Obsessive-compulsive disorder (OCD) is a potentially disabling anxiety disorder. The person afflicted with OCD becomes trapped in a pattern of repetitive senseless thoughts and behaviors that are very difficult to overcome. A person's level of OCD can be anywhere from mild to severe, but if severe and left untreated, it can destroy a person's capacity to function at work, at school or even to lead a comfortable existence in the home.
For many years, mental health professionals thought of OCD as a rare disease because only a small minority of their patients admitted to having the condition. The disorder often went unrecognized because many of those afflicted with OCD, ashamed of their repetitive thoughts and behaviors, failed to seek treatment. This led to underestimates of the number of people with the illness. However, a survey conducted in the early 1980s by the National Institute of Mental Health (NIMH) provided new knowledge about the prevalence of OCD. The NIMH survey showed that OCD affects more than 2 percent of the population, meaning that OCD is more common than such severe mental illnesses as schizophrenia, bipolar disorder or panic disorder. OCD strikes people of all ethnic groups. Males and females are equally affected.
Although OCD symptoms typically begin during the teen years or early adulthood, research shows that some children may even develop the illness during preschool. Studies indicate that at least one-third of cases of adult OCD began in childhood. Suffering from OCD during early stages of a child's development can cause severe problems for the child. It is important that the child receive evaluation and treatment as soon as possible to prevent the child from missing important opportunities because of this disorder.
Unwanted repetitive ideas or impulses 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. Again and again, the individual experiences a disturbing thought, such as, "This bowl is not clean enough. I must keep washing it." "I may have left the door unlocked." Or "I know I forgot to put a stamp on that letter." These thoughts are intrusive, unpleasant and produce a high degree of anxiety.
In response to their obsessions, most people with OCD resort to repetitive behaviors called compulsions. The most common of these are checking and washing. Other compulsive behaviors include repeating, hoarding, rearranging, counting (often while performing another compulsive action such as lock-checking). Mentally repeating phrases, checking or list making are also common. These behaviors generally are intended to ward off harm to the person with OCD or others. Some people with OCD have regimented rituals: Performing things the same way each time may give the person with OCD some relief from anxiety, but it is only temporary.
People with OCD show a range of insight into the uselessness of their obsessions. They can sometimes recognize that their obsessions and compulsions are unrealistic. At other times 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 take over the sufferers' lives and make it impossible for them to have lives outside the home.
OCD tends to last for years, even decades. The symptoms may become less severe from time to time, and there may be long intervals when the symptoms are mild, but for most individuals with OCD, the symptoms are chronic.
The old belief that OCD was the result of life experiences has become less valid with the growing focus on biological factors. The fact that OCD patients respond well to specific medications that affect the neurotransmitter serotonin suggests the disorder has a neurobiological basis. For that reason, OCD is no longer attributed only to attitudes a patient learned in childhood -- inordinate emphasis on cleanliness, 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 cognitive processes.
OCD is sometimes 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 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 having -- despite medical evaluation and reassurance -- a serious disease). Researchers are investigating the place of OCD within 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 trichotillomainia, body dysmorphic disorder and hypochondriasis.
There are also theories about OCD linking it to the interaction between behavior and the environment, which are not incompatible with biological explanations.
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 sometimes called "compulsive" for being perfectionists and highly organized. This type of "compulsiveness" often serves a valuable purpose, contributing to a person's self-esteem and success on the job. In that respect, it differs from the life-wrecking obsessions and rituals of the person with OCD.
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. One patient may benefit significantly from behavior therapy, yet another will benefit from pharmacotherapy. And others may benefit best from both. Others 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.
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 anti-depressant clomipramine (Anafranil). It was followed by other SRIs that are called "selective serotonin re-uptake inhibitors" (SSRIs). Those that have been approved by the Food and Drug Administration for the treatment of OCD are flouxetine (Prozac), fluvoxamine (Luvox) and paroxetine (Paxil). Another that has been studied in controlled clinical trials is 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.
Traditional psychotherapy, aimed at helping the patient develop insight into his or her problem, is generally not helpful for OCD. However, 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 patient is strongly encouraged to refrain from ritualizing, with support and structure provided by the therapist, and possibly by others whom the patient recruits for assistance. 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.
Studies of behavior therapy for OCD find it to be a successful treatment for the majority of patients who complete it, and the positive effects endure once treatment has ended, if there are follow-up sessions and other relapse-prevention components. According to studies, more than 300 OCD patients who were treated by exposure and response prevention, an average of 76 percent showed lasting results from 3 months to 6 years after treatment.
One study provides new evidence that cognitive-behavioral therapy may prove an effective aid for those with OCD. This variant of behavior therapy emphasizes changing the OCD sufferer's beliefs and thinking patterns. Further studies are required before cognitive-behavioral therapy can be adequately evaluated.
Self-Care and Family Support
People with OCD will do best if they attend therapy, take all prescribed medications, seek support of family, friends, and a discussion group. When a family member suffers from obsessive-compulsive disorder it's helpful to be patient about their progress and acknowledge any successes, no matter how small.