What is OCD (Obsessive-Compulsive Disorder)?
Obsessive-Compulsive Disorder, commonly known as OCD, was formerly thought to be an anxiety disorder, however, it has since been classified as a unique mental condition.
It is an illness that can have a disabling impact on the patient, trapping them in an endless cycle of repetitive behaviours and thoughts. These thoughts are often distressing and tend to plague the person suffering from the condition. Anxiety is often the result of these thoughts as they make the patient feel as though they must complete a specific ritual or routine in order to alleviate the feeling of anxiety.
These rituals or routines are regarded as compulsive behaviour and are performed in an attempt to rid the patient of their obsessive thoughts, although this relief is often temporary and the patient may be met with the same anxiousness later on in their day when performing a certain task.
This is known as an OCD cycle, and it is out of the patient’s control. This cycle can get progressively worse if not dealt with and can take up large amounts of time in the day, significantly impacting and interfering with daily tasks and activities.
Someone with OCD is often aware of these unrealistic compulsions and obsessions, but their need to complete them can be so overwhelming, that they simply cannot stop themselves from completing them.
The difference between an obsession and a compulsion, both of which are experienced in obsessive-compulsive disorder, is that an obsession is a thought or an idea that intrudes or preoccupies the patient’s mind. Whereas a compulsion is seen as an irresistible urge that pressures the patient to behave or act in a certain way, feeling forced to complete a certain task, compulsions are known to be uncontrollable impulses and actions.
Therefore, a compulsion is a rule-bound repetitive behaviour that the patient feels they have to perform in order to rid themselves of the anxiety they feel in needing to complete the action, and an obsession is a persistent, unwanted and somewhat disturbing thought or image in the patient’s mind.
Obsessions, or obsessive thoughts, often drive the patient to complete an act or perform a routine, this is the compulsion. Simply put, obsessions drive compulsions.
For example, Nick has a shower and dries himself off with a towel. After which, he hangs the towel back on the railing in his bathroom. Although he knows it to be unproductive and unreasonable, he has to place his towel with the label facing outwards from the railing. This is because today is Monday. On Tuesday however, the label must face inwards. He does not know why this has to be done, but he feels compelled to complete the action otherwise he will think about for the duration of his day, and if he does not complete his morning ritual, he may even believe that his day will be compromised in some way.
This is just one example of Nick’s morning, he may experience several more obsessions and compulsions throughout his day and even in his morning routine.
Obsessions and compulsions can range in severity. And some OCD sufferers may only experience compulsions or obsessions as standalone symptoms.
Obsessive-compulsive disorder is a condition that may become evident in childhood, in the teenage years or in early adulthood, although it is not always recognised or accurately diagnosed. This means that many sufferers wait years before they are able to receive effective treatment.
The condition occurs in the same number of women as men and can affect all people, regardless of their age, race or socioeconomic background. OCD affects more than 2% of the global population, with more than one in 50 people being diagnosed with the condition.
In the following article, we will go into detail about the condition, what the symptoms, causes, risks and complications are and how it is diagnosed and treated. After reading this you should have a clear understanding of what OCD is and what it entails. Please be advised that this information is written purely as a guideline and should be treated as such.
What are the symptoms of obsessive-compulsive disorder (OCD)?
As stated, OCD normally includes the symptoms of obsessions and compulsions. But, it is also possible that some patients only experience the symptoms of obsession or only the symptoms of compulsion. However, more often than not, the patient will experience both of the above symptoms.
The obsessions of obsessive-compulsive disorder are known as persistent, repeated and unwanted urges, thoughts or images that intrude upon the patient’s mind and result in anxiety and an overwhelming feeling of stress. The patient may attempt to ignore these obsessions or rid their minds of them through completing a compulsive behaviour or a ritual.
Obsessions typically invade the patient’s mind when they are trying to work or think. They are known to have themes or categories to them, and the types of obsessions can include one or several of the following and vary from case to case:
- The fear of dirt or contamination
- Needing things to be ordered, symmetrical or colour-coded
- Unwanted thoughts that can include those of sexual intentions, aggression or religious subjects
- Horrific or aggressive thoughts of harming themselves or others
- Safety and securing one’s environment
- Doubt with regard to one’s perception and memory
Now that we have covered the basic themes of obsessions, the following further explains the examples that fall under these themes:
- Not wanting to touch anything dirty, or in some more severe cases, not wanting to touch anything in the fear of being contaminated by it.
- Avoiding situations that often trigger obsessions, such as not wanting to shake hands with someone in fear of contamination.
- Feeling intensely stressed when an object is not ordered or is not facing the ‘right’ way. The patient will be the judge of which way is the ‘right’ way.
- Feeling distressed over certain sexual images in their heads.
- Having thoughts of acting out inappropriately or shouting out obscenities that make the patient feel uncomfortable and in fear that they may act on these thoughts.
- Experiencing images of hurting themselves or others, these images are often unwanted and can make the patient uncomfortable and anxious.
- Constantly doubting whether the door is locked or the stove was turned off.
- Constantly doubting if an event occurred in the way the sufferer thinks it did.
- Difficulty in remembering if an action was performed.
The compulsions of obsessive-compulsive disorder are known as repetitive behaviours that the patient feels driven to act on or perform. These behaviours are mental ideas that are acted upon in an attempt to reduce or prevent the anxiety that is related to the patient’s obsessions or to make the patient feel that by completing these acts, he or she is preventing something bad from happening.
However, it is often the case that when the patient performs a compulsive behaviour that they only experience temporary relief from their anxiety or stress.
Patients may create rules for themselves to follow to aid in controlling their anxiety when experiencing obsessive thoughts. These compulsive behaviours are often excessive and unrealistic or illogical and irrelevant to the issue they are intended to solve.
Compulsions are similar to obsessions in that they can also be categorised into themes.
These themes are:
- Cleaning and washing
- Demanding reassurances
- Counting or repetitive actions
- Continual checking
- Sticking to a routine
- Making lists
- Tapping or touching things
- Storing things in a hoarding fashion
Following the basic themes of compulsions, they can be further explained as follows:
- Washing hands until the skin is raw.
- Spending extended periods cleaning surfaces and disinfecting these at regular intervals regardless of use.
- Counting the number of steps taken wherever one walks.
- Arranging bottles, cans, or any items with labels to face the same way.
- Arranging belongings to be in a specific order, such as colour-coding clothes.
- Repeatedly checking doors to ensure they are locked.
- Constantly checking to ensure that the stove is off.
- Repeatedly saying a phrase, word or prayer silently.
- Performing daily activities in an exact order each day with no deviation and any interruptions causing anxiety.
- Making lists of everything from friends and acquaintances to foods consumed or TV shows watched.
- Tapping or touching things in a certain way and a specific number of times.
- Keeping seemingly useless items and hoarding them.
Variation in OCD severity
OCD normally starts to show signs in childhood or the adolescent years. The symptoms will usually start gradually and then vary in their severity throughout the patient’s life. Stress is known to worsen the symptoms. Obsessive-compulsive disorder is considered to be a lifelong condition, with symptoms ranging from mild to moderate and then severe. In severe cases, the patient’s symptoms are often disabling.
When to see a doctor
It is important to note that there is a difference between when someone is a perfectionist in requiring flawless performance or results and when someone has OCD. OCD symptoms are not simply worrying about real-world issues in the patient’s life or just liking things arranged or ordered in a certain way.
The difference between someone being a perfectionist and someone having OCD is that the perfectionist will like their clothes neatly folded and their house being ordered in an organised fashion. However, someone with OCD may feel compelled to have their orange and white shirts together (for no reasonable explanation) and has to wipe their right foot three times before entering their house. This is just an example, but the difference between the two people is clear. Perfectionism is a characteristic and is accompanied by realistic, albeit sometimes frustrating, mannerisms. Someone who is a perfectionist can often control their urges to clean or organise. Whereas OCD is a mental disorder accompanied by obsessions and compulsions that the patient has no control over.
If the patient is experiencing obsessions and compulsions that are affecting their quality of life, then is it advised that they seek professional mental health care assistance.
What are the causes, risk factors and complications of OCD?
The exact cause of obsessive-compulsive disorder is not yet understood to its full extent. A number of studies have shown that the causes of OCD may be a combination of biological, genetic and environmental aspects. These contributing causes are explained as follows:
OCD may be due to changes in the patient’s natural body chemistry or the functions of their brain.
The brain, being an extremely complex structure, contains numerous nerve cells, known as neurons, that are tasked with communicating and working with one another in order to send important messages to the brain to allow for the body to function correctly.
These neurons communicate through chemicals known as neurotransmitters (imagine these chemicals to be the cell phone needed in order to get the message across to another neuron). These neurotransmitters allow for the flow and passing of information.
There was a theory that suggested that serotonin was the chemical in the brain that was responsible for the development of obsessive-compulsive disorder. This theory has since been proved wrong as scientists now believe that OCD is the result of issues in the pathways of the patient’s brain that are responsible for linking the sections of the brain that deal with planning and judgments with another section that filters the messages that coordinate and advise the body on how to move and function.
To explain this simply, if the brain is trying to tell the body to move or act in a certain way according to its environment, this communication can experience a loss of signal between the neurons. Therefore, the neurotransmitters do not allow for the right communication or message to be sent.
There is also additional evidence that suggests that the symptom of OCD can be passed from a parent to a child. However, the genes thought to be responsible for the condition are yet to be identified.
There are a number of environmental factors that have been identified as stressors that can trigger the condition. However, these only act as a trigger in those who already have the tendency to develop OCD.
These factors have been known to include:
- Childhood abuse
- Changes in the home or living situation
- Concerns and stresses in relationships
- Death of someone close
- School or work-related issues or changes
Studies have also discovered a link between OCD and a specific type of infections that is caused by the bacteria Streptococcus. If this specific strep infection is recurrent and left untreated, it has been known to trigger the development of mental disorders such as OCD in children.
There are certain factors that have been identified in the development or triggering of OCD, these can include any one of the following factors:
- If the patient has a family member with the condition, their risk of developing OCD is increased.
- If the patient experiences a life event that is deemed stressful such a car accident or death of a loved one, such events have been known to trigger the reaction of intrusive thoughts, emotional distress and other characteristics of OCD.
- If the patient experiences other mental disorders such as depression, anxiety or a tic disorder (such as Tourette syndrome), they may be at risk of developing OCD too. In some cases where the patient has an obsession over shouting out obscene words or performing strange actions, this may also be diagnosed as Tourette syndrome. However, in Tourette’s, the patient will feel a tingling and irresistible urge to perform the compulsion, while those with OCD may not act on the compulsion or feel such a strong physical sense of urgency to complete it.
Problems and complications that are the result of OCD can include one or a combination of the results below:
- Trouble in relationships as loved ones find the patient’s symptoms difficult to deal with.
- Inability to go to work or school, or to engage in social activities.
- Suicidal behaviour or thoughts.
- Dermatitis from continual hand washing and other health issues.
- Inadequate quality of life.
How is OCD diagnosed?
A doctor will diagnose the patient once he or she has performed an assessment of the symptoms, as well as the duration of time the patient spends when performing their ritualistic behaviours.
There are several steps that a doctor may use in order to diagnose the condition:
- A physical examination – This is often done in order to rule out any other mental health issues that may be the cause of the symptoms. This also checks for any complications that could be related.
- Laboratory tests – The doctor may check that the patient’s thyroid is functioning correctly, he or she may also screen for the presence of drugs and alcohol and also conduct a blood test to check the patient’s CBC (complete blood count).
- A psychological evaluation – The doctor or mental health professional may ask the patient to discuss their thoughts, symptoms and feelings. This allows the doctor to evaluate the patterns of behaviour. Should the patient allow for it, friends and family may also be called in for a group session.
- Diagnostic criteria specifically for OCD – The doctor may make use of the criteria published by the American Psychiatric Association, these criteria are known as the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Challenges in diagnosing OCD
It can often be difficult to diagnose OCD due to the symptoms being similar to those of other mental conditions such as anxiety disorders, schizophrenia, depression and obsessive-compulsive personality disorder (OCPD). OCPD is often confused with OCD, however, OCPD is characterised by extreme perfectionism. Obsessions and compulsions are not symptoms of OCPD.
A patient with OCPD acts within reason and performs according to strict schedules, rules and organisational behaviours that often make them feel reassured and comfortable in their completion as opposed to OCD, where the patient may perform unreasonable actions which often lead to anxiety. Men are more likely to be diagnosed with OCPD than women and researchers often attribute this to gender stereotyping and the fact that in most societies it is more acceptable for men to display acts of stubbornness, domination and control.
Although both disorders can be time-consuming, OCD symptoms often result in the patient’s day being interrupted and this takes a toll on productivity and can lead to the patient experiencing guilt in losing their time to their obsessions and compulsions.
It is best for the patient to work with their doctor in order to achieve the best result and ensure that they are being treated correctly.
How is OCD treated?
Obsessive-compulsive disorder does not simply disappear on its own, therefore, it is vital to seek professional help and treatment. Doctors tend to opt for the most effective method of treatment which combines the use of cognitive behavioural therapy (a form of psychotherapy) and medication.
There is no known cure for OCD, and treatment seeks to control the symptoms so as to prevent them from interfering with the patient’s daily life and activities. Some patients require lifelong treatment.
CBT (cognitive behavioural therapy), which as previously stated is a form of psychotherapy, has been seen to have effective results in a number of OCD cases. A type of this treatment is known as ERP (exposure and response prevention). This involves gradually exposing the patient to an object or obsession they fear, such as germs and dirt. After which, the patient is then taught certain coping techniques to manage their guilt or anxiety associated with the obsession. This form of treatment requires practice and effort, but can often result in the patient living a more productive and normal life as they learn to recognise and deal with their obsessions and compulsions.
Psychotherapy may take place with a psychiatrist and the patient only, or family and friends may also be invited for group sessions in order to help the patient when he or she faces obsessions in the future.
There are a number of specific psychiatric medications that can be prescribed to help control the patient’s obsessive and compulsive behaviour. The most common form of medication first prescribed is antidepressants.
The following antidepressants have been approved to treat OCD:
- For children who are 10 years old or older as well as adults - Clomipramine (Anafranil)
- For children who are seven years or older as well as adults - Fluoxetine (Prozac)
- For children who are eight years or older as well as adults – Fluvoxamine
- For adults only - Paroxetine (Paxil and Pexeva)
- For children who are six years old or older as well as adults - Sertraline (Zoloft)
Antidepressants may be prescribed with other psychiatric medications too.
Medications: What to take into consideration
There are a number of issues for the patient to discuss with their doctor for the treatment of obsessive-compulsive disorder, these are:
- Choosing the right medication – The end-goal is to control the symptoms of OCD with the lowest dose possible in order to get the most effective results. It is often the case that the doctor and patient will work together and try a number of medications before they are able to find the most effective one. The doctor may recommend that the patient takes a combination of more than one medication. It can sometimes take weeks or months in order to see the results and judge the effectiveness of the medication.
- Side effects – All forms of psychiatric medication have side effects. It is advised that the patient speaks to their doctor about the potential health risks due to these side effects and that the patient fully discloses any side effects to their doctor.
- The risk of suicide – In general, antidepressants are safe to use as a form of medication. In rare cases, children and adolescents experience suicidal thoughts or behaviour when they take antidepressants, particularly in the first couple of weeks of treatment, or if the dosage is changed. If thoughts of suicide appear, the patient is advised to seek immediate medical attention and that their treatment is changed. However, it is important to also bear in mind that the long-term treatment effect of antidepressants results in the improvement of the patient’s mood.
- The interaction of other substances – If the patient is currently taking antidepressants, it is advised that they tell their doctor about any other over-the-counter or prescription medication, supplements or herbs they may also be taking. This is due to the fact that some antidepressants have been known to result in dangerous reactions if they are combined with other supplements or medications.
- Stopping antidepressants – Although taking antidepressants does not lead to an addiction to the medication, sometimes a physical dependence can develop. Should the patient abruptly stop treatment or miss a number of doses, they may start to experience symptoms similar to those of withdrawal. This is sometimes referred to as discontinuation withdrawal. By stopping the medication, the patient’s symptoms can resurface. Should the patient wish to discontinue their medication due to side effects or personal reasons, it is best that they speak to their doctor about lowering the dosage in phases so as to gradually stop the treatment.
Other forms of treatment
In some cases, psychotherapy and medications are not an effective solution to control the symptoms of OCD. There is ongoing research being done to evaluate the effectiveness of DBS (deep brain stimulation) for the treatment of patients with obsessive-compulsive disorder who do not respond to the approach of traditional treatment. At this stage, the treatment is still regarded as experimental.
DBS is a procedure that uses the implantation of a device that measures brain activity. A thin wire with several electrodes at the tips of it is implanted into the specific parts of the brain responsible for causing the obsessive behaviour associated with OCD, this device then stimulates these areas of the brain in order to measure how to brain reacts. These electrical impulses may also aid in blocking certain areas of the brain, preventing dysfunction and normalising brain activity.
In more severe cases of OCD, ECT (electroconvulsive therapy) has been used to treat the condition. During ECT, a small current is applied to the patient’s brain via electrodes which are placed on the scalp while he or she is put into a state of sleep under a general anaesthetic. This small current causes a seizure in the patient’s brain. This form of treatment is said to improve the symptoms of OCD through ‘re-wiring’ the framework of the brain through the brief seizure.
Can OCD be prevented?
Obsessive-compulsive disorder is unable to be prevented. Through early diagnosis and treatment, patients are often able to control their symptoms and in turn, reduce the time spent on obsessive and compulsive behaviour effectively.
What is the outlook for OCD?
The majority of cases of OCD are able to be effectively treated through medication and psychotherapy, or a combination of both. Through ongoing treatment, a lot of patients are able to achieve relief from their symptoms that is long-term, allowing them to lead normal and healthy lives.