What Is Obsessive-Compulsive Disorder?

Obsessive-compulsive disorder (OCD) is an anxiety disorder in which time people have recurring, unwanted thoughts, ideas or sensations (obsessions) that make them feel driven to do something repetitively (compulsions). The repetitive behaviors, such as hand washing, checking on things or cleaning, can significantly interfere with a person’s daily activities and social interactions.

Many people have focused thoughts or repeated behaviors. But these do not disrupt daily life and may add structure or make tasks easier. For people with OCD, thoughts are persistent and unwanted routines and behaviors are rigid and not doing them causes great distress. Many people with OCD know or suspect their obsessions are not true; others may think they could be true (known as poor insight). Even if they know their obsessions are not true, people with OCD have a hard time keeping their focus off the obsessions or stopping the compulsive actions.

A diagnosis of OCD requires the presence of obsession and/or compulsions that are time-consuming (more than one hour a day), cause major distress, and impair work, social or other important function.

Obsessions

Obsessions are recurrent and persistent thoughts, impulses, or images that cause distressing emotions such as anxiety or disgust. Many people with OCD recognize that the thoughts, impulses, or images are a product of their mind and are excessive or unreasonable. Yet these intrusive thoughts cannot be settled by logic or reasoning. Most people with OCD try to ignore or suppress such obsessions or offset them with some other thought or action. Typical obsessions include excessive concerns about contamination or harm, the need for symmetry or exactness, or forbidden sexual or religious thoughts.

Compulsions

Compulsions are repetitive behaviors or mental acts that a person feels driven to perform in response to an obsession. The behaviors are aimed at preventing or reducing distress or a feared situation. In the most severe cases, a constant repetition of rituals may fill the day, making a normal routine impossible. Compounding the anguish these rituals cause is the knowledge that the compulsions are irrational. Although the compulsion may bring some relief to the worry, the obsession returns and the cycle repeats over and over.

Some examples of compulsions:

Cleaning to reduce the fear that germs, dirt, or chemicals will "contaminate" them some spend many hours washing themselves or cleaning their surroundings. Some people spend many hours washing themselves or cleaning their surroundings.

Repeating to dispel anxiety. Some people utter a name or phrase or repeat a behavior several times. They know these repetitions won’t actually guard against injury but fear harm will occur if the repetitions aren’t done.

Checking to reduce the fear of harming oneself or others by, for example, forgetting to lock the door or turn off the gas stove, some people develop checking rituals. Some people repeatedly retrace driving routes to be sure they haven’t hit anyone.

Ordering and arranging to reduce discomfort. Some people like to put objects, such as books in a certain order, or arrange household items “just so,” or in a symmetric fashion.

Mental compulsions to response to intrusive obsessive thoughts, some people silently pray or say phrases to reduce anxiety or prevent a dreaded future event.

Types

There are several types of OCD that present in different ways.

Checking: This is a need to repeatedly check something for harm, leaks, damage, or fire. Checking can include repeatedly monitoring taps, alarms, car doors, house lights, or other appliances.

It can also apply to “checking people.” Some people with OCD diagnose illnesses they feel that they and the people close to them might have. This checking can occur hundreds of times and often for hours, regardless of any commitments the individual may have.

Checking can also involve repeatedly confirming the authenticity of memories. A person with OCD might repeatedly validate letters and e-mails for fear of having made mistakes. There may be a fear of having unintentionally offended the recipient.

Contamination or mental contamination: This occurs when a person with OCD feels a constant and overbearing need to wash and obsesses that objects they touch are contaminated. The fear is that the individual or the object may become contaminated or ill unless repeated cleaning takes place.

It can lead excessive toothbrushing, overcleaning certain rooms in the house, such as the bathroom or kitchen, and avoiding large crowds for fear of contracting germs.

Mental contamination is the feeling of being ‘dirty’ after being mistreated or put down. In this type of contamination, it is always another person that is responsible. A person with OCD will try to ‘scrub away’ this feeling by showering and washing excessively.

Hoarding: This is the inability to throw away used or useless possessions.

Rumination: Ruminating involves an extended and unfocused obsessive train of thought that focuses on wide-ranging, broad, and often philosophical topics, such as what happens after death or the beginning of the universe.

The person may seem detached and deep in thought. However, the ruminating never reaches a satisfactory conclusion.

Intrusive thoughts: These are often violent, horrific, obsessional thoughts that often involve hurting a loved one violently or sexually.

They are not produced out of choice and can cause the person with OCD severe distress. Because of this distress, they are unlikely to follow through on these thoughts.

These thoughts can include obsessions about relationships, killing others or suicide, a fear of being a pedophile, or being obsessed with superstitions.

Symmetry and orderliness: A person with OCD may also obsess about objects being lined up to avoid discomfort or harm. They may adjust the books on their shelf repeatedly so that they are all straight and perfectly lined up, for example.

While these are not the only types of OCD, obsessions and compulsions will generally fall into these categories.

Causes

OCD is thought to have a neurobiological basis, with neuroimaging studies showing that the brain functions differently in people with the disorder. An abnormality, or an imbalance in neurotransmitters, is thought to be involved in OCD.

The disorder is equally common among adult men and women.

OCD in children

OCD that begins in childhood is more common in boys than girls, with the usual time of onset of OCD later for females than males.

The condition might be triggered by a combination of genetic, neurological, behavioral, cognitive, and environmental factors.

Genetic causes

OCD runs in families and can be considered a “familial disorder.” The disease may span generations with close relatives of people with OCD significantly more likely to develop OCD themselves.

Twin studies of adults suggest that obsessive-compulsive symptoms are moderately able to be inherited, with genetic factors contributing 27 to 47 percent variance in scores that measure obsessive-compulsive symptoms. However, no single gene has been identified as the “cause” of OCD.

Autoimmune causes

Some rapid-onset cases of OCD in children might be consequences of Group A streptococcal infections, which cause inflammation and dysfunction in the basal ganglia.

These cases are grouped and referred to as pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).

In recent years, however, other pathogens, such as the bacteria responsible for Lyme disease and the H1N1 flu virus, have also been associated with the rapid onset of OCD in children. As such, clinicians have altered the acronym to PANS, which stands for Pediatric Acute-onset Neuropsychiatric Syndrome.

Behavioral causes

The behavioral theory suggests that people with OCD associate certain objects or situations with fear. They learn to avoid those things or learn to perform “rituals” to help reduce the fear. This fear and avoidance or ritual cycle may begin during a period of intense stress, such as when starting a new job or just after an important relationship comes to an end.

Once the connection between an object and the feeling of fear becomes established, people with OCD begin to avoid that object and the fear it generates, rather than confronting or tolerating the fear.

Cognitive causes

The behavioral theory outlined above focuses on how people with OCD make an association between an object and fear. The cognitive theory, however, focuses on how people with OCD misinterpret their thoughts.

Most people have unwelcome or intrusive thoughts at certain times, but for individuals with OCD, the importance of those thoughts are exaggerated.

For example, a person who is caring for an infant and who is under intense pressure may have an intrusive thought of harming the infant either deliberately or accidentally.

Most people can shrug off and disregard the thought, but a person with OCD may exaggerate the importance of the thought and respond as though it signifies a threat. As long as the individual with OCD interprets these intrusive thoughts as cataclysmic and true, they will continue the avoidance and ritual behaviors.

Neurological causes

Brain imaging techniques have allowed researchers to study the activity of specific areas of the brain, leading to the discovery that some parts of the brain are different in people with OCD when compared to those without.

Despite this finding, it is not known exactly how these differences relate to the development of OCD.

Imbalances in the brain chemicals serotonin and glutamate may play a part in OCD.

Environmental causes

Environmental stressors may be a trigger for OCD in people with a tendency toward developing the condition.

Traumatic brain injury (TBI) in adolescents and children has also been associated with an increased risk of onset of obsessive-compulsions. One study found that 30 percent of children aged 6 to 18 years who experienced a TBI developed symptoms of OCD within 12 months of the injury.

Overall, studies indicate that people with OCD frequently report stressful and traumatic life events before the illness begins.

Diagnosis

According to the American Psychiatric Association (APA), the diagnostic criteria for OCD include:

the presence of obsessions, compulsions or both

the obsessions and compulsions are time-consuming or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

the obsessive-compulsive symptoms are not due to the physiological effects of a substance, for example, drug abuse or medication for another condition.

the disturbance is not better explained by another mental disorder

If the above criteria are met, a diagnosis of OCD might be given.

A number of other psychiatric and neurological disorders, such as depression and anxiety, have similar features to OCD and can occur alongside the condition.

Treatments

Cognitive-Behavioral Therapy

One effective treatment is a type of cognitive-behavioral therapy known as exposure and response prevention. During treatment sessions, patients are exposed to the situations that create anxiety and provoke compulsive behavior or mental rituals. Through exposure, patients learn to decrease and then stop the rituals that consume their lives. They find that the anxiety arising from their obsessions lessens without engaging in ritualistic behavior. This technique works well for patients whose compulsions focus on situations that can be re-created easily. For patients who engage in compulsive rituals because they fear catastrophic events that can’t be re-created, therapy relies on imagining exposure to the anxiety-producing situations. Throughout therapy the patient follows exposure and response prevention guidelines on which the therapist and patient agree.

Cognitive-behavior therapy can help many OCD patients substantially reduce their OCD symptoms. However, treatment only works if patients adhere to the procedures. Some patients will not agree to participate in cognitive-behavioral therapy because of the anxiety it involves.

Medication

A class of medications known as selective serotonin reuptake inhibitors (SSRIs) is effective in the treatment of OCD. (The SSRI dosage used to treat OCD may be higher than that used to treat depression.) Patients who do not respond to one medication sometimes respond to another. Other psychiatric medications can also be effective. Noticeable benefit usually takes six to twelve weeks to occur.

Patients with OCD who have received appropriate treatment have shown to have increased quality of life and improved functioning. Successful treatment may improve the individual's ability to attend school, work, develop and enjoy relationships and pursue leisure activities.

Self-help and Coping

Keeping a healthy lifestyle and being aware of warning signs and what to do if they return can help in coping with OCD and related disorders. Also, using basic relaxation techniques, such as meditation, yoga, visualization, and massage, can help ease the stress and anxiety caused by OCD.