David Baxter PhD
Late Founder
Expert Insights: Obsessive-Compulsive Disorder
By H. Blair Simpson, MD, PhD, in Psychiatric Times
October 03, 2013
In this video, Dr H. Blair Simpson gives a brief overview of the hallmarks, themes, and common comorbidities found in obsessive-compulsive disorder (OCD) and explains what to look for when treating OCD in connection with other psychiatric illnesses. Dr Simpson is Professor of Clinical Psychiatry, Columbia University, and Director of the Anxiety Disorders Clinic and the Center for OCD and Related Disorders at New York State Psychiatric Institute in New York City. Dr Simpson, along with Edna Foa, PhD and colleagues, recently published a paper on their research.1
Transcript:
OCD is one of our most important psychiatric illnesses. People think about a lot of other disorders—schizophrenia, bipolar disorder, depression—but sometimes OCD doesn’t get as much recognition or enough awareness as it should. First, [OCD] is a very disabling illness. Many of the people who have it can be [very] impaired by it, and yet it is often hidden in the sense that it isn’t as dramatic or obvious so people often suffer in privacy.
OCD is relatively much more common than people thought; it is about 2% lifetime prevalence and in comparison, schizophrenia is 1%. It is more common than schizophrenia. Its onset is in adolescence or young adulthood, with about a quarter of cases starting in childhood. So again, putting it in perspective, about half of the cases of OCD will start by age 19 and in comparison, about half of the cases of depression start at age 32. So it has a much earlier age of onset. Typically, the course of it once you get it is typically chronic, waxing and waning symptoms.
Finally, the severity of it is much more than . . . other anxiety disorders. If you have the disorder, the vast majority will have moderate or severe symptoms.
If you add that all up—early onset, how common it is, chronic course, and severe symptoms—you can see that it can be very disabling. What happens is that people get the disorder relatively early in life and it can get them off track.
Hallmarks of OCD
It’s in the name—obsessions and compulsions. So what are obsessions? Intrusive thoughts, images, or impulses that someone has that they don’t want and that they find very distressing. And what are compulsions? They are behaviors or mental acts that someone does over and over again to try to reduce the stress typically that the obsession has caused.
It is very important to realize that obsessions are not just thoughts. They can be images or impulses. For example, I worked with someone who had intrusive thoughts of coffins popping into his head all day long and it generated incredible distress . . . The other part of it is that compulsions are not just behaviors. They can be something that someone does over and over again in their head all day long. For example, the person who had those intrusive images of coffins . . . the compulsion was to then call up a positive image to try to neutralize the obsession.
[The vast majority of patients who seek clinical treatment have both obsessions and compulsions], and usually they’re related to each other. What I mean by that is there are certain themes that usually go together.
Contamination concerns
People will have intrusive thoughts about illness or about germs—and often the compulsion could be washing rituals. So the theme goes together.
Fears of harm
That could be fear of harm befalling yourself or befalling someone you love. That can lead to a lot of checking behaviors or checking in your head that that harm didn’t actually occur.
Concerns about symmetry or things being “just right”
These are people who can actually either be spending hours arranging and ordering their home or office to make sure things are just aligned or it can be as they read or as they walk, making sure things are done in a certain number or a certain rhythm.
Hoarding disorder
In general [hoarding] has been considered part of OCD, but the current thinking is that people who only hoard objects and have huge stashes of things and can’t get rid of things [are dealing with] a separate [issue]. But there is still a part of a hoarding behavior that can be part of OCD . . . someone who has a concern about harm (eg, don’t want to harm anyone), and they can’t let go of any of those newspapers that have medical information in them for fear that they might harm one of their extended family members or friends if they don’t send it to them. That would be an example of hoarding behavior but it is in the context of OCD.
Taboo thoughts
These are sexual, religious, or aggressive thoughts. These are also very upsetting to people, such as doing things that are sacrilegious to your God, or awful sexual or aggressive images that the person doesn’t want.
Everybody with OCD has obsessions and compulsions; they need to be distressing, time consuming, and impairing. The actual content of the obsessions and compulsions can vary widely among patients, and one that most people know are the contamination and washing rituals, but this is only one of multiple themes that are common in OCD . . . there are many different contents and themes but they all have the same sort of organization of obsessions and compulsions.
Affects and insight
People can not only have different themes and types of symptoms but they can also have different types of affects. What I mean by that is some people get very anxious when they get in front of one of their OCD triggers. They can have paralyzing anxiety, including panic attacks. It is not panic disorder; it’s OCD with panic attacks. Other people can have an intense sense of . . . not so much anxiety, but disgust. Another group can have a sense of increasing tension and a sense of things not being “just right.” So there is a range of affects that people can have with OCD; it’s not only anxiety.
There is also a range of insight . . . some OCD patients can say to you [what they’re feeling] doesn’t make any sense: “I know if I touch the subway pole on the New York City subway, I’m not going to get AIDS. That’s not how you get HIV.” Other people believe that if they touch that pole on the subway, they really might get ill and die. So that’s what I mean by a range of rationality about their OCD symptoms—some with good insight who can tell you these behaviors don’t make any sense but they can’t stop doing them; and a small minority actually have zero insight and . . . appear delusional.
[However], that isn’t a psychotic disorder; it is absent insight in the context of OCD. So there is a range of insight . . . not just between individuals, but oftentimes over the trajectory of the illness. I often see adults, and the adults can say to me, “When I was 12 and I got that image, I . . . [believed] that my thoughts could kill my parents. I now realize that that was my OCD but back then, I really thought I could do it.” As people get educated about the illness, their insight improves because they realize their thoughts aren’t true, but at an earlier stage of the illness, they might not have been as sure.
The other thing is that sometimes people’s insight can change when you’re right in front of them. If I have someone in my office and we’re talking about their OCD, they can [say], “It doesn’t make any sense; I shouldn’t have to wash this much.” If I then go and do an exposure experiment with them in the New York City subway, right in front of me, they’ll lose their ability to know that this doesn’t make any sense, and they’ll be terrified.
Severity
So insight varies, different types of affects, and the themes of the OCD can vary . . . everyone has obsessions and compulsions or the vast majority—over 95% of people seeking treatment will have both, and they often have the relationship to each other—and that’s what you’re looking for diagnostically.
Sometimes people worry [that if they have an intrusive thought from time to time, they might have OCD]. It is important to distinguish OCD from normality. Everybody has intrusive thoughts—the funny image or thought pops in your head. Many people have what I would call habits. Most of us get anxious. If we’re flying to a distant city, we check more than once whether we have our airplane ticket before we go to the airport. Is that OCD? Absolutely not. Those are completely normal behaviors and it is how our brain works.
OCD is something very different, and if you actually see patients with OCD, it is not typically mild. It is usually moderate to severe, and these people spend [at least an hour a day—and many people spend 3, 5, 8 hours or all day—obsessing and compulsing] and their life is impaired. They often don’t socialize because of either the content of their obsessions and compulsions or because of the time it takes. They often are avoiding important things in their life to not trigger the OCD. You can see that it impacts [a person’s] work life, school life, and romantic relationships. So [OCD is] a very impairing illness.
Common comorbidities
The most common co-occurring psychiatric disorders that people with OCD have are other depressive disorders and other anxiety disorders, and those are the most frequent . . . So when you see someone with OCD, you should be doing a careful evaluation. Do they also have panic disorder? Do they also have social anxiety disorder? Do they have posttraumatic stress disorder? Making those distinctions is important in your treatment plan. Depression is often comorbid as well.
Other [comorbidities] that are lower on the list but often frequent: OCD often co-occurs with obsessive-compulsive personality disorder, which is a different thing than OCD. It isn’t mild OCD. Obsessive-compulsive personality disorder is a long-standing pattern of maladaptive perfection, rigidity, and emotional restraint. That combination and those types of personality traits coupled with OCD has been shown to . . . be a negative predictor for course in OCD, as well as in other disorders.
The other thing that can . . . occur in about a third of people is comorbid tic disorders. What I mean by that is chronic tic disorder as well as Tourette’s disorder.
Lower down on the list . . . for psychiatrists who see a lot of patients with schizophrenia, bipolar disorder, autism disorder, or eating disorders, the thing for you to know is that OCD is more common in those disorders than would be expected by its lifetime prevalence of 2%. For example, there are studies in patients with schizophrenia or schizoaffective disorder that maybe as many as 12% meet criteria for OCD as well, and there’s a higher rate of obsessive-compulsive symptoms in those psychotic disorders. My point here is OCD itself should be looked for at a 2% lifetime prevalence (more common than schizophrenia), but if you’re seeing a lot of patients with anxiety and depression, you should ask about OCD. If you’re seeing a lot of patients with eating disorders, autism, schizophrenia, tic disorders, or Tourette’s, you should definitely be asking for OCD. When you see OCD, you should definitely be [looking for] depression, anxiety, tic disorders, obsessive-compulsive personality disorder—because those will make a difference in your treatment plan.
Further reading
References
1. Simpson HB, Foa EB, Liebowitz MR, et al. Cognitive-behavioral therapy vs risperidone for augmenting serotonin reuptake inhibitors in obsessive-compulsive disorder: a randomized clinical trial. JAMA Psychiatry. 2013 Sep 11. JAMA Network | JAMA Psychiatry | Cognitive-Behavioral Therapy vs Risperidone for Augmenting Serotonin Reuptake Inhibitors in Obsessive-Compulsive Disorder: ?*A Randomized Clinical Trial. Accessed September 12, 2013.
Dr Simpson is funded by the National Institute of Mental Health (NIMH). Her team is recruiting adults for an OCD treatment study. Information can be found at:
By H. Blair Simpson, MD, PhD, in Psychiatric Times
October 03, 2013
In this video, Dr H. Blair Simpson gives a brief overview of the hallmarks, themes, and common comorbidities found in obsessive-compulsive disorder (OCD) and explains what to look for when treating OCD in connection with other psychiatric illnesses. Dr Simpson is Professor of Clinical Psychiatry, Columbia University, and Director of the Anxiety Disorders Clinic and the Center for OCD and Related Disorders at New York State Psychiatric Institute in New York City. Dr Simpson, along with Edna Foa, PhD and colleagues, recently published a paper on their research.1
Transcript:
OCD is one of our most important psychiatric illnesses. People think about a lot of other disorders—schizophrenia, bipolar disorder, depression—but sometimes OCD doesn’t get as much recognition or enough awareness as it should. First, [OCD] is a very disabling illness. Many of the people who have it can be [very] impaired by it, and yet it is often hidden in the sense that it isn’t as dramatic or obvious so people often suffer in privacy.
OCD is relatively much more common than people thought; it is about 2% lifetime prevalence and in comparison, schizophrenia is 1%. It is more common than schizophrenia. Its onset is in adolescence or young adulthood, with about a quarter of cases starting in childhood. So again, putting it in perspective, about half of the cases of OCD will start by age 19 and in comparison, about half of the cases of depression start at age 32. So it has a much earlier age of onset. Typically, the course of it once you get it is typically chronic, waxing and waning symptoms.
Finally, the severity of it is much more than . . . other anxiety disorders. If you have the disorder, the vast majority will have moderate or severe symptoms.
If you add that all up—early onset, how common it is, chronic course, and severe symptoms—you can see that it can be very disabling. What happens is that people get the disorder relatively early in life and it can get them off track.
Hallmarks of OCD
It’s in the name—obsessions and compulsions. So what are obsessions? Intrusive thoughts, images, or impulses that someone has that they don’t want and that they find very distressing. And what are compulsions? They are behaviors or mental acts that someone does over and over again to try to reduce the stress typically that the obsession has caused.
It is very important to realize that obsessions are not just thoughts. They can be images or impulses. For example, I worked with someone who had intrusive thoughts of coffins popping into his head all day long and it generated incredible distress . . . The other part of it is that compulsions are not just behaviors. They can be something that someone does over and over again in their head all day long. For example, the person who had those intrusive images of coffins . . . the compulsion was to then call up a positive image to try to neutralize the obsession.
[The vast majority of patients who seek clinical treatment have both obsessions and compulsions], and usually they’re related to each other. What I mean by that is there are certain themes that usually go together.
Contamination concerns
People will have intrusive thoughts about illness or about germs—and often the compulsion could be washing rituals. So the theme goes together.
Fears of harm
That could be fear of harm befalling yourself or befalling someone you love. That can lead to a lot of checking behaviors or checking in your head that that harm didn’t actually occur.
Concerns about symmetry or things being “just right”
These are people who can actually either be spending hours arranging and ordering their home or office to make sure things are just aligned or it can be as they read or as they walk, making sure things are done in a certain number or a certain rhythm.
Hoarding disorder
In general [hoarding] has been considered part of OCD, but the current thinking is that people who only hoard objects and have huge stashes of things and can’t get rid of things [are dealing with] a separate [issue]. But there is still a part of a hoarding behavior that can be part of OCD . . . someone who has a concern about harm (eg, don’t want to harm anyone), and they can’t let go of any of those newspapers that have medical information in them for fear that they might harm one of their extended family members or friends if they don’t send it to them. That would be an example of hoarding behavior but it is in the context of OCD.
Taboo thoughts
These are sexual, religious, or aggressive thoughts. These are also very upsetting to people, such as doing things that are sacrilegious to your God, or awful sexual or aggressive images that the person doesn’t want.
Everybody with OCD has obsessions and compulsions; they need to be distressing, time consuming, and impairing. The actual content of the obsessions and compulsions can vary widely among patients, and one that most people know are the contamination and washing rituals, but this is only one of multiple themes that are common in OCD . . . there are many different contents and themes but they all have the same sort of organization of obsessions and compulsions.
Affects and insight
People can not only have different themes and types of symptoms but they can also have different types of affects. What I mean by that is some people get very anxious when they get in front of one of their OCD triggers. They can have paralyzing anxiety, including panic attacks. It is not panic disorder; it’s OCD with panic attacks. Other people can have an intense sense of . . . not so much anxiety, but disgust. Another group can have a sense of increasing tension and a sense of things not being “just right.” So there is a range of affects that people can have with OCD; it’s not only anxiety.
There is also a range of insight . . . some OCD patients can say to you [what they’re feeling] doesn’t make any sense: “I know if I touch the subway pole on the New York City subway, I’m not going to get AIDS. That’s not how you get HIV.” Other people believe that if they touch that pole on the subway, they really might get ill and die. So that’s what I mean by a range of rationality about their OCD symptoms—some with good insight who can tell you these behaviors don’t make any sense but they can’t stop doing them; and a small minority actually have zero insight and . . . appear delusional.
[However], that isn’t a psychotic disorder; it is absent insight in the context of OCD. So there is a range of insight . . . not just between individuals, but oftentimes over the trajectory of the illness. I often see adults, and the adults can say to me, “When I was 12 and I got that image, I . . . [believed] that my thoughts could kill my parents. I now realize that that was my OCD but back then, I really thought I could do it.” As people get educated about the illness, their insight improves because they realize their thoughts aren’t true, but at an earlier stage of the illness, they might not have been as sure.
The other thing is that sometimes people’s insight can change when you’re right in front of them. If I have someone in my office and we’re talking about their OCD, they can [say], “It doesn’t make any sense; I shouldn’t have to wash this much.” If I then go and do an exposure experiment with them in the New York City subway, right in front of me, they’ll lose their ability to know that this doesn’t make any sense, and they’ll be terrified.
Severity
So insight varies, different types of affects, and the themes of the OCD can vary . . . everyone has obsessions and compulsions or the vast majority—over 95% of people seeking treatment will have both, and they often have the relationship to each other—and that’s what you’re looking for diagnostically.
Sometimes people worry [that if they have an intrusive thought from time to time, they might have OCD]. It is important to distinguish OCD from normality. Everybody has intrusive thoughts—the funny image or thought pops in your head. Many people have what I would call habits. Most of us get anxious. If we’re flying to a distant city, we check more than once whether we have our airplane ticket before we go to the airport. Is that OCD? Absolutely not. Those are completely normal behaviors and it is how our brain works.
OCD is something very different, and if you actually see patients with OCD, it is not typically mild. It is usually moderate to severe, and these people spend [at least an hour a day—and many people spend 3, 5, 8 hours or all day—obsessing and compulsing] and their life is impaired. They often don’t socialize because of either the content of their obsessions and compulsions or because of the time it takes. They often are avoiding important things in their life to not trigger the OCD. You can see that it impacts [a person’s] work life, school life, and romantic relationships. So [OCD is] a very impairing illness.
Common comorbidities
The most common co-occurring psychiatric disorders that people with OCD have are other depressive disorders and other anxiety disorders, and those are the most frequent . . . So when you see someone with OCD, you should be doing a careful evaluation. Do they also have panic disorder? Do they also have social anxiety disorder? Do they have posttraumatic stress disorder? Making those distinctions is important in your treatment plan. Depression is often comorbid as well.
Other [comorbidities] that are lower on the list but often frequent: OCD often co-occurs with obsessive-compulsive personality disorder, which is a different thing than OCD. It isn’t mild OCD. Obsessive-compulsive personality disorder is a long-standing pattern of maladaptive perfection, rigidity, and emotional restraint. That combination and those types of personality traits coupled with OCD has been shown to . . . be a negative predictor for course in OCD, as well as in other disorders.
The other thing that can . . . occur in about a third of people is comorbid tic disorders. What I mean by that is chronic tic disorder as well as Tourette’s disorder.
Lower down on the list . . . for psychiatrists who see a lot of patients with schizophrenia, bipolar disorder, autism disorder, or eating disorders, the thing for you to know is that OCD is more common in those disorders than would be expected by its lifetime prevalence of 2%. For example, there are studies in patients with schizophrenia or schizoaffective disorder that maybe as many as 12% meet criteria for OCD as well, and there’s a higher rate of obsessive-compulsive symptoms in those psychotic disorders. My point here is OCD itself should be looked for at a 2% lifetime prevalence (more common than schizophrenia), but if you’re seeing a lot of patients with anxiety and depression, you should ask about OCD. If you’re seeing a lot of patients with eating disorders, autism, schizophrenia, tic disorders, or Tourette’s, you should definitely be asking for OCD. When you see OCD, you should definitely be [looking for] depression, anxiety, tic disorders, obsessive-compulsive personality disorder—because those will make a difference in your treatment plan.
Further reading
- What is obsessive-compulsive disorder? National Institute of Mental Health.
- Nauert R. CBT technique aids treatment of OCD. PsychCentral. September 20, 2013.
- Adding psychotherapy to medication treatment improves outcomes in pediatric OCD. September 21, 2013. National Institute of Mental Health.
References
1. Simpson HB, Foa EB, Liebowitz MR, et al. Cognitive-behavioral therapy vs risperidone for augmenting serotonin reuptake inhibitors in obsessive-compulsive disorder: a randomized clinical trial. JAMA Psychiatry. 2013 Sep 11. JAMA Network | JAMA Psychiatry | Cognitive-Behavioral Therapy vs Risperidone for Augmenting Serotonin Reuptake Inhibitors in Obsessive-Compulsive Disorder: ?*A Randomized Clinical Trial. Accessed September 12, 2013.
Dr Simpson is funded by the National Institute of Mental Health (NIMH). Her team is recruiting adults for an OCD treatment study. Information can be found at:
