Obsessive-compulsive disorder (OCD) is one of the broadband of disorders that include body dysmorphic disorder (believes that a part of their body is abnormal), hoarding disorder, trichotillomania (hair-pulling), excoriation disorder (skin-picking), and other unspecified OCD related disorders. Together with anxiety disorders, it formed the single largest segment of disorders among my clientele when I was in practice, nearly 50%. Despite OCD’s separate categorisation in DSM-5 from anxiety disorders, it is nevertheless an anxiety disorder in which people have recurring, unwanted thoughts, ideas or sensations (obsessions) that make them feel driven to do something repetitively (compulsions). The repetitive behaviours, such as hand washing, checking on things or cleaning, can significantly interfere with a person’s daily activities and social interactions. Many people have focused thoughts or repeated behaviours, but these do not disrupt daily life and may add structure or make tasks easier. For people with OCD, thoughts are persistent and unwanted routines, and behaviours are rigid and not doing them causes great distress. Many people with OCD know or suspect their obsessions are not true; others may think they could be true (known as poor insight). Even if they know their obsessions are not true, people with OCD have a hard time keeping their focus off the obsessions or stopping the compulsive actions. It is also not uncommon for family members to be drawn in by an OCD sufferer to collude with their compulsions (see article below for family members).
A diagnosis of OCD requires the presence of obsession and compulsions that are time-consuming (more than one hour a day), cause major distress, and impair work, social or other important function. About 1.2 percent of Americans have OCD, and among adults, slightly more women than man are affected. OCD often begins in childhood, adolescence or early adulthood; the average age symptoms appear 19 years old.
Obsessions are recurrent and persistent thoughts, impulses, or images that cause distressing emotions such as anxiety or disgust. Many people with OCD recognize that the thoughts, impulses, or images are a product of their mind and are excessive or unreasonable. These intrusive thoughts cannot be settled by logic or reasoning. Most people with OCD try to ignore or suppress such obsessions or offset them with some other thought or action. Typical obsessions include excessive concerns about contamination or harm, the need for symmetry or exactness, or forbidden sexual or religious thoughts.
Compulsions are repetitive behaviours or mental acts that a person feels driven to perform in response to an obsession. The behaviours are aimed at preventing or reducing distress or a feared situation. In the most severe cases, a constant repetition of rituals may fill the day, making a normal routine impossible. Compounding the anguish these rituals cause is the knowledge that the compulsions are irrational. Although the compulsion may bring some relief to the worry, the obsession returns and the cycle repeats over and over.
Not all rituals or habits are compulsions. Everyone double checks things sometimes. But a person with OCD generally:
- Can’t control his or her thoughts or behaviours, even when those thoughts or behaviours are recognised as excessive;
- Spends at least one hour a day on these thoughts or behaviours;
- Doesn’t get pleasure when performing the behaviours or rituals, but may feel brief relief from the anxiety the thoughts cause; and
- Experiences significant problems in their daily life due to these thoughts or behaviours.
The causes of OCD are unknown, but risk factors include:
Genetics: Twin and family studies have shown that people with first-degree relatives (such as a parent, sibling, or child) who have OCD are at a higher risk for developing OCD themselves. The risk is higher if the first-degree relative developed OCD as a child or teen. Ongoing research continues to explore the connection between genetics and OCD and may help improve OCD diagnosis and treatment.
Brain Structure and Functioning: Imaging studies have shown differences in the frontal cortex and subcortical structures of the brain in patients with OCD. There appears to be a connection between the OCD symptoms and abnormalities in certain areas of the brain, but that connection is not clear. Research is still underway. Understanding the causes will help determine specific, personalised treatments to treat OCD.
Environment: People who have experienced abuse (physical or sexual) in childhood or other trauma are at an increased risk of developing OCD.
In some cases, children may develop OCD or OCD symptoms following a streptococcal infection—this is called Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS).
OCD is typically treated with medication, psychotherapy or a combination of the two. Although most patients with OCD respond to treatment, some patients continue to experience symptoms. Sometimes people with OCD also have other mental disorders, such as anxiety, depression, and body dysmorphic disorder. It is important to consider these other disorders when making decisions about treatment.
Serotonin reuptake inhibitors (SRIs) and selective serotonin reuptake inhibitors (SSRIs) are used to help reduce OCD symptoms. Psychotherapy can be an effective treatment for adults and children with OCD. Research shows that certain types of psychotherapy, including cognitive behaviour therapy (CBT) and other related therapies (e.g., habit reversal training) can be as effective as medication for many individuals. Research also shows that a type of CBT called Exposure and Response Prevention (EX/RP) is effective in reducing compulsive behaviours in OCD, even in people who did not respond well to SRI medication. For many patients, EX/RP is the add-on treatment of choice when SRIs or SSRIs medication does not effectively treat OCD symptoms.
Credit: American Psychiatric Association, National Institute of Mental Health.
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