Understanding Obsessive-Compulsive Disorder (OCD)

Obsessive-compulsive disorder is classified as an anxiety disorder and it can present itself in an individual in a variety of ways. Common to most sufferers is an obsessive drive to perform a particular task or group of tasks (termed rituals) in order to ward off feelings of unease or impending doom. It is estimated that some 2.3% of the U.S. population—about 3.3 million Americans—suffer from OCD in any given year.

Many people hold superstitious beliefs (e.g., don’t walk under a ladder, step over cracks in the sidewalk, etc.) but not to the extent that they become pervasive in their everyday lives. OCD sufferers, however, become so preoccupied with these beliefs as to obsess on them and the compulsion to perform what they see as mitigating rituals begins to impact their daily lives. For example, it is a good idea to wash your hands before you eat a meal, in order to reduce your chances of catching a cold or other sickness. For a person with OCD, this sound advice is taken to a ridiculous extreme, wherein he will compulsively wash his hands over and over in order to assuage the fear of contamination.

OCD Defined

For the purposes of this presentation, let us operationalize what the terms obsession and compulsion mean, as defined by the DSM-IV, Fourth Edition:

Obsession.

Recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
The thoughts, impulses, or images are not simply excessive worries about real-life problems.
The person attempts to ignore such thoughts, impulses, or images, or to neutralize them with some other thought or action.
The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought intrusion).

Compulsion.

Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g.,. praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly.
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.

Some common symptoms of OCD

Other Common Features of OCD

Obsessive thoughts and compulsive behaviors take up a lot of time, typically more than one hour per day.
OCD symptoms begin to interfere with the sufferer’s work, social life, and personal relationships.
Most sufferers will eventually recognize that obsessions are coming from within their own minds and that their compulsions are unreasonable. In such cases they are classified as having OCD with good insight. Children—and a small minority of adult sufferers—do not recognize that their thoughts and behaviors are irrational, and so they are classified s OCD with poor insight.
How OCD tracks over time varies from individual to individual. For some, symptoms may come and go, for others they may ease over time, and for some they can grow progressively worse both in frequency and intensity.

Who Gets OCD

As noted earlier, more than three million Americans suffer with OCD at any given time, and this affliction occurs equally in women and men. Typical sufferers range in age between 18 and 54 years old, although while a large percentage of persons with OCD (33% to 50%) report its onset during their childhood, it can also begin at any time in young adulthood (age 40 and under). This statistic is somewhat problematic because OCD also tends to be underdiagnosed and undertreated.

There are several reasons why this may be so. First, OCD sufferers may not be forthcoming in describing their symptoms, for fear of embarrassment and social stigma. Second, both sufferers and their healthcare providers may lack the knowledge and insight to recognize the onset of OCD. Third, not every physician or mental health professional is trained specifically in how to treat OCD. This is unfortunate, as early detection and treatment can help victims avoid developing depression and experiencing marital and work difficulties. It is also notable that in 1990 the total social and economic cost of OCD in the U.S. was estimated at $8.4 billion, and nearly 10% of all monies spent on mental treatment that same year was for OCD.

Origins of OCD

Although science is not yet able to pinpoint an “OCD gene”, there is compelling evidence that this disorder is at least partly due to genetics. To wit, research shows that childhood-onset OCD tends to run in families. Other research suggests that OCD is caused by synaptic abnormalities between the frontal part of the brain (orbital cortex) and deeper areas within the brain (basal ganglia), and that the brains of OCD sufferers—for reasons yet unknown—may produce inadequate amounts of serotonin. Serotonin is a neurotransmitter that enables an organism to feel a sense of wellbeing. There is, however, no blood test or other physiological way of testing this hypothesis, and so diagnoses of OCD are typically made based on the sufferer’s presenting symptoms. There is also a growing body of evidence suggesting a connection between abnormal levels of dopamine as well in the onset of OCD.

The once-popular notion that OCD is caused by family problems or attitudes learned in childhood (e.g., one or both parents were cleaning fanatics) is today largely discounted by mounting scientific evidence. For example, brain imaging studies using positron emission tomography (PET) technology have detected abnormal brain activity patterns among test groups of OCD sufferers as compared with control groups of non-OCD sufferers.

OCD and Co-Occurring Disorders

Other disorders that can sometimes accompany OCD include depression, eating disorders, attention deficit hyperactivity disorder (ADHD), and other anxiety disorders. Often, persons who have suffered for years with OCD and have not been treated can eventually develop depression. Such persons may also develop substance abuse and addiction problems when they turn to alcohol and drugs to help control their obsessive thoughts.

Other conditions that may commonly exist along with OCD include Tourette’s Syndrome and the presence of facial tics.

Treating OCD

Research conducted by the National Institute of Mental Health and other organizations has shown that behavioral therapy combined with medication are effective approaches to treating OCD. The combination of therapy and medications has been shown in at least one study to produce synaptic changes in the striatum of the brain.

However, one challenge facing healthcare providers and the families of OCD sufferers is helping these patients realize that they have a problem in the first place. Herbert Gravitz, psychologist with the Obsessive-Compulsive Foundation, asserts that the reason some sufferers are reluctant to accept that they have OCD is because they are either misinformed or uninformed, and this in turn creates fear. Gravitz advocates a straightforward, affirming approach. He writes,

These fears and worries are normal and must be addressed. What often helps in all of these situations is to “speak to the fear,” not the person refusing treatment or medication—(e.g., you are not crazy; you have a diagnosable and treatable disorder; your body will adjust to the side effects; you will be more creative, your true self will be more present). Also, mental illness still has much stigma attached to it, so you might try “speaking to the stigma.” (e.g., it takes a courageous person to know when they need help; only strong people seek help).

Gravitz adds that if this approach fails, family members may want to contact their local police or mobile crisis intervention team to initiate the sufferer’s involvement in the mental health system.

Behavioral Approaches

Cognitive behavioral therapy (CBT) is widely considered the treatment of choice for children, adolescents, and adults with OCD. Research shows that psychotherapy generally is more effective in controlling OCD symptoms and sustaining long-term absence of symptoms, than is medication alone. One of the goals of CBT is to help the client internalize a lifelong strategy to help him resist obsessive thoughts and their associated compulsive rituals.

CBT generally involves one one-hour session per week over the course of 12 to 20 weeks. An intensive version of CBT also exists, wherein the therapist provides two to three hours of daily therapy for a period of three weeks. For most OCD patients, traditional weekly CBT is indicated.

Within this treatment approach there are several specific therapies that include the following:

Exposure and Response Prevention (E/RP). This form of cognitive behavioral therapy involves exposing the client (with his or her informed consent) to whatever triggers their obsessive thoughts (for example, seeing a crumb on the floor triggers obsessive thoughts about cleaning). The therapist then works with the client to deal with the anxiety and curb the compulsive rituals. Following is a more detailed discussion of how E/RP works:

Exposure. This is based on the principle that one’s anxiety over a triggering object or event will usually diminish with continued contact with it. So if a client obsesses about germs, for example, she is instructed to handle “germy” things such as money, dirty dish sponges, and the like, until she no longer feels anxiety around them.

Response Prevention. As the client is being desensitized through exposure to the things that trigger her anxiety, she is also instructed to not engage in the ritualistic behaviors associated with her being in contact with them. Using the above example, the client would have to refrain from washing her hands after handling the money and the sponges.

E/RP treatment is typically conducted in the therapist’s office, and involves assigning clients weekly homework that is designed around the unique situations and objects that trigger their particular obsessions. Where intensive CBT is prescribed, the therapy may be conducted in the client’s home or workplace. In rare occasions where OCD is particularly severe, intensive CBT may take place in a hospital setting.

Cognitive Therapy. The cognitive portion of CBT is important to helping the client mitigate catastrophic and irrational thinking. For example, a man with OCD believes that if he fails to wash his hands every time he touches a doorknob he will contract a serious illness and die. By using cognitive techniques with this client, this man’s therapist can help him re-examine and challenge the irrationality of his obsessive thought.

Theoretically, once the client has “proof” that his obsession is irrational, he will be better equipped to engage in the E/RP phase of treatment.

Other less widely used (and somewhat less effective) treatment approaches include:

Satiation. A process of therapeutically listening to one’s obsession repeated on a closed-loop cassette tape in order to begin to examine its rationality. Taking the above example of compulsive hand washing, the client—under the therapist’s care and direction—would repeatedly listen to his own, recorded description of his obsession with germs, all the while being challenged by the therapist to examine its logic and validity.

Habit Reversal. In this technique, the therapist helps the client develop a new, non-OCD ritual to replace the ritual associated with her obsession. For example, instead of washing his hands whenever they touch a doorknob, the client would agree to engage in another, more innocuous behavior (such as rubbing his hands together for a second or two) in its place.

Contingency Management. This approach uses token economies (rewards and costs) as incentives to not engaging in ritual behaviors. So in the same example, the client would agree to set $1 dollar aside to treat himself to a steak dinner, every time he resists a compulsive hand-wash, and conversely, he would take away a dollar from this dinner fund every time he gives in to that compulsion.

Efficacy of CBT Therapy in Treating OCD

According to the Obsessive-Compulsive Foundation, those clients who complete cognitive-behavioral therapy (12-20 sessions) report reductions in OCD symptoms by as much as 50% to 80%. “Just as important,” the Foundation notes on its website, “people with OCD who respond to CBT usually stay well, often for years to come.”

Medication Approaches

Although less effective than psychotherapy, medications do play a part in alleviating OCD symptoms. These prescription medications are broken down into several categories, listed first by generic and parenthetically by brand names:

Selective Serotonin Reuptake Inhibitors (SSRIs). These include: paroxetine (Paxil, Aropax), sertraline (Zoloft), fluoxetine (Prozac), and fluvoxamine.

Tricyclic antidepressants, particularly clomipramine (Anafranil).

Antipsychotic medications, including gabapentin (Neurontin), lamotrigine (Lamictal), olanzapine (Zyprexa), and risperidone (Risperdal).

In addition, anecdotal reports suggest that some OCD sufferers obtain a degree of symptom relief by self-medicating with opiods, in particular Ultram and Vicodin, but this practice is discouraged by medical experts because of those drugs’ addictive properties.

Again, as stated earlier, medications alone do not generally work as well as psychotherapy alone, and research shows that less than 20% of OCD patients treated solely with medications have significant mitigation of symptoms. The best results are when medications are prescribed under a psychiatrist’s care as an adjunct to psychotherapy.

A common frustration with medications is that they (a) take time to build up in the body before they can work (typically three to four weeks), and that (b) usually at least one medication adjustment (i.e., stronger dosage or switching to a different medication) is often needed. This is particularly true with SSRIs.

The downside of medications is that while they are designed to relieve symptoms, they also cause side effects. For SSRI medications, these may include nervousness, insomnia, restlessness, nausea, and diarrhea, and in some cases sexual dysfunction. Antidepressants can cause irregular heartbeats and blood pressure problems. Generally, side effects diminish with regular, long-term use, but if they do not it is important for the user to tell his or her doctor as soon as possible.

Special Consideration: OCD in Children

As previously noted, between 33%-50% of adult OCD sufferers report that their symptoms began in childhood. Typical stressors for children with OCD include fear of germs and fear of foods. Because children are at different developmental stages than are adults, this presents special challenges for them.

Fear that they are “crazy”. Children are very sensitive to fitting in with their peers. Knowing that their friends and classmates do not share in their obsessive thinking or ritualistic behaviors can affect their self-esteem to where they feel they are “bizarre” or “out of control.”

Excessive stress, particularly at morning and at night. A child’s compulsion to do his or her rituals exactly right in the morning can cause them to feel pressured, stressed, and irritable for the rest of the day. At night, they may delay going to bed in order to complete their nighttime rituals, thus leaving them exhausted the following day.

Frequent physical complaints. These include stress-related ailments such as headaches and upset stomachs.

Anger towards parents. This can occur as parents attempt to set boundaries for their children’s compulsive behaviors. For example, a child with a fear of germs becomes angry when his parents do not allow him to shower for hours, or they refuse to wash his clothes a certain way.

Social problems with peers. If a child tries to hide her obsessive-compulsiveness from her friends, she can feel stress over those relationships. When a child’s symptoms are too severe for him to hide, he can become the object of teasing. The child’s constant preoccupation with rituals can also lead to isolation from peers.

Other psychiatric problems. Children with OCD tend to have other psychiatric diagnoses (comorbidity), the most common of which are: panic disorder, social phobia, or other anxiety disorder; depression or dysthymia; disruptive behaviors such as oppositional defiant disorder (ODD) or attention-deficit hyperactivity disorder (ADHD); learning disorders such as dyslexia; tic disorders such as Tourette’s Syndrome; trichotillomania (hair pulling); and body dysmorphic disorder (believing they are ugly or deformed when they are not).

Treatment for Children

As with adults, CBT is recommended. Medications should be given only if the OCD is severe and when CBT is either unavailable or has been only partially effective. Medications for children with OCD are the same as for adults, but the dosages are obviously smaller.

Finding a Good Therapist (Reproduced from Wikipedia.org)

Finding a good therapist who really knows how to use cognitive behavior therapy to treat OCD involves two steps: First, getting some names; and secondly, evaluating their qualifications and ability.

Getting Names

Often the best way to find good therapists in your area is by asking the leaders or members of local OCD support groups. The OC Foundation has a list of support groups on their website [www.ocfoundation.org]. Even if the nearest support group is some distance from you, they may know of good therapists near you.

The OC Foundation can also provide you with a list of professionals in your state who have indicated that they treat OCD. The Association for the Advancement of Behavior Therapy (AABT) and the Anxiety Disorders Association of America (ADAA) also list professionals by geographical area with their areas of expertise on their websites [respectively, www.aabt.org and www.aada.org].

Wikipedia also has links to numerous OCD support groups, treatment facilities, and individual treatment professionals on its website: http://e.wikipedia.org.

You can also contact your state’s mental health, psychological, and psychiatric associations, who generally keep referral lists. If you don’t have health insurance and cannot afford private therapy, these organizations may be able to offer suggestions.

If you live near universities that have graduate programs in mental health (e.g., psychology, psychiatry, social work), find out if they have any clinical training programs where you could receive therapy from their therapists-in-training. Although they are students, they are closely supervised, and the quality of their therapy is usually very good.

Evaluating Qualifications and Ability

You should look for a mental health professional who is licensed to practice in your state. Although their specific academic discipline is not as important as their experience and ability, in general, you will find that cognitive behavior therapy is practiced by psychologists, social workers, licensed professional counselors, and marriage and family therapists. Medications need to be prescribed by MDs.

You should be aware that being listed with OCF, AABT, ADAA, or other professional organizations does not guarantee expertise in treating OCD. Usually all that is required to be listed is proof of state licensure. Often professionals pay a fee to be listed. In a way, then, these are a little bit like yellow page listings—an okay place to start, but not to stop.

Once you have some names of potential therapists, call each of them on the phone. There’s no point in paying for a session to get this information. Try to get past the receptionist to talk with the therapist directly. First, say you’re looking for a therapist who has experience (use that phrase, not “who has expertise” or “who specializes”) in treating OCD. They will all say yes. Then say, “Can I ask what approach you take?” You want to hear “behavioral” or “cognitive-behavioral.”

Be cautious if someone:

Offers a treatment you’ve never heard of.
Guarantees their treatment or seems overly confident.
Talks of “curing” OCD.
States that treatment will take a specified number of sessions.
Refuses to give any idea of how long treatment might be expected to take.

Other Similar Anxiety Disorders

Posttraumatic Stress Disorder. When a person repeatedly experiences a past traumatic event and reexperiences it, either through intrusive thoughts, recurrent, distressing dreams, acting or feeling as if the event were happening again (e.g., flashbacks), intense psychological and/or physiological distress when exposed to internal or external cues.

Acute Stress Disorder. When a person has been exposed to a traumatic event in which he/she was confronted with threat of death or serious injury to self or others, and wherein the person’s response involved intense fear, helplessness, or horror (e.g., September 11, 2001). Symptoms include numbing, detachment, lack of emotional response, daze, derealization, depersonalization, and associative amnesia.

General Anxiety Disorder. Excessive anxiety and worry that occur more often than not for at least six months, and which focus on a number of real situations such as work or school performance. Symptoms include restlessness and feeling on edge, becoming easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance.

Panic Attack. Panic attack itself is not a codable disorder, but is usually associated with other diagnoses such as phobias. It is a discrete period of intense fear or discomfort, characterized by four or more of the following symptoms: heart palpitations, tachycardia, sweating, trembling or shaking, shortness of breath or sensation of smothering; choking sensation, chest pain or discomfort, nausea or abdominal distress, dizziness or unsteadiness, fear of losing control or going crazy, fear of dying, numbness, and/or chills and hot flashes.

Phobias (includes agoraphobia, social phobia, and other specific phobias. These are generally described as “marked and persistent fear of clearly discernable, circumscribed objects or situations. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response…” This response often involves a panic attack. Other characteristics of a phobia are: (a) the person recognizes that the fear is unreasonable (not true for children); (b) they either avoid the stimulus or endure it with great discomfort; (c) this avoidance or distress reaction “interferes significantly with the person’s normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.”

References

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (3^rd ed.). Arlington, VA: Author.

Baron, R.A. (2001). Psychology (5^th ed.). Needham Heights, MA: A. Pearson Education Company.

Freedom From Fear (n.d.). Obsessive-Compulsive Disorder. Retrieved November 1, 2005 from http://freedomfromfear.org/aanx_factsheet.asp?id=23.

Healthy Place (n.d.). Treatment. Retrieved October 27, 2005 from http://www.healthyplace.com/communities/ocd/nimh/treatment.htm.

Healthy Place (n.d.). What is Obsessive-Compulsive Disorder. Retrieved October 27, 2005 from http://www.healthyplace.com/communities/ocd.htm.

Obsessive-Compulsive Foundation (n.d.). Getting Help for Family Members Who Refuse OCD Treatment. Retrieved October 28, 2005 from http://ocfoundation.org/ocf_0007.htm.

Obsessive-Compulsive Foundation (n.d.). How is OCD Treated? Retrieved October 28, 2005 from http://ocfoundation.org/ocf1030a.htm.

Obsessive-Compulsive Foundation (n.d.). OCD Medication: Adults. Retrieved October 28, 2005 from http://ocfoundation.org/ocf1050a.htm.

Obsessive-Compulsive Foundation (n.d.). OCD in Children. Retrieved October 28, 2005 from http://ocfoundation.org/ocf1060a.htm.

Obsessive-Compulsive Foundation (n.d.). What is OCD? Retrieved October 28, 2005 from http://ocfoundation.org/ocf1010a.htm.

Stein, D.J., (2000). Neurobiology of the Obsessive-Compulsive Spectrum Disorders. Biological Psychiatry, 41, 296-304.

Wikipedia (n.d.). Obsessive-Compulsive Disorder. Retrieved November 1, 2005 from http://en.wikipedia.org/wiki/Obsessive-compulsive_disorder

Obsession

Common Compulsion