Obsessive-compulsive disorder

DEFINITION: A disorder characterized by intrusive and unwanted but uncontrollable thoughts (obsessions) that lead to repeated behaviors (compulsions); the obsessions and/or compulsions cause severe stress, consume an excessive amount of time, and greatly interfere with a person’s normal routine, activities, or relationships.

ANATOMY OR SYSTEM AFFECTED: Psychic-emotional system

CAUSES: Psychological factors; may involve genetic, cognitive, and/or neurobiological factors

SYMPTOMS: Repetitive behaviors, anxiety, persistent intrusive and uncontrollable thoughts, irrational fears

DURATION: Often chronic with acute episodes

TREATMENTS: Psychotherapy, drug therapy

Causes and Symptoms

Obsessive-compulsive disorder (OCD) is a disorder characterized by persistent intrusive and uncontrollable thoughts and the subsequent need to perform specific behaviors repeatedly. The presence of obsessions or compulsions must be time-consuming, cause distress or impairment, and be recognized as excessive or unreasonable by the person with OCD. The obsessions and compulsions must not be caused by medication, drug abuse, or another medical condition. Obsessive-compulsive behavior is highly distressing because it feels as if one’s behavior or thoughts are no longer voluntarily controlled. The more frequently these uncontrolled alien and perhaps unacceptable thoughts or actions are performed, the more distress is induced. An individual with OCD may at various times have either obsessions (which are thought-related) or compulsions (which are action-related), or both.

According to the National Institute of Mental Health (NIMH), OCD affects around 1.2 percent of the US adult population in a given year, and the lifetime prevalence is about 2.3 percent among US adults. Onset is bimodal and typically occurs before the age of thirty; most of those with the condition begin experiencing the disorder in late childhood (mean age ten years) or early adulthood (mean age twenty-one years). Onset is often preceded by a stressful event such as pregnancy, childbirth, or family conflict. It may be closely associated with mood disorders such as depression or anxiety, with OCD developing soon after a mood disorder or the mood disorder developing as a result of the OCD. OCD affects men and women in roughly equal numbers.

Individuals with OCD generally recognize and are distressed by the irrational or excessive nature of their obsessions and compulsions. However, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) outlines specifiers for OCD related to the individual's degree of insight about the nature of their obsessions and compulsions, including good or fair insight, poor insight, and absent insight/delusional, which involves an absolute conviction that the OCD beliefs are valid and true. Obsessions generally fall into one of five recognized categories. Obsessive doubts are persistent doubts that a task has been completed; the individual is unwilling to accept and believe that the work is done satisfactorily. Obsessive thinking is an almost infinite chain of thought, targeting future events. Obsessive impulses are very strong urges to perform certain actions, whether they are trivial or serious, that would likely be harmful to the affected person or someone else or that are socially unacceptable. Obsessive fears are thoughts that the person has lost control and will act in some way that will cause public embarrassment. Obsessive images are continued visual pictures of either a real or an imagined event. Common obsessions relate to contamination, safety, the fear of committing a socially unacceptable behavior, the need for order, and sexual or aggressive thoughts.

Four factors are commonly associated with obsessive characteristics, not only in people with OCD but in the general population as well. First, obsessive individuals are unable to control their mental processes completely. Practically, this means the loss of control over thinking processes, such as intrusive thoughts of a loved one dying or worries about hurting someone unintentionally. Second, there may be thoughts and worries over the potential loss of motor control, perhaps causing impulses such as shouting obscenities in public or performing inappropriate sexual acts. Third, many obsessive individuals may be afraid of contamination and suffer irrational fear and worry over exposure to germs, dirt, or diseases. The last factor is checking behavior, or backtracking previous actions to ensure that the behavior was done properly, such as checking that doors and windows are shut, faucets are turned off, and so on.

Compulsions may be either mild or severe and debilitating. Mild compulsions might be superstitions, such as refusing to walk under a ladder, knocking on wood, or throwing salt over one’s shoulder. Severe compulsions become fixed, unvaried ritualized behaviors; if these compulsions are not practiced precisely in a particular manner or a prescribed number of times, then intense anxiety may result. These strange behaviors may be rooted in superstition; many of those suffering from the disorder believe that performing the behavior may ward off danger. Compulsive acts are not ends in themselves but are “necessary” to produce or prevent a future event from occurring. Although the enactment of the ritual may assuage tension, the act does not give the person with OCD pleasure.

Common compulsions include cleaning, checking, counting, arranging, touching objects, hoarding, seeking reassurance, and making lists. For people with repeating compulsions, they must do everything by numbers. Checking is another compulsive act; a compulsive checker believes that it is necessary to check and recheck that everything is in order. Cleaning is a behavior in which the person believes they must engage; they may wash and scrub repeatedly, especially if they think that they have touched something dirty. A fourth common compulsive action is avoidance; for certain superstitious or magical reasons, certain objects must be avoided. Some individuals with compulsions experience compelling urges for perfection in even the most trivial of tasks; often the task is repeated to ensure that it has been done correctly. Some determine that objects must be in a particular arrangement; these individuals are considered “meticulous.” A few people with OCD have hoarding compulsions; they are unable to throw away trash or rubbish. Many individuals have a constant need for reassurance; for example, they want to be told repeatedly that they have not been contaminated.

The direct cause of OCD is uncertain, and no single cause for OCD has been isolated. Sigmund Freud (1856–1939) first proposed that obsessive thoughts are a replacement for more disturbing thoughts or actions that induce guilt or anxiety in the sufferer. However, this view has been discredited, and today it is believed that OCD is caused by a complex interaction of genetic, behavioral, cognitive, cultural, and neurobiological factors. OCD tends to run in families; however, genes appear to be only partly responsible for causing OCD. Twin studies have suggested that genetic factors influence 45 to 65 percent of cases of childhood-onset OCD and 27 to 47 percent of adult-onset OCD. Other suspected influences include abnormalities with the neurotransmitter serotonin in the brain.

Treatment and Therapy

Diagnostic techniques for evaluating OCD usually involve psychological evaluation. It is important to determine whether an individual is actually experiencing OCD or other potential problems such as schizophrenia or a mood disorder. Additionally, it is important to determine whether more than one disorder is present. OCD may occur in conjunction with other disorders, such as substance use disorders, eating disorders, and mood disorders. When this occurs, treatment must be adjusted. For example, when depression is also noted, both disorders must be addressed in treatment. OCD is related to other disorders characterized by repetitive behaviors and intrusive thoughts, including body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation disorder.

In cases when differentiation is required between OCD and schizophrenia, the concern is to understand the nature of the dysfunctional thoughts and behaviors. For instance, a distinction can be made by determining the motive behind the ritualized behavior. Stereotyped behaviors are symptomatic of both disorders. In the person with schizophrenia, however, the behavior is triggered by delusions rather than by compulsions. People suffering from delusions do not resist the ideas inundating their minds, and ritualized behavior does not necessarily decrease the feelings associated with the intrusive ideas. On the other hand, people with OCD usually experience decreases in anxiety when they perform their rituals and may be absolutely certain of the need to perform their rituals, though other aspects of their thinking and logic are perfectly clear. They generally resist the ideas that enter their minds and realize the absurdity or abnormality of the thoughts to some extent. As thoughts and images intrude into the mind, the person may sometimes appear to have symptoms that mimic schizophrenia.

Other problems having symptoms in common with OCD are stimulant abuse, Tourette syndrome, and other tic disorders. What seems to separate the symptoms of these disorders from those experienced with OCD is that the former are organically induced. Thus, the actions of a sufferer from Tourette syndrome may be mechanical since they are not purposely enacted. In the case of the stimulant user, the acts may bring pleasure and are not resisted, but reinforced by the drug effects.

Most people experience obsessive thoughts on occasion; in fact, the obsessions of individuals without OCD are not significantly different from the obsessions of those with OCD. The major difference is that those with the disorder have longer-lasting, more intense, and less easily dismissed obsessive thoughts. The importance of this overlap is that mere symptoms are not a reliable tool to diagnose OCD, since some of the same symptoms are experienced by the general population.

Assessment of OCD separates the obsessive from the compulsive components so that each can be examined. Obsession assessment should determine the triggering fears of the disorder, both internal and external, including thoughts of unpleasant consequences. The amount of anxiety that these obsessions produce should be monitored. The compulsive behaviors then should be examined in the same light. DSM-5 criteria include the presence of time-consuming (more than one hour per day) obsessions and compulsions that cause significant distress; that interfere with or reduce the quality of the individual's social, academic, or occupational functioning; and that are not better explained by another mental disorder or substance use.

The greatest chance for successful treatment occurs with individuals who experience mild symptoms who seek help soon after the onset of symptoms and who had few problems before the disorder began. Many valuable and successful treatment strategies are available for OCD. The American Psychiatric Association and the US National Institute for Health and Care Excellence (NICE) recommend exposure-and-response-prevention, a form of cognitive-behavioral therapy (CBT), and/or selective serotonin reuptake inhibitors (SSRIs) as first-line treatments, depending on the patient's preference, the level of OCD complexity and severity, and the presence of depressive symptoms. The NICE recommends low-intensity CBT alone for mild cases of OCD.

The most effective treatment for controlling OCD is behavioral therapy. CBT involves the identification of misperceptions and negative thoughts and repeated attempts to challenge these beliefs and replace them with less distressing thoughts. CBT may include psychoeducation, cognitive training, mapping OCD target symptoms, and exposure-and-response-prevention therapy. Exposure-and-response-prevention therapy (also called exposure-and-ritual-prevention therapy) is a form of CBT specifically designed to treat OCD symptoms. It involves gradual yet prolonged confrontation with the anxiety-producing stimuli in the presence of a supportive therapy. This exposure often begins with imagined stimuli or photographs and eventually progresses to real-life exposure to the anxiety-provoking stimuli. The exposure continues until the person's anxiety decreases, in a process called habituation. Exposure-and-response-prevention therapy also involves active abstinence from rituals and compulsive behaviors, although this approach does not involve active blocking of the person's compulsions. Exposure-and-response-prevention therapy is highly effective in the treatment of OCD, particularly when the client has less severe forms of OCD, does not have a comorbid diagnosis of depression, adheres to exposure homework early in the therapeutic process, has contamination fears or overt ritualistic behaviors, and has undergone no previous treatment.

Therapeutic approaches to the treatment of OCD may be supplemented with medications. Selective serotonin reuptake inhibitors (SSRIs) are considered to be the first-line agents for the treatment of OCD and often have remarkable effects on OCD, helping individuals to experience a change in their thinking and behavior, as well as providing relief. SSRIs appear to improve OCD symptoms compared with tricyclic antidepressants or monoamine oxidase inhibitors. Approximately 40 to 60 percent of people with OCD will respond to SSRIs.

Some psychiatrists may recommend neurosurgery to relieve a patient’s symptoms in very severe or intractable cases. Cingulotomy and deep brain stimulation are reported to reduce symptom severity in patients with treatment-refractory OCD. Electroconvulsive therapy has also been reported to be effective in the treatment of OCD in case reports; however, no high-quality, placebo-controlled trials have studied the efficacy of this treatment. Alternative treatments for OCD that have demonstrated benefit include kundalini yoga, mindfulness meditation, and progressive muscle relaxation.

Perspective and Prospects

Descriptions of OCD-like behavior go back to medieval times; a young man who could not control his urge to stick out his tongue or blurt out obscenities during prayer was reported in the fifteenth century. Medical accounts of the disorder and the term “obsessive-compulsive” originated in the mid-nineteenth century. At that time, obsessions were believed to occur when mental energy ran low. Later, Freud attributed the characteristics to a regression to early childhood, when there are perhaps strong urges to be violent and/or to dirty and mess one’s surroundings. To avoid acting on these tendencies, he theorized, an avoidance mechanism is employed, and the symptoms of obsession and/or compulsion appear.

Although not totally disabling, OCD behaviors can be strongly incapacitating and cause a significant amount of distress. Most parents will agree that children commonly have rituals to which they must adhere or compulsive actions they carry out. A particular bedtime story may be read every night for months on end, and children’s games involve counting or checking rituals. It is also not atypical for adults without psychiatric disorders to experience some mild obsessive thoughts or compulsive actions, as seen in an overly tidy person or in group rituals performed in some religious sects. Excessively stressful events may trigger obsessions as well. Further research into the biopsychosocial causes of OCD will be important in developing future treatment approaches.

The global coronavirus disease 2019 (COVID-19) pandemic declared in March 2020 led some experts in psychological and psychiatric fields, due to past studies showing a link between traumatic, stressful events and the development or worsening of OCD behaviors, to focus on how the pandemic affected people already and newly diagnosed with OCD. It was reported that there were many cases of people with obsessions and compulsions related to germs and cleanliness experiencing an exacerbation of their OCD behaviors in response to the anxiety-inducing outbreak of the novel virus that continued to spread widely over the following months and years. At the same time, psychologists and psychiatrists also saw an increase in patients experiencing OCD behaviors who had not previously. Other concerns included analyzing how those with OCD who had already been receiving therapeutic treatment, as opposed to those who were not, coped with the lifestyle changes brought on by the pandemic, and how people with OCD were distinguishing between their compulsions and the types of reactions and behaviors appropriate for healthy, safe living during a pandemic. Because of virus control measures such as lockdowns and physical distancing, the alternative to in-person treatment, telehealth, was used and tested on an unprecedentedly widespread scale for both physical and mental issues, including OCD, allowing experts to refine their approach to and use of this virtual method.

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