Obsessive Compulsive Disorder

Obsessive–compulsive disorder (OCD) is a mental disorder characterized by intrusive thoughts that produce anxiety, by repetitive behaviors aimed at reducing anxiety, or by combinations of such thoughts (obsessions) and behaviors (compulsions). The symptoms of this anxiety disorder range from repetitive hand-washing and extensive hoarding to preoccupation with sexual, religious, or aggressive impulses. These symptoms can be alienating and time-consuming, and often cause severe emotional and economic loss. The acts of those who have OCD may appear paranoid and come across to others as psychotic. However, except in young children, OCD sufferers generally recognize their thoughts and subsequent actions as irrational, and they may become further distressed by this realization.

OCD is the fourth most common mental disorder and is diagnosed nearly as often as asthma and diabetes mellitus. In the United States, one in 50 adults has OCD. The phrase "obsessive–compulsive" has become part of the English lexicon, and is often used in an informal or caricatured manner to describe someone who is meticulous, perfectionistic, absorbed in a cause, or otherwise fixated on something or someone. Although these signs may be present in OCD, a person who exhibits them does not necessarily have OCD, and may instead have obsessive–compulsive personality disorder (OCPD) or some other condition, such as an autism spectrum disorder. The symptoms of OCD can range from difficulty with odd numbers to nervous habits such as opening a door and closing it a certain number of times before one leaves it either open or shut.

Signs and symptoms

Obsessions

The typical sufferer performs tasks, or compulsions, to seek relief from obsession-related anxiety. Within and among individuals, the initial obsessions, or intrusive thoughts, can vary in their clarity and vividness. A relatively vague obsession could involve a general sense of disarray or tension, accompanied by a belief that life cannot proceed as normal while the imbalance remains. A more articulable obsession could be a preoccupation with the thought or image of someone close to them dying. A survey of healthy university students found that virtually all of them had these types of thoughts from time to time. Like these students, OCD sufferers do not enact or enjoy these violent thoughts. Other obsessions concern the possibility that someone or something other than oneself—such as God, the Devil, or disease—will harm either the sufferer or the people or things that the sufferer cares about. Some people dread entire concepts, fearing their materialization by causes that may seem implausible or indiscriminate to others. For example, a generalized fear of contamination might entail not only wariness of bodily secretions or excretions, but also apprehension toward household chemicals, radioactivity, newsprint, pets, or even soap.

Sexual obsessions may involve intrusive thoughts or images of "kissing, touching, fondling, oral sex, anal sex, intercourse, and rape" with "strangers, acquaintances, parents, children, family members, friends, coworkers, animals and religious figures", and can include "heterosexual or homosexual content" with persons of any age. As with other intrusive, unpleasant thoughts or images, most people have some disquieting sexual thoughts at times, but people with OCD may attach extraordinary significance to the thoughts. For example, obsessive fears about sexual orientation can appear to the sufferer, and even to those around them, as a crisis of sexual identity. The doubt that accompanies OCD leads to uncertainty regarding whether one might act on the troubling thoughts, resulting in self-criticism or self-loathing.

Some people with OCD may sense that the physical world is qualified by certain immaterial conditions. These people might intuit invisible protrusions from their bodies, or could feel that inanimate objects are ensouled. These intuitions and feelings do not stem from socially accepted religious or metaphysical convictions, such as animism; even a child with OCD might find their obsessive notions ultimately silly. However, even though the OCD sufferer understands that their notions do not correspond with the external world, they feel that they must act as though their notions were correct. For example, an individual who engages in compulsive hoarding might be inclined to treat inorganic matter as if it had the sentience or rights of living organisms, but such an individual might find their consequent behavior irrational on a more intellectual level. However, Insel and Akiskal (1986) noted that in severe OCD, obsessions can shift into delusions when resistance to the obsession is abandoned and insight into its senselessness is lost.

Compulsions

While some with OCD perform compulsive rituals because they inexplicably feel they must, others act compulsively so as to mitigate the anxiety that stems from particular obsessive thoughts. The sufferer might feel that these actions somehow either will prevent a dreaded event from occurring, or will push the event from their thoughts. In any case, the sufferer's reasoning is so idiosyncratic or distorted that it results in significant distress for the sufferer or for those around them.

Compulsions include counting specific things (such as footsteps) or in specific ways (for instance, by intervals of two) and doing other repetitive actions, often with atypical sensitivity to numbers or patterns. People might repeatedly wash their hands or clear their throats, repeatedly check that their parked cars have been locked before leaving them, turn lights on and off, keep doors shut or closed at all times, touch objects a certain number of times before exiting a room, or walk in a certain routine way like only stepping on a certain color of tile.

People rely on compulsions as an escape from their obsessive thoughts; however, they are aware that the relief is only temporary, that the intrusive thoughts will soon come back. Some people use compulsions to avoid situations that may trigger their obsessions. Although some people do certain things over and over again, they don't necessarily perform these actions compulsively. For example, bedtime routines, learning a new skill, and religious practices are not compulsions. Whether or not behaviors are compulsions or mere habit depends on the context in which the behaviors are performed. For example, arranging and ordering DVDs or videos for eight hours a day would be expected of one who works in a video store, but would seem abnormal in other situations. Put another way, if the activity helps bring efficiency to one's life, it is probably a habit, if it interferes with one's normal enjoyment of life, it is probably a compulsion.

For some people with OCD, these tasks, along with the attendant anxiety and fear, can take hours of each day, making it hard for the person to fulfill their work, family, or social roles. In some cases, these behaviors can also cause adverse physical symptoms: People who obsessively wash their hands with antibacterial soap and hot water (to remove germs) can make their skin red and raw with dermatitis. To others, these tasks may appear odd and unnecessary. But for the sufferer, such tasks can feel critically important, and must be performed in particular ways. OCD sufferers are aware that their thoughts and behavior are not rational, but they feel bound to comply with them to fend off feelings of panic or dread.

OCD without overt compulsions

OCD sometimes manifests without overt compulsions. Informally nicknamed "Pure-O", OCD without overt compulsions could, by one estimate, characterize as many as 50 percent to 60 percent of OCD cases. Rather than engaging in observable compulsions, the person with this subtype might perform more covert, mental rituals, or might feel driven to avoid the situations in which particular thoughts seem likely to intrude. As a result of this avoidance, people can struggle to fulfill both public and private roles, even if they place great value on these roles and even if they had fulfilled the roles successfully in the past. Moreover, a sufferer's avoidance can confuse others who do not know its origin or intended purpose, as it did in the case of a man whose wife began to wonder why he would not hold their infant child.

Causes

Psychological

Scholars generally agree that both psychological and biological factors play a role in causing the disorder, although they differ in their degree of emphasis upon either type of factor.

From the 14th to the 16th century in Europe, it was believed that people who experienced blasphemous, sexual, or other obsessive thoughts were possessed by the Devil. Based on this reasoning, treatment involved banishing the "evil" from the "possessed" person through exorcism. In the early 1910s, Sigmund Freud attributed obsessive–compulsive behavior to unconscious conflicts which manifested as symptoms. Freud describes the clinical history of a typical case of "touching phobia" as starting in early childhood, when the person has a strong desire to touch an item. In response, the person develops an "external prohibition" against this type of touching. However, this "prohibition does not succeed in abolishing" the desire to touch; all it can do is repress the desire and "force it into the unconscious".

The cognitive–behavioral model suggests that compulsive behaviour is carried out to remove anxiety-provoking intrusive thoughts. Unfortunately this only brings about temporary relief as the thought re-emerges. Each time the behaviour occurs it is negatively reinforced by the relief from anxiety, thereby explaining why the dysfunctional activity increases and generalizes (extends to other, related stimuli) over a period of time. For example, after touching a door-knob a person might have the thought that they may develop a disease as a result of contamination. They then experience anxiety, which is relieved when they wash their hands. This might be followed by the thought "but did I wash them properly?" causing an increase in anxiety once more, the hand-washing once again rewarded by the removal of anxiety (albeit briefly) and the cycle being repeated when thoughts of contamination re-occur. The distressing thoughts might then spread to fear of contamination from e.g. a chair (someone might have touched the chair after touching the door handle). The National Institute of Mental Health estimates that more than two percent of the U.S. population suffers from obsessive–compulsive disorder or OCD. Approximately 50% of men that suffer from obsessive–compulsive disorder, suffer from sexual side-effects as a result of OCD, and that 37% of men suffering from OCD are plagued with erectile dysfunction.

Biological

OCD has been linked to abnormalities with the neurotransmitter serotonin, although it could be either a cause or an effect of these abnormalities. Serotonin is thought to have a role in regulating anxiety. To send chemical messages from one neuron to another, serotonin must bind to the receptor sites located on the neighboring nerve cell. It is hypothesized that the serotonin receptors of OCD sufferers may be relatively understimulated. This suggestion is consistent with the observation that many OCD patients benefit from the use of selective serotonin reuptake inhibitors (SSRIs), a class of antidepressant medications that allow for more serotonin to be readily available to other nerve cells.

A possible genetic mutation may contribute to OCD. A mutation has been found in the human serotonin transporter gene, hSERT, in unrelated families with OCD. Moreover, data from identical twins supports the existence of a "heritable factor for neurotic anxiety". Further, individuals with OCD are more likely to have first-degree family members exhibiting the same disorders than do matched controls. In cases where OCD develops during childhood, there is a much stronger familial link in the disorder than cases in which OCD develops later in adulthood. In general, genetic factors account for 45-65% of OCD symptoms in children diagnosed with the disorder.[28] Environmental factors also play a role in how these anxiety symptoms are expressed; various studies on this topic are in progress and the presence of a genetic link is not yet definitely established.

Abnormal brain development and subsequent malfunction may contribute to the manifestation of OCD. A miscommunication between the orbitofrontal cortex (OFC), caudate nucleus, and thalamus may be a factor. The caudate nucleus lies between the OFC and thalamus and ordinarily prevents signals from being returned to the thalamus; if the caudate nucleus does not function normally the thalamus may become hyperactive and create an unceasing cycle of activity between the OFC and the thalamus, resulting in heightened anxiety. People with OCD evince increased grey matter volumes in bilateral lenticular nuclei, extending to the caudate nuclei, while decreased grey matter volumes in bilateral dorsal medial frontal/anterior cingulate gyri. OFC overactivity is attenuated in patients who have successfully responded to SSRI medication, a result believed to be caused by increased stimulation of serotonin receptors 5-HT2A and 5-HT2C. The striatum, linked to planning and the initiation of appropriate actions, has also been implicated; mice genetically engineered with a striatal abnormality exhibit OCD-like behavior, grooming themselves three times as frequently as ordinary mice. Recent evidence supports the possibility of a heritable predisposition for neurological development favoring OCD.

Rapid onset of OCD in children may be caused by Group A streptococcal infection, a condition identified by its acronym PANDAS. It has been suggested that PANDAS should be addressed as a possible cause of child OCD before other pharmacological remedies are attempted.

Diagnosis

Formal diagnosis may be performed by a psychologist or a psychiatrist. To be diagnosed with OCD, a person must have obsessions, compulsions, or both, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM). The Quick Reference to the 2000 edition of the DSM suggests that several features characterize clinically significant obsessions and compulsions. Such obsessions, the DSM says, are recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and that cause marked anxiety or distress. These thoughts, impulses, or images are of a degree or type that lies outside the normal range of worries about conventional problems. A person may attempt to ignore or suppress such obsessions, or to neutralize them with some other thought or action, and will tend to recognize the obsessions as idiosyncratic or irrational.

Compulsions become clinically significant when a person feels driven to perform them in response to an obsession, or according to rules that must be applied rigidly, and when the person consequently feels or causes significant distress. Therefore, while many people who do not suffer from OCD may perform actions often associated with OCD (such as ordering items in a pantry by height), the distinction with clinically significant OCD lies in the fact that the person who suffers from OCD must perform these actions, otherwise they will experience significant psychological distress. These behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these activities are not logically or practically connected to the issue, or they are excessive. In addition, at some point during the course of the disorder, the individual must realize that their obsessions or compulsions are unreasonable or excessive. Moreover, the obsessions or compulsions must be time-consuming (taking up more than one hour per day) or cause impairment in social, occupational, or scholastic functioning. It is helpful to quantify the severity of symptoms and impairment before and during treatment for OCD. In addition to the patient’s estimate of the time spent each day harboring obsessive-compulsive thoughts or behaviors, Fenske and Schwenk in their article “Obsessive-Compulsive Disorder: Diagnosis and Management,” argue that more concrete tools should be used to gauge the patient’s condition (2009). This may be done with rating scales, such as the most trusted Yale-Brown Obsessive Compulsive Scale (Y-BOCS). With measurements like these, psychiatric consultation can be more appropriately determined because it has been standardized.

Differential diagnosis

OCD is often confused with the separate condition obsessive–compulsive personality disorder. The two are not the same condition, however. OCD is egodystonic, meaning that the disorder is incompatible with the sufferer's self-concept. Because disorders that are ego dystonic go against an individual's self-concept, they tend to cause much distress. OCPD, on the other hand, is ego syntonic—marked by the individual's acceptance that the characteristics displayed as a result of this disorder are compatible with their self-image. Ego syntonic disorders understandably cause no distress. Persons suffering from OCD are often aware that their behavior is not rational and are unhappy about their obsessions but nevertheless feel compelled by them. Persons with OCPD are not aware of anything abnormal about themselves; they will readily explain why their actions are rational, and it is usually impossible to convince them otherwise. Persons with OCD are ridden with anxiety; persons who suffer from OCPD, by contrast, tend to derive pleasure from their obsessions or compulsions.

Equally frequently, these rationalizations do not apply to the overall behavior, but to each instance individually; for example, a person compulsively checking their front door may argue that the time taken and stress caused by one more check of the front door is considerably less than the time and stress associated with being robbed, and thus the check is the better option. In practice, after that check, the individual is still not sure, and deems it is still better in terms of time and stress to do one more check, and this reasoning can continue as long as necessary.

Some OCD sufferers exhibit what is known as overvalued ideas. In such cases, the person with OCD will truly be uncertain whether the fears that cause them to perform their compulsions are irrational or not. After some discussion, it is possible to convince the individual that their fears may be unfounded. It may be more difficult to do ERP therapy on such patients, because they may be, at least initially, unwilling to cooperate. For this reason OCD has often been likened to a disease of pathological doubt, in which the sufferer, while not usually delusional, is often unable to realize fully which dreaded events are reasonably possible and which are not. There are severe cases when the sufferer has an unshakeable belief within the context of OCD which is difficult to differentiate from psychosis.

OCD is different from behaviors such as gambling addiction and overeating. People with these disorders typically experience at least some pleasure from their activity; OCD sufferers do not actively want to perform their compulsive tasks, and experience no pleasure from doing so. OCD is characterized as an anxiety disorder, but like many forms of chronic stress it can lead to clinical depression over time. The constant stress of the condition can cause sufferers to develop a deadening of spirit, a numbing frustration, or sense of hopelessness. OCD's effects on day-to-day life—particularly its substantial consumption of time—can produce difficulties with work, finances and relationships. There is no known cure for OCD as of yet, but there are a number of successful treatment options available.

Management

According to a team of Duke University-led psychiatrists, behavioral therapy (BT), cognitive behavioral therapy (CBT), and medications should be regarded as first-line treatments for OCD. Psychodynamic psychotherapy may help in managing some aspects of the disorder. The American Psychiatric Association notes a lack of controlled demonstrations that psychoanalysis or dynamic psychotherapy are effective "in dealing with the core symptoms of OCD."

Behavioral therapy

The specific technique used in BT/CBT is called exposure and ritual prevention (also known as "exposure and response prevention") or ERP; this involves gradually learning to tolerate the anxiety associated with not performing the ritual behavior. At first, for example, someone might touch something only very mildly "contaminated" (such as a tissue that has been touched by another tissue that has been touched by the end of a toothpick that has touched a book that came from a "contaminated" location, such as a school.) That is the "exposure". The "ritual prevention" is not washing. Another example might be leaving the house and checking the lock only once (exposure) without going back and checking again (ritual prevention). The person fairly quickly habituates to the anxiety-producing situation and discovers that their anxiety level has dropped considerably; they can then progress to touching something more "contaminated" or not checking the lock at all—again, without performing the ritual behavior of washing or checking.

Exposure ritual/response prevention (ERP) has been demonstrated to be the most effective treatment for OCD. Using ERP alone, one can become completely symptom free. However, the individual must be highly motivated and consistent. It has generally been accepted that psychotherapy, in combination with psychotropic medication, is more effective than either option alone. However, more recent studies have shown no difference in outcomes for those treated with the combination of medicine and CBT versus CBT alone.

Association splitting is a new technique aimed at reducing obsessive thoughts. The method draws upon the “fan effect” of associative priming: The sprouting of new associations diminishes the strength of existing ones. As OCD patients show marked biases or restrictions in OCD-related semantic networks (e.g., cancer is only associated with “illness” or “death”, fire is only associated with “danger” or “destruction”), they are encouraged to imagine neutral or positive associations to OCD-related cognitions (cancer = zodiac sign, animal, lobster; fire = fireflies, fireworks, candlelight-dinner). First studies tentatively confirm the feasibility and effectiveness of the approach for a subgroup of patients.

Medication

Medications as treatment include selective serotonin reuptake inhibitors (SSRIs) such as paroxetine, sertraline, fluoxetine, escitalopram, and fluvoxamine as well as the tricyclic antidepressants, in particular clomipramine. SSRIs prevent excess serotonin from being pumped back into the original neuron that released it. Instead, serotonin can then bind to the receptor sites of nearby neurons and send chemical messages or signals that can help regulate the excessive anxiety and obsessive thoughts. In some treatment-resistant cases, a combination of clomipramine and an SSRI has shown to be effective even when neither drug on its own has been efficacious.

Treatment of obsessive–compulsive disorder is an area requiring significant improvement in prescribing regimes. Benzodiazepines are sometimes used for obsessive compulsive disorder, although they are generally believed to be ineffective for this indication; effectiveness was however, found in one small study. Benzodiazepines can be considered as a treatment option in treatment resistant cases. Morphine and other less potent pain killers, which possess agonist actions at the μ-opioid receptor and inhibit the reuptake of norepinephrine and serotonin, have shown effectiveness in the treatment of OCD.

Serotonergic antidepressants typically take longer to show benefit in OCD than with most other disorders they are used to treat. It is common for 2–3 months to elapse before any tangible improvement is noticed. In addition to this, treatment usually requires high doses. Fluoxetine, for example, is usually prescribed in doses of 20 mg per day for clinical depression, whereas with OCD the dose will often range from 20 mg to 80 mg or higher, if necessary. In most cases antidepressant therapy alone will only provide a partial reduction in symptoms, even in cases that are not deemed treatment-resistant. Much current research is devoted to the therapeutic potential of the agents that affect the release of the neurotransmitter glutamate or the binding to its receptors. These include riluzole, memantine, gabapentin, N-Acetylcysteine and lamotrigine. MDMA, which is a powerful and illicit serotonergic drug, has also been anecdotally reported to temporarily alleviate the symptoms of OCD.

Low doses of the newer atypical antipsychotics olanzapine, quetiapine, ziprasidone and risperidone have also been found to be useful as adjuncts in the treatment of OCD. The use of antipsychotics in OCD must be undertaken carefully, however, since, although there is very strong evidence that at low doses they are beneficial (most likely due to their dopamine receptor antagonism), at high doses these same antipsychotics have proven to cause dramatic obsessive–compulsive symptoms even in those patients who do not normally have OCD. This can be due to the antagonism of 5-HT2A receptors becoming very prominent at these doses and outweighing the benefits of dopamine antagonism. However, the antidepressant mirtazapine, which is a 5-HT2A antagonist, has been shown to benefit to OCD patients. Another point that must be noted with antipsychotic treatment is that SSRIs inhibit the chief enzyme that is responsible for metabolising antipsychotics—CYP2D6—so the dose will be effectively higher than expected when these are combined with SSRIs. Also, it must be noted that antipsychotic treatment should be considered as augmentation treatment when SSRI treatment does not bring positive results.

Alternative drug treatments

The naturally occurring sugar inositol has been suggested as a treatment for OCD, as it appears to modulate the actions of serotonin and reverse desensitisation of neurotransmitter receptors. St John's Wort has been claimed to be of benefit due to its (non-selective) serotonin re-uptake inhibiting qualities, although a double-blind study using a flexible-dose schedule (600–1800 mg/day) found no difference between St John's Wort and a placebo.

Nutrition deficiencies may also contribute to OCD and other mental disorders. Vitamin and mineral supplements may aid in such disorders and provide nutrients necessary for proper mental functioning.

Opioids may rapidly ameliorate OCD symptoms. Tramadol is an atypical opioid that appears to provide the anti-OCD effects of an opiate and inhibit the re-uptake of serotonin (in addition to norepinephrine). Oral morphine, administered once weekly, has been shown to reduce OCD symptoms in some treatment-resistant patients. The mechanism of therapeutic action is unknown.

Psychedelics such as LSD, peyote, and Tryptamine alkaloid psilocybin have been proposed as treatment due to their observed effects on OCD symptoms. It has been hypothesised that hallucinogens may stimulate 5-HT2A receptors and, less significantly, 5-HT2C receptors, causing an inhibitory effect on the orbitofrontal cortex, an area of the brain strongly associated with hyperactivity and OCD.

Regular nicotine treatment may ameliorate symptoms of OCD, although the pharmacodynamical mechanism by which this is achieved is not yet known, and more detailed studies are needed to fully confirm this hypothesis.

Electroconvulsive therapy (ECT)

This has been found effective in severe and refractory cases.

Psychosurgery

For some, neither medication, support groups nor psychological treatments are helpful in alleviating obsessive–compulsive symptoms. These patients may choose to undergo psychosurgery as a last resort. In this procedure, a surgical lesion is made in an area of the brain (the cingulate cortex). In one study, 30% of participants benefited significantly from this procedure. Deep-brain stimulation and vagus nerve stimulation are possible surgical options which do not require destruction of brain tissue. In the US, the Food and Drug Administration approved deep-brain stimulation for the treatment of OCD under a humanitarian device exemption requiring that the procedure be performed only in a hospital with specialist qualifications to do so.

In the US, psychosurgery for OCD is a treatment of last resort and will not be performed until the patient has failed several attempts at medication (at the full dosage) with augmentation, and many months of intensive cognitive–behavioral therapy with exposure and ritual/response prevention. Likewise, in the UK, psychosurgery cannot be performed unless a course of treatment from a suitably qualified cognitive–behavioral therapist has been carried out.

Treatment in children and adolescents

Although the causes of OCD in younger age groups range from brain abnormalities to psychological preoccupations, life stress may also contribute to childhood cases of OCD—acknowledging these stressors plays an important role in treating the disorder. In her article “Factors Influencing the Onset of Childhood Obsessive Compulsive Disorder” Tina M. D’Alessandro reports that such stressors as bullying and traumatic familial deaths have caused anxiety and depression in children, conditions that have led to their development of OCD. In order to reduce suffering and prevent OCD-related mortality in adulthood, D’Alessandro emphasizes the importance of considering these stressors early-on so as to guide the child toward treatment as soon as possible.

As with adults, behavioral treatment has proven to be quite effective in reducing ritual behaviors of OCD. A key component to the success of such treatments in children and adolescents consists of family member involvement which can be established in a number of different ways. Dr. Judith L. Rapoport stresses the importance of familial participation during the child’s therapy sessions as well as outside the sessions, in the form of creating behavioral observations and reports. Additionally, parental intervention aids in providing positive reinforcement for the child when s/he exhibits appropriate behaviors as alternatives to his/her compulsive response. Therapy, in general, has proven very helpful to children and adolescents with OCD according to Dr. Paul L. Adams. Parents may expect the duration of weekly sessions to last one to two years, but the results are quite valuable. Adams reports such changes in his own patients as the acquisition of a larger circle of friends, the child exhibiting less shyness, and being far less self-critical after considering the true meaning behind his/her obsession and learning how to cope with it in therapy sessions.

For phasing out obsessive thoughts, Rapoport reports that the mental technique of “thought stopping” has been successful particularly among adolescents. In this procedure, whenever the individual has an obsessive thought, s/he is encouraged to either mentally or verbally pronounce “STOP” in mid-thought to interrupt the obsession. Additionally, Rapoport reports a modification of this process so as to prevent “STOP” for becoming a stimulus to the obsessive thoughts: the child is to call to mind the thought, interrupt by loudly counting backward from ten, and then evoke a pleasant scene—in one subject, this reduced the obsessive frequencies by 80% in just one week and eliminated them in four.