Obsessive Compulsive Disorder (OCD)

• Obsessive-compulsive disorder (OCD) is one of a number of obsessive compulsive and related disorders that has irresistible ideas or images (obsessions) and/or specific rituals/behaviors or mental acts (compulsions) that may be driven by obsessions as characteristics of the illness.
• OCD occurs in a small percentage of populations worldwide in every culture.
• The average age for OCD to begin is 19 years of age, and it usually begins by the time the individual is 30 years old.
• People with OCD are at risk for also suffering from anxiety disorders.
• While there is no known specific cause for OCD, having other family members with the condition and an imbalance of the brain chemical serotonin increase the likelihood of OCD occurring.
• A health care professional diagnoses OCD by looking for signs and symptoms of this and other emotional problems, as well as assessing for the presence for a medical condition that might be a contributing to developing the disorder.
• OCD most likely improves when treated with a combination of behavior therapies like exposure and ritual prevention, group or individual cognitive behavioral therapy, and medications.
• Although not thought to be as effective in treating OCD symptoms as clomipramine (Anafranil), SSRIs are the group of medications that physicians most often use to treat this illness since the SSRIs tend to cause fewer side effects.
• SSRIs work by increasing the activity of serotonin in the brain.
• When the combination of psychotherapy and SSRI treatment does not produce adequate symptom relief, doctors may add a neuroleptic medication to improve the treatment outcome.
• For some people with severe OCD, deep brain stimulation can be helpful, and researchers continue to study treatment with hallucinogen medications.
• Although the symptoms of OCD may last indefinitely, the prognosis for OCD sufferers is best when the person's symptoms are milder and have been present for a short time, and the OCD sufferer has no other emotional problems.
• If left untreated, OCD can worsen to the point that the sufferer develops physical problems, becomes unable to function, or experiences suicidal thoughts. About 1% of OCD sufferers die by suicide.

A departure from its classification in the previous edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), where it was grouped with anxiety disorders, obsessive-compulsive disorder (OCD) is now classified as one of a number of obsessive compulsive and related disorders in the DSM-5. Repeated obsessions and/or compulsions that interfere with the sufferer's ability to function in their relationships, at work or in school, either because of all the time that is consumed by the symptoms or the marked apprehension, fear or other distress suffered by the person characterize OCD. Other separate kinds of obsessive compulsive and related disorders include body dysmorphic disorder (preoccupation with at least one perceived flaw in one's physical appearance that others do not observe); hoarding disorder (chronic difficulty discarding possessions); trichotillomania (hair-pulling disorder); excoriation disorder (skin picking), as well as OCD and related disorders that are caused by a medical condition or exposure to a substance.

Obsessions are recurrently intrusive or unrelenting, unwanted thoughts, impulses, or images that may cause severe anxiety. These ideas are irresistible to the OCD sufferer despite the person's usually understanding that these ideas are irrational. That understanding may lead to their feeling guilt at being unable to resist having the ideas. Examples of obsessions include sexual obsessions, religious obsessions (scrupulosity), fear of germs/worries about cleanliness, or worries about safety or order. A compulsion is a ritualistic or otherwise repetitive behavior or mental act that the individual with OCD engages in, because of their obsessions or according to rigid rules. Obsessive thoughts may cause compulsions like excessive hand washing, skin picking, lock checking, repeatedly going over intrusive thoughts, meaningless counting, repetition of one's own words, repeatedly arranging items, or other repetitive actions. Compulsive hoarding is also a manifestation of OCD.

In contrast to the repetitive behaviors of compulsions, habits are actions that occur with little to no thought, occur routinely, are not caused by an obsession, are not excessively time-consuming, and do not result in stress. Examples of habits include cracking knuckles or storing a wallet in a purse or pocket.

Medicinal writings have described OCD for at least the past century. Statistics on how many people in the United States have OCD range from 1%-2%, or more than 2 million adults. About one in 200 children and adolescents, or half a million minors, have OCD. Interestingly, how often this condition occurs and the symptoms involved are remarkably similar across cultures. While it often starts in childhood and adolescence, the average age of onset of the disorder is 19 years of age. OCD usually develops by 30 years of age, afflicting more males than females.

Children with OCD do not always realize that their obsessions or compulsions are unreasonable. They might have tantrums when prevented from completing rituals. Also in contrast to adults, children and teenagers tend to develop physical complaints like tiredness, headaches, and stomach upset when afflicted with OCD.

People with OCD are at risk for also developing chronic hair pulling (trichotillomania) or muscle or vocal tics (Tourette's disorder). People who have both Tourette's or another tic disorder and OCD are more likely to suffer from more OCD symptoms, like aggressive, religious or sexual obsessions, and certain compulsions than do those who do not have tics with their OCD. OCD sufferers are also more likely to develop an eating disorder like anorexia or bulimia, or mood problems, like depression, generalized anxiety disorder, panic attacks, and full-blown panic disorder. This mental illness also increases the risk of sufferers having excessive concerns about their bodies (somatoform disorders) like hypochondriasis, which is excessive worry about having a serious illness. People with OCD are more vulnerable to having bipolar disorder, also called manic depression.

While it is sometimes confused with OCD, characteristics of obsessive compulsive personality disorder (OCPD) include perfectionism and an unyielding expectation that the sufferer and others will adhere to a rigid set of rules. People with OCPD do not tend to engage in compulsions. However, people with OCD are at higher risk for developing OCPD than those without OCD.

While there is no clear cause for OCD, family history and possible chemical imbalances in the brain contribute to developing the illness. While people who have relatives with the illness are at a higher risk of developing OCD, most people with the condition have no such family history. A specific genetic variation of the catechol-O-methyltransferase (COMT) gene potentially doubles the chances of a person developing OCD in general, as well as having a significant association with developing this disorder at an early age. An imbalance of the chemical serotonin in the brain may also contribute to the development of this disorder. Certain life stressors, like being the victim of childhood sexual abuse, is a risk factor for developing OCD during adulthood.

Some health care professionals will give a self-test of screening questions to people whom they suspect may have OCD. One such scale, the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), is a widely accepted measure of OCD symptoms. In addition to looking for symptoms of obsessive thoughts and compulsive behaviors by conducting a mental health interview and mental status examination, mental health practitioners will explore the possibility that an emotional disorder instead of or in addition to OCD cause the person's symptoms. For example, people with addiction often have obsessive thoughts or compulsions, but those characteristics usually just involve the addiction. Individuals who suffer from narcissism may have obsessions, but those tend to be limited to self-obsession. The professional will also likely ensure that a medical examination and any other necessary tests consider whether there is any medical issue that could be causing any of the signs or symptoms of OCD.

Most individuals with OCD have some symptoms of the disorder indefinitely, comprised of times of improvement alternating with times of increased symptoms. The prognosis for this disorder is most favorable for sufferers who have milder symptoms that have occurred for less time and who have no other medical or mental-health issues prior to developing OCD.

Treatment of OCD includes cognitive behavioral psychotherapy, behavioral therapies, and medications. Behavioral therapies for OCD include systematic desensitization therapy, aversion therapy, rational emotive behavior therapy, and ritual prevention and exposure therapy. Prevention of rituals involves a mental-health professional helping the person with OCD endure longer and longer periods of resisting the urge to engage in compulsive behaviors. Exposure and response prevention therapy is a type of behavior modification that involves the individual getting in touch with situations that tend to increase their urge to perform compulsions then helping the person resist that urge. Cognitive/behavioral therapy begins with psycho-education of the OCD sufferer regarding their illness and works towards changing the negative ways of thinking and behaving associated with the anxiety involved with obsessive-compulsive disorder.

Selective serotonin reuptake inhibitors (SSRIs) are the medications that doctors prescribe most often to treat OCD. These medications increase the amount of the neurochemical serotonin in the brain. (Brain serotonin levels are low in OCD.) SSRIs work by selectively inhibiting (blocking) serotonin reuptake in the brain, specifically at the synapse, the place where brain cells (neurons) connect to each other. Serotonin is one of the brain chemicals that carries messages across synapses from one neuron to another.

SSRIs work by keeping serotonin present in high concentrations in the synapses. These medications do so by preventing the reuptake of serotonin back into the nerve cell that is transmitting an impulse. Since the reuptake of serotonin is responsible for turning off the production of new serotonin, the serotonin message keeps on coming through. This helps activate cells that have been deactivated by OCD, thereby relieving the symptoms of the condition.

SSRIs have fewer side effects than clomipramine, which is an older medication that is somewhat more effective in treating OCD but might cause orthostatic hypotension (a sudden drop in blood pressure when sitting up or standing that can cause fainting) and heart-rhythm disturbances. Therefore, SSRIs are often the first-line treatment for this disorder. Examples of SSRIs include fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), fluvoxamine (Luvox), escitalopram (Lexapro), vortioxetine (Trintellix), and vilazodone (Viibryd). When the improvement that people with OCD experience is not optimal when an SSRI is the only medication prescribed, the addition of a neuroleptic medication like risperidone (Risperdal), olanzapine (Zyprexa), aripiprazole (Abilify), quetiapine (Seroquel), ziprasidone (Geodon), paliperidone (Invega), asenapine (Saphris), or lurasidone (Latuda) can sometimes help.

Some studies show that SNRI medications like venlafaxine (Effexor), duloxetine (Cymbalta), and desvenlafaxine (Pristiq) can be an effective alternative to SSRIs. These medications increase the amount of the neurochemicals serotonin, epinephrine and norepinephrine in the brain. Some mental health prescribers use buspirone (Buspar) to treat OCD and related disorders, particularly when added to other medications in an attempt to improve the response of people who did not improve optimally to one medication. However, this medication is not a primary treatment for these disorders.

Patients generally tolerate SSRIs well, and side effects are usually mild. The most common side effects include nausea, diarrhea, agitation, insomnia, and headache. However, these side effects generally go away within the first month of SSRI use. Some individuals experience sexual side effects, like decreased sexual desire (libido), delayed orgasm, or an inability to have an orgasm. Some patients develop tremors with SSRIs. The so-called serotonergic (meaning caused by serotonin) syndrome is a serious neurologic condition associated with the use of this group of medications that is characterized by high fevers, seizures, and heart-rhythm disturbances. This condition is very rare, and physicians have only reported this in very sick psychiatric patients taking multiple psychiatric medications.

Newer, often called atypical, neuroleptic medications like the ones named above tend to cause fewer side effects than many of the older medications in this class. The most common side effects of atypical neuroleptics include sleepiness, dizziness, dry mouth, and weight gain. Sometimes, people can be more sensitive to the effects of the sun while taking these medications and therefore should be sure to wear adequate sunblock whenever exposed to the sun. Less commonly, side effects of atypical neuroleptic medications can result in painless, although abnormal, muscle movements like tremors, stiffness, and very rarely a syndrome of permanent muscle twitches called tardive dyskinesia.

Mood stabilizers like carbamazepine (Tegretol), divalproex sodium (Depakote), and lamotrigine (Lamictal) sometimes treat OCD, particularly in individuals who also suffer from bipolar disorder. The side effects that professionals look for tend to vary depending on the prescribed medication. Professionals tend to watch for mild side effects like sleepiness when using Depakote or Tegretol or stomach upset when using any of these medications. Professionals also monitor patients for serious side effects like severely low white blood cell count with Tegretol or severe autoimmune reactions like Stevens-Johnson syndrome with Depakote or Lamictal. While lithium remains a hallmark treatment for bipolar disorder, particularly in adults, studies have not indicated significant benefit for its use in treating OCD.

Studies on the effectiveness of treatment of OCD in adults have variable results. Some indicate that medications, response prevention, and CBT are equally, although only mildly to moderately, effective in treating this problem. Cognitive behavioral group psychotherapy (CBGT) is an effective treatment for OCD.

Research on treating OCD in children and adolescents indicates that while medications are clearly effective in treating this disorder, the improvement that is experienced is quite mild. However, clomipramine tends to be more effective than the SSRIs, and the individual SSRIs tend to be equally effective as each other. Similar to adults, people under 18 years of age tend to improve more significantly when treated with a combination of medication and CBT. There is increasing evidence that deep brain stimulation may be effective in treating severe OCD that has not responded to other treatments. Clinical trials on OCD are primarily focusing on novel ways of understanding the illness and developing new ways to help treatment-resistant patients. For people who are severely disabled by their OCD symptoms, brain surgical and stimulation procedures are a focus of research.

Without treatment, the severity of OCD can worsen to the point that it consumes the sufferer's life. Specifically, it can inhibit their ability to attend school, keep a job, and/or can lead to social isolation. Many people with this condition consider killing themselves, and about 1% die by suicide.

Regarding the prognosis for the specific symptoms, it is rare for any to progress to a physically debilitating level. However, problems like compulsive hand washing can eventually cause complications like the skin becoming dry and even breaking down, and trichotillomania can result in unsightly scabs on the person's scalp.

While in about 40% of people diagnosed with OCD the symptoms tend to persist indefinitely to some degree, most are only mildly to moderately affected by those symptoms if adequately treated. People who have the symptoms of this condition longer prior to being diagnosed and treated are both at higher risk of having more severe OCD and of developing other mental health illnesses (co-morbidity) in the future. Youth with OCD are at risk for having academic difficulties, participating in fewer recreational activities, and experiencing problems with peer relationships.

OCD is best prevented through early recognition and treatment. Specifically, recognizing warning signs that a child may be at risk for developing this illness can be a place to start. Examples of such early warning signs include excessive complaints by or agitation of (hypersensitivity) the child that certain clothes or food textures are intolerable, specific food aversion, as well as the child engaging in rigid patterns of behavior.

Further information about OCD can be gained from the following resources.

Anxiety Disorders Association of America
240-485-1001
http://www.adaa.org

American Psychiatric Association
703-907-7300
http://www.psych.org

National Institute of Mental Health
866-615-6464
http://www.nimh.nih.gov

International OCD Foundation
http://www.ocfoundation.org/
PO Box 961029
Boston, Mass. 02196
617-973-5801

Obsessive Compulsive Anonymous World Services (OCA)
516-741-4901
http://www.obsessivecompulsiveanonymous.org

OCD Recovery Centers of America
http://www.ocdrecoverycenters.com/

OCD Online
http://www.ocdonline.com/

Tourette Syndrome Association
http://www.tsa-usa.org/