sections include: obsessions and compulsions, what causes OCD?, diagnosis and treatment
Recurrent thoughts and rituals can be a part of normal, daily life. Many people wonder when they leave home whether they turned off the coffeepot or locked the door. Some of us might wash our hands every day when we return home from work, or be repelled by the idea of eating from a utensil that has fallen on the floor. It is also quite normal for growing children to go through periods when their playthings, food, bedtime routine, or other aspects of life must be “just so.” For some adults and children, however, such obsessions and compulsions can reach a level that causes marked distress, consumes large amounts of time, or significantly interferes with daily life. These people suffer from obsessive compulsive disorder (OCD).
OCD is an anxiety disorder in which a person has recurrent and persistent thoughts, impulses, or imaginings that are intrusive and inappropriate, and that cause marked anxiety or distress. The individual usually tries to ignore, suppress, or neutralize these obsessions with thoughts and actions. These responses can become compulsive— repetitive behaviors or mental acts that a person may feel driven to perform by an obsession, or to prevent or reduce anxiety or distress.
In general, people with OCD recognize that their anxious thoughts and rituals are unreasonable and excessive, but they feel helpless about stopping them. Thus, while they may have irrational or bizarre thoughts related to their symptoms, they are in touch with reality. OCD is not a psychotic disorder.
The lifetime prevalence of OCD in adults is 2 percent to 3 percent. This level, established by surveys in the 1980s, was considerably higher than expected, indicating the possibility that many people do not have their difficulties diagnosed and treated. One third to one half of adults with OCD report that their illness began in childhood or adolescence. Only about 15 percent of patients with OCD have onset after age 35. “Late onset” OCD (after age 50) is unusual and is most likely to be due to organic causes, such as strokes (ischemic, hemorrhagic) in the basal ganglia or frontal lobes. In adults, women are more likely to have OCD than men, but before adolescence boys are more likely to have the condition than girls.
Obsessions and Compulsions
A person with OCD may have obsessions, compulsions, or both. Often a person’s obsessions and compulsions are characterized by anxiety or fear that something bad might happen. Some people with OCD fear contamination, whether from dirt, germs, certain illnesses (AIDS, rabies), bodily wastes or secretions (urine, feces, saliva), environmental contaminants (asbestos, radiation, toxic wastes), or household items (cleaners, solvents). These people might have the recurring and upsetting thought that someone they passed on the street, or sat beside in a meeting, might have contaminated them. Some individuals go to great lengths to avoid certain places or people, such as not shopping in malls for fear that they might have to use a rest room where they could catch an illness.
Others who suffer from OCD fear that their actions could unwittingly cause harm to themselves or others. A person might worry that leaving an envelope on a table next to a light might cause the paper to catch fire and burn down the house, killing their loved ones. A child might have recurrent thoughts that his or her parents will be kidnapped, whereas a parent might worry that his or her child will be abducted.
Some people with OCD suffer from aggressive or sexualized thoughts or images, fearing that they might harm themselves or their loved ones. For example, a person might have a recurring worry that he or she has caused harm to another person, although no such incident has happened. Other people have recurring fears of doing something embarrassing, such as screaming out in church or temple. Still others are obsessed with doing things perfectly, or being good. Some people are obsessed with the need for reassurance. Occasionally, the obsession can be an image or tune in one’s head.
Compulsions (or rituals) are repetitive behaviors or mental acts that a person with OCD might often carry out to “undo” or “neutralize” the obsession. Common compulsions include washing, cleaning, checking, counting, repeating, arranging, touching, and hoarding. Excessive praying is an example of a mental compulsion called scrupulosity. Sometimes the compulsive act has no logical connection to a person’s fear: feeling that one must touch particular objects on one’s desk before handing in an important report, for instance. At other times, there may be a logical connection between an obsession (cleanliness) and a compulsion (washing), but a person performs the action at an excessive level.
Often compulsive behavior produces clear signs of difficulty. A classic symptom in a person who fears contamination is hands that are red and cracked from excessive washing. Very ritualized showering, grooming, and toothbrushing that is excessive and problematic are also likely to reflect OCD. An individual obsessed with leaving a door locked may feel compelled to check it repeatedly, and may be constantly late to work because of going back home to check. Someone obsessed with cleanliness might do so much laundry that it affects the household bills.
Some people with OCD establish elaborate rituals without knowing why. They may have to do things exactly three, four, or another number of times. Repeating actions—such as turning a light off and on, stepping, touching, or tapping “until it feels right”—might be an OCD symptom. Needing one’s possessions to be in the exact right position could be an OCD symptom. Saving sentimental objects is normal, but amassing useless items (used gum wrappers, expired coupons, old newspapers) may be symptomatic of OCD.
Most people with OCD have many different obsessions and compulsions over the course of their illness, and the specific symptoms change in severity. Children with OCD have essentially the same symptoms as adults, although more age appropriate: arranging their toys ritually rather than the items in their offices. It is particularly interesting that individuals from different cultures all over the world have essentially identical obsessions or compulsions, which speaks to the underlying neurobiology of the disorder.
Some activities similar to behaviors associated with OCD, but not actually part of the illness, are grouped under a new term, OC spectrum illnesses. Trichotillomania is the repeated pulling out of one’s hair (scalp, eyebrows, eyelashes, body hair). Body dysmorphic disorder is a preoccupation with an imagined defect in one’s appearance that causes great distress and impairment; someone who has had multiple unsatisfactory plastic surgeries might have this disorder. Compulsive eating, spending, and gambling are also not considered part of OCD.
What Causes OCD?
Obsessive-compulsive disorder is a heterogeneous disorder, meaning that it may have different risk factors (or causes) in different people. It tends to run in families, so we believe people can inherit a genetic vulnerability. Family studies suggest that OCD and chronic tic disorders, including Tourette’s syndrome, may represent alternative expressions of the same gene or genes. In other words, these genes may be expressed as OCD in some people, as tics in others, and occasionally as both.
OCD has both neurological and psychiatric symptoms. One piece of evidence that it is brain based comes from its association with several neurological illnesses: Sydenham’s chorea, Huntington’s chorea, and illness or trauma that leads to alterations in the basal ganglia. Although these cases of OCD’s association with neurological illness are rare, they might provide clues about where the brain is malfunctioning.
Neuroimaging studies of both the brain’s structure and function in people with OCD have provided evidence of a change in the normal physiology of connections between the orbitofrontal area and the subcortical areas of the brain (specifically the striatum and thalamus). Some doctors now think that OCD symptoms may arise from an imbalance in the feedback loops in this area of neurocircuitry. Specific neurotransmitter systems—serotonin, probably dopamine, and others—seem to become hyperactive in these circuits. When physicians use cognitive behavioral therapy, medication, or occasionally, surgery to inhibit or interrupt these circuits, OCD symptoms can diminish for many people.
Studies have found that medications that alter the amount of serotonin in the brain’s synapses are the most effective way to treat OCD medically. These drugs seem to work by altering the balance in the feedback loops of the neural circuits. Interestingly, cognitive behavioral therapy (CBT) may act on the brain in a similar way. Some brain imaging studies have reported that activity in these circuits changes after successful CBT treatment.
Some researchers also suggest that OCD is a result of “neuroethological” behaviors that we humans developed for survival and retain even though they are no longer necessary. According to this theory, behaviors normally required in the wild—such as perceiving and avoiding danger, protecting the young, and grooming—become magnified and cannot be turned off. Thus, obsessive-compulsive behaviors, such as repeatedly checking on children, excessive washing, or hoarding, may be the unleashing of an innate adaptive behavioral pattern gone awry.
Diagnosis and Treatment
Many people who suffer from OCD are embarrassed by their illness. They may try to hide their symptoms and not seek help. Furthermore, there is no blood test, or brain test, to make the diagnosis clear-cut. Rather, doctors must rely on a clinical interview. They seek to find out if the person spends at least one hour a day in obsessing or carrying out rituals, or if those compulsions significantly interfere with the person’s life in other ways. A primary care physician may make an initial diagnosis and refer a person for further treatment, typically to a clinical psychologist with expertise in cognitive behavioral therapy or to a psychiatrist.
Doctors usually do a comprehensive psychiatric evaluation, but unless there is something unusual about a person’s case, they won’t do a specific medical workup. However, someone who is over 50 and is experiencing the symptoms of OCD for the first time may have another illness, in which case a doctor typically performs a neurological workup.
A psychiatrist or psychologist must distinguish OCD from illnesses that appear similar, such as other anxiety disorders, eating disorders, depression or a psychosomatic illness. Children may exhibit rigid and ritualized behaviors as symptoms of such developmental disorders as Asperger’s syndrome or as a passing stage of normal development. Furthermore, other disorders may coexist with OCD and may obscure the symptoms. It is not uncommon for a person to have other anxiety disorders or a depressive disorder at the same time. A child with OCD has a higher risk of also having a tic disorder or Tourette’s syndrome and sometimes a complex motor tic resembles a ritual. Among children with OCD, there is also a higher than average rate of attention deficit/ hyperactivity disorder.
We have two effective methods for treating OCD: CBT and drug treatment. There is no clear way to predict which treatment, or what combination, will work best for a particular individual.
A very specific kind of CBT, called exposure with response prevention (ERP), is the psychotherapeutic treatment of choice. It involves progressively exposing the person to the stimulus he or she fears until it no longer brings on the anxious response. Individuals choosing CBT should seek a therapist with experience in delivering this specific form. Some studies estimate that ERP helps people improve their symptoms by 50 percent to 65 percent. More general types of family and individual psychotherapy are sometimes useful for related issues, but not typically for the primary symptoms of OCD.
As we noted above, medications that inhibit serotonin reuptake appear uniquely effective in treating OCD symptoms. These include the serotonin reuptake inhibitor clomipramine (Anafranil) and such selective serotonin reuptake inhibitors (SSRIs) as fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft). These drugs are most commonly used to treat depression. Children and adults appear to have similar responses to them.
Many people’s OCD symptoms will not respond until after two or even three months of medication, so it is important for the doctor to wait a sufficient time before changing medications, raising doses past target doses, or adding additional medications. It is estimated that one out of three people fails to respond to a given SSRI. Sometimes those who have a partial response to one SSRI are given a second medication as an “augmenting agent.” Some doctors believe that drug treatment and CBT are a logical combination and work well together, but studies have not yet been completed to support the superiority of using both treatments together.
For severely incapacitated adults with OCD whose symptoms have not responded to intensive CBT and medication, researchers are studying surgical treatments. The newest investigational procedure is deep brain stimulation (DBS), which involves implanting electrodes into the brain that are connected to an electrical device similar to a heart pacemaker, as in a currently approved treatment for neurological illness such as severe tremor. There is more experience with older operations, such as cingulotomy and capsulotomy. Both of these procedures involve making careful lesions within brain circuits believed to mediate OCD symptoms. In cingulotomy, holes are made in the skull through which a thermal probe is inserted to heat and destroy part of the cingulate gyrus. Capsulotomy, where the target is the anterior internal capsule, was initially done this way as well. A newer capsulotomy procedure allows smaller lesions to be precisely made in the capsule without opening the skull, using a device, a “gamma knife,” that focuses many beams of radiation.
Unfortunately, for many individuals OCD is a chronic and debilitating illness. About one third of people get better and stay in remission, one third have continued illness, and one third appear to get worse. Thus, OCD is not a progressive illness in which a person must expect more and more impairment, but those people with a chronic course may never be symptom-free. The development of new drug treatments and specific CBT interventions are believed to improve the long-term prognosis.
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