Obsessive-Compulsive Disorder - OCD

Obsessive-compulsive disorder has two parts: obsessions are uncomfortable, intrusive and recurrent thoughts; compulsions are rituals or behavior that you have a strong urge to repeat, aimed at reducing your anxiety, but which bring only temporary relief. Sufferers can have either obsessions or compulsions or both. About 1.3 percent of adults suffer from obsessive compulsive disorder.[1]

There are effective treatments for obsessive-compulsive disorder. You can get better. A good place to begin is with an overview of anxiety including the symptoms, causes, and treatment.

Symptoms of Obsessive-Compulsive Disorder

Five Common Obsessions:

• Fear of germs or contamination
• Fear of losing or misplacing things
• Thoughts that objects must be symmetrical or in the right order
• Thoughts involving forbidden subjects such as sex or religion
• Fear of hurting yourself or others

If you have intrusive thoughts of hurting yourself or others, seek professional help immediately. But understand that having these thoughts does not automatically mean you will act on them. Most people have had brief thoughts of hurting someone else, but they are able to quickly let them go.

Five Common Compulsions:

• Excessive cleaning and/or handwashing
• Ordering and arranging things in a particular way
• Repeated checking
• Compulsive counting
• Hoarding things

Not all rituals or habits are compulsions. Everyone double checks things occasionally. But people with OCD have difficulty controlling their rituals, even when they recognize the rituals are excessive or unreasonable.

Definition of Obsessive-Compulsive Disorder

Obsessive-compulsive disorder criteria based on the DSM-5.[1] You can have either obsessions or compulsions or both.

Diagnosis of Obsessions:

• Do you have intrusive and recurrent thoughts, urges, or images that are uncomfortable and hard to let go?
• Do you try to suppress or ignore these thoughts, urges, or images with some other thought or through some action?
• Do you spend at least one hour per day on your obsessions?
• Have your obsessions had a significant negative impact on your life (relationships, work, social, or emotional life.)?

Diagnosis of Compulsions:

• Do you perform repetitive behaviors (such as hand washing or checking) in response to your intrusive thoughts, urges, or images (the obsession)? Or do you perform repetitive mental acts that must follow rigid rules (such as counting or repeating words) in response to your obsession?
• Are your repetitive behaviors or mental acts aimed at reducing your anxiety or preventing some dreaded event? But is their effect only temporary?
• Do other people consider your repetitive behaviors to be excessive?
• Do you spend at least one hour per day on your compulsions?
• Have your compulsions had a significant negative impact on your life (relationships, work, social, or emotional life.)?

If you answered yes to all of the above criteria, you may meet the DSM definition of obsessive-compulsive disorder.

Individuals with obsessive-compulsive disorder have a 75% chance of developing another anxiety disorder during their lifetime, and a 40% chance of developing a major depression.[1]

Tests

Medical Tests

Your health care provider can determine if your obsessive-compulsive disorder is caused by an underlying medical condition, such as heart disease or thyroid problems. This may require blood tests and an electrocardiogram (ECG). A complete assessment should also include questions about your caffeine and alcohol consumption, and any substance use, which can contribute to an anxiety disorder.

Standardized Screening Tests for Obsessive-Compulsive Disorder

The Yale-Brown Obsessive-Compulsive Scale (YBOCS) is a 10-question self-assessment test.[2] It has been confirmed as an effective self-test and diagnostic screening tool.[3]

Here is an online version of the Yale–Brown Obsessive–Compulsive Scale (pdf).

Causes of Obsessive-Compulsive Disorder

Before looking at the treatment of obsessive-compulsive disorder, it helps to understand the causes because they can help guide the treatment.

Anxiety-Avoidance Cycle

Obsessive-compulsive disorder develops when the anxiety-avoidance cycle is unchecked.

• In the first step, you learn to associate fear with certain things or situations.
• Instead of challenging the fear, you then develop “rituals” to avoid the fear.
• If the rituals are partly effective, you continue to use them, because you think it’s easier to perform the rituals than challenge your anxiety.
• The rituals then become reinforced.
• If you continue to avoid your fear, you will eventually believe that you don’t have the skills to deal with the world without your rituals.
• This will increase your anxiety and further feed the anxiety-avoidance cycle.

Suppose you are going through a stressful time in your life. As you leave your house one day, you forget if you locked the door. When you go back to check, you discover that you did forget to lock the door this time.

The next time you leave the house, you might check the lock a second time, just to be sure. If you’re under stress, later in the day, you may again wonder if you locked the door. Maybe that thought eats away at you until you get home.

The next time you leave the house, you may decide to check the lock three times, just to be sure. This time when you’re at work, you’ll feel more relaxed because you know you checked the door three times. Three times then becomes a magic number for you. You may think that you can’t trust yourself unless you check the door three times. You may even start to check other things in your life, such as the car door or the oven.

As the disorder progresses, the ritual that was initially a source of comfort becomes a burden that you have to perform just to feel normal.

Negative Thinking

Obsessive-compulsive disorder is fed by a combination of all-or-nothing thinking and catastrophizing.

For example, you may think that checking your house lock anything less than three times is inadequate and checking it three times is enough. You may think that washing your hands four times, will prevent you from getting an infection, and anything less is inadequate.

• If you think the consequences of what you fear can be catastrophic, you will likely go to extreme lengths to avoid it.
• If you are afraid of making mistakes, and think that anything less than perfect is unacceptable, you may rely on rituals to avoid making mistakes.
• If you grew up in chaos, you may have an excessive need for order. You may think that anything less than total cleanliness or order or symmetry is chaotic and disturbing.
• If you grew up in an irresponsible household, you may have an exaggerated sense of responsibility. You may believe that being on guard and performing certain rituals is essential to prevent catastrophic things from happening to you or people you care about.
• If you grew up in an overly controlling environment, you may think it is important to avoid certain thoughts and that performing certain rituals will help.

The treatment in all these cases is to challenge your negative thinking and to challenge the magical power that you have given your rituals.

Life Events

Adults who experienced trauma in childhood, such as abuse or the death of a close relative are more likely to develop OCD.[4]

Genetics

About 27 to 45 percent of the chance of developing OCD in adulthood is due to genes. Whereas, 45 to 65 percent of the chance of developing OCD in childhood is due to genes.[5]

Substance Use

Tobacco, caffeine, and substance abuse of drugs or alcohol can all increase anxiety and the risk of developing obsessive-compulsive disorder.

Medical Causes

A number of medical conditions can cause anxiety symptoms. These include an overactive thyroid, hypoglycemia, mitral valve prolapse, anemia, asthma, COPD, inflammatory bowel disease, Parkinson's disease, and dementia among others. Your physician may perform certain tests to rule out these conditions. But it is important to remember that anxiety is more often due to poor coping skills or substance abuse than any medical condition.

Treatment of Obsessive-Compulsive Disorder

The three main treatments for obsessive-compulsive disorder are cognitive behavioral therapy, mindfulness-meditation, and anti-anxiety medications.

Five Things You Can Do About Your Obsessive-Compulsive Disorder

• Quit smoking, reduce your alcohol and caffeine use. These can all cause or worsen anxiety symptoms.
• Review your over-the-counter medications such as diet pills and cold medications that can contain stimulants, which may trigger anxiety.
• Learn relaxation and stress-management techniques and make them part of your life. Develop healthy coping skills.
• Rule out any medical causes for your symptoms.
• Ask for help. Talk with a health professional about your anxiety. Review your thought patterns, and identify any negative thinking that can contribute to your anxiety.

Cognitive Behavioral Therapy for OCD

Cognitive behavioral therapy (CBT) is useful for treating obsessive-compulsive disorder. CBT helps you gently and gradually find new ways of thinking, behaving, and reacting to situations so that you will feel less anxious.

CBT helps you examine the evidence that supports and does not support your obsessions. The more you challenge your negative thinking, the more you take back control of your life. You see that your worries are not based on fact but on distorted beliefs that you have reinforced over time.

MRI studies have shown that cognitive behavioral therapy changes brain pathways and results in a more permanent change in thinking and behavior.[6, 7]

Cognitive behavioral therapy also has a behavioral component. The idea is to take small steps into your anxiety-provoking situations as you develop healthier thinking patterns. You see that nothing will happen if you sit with your anxiety and don’t act on your compulsion. In this way you begin to develop confidence that you can overcome OCD. (Learn more about cognitive behavioral therapy)

Stress Management, Meditation and Mindfulness for OCD

Stress management methods such as meditation and mindfulness are being incorporated into medicine. The evidence is overwhelming that these methods are effective in treating anxiety disorders.[8, 9] There are a number of stress management techniques to choose from. All are effective, and which one works for you is largely a matter of personal choice. Start slowly with ten minutes a day, and see how you will reduce your anxiety and change your life. (Learn more about stress management and mindfulness)

Medication Treatment for OCD

SSRI antidepressants are usually the first line of medication used for OCD.[10]

• Celexa (citalopram)
• Lexapro, Cipralex (escitalopram)
• Paxil (paroxetine)
• Prozac (fluoxetine)
• Zoloft (sertraline)

It may take up to 3 months before you notice any results. About half of all people with OCD do not respond to SSRI treatment alone. In these cases, atypical antipsychotic medications are sometimes added.[11]

Obsessive-compulsive disorder is treatable. The most important step you can take is reaching out and asking for help. You can change your life.

References

1. American Psychiatric Association, DSM-5 The Diagnostic and Statistical Manual of Mental Disorders. 5 ed, ed. D. Kupfer: American Psychiatric Association.
2. Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., et al., The Yale-Brown Obsessive Compulsive Scale. I. Development, use, and reliability. Arch Gen Psychiatry, 1989. 46(11): p. 1006-11.
3. Rapp, A. M., Bergman, R. L., Piacentini, J., & McGuire, J. F., Evidence-Based Assessment of Obsessive-Compulsive Disorder. J Cent Nerv Syst Dis, 2016. 8: p. 13-29. PMC4994744.
4. Grisham, J. R., Fullana, M. A., Mataix-Cols, D., Moffitt, T. E., et al., Risk factors prospectively associated with adult obsessive-compulsive symptom dimensions and obsessive-compulsive disorder. Psychol Med, 2011. 41(12): p. 2495-506.
5. van Grootheest, D. S., Cath, D. C., Beekman, A. T., & Boomsma, D. I., Twin studies on obsessive-compulsive disorder: a review. Twin Res Hum Genet, 2005. 8(5): p. 450-8.
6. Beutel, M. E., Stark, R., Pan, H., Silbersweig, D., et al., Changes of brain activation pre- post short-term psychodynamic inpatient psychotherapy: an fMRI study of panic disorder patients. Psychiatry Res, 2010. 184(2): p. 96-104.
7. Linden, D. E., How psychotherapy changes the brain--the contribution of functional neuroimaging. Mol Psychiatry, 2006. 11(6): p. 528-38.
8. Manzoni, G. M., Pagnini, F., Castelnuovo, G., & Molinari, E., Relaxation training for anxiety: a ten-years systematic review with meta-analysis. BMC Psychiatry, 2008. 8: p. 41. PMC2427027.
9. Vollestad, J., Nielsen, M. B., & Nielsen, G. H., Mindfulness- and acceptance-based interventions for anxiety disorders: a systematic review and meta-analysis. Br J Clin Psychol, 2012. 51(3): p. 239-60.
10. Decloedt, E. H., & Stein, D. J., Current trends in drug treatment of obsessive-compulsive disorder. Neuropsychiatr Dis Treat, 2010. 6: p. 233-42. PMC2877605.
11. Kellner, M., Drug treatment of obsessive-compulsive disorder. Dialogues Clin Neurosci, 2010. 12(2): p. 187-97. PMC3181958.