Obsessive-Compulsive Disorder

Unwanted intrusive thoughts and repetitive behaviors afflict about 2 percent of the population, typically
beginning in the teen years but often much earlier. The chronic condition, caused by a mix of neurobiologic,
genetic, and environmental factors, responds to both drug therapy and exposure psychotherapy.

Definition

Obsessive-compulsive disorder (OCD) is an anxiety disorder in which people have unwanted and repeated
thoughts, feelings, images, and sensations (obsessions) and engage in behaviors or mental acts in
response to these thoughts or obsessions.Often the person carries out the behaviors to reduce the impact
or get rid of the obsessive thoughts, but this only brings temporary relief. Not performing the obsessive
rituals can cause great anxiety. A person's level of OCD can be anywhere from mild to severe, but if left
untreated, it can limit his or her ability to function at work or school or even to lead a comfortable existence
at home or around others.

OCD affects about 2.2 million American adults, and the problem can be accompanied by other anxiety
disorders, depression, and eating disorders. It strikes men and women in roughly equal numbers and
usually appears in childhood, adolescence, or early adulthood. One-third of adults with OCD developed
symptoms as children, and research indicates that OCD might run in families.

Although OCD symptoms typically develop during the teen years or early adulthood, research shows that at
least one-third of adult cases began in childhood. Suffering from OCD during the early stages of
development can cause severe problems for a child. It is important that children receive evaluation and
treatment as soon as possible to prevent their missing important opportunities because of this disorder.

Symptoms

People with OCD:

Have repeated thoughts, images, and urges about diverse issues, including being compulsively neat
and organized; fearing germs, dirt, contamination, intruders, or violence; or imagining hurting loved
ones or committing sexual acts or behaving in a way that conflicts with religious beliefs.

Engage in repetitive behaviors or mental acts such as washing hands, locking and unlocking doors,
counting, keeping unneeded items (hoarding), or repeating the same steps to any task again and
again.

Have obsessions that are intrusive and compulsions that often feel out of the person's control but
dictated by a rule that must be applied rigidly.

Get no pleasure from engaging in the behaviors or rituals but do receive some relief from the anxiety
the thoughts cause.

Spend at least an hour a day on the thoughts and rituals, which cause distress and get in the way of
daily life.

Obsessions

Unwanted, repetitive and intrusive ideas, urges or images frequently well up in the mind of the person with
OCD. Persistent paranoid fears, an unreasonable concern with becoming contaminated, or an excessive
need to do things perfectly, are common. The individual experiences a disturbing thought, such as, This
bowl is contaminated; it's not clean, and responds by repeatedly washing it. Or, he or she thinks: I may
have left the door unlocked, or I know I forgot to put a stamp on that letter. These thoughts are intrusive
and unpleasant and produce a high degree of anxiety. Other examples of obsessions include fear of being
hurt or of hurting others, and troubling religious or sexual thoughts.

Compulsions

In response to their obsessions, most people with OCD resort to repetitive behaviors, or compulsions. The
most common of these are putting things in order, checking, and washing. Other compulsive behaviors
include rearranging, counting (often while performing another compulsive action such as lock-
checking), mentally repeating phrases, list making, and avoiding. These behaviors generally are intended
to ward off harm to the person with OCD or to others. Some people with OCD have regimented
rituals. Performing the rituals in the same manner provides the person some relief from anxiety and a
sense of control, but this is only temporary.

People with OCD vary in terms of their insight into their illness. Sometimes they are able to recognize that
their obsessions and compulsions are unrealistic or illogical. At other times, however, they may be unsure
about their fears or even believe strongly in their validity.

Most people with OCD struggle to banish their unwanted thoughts and compulsive behaviors. Many are
able to keep their obsessive-compulsive symptoms under control during the hours when they are engaged
at school or work. But over time, resistance may weaken, and when this happens, OCD may become so
severe that time-consuming rituals make it impossible for them to have outside relationships and cause
them to lose their autonomy and financial independence.

The course of the disease is quite varied. Symptoms may come and go, ease over time, or get worse. If
OCD becomes severe, it can keep a person from working or carrying out normal responsibilities at home.
People with OCD may try to help themselves by avoiding situations that trigger their obsessions, or they
may use alcohol or drugs to deal with their mood, anxieties, and fears.

Causes

Biological factors are implicated in the risk of OCD. The fact that OCD patients respond well to specific
medications that affect the neurotransmitter serotonin suggests the disorder has a neurobiological basis.
There is also a higher rate of OCD among first-degree relatives of adults with the disorder. OCD is no
longer attributed only to attitudes a patient learned in childhoodinordinate emphasis on cleanliness,
say, or a belief that certain thoughts are dangerous or unacceptable. The search for causes now focuses
on the interaction of neurobiological factors and environmental influences, as well as on cognitive
processes. Physical or sexual abuse in childhood or other traumatic events are associated with a risk of
developing OCD. There are also theories that link OCD to the interaction between behavior and the
environment, which are not incompatible with biological explanations.

OCD is often accompanied by depression, eating disorders, substance abuse, a personality disorder,
attention deficit disorder, or another of the anxiety disorders. Coexisting disorders can make OCD more
difficult both to diagnose and to treat. Symptoms of OCD are seen in association with some other
neurological disorders. There is an increased rate of OCD in people with Tourette's syndrome, an illness
characterized by involuntary movements and vocalizations. Investigators are currently studying the
hypothesis that a genetic relationship exists between OCD and the tic disorders.

Other illnesses that may be linked to OCD are hoarding behaviors (difficulty parting with possessions),
trichotillomania (the repeated urge to pull out scalp hair, eyelashes, eyebrows, or other body hair), body
dysmorphic disorder (excessive preoccupation with imaginary or exaggerated defects in appearance), and
hypochondriasis (the fear of havingdespite medical evaluation and reassurancea serious disease).
Researchers are investigating the place of OCD on a spectrum of disorders that may share certain
biological or psychological bases. It is currently unknown how closely related OCD is to other disorders,
such as trichotillomania, body dysmorphic disorder, and hypochondriasis.

A person with OCD has obsessive and compulsive behaviors that are extreme enough to interfere with
everyday life. People with OCD should not be confused with a much larger group of people who are
sometimes called "compulsive" for being perfectionists and highly organized. This other type of
compulsiveness, however, is more in line with a pattern of excessive perfectionism and rigid control as
personality traits. In OCD, the compulsive behaviors are performed in reaction to the intrusive thoughts,
images, and obsessions.

Treatments

Clinical and animal research sponsored by NIMH and other scientific organizations has provided
information leading to both pharmacological and behavioral treatments that can benefit the person with
OCD. While some benefit significantly from behavior therapy and others are helped by
pharmacotherapy, research indicates that a robust treatment of OCD includes both medication and therapy.
Patients may begin with medication to gain control over their symptoms and then continue with behavior
therapy. Which therapy to use should be decided by the individual patient in consultation with his or her
therapist.

Medication

Clinical trials in recent years have shown that drugs that affect the neurotransmitter serotonin can
significantly decrease the symptoms of OCD. The first of these serotonin re-uptake inhibitors (SRIs)
specifically approved for the use in the treatment of OCD was the tricyclic antidepressant clomipramine
(Anafranil). It was followed by "selective" serotonin re-uptake inhibitors (SSRIs). Those that have been
approved by the Food and Drug Administration for the treatment of OCD are citalopram (Celexa), flouxetine
(Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft).

Large studies have shown that more than three-quarters of patients are helped by these medications at
least a little. And in more than half of patients, medications relieve symptoms of OCD by diminishing the
frequency and intensity of the obsessions and compulsions. Improvement usually takes at least three
weeks or longer. If a patient does not respond well to one of these medications, or has unacceptable side
effects, another SRI may give a better response. For patients who are only partially responsive to these
medications, research is being conducted on the use of an SRI as the primary medication and one of a
variety of medications as an additional drug (an augmenter). Medications are of help in controlling the
symptoms of OCD, but often, if the medication is discontinued, relapse will follow.

Behavior Therapy

Cognitive behavior therapy (CBT) has been shown to be the most effective type of psychotherapy for this
disorder. CBT aims to diminish thoughts and beliefs in order to help modify behaviors and vice versa.
Medication and CBT together are considered to be better than either treatment alone at reducing
symptoms.

A specific behavior therapy approach called "exposure and response prevention" is effective for many
people with OCD. In this approach, the patient deliberately and voluntarily confronts the feared object or
idea, either directly or by imagination. At the same time, the therapist, and possibly others the patient has
recruited for assistance, offer support and structure, strongly encouraging the patient to refrain from using
rituals or avoidance. For example, a compulsive hand washer may be encouraged to touch an object
believed to be contaminated and then urged to avoid washing for several hours, until the anxiety provoked
has greatly decreased. Treatment then proceeds on a step-by-step basis, guided by the patient's ability to
tolerate the anxiety and control the rituals. As treatment progresses, most patients gradually experience
less anxiety from the obsessive thoughts and are able to resist the compulsive urges.

Other forms of therapy can also provide effective ways of reducing stress or anxiety by helping the patient
become aware of and resolve inner conflicts.

Ways to Make Treatment More Effective

Many people with anxiety disorders benefit from joining a self-help or support group and sharing their
problems and achievements with others. Internet chat rooms can also be useful in this regard, but any
advice received over the Internet should be used with caution as Internet acquaintances have usually never
seen each other and false identities are common. Talking with a trusted friend or member of the clergy can
also provide support but is not a substitute for care from a mental health professional.

Stress management techniques and meditation can help people with anxiety disorders calm themselves
and may enhance the effects of therapy. There is preliminary evidence that aerobic exercise may have a
calming effect. Since caffeine, certain illicit drugs, and even some over-the-counter cold medications can
aggravate the symptoms of anxiety disorders, they should be avoided. Check with your physician or
pharmacist before taking any additional medications.

The family is very important in the recovery of a person with an anxiety disorder. Ideally, the family should
be supportive and avoid perpetuating their loved one's symptoms. Relatives should not trivialize the
disorder or demand improvement without treatment. When a family member suffers from obsessive-
compulsive disorder, it's helpful to be patient about any progress and acknowledge successes, no matter
how small.