Multiple: Obsessive-Compulsive Disorder

Definition
Description
Demographics
Causes and Symptoms
Diagnosis
Treatment
Prognosis
Prevention
The Future
For more information

Definition

Obsessive-compulsive disorder (OCD) is an anxiety disorder. People with OCD experience recurrent bothersome thoughts or mental images (obsessions) that worry the person. He or she then tries to control or ward off the anxiety by carrying out repetitious behaviors or mental acts (compulsions).

Description

OCD is sometimes described as a malfunction of the brain's information processing system. Everyone has upsetting thoughts or impulses from time to time—such as the urge to shout dirty words in public or thinking about hitting someone. However, most people are able to let go of these things and not worry about them. A person with OCD gets stuck on the thoughts or impulses and cannot put them aside. These thoughts or impulses are called obsessions. The person who has them may think that he or she is “going crazy” or will not be able to keep from acting on the thoughts. To cope with the anxiety, the person with OCD engages in repetitive behaviors or mental acts to undo, counteract, or control the obsessions. These behaviors are called compulsions.

Common obsessions include fears of contamination by germs or dirt; fear that one has harmed someone; thoughts of violence or of killing a pet or family member; worrying about thoughts that violate one's religious beliefs; and fear of performing sexual acts that the person dislikes. Common compulsions include repeated hand washing or bathing; checking doors or car windows over and over to be sure they are locked; counting objects; insisting that personal possessions like clothes in a closet or items on a desk be arranged “just so”; touching objects in a specific sequence; and hoarding items that are not needed.

It is important to recognize that people with OCD are distressed by these behaviors and usually realize that they do not make sense. Compulsions may consume several hours of the patient's day, interfering with work, family life, and other activities. They can also be harmful to health. There are instances of people damaging their skin by frequent hand washing or taking long showers. Unlike people with substance abuse or

eating disorders, people with OCD do not find their rituals pleasurable or satisfying; the acts are done only to manage their fears.

Demographics

OCD is a common anxiety disorder. According to some estimates, one adult in every fifty currently has the disorder, and two out of fifty have had it at some point in their lives. As of 2008 it is thought that about 2.2 million adults in the United States have OCD. It is likely, however, that the disorder is underdiagnosed because many people who suffer from it are embarrassed by their symptoms and often skilled at hiding them from others.

OCD can begin at any age, including childhood. In fact, between a third and a half of adults diagnosed with the disorder say that their symptoms began in childhood. The most common age for the emergence of symptoms is between ten and twenty-four years.

OCD is equally common in all races and ethnic groups in the United States, although patients' specific obsessions are sometimes influenced by their cultural background. For example, fears of violating religious practices or beliefs are reported to be more common among Roman Catholics and Orthodox Jews than among Protestants.

Males and females are equally likely to develop OCD. However, males are more likely to begin showing symptoms in childhood and

adolescence, and females are more likely to develop symptoms in their early twenties.

Howard Hughes and OCD

During his lifetime, Howard Hughes (1905–1976) was an aviator, film producer, and one of the wealthiest people in the world. In 1953 he founded the Howard Hughes Medical Institute, which is one of the largest privately funded medical research institutions in the United States today. Although the institute has helped many people with its research on genetics and the immune system, it could not help Hughes with his OCD.

Hughes's behavior was fairly normal until the 1930s. At that time, his friends and business partners began to notice some strange behaviors, such as a compulsion to sort peas by size with a fork for hours. Another of Hughes's obsessions concerned contamination. He used paper tissues to pick up objects to avoid being exposed to germs. He also burned his clothing if he found out that someone he had met while wearing it had an illness. In the late 1960s, his obsession with contamination focused on radioactivity. At the time, Hughes was living in Nevada, where underground nuclear weapons tests were being conducted. He was so worried about being poisoned by radiation that he offered two successive presidents—Lyndon Johnson and Richard Nixon—million-dollar bribes to stop the tests.

Hughes eventually left the United States for the Bahamas. When he died in 1976, he weighed only 90 pounds and could only be identified by his fingerprints. The cause of death was kidney failure brought on by malnutrition. Howard Hughes's OCD led him to fear that his food was poisoned.

Causes and Symptoms

At one time it was thought that OCD was caused by childrearing practices that made the person anxious. Such compulsions as repeated washing or checking door locks were explained as rituals intended to please parents who were overly concerned with cleanliness or safety. This type of psychological explanation is no longer considered useful.

There are several recent theories about the possible causes of OCD:

• Genetic. It is known that having other family members with OCD increases a person's risk of developing the disorder. Although two genes have been linked to OCD, one discovered in 1994 and the other in 2007, researchers have not yet been able to prove that either or both cause the disorder.
• Abnormally low levels of serotonin in the brain. Serotonin is a chemical produced by the brain that regulates mood, appetite, sleep, and memory. One piece of evidence that supports the serotonin theory is that patients with OCD, who are given a type of antidepressant that makes more serotonin available to brain cells, obtain some relief from their symptoms. These antidepressants are called selective serotonin reuptake inhibitors, or SSRIs.
• Differences in brain structure. Researchers who have used magnetic resonance imaging (MRI) to map the regions of the brain have found that people with OCD have abnormally high levels of activity in some areas.
• Infections. OCD in children has sometimes been attributed to a complication of strep throat. This theory holds that the child's body produces antibodies against the strep throat bacteria. These antibodies then attack the brain and cause a sudden onset of OCD. However, this theory is controversial and is considered unproven.

The symptoms of OCD are obsessions and compulsions that interfere with the person's schoolwork, job, or social functioning, and that have no real-life basis in the person's present situation. (For example, a person with an immune system disorder would have a real-life reason for worrying about germs and infection, and a person living in a high-crime neighborhood would be understandably very concerned about checking locks). Common obsessions include:

• Fear of dirt, germs, radioactivity, or other types of contamination
• Doubting whether one has completed a task
• Needing to have things in perfect order or in some kind of symmetrical arrangement
• Sexual thoughts
• Aggressive or violent thoughts.

Common compulsions include:

• Repeatedly washing one's body, clothing, or other personal items
• Repeatedly checking one's work
• Constantly asking others for reassurance
• Repeatedly counting or rearranging items
• Counting numbers in certain patterns (all odd or even numbers, for example)
• Hoarding (such as buying several years worth of cleaning supplies) or being unable to throw out old magazines or worn-out items

Diagnosis

The diagnosis of OCD is often delayed because patients are ashamed of their symptoms and skilled at hiding them. It has been estimated that it takes an average of seventeen years from the time that a patient's symptoms begin for them to be diagnosed correctly and receive treatment for OCD. Another reason for the delay is that a person with OCD often has other disorders, including substance abuse disorders, bipolar disorder, panic disorder, or depression, and the OCD symptoms may be attributed to the other disorders. In children, OCD is sometimes misdiagnosed as autism or Tourette syndrome.

There are no laboratory tests for OCD. The person's primary care doctor will refer the patient to a psychiatrist or psychologist for a specialized interview. The diagnosis is based on a combination of the patient's history of symptoms and his or her answers to a diagnostic questionnaire. The questionnaire most often used is the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). The Y-BOCS has ten items, five for obsessions and five for compulsions. The questions evaluate the time consumed by symptoms, the extent to which they interfere with functioning, how much they distress the patient, and what the patient has done to try to control them.

Treatment

Treatment for OCD is usually based on a combination of medications and a type of psychotherapy called exposure and ritual prevention (or exposure and response prevention) or ERP. ERP is a form of cognitive behavior therapy in which patients are forced to confront their fears without resorting to their usual safety rituals. For example, someone who is afraid of contamination might be asked to touch an object that has

been touched by another object that has been touched by a piece of cloth from a “contaminated” location or source, and then refrain from washing his or her hands. The next time the patient might be asked to touch an object that has been directly touched by the cloth, and again not to wash. In most cases the patient's anxiety level drops fairly quickly and he or she can then give up the safety ritual.

The medications usually prescribed to treat OCD are the selective serotonin reuptake inhibitors or SSRIs. These include drugs like Paxil, Prozac, and Zoloft. As noted earlier, these drugs work by increasing the amount of serotonin available to some of the nerve endings in the brain.

A very small number of patients with severe OCD that does not respond to medications or ERP are treated surgically. The surgeon makes a small cut in a part of the brain called the cingulate bundle. This technique produces significant benefits for about 30 percent of patients who receive the operation. It is considered a treatment of last resort for severe OCD.

Prognosis

The prognosis of OCD varies from person to person. The disorder rarely goes away on its own. About 70 percent of patients benefit from treatment. However, the patient's symptoms may increase and decrease in a cyclical pattern over time. About 15 percent of patients get steadily worse over time even with treatment and may eventually become unable to function.

Prevention

There is no known way to prevent OCD. However, early diagnosis and prompt treatment can help to prevent the patient's symptoms from getting worse.

The Future

It is not known at present whether OCD is becoming more commonplace in the general population or whether a recent increase in the number of reported cases is due to wider recognition of the disorder and improved diagnosis.

Researchers are presently studying the effectiveness of newer drugs in treating OCD as well as deep brain stimulation or DBS. In DBS, thin wires are implanted in the parts of the brain that have been linked to OCD symptoms. A battery-powered stimulator sends electrical pulses to the

brain at regular intervals in order to interfere with the activity of the nerve cells in the target areas. DBS has already been used to treat Parkinson disease and is considered an experimental treatment for Tourette syndrome.

SEE ALSO Bipolar disorder; Depression; Panic disorder; Strep throat; Tourette syndrome

WORDS TO KNOW

Compulsion : A repeated behavior or mental act carried out to control or neutralize obsessions.

Obsession : A recurrent, distressing, intrusive thought, image, or impulse.

Selective serotonin reuptake inhibitors (SSRIs) : A group of antidepressants that work by increasing the amount of serotonin available to nerve cells in the brain.

Serotonin : A brain chemical that influences mood, anger, anxiety, body temperature, and appetite. It may be involved in OCD.

For more information

BOOKS

Deane, Ruth. Washing My Life Away: Surviving Obsessive-Compulsive Disorder. Philadelphia: Jessica Kingsley Publishers, 2005.

Hyman, Bruce M., and Cherry Pedrick. Obsessive-Compulsive Disorder. Brookfield, CT: Twenty-First Century Books, 2003.

Wagner, Aureen Pinto. Up and Down the Worry Hill: A Children's Book about Obsessive-Compulsive Disorder and Its Treatment. Rochester, NY: Lighthouse Press, 2004.

WEB SITES

American Academy of Family Physicians (AAFP). Obsessive-Compulsive Disorder: What It Is and How to Treat It. Available online at http://familydoctor.org/online/famdocen/home/common/mentalhealth/anxiety/133.html (updated November 2006; accessed August 18, 2008).

Anxiety Disorders Association of America (ADAA). Obsessive-Compulsive Disorder. Available in PDF format at http://www.adaa.org/bookstore/Brochures/OCD_adaa%20rev%20506.pdf (accessed August 18, 2008).

Mayo Clinic. Obsessive-Compulsive Disorder (OCD). Available online at http://www.mayoclinic.com/health/obsessive-compulsive-disorder/DS00189 (updated December 21, 2006; accessed August 18, 2008).

National Alliance on Mental Illness (NAMI). Obsessive-Compulsive Disorder. Available online at http://www.nami.org/Template.cfm?Section=By_Illness&Template=/TaggedPage/TaggedPageDisplay.cfm&TPLID=54&ContentID=23035 (updated May 2003; accessed August 18, 2008).

National Institute of Mental Health (NIMH). Obsessive-Compulsive Disorder(OCD). Available online at http://www.nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd/index.shtml (updated April 2, 2008; accessed August 18, 2008).

Obsessive Compulsive Foundation (OCF). About OCD. Available online at http://www.ocfoundation.org/what-is-ocd.html (accessed August 18, 2008).