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OBSESSIVE COMPULSIVE DISORDERS
Obsessive-Compulsive Disorder
What is OCD?
Obsessive-compulsive disorder (OCD), one of the anxiety disorders, is a
potentially disabling condition that can persist throughout a person's
life. The individual who suffers from OCD becomes trapped in a pattern of
repetitive thoughts and behaviors that are senseless and distressing but
extremely difficult to overcome. OCD occurs in a spectrum from mild to
severe, but if severe and left untreated, can destroy a person's capacity
to function at work, at school, or even in the home.
The case histories in this brochure are typical for those who suffer
from obsessive-compulsive disorder--a disorder that can be effectively
treated. However, the characters are not real.
How Common Is OCD?
For many years, mental health professionals thought of OCD as a rare
disease because only a small minority of their patients had the condition.
The disorder often went unrecognized because many of those afflicted with
OCD, in efforts to keep their repetitive thoughts and behaviors secret,
failed to seek treatment. This led to underestimates of the number of
people with the illness. However, a survey conducted in the early 1980s by
the National Institute of Mental Health (NIMH)--the Federal agency that
supports research nationwide on the brain, mental illnesses, and mental
health--provided new knowledge about the prevalence of OCD. The NIMH
survey showed that OCD affects more than 2 percent of the population,
meaning that OCD is more common than such severe mental illnesses as
schizophrenia, bipolar disorder, or panic disorder. OCD strikes people
of all ethnic groups. Males and females are equally affected. The social
and economic costs of OCD were estimated to be $8.4 billion in 1990
(DuPont et al, 1994).
Although OCD symptoms typically begin during the teenage years or
early adulthood, recent research shows that some children develop the
illness at earlier ages, even during the preschool years. Studies indicate
that at least one-third of cases of OCD in adults began in childhood.
Suffering from OCD during early stages of a child's development can cause
severe problems for the child. It is important that the child receive
evaluation and treatment by a knowledgeable clinician to prevent the child
from missing important opportunities because of this disorder.
Obsessions
These are unwanted ideas or impulses that repeatedly well up in the
mind of the person with OCD. Persistent fears that harm may come to self
or a loved one, an unreasonable concern with becoming contaminated, or
an excessive need to do things correctly or perfectly, are common. Again
and again, the individual experiences a disturbing thought, such as,
"My hands may be contaminated--I must wash them"; "I may have left the gas
on"; or "I am going to injure my child." These thoughts are intrusive,
unpleasant, and produce a high degree of anxiety. Sometimes the obsessions
are of a violent or a sexual nature, or concern illness.
Compulsions
In response to their obsessions, most people with OCD resort to
repetitive behaviors called compulsions. The most common of these are
washing and checking. Other compulsive behaviors include counting (often
while performing another compulsive action such as hand washing),
repeating, hoarding, and endlessly rearranging objects in an effort to keep
them in precise alignment with each other. Mental problems, such as
mentally repeating phrases, listmaking, or checking are also common. These
behaviors generally are intended to ward off harm to the person with OCD or
others. Some people with OCD have regimented rituals while others have
rituals that are complex and changing. Performing rituals may give the
person with OCD some relief from anxiety, but it is only temporary.
Insight
People with OCD show a range of insight into the senselessness of their
obsessions. Often, especially when they are not actually having an
obsession, they can recognize that their obsessions and compulsions are
unrealistic. At other times they may be unsure about their fears or even
believe strongly in their validity.
Resistance
Most people with OCD struggle to banish their unwanted, obsessive
thoughts and to prevent themselves from engaging in compulsive behaviors.
Many are able to keep their obsessive-compulsive symptoms under control
during the hours when they are at work or attending school. But over the
months or years, resistance may weaken, and when this happens, OCD may
become so severe that time-consuming rituals take over the sufferers'
lives, making it impossible for them to continue activities outside the
home.
Shame and Secrecy
OCD sufferers often attempt to hide their disorder rather than seek
help. Often they are successful in concealing their obsessive-compulsive
symptoms from friends and coworkers. An unfortunate consequence of this
secrecy is that people with OCD usually do not receive professional help
until years after the onset of their disease. By that time, they may have
learned to work their lives--and family members' lives--around the rituals.
Long-lasting Symptoms
OCD tends to last for years, even decades. The symptoms may become less
severe from time to time, and there may be long intervals when the symptoms
are mild, but for most individuals with OCD, the symptoms are chronic.
What Causes OCD?
The old belief that OCD was the result of life experiences has been
weakened before the growing evidence that biological factors are a primary
contributor to the disorder. The fact that OCD patients respond well to
specific medications that affect the neurotransmitter serotonin suggests
the disorder has a neurobiological basis. For that reason, OCD is no
longer attributed only to attitudes a patient learned in childhood--for
example, an inordinate emphasis on cleanliness, or a belief that certain
thoughts are dangerous or unacceptable. Instead, the search for causes now
focuses on the interaction of neurobiological factors and environmental
influences, as well as cognitive processes.
OCD is sometimes accompanied by depression, eating disorders, substance
abuse disorder, a personality disorder, attention deficit disorder, or
another of the anxiety disorders. Co-existing disorders can make OCD more
difficult both to diagnose and to treat.
In an effort to identify specific biological
factors that may be important in the onset or persistence of OCD,
NIMH-supported investigators have used a device called the positron
emission tomography (PET) scanner to study the brains of patients with OCD.
Several groups of investigators have obtained findings from PET scans
suggesting that OCD patients have patterns of brain activity that differ
from those of people without mental illness or with some other mental
illness. Brain-imaging studies of OCD showing
abnormal neurochemical activity in regions known to play a role in certain
neurological disorders suggest that these areas may be crucial in the
origins of OCD. There is also evidence that treatment with medications or
behavior therapy induce changes in the brain coincident with clinical
improvement.
Recent preliminary studies of the brain using magnetic resonance
imaging showed that the subjects with obsessive-compulsive disorder had
significantly less white matter than did normal control subjects,
suggesting a widely distributed brain abnormality in OCD. Understanding
the significance of this finding will be further explored by functional
neuroimaging and neuropsychological studies (Jenike et al, 1996).
Symptoms of OCD are seen in association with some other neurological
disorders. There is an increased rate of OCD in people with Tourette's
syndrome, an illness characterized by involuntary movements and
vocalizations. Investigators are currently studying the hypothesis that a
genetic relationship exists between OCD and the tic disorders.
Other illnesses that may be linked to OCD are trichotillomania (the
repeated urge to pull out scalp hair, eyelashes, eyebrows or other body
hair), body dysmorphic disorder (excessive preoccupation with imaginary or
exaggerated defects in appearance), and hypochondriasis (the fear of
having--despite medical evaluation and reassurance--a serious disease).
Genetic studies of OCD and other related conditions may enable scientists
to pinpoint the molecular basis of these disorders.
Other theories about the causes of OCD focus on the interaction between
behavior and the environment and on beliefs and attitudes, as well as how
information is processed. These behavioral and cognitive theories are not
incompatible with biological explanations.
Do I Have OCD?
A person with OCD has obsessive and compulsive behaviors that are
extreme enough to interfere with everyday life. People with OCD should not
be confused with a much larger group of individuals who are sometimes
called "compulsive" because they hold themselves to a high standard of
performance and are perfectionistic and very organized in their work and
even in recreational activities. This type of "compulsiveness" often
serves a valuable purpose, contributing to a person's self-esteem and
success on the job. In that respect, it differs from the life-wrecking
obsessions and rituals of the person with OCD.
Treatment of OCD; Progress Through
Research
Clinical and animal research sponsored by NIMH and other scientific
organizations has provided information leading to both pharmacologic and
behavioral treatments that can benefit the person with OCD. One patient
may benefit significantly from behavior therapy, while another will benefit
from pharmacotherapy. Some others may use both medication and behavior
therapy. Others may begin with medication to gain control over their
symptoms and then continue with behavior therapy. Which therapy to use
should be decided by the individual patient in consultation with his or her
therapist.
Pharmacotherapy
Clinical trials in recent years have shown that drugs that affect the
neurotransmitter serotonin can significantly decrease the symptoms of OCD.
The first of these serotonin reuptake inhibitors (SRIs) specifically
approved for the use in the treatment of OCD was the tricyclic
antidepressant clomipramine (AnafranilR). It was followed by
other SRIs that are called "selective serotonin reuptake inhibitors"
(SSRIs). Those that have been approved by the Food and Drug Administration
for the treatment of OCD are flouxetine (ProzacR), fluvoxamine
(LuvoxR), and paroxetine (PaxilR). Another that has
been studied in controlled clinical trials is sertraline
(ZoloftR). Large studies have shown that more than
three-quarters of patients are helped by these medications at least a
little. And in more than half of patients, medications relieve symptoms of
OCD by diminishing the frequency and intensity of the obsessions and
compulsions. Improvement usually takes at least three weeks or longer. If
a patient does not respond well to one of these medications, or has
unacceptable side effects, another SRI may give a better response. For
patients who are only partially responsive to these medications, research
is being conducted on the use of an SRI as the primary medication and one
of a variety of medications as an additional drug (an augmenter).
Medications are of help in controlling the symptoms of OCD, but often, if
the medication is discontinued, relapse will follow. Indeed, even after
symptoms have subsided, most people will need to continue with medication
indefinitely, perhaps with a lowered dosage.
Behavior Therapy
Traditional psychotherapy, aimed at helping the patient develop insight
into his or her problem, is generally not helpful for OCD. However, a
specific behavior therapy approach called "exposure and response
prevention" is effective for many people with OCD. In this approach, the
patient deliberately and voluntarily confronts the feared object or idea,
either directly or by imagination. At the same time the patient is
strongly encouraged to refrain from ritualizing, with support and structure
provided by the therapist, and possibly by others whom the patient recruits
for assistance. For example, a compulsive hand washer may be encouraged
to touch an object believed to be contaminated, and then urged to avoid
washing for several hours until the anxiety provoked has greatly decreased.
Treatment then proceeds on a step-by-step basis, guided by the patient's
ability to tolerate the anxiety and control the rituals. As treatment
progresses, most patients gradually experience less anxiety from the
obsessive thoughts and are able to resist the compulsive urges.
Studies of behavior therapy for OCD have found it to be a successful
treatment for the majority of patients who complete it. For the treatment
to be successful, it is important that the therapist be fully trained to
provide this specific form of therapy. It is also helpful for the patient
to be highly motivated and have a positive, determined attitude.
The positive effects of behavior therapy endure once treatment has
ended. A recent compilation of outcome studies indicated that, of more
than 300 OCD patients who were treated by exposure and response prevention,
an average of 76 percent still showed clinically significant relief from 3
months to 6 years after treatment (Foa & Kozak, 1996). Another study has
found that incorporating relapse-prevention components in the treatment
program, including follow-up sessions after the intensive therapy,
contributes to the maintenance of improvement (Hiss, Foa, and Kozak, 1994).
One study provides new evidence that cognitive-behavioral therapy may
also prove effective for OCD. This variant of behavior therapy emphasizes
changing the OCD sufferer's beliefs and thinking patterns. Additional
studies are required before the promise of cognitive-behavioral therapy can
be adequately evaluated. The ongoing search for causes, together with
research on treatment, promises to yield even more hope for people with OCD
and their families.
How to Get Help for OCD
If you think that you have OCD, you should seek the help of a mental
health professional. Family physicians, clinics, and health maintenance
organizations may be able to provide treatment or make referrals to mental
health centers and specialists. Also, the department of psychiatry at a
major medical center or the department of psychology at a university may
have specialists who are knowledgeable about the treatment of OCD and are
able to provide therapy or recommend another doctor in the area.
What the Family Can Do to Help
OCD affects not only the sufferer but the whole family. The family
often has a difficult time accepting the fact that the person with OCD
cannot stop the distressing behavior. Family members may show their anger
and resentment, resulting in an increase in the OCD behavior. Or, to keep
the peace, they may assist in the rituals or give constant reassurance.
Education about OCD is important for the family. Families can learn
specific ways to encourage the person with OCD to adhere fully to behavior
therapy and/or pharmacotherapy programs. Self-help books are often a good
source of information. Some families seek the help of a family therapist
who is trained in the field. Also, in the past few years, many families
have joined one of the educational support groups that have been organized
throughout the country.
CONTINUING RESEARCH
Research into treatment for OCD is ongoing in several areas--ways of
increasing availability of effective behavior therapy; cognitive therapy;
relapse prevention; methods of reducing medication in patients who have a
history of being unable to tolerate medication, such as small, liquid doses
of flouxetine or the use of intravenous clomipramine; and neurosurgery, a
new approach to treatment-refractory OCD. In the very few centers where
neurosurgery has been performed as a clinical procedure, candidates are
generally restricted to those who have failed to respond to conventional
treatments, including behavior therapy and pharmacotherapy.
In addition to research into treatment modalities, NIMH researchers are
conducting studies into possible linkage of OCD to some autoimmune diseases
(diseases in which infection-fighting cells, or antibodies, turn against
the body, trying to destroy it). Other NIMH-supported studies compare
behavior therapy, pharmacotherapy, and a combination of both.
Anecdotal reports of the successful use of electroconvulsive therapy
(ECT) in OCD have been published over the past several decades. Most
often, the benefit from ECT has been short lived, and this treatment is now
generally restricted to instances of treatment-resistant OCD accompanied by
severe depression.
Books Suggested for Further Reading
Baer L. Getting Control. Overcoming Your Obsessions and
Compulsions. Boston: Little, Brown & Co., 1991.
DeSilva P and Rachman S. Obsessive-compulsive Disorder: that
Facts. Oxford: Oxford University Press, 1992.
Foa EB and Wilson R. Stop Obsessing! How to Overcome Your Obsessions
and Compulsions. New York: Bantam Books, 1991.
Foster CH. Polly's Magic Games: A Child's View of
Obsessive-Compulsive Disorder. Ellsworth, ME: Dilligaf Publishing,
1994.
Greist JH. Obsessive Compulsive Disorder: A Guide. Madison, WI:
Obsessive Compulsive Disorder Information Center. rev. ed., 1992.
(Thorough discussion of pharmacotherapy and behavior therapy)
Jenike MA. Drug Treatment of OCD in Adults. Milford, CT: OC
Foundation, 1996. (Answers frequently asked questions about OCD and drug
treatments)
Johnston HF. Obsessive Compulsive Disorder in Children and
Adolescents: A Guide. Madison, WI: Child Psychopharmacology
Information Center, 1993.
Matisik EN. The Americans with Disabilities Act and the Rehabilitation
Act of 1973: Reasonable Accommodation for Employees with OCD. Milford,
CT: OC Foundation, 1996.
Neziroglu F. and Yaryura-Tobias JA. Over and Over Again: Understanding
Obsessive-compulsive Disorder. Lexington, MA: DC Health, 1991.
Rapoport JL. The Boy Who Couldn't Stop Washing: The Experience and
Treatment of Obsessive-Compulsive Disorder. New York: E.P. Dutton,
1989.
Steketee GS and White K. When Once Is Not Enough: Help for Obsessive
Compulsives. Oakland, CA: New Harbinger, 1990.
VanNoppen BL, Pato MT, and Rasmussen S. Learning to Live with OCD.
Milford, CT: OC Foundation, 1993.
Videotape
The Touching Tree. Jim Callner, writer/director, Awareness films.
Distributed by the O.C. Foundation, Inc., Milford, CT. (about a child with
OCD)
References
DuPont RL, Rice DP, Shiraki S, and Rowland C. Economic costs of
obsessive-compulsive disorder. Unpublished, 1994.
Foa EB and KoZak MJ. Obsessive-compulsive disorder: long-term outcome of
psychological treatment. In Mavissakalian & Prien (Eds.), Long-term
Treatments of Anxiety Disorders. Washington, DC: American Psychiatric
Press, 1996, 285-309.
Hiss H, Foa EB, and Kozak MJ. Relapse prevention program for treatment of
obsessive-compulsive disorder. Journal of Consulting and Clinical
Psychology 62:4:801-808, 1994.
Jenike MA. Obsessive-compulsive Disorder: efficacy of specific treatments
as assessed by controlled trials. Psychopharmacology Bulletin
29:4:487-499, 1993.
Jenike MA. Managing the patient with treatment-resistant
obsessive-compulsive disorder: current strategies. Journal of Clinical
Psychiatry 55:3 (suppl):11-17, 1994.
Jenike MA et al. Cerebral structural abnormalities in obsessive-compulsive
disorder. Archives of General Psychiatry 53:7:625-632, 1996.
Leonard HL, Swedo SE, Lenane MC, Rettew DC, Hamburger SD, Bartko JJ, and
Rapoport JL. A 2- to 7-Year follow-up study of 54 obsessive-compulsive
children and adolescents. Archives of General Psychiatry
50:429-439, 1993.
March JS, Mulle K, and Herbel B. Behavioral psychotherapy for children
and adolescents with obsessive-compulsive disorder: an open trial of a new
protocol-driven treatment package. Journal of the American Academy of
Child and Adolescent Psychiatry 33:3:333-341, 1994.
Pato MT, Zohar-Kadouch R, Zohar J, and Murphy DL. Return of symptoms
after discontinuation of clomipramine in patients with obsessive-compulsive
disorder. American Journal of Psychiatry 145:1521-1525, 1988.
Swedo SE and Leonard HL. Childhood movement disorders and
obsessive-compulsive disorder. Journal of Clinical Psychiatry
55:3 (suppl):32-37.
Swedo SE and Leonard HL. Excessively compulsive or obsessive-compulsive
disorder? It's Not All in Your Head. New York, NY: HarperCollins,
1996.
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