Obsessive-compulsive disorder

Definition

Obsessive-compulsive disorder (OCD) is currently classified as an anxiety disorder marked by the recurrence of intrusive or disturbing thoughts, impulses, images or ideas (obsessions) accompanied by repeated attempts to suppress these thoughts through the performance of certain irrational and ritualistic behaviors or mental acts (compulsions). The obsessions and compulsions take up large amounts of the patient's time (an hour or longer every day) and usually cause significant emotional distress for the patient and difficulties in his or her relationships with others.

Some researchers have questioned whether OCD really belongs with the other anxiety disorders. They think that it should be grouped with the spectrum of such obsessive-compulsive disorders as Tourette's syndrome, which are known to have biological causes.

OCD should not be confused with obsessive-compulsive personality disorder even though the two disorders have similar names. Obsessive-compulsive personality disorder is not characterized by the presence of obsessions and compulsions; rather, it is a lifelong pattern of insistence on control, orderliness, and perfection that begins no later than the early adult years. It is possible, however, for a person to have both disorders.

Description

Obsessive-compulsive disorder is a mental disorder with two components: obsessions, which consist of thoughts, impulses, or mental images; and compulsions, which are repetitive behaviors that the person feels driven to perform in response to the obsessions. In some cases, the compulsion may represent a strict rule that the patient must apply rigidly in every situation (tying one's shoes a certain number of times, for example) in order to feel "right." The exact content of obsessions varies from person to person, although certain themes are common. People with OCD experience their disturbing thoughts and images as intrusive and troublesome, but they recognize that their thoughts are products of their own minds. Obsessive thoughts are different from worries about such real-life problems as losing one's job or bad grades in school. In addition, obsessive thoughts are not usually related to any real-life problems.

The most common types of obsessions in persons with OCD in Western countries are:

• fear of contamination (impurity, pollution, badness)
• doubts (worrying about whether one has omitted to do something)
• an intense need to have or put things in a particular order
• aggressive or frightening impulses
• recurrent sexual thoughts or images

It is important to understand that patients diagnosed with OCD do not perform their compulsions for pleasure or satisfaction. A compulsive behavior becomes linked to an obsessional thought because the behavior lowers the level of anxiety produced by the obsession(s).

The most common compulsions in Western countries are:

• washing/cleaning
• counting
• hoarding
• checking
• putting objects in a certain order
• repeated "confessing" or asking others for assurance
• repeated actions
• making lists

Although descriptions of patients with OCD have been reported since the fifteenth century in religious and psychiatric literature, the condition was widely assumed to be rare until very recently. Epidemiological research since 1980 has now identified OCD as the fourth most common psychiatric illness, after phobias, substance use disorders, and major depressive disorders. OCD is presently classified as a form of anxiety disorder, but current studies indicate that it results from a combination of psychological, neurobiological, genetic, and environmental causes.

Causes and symptoms

Causes

PSYCHOSOCIAL. In the early part of the century, Sigmund Freud theorized that OCD symptoms were caused by punitive, rigid toilet-training practices that led to internalized conflicts. Other theorists thought that OCD was influenced by such wider cultural attitudes as insistence on cleanliness and neatness, as well as by the attitudes and parenting style of the patient's parents. Cross-cultural studies of OCD indicate that, while the incidence of OCD seems to be about the same in most countries around the world, the symptoms are often shaped by the patient's culture of origin. For example, a patient from a Western country may have a contamination obsession that is focused on germs, whereas a patient from India may fear contamination by touching a person from a lower social caste.

Studies of families with OCD members indicate that the particular expression of OCD symptoms may be affected by the responses of other people. Families with a high tolerance for the symptoms are more likely to have members with more extreme or elaborate symptoms. Problems often occur when the OCD member's obsessions and rituals begin to control the entire family.

BIOLOGICAL. There is considerable evidence that OCD has a biological component. Some researchers have noted that OCD is more common in patients who have suffered head trauma or have been diagnosed with Tourette's syndrome. Recent studies using positron emission tomography (PET) scanning indicate that OCD patients have patterns of brain activity that differ from those of people without mental illness or with some other mental illness. Other studies using magnetic resonance imaging (MRI) found that patients diagnosed with OCD had significantly less white matter in their brains than did normal control subjects. This finding suggests that there is a widely distributed brain abnormality in OCD. Some researchers have reported abnormalities in the metabolism of serotonin, an important neurotransmitter, in patients diagnosed with OCD. Serotonin affects the efficiency of communication between the front part of the brain (the cortex) and structures that lie deeper in the brain known as the basal ganglia. Dysfunction in the serotonergic system occurs in certain other mental illnesses, including major depression. OCD appears to have a number of features in common with the so-called obsessive-compulsive spectrum disorders, which include Tourette's syndrome; Sydenham's chorea; eating disorders; trichotillomania ; and delusional disorders.

There appear to be genetic factors involved in OCD. The families of persons who are diagnosed with the disorder have a greater risk of OCD and tic disorders than does the general population. Childhood-onset OCD appears to run in families more than adult-onset OCD, and is more likely to be associated with tic disorders. Twin studies indicate that monozygotic, or identical twins, are more likely to share the disorder than dizygotic, or fraternal twins. The concordance (match) rate between identical twins is not 100%, however, which suggests that the occurrence of OCD is affected by environmental as well as genetic factors. In addition, it is the general nature of OCD that seems to run in families rather than the specific symptoms; thus, one family member who is affected by the disorder may have a compulsion about washing and cleaning while another is a compulsive counter.

Large epidemiological studies have found a connection between streptococcal infections in childhood and the abrupt onset or worsening of OCD symptoms. The observation that there are two age-related peaks in the onset of the disorder increases the possibility that there is a common causal factor. Patients with childhood-onset OCD often have had one of two diseases caused by a group of bacteria called Group A beta-hemolytic streptococci ("strep" throat and Sydenham's chorea) prior to the onset of the OCD symptoms. The disorders are sometimes referred to as pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, or PANDAS. It is thought that antibodies in the child's blood cross-react with structures in the basal ganglia, producing or worsening the symptoms of OCD or tic disorders.

Symptoms

The symptoms of OCD should not be confused with the ability to focus on detail or to check one's work that is sometimes labeled "compulsive" in everyday life. This type of attentiveness is an important factor in academic achievement and in doing well in fields that require close attention to detail, such as accounting or engineering. By contrast, the symptoms of OCD are serious enough to interfere with the person's day-to-day functioning. Historical examples of OCD include a medieval Englishman named William of Oseney, who spent twelve hours per day reading religious books in order to be at peace with God; and Freud's Rat Man, a patient who had repeated dreams of cursing Freud and covering him with dung. While the Rat Man was ashamed of these impulses and had no explanation for them, he could not control them.

More recent accounts of OCD symptoms include those of a young man who compulsively touched every electrical outlet as he passed, washed his hands several times an hour, and returned home repeatedly to check that the doors and windows were locked. Another account describes a firefighter who was worried that he had throat cancer. He spent three hours a day examining his throat in the mirror, feeling his lymph nodes, and asking his wife if his throat appeared normal.

Brief descriptions of the more common obsessions and compulsions follow.

CONTAMINATION. People with contamination obsessions are usually preoccupied with a fear of dirt or germs. They may avoid leaving home or allowing visitors to come inside in order to prevent contact with dirt or germs. Some people with contamination obsessions may wear gloves, coats, or even masks if they are forced to leave their house for some reason. Obsessions with contamination may also include abnormal fears of such environmental toxins as lead, asbestos, or radon.

Washing compulsions are commonly associated with contamination obsessions. For example, a person concerned about contamination from the outside may shower and launder all clothing immediately upon coming home. The compulsion may be triggered by direct contact with the feared object, but in many cases, even being in its general vicinity may stir up intense anxiety and a strong need to engage in a washing compulsion. One man who was afraid of contamination could not even take a short walk down the street without experiencing a compulsion to disinfect the soles of his shoes, launder all his clothing, and wash his hands until they were raw after he returned to his apartment.

Washing compulsions may not always be caused by a fear of germs. That is, a need for perfection or for symmetry may also lead to unnecessary washing. In such cases, the individual may be concerned about being "perfectly" clean, or feel that he cannot leave the shower until his left foot has been washed exactly as many times as his right foot. Other people with washing compulsions may be unable to tolerate feeling sweaty or otherwise not clean.

OBSESSIONAL DOUBTING. Obsessional doubting refers to the fear of having failed to perform some task adequately, and that dire consequences will follow as a result. Although the person may try to suppress the worrisome thoughts or images, he or she usually experiences a rising anxiety which then leads to a compulsion to check the task. For example, someone may worry about forgetting to lock the door or turn off the gas burner on the stove and spend hours checking these things before leaving home. In one instance, a man was unable to throw away old grocery bags because he feared he might have left something valuable inside one of them. Immediately after looking into an empty bag, he would again have the thought, "What if I missed something in there?" In many cases, no amount of checking is sufficient to dispel the maddening sense of doubt.

NEED FOR SYMMETRY. Persons suffering from an obsession about symmetry often report feeling acutely uncomfortable unless they perform certain tasks in a symmetrical or balanced manner. Thus, crossing one's legs to the right must be followed by crossing legs to the left; scratching one side of the head must be followed by scratching the other; tapping the wall with a knuckle on the right hand must be followed by tapping with one on the left, etc. Sometimes the person may have a thought or idea associated with the compulsion, such as a fear that a loved one will be harmed if the action is not balanced, but often there is no clearly defined fear, only a strong sense of uneasiness.

AGGRESSIVE AND SEXUAL OBSESSIONS. Aggressive and sexual obsessions are often particularly horrifying to those who experience them. For some people, obsessive fears of committing a terrible act in the future compete with fears that they may already have done something awful in the past. Compulsions to constantly check and confess cause such individuals to admit to evildoing they had no part in, a phenomenon familiar to law enforcement following highly publicized crimes. These obsessions often involve violent or graphic imagery that is upsetting and disgusting to the person, such as rape, physical assault, or even murder. One case study concerned a young woman who constantly checked the news to reassure herself that she had not murdered anyone that day; she felt deeply upset by unsolved murder cases. A middle-aged man repeatedly confessed to having molested a woman at work, despite no evidence of such an action ever occurring in his workplace.

SYMPTOMS IN CHILDREN. Obsessions and compulsions in children are often focused on germs and fears of contamination. Other common obsessions include fears of harm coming to self or others; fears of causing harm to another person; obsessions about symmetry; and excessive moralization or religiosity. Childhood compulsions frequently include washing, repeating, checking, touching, counting, ordering and arranging. Younger children are less likely to have full-blown anxiety-producing obsessions, but they often report a sense of relief or strong satisfaction (a "just right" feeling) from completing certain ritualized behaviors. Since children are particularly skillful in disguising their OCD symptoms from adults, they may effectively hide their disorder from parents and teachers for years.

Unusual behaviors in children that may be signs of OCD include:

• Avoidance of scissors or other sharp objects. A child may be obsessed with fears of hurting herself or others.
• Chronic lateness or dawdling. The child may be per forming checking rituals (repeatedly making sure all her school supplies are in her bookbag, for example).
• Daydreaming or preoccupation. The child may be counting or performing balancing rituals mentally.
• Spending long periods of time in the bathroom. The child may have a handwashing compulsion.
• Schoolwork handed in late or papers with holes erased in them. The child may be repeatedly checking and cor recting her work.

For both children and adults, the symptoms of OCD wax and wane in severity; and the specific content of obsessions and compulsions may change over time. The disorder, however, very seldom goes away by itself without treatment. People with OCD in all age groups typically find that their symptoms worsen during major life changes or following highly stressful events.

Demographics

As noted above, OCD is a relatively common mental disorder, with about 2.3% of the population of the United States being diagnosed with the condition at some point in their lives. As of 2000, the annual social and economic costs of OCD in the United States are estimated at $9 billion. Although the disorder may begin at any age, the typical age of onset is late adolescence to young adulthood, with slightly more women than men being diagnosed with OCD. Interestingly, childhood OCD is more common in males, and the sex ratio does not favor females until adulthood. People with OCD appear to be less likely to marry than persons diagnosed with other types of mental disorders.

Diagnosis

OCD is a disorder that may not be diagnosed for years. People who suffer from its symptoms are often deeply ashamed, and go to great lengths to hide their ritualistic behaviors. The disorder may be diagnosed when family members get tired of the impact of the patient's behaviors on their lives, and force the patient to consult a doctor. In other cases, the disorder may be self-reported. The patient may have come to resent the amount of time wasted by the compulsions; or he or she may have taken a screening questionnaire such as the brief screener available on the NIMH website (listed in the Resources section below).

The diagnosis of OCD may be complicated because of the number of other conditions that resemble it. For example, major depression may be associated with self-perceptions of being guilty, bad, or worthless that are excessive and unreasonable. Similarly, eating disorders often include bizarre thoughts about size and weight, ritualized eating habits, or the hoarding of food. Delusional disorders may entail unusual beliefs or behaviors, as do such other mental disorders as trichotillomania, hypochondriasis , the paraphilias , and substance use disorders. Thus, accurate diagnosis of OCD depends on the careful analysis of many variables to determine whether the apparent obsessions and compulsions might be better accounted for by some other disorder, or to the direct effects of a substance or a medical condition.

In addition, OCD may coexist with other mental disorders, most commonly depression. It has been estimated that about 34% of patients diagnosed with OCD are depressed at the time of diagnosis, and that 65% will develop depression at some point in their lives.

Treatments

As of 2002, a combination of behavioral therapy and medications appears to be the most effective treatment for OCD. The goal of treatment is to reduce the frequency and severity of the obsessions and compulsions so that the patient can work more efficiently and have more time for social activities. Few OCD patients become completely symptom-free, but most benefit considerably from treatment.

Psychotherapy

Behavioral treatments using the technique of exposure and response prevention are particularly effective in treating OCD. In this form of therapy, the patient and therapist draw up a list, or hierarchy, of the patient's obsessive and compulsive symptoms. The symptoms are arranged in order from least to most upsetting. The patient is then systematically exposed to the anxiety-producing thoughts or behaviors, beginning with the least upsetting. The patient is asked to endure the feared event or image without engaging in the compulsion normally used to lower anxiety. For example, a person with a contamination obsession might be asked to touch a series of increasingly dirty objects without washing their hands. In this way, the patient learns to tolerate the feared object, reducing both worrisome obsessions and anxiety-reducing compulsions. About 75%–80% of patients respond well to exposure and response prevention, with very significant reductions in symptoms.

Other types of psychotherapy have met with mixed results. Psychodynamic psychotherapy is helpful to some patients who are concerned about the relationships between their upbringing and the specific features of their OCD symptoms. Cognitive-behavioral psychotherapy may be valuable in helping the patient to become more comfortable with the prospect of exposure and prevention treatments, as well as helping to identify the role that the patient's particular symptoms may play in his or her own life and what effects family members may have on the maintenance and continuation of OCD symptoms. Cognitive-behavioral psychotherapy is not intended to replace exposure and response prevention, but may be a helpful addition to it.

Medications

The most useful medications for the treatment of OCD are the selective serotonin reuptake inhibitors (SSRIs), which affect the body's reabsorption of serotonin, a chemical in the brain that helps to transmit nerve impulses across the very small gaps between nerve cells. These drugs, specifically clomipramine (Anafranil), fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), and paroxetine (Paxil) have been found to relieve OCD symptoms in over half of the patients studied. It is not always possible for the doctor to predict which of the SSRIs will work best for a specific patient. Lack of response to one SSRI does not mean that other drugs within the same family will not work. Treatment of OCD often proceeds slowly, with various medications being tried before the most effective one is found. While studies report that about half of those treated with SSRIs show definite improvement, relapse rates may be as high as 90% when medications are discontinued.

Other mainstream approaches

Some treatments that have been used for OCD include electroconvulsive therapy (ECT) and, as a technique of last resort, psychosurgery for truly intractable OCD. Some patients have benefited from ECT; however, the National Institute of Mental Health (NIMH) recommends reserving ECT for OCD patients who have not responded to psychotherapy or medication.

Prognosis

While most patients with OCD benefit from a combination of medications and psychotherapy, the disorder is usually a lifelong condition. In addition, the presence of personality disorders or additional mental disorders is associated with less favorable results from treatment. The total elimination of OCD symptoms is very rare, even with extended treatment.

The onset of OCD in childhood is the single strongest predictor of a poor prognosis. Treatment in children is also complicated by the fact that children may find the response and exposure techniques very stressful. It is also hard for children to understand the potential value of such treatments; however, creative therapists have learned to use anxiety reduction strategies, education, and behavioral rewards to help their young patients with the treatment tasks. Concern about the long-term use of medications in children with OCD has further encouraged the use of cognitive-behavioral techniques whenever possible.

See also: Exposure treatment; Tic disorders

Resources

BOOKS

Kay, Jerald, M.D., and Allan Tasman, M.D. eds. "Obsessive-Compulsive Disorder." In Psychiatry:Behavioral Science and Clincial Essentials. Philadelphia: W.B. Saunders Company, 2000.

Millon, Theodore, M.D. Personality-Guided Therapy. New York:Wiley and Sons,1999.

Pato, Michele T., and others. " Obsessive-Compulsive Disorder." In Psychiatry Volume 2. Philadelphia: W.B. Saunders Company, 1997.

Piacentini, John, Ph.D., and Lindsey Bergman, Ph.D. "Anxiety Disorders in Children." In Kaplan and Sadock's Comprehensive Textbook of Psychiatry. Volume II. Edited by Benjamin Sadock, M.D. and Virginia Sadock, M.D. Philadelphia: Lippincott, Williams and Wilkins, 2000.

Sadock, Benjamin, M.D. and Sadock, Virginia, M.D. eds. Kaplan and Sadock's Comprehensive Textbook of Psychiatry. Volume I. 7th edition. Philadelphia: Lippincott, Williams, and Wilkins, 2000.

PERIODICALS

Abramowitz, J. S. "Effectiveness of Psychological and Pharmacological Treatments for Obsessive-Compulsive Disorder: A Quantitative Review." Journal of Consulting and Clinical Psychology 65 (1997): 44-52.

McLean, Peter D. and others. "Cognitive Versus Behavioral Therapy in the Group Treatment of Obsessive-Compulsive Disorder." Journal of Consulting and Clinical Psychology 69, no.2 (2001): 205-214.

ORGANIZATIONS

Anxiety Disorders Association of America (ADAA). 11900 Parklawn Drive, Suite 100, Rockville, MD 20852-2624.(301) 231-9350. <www.adaa.org>.

Freedom From Fear. 308 Seaview Avenue, Staten Island, NY 10305 (718) 351-1717. <www.freedomfromfear.com>.

Obsessive-Compulsive Foundation, Inc. 337 Notch Hill Road, North Branford, CT 06471. (203) 315-2196. <www.ocfoundation.org>.

OTHER

National Institute of Mental Health (NIMH). Obsessive-Compulsive Disorder, 3rd revised edition, 1999. NIH Publication No. 99-3755. <www.nimh.nih.gov/publicat/ocd.cfm>.

National Institute of Mental Health (NIMH). A Screening Test for Obsessive-Compulsive Disorder. <www.nimh.nih.gov/publicat/ocdtrt1.htm.>.

Jane A. Fitzgerald, Ph.D.

Obsessive-compulsive disorder

Definition

Obsessive-compulsive disorder (OCD) is a type of anxiety disorder characterized by distressing repetitive thoughts, impulses, or images that are intense, frightening, absurd, or unusual. These thoughts are followed by ritualized actions that are usually bizarre and irrational. These ritual actions, known as compulsions, help reduce anxiety caused by the individual's obsessive thoughts. Often described as the "disease of doubt," the sufferer usually knows the obsessive thoughts and compulsions are irrational but, on another level, fears they may be true.

Description

Almost one out of every 40 people will suffer from obsessive-compulsive disorder at some time in their lives. The condition is two to three times more common than either schizophrenia or manic depression , and strikes men and women of every ethnic group, age, and social level. Because the symptoms are so distressing, sufferers often hide their fears and rituals but cannot avoid acting on them. OCD sufferers are often unable to decide if their fears are realistic and need to be acted upon.

Most people with obsessive-compulsive disorder have both obsessions and compulsions, but occasionally a person will have just one or the other. The degree to which this condition can interfere with daily living also varies. Some people are barely bothered, while others find the obsessions and compulsions to be profoundly traumatic and spend a great deal of time each day in compulsive actions.

Obsessions are intrusive, irrational thoughts that keep popping up in a person's mind, such as, "My hands are dirty, I must wash them again." Typical obsessions include fears of dirt, germs, contamination, and violent or aggressive impulses. Other obsessions include feeling responsible for others' safety, or an irrational fear of hitting a pedestrian with a car. Additional obsessions may involve intrusive sexual thoughts. The patient may fear acting out the strong sexual thoughts in a hostile way. People with obsessive-compulsive disorder may have an intense preoccupation with order and symmetry, or be unable to throw anything out.

Compulsions usually involve repetitive rituals such as excessive washing (especially handwashing or bathing), cleaning, checking and touching, counting, arranging, or hoarding. As the person performs these acts, he may feel temporarily better, but there is no long lasting sense of satisfaction or completion after the act is performed. Often, a person with obsessive-compulsive disorder believes that if the ritual isn't performed, something dreadful will happen. While these compulsions may temporarily ease stress , short-term comfort is purchased at a heavy price—time spent repeating compulsive actions and a long-term interference with life.

The difference between OCD and other compulsive behavior is that while people who have problems with gambling, overeating, or substance abuse may appear to be compulsive, these activities also provide pleasure to some degree. The compulsions of OCD, on the other hand, are never pleasurable.

OCD may be related to some other conditions, such as the continual urge to pull out body hair (trichotillomania); fear of having a serious disease (hypochondriasis), or preoccupation with imagined defects in personal appearance disorder (body dysmorphic disorder). Some people with OCD also have Tourette syndrome , a condition featuring tics and unwanted vocalizations (such as swearing). OCD is often linked with depression and other anxiety disorders.

Causes & symptoms

The tendency to develop obsessive-compulsive dis-order appears to be inherited. In the summer of 2002, researchers at the University of Michigan identified a segment of human chromosome 9p as containing genes for susceptibility to OCD. Other chromosomes that may also be linked to OCD are 19q and 6p.

There are several theories behind the cause of OCD. Some experts believe that OCD is related to a chemical imbalance within the brain that causes a communication problem between the front part of the brain (frontal lobe) and deeper parts of the brain responsible for the repetitive behavior. Research has shown that the orbital cortex located on the underside of the brain's frontal lobe is overactive in OCD patients. This may be one reason for the feeling of alarm that pushes the patient into compulsive, repetitive actions. The higher-than-average rate of concurrent eating disorders in patients diagnosed with OCD has been attributed to the fact that hyperactivity in the orbital cortex is associated with both disorders. It is possible that people with OCD experience overactivity deep within the brain that causes the cells to get "stuck," much like a jammed transmission in a car damages the gears. This could lead to the development of rigid thinking and repetitive movements common to the disorder. The fact that drugs which boost the levels of serotonin (a brain chemical linked to emotion) in the brain can reduce OCD symptoms may indicate that to some degree OCD is related to brain serotonin levels.

Recently, scientists have identified an intriguing link between childhood episodes of strep throat and the development of OCD. It appears that in some vulnerable children, strep antibodies attack a certain part of the brain. Antibodies are cells that the body produces to fight specific diseases. That attack results in the development of excessive washing or germ phobias . A phobia is a strong but irrational fear. In this instance the phobia is fear of disease germs present on commonly handled objects. These symptoms would normally disappear over time, but some children who have repeated infections may develop full-blown OCD. Treatment with antibiotics has resulted in lessening of the OCD symptoms in some of these children.

If one person in a family has obsessive-compulsive disorder, there is a 25% chance that another immediate family member has the condition. It also appears that stress and psychological factors may worsen symptoms, which usually begin during adolescence or early adulthood.

Some studies indicate that the nature of parent-child interactions is an important factor in the development of OCD. Observers have often remarked that parents and children in OCD families can be differentiated from members of other types of families on the basis of behavior. One Australian study described the parents of children with OCD as "..less confident in their child's ability, less rewarding of independence, and less likely to use positive problem solving."

OCD has also sometimes been linked to religion, in that the symptoms of some persons diagnosed with OCD reflect religious beliefs or practices. Christian clergy have been trained since the Middle Ages to recognize a specific spiritual problem known as scrupulosity, in which a person is troubled by excessive fears of God's punishment or fears of having sinned and offended God. A new inventory for measuring scrupulosity in devout Jews as well as Protestants and Catholics has been tested at the University of Pennsylvania and appears to be a reliable instrument for evaluating OCD symptoms that take religious forms. Scrupulosity has been traditionally treated in both Judaism and Christianity by consultation with a rabbi, priest, or pastor who is able to correct the distorted beliefs that underlie the obsessions or compulsions. In some cases the clergyperson may also use an appropriate religious ritual in treating scrupulosity.

Diagnosis

People with obsessive-compulsive disorder feel ashamed of their problem and often try to hide their symptoms. They may avoid seeking treatment. Because they can be very good at keeping their problem from friends and family, many sufferers do not get the help

they need until the behaviors are deeply ingrained habits and harder to change. As a result, the condition is often misdiagnosed or underdiagnosed. All too often, it can take more than a decade between the onset of symptoms and proper diagnosis and treatment.

While scientists seem to agree that OCD is related to a disruption in serotonin levels, there is no blood test for the condition. Instead, doctors diagnose OCD after evaluating a person's symptoms and history.

Treatment

Because OCD sometimes responds to selective serotonin reuptake inhibitors (SSRI) antidepressants, herbalists believe a botanical medicine called St. John's wort (Hypericum perforatum ) might have some beneficial effect as well. Known popularly as "Nature's Prozac," St. John's wort is prescribed by herbalists for the treatment of anxiety and depression. They believe that this herb affects brain levels of serotonin in the same way that SSRI antidepressants do. Herbalists recommend a dose of 300 mg, three times per day. In about one out of 400 people, St. John's wort (like Prozac) may initially increase the level of anxiety. Homeopathic constitutional therapy can help rebalance the patient's mental, emotional, and physical well-being, allowing the behaviors of OCD to abate over time.

Other alternative treatments for OCD are intended to lower the patient's anxiety level; some are thought to diminish the compulsions themselves. Alternative recommendations include the following:

• Bach flower remedies : White chestnut, for obsessive thoughts and repetitive thinking.
• Traditional Chinese medicine: a mixture of bupleurum and dong quai , to strengthen the spleen and regulate the liver. In Chinese medicine, obsessive-compulsive disorder is due to liver stagnation and a weak spleen.
• Aromatherapy: a mixture of lavender, rosemary , and valerian for relaxation.
• Yoga: Yogis in India developed a special technique of yogic breathing specifically for OCD. The specific yogic technique for treating OCD requires blocking the right nostril with the tip of the thumb; slow deep inspiration through the left nostril; holding the breath; and slow complete expiration through the left nostril. This is followed by a long breath-holding out period.
• Schuessler tissue salts: for OCD, 10 tablets of Ferrum phosphorica 30X and 10 tablets of Kali phosphorica 200X, twice daily.
• Massage therapy: with special emphasis on loosening the muscles in the neck, back, and shoulders.

Cognitive-behavioral therapy (CBT) teaches patients how to confront their fears and obsessive thoughts by making the effort to endure or wait out the activities that usually cause anxiety without compulsively performing the calming rituals. Eventually their anxiety decreases. People who are able to alter their thought patterns in this way can lessen their preoccupation with the compulsive rituals. At the same time, the patient is encouraged to refocus attention elsewhere, such as on a hobby.

Allopathic treatment

Obsessive-compulsive disorder can be effectively treated by a combination of cognitive-behavioral therapy and medication that regulates the brain's serotonin levels. Drugs that are approved to treat obsessive-compulsive disorder include fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft), all SSRIs that affect the level of serotonin in the brain. Drugs should be taken for at least 12 weeks before deciding whether or not they are effective.

In a few severe cases where patients have not responded to medication or behavioral therapy , brain surgery may be attempted to relieve symptoms. Surgery can help up to a third of patients with the most severe form of OCD. The most common operation involves removing a section of the brain called the cingulate cortex. The serious side effects of this surgery for some patients include seizures, personality changes, and decreased ability to plan.

Expected results

Obsessive-compulsive disorder is a chronic disease that, if untreated, can last for decades, fluctuating from mild to severe and worsening with age. When treated by a combination of drugs and behavioral therapy, some patients go into complete remission. Unfortunately, not all patients have such a good response. About 20% of people cannot find relief with either drugs or behavioral therapy. Hospitalization may be required in some cases.

Resources

BOOKS

Dumont, Raeann. The Sky is Falling: Understanding and Coping with Phobias, Panic and Obsessive-Compulsive Disorders. New York: W.W. Norton & Co., 1996.

Pelletier, Kenneth R., MD. The Best Alternative Medicine, Part II, "CAM Therapies for Specific Conditions: Anxiety." New York: Simon & Schuster, 2002.

Schwartz, Jeffrey. Brain Lock. New York: HarperCollins, 1996.

Schwartz, Jeffrey. Free Yourself from Obsessive-Compulsive Behavior: A Four-Step Self-Treatment Method to Change Your Brain Chemistry. New York: HarperCollins, 1996.

Swedo, S.E., and H. L. Leonard. It's Not All In Your Head. New York: HarperCollins, 1996.

PERIODICALS

Abramowitz, J. S., J. D. Huppert, A. B. Cohen, et al. "Religious Obsessions and Compulsions in a Non-Clinical Sample: The Penn Inventory of Scrupulosity (PIOS)." Behaviour Research and Therapy 40 (July 2002): 825-838.

Barrett, P., A. Shortt, and L. Healy. "Do Parent and Child Behaviours Differentiate Families Whose Children Have Obsessive-Compulsive Disorder from Other Clinic and Non-Clinic Families?" Journal of Child Psychology and Psychiatry 43 (July 2002): 597-607.

Hanna, G. L., J. Veenstra-Vanderweele, N. J. Cox, et al. "Genome-Wide Linkage Analysis of Families with Obsessive-Compulsive Disorder Ascertained through Pediatric Probands." American Journal of Medical Genetics 114 (July 8, 2002): 541-552.

Lin, H., C. B. Yeh, B. S. Peterson, et al. "Assessment of Symptom Exacerbations in a Longitudinal Study of Children with Tourette's Syndrome or Obsessive-Compulsive Dis-order." Journal of the American Academy of Child and Adolescent Psychiatry 41 (September 2002): 1070-1077.

Pelchat, M. L. "Of Human Bondage: Food Craving, Obsession, Compulsion, and Addiction." Integrative Physiological and Behavioral Science 76 (July 2002): 347-352.

Sica, C., C. Novara, and E. Sanavio. "Religiousness and Obsessive-Compulsive Cognitions and Symptoms in an Italian Population." Behaviour Research and Therapy 40 (July 2002): 813-823.

Stein, D. J. "Obsessive-Compulsive Disorder." Lancet 360 (August 3, 2002): 397-405.

Talan, Jamie. "A Link to Strep, Behavior: The Infection May Trigger Obsessive-Compulsive Symptoms." Newsday (May 21, 1996): B31.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007. (202) 966-7300. Fax: (202) 966-2891. <www.aacap.org.>.

American Psychiatric Association. 1400 K Street, NW. Washington, DC 20005. (202) 682-6220. <www.psych.org.>.

Anxiety Disorders Association of America. 11900 Parklawn Dr., Ste. 100, Rockville, MD 20852. (301) 231-9350. http://adaa.org.

National Alliance for the Mentally Ill (NAMI). 200 N.Glebe Rd., #1015, Arlington, VA 22203-3728. (800) 950-NAMI. http://www.nami.org.

National Anxiety Foundation. 3135 Custer Dr., Lexington, KY 40517. (606) 272-7166. http://www.lexington-online.com/naf.html.

National Institutes of Mental Health (NIMH). Information Resources and Inquires Branch. 5600 Fishers Lane, Rm.7C-02, MSC 8030, Bethesda, MD20892. (301) 443-4513. http://www.nimh.nih.gov.

Paula Ford-Martin

Rebecca J. Frey, PhD

Obsessive-Compulsive Disorder

Definition

Obsessive-compulsive disorder (OCD) is a type of anxiety disorder. Anxiety disorder is the experience of prolonged, excessive worry about circumstances in one's life. OCD is characterized by distressing repetitive thoughts, impulses or images that are intense, frightening, absurd, or unusual. These thoughts are followed by ritualized actions that are usually bizarre and irrational. These ritual actions, known as compulsions, help reduce anxiety caused by the individual's obsessive thoughts. Often described as the "disease of doubt," the sufferer usually knows the obsessive thoughts and compulsions are irrational but, on another level, fears they may be true.

Description

Almost one out of every 40 people will suffer from obsessive-compulsive disorder at some time in their lives. The condition is two to three times more common than either schizophrenia or manic depression, and strikes men and women of every ethnic group, age and social level. Because the symptoms are so distressing, sufferers often hide their fears and rituals but cannot avoid acting on them. OCD sufferers are often unable to decide if their fears are realistic and need to be acted upon.

Most people with obsessive-compulsive disorder have both obsessions and compulsions, but occasionally a person will have just one or the other. The degree to which this condition can interfere with daily living also varies. Some people are barely bothered, while others find the obsessions and compulsions to be profoundly traumatic and spend much time each day in compulsive actions.

Obsessions are intrusive, irrational thoughts that keep popping up in a person's mind, such as "my hands are dirty, I must wash them again." Typical obsessions include fears of dirt, germs, contamination, and violent or aggressive impulses. Other obsessions include feeling responsible for others' safety, or an irrational fear of hitting a pedestrian with a car. Additional obsessions can involve excessive religious feelings or intrusive sexual thoughts. The patient may need to confess frequently to a religious counselor or may fear acting out the strong sexual thoughts in a hostile way. People with obsessive-compulsive disorder may have an intense preoccupation with order and symmetry, or be unable to throw anything out.

Compulsions usually involve repetitive rituals such as excessive washing (especially handwashing or bathing), cleaning, checking and touching, counting, arranging or hoarding. As the person performs these acts, he may feel temporarily better, but there is no long-lasting sense of satisfaction or completion after the act is performed. Often, a person with obsessive-compulsive disorder believes that if the ritual is not performed, something dreadful will happen. While these compulsions may temporarily ease stress, short-term comfort is purchased at a heavy price—time spent repeating compulsive actions and a long-term interference with life.

The difference between OCD and other compulsive behavior is that while people who have problems with gambling, overeating or with substance abuse may appear to be compulsive, these activities also provide pleasure to some degree. The compulsions of OCD, on the other hand, are never pleasurable.

OCD may be related to some other conditions, such as the continual urge to pull out body hair (trichotillomania) fear of having a serious disease (hypochondriasis ) or preoccupation with imagined defects in personal appearance disorder (body dysmorphia). Some people with OCD also have Tourette syndrome, a condition featuring tics and unwanted vocalizations (such as swearing). OCD is often linked with depression and other anxiety disorders.

Causes and symptoms

While no one knows for sure, research suggests that the tendency to develop obsessive-compulsive disorder is inherited. There are several theories behind the cause of OCD. Some experts believe that OCD is related to a chemical imbalance within the brain that causes a communication problem between the front part of the brain (frontal lobe) and deeper parts of the brain responsible for the repetitive behavior. Research has shown that the orbital cortex located on the underside of the brain's frontal lobe is overactive in OCD patients. This may be one reason for the feeling of alarm that pushes the patient into compulsive, repetitive actions. It is possible that people with OCD experience overactivity deep within the brain that causes the cells to get "stuck," much like a jammed transmission in a car damages the gears. This could lead to the development of rigid thinking and repetitive movements common to the disorder. The fact that drugs which boost the levels of serotonin, a brain messenger substance linked to emotion and many different anxiety disorders, in the brain can reduce OCD symptoms may indicate that to some degree OCD is related to levels of serotonin in the brain.

Recently, scientists have identified an intriguing link between childhood episodes of strep throat and the development of OCD. It appears that in some vulnerable children, strep antibodies attack a certain part of the brain. Antibodies are cells that the body produces to fight specific diseases. That attack results in the development of excessive washing or germ phobias. A phobia is a strong but irrational fear. In this instance the phobia is fear of disease germs present on commonly handled objects. These symptoms would normally disappear over time, but some children who have repeated infections may develop full-blown OCD. Treatment with antibiotics has resulted in lessening of the OCD symptoms in some of these children.

If one person in a family has obsessive-compulsive disorder, there is a 25% chance that another immediate family member has the condition. It also appears that stress and psychological factors may worsen symptoms, which usually begin during adolescence or early adulthood.

Diagnosis

People with obsessive-compulsive disorder feel ashamed of their problem and often try to hide their symptoms. They avoid seeking treatment. Because they can be very good at keeping their problem from friends and family, many sufferers do not get the help they need until the behaviors are deeply ingrained habits and hard to change. As a result, the condition is often misdiagnosed or underdiagnosed. All too often, it can take more than a decade between the onset of symptoms and proper diagnosis and treatment.

While scientists seem to agree that OCD is related to a disruption in serotonin levels, there is no blood test for the condition. Instead, doctors diagnose OCD after evaluating a person's symptoms and history.

Treatment

Obsessive-compulsive disorder can be effectively treated by a combination of cognitive-behavioral therapy and medication that regulates the brain's serotonin levels. Drugs that are approved to treat obsessive-compulsive disorder include fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft), all selective serotonin reuptake inhibitors (SSRIs) that affect the level of serotonin in the brain. Older drugs include the antidepressant clomipramine (Anafranil), a widely-studied drug in the treatment of OCD, but one that carries a greater risk of side effects. Drugs should be taken for at least 12 weeks before deciding whether or not they are effective.

Cognitive-behavioral therapy (CBT) teaches patients how to confront their fears and obsessive thoughts by making the effort to endure or wait out the activities that usually cause anxiety without compulsively performing the calming rituals. Eventually their anxiety decreases. People who are able to alter their thought patterns in this way can lessen their preoccupation with the compulsive rituals. At the same time, the patient is encouraged to refocus attention elsewhere, such as on a hobby.

In a few severe cases where patients have not responded to medication or behavioral therapy, brain surgery may be tried as a way of relieving the unwanted symptoms. Surgery can help up to a third of patients with the most severe form of OCD. The most common operation involves removing a section of the brain called the cingulate cortex. The serious side effects of this surgery for some patients include seizures, personality changes and less ability to plan.

Alternative treatment

Because OCD sometimes responds to SSRI antidepressants, a botanical medicine called St. John's wort (Hypericum perforatum ) might have some beneficial effect as well, according to herbalists. Known popularly as "Nature's Prozac," St. John's wort is prescribed by herbalists for the treatment of anxiety and depression. They believe that this herb affects brain levels of serotonin in the same way that SSRI antidepressants do. Herbalists recommend a dose of 300 mg., three times per day. In about one out of 400 people, St. John's wort (like Prozac) may initially increase the level of anxiety. Homeopathic constitutional therapy can help rebalance the patient's mental, emotional, and physical well-being, allowing the behaviors of OCD to abate over time.

Prognosis

Obsessive-compulsive disorder is a chronic disease that, if untreated, can last for decades, fluctuating from mild to severe and worsening with age. When treated by a combination of drugs and behavioral therapy, some patients go into complete remission. Unfortunately, not all patients have such a good response. About 20% of people cannot find relief with either drugs or behavioral therapy. Hospitalization may be required in some cases.

Despite the crippling nature of the symptoms, many successful doctors, lawyers, business people, performers and entertainers function well in society despite their condition. Nevertheless, the emotional and financial cost of obsessive-compulsive disorder can be quite high.

Resources

ORGANIZATIONS

Anxiety Disorders Association of America. 11900 Park Lawn Drive, Ste. 100, Rockville, MD 20852. (800) 545-7367. 〈http://www.adaa.org〉.

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd., Ste. 300, Arlington, VA 22201-3042. (800) 950-6264. 〈http://www.nami.org〉.

National Anxiety Foundation. 3135 Custer Dr., Lexington, KY 40517. (606) 272-7166. 〈http://www.lexington-on-line.com/naf.html〉.

Obsessive-Compulsive Anonymous. P.O. Box 215, New Hyde Park, NY 11040. (516) 741-4901. 〈west24th@aol.com〉 〈http://members.aol.com/west24th/index.html〉.

Obsessive-Compulsive Foundation. P.O. Box 70, Milford, CT 06460. (203) 874-3843. 〈JPHS28A@Prodigy.com〉 〈http://pages.prodigy.com/alwillen/ocf.html〉.

KEY TERMS

Anxiety disorder— This is the experience of prolonged, excessive worry about circumstances in one's life. It disrupts daily life.

Cognitive-behavior therapy— A form of psychotherapy that seeks to modify behavior by manipulating the environment to change the patient's response.

Compulsion— A rigid behavior that is repeated over and over each day.

Obsession— A recurring, distressing idea, thought or impulse that feels "foreign" or alien to the individual.

Selective serotonin reuptake inhibitors (SSRIs)— A class of antidepressants that work by blocking the reabsorption of serotonin in brain cells, raising the level of the chemical in the brain. SSRIs include Prozac, Zoloft, Luvex, and Paxil.

Serotonin— One of three major neurotransmitters found in the brain that is related to emotion, and is linked to the development of depression and obsessive-compulsive disorder.

Obsessive-compulsive disorder

Definition

Obsessive-compulsive disorder (OCD) is a type of anxiety disorder. Anxiety disorder is the experience of prolonged, excessive worry about circumstances in one's life. OCD is characterized by distressing repetitive thoughts, impulses, or images that are intense, frightening, absurd, or unusual. These thoughts are followed by ritualized actions that are usually bizarre and irrational. These ritual actions, known as compulsions, help reduce anxiety caused by the individual's obsessive thoughts. Often described as the "disease of doubt," the sufferer usually knows the obsessive thoughts and compulsions are irrational but, on another level, fears they may be true.

Description

Most people with obsessive-compulsive disorder have both obsessions and compulsions, but occasionally a person will have just one or the other. The degree to which this condition can interfere with daily living also varies. Some people are barely bothered, while others find the obsessions and compulsions to be profoundly traumatic and spend much time each day in compulsive actions. Because the symptoms are so distressing, sufferers often hide heir fears and rituals but cannot avoid acting on them. OCD sufferers are often unable to decide if their fears are realistic and need to be acted upon.

Obsessions are intrusive, irrational thoughts that keep popping up in a person's mind, such as the urgency to wash one's hands again. Typical obsessions include fears of dirt, germs, contamination, and violent or aggressive impulses. Other obsessions include feeling responsible or others' safety or an irrational fear of hitting a pedestrian with a car. Additional obsessions can involve excessive religious feelings or intrusive sexual thoughts. The patient may need to confess frequently to a religious counselor or may fear acting out the strong sexual thoughts in a hostile way. People with obsessive-compulsive disorder may have an intense preoccupation with order and symmetry or may be unable to throw anything out.

Compulsions usually involve repetitive rituals such as excessive washing (especially hand washing or bathing), cleaning, checking and touching, counting, arranging, and/or hoarding. As the person performs these acts, he may feel temporarily better, but there is no long-lasting sense of satisfaction or completion after the act is performed. Often, a person with obsessive-compulsive disorder believes that if the ritual is not performed, something dreadful will happen. While these compulsions may temporarily ease stress, short-term comfort is purchased at a heavy price—time spent repeating compulsive actions and a long-term interference with life.

The difference between OCD and other compulsive behavior is that while people who have problems with gambling, overeating, or with substance abuse may appear to be compulsive, these activities also provide pleasure to some degree. The compulsions of OCD, on the other hand, are never pleasurable.

OCD may be related to some other conditions, such as the continual urge to pull out body hair (trichotillomania ); fear of having a serious disease (hypochondriasis); or preoccupation with imagined defects in personal appearance disorder (body dysmorphia). Some people with OCD also have Tourette syndrome , a condition featuring tics and unwanted vocalizations (such as swearing). OCD is often linked with depression and other anxiety disorders.

Demographics

Almost one out of every 40 people suffers from obsessive-compulsive disorder at some time in their lives. The condition is two to three times more common than either schizophrenia or manic depression and strikes men and women of every ethnic group, age, and social level.

If one person in a family has obsessive-compulsive disorder, there is a 25 percent chance that another immediate family member has the condition. It also appears that stress and psychological factors may worsen symptoms, which usually begin during adolescence or early adulthood.

Causes and symptoms

Research suggests that the tendency to develop obsessive-compulsive disorder is inherited. There are several theories behind the cause of OCD. OCD may be related to a chemical imbalance within the brain that causes a communication problem between the front part of the brain (frontal lobe) and deeper parts of the brain responsible for the repetitive behavior. The orbital cortex located on the underside of the brain's frontal lobe is overactive in OCD patients. This may be one reason for the feeling of alarm that pushes the patient into compulsive, repetitive actions. It is possible that people with OCD experience overactivity deep within the brain that causes the cells to get "stuck," much like a jammed transmission in a car damages the gears. This could lead to the development of rigid thinking and repetitive movements common to the disorder. The fact that drugs which boost the levels of serotonin, a brain messenger substance linked to emotion and many different anxiety disorders, in the brain can reduce OCD symptoms may indicate that to some degree OCD is related to levels of serotonin in the brain.

There may also be a link between childhood episodes of strep throat and the development of OCD. In some vulnerable children, strep antibodies attack a certain part of the brain. Antibodies are cells that the body produces to fight specific diseases. That attack results in the development of excessive washing or germ phobias . A phobia is a strong but irrational fear. In this instance the phobia is fear of disease germs present on commonly handled objects. These symptoms would normally disappear over time, but some children who have repeated infections may develop full-blown OCD. Treatment with antibiotics , immunoglobulin, or blood cleansing procedures can decrease the circulating anti-strep antibodies in the blood, thus lessening the OCD symptoms in some of these children.

Diagnosis

People with obsessive-compulsive disorder feel ashamed of their problem and often try to hide their symptoms. They avoid seeking treatment. Because they can be very good at keeping their problem from friends and family, many sufferers do not get the help they need until the behaviors are deeply ingrained habits and hard to change. As a result, the condition is often misdiagnosed or underdiagnosed. All too often, it can take more than a decade between the onset of symptoms and proper diagnosis and treatment.

OCD appears to be related to a disruption in serotonin levels, there is no blood test for the condition. Instead, doctors diagnose OCD after evaluating a person's symptoms and history.

Treatment

Obsessive-compulsive disorder can be effectively treated by a combination of cognitive-behavioral therapy and medication that regulates the brain's serotonin levels. Drugs that are approved to treat obsessive-compulsive disorder include fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft), all selective serotonin reuptake inhibitors (SSRIs) that affect the level of serotonin in the brain. Older drugs include the antidepressant clomipramine (Anafranil), a widely studied drug in the treatment of OCD, but one that carries a greater risk of side effects. Drugs should be taken for at least 12 weeks before a person decides whether they are effective.

Cognitive-behavioral therapy (CBT) teaches patients how to confront their fears and obsessive thoughts by making the effort to endure or wait out the activities that usually cause anxiety without compulsively performing the calming rituals. Eventually their anxiety decreases. People who are able to alter their thought patterns in this way can lessen their preoccupation with the compulsive rituals. At the same time, the patient is encouraged to refocus attention elsewhere, such as on a hobby.

In a few very severe cases in which patients have not responded to medication or behavioral therapy, brain surgery may be tried as a way of relieving the unwanted symptoms. Surgery can help up to one third of patients with the most severe form of OCD. The most common operation involves removing a section of the brain called the cingulate cortex. The serious side effects of this surgery for some patients are seizures, personality changes, and less ability to plan.

Prognosis

Obsessive-compulsive disorder is a chronic disease that, if untreated, can last for decades, fluctuating from mild to severe and worsening with age. When treated by a combination of drugs and behavioral therapy, some patients go into complete remission. Unfortunately, not all patients have such a good response. About 20 percent of people cannot find relief with either drugs or behavioral therapy. Hospitalization may be required in some cases.

Despite the crippling nature of the symptoms, many successful doctors, lawyers, business people, performers, and entertainers function well in society despite their condition. Nevertheless, the emotional and financial cost of obsessive-compulsive disorder can be quite high.

Parental concerns

Some people have referred to obsessive-compulsive disorder as "the great pretender," because its symptoms can mimic a number of other disorders. Furthermore, children may become skilled at hiding the more embarrassing features of their condition. Because of these characteristics of the disorder, obsessive-compulsive disorder may go undiagnosed for some time.

KEY TERMS

Anxiety disorder —A mental disorder characterized by prolonged, excessive worry about circumstances in one's life. Anxiety disorders include agoraphobia and other phobias, obsessive-compulsive disorder, post-traumatic stress disorder, and panic disorder.

Cognitive-behavioral therapy —A type of psychotherapy in which people learn to recognize and change negative and self-defeating patterns of thinking and behavior.

Compulsion —A repetitive or ritualistic behavior that a person performs to reduce anxiety. Compulsions often develop as a way of controlling or "undoing" obsessive thoughts.

Obsession —A persistent image, idea, or desire that dominates a person's thoughts or feelings.

Selective serotonin reuptake inhibitors (SSRIs) —A class of antidepressants that work by blocking the reabsorption of serotonin in the brain, thus raising the levels of serotonin. SSRIs include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil).

Serotonin —A widely distributed neurotransmitter that is found in blood platelets, the lining of the digestive tract, and the brain, and that works in combination with norepinephrine. It causes very powerful contractions of smooth muscle and is associated with mood, attention, emotions, and sleep. Low levels of serotonin are associated with depression.

Resources

BOOKS

Herbert, Fredrick B. "Obsessive-Compulsive Disorder in Children and Adolescents." In Psychiatric Secrets. Edited by James L. Jacobson et al. Philadelphia: Hanley and Belfus, 2001.

Stafford, Brian, et al. "Anxiety Disorders." In Nelson Textbook of Pediatrics. Edited by Richard E. Behrman et al. Philadelphia: Saunders, 2004.

PERIODICALS

Barrett, P. "Cognitive-behavioral family treatment of childhood obsessive-compulsive disorder: a controlled trial." Journal of the American Academy of Child and Adolescent Psychiatry 43 (January 2004): 46–62.

Storch, E. A. "Behavioral treatment of a child with PANDAS." Journal of the American Academy of Child and Adolescent Psychiatry 86 (May 2004): 510–1.

ORGANIZATIONS

Anxiety Disorders Association of America. 11900 Park Lawn Drive, Suite 100, Rockville, MD 20852. Web site: <www.adaa.org>.

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA 22201–3042. Web site: <www.nami.org>.

National Anxiety Foundation. 3135 Custer Dr., Lexington, KY 40517. Web site: <www.lexington-on-line.com/naf.html>.

Carol A. Turkington Rosalyn Carson-DeWitt, MD

Obsessive-Compulsive Disorder

What Is Obsessive-Compulsive Disorder?

What Causes Obsessive-Compulsive Disorder?

What Are Obsessions?

What Are Compulsions?

How Is Obsessive-Compulsive Disorder Treated?

Resources

Obsessive-compulsive (ob-SES-iv-kom-PUL-siv) disorder (OCD) causes people to become trapped in a pattern of repeated, unwanted thoughts, called obsessions (ob-SESH-unz), and a pattern of repetitive behavior, called compulsions (kom-PUL-shunz). Thoughts that feel impossible to control cause distress and anxiety (ang-ZY-e-tee) that is often neutralized, or offset, by the particular compulsive behavior patterns.

KEYWORDS

for searching the Internet and other reference sources

Anxiety disorders

Brain chemistry (neurochemistry)

Compulsion

Obsession

Many people knock on wood to ward off bad luck. Others may walk around, rather than under, ladders, or they may step over, rather than on, cracks in the sidewalk. These are familiar examples of superstitions. Superstitions are irrational beliefs resulting from false ideas, fear of the unknown, or trust in magic or chance. Superstitions are common in everyday life. However, for people with OCD, rituals go much further than that. People with this disorder may feel driven to wash their hands until they bleed, count objects for hours on end, or go through a complex, 30-minute routine before leaving the house.

These Pandas Are a Bear

PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections) is a term for unusual, OCD-like symptoms that arise in a small number of children after strep throat, a common throat infection caused by bacteria. The behavior of the children usually changes quite suddenly. Almost overnight, they develop obsessions, compulsions, or tics; uncontrollable muscle twitches; or verbal outbursts. The cause is still unknown. One theory, though, is that a strep infection in childhood prompts the body to form antibodies (AN-ti-bo-deez), substances in the blood that fight bacteria and other foreign matter. The next time strep develops, the body is ready to fight back. It releases a barrage of antibodies, but some miss their mark and head for the part of the brain that is thought to affect behavior and movement—resulting in OCD symptoms.

What Is Obsessive-Compulsive Disorder?

People with OCD can become trapped in a pattern of repeated, unwanted behaviors and thoughts that are senseless and upsetting but that seem impossible to control. The behaviors and thoughts can take up so much time and energy that people have trouble getting on with their daily lives. The problem often begins with disturbing thoughts, called obsessions. People then go through repeated rituals, called compulsions, in an effort to prevent these thoughts or make the distress caused by the thoughts go away. For example, people may wash their hands, count objects on a shelf, or check a door lock over and over again. For people with OCD, there is no pleasure in doing these things. There is only short-lived relief from the upsetting thoughts (for example, that the house will catch on fire or that a close relative is sick), which all too soon return.

Most people have a few odd habits. For example, they may check an oven to be sure it is off and then recheck it a few seconds later. Such behaviors are signs of OCD only when they take considerable amounts of time each day, cause much distress, and interfere with other activities.

What Causes Obsessive-Compulsive Disorder?

About 2 percent of adults in the United States have OCD in any given year. OCD usually begins during childhood or the teenage years, and it affects men and women equally. In the past, it was believed that OCD was due mainly to family problems or attitudes learned as children. Today, however, researchers stress the link between biological factors and life experiences. Brain imaging studies (special brain “x-rays”) have shown that people with OCD have patterns of brain activity that differ from the patterns of people with other mental disorders and of people with no disorders at all.

OCD occurs more often than average in people with certain other conditions that affect the brain and nervous system*. For example, there is an increased risk of OCD in people with Tourette (tu-RET) syndrome, an inherited nervous system disorder that causes repeated, uncontrollable muscle twitches and verbal outbursts. Researchers now are trying to find out if there is a genetic* link between OCD and Tourette syndrome.

* nervous system

is a network of specialized tissue made of nerve cells, or neurons, that processes messages to and from different parts of the human body.

* genetic

(je-NE-tik) pertains to genes, which are chemicals in the body that help determine a person’s characteristics, such as hair or eye color. They are inherited from a person’s parents and are contained in the chromosomes, threadlike structures inside the cells of the body.

What Are Obsessions?

Obsessions are unwanted ideas or wishes that repeatedly well up in the minds of people with OCD. The thoughts create constant worry and fear. People who do not experience OCD believe that the worry is silly or strange. People with OCD also can agree that the worry is needless; however, they cannot stop feeling the worry that comes with the thoughts. Interestingly, thoughts and behaviors may not be related. The thought “I might get sick” could be followed by the behavior of counting to seven. Common obsessions include:

Compelling Reading

The word “compulsive” has more than one meaning in the mental health world. When people talk about obsessive-compulsive disorder, they are using the word in a formal way to refer to a specific kind of repeated ritual. When people talk about compulsive gambling or compulsive internet use, however, they are using the word in a less strict sense to refer to people who have an intense craving that is out of control.

• worries about germs and dirt, for example, worrying about getting germs from shaking hands
• repeated doubts, for example, worrying about leaving a door unlocked
• worries about keeping things in order, for example, becoming very upset when things are out of place
• violent impulses, for example, thinking repetitively about hurting someone
• sexual impulses, for example, thinking repetitively about a sexual act.

What Are Compulsions?

People try to keep these unwanted thoughts in check with repeated actions that they feel driven to perform. Some people have set routines, while others have complex, changing rituals. The actions provide some relief from worry, but only temporarily. Common compulsions include:

• Washing: For example, people worried about germs and dirt may spend hours washing their hands.
• Checking: For example, people with repeated doubts about leaving a door unlocked may check the lock over and over.
• Ordering: For example, people worried about keeping things in order may arrange and rearrange the objects on a shelf.
• Counting: For example, people with disturbing violent or sexual thoughts may block them out by counting to 11 again and again.

Teenagers and adults with OCD know that their behavior is pointless, but the distress is so great that they feel unable to stop the behavior. At times, they may even start to believe their own unreasonable fears. People with OCD may be able to keep their behavior under control at school or at work for a while. They often are afraid to tell others, believing that they will be thought of as “weird.” Without treatment, though, the problem may get worse over time. For some individuals, the constant worries and time-consuming rituals can take over their lives.

How Is Obsessive-Compulsive Disorder Treated?

Medications

Studies have shown that medicines that affect a brain chemical called serotonin* can reduce the symptoms of OCD. While medicines may help control OCD, the symptoms may return once people stop taking medication. For this reason, doctors often recommend a combination of prescription medication and visits to a behavior therapist. Some individuals whose OCD is not significantly debilitating* might choose behavior therapy alone as the preferred treatment.

* serotonin

(ser-o-TO-nin) is a neurotransmitter, a substance that helps transmit information from one nerve cell to another.

* debilitating

(de-BI-li-tay-ting) means making weak or sap-ping strength.

Behavioral therapy

Behavioral (be-HAY-vyor-al) therapy helps people change specific unwanted behaviors. For OCD, this often means using an approach called exposure and response prevention. In this approach, people purposely are exposed to a feared object or idea, either directly or through imagination. Then they prevent themselves from carrying out the usual response (the compulsion), instead using other methods to manage the anxiety they feel. For example, people with a handwashing compulsion might be encouraged to touch objects that they believe to be dirty. Then with the therapist’s help, they resist the compulsion to wash for several hours. During this time, the anxiety associated with the obsession decreases and so does the compulsion to wash. Research has shown that this approach can be effective for treating OCD. People who remain in therapy may gradually learn to worry less about their obsessive thoughts, and eventually they may learn to go for long periods of time without falling back on their old compulsive actions. With exposure and response prevention, thoughts and compulsions frequently (and sometimes quickly) disappear or become manageable.

See also

Anxiety and Anxiety Disorders

Brain Chemistry (Neurochemistry)

Habits and Habit Disorders

Therapy

Tourette Syndrome

Resources

Book

Rapoport, Judith L. The Boy Who Couldn’t Stop Washing. New York: Plume, reissued 1990. One of the first books to bring obsessive-compulsive disorder to public attention.

Organizations

Anxiety Disorders Association of America, 11900 Parklawn Drive, Suite 100, Rockville, MD 20852. This nonprofit group promotes public awareness of OCD. Telephone 301-231-9350 http://www.adaa.org

Anxiety Disorders Education Program, U.S. National Institute of Mental Health, 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. This government program provides reliable information about OCD. Telephone 888-8ANXIETY http://www.nimh.nih.gov/anxiety

Obsessive-Compulsive Foundation, 337 Notch Hill Road, North Branford, CT 06471. This organization is for people with OCD and others with an interest in the disorder. Telephone 203-315-2190 http://ocfoundation.org