Vulnerability Hypothesis”. Journal of Behavior Therapy and Experimental Psychiatry. 44 (4): 433–440. doi:10.1016/j.jbtep.2013.05.003. PMID 23792752.

[13] Osgood-Hynes, Deborah. Thinking Bad Thoughts (PDF). MGH/McLean OCD Institute, Belmont, MA, published by the OCD Foundation, Milford, CT. Retrieved on 30 December 2006.

[14] Steven Phillipson I Think It Moved Center for Cognitive-Behavioral Psychotherapy, OCDOnline.com. Retrieved on 14 May 2009.

[15] Mark-Ameen Johnson, I’m Gay and You’re Not : Understanding Homosexuality Fears brainphysics.com.

[16] Pediatric Obsessive-Compulsive Disorder Differential Diagnoses – 2012

[17] Mansueto CS, Keuler DJ (2005). “Tic or compulsion?: it’s Tourettic OCD.”. Behavior Modification. 29 (5): 784–99. doi:10.1177/0145445505279261. PMID 16046664.

[18] “OCD and Tourette Syndrome: Re-examining the Relationship”. International OCD Foundation.

[19] Clark, David (2012). Cognitive-Behavioral Therapy for OCD. Guilford Press. p. Chapter 4. ISBN 9781462506651.

[20] Ozertugrul,, Engin (April 21, 2015). Interview with OCD: Forty-five Days to End of a New Beginning.

[21] Freeston M, Ladouceur R (2003). “What do patients do with their obsessive thoughts?”. Behaviour Research and Therapy. 35 (4): 335–348. doi:10.1016/S0005-7967(96)00094-0.

[22] Weisman M.M.; Bland R.C.; Canino G.J.; Greenwald S.; Hwu H.G.; Lee C.K.; et al. (1994). “The cross national epidemiology of obsessive–compulsive disorder”. Journal of Clinical Psychiatry. 55: 5–10.

[23] Hyman, Bruce and Troy DeFrene. Coping with OCD. 2008. New Harbinger Publications.

[24] Hyman, B. M., & Pedrick, C. (2005). The OCD workbook: Your guide to breaking free from obsessive–compulsive disorder (2nd ed.). Oakland, CA: New Harbinger, pp. 125–126.

[25] Highlights of Changes from DSM-IV-TR to DSM-5 (PDF), American Psychiatric Association, 2013, p. 7, retrieved 12 Apr 2016

[26] Conelea; et al. (2014), “Tic-related obsessive-compulsive disorder (OCD): phenomenology and treatment outcome in the Pediatric OCD Treatment Study II”, Journal of the American Academy of Child & Adolescent Psychiatry, 53 (12): 1308–16, doi:10.1016/j.jaac.2014.09.014, PMC 4254546, PMID 25457929

[27] Chen YW, Dilsaver SC (1995). “Comorbidity for obsessive-compulsive disorder in bipolar and unipolar disorders”. Psychiatry Research. 59 (1–2): 57–64. doi:10.1016/0165-1781(95)02752-1PMID 8771221.

[28] Mineka S, Watson D, Clark LA (1998). “Comorbidity of anxiety and unipolar mood disorders”. Annual Review of Psychology. 49: 377–412. doi:10.1146/annurev.psych.49.1.377. PMID 9496627.

[29] Turner J, Drummond LM, Mukhopadhyay S, Ghodse H, White S, Pillay A, Fineberg NA (June 2007). “A prospective study of delayed sleep phase syndrome in patients with severe resistant obsessive–compulsive disorder”. World Psychiatry. 6 (2): 108–111. PMC 2219909. PMID 18235868.

[30] Paterson JL, Reynolds AC, Ferguson SA, Dawson D (2013). “Sleep and obsessive-compulsive disorder (OCD)”. Sleep Medicine Reviews. 17 (6): 465–74. doi:10.1016/j.smrv.2012.12.002. PMID 23499210.

[31] Abramowitz JS, Taylor S, McKay D (2009). “Obsessive-compulsive disorder”. Lancet. 374(9688): 491–9. doi:10.1016/S0140-6736(09)60240-3. PMID 19665647.

[32] Menzies L, Achard S, Chamberlain SR, Fineberg N, Chen CH, del Campo N, Sahakian BJ, Robbins TW, Bullmore E (2007). “Neurocognitive endophenotypes of obsessive-compulsive disorder”. Brain. 130 (Pt 12): 3223–36. doi:10.1093/brain/awm205. PMID 17855376.

[33] Ozaki N, Goldman D, Kaye WH, Plotnicov K, Greenberg BD, Lappalainen J, Rudnick G, Murphy DL (2003). “Serotonin transporter missense mutation associated with a complex neuropsychiatric phenotype”. Mol. Psychiatry. 8 (11): 933–6. doi:10.1038/sj.mp.4001365. PMID 14593431.

[34] “Obsessive-Compulsive Disorder (OCD) – Cause”. WebMD.

[35] van der Wee NJ, Stevens H, Hardeman JA, Mandl RC, Denys DA, van Megen HJ, Kahn RS, Westenberg HM (2004). “Enhanced dopamine transporter density in psychotropic-naive patients with obsessive-compulsive disorder shown by [123I]{beta}-CIT SPECT”. Am J Psychiatry. 161 (12): 2201–6. doi:10.1176/appi.ajp.161.12.2201. PMID 15569890.

[36] Wu K, Hanna GL, Rosenberg DR, Arnold PD (2012). “The role of glutamate signaling in the pathogenesis and treatment of obsessive–compulsive disorder”. Pharmacology Biochemistry and Behavior. 100 (4): 726–735. doi:10.1016/j.pbb.2011.10.007. PMC 3437220. PMID 22024159.

[37] Kim KW, Lee DY (2002). “Obsessive-Compulsive Disorder Associated With a Left Orbitofrontal Infarct”. Journal of Neuropsychiatry and Clinical Neurosciences. 14 (1): 88–89. doi:10.1176/appi.neuropsych.14.1.88. PMID 11884667.

[38] Aardema F., O’Connor (2007). “The menace within: obsessions and the self”. International Journal of Cognitive Therapy. 21: 182–197. doi:10.1891/088983907781494573.

Links to further material of interest on OCD:

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This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition.