Obsessive-Compulsive Disorder (OCD)

Key Takeaways:

• Someone with obsessive-compulsive disorder experiences obsessions and compulsions that cause significant distress and make it difficult to carry out everyday tasks required for education, work, and social activities.

• Obsessive-compulsive disorder affects between 1-3% of the population. Up to 10 million Americans will experience this during their lifetime.

• Obsessive-compulsive disorder can be successfully treated through medication, talk therapy, or a combination of the two.

Understanding Obsessive-Compulsive Disorder

OCD is a mental disorder characterized by the presence of obsessions and compulsions. It falls within the “Obsessive-compulsive and related disorders” category in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

Obsessions are intrusive and unwanted thoughts, feelings, urges, or mental images that cause significant anxiety and distress. Compulsions refer to specific behaviors or mental rituals that people with OCD perform to reduce the distress caused by the obsessions. The vast majority of individuals with OCD have both obsessions and compulsions, although some individuals may only deal with one of these factors. ^[1]

How Common is OCD?

OCD affects up to 3% of the general population, although it is widely underdiagnosed. It is 1.5 times more commonly found in women than men, although this gender imbalance decreases among people seeking treatment. It can first appear in childhood, but it most frequently starts in adults aged 18 to 29. ^[1]

Symptoms of OCD

The primary symptoms of OCD can be categorized as obsessions and compulsions. Obsessions are recurring intrusive thoughts that are unwelcome and usually distressing. Compulsions are rigid, repetitive actions or mental patterns people with OCD feel they have to complete in response to their obsessions. These are disruptive, taking over an hour to complete every day. ^[1]

Obsessions

Obsessions often have common themes, such as fear of contamination, the need for order, or thoughts related to sexuality, morality, and violence, among others. Common obsessions include: ^{[2] [3]}

• Fear of being contaminated by germs, dirt, or bodily fluids

• Worry that you might harm someone

• Fear of forgetting, misplacing or losing something

• Intrusive, unwanted sexual thoughts or urges. These are often taboo or against your moral views

• The need to keep perfect order in the house, such as object locations and orientations

• Worry about losing control

Compulsions

Compulsions are often a direct response to the obsessions and, therefore, are typically thematically related. Examples of compulsions in OCD include: ^{[2] [3]}

• Frequent hand washing or cleaning

• Repeated checking behavior, such as confirming whether doors are locked or the stove is turned off. These may need to be repeated a specific number of times

• Ordering and arranging items in a particular way

• Mental counting

• Repeating a specific word, phrase, or prayer in your head

• Frequent reassurance seeking from others

Early Signs of OCD

OCD can appear early in life, sometimes before the age of 10.: Behaviors that could signal a child is at risk of OCD include

• Repetitive behaviors, especially to make sure things are “just right”

• Spending more time than normal on routine tasks, such as hygiene or leaving the house

• Having an overly rigid routine or system that you follow

• Increased worries, doubts, or fears

• Unwanted thoughts, images, or or urges that appear more often than normal

• Difficulty tolerating uncertainty

If you notice these signs in a child, you may want to consider asking your pediatrician or asking for a specialist referral for OCD.

Other Compulsive Disorders

OCD is one of several compulsive disorders. Common disorders in this category include:

• Body dysmorphic disorder: Intense worry about perceived flaws with one’s physical appearance that are very slight or not noticeable to others.

• Hoarding disorder: Difficulty getting rid of possessions, which leads to a cluttered, congested living environment.

• Trichotillomania (Hair-pulling disorder): Repeated pulling out of one’s hair, despite efforts to stop.

• Excoriation (skin-picking disorder): Recurrent picking of skin, despite efforts to stop, which results in skin lesions.

Other compulsive disorders include substance/medication-induced obsessive-compulsive and related disorder, obsessive-compulsive and related disorder due to another medical condition, other specified obsessive-compulsive and related disorder, and unspecified obsessive-compulsive and related disorder.

Causes of OCD

The exact causes of OCD are unknown, but scientists believe that it is likely caused by a combination of genetic, biological, cognitive/psychological, and environmental factors.

Having a family member with OCD increases the risk of OCD development, indicating a genetic basis, although the specific genes have not yet been identified. The heritability rate is between 35 to 48%. ^{[1] [3]}

Evidence also suggests that brain differences or abnormalities may play a role in OCD development. Researchers are exploring the cortico-striato-thalamo-cortical (CSTC) loop as an area that may be important for the development of OCD, particularly as it is related to behavioral control and emotional responses.^{[1] [3] [5]}

Cognitive, personality, and psychological factors may also contribute to obsessions and compulsions. Examples of risk factors in these areas include perfectionism, threat overestimation, overemphasizing thoughts, being more reserved, and a tendency towards negativity or pessimism. ^{[1] [3]}

Environmental factors, such as childhood trauma or experiencing stressful events, are unlikely to ‘cause’ OCD, but they may act as a trigger for an existing vulnerability. Individuals who have a history of anxiety and depression also are at greater risk of OCD. ^{[1] [3]}

Is it Preventable?

OCD isn’t entirely preventable, especially since genetic and heritability factors account for a significant portion of the total risk. Factors that may help reduce the likelihood of developing OCD, and reduce the impact it has on those who do develop it, include:

• Early diagnosis and treatment

• Stress management and support strategies

• Management of other mental health issues (if present)

Risks and Complications of OCD

OCD causes significant disruption to everyday life, leading to it being considered one of the top 10 most disabling disorders by the World Health Organization (WHO). Individuals with OCD often spend a significant portion of their days engaging in obsessions and compulsions, which negatively impacts relationships, work, school, daily life, and overall well-being. ^[1]

Individuals with OCD often have limited social relationships, have trouble with work, and often remain isolated. They may experience loneliness, shame, poor self-esteem, and other mental health issues, including anxiety and depression. 90% of individuals with OCD meet the criteria for at least one other mental disorder. ^{[1] [2]}

Obsessions and compulsions often occur in a cycle. Compulsive behaviors are used to reduce distress, but these only reinforce the idea that the obsessions pose a threat, which makes future compulsive behaviors more likely to occur. As such, OCD can become more severe over time, and prompt treatment is essential.^[4]

Diagnosing OCD

Diagnosing OCD requires a comprehensive assessment from a qualified mental health professional. If you are experiencing symptoms typical of OCD, the first step is to talk with your healthcare provider. They will usually carry out an initial screening process, and refer you to a mental health professional if OCD is suspected as a possibility.

The diagnostic process also involves screening for other mental disorders, such as anxiety, depression, and bipolar disorder. A mental status examination is also used for further insight and to judge symptom severity. ^[1]

OCD Tests and Assessments

At first, initial screening tools will be used to indicate possible OCD. Examples include: ^[1]

• OCD Screener: This has 6 total questions to screen for symptoms of OCD.

• Yale-Brown Obsessive Compulsive Scale: This scale has 10 OCD-related items that are ranked from 0 to 4 based on severity. It is the most widely accepted OCD screening tool

If OCD is suspected, the next step is a comprehensive assessment and evaluation of symptoms, which are compared to the criteria in the DSM-5. The criteria are: ^[1]

• The presence of obsessions, compulsions, or both, based on these definitions:

• Obsessions

• Recurrent, persistent thoughts, images, or urges that are unwanted, intrusive, and often cause significant anxiety and distress.

• The individual tries to ignore or eliminate these thoughts, urges, or images, or tries to replace these with another thought or action

• Compulsions

• Repetitive behaviors or mental acts that the individual feels a need to perform in response to the obsessions or based on rigid rules

• The behaviors or mental acts are used to try to prevent anxiety or distress, or to prevent a dreaded outcome or situation; however, these are not realistically connected with what they’re designed to neutralize or prevent, or they are excessive.

• The obsessions and/or compulsions are time-consuming or cause significant distress or impairment in important areas of life functioning

• Symptoms are not caused by substance use or a medical condition

• Symptoms are not better explained by the symptoms of another mental disorder

A full medical history and physical exam will usually be conductedat this stage to rule out other causes for your symptoms, such as drug or medication use. The practitioner will also discuss other aspects of your life, including your family history, to understand what you are experiencing. ^[1]

Difficulties and Misdiagnosis

Diagnosing OCD is sometimes difficult because symptoms may overlap with other mental disorders, such as anxiety disorders, depression, or schizophrenia. OCD laos has high levels of co-morbidity, with 90% of OCD patients meeting the criteria for at least one other mental disorder. ^[1]

In addition, individuals with OCD may not fully communicate their obsessions and compulsions due to fear of judgment, and children may not know how to accurately describe their symptoms. This may contribute to the underdiagnosis of OCD. ^{[1] [3]}

Treatment Approaches for OCD

The most common treatment approaches for OCD are psychotherapy and medication. For patients who don’t respond to these treatments, new and emerging treatments may provide relief.

Psychotherapy

Psychotherapy, also known as talk therapy, addresses the thoughts, behaviors, and other psychological factors that are causing and/or worsening symptoms.

One of the most effective forms of psychotherapy is a type of cognitive behavioral therapy (CBT) known as exposure and response prevention (ERP). This involves gradually exposing individuals to the situations or stimuli that cause anxiety and distress, while avoiding the temptation to resort to their compulsive behaviors as a response. This helps individuals experience safety without their compulsive behaviors, reducing anxiety and obsessive thoughts. ^{[1] [3] [5]}

For example, if your OCD symptoms center around a fear of contamination, you may be asked to touch a doorknob in public and refrain from immediately washing your hands.

Medication

Selective serotonin reuptake inhibitors (SSRIs) are recommended as first-line medications for OCD. Examples of SSRIs include fluoxetine, fluvoxamine, and sertraline. ^{[1] [5]}

Sometimes, additional medications may be used either instead of or alongside SSRIs. These include ^{[1] [5]}

• Tricyclic antidepressants, such as clomipramine

• Antipsychotics, such as risperidone and aripiprazole

• Glutamatergic modulators, such as memantine, n-acetyl cysteine, and riluzole

Combining medication with psychotherapy may prove more effective than either by itself

Other Therapies

Other therapies are being explored for the treatment of OCD, including transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), and stereotactic ablation. These are typically only offered in severe, treatment-resistant cases. ^{[1] [3] [5]}

TMS magnetically stimulates nerve cells in targeted regions of the brain through the use of an electromagnetic coil placed on the scalp.

DBS is more intrusive, requiring a surgeon to implant an electrode precisely in a specific region of the brain. This can then be used to send electrical signals directly to neurons within that area.

Stereotactic ablation is a surgical procedure that involves making lesions in specific areas of the brain to help with hyperactivity of certain brain regions implicated in OCD. This has been found to be slightly more effective than DBS for severe cases.

Living with OCD

OCD can cause a lot of anxiety and distress, but there are things you can do to make living with OCD more manageable. These should always be used in combination with professional treatment, not on their own. Tips for living with OCD include: ^[3][6]

• Journaling to identify and specify obsessions and compulsions

• Stress management techniques, such as grounding, meditation, breathing exercises

• Distract yourself with something fun, creative, or productive

• Seek support from trusted family and friends, making sure that you communicate openly and honestly

• Join an in-person or online support group

Depending on the type of talk therapy you try, you may be taught skills to use on your own after therapy has ended. This could include learning how to gently and progressively challenge your obsessions and compulsions. When using these techniques, remember that they are supposed to be part of a slow, careful process with ample support and self-compassion. Pushing yourself too quickly or taking a perfectionist perspective may do more harm than good.

When to Seek Help

Obsessions and compulsions may happen to some degree in everyone from time to time. However, if these are taking up a large part of your day and negatively impacting your daily functioning and overall well-being, it’s vital to seek professional help as soon as possible.