Obsessive compulsive disorder

Related Terms

Angina, anxiety disorder, arrhythmias, basal ganglia, chest pain, cingulate gyrus, cingulotomy, cingulum, cognitive-behavioral therapy, compulsion, frontal lobes, group A beta-hemolytic streptococcal pharyngitis, heart palpitations, irregular heart beat, nausea, nervousness, obsession, postpartum, pregnancy, serotonin, shortness of breath, strep throat, stress, tension headache.

Background

Obsessive-compulsive disorder (OCD) is a potentially disabling anxiety disorder. Anxiety disorders are characterized by an unpleasant complex combination of emotions often accompanied by physical sensations such as heart palpitations (arrhythmias or irregular heart beat), nausea, angina (chest pain), shortness of breath, tension headache, and nervousness. Symptoms of OCD can lead to generalized anxiety.
OCD can be debilitating, and is composed of two anxiety-related features: obsessions (undesirable, recurrent, disturbing thoughts) and compulsions (repetitive or ritualized behaviors).
An individual with OCD has intrusive and unwanted thoughts and repeatedly performs tasks to get rid of the thoughts. For example, individuals with OCD may fear that everything they touch is contaminated with germs, and in order to ease that fear, they repeatedly wash their hands. It is noted that these activities must interfere with daily function and quality of life before OCD is diagnosed.
The effects of OCD range from mild to severe. OCD can disrupt an individual's social life and relationships as well as their ability to work, make a living, or go to school.
Obsessive-compulsive disorder occurs equally in men and women. According to the National Institute of Mental Health, about 2.2 million adults in the United States have OCD. About 80% of individuals who develop OCD show signs of the disorder in childhood, although the disorder usually develops fully in adulthood. Also, OCD is more common among people of higher education, IQ, and socioeconomic status.
Though its course is chronic and usually lasts a lifetime, it is treatable with medication, behavioral therapy, and, in extremely rare cases, brain surgery. Although symptoms can be alleviated with medications, OCD is not curable.

Signs and symptoms

Early indications of obsessive-compulsive disorder (OCD) can be seen in children and teenagers. The disease usually begins gradually and worsens with age. Symptoms of OCD can be mild or severe.
Most individuals, especially children, do not perceive obsessions and compulsive behaviors as irrational. For example, children do not mind avoiding cracks in the sidewalk. And though adults might worry about their problems, they usually do so because their problems and solutions are meaningful to adult life. But all individuals with OCD realize that in addition to being excessive and disruptive, their obsessions and compulsions are compulsive, unreasonable, and may disrupt normal daily activities and function.
This realization is characteristic of the disease and is accounted for in the American Psychiatric Association's (APA) criteria for diagnosis. Moreover, it distinguishes OCD from obsessive-compulsive personality disorder (OCPD), once thought to be closely related to OCD. People with OCPD are usually undisturbed by their obsessive-compulsive behavior.
Individuals with OCD often feel embarrassed and ashamed of their illness and rarely reveal their symptoms, if they can help it. Many hide their symptoms from family and friends for years. These individuals recognize the absurdity of their behaviors, but without intervention, they often learn to live with them.
Obsessions: Obsessions are recurrent, intrusive, and unwanted thoughts, impulses, or images that cause significant anxiety. At first, the obsession may be experienced as relatively benign. Over time, the person associates it with fear and disabling anxiety. Obsessions fall into the following common categories: fear of contamination with dirt, germs, or poisons; fear of having a serious illness; fear that one's actions hurt other people or cause bad things to happen; inability to discard useless items (hoarding); inappropriate sexual and aggressive thoughts and images; and need for symmetry, order, or exactness.
Individuals who fear contamination may obsess about shaking hands or touching public doorknobs. Those who obsess about the implications of their actions often fear they endanger others. They may feel they have left a door unlocked or hit someone while driving. Obsessions with symmetry and order may cause significant anxiety over furniture arrangement, eating habits, or clothing. Inappropriate sexual impulses and pornographic images, often of an aggressive nature, can dominate a person's mind. Obsessions of aggression can also center on violent emotions, shouting out in public, or harming others. Hoarding useless items, like outdated catalogs or clothing, is common in OCD and may coincide with an obsession with order.
Individuals suffering from OCD realize that they create their obsessions. They feel that the content of their obsessions is out of their control, inappropriate, not indicative of their character, and something they would not normally think or communicate to others. Thus, their anxiety is intensified not only by recurrent obsessions, but also by the strangeness of the obsessions.
Compulsions: Compulsions are repetitive, often ritualized behaviors that are intended to suppress the anxiety caused by obsessions. Compulsions common in OCD include: asking for assurances; avoiding places or situations; cleaning; counting; doing certain tasks slowly and deliberately; doubting and checking, such as door or car locks, lights, water faucets, and ovens; hoarding possessions; ordering or arranging; repeating behaviors, including speech and action; and washing, such as excessive hand-washing or bathing.
Compulsive washing and cleaning are subsequent to the obsessive fear of germs or contamination. Compulsive people have been known to shower for four hours, or to wash their hands until they are raw. Others make sure their bath towels are arranged by some exact design, or that the soap is dry before they leave it. Individuals may check the lock on a door several times an hour, or repetitively return home to make sure the oven is off. Some people count incessantly in an attempt to distract or soothe aggressive thoughts. Others depend on patterned behavior to control anxiety, such as avoiding traffic intersections or avoiding a change in routine.
A general theme of compulsive behavior is adherence to some often elaborate set of rules or routine. Individuals with OCD will go to great lengths to satisfy the requirements of a routine, which often results in patterned, idiosyncratic behavior, such as slowly and meticulously preparing a bathroom for a shower that lasts for several hours. People who know OCD sufferers may call them perfectionists, especially if they only get a glimpse of the compulsive behavior.
Obsessive-compulsive behavior often leads to secondary avoidance behavior. For example, people who obsess about germs compulsively wash their hands, and may also compulsively avoid places and situations that cause their anxiety in the first place, such as public restrooms, doorknobs, and handshaking. Avoidance-related anxiety prohibits some people from leaving the house. And compulsive washing can lead to dermatological problems.
The fact that compulsive behavior can consume most of an individual's time makes OCD a particularly devastating disease, especially when behavior becomes routine.
Adult sufferers recognize the futility of their compulsive behavior, but they are powerless to change it and cannot provide reason for their compulsive behavior. Some individuals lack this insight, a factor that is specified in the criteria for diagnosis.

Diagnosis

A mental health professional will diagnose obsessive-compulsive disorder after a thorough evaluation. Criteria are based upon the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), a clinical book of mental illness diagnoses. OCD diagnosis is based upon: recurrent and persistent thoughts, impulses, or images that are intrusive and cause distress; thoughts that are not simply excessive worries about real problems; an attempt to ignore or suppress these thoughts, images, or impulses; and the recognition that these thoughts, images, and impulses are a product of the mind.
Compulsions must meet specific criteria including repetitive behaviors, such as hand washing, or repetitive mental acts, such as counting silently, that individuals feel driven to perform. These behaviors or mental acts are meant to prevent or reduce distress about unrealistic obsessions.
OCD can be mild or severe. There are four essential factors in the diagnosis of OCD that distinguish OCD from ordinary, mildly intrusive worries or brooding. These factors include: symptoms cause significant distress; symptoms take up more than one hour a day; symptoms significantly interfere with work, relationships, or daily functioning; and the individual recognizes that his or her obsessions and compulsions are unreasonable or excessive.
Doctors must also distinguish OCD from other psychiatric disorders, called differential diagnosis. The following psychiatric disorders feature symptoms that may, at first, resemble OCD: major depressive disorder; anxiety disorders; eating disorders, such as anorexia; alcoholism or other substance-related disorders; Tourette's syndrome (a neurological disorder); and schizophrenia.
All of these conditions are differentiated from OCD by type and severity of symptoms. For example, although schizophrenic delusions may resemble obsessions common in OCD, individuals with schizophrenia believe what they are experiencing is real, often losing their contact with reality. They believe the delusions involve external influence and are not the product of their own mind. Some of these disorders may occur with OCD.

Complications

Left untreated, obsessive-compulsive disorder (OCD) can make an individual's life unpleasant and unbearable. Normal routine and activities are disrupted, and school, work, and social relationships all can suffer as more of the individual's time is devoted to their obsessions and compulsive behavior.
OCD can also increase the risk of suicide because it can be so demoralizing and distressing. OCD may also increase the risk of alcohol and substance abuse as individuals turn to unhealthy coping mechanisms. In some cases, OCD can cause physical complications. For instance, the person may feel compelled to wash their hands so often and so harshly that conditions such as dermatitis may develop. Others may act out inappropriately sexually.

Treatment

Obsessive-compulsive disorder treatment can sometimes be difficult, and it may not offer a cure. However, OCD treatment can help bring symptoms under control so that they do not rule and disrupt the individual's daily life. OCD cannot be cured, but treatment can help manage symptoms and allow the individual to function normally in daily activities.
Medications: Antidepressant medicines called selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac?) and sertraline (Zoloft?), are most commonly used. Symptoms may begin to improve within one to three weeks of taking an SSRI. However, it can take as many as six to eight weeks to see more improvement. SSRIs may cause sexual side effects, such as loss of libido (sex drive), drowsiness, and sedation.
Tri-cyclic antidepressants (TCAs), such as clomipramine (Anafranil?), may be prescribed for OCD. The tricyclics typically take around two weeks to provide symptom relief. Side effects of TCAs include dry mouth, sedation, constipation, and blurred vision.
About 70% of people with OCD respond notably to antidepressant medication, and about 40% experience a partial reduction of symptoms. However, only about 10-15% experience a full remission of symptoms, so the disease is chronic for most individuals even with treatment. Most take medication indefinitely, and about 85% of people relapse within one or two months after discontinuing it.
Cognitive-behavioral therapy: Counseling used to treat OCD includes exposure and response prevention, a type of cognitive-behavioral therapy. Cognitive-behavioral therapy is a psychotherapy based on modifying cognitions, assumptions, beliefs, and behaviors, with the aim of influencing disturbed emotions such as compulsions. Exposure and response prevention is behavioral therapy that provides gradually increasing contact with the feared obsession so that anxiety is reduced. For example, if an individual was obsessed about germ contamination, they would repeatedly touch an object they believed is contaminated and not wash their hands afterward. The individual would repeat that behavior until their anxiety was reduced. Cognitive therapy may also be used to help overcome the faulty beliefs, such as fear of contamination, that lead to OCD behaviors.
The most effective treatment for OCD may be using both counseling and medication.
Cingulotomy: Occasionally, surgical treatment of the cingulum (fibers that allow communication between components of the limbic system) may be beneficial to people who have severe symptoms and who do not respond to treatment. A cut is made between certain nerve fibers that trigger emotional arousal (cingulate gyrus) and the limbic system, which is involved in mood and intense emotion. About 30% of cingulotomies result in improvement. The procedure is relatively uncomplicated and is not thought to negatively affect memory, cognition, or intellect. As with any type of brain surgery, cingulotomy carries the risk of permanent brain damage, although improvements in technique (such as using a laser) have decreased problems. A cingulotomy is usually a last restort effort to control symptoms of OCD.
Hospitalization: As with any psychiatric disorder, OCD can cause a range of impairment. In rare cases, psychiatric inpatient hospitalization is necessary for individuals with severe OCD symptoms. OCD can become debilitating at times and significantly affect one's functioning.

Integrative therapies

Good scientific evidence:
Psychotherapy: Psychotherapy is an interactive process between a person and a qualified mental health professional (psychiatrist, psychologist, clinical social worker, licensed counselor, or other trained practitioner). A broad range of psychotherapies are effective for the treatment of depression, including behavior therapy, cognitive-behavioral therapy, and interpersonal therapy. Brief dynamic therapy, marital therapy, and family therapy may work best, depending on the patient's problems and circumstances. Although prescription medication is considered the most effective treatment for obsessive-compulsive disorder, psychotherapy may help patients take their medication, prevent relapses, and reduce suicidal behavior.
Some forms of psychotherapy may evoke strong emotional feelings and expression.
Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Early descriptions of yoga are written in Sanskrit, the classical literary language of India. The first known work is "The Yoga Sutras," written more than 2,000 years ago, although yoga may have been practiced up to 5,000 years ago. Several human studies support the use of yoga therapy in the treatment of obsessive-compulsive disorder. Additional well-designed studies with clearly defined patient groups are needed.
Yoga is generally considered safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine or fragile or atherosclerotic neck arteries. Avoid if at risk for blood clots or with high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques should be avoided in people with heart or lung diseases. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction. However, poses that put pressure on the uterus, such as abdominal twists, should be avoided during pregnancy.
Unclear or conflicting scientific evidence:
Kundalini yoga: Kundalini yoga is one of many traditions of yoga that share common roots in ancient Indian philosophy. It is comprehensive in that it combines physical poses with breath control exercises, chanting (mantras), meditations, prayer, visualizations, and guided relaxation. Small clinical trials have examined a specific multi-faceted regime of Kundalini yoga techniques for obsessive-compulsive disorder. These limited studies suggested broad psychological benefits (reduced anxiety and depression) from the practices as well as reduced symptoms of OCD for up to 19 months. Both studies were limited by small sample size, inadequate control group, and incomplete description of randomization. More studies are needed.
Avoid exercises that involve stoppage of breath with heart or lung problems, insomnia, or poor memory or concentration. Avoid certain inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Use cautiously with mental disorders. Kundalini yoga is considered safe and beneficial for use during pregnancy and lactation when practiced under the guidance of expert instruction. Teachers of yoga are generally not medically qualified and should not be regarded as sources of medical advice for management of clinical conditions.
Relaxation therapy: Relaxation techniques include behavioral therapeutic approaches that differ widely in philosophy, methodology, and practice. The primary goal is usually non-directed relaxation. Most techniques share the components of repetitive focus (on a word, sound, prayer phrase, body sensation, or muscular activity), adoption of a passive attitude towards intruding thoughts, and return to the focus. Results of randomized controlled studies of relaxation techniques for obsessive-compulsive disorder show conflicting results. Further research is needed before conclusions can be drawn.
Avoid with psychiatric disorders such as schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, then relaxing the muscles) should be used cautiously with illnesses like heart disease, high blood pressure, or musculoskeletal injury. Relaxation therapy is not recommended as the sole treatment approach for potentially serious medical conditions and should not delay the time to diagnosis or treatment with more proven techniques.
St. John's wort: The most common modern-day use of St. John's wort (Hypericum perforatum) is the treatment of depression. There are a few reported cases of possible benefits of St. John's wort in patients with obsessive-compulsive disorder (OCD). Overall, there is not enough scientific evidence at this time to support the use of St. John's wort for OCD.
St. John's wort may interact with many drug therapies, and should not be used in OCD unless under the supervision of a doctor. Rare skin reactions, including rash and itching, are reported in human studies. Avoid if pregnant or breastfeeding.
Traditional or theoretical uses lacking sufficient evidence:
5-HTP: 5-HTP, or 5-hydroxytryptophan, is the precursor of the neurotransmitter serotonin. It is obtained commercially from the seeds of the plant Griffonia simplicifolia. Some clinicians use 5-HTP in the integrative treatment of obsessive-compulsive disorder, although there is a lack of clinical studies to support this use.
Avoid if allergic or hypersensitive to 5-HTP; signs of allergy to 5-HTP may include rash, itching or shortness of breath. Avoid with eosinophilia syndromes, Down syndrome, or mitochondrial encephalomyopathy. Use cautiously if taking antidepressant medications such as TCAs, MAOIs, SSRIs, nefazodone, trazodone, venlafaxine, mirtazapine, bupropion; 5-HTP receptor agonists such as sumatriptan, rizatriptan, naratriptan, zolmitriptan, eletriptan, imotriptan, and frovatriptan; and carbidopa, phenobarbital, pindolol, reserpine, tramadol, or zolpidem. Use cautiously with kidney insufficiency, HIV/AIDS, epilepsy, or with a history of mental disorders. Avoid if pregnant or breastfeeding.
Guided imagery: Therapeutic guided imagery may be used to help patients relax and focus on images associated with personal issues that they are confronting. Some clinicians use guided imagery in the integrative treatment of obsessive-compulsive disorder, although there is a lack of clinical studies to support this use.
Guided imagery is usually intended to supplement medical care, not to replace it, and guided imagery should not be relied on as the sole therapy for a medical problem. Contact a qualified healthcare provider if mental or physical health is unstable or fragile. Never use guided imagery techniques while driving or doing any other activity that requires strict attention. Use cautiously with physical symptoms that can be brought about by stress, anxiety, or emotional upset because imagery may trigger these symptoms. If feeling unusually anxious while practicing guided imagery, or with a history of trauma or abuse, speak with a qualified healthcare provider before practicing guided imagery.

Prevention

Preventing symptoms of OCD may not be possible, but taking medications and other therapies as prescribed by a healthcare professional may help decrease or stabilize symptoms.

Author information

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

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Causes

Biological factors: Biological factors associated with OCD development may include changes in brain structure and brain activation. Abnormalities of the frontal lobes, basal ganglia, and cingulum are common in people with OCD. Basal ganglia are involved in routine behaviors, like grooming, and the frontal lobes in organizing behaviors and in planning. The cingulum consists of fibrous bands that assist in communicating the brain's behavioral and emotional messages. Support for its role in OCD is the fact that surgical severing of the cingulum has relieved and even cured people with the disorder.
Serotonin: An abnormally low level of serotonin, a neurotransmitter in the brain involved in "calming," is perhaps the most well-established link between the brain and OCD. Serotonin is a chemical neurotransmitter that transmits information from one nerve to another throughout the brain. Serotonin is believed to play an important role in the regulation of anger, aggression, body temperature, mood, sleep, vomiting, sexuality, and appetite. Drugs used to treat OCD, known as selective serotonin reuptake inhibitors (SSRIs), increase and sustain serotonin levels and reduce or eliminate symptoms.
Strep throat: Some studies suggest that some children develop OCD after infection with group A beta-hemolytic streptococcal pharyngitis, otherwise known as strep throat. Some research suggests that an antibody against strep throat bacteria sometimes mistakenly acts like a brain enzyme. This disrupts communication between neurons in the brain, altering levels of neurochemicals such as serotonin. These complications may trigger OCD. The linkage of strep throat to OCD appears to be rare, affecting about one in 1,000 children.
Other causes: There are environmental stressors that can trigger OCD in individuals with a tendency toward developing the condition. Certain environmental factors may also cause a worsening of symptoms. These factors include: physical and emotional abuse, changes in living situation, illness, death of a loved one, work or school-related changes or problems, and relationship problems.

Risk factors

Age: Obsessive-compulsive disorder (OCD) can affect adults and children. The disorder often begins during adolescence or early childhood, usually around age ten. In adults, OCD generally begins around age 21. OCD symptoms may worsen with age, especially if not treated appropriately. Typical age of onset for boys is six to 15 years, while for women it is often later, between 20-30 years.
Family history: Having parents or other family members with the disorder can increase an individual's risk of developing OCD. An individual with OCD has a 25% chance of having a blood relative who has it. Like other mental illnesses, it is more prevalent among identical twins than fraternal. There is a 70% chance that identical twins with share it, and a 50% chance for fraternal twins. Currently, researchers do not understand OCD's genetic causes, though they suspect multiple genes are involved.
Stress: Individuals that are under chronic (long-term) stress may develop OCD more readily than those that are not. This reaction may, possibly due to hormonal changes, trigger the intrusive thoughts, rituals, and emotional distress characteristic of obsessive-compulsive disorder.
Pregnancy: Women with OCD may experience a worsening of symptoms during pregnancy and postpartum (after childbirth). Studies have suggested that fluctuating hormones may trigger symptoms during pregnancy, with an incidence of OCD in 30% of women observed. The arrival of a baby brings new responsibility, a new set of concerns, and changes in routine. While normal reaction to a newborn may include some anxiety, postpartum OCD features disturbing thoughts and excessive behavior regarding the baby's well-being. These feelings and behaviors may occur immediately, but often begin four to six weeks after giving birth. Treatment is necessary to control symptoms and to ensure care of the baby. It is very important to take prescribed medications appropriately while pregnant.