Obsessive-compulsive disorder (OCD)

[David Baxter PhD]

Obsessive-compulsive disorder (OCD)
By Mayo Clinic Staff
Dec. 19, 2008

Obsessive-compulsive disorder (OCD) is a type of anxiety disorder in which you have unreasonable thoughts and fears (obsessions) that lead you to engage in repetitive behaviors (compulsions). With obsessive-compulsive disorder, you may realize that your obsessions aren't reasonable, and you may try to ignore them or stop them. But that only increases your distress and anxiety. Ultimately, you feel driven to perform compulsive acts in an effort to ease your distress.

Obsessive-compulsive disorder often centers around themes, such as a fear of getting contaminated by germs. To ease your contamination fears, you may compulsively wash your hands until they're sore and chapped. Despite your efforts, the distressing thoughts of obsessive-compulsive disorder keep coming back. This leads to more ritualistic behavior — and a vicious cycle that's characteristic of obsessive-compulsive disorder.

Symptoms
Obsessive-compulsive disorder symptoms include both obsessions and compulsions.

OCD obsession symptoms
OCD obsessions are repeated, persistent and unwanted ideas, thoughts, images or impulses that you have involuntarily and that seem to make no sense. These obsessions typically intrude when you're trying to think of or do other things.

Obsessions often have themes to them, such as:

• Fear of contamination or dirt
• Having things orderly and symmetrical
• Aggressive or horrific impulses
• Sexual images or thoughts

OCD symptoms involving obsessions may include:

• Fear of being contaminated by shaking hands or by touching objects others have touched
• Doubts that you've locked the door or turned off the stove
• Thoughts that you've hurt someone in a traffic accident
• Intense distress when objects aren't orderly or facing the right way
• Images of hurting your child
• Impulses to shout obscenities in inappropriate situations
• Avoidance of situations that can trigger obsessions, such as shaking hands
• Replaying pornographic images in your mind
• Dermatitis because of frequent hand washing
• Skin lesions because of picking at your skin
• Hair loss or bald spots because of hair pulling

OCD compulsion symptoms
OCD compulsions are repetitive behaviors that you feel driven to perform. These repetitive behaviors are meant to prevent or reduce anxiety or distress related to your obsessions. For instance, if you believe you ran over someone in your car, you may return to the apparent scene over and over because you just can't shake your doubts. You may also make up rules or rituals to follow that help control the anxiety you feel when having obsessive thoughts.

As with OCD obsessions, compulsions typically have themes, such as:

• Washing and cleaning
• Counting
• Checking
• Demanding reassurances
• Performing the same action repeatedly
• Orderliness

OCD symptoms involving compulsions may include:

• Hand washing until your skin becomes raw
• Checking doors repeatedly to make sure they're locked
• Checking the stove repeatedly to make sure it's off
• Counting in certain patterns
• Making sure all your canned goods face the same way

When to see a doctor
There's a difference between being a perfectionist and having obsessive-compulsive disorder. Perhaps you keep the floors in your house so clean that you could eat off them. Or you like your knickknacks arranged just so. That doesn't necessarily mean that you have obsessive-compulsive disorder.

Obsessive-compulsive disorder can be so severe and time-consuming that it literally becomes disabling. You may be able to do little else but spend time on your obsessions and compulsions — washing your hands for hours each day, for instance. With OCD, you may have a low quality of life because the condition rules most of your days. You may be very distressed but feel powerless to stop your urges. Most adults can recognize that their obsessions and compulsions don't make sense. Children, however, may not understand what's wrong.

If your obsessions and compulsions are affecting your life, see your doctor or mental health provider. It's common for people with OCD to be ashamed and embarrassed about the condition. But even if your rituals are deeply ingrained, treatment can help.

Causes
The cause of obsessive-compulsive disorder isn't fully understood. Main theories include:

• Biology. Some evidence shows that OCD may be a result of changes in your body's own natural chemistry or brain functions. Some evidence also shows that OCD may have a genetic component, but specific genes have yet to be identified.
• Environment. Some researchers believe that OCD stems from behavior-related habits that you learned over time.
• Insufficient serotonin. An insufficient level of serotonin, one of your brain's chemical messengers, may contribute to obsessive-compulsive disorder. Some studies that compare images of the brains of people who have obsessive-compulsive disorder with the brains of those who don't show differences in brain activity patterns. In addition, people with obsessive-compulsive disorder who take medications that enhance the action of serotonin often have fewer OCD symptoms.
• Strep throat. Some studies suggest that some children develop OCD after infection with group A beta-hemolytic streptococcal pharyngitis — strep throat. However, these studies are controversial and more evidence is needed before strep throat can be blamed.

Risk factors
Factors that may increase the risk of developing or triggering obsessive-compulsive disorder include:

• Family history. Having parents or other family members with the disorder can increase your risk of developing OCD. However, researchers haven't identified any genes responsible for obsessive-compulsive disorder.
• Stressful life events. If you tend to react strongly to stress, your risk may increase. This reaction may, for some reason, trigger the intrusive thoughts, rituals and emotional distress characteristic of obsessive-compulsive disorder.
• Pregnancy. Some studies show that pregnant women and new mothers are at increased risk, but it's not clear why. In these cases, OCD symptoms center mainly on thoughts of harming the baby.

It was once thought that obsessive-compulsive disorder was a rare condition. But it's now known to be more common than many other mental illnesses. In fact, about 2.2 million Americans have obsessive-compulsive disorder, according to the National Institute of Mental Health.

Obsessive-compulsive disorder often begins during early childhood or adolescence, usually around age 10. In adults, OCD typically begins around age 21.

Complications
Complications that obsessive-compulsive disorder may cause or be associated with include:

• Suicidal thoughts and behavior
• Alcohol or substance abuse
• Other anxiety disorders
• Depression
• Eating disorders
• Contact dermatitis from frequent hand washing
• Inability to attend work or school
• Troubled relationships
• Overall poor quality of life

Preparing for your appointment
In some cases, a health care provider or other professional may ask you about your mood, thoughts or behavior. Your doctor may bring it up during a routine medical appointment, especially if you seem to be agitated or distressed. Or you may decide to schedule an appointment with your family doctor to talk about your concerns. In either case, because obsessive-compulsive disorder often requires specialized care, you may be referred to a mental health provider, such as a psychiatrist or psychologist, for evaluation and treatment. In other cases, you may seek out a mental health provider on your own first.

What you can do
Being an active participant in your care can help your efforts to manage your OCD. One way to do this is by preparing for your appointment. Think about your needs and goals for treatment. Also, write down a list of questions to ask. These may include:

• Write down any symptoms you've noticed, including any that may seem unrelated to the reason for which you've scheduled the appointment. Try to have specific examples ready.
• Write down key personal information, including any major stresses or recent life changes.
• Take a list of all medications, as well as any vitamins or supplements.

Questions to ask
Also, write down a list of questions to ask. These questions may include:

• Why do you think I have obsessive-compulsive disorder?
• How do you treat obsessive-compulsive disorder?
• How can treatment help me?
• Are there medications that might help?
• Will psychotherapy help?
• How long will treatment take?
• What can I do to help myself?
• Are there any brochures or other printed material that I can take home with me? Or can you recommend reliable Web sites to visit?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions whenever you don't understand something being discussed.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

• Do certain thoughts go through your mind over and over despite your attempts to ignore them?
• Do you have to have things arranged in a certain way?
• Do you have to wash your hands, count things or check things over and over?
• When did your symptoms start?
• Have symptoms been continuous or occasional?
• What, if anything, seems to improve the symptoms?
• What, if anything, appears to worsen the symptoms?
• How do the symptoms affect your daily life?
• Have any relatives had a mental illness?
• Have you experienced any trauma or stress?

Tests and diagnosis
If your doctor or mental health provider believes you may have obsessive-compulsive disorder, he or she typically runs a series of medical and psychological tests and exams. These can help pinpoint a diagnosis, rule out other problems that could be causing your symptoms and check for any related complications.

These exams and tests generally include:

• Physical exam. This may include measuring height and weight, checking vital signs, such as heart rate, blood pressure and temperature, listening to your heart and lungs, and examining your abdomen.
• Laboratory tests. These may include a complete blood count (CBC), screening for alcohol and drugs, and a check of your thyroid function.
• Psychological evaluation. A doctor or mental health provider will talk to you about your thoughts, feelings and behavior patterns. He or she will ask about your symptoms, including when they started, how severe they are, how they affect your daily life and whether you've had similar episodes in the past. You'll also discuss any thoughts you may have of suicide, self-harm or harming others. Your doctor may also want to talk to family or friends, if possible.

Diagnostic criteria for obsessive-compulsive disorder
To be diagnosed with obsessive-compulsive disorder, you must meet the criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health professionals to diagnose mental illnesses and by insurance companies to reimburse for treatment.

For OCD to be diagnosed, you must first meet these general criteria:

• You must have either obsessions or compulsions.
• You must realize that your obsessions and compulsions are excessive or unreasonable.
• Obsessions and compulsions significantly interfere with your daily routine.

Your obsessions must meet these specific criteria:

• Recurrent and persistent thoughts, impulses or images that are intrusive and cause distress.
• The thoughts aren't simply excessive worries about real problems in your life.
• You try to ignore or suppress these thoughts, images or impulses.
• You know that these thoughts, images and impulses are a product of your own mind.

Compulsions must meet these specific criteria:

• Repetitive behavior that you feel driven to perform, such as hand washing, or repetitive mental acts, such as counting silently.
• These behaviors or mental acts are meant to prevent or reduce distress about unrealistic obsessions.

Diagnostic challenges
It's sometimes difficult to diagnose obsessive-compulsive disorder because symptoms can be similar to those of generalized anxiety disorder, depression, schizophrenia or other mental illnesses. Be sure to stick with it, though, so that you can get appropriate treatment.

Treatments and drugs
Obsessive-compulsive disorder treatment can be difficult, and it may not offer a cure. You may need treatment for the rest of your life. However, OCD treatment can help you bring symptoms under control so that they don't rule your daily life.

Main obsessive-compulsive disorder treatments
The two main treatments for obsessive-compulsive disorder are:

• Psychotherapy
• Medications

Which option is best for you depends on your personal situation and preferences. Often, treatment is most effective with a combination of medications and psychotherapy.

Psychotherapy for obsessive-compulsive disorder
A type of therapy called cognitive behavioral therapy (CBT) has been shown to be the most effective form of therapy for OCD in both children and adults. Cognitive behavioral therapy involves retraining your thought patterns and routines so that compulsive behaviors are no longer necessary.

One CBT approach in particular is called exposure and response prevention. This therapy involves gradually exposing you to a feared object or obsession, such as dirt, and teaching you healthy ways to cope with your anxiety. Learning the techniques and new thought patterns takes effort and practice. But you may enjoy a better quality of life once you learn to manage your obsessions and compulsions.

Therapy may take place in individual, family or group sessions.

Medications for obsessive-compulsive disorder
Certain psychiatric medications can help control the obsessions and compulsions of OCD. Most commonly, antidepressants are tried first. Antidepressants may be helpful for OCD because they may help increase levels of serotonin, which may be lacking when you have OCD.

Antidepressants that have been specifically approved by the Food and Drug Administration to treat OCD include:

• Clomipramine (Anafranil)
• Fluvoxamine (Luvox) ¹
• Fluoxetine (Prozac)
• Paroxetine (Paxil)
• Sertraline (Zoloft)

However, many other antidepressants and other psychiatric medications on the market may also be used to treat OCD off-label. Off-label use is a common and legal practice of using a medication to treat a condition or age group not specifically listed on its prescribing label as an FDA-approved use.

Choosing a medication
In general, the goal of OCD treatment with medications is to effectively control signs and symptoms at the lowest possible dosage. Which medication is best for you depends on your own individual situation. It can take several weeks after first starting a medication to notice an improvement in your symptoms.

With obsessive-compulsive disorder, it's not unusual to have to try several medications before finding one that works well to control your symptoms. Your doctor also might recommend combining medications, such as antidepressants and antipsychotic medications, to make them more effective in controlling your symptoms.

Don't stop taking your medication without talking to your doctor, even if you're feeling better. You may have a relapse of OCD symptoms if you stop taking your medication. Also, some medication needs to be tapered off, rather than stopped abruptly, to avoid withdrawal symptoms.

Medication side effects and risks
All psychiatric medications have side effects and possible health risks. Be sure to talk to your doctor about all of the possible side effects and about any health monitoring that's necessary while taking psychiatric medications, especially antipsychotic medications. Some medications can have dangerous interactions with other medications, foods or other substances. Tell your doctors about all medications and over-the-counter substances you take, including vitamins, minerals and herbal supplements.

Other treatment options
Sometimes, medications and psychotherapy aren't effective enough in controlling your OCD symptoms. In rare cases, other treatment options may include:

• Psychiatric hospitalization
• Residential treatment
• Electroconvulsive therapy (ECT)
• Transcranial magnetic stimulation
• Deep brain stimulation

Because these treatments haven't been thoroughly tested for use in obsessive-compulsive disorder, make sure you understand all the pros and cons and possible health risks.

Lifestyle and home remedies
Obsessive-compulsive disorder is a chronic condition, which means it may always be part of your life. While you can't treat OCD on your own, you can do some things for yourself that will build on your treatment plan:

• Take your medications as directed. Even if you're feeling well, resist any temptation to skip your medications. If you stop, OCD symptoms are likely to return.
• Pay attention to warning signs. You and your doctors may have identified things that may trigger your OCD symptoms. Make a plan so that you know what to do if symptoms return. Contact your doctor or therapist if you notice any changes in symptoms or how you feel.
• Avoid drugs and alcohol. Alcohol and illicit drugs may worsen OCD symptoms. Also, get appropriate treatment for a substance abuse problem.
• Check first before taking other medications. Contact the doctor who's treating you for OCD before you take medications prescribed by another doctor or before taking any over-the-counter medications, vitamins, minerals or supplements. These may interact with your OCD medications.

Coping and support
Coping with obsessive-compulsive disorder can be challenging. Medications can have unwanted side effects, and you might feel angry or resentful about having a condition that can require long-term treatment. Here are some ways to help cope with OCD:

• Learn about obsessive-compulsive disorder. Education about your condition can empower you and motivate you to stick to your treatment plan.
• Join a support group. Support groups for people with OCD can help you reach out to others facing similar challenges.
• Stay focused on your goals. Recovery from OCD is an ongoing process. Stay motivated by keeping your recovery goals in mind. Remind yourself that you're responsible for managing your illness and working toward your goals.
• Find healthy outlets. Explore healthy ways to channel your energy, such as hobbies, exercise and recreational activities.
• Learn relaxation and stress management. Try such stress management techniques as meditation, muscle relaxation, deep breathing, yoga or tai chi.
• Structure your time. Plan your day and activities. Try to stay organized. You may find it helpful to make a list of daily tasks.

Prevention
There's no sure way to prevent obsessive-compulsive disorder. However, getting treatment as soon as possible may help prevent OCD from worsening.

¹ At least one large scale study conducted in Ottawa, Canada, has suggested that fluvoxamine (Luvox) may be more effective than other SSRIs in treating OCD symptoms, and that the brand name (Luvox) is more effective than the generic (fluvoxamine) for this medication. ~ David Baxter

 

[Daniel E.]

Frequently Asked Questions about OCD
by Wayne Goodman, MD

What is the difference between the ruminations of depression and the obsessions of OCD?

Morbid preoccupations (sometimes called ruminations) of depression can be mislabeled as obsessional thinking. The depressed patient typically dwells on matters that are meaningful to most people (e.g., one?s accomplishments or other measures of self-worth), but the patient?s perceptions or interpretations of these events and issues are colored by the depressed mood.

In contrast to obsessions, depressed patients usually defend morbid preoccupations as realistic concerns. Another difference is that a depressed patient often is preoccupied with past mistakes and regrets, whereas the person with OCD is more concerned about recent events or averting future harm.

What is the difference between a worry and an obsession?

The worries of generalized anxiety disorder (GAD) can be distinguished from obsessions on the basis of the content and the absence of anxiety-relieving compulsions. The concerns of GAD involve real-life situations (e.g., finances and job or school performance), but the degree of apprehension about them clearly is excessive. In contrast, true obsessions usually reflect unrealistic fears, such as inadvertently poisoning dinner guests.

Can people with OCD also have panic attacks?

Panic attacks can be present in OCD, but an additional diagnosis of panic disorder should not be considered unless the attacks occur out of the blue. Some patients with OCD report the occurrence of panic attacks following exposure to a fearful stimulus, such as a trace of blood encountered by someone with an AIDS obsession. In contrast to panic disorder, the person in this example is not afraid of the panic attack, he or she is fearful of the consequences of contamination.

Is compulsive self-damaging behavior a form of OCD?

There continues to be debate regarding the relationship of ?compulsive? self-damaging behaviors to that of the compulsions of OCD. At present, self-mutilation behaviors (e.g., severe nail biting) should not be considered as compulsions when making the diagnosis of OCD. Likewise, behaviors that actually result in physical harm to others are outside the bounds of OCD.

Are people with OCD who have unwanted thoughts about hurting someone at risk of acting on their fears?

If they truly have OCD, the answer is no. Patients with OCD may have unfounded fears about acting on violent and irrational impulses, but they do not act on them. That act of violence represents the most abhorrent idea they can imagine. In evaluating a patient with violent or horrific thoughts, the clinician must decide, based on clinical judgment and the patient?s history, whether these symptoms are obsessions or part of the fantasy life of a potentially violent person. If it is the latter, the patient needs help with maintaining self-control, not reassurance.

What is the difference between having an obsessive-compulsive personality and having OCD?

The relationship between OCD and compulsive traits or personality is the subject of many diagnostic questions. Historically, the psychiatric literature has often blurred the distinction between OCD and obsessive-compulsive personality disorder (OCPD). Psychiatry?s diagnostic system has perpetuated the confusion by selecting very similar diagnostic labels. Although some patients with OCD may have traits listed as criteria for OCPD (particularly perfectionism, preoccupation with details, indecisiveness), most OCD patients do not meet full criteria for OCPD, which also includes restricted expression of feelings, stinginess and excessive devotion to productivity.

Studies have found that no more than 15 percent of patients with OCD meet full criteria for OCPD. The quintessential OCPD patient is the workaholic draconian supervisor who, at home, shows contempt for displays of tender emotions and insists that the family submit to his will. He does not have insight into his behavior and is not likely to seek psychiatric help on his own. Strictly defined obsessions and compulsions are not present in OCPD. Hoarding behavior is generally regarded as a symptom of OCD although it is listed as a criterion for OCPD. Being detail-oriented, hardworking and productive is not the same as having OCPD; in fact, these traits are considered advantageous and adaptive in many settings.

When does normal checking end and pathological checking begin?

A diagnosis of OCD is warranted when the symptoms cause marked distress, are time-consuming (take more than an hour a day), or significantly interfere with the person?s functioning. A person who needs to check the door exactly six times before leaving the house but is otherwise free of obsessive-compulsive symptoms may have a compulsive symptom, but does not have OCD. The impairment associated with OCD ranges from mild (little interference in functioning) to extreme (incapacitated).

OCD probably contributed to the death of the billionaire Howard Hughes. Several accounts suggest that Hughes suffered from fears of contamination. He tried to create a germ-free environment that isolated him from contact with the outside world. Instead of performing compulsions himself, he had the means to hire others to perform elaborate rituals on his behalf. Paradoxically, his grooming and self-care deteriorated as more and more routine activities were curtailed. His self-imposed dietary restrictions further hastened the decline in his physical condition. Some severely ill patients with OCD require hospitalization ? it can be a life-saving intervention.

The Impact of Obsessive-Compulsive Disorder
by Wayne Goodman, MD

...The onset of OCD usually occurs in adolescence or early adulthood. Nearly one-half of all cases begin in childhood, and it is rare to see onset after age 35. In adults with OCD, men and women are almost equally affected. This contrasts with both depression and panic disorder, two disorders with a clear preponderance of women. In cases of childhood OCD, boys outnumber girls and the age of onset is earlier. Studies from the National Institute of Mental Health suggest that very early onset (before age seven) of OCD in boys may be related to Tourette?s Syndrome, a disorder involving multiple sudden, involuntary movements called tics.

OCD strikes people from all walks of life and all levels of education. Factors that predispose individuals to the development of OCD have not been identified. Strict religious training is thought to shape the content of one?s obsessions (i.e., increased concerns with scruples and sacrilege), but has not been shown to increase the likelihood of developing OCD.

Few modifications are needed for making the diagnosis of OCD in children. The clinical presentation in children and in adults is remarkably similar. While most children recognize that the symptoms are unwanted, it may be more difficult to evaluate insight in younger children with OCD. Not all rituals in childhood should be considered pathological. A need for sameness and consistency may promote a sense of security at times of transition. For example, many normal children engage in bedtime rituals such as arranging their bedding in a particular way, ensuring that their toes are covered or checking for ?monsters? under the bed. Childhood rituals should be suspected as signs of OCD when they become maladaptive (i.e., time-consuming or distressing) and persistent...

The Course of Obsessive-Compulsive Disorder
by Wayne Goodman, MD

OCD can be relentless. If untreated, OCD is usually chronic and follows a waxing and waning course. That is, symptoms may get somewhat better for months or even years, only to get worse again before returning to a lower level of severity. Only about 5 to 10 percent of OCD sufferers enjoy a spontaneous remission in which all symptoms of OCD go away for good. Another 5 to 10 percent experience progressive deterioration in their symptoms. Stress can make OCD worse, but trying to eliminate all stress is unlikely to quell OCD. In fact, it is better for most people with OCD to keep busy. Idleness can be the breeding ground for increased obsessional thinking. Changes in the severity of OCD may be related to fluctuations in the body?s internal chemical environment. Women with OCD often report that their symptoms become more severe the week before their menstrual period. Presumably, this is related to the natural ebb and flow of hormones that regulate the menstrual cycle. Diet has not been shown to influence OCD.

In the majority of cases, the onset of OCD is not associated with an external event...