What is obsessive-compulsive disorder?
Obsessions are intrusive, irrational thoughts—unwanted ideas or impulses that repeatedly appear in a person's mind. Again and again, the person experiences disturbing thoughts, such as "My hands must be contaminated; I need to wash them"; "I may have left the gas stove on; I need to go check it fast"; "I am going to injure my child by accident; I need to be very careful or else something bad will happen." On one level, the person experiencing these thoughts knows their obsessions are irrational. But on another level, he or she fears these thoughts might be true. Trying to avoid such thoughts creates great anxiety, distress and dysfunction.
Compulsions are repetitive rituals such as hand washing, counting, checking, hoarding or arranging. An individual repeats these actions many times throughout the day and performing these actions releases anxiety, but only momentarily. People with OCD feel they must perform these compulsive rituals or something bad will happen to them or their loved ones.
Most people at one time or another experience obsessive thoughts or compulsive behaviors. Obsessive-compulsive disorder occurs when an individual experiences obsessions and compulsions for more than an hour each day, in a way that interferes with his or her life. The National Institute of Mental Health estimates that more than 2 percent of the U.S. population, or nearly one out of every 40 people, will be diagnosed with OCD at some point in their lives. The disorder is two to three times more common than schizophrenia and bipolar disorder.
OCD is often described as "a disease of doubt." Individuals living with OCD experience "pathological doubt" because they are unable to distinguish between what is possible, what is probable and what is unlikely to happen.
Who gets OCD?
People from all walks of life can get OCD. It strikes people of all social and ethnic groups and both males and females. Symptoms typically begin during childhood, the teenage years or young adulthood. The sudden appearance of OCD symptoms later in life merits a thorough medical evaluation to ensure that another illness is not the cause of these symptoms.
What causes OCD?
People with OCD can often say "why" they have obsessive thoughts or “why” they behave compulsively, but the thoughts and the behavior continue. A large body of scientific evidence suggests that OCD results from a chemical imbalance in the brain. For years, mental health professionals incorrectly assumed OCD resulted from bad parenting or personality defects. This theory has been disproven over the last few decades. People whose brains are injured sometimes develop OCD, which suggests it is a medical condition. If a placebo pill is given to people who are depressed or who experience panic attacks, nearly 40 percent will say they feel better. If a placebo is given to people who experience obsessive-compulsive disorder, only about two percent say they feel better. This also suggests that OCD is a biological condition as opposed to a “personality problem.”
Genetics are thought to be very important in OCD. If you, or your parent or sibling, have OCD, there's close to a 25 percent chance that another of your immediate family members will have it.
OCD has been found to be connected with dysfunction in certain parts of the brain, specifically the basal ganglia and the frontal lobes. Inappropriate functioning of these regions in the brain can cause the repetitive movements and rigid thinking that effects people with OCD. Successful treatment with medication or behavior therapy changes the activity in these brain regions, which decreases the symptoms of OCD. Two specific chemicals in the brain—a neurotransmitter called serotonin and a hormone called vasopressin—have also be studied by scientists who have found a link between these chemicals and OCD. Researchers believe OCD, anxiety disorders, Tourette's and eating disorders, such as anorexia and bulimia, can be triggered by some of the same chemical changes in the brain.
A world-renowned expert, Judith Rapoport M.D., describes OCD by writing, “something in the brain is stuck, like a broken record.”
How do people with OCD typically react to their disorder?
People with OCD generally attempt to hide their problem rather than seek help. Often they are remarkably successful in concealing their obsessive-compulsive symptoms from friends and co-workers. An unfortunate consequence of this secrecy is that people with OCD generally do not receive professional help until years after the onset of their disease when symptoms have become too severe to control. By that time, the obsessive-compulsive rituals may be deeply ingrained and very difficult to change.
OCD usually starts at an early age, often before adolescence. It may be mistaken at first for autism, pervasive developmental disorder or Tourette's syndrome: a disorder that may include obsessive doubting and compulsive touching as symptoms.
Like depression, OCD tends to worsen as the person grows older, if left untreated. Scientists hope, however, that when the OCD is treated while the person is still young, the symptoms will not get worse with time.
What are other examples of behaviors typical of people who live with OCD?
People who do the following may have OCD:
- Repeatedly check things, perhaps dozens of times, before feeling secure enough to leave the house. Is the stove off? Is the door locked?
- Fear they will harm others. Example: A man's car hits a pothole on a city street and he fears it was actually a pedestrian and drives back to check for injured persons.
- Feel dirty and contaminated. Example: A woman is fearful of touching her baby because she might contaminate the child and cause a serious infection.
- Constantly arrange and order things. Example: A child can't go to sleep unless he lines up all his shoes correctly.
- Are ruled by numbers, believing that certain numbers represent good and others represent evil. Example: a college student is unable to send an email unless the “correct sequence of numbers” is recalled prior to using his computer.
- Are excessively concerned with sin or blasphemy in a way that is not the cultural or religious norm for other members of their community. Example: a woman must recite “Hail Mary” thirty-three times every morning before getting out of bed and is frequently late for work because of this.
Is OCD commonly recognized by professionals?
Not nearly commonly enough. OCD is often misdiagnosed, and it is often underdiagnosed. Many people have dual disorders of OCD and schizophrenia, or OCD and bipolar disorder, but the OCD part of their illness is not diagnosed or treated. In children, parents (and teachers and doctors) often are aware of some anxiety or depression but not of the underlying OCD.
Can OCD be effectively treated?
OCD will not go away by itself, so it is important to seek treatment. Although symptoms may become less severe from time to time, OCD is a chronic disease. Fortunately, effective treatments are available that make life with OCD much easier to manage. OCD symptoms are not cured by talking about them and “trying to make it go away.” With medication and behavior therapy, OCD can be treated effectively. Both medications and behavioral therapy affect brain chemistry, which in turn affects behavior. Doctors are also increasingly aware of the role that regular exercise, getting enough sleep, and a healthy diet have in the treatment of OCD. If a person with OCD can live a healthy lifestyle and receive effective treatment of any other medical conditions they might have, it is likely that their OCD symptoms will improve.
Are medications useful in treating OCD?
Medication can regulate certain chemicals in the brain—including serotonin—reducing obsessive thoughts and compulsive behaviors.
Many of the antidepressant medications known as selective serotonin reuptake inhibitors (SSRIs) have been proven to be effective in treating the symptoms associated with OCD. The SSRIs most commonly prescribed for OCD are fluvoxamine (Luvox), paroxetine (Paxil), fluoxetine(Prozac), sertraline (Zoloft), citalopram (Celexa), and escitalopram (Lexapro). Clomipramine (Anafranil) and venlafaxine (Effexor) are other antidepressants from different medication classes that are often used to treat OCD.
The most common side effects associated with these medications are upset stomach (including nausea, constipation, diarrhea and vomiting), problems sleeping (both insomnia and excessive sleepiness), dizziness and headache. Some people experience sexual side-effects including problems with maintaining an erection or difficulty having an orgasm. It should also be noted that the FDA (The United States Food and Drug Administration) has placed a “Black Box Warning” on all of these medications suggesting that there may be an increased risk of suicidal thoughts and behaviors in people taking these medications. That is why all people who are thinking of taking medications should have a thorough discussion with their doctors prior to starting any medication in order to fully understand the benefits and risks of beginning a new treatment.
Some physicians make the mistake of prescribing an antidepressant medication for only three or four weeks before judging that it’s working or not. That simply isn't long enough. Medication should be tried consistently for 10 to 12 weeks before its effectiveness can be judged.
Other medications are often prescribed to help treat severe symptoms of OCD. Of these additional medications, some of the most frequently prescribed include antipsychotic medications such as risperidone (Risperdal) and haloperidol (Haldol). Other medications have also been tried in people with OCD but their effectiveness and safety have not been studied as thoroughly as some of the medications mentioned in this article.
About one-half of people who are treated with medications will have a positive response to treatment. It is often recommended that people who experience a positive response to treatment with medications will continue this treatment for up to 1-2 years even after their symptoms improve. This is something that should be discussed with each individual’s physician.
What is behavior therapy, and can it effectively relieve symptoms of OCD?
Behavior therapy is not traditional psychotherapy. It is often called Cognitive-Behavior Therapy or "Exposure and Response Prevention," and it is highly effective for many people with OCD. People with OCD are deliberately exposed to a feared object or thought, either directly or by imagination, and are then discouraged or prevented from carrying out the usual compulsive response. For example, a compulsive hand-washer may be urged to touch an object he or she believes is contaminated and denied the opportunity to wash for several hours. This helps people to become accustomed to dealing with an uncomfortable situation and to learn how to decrease the associated anxiety. When the treatment works well, the person gradually experiences less anxiety from the obsessive thoughts and becomes able to refrain from the compulsive actions for extended periods of time.
About one-half of the people with this disorder who receive behavioral therapy improve substantially; the rest improve moderately.
Will OCD symptoms go away completely with medication and behavior therapy?
Response to treatment varies from person to person. Several studies suggest that medication and behavior therapy are equally effective in alleviating symptoms of OCD. Furthermore, the combination of medications and therapy has been found in many cases to be superior to either treatment on its own.
A small percentage of people with OCD find that neither medication nor behavioral treatment produces any significant change. Most people who receive effective treatments find their symptoms reduced by about 40 percent to 50 percent. That can often be enough to change their lives, to transform them into individuals who can go back to school, work and their families. Another percentage of people are fortunate to have a complete remission of their symptoms when treated with effective medication and/or behavior therapy.
Reviewed by Ken Duckworth, M.D. and Jacob L. Freedman, M.D., April 2012
The authors would like to thank Judith Rapoport, M.D. who was responsible for completing a previous draft of this article.