Depression

Updated 11 July 2014

Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a psychiatric disorder characterised by obsessions and compulsions.

Summary

  • Obsessive-compulsive disorder (OCD) is a psychiatric disorder characterised by obsessions and compulsions.
  • Obsessions are unwanted ideas, images or impulses, which repeatedly enter an individual's mind; compulsions are repetitive behaviours or mental acts, often linked to obsessions.
  • There is growing evidence that certain parts of the brain (basal ganglia) and specific brain chemicals (serotonin) are important in mediating OCD.
  • OCD affects between 1% and 3.3% of people; it is one of the most common and disabling of the psychiatric disorders.
  • Combining antidepressant medication and cognitive behavioural therapy has been found to be the most effective treatment for OCD.

What is obsessive-compulsive disorder (OCD)?

Obsessive-compulsive disorder (OCD) is a psychiatric disorder characterised by obsessions and compulsions. Obsessions are persistent, "self generated" thoughts that cause you distress. However, compulsions are not inherently enjoyable and do not result in the completion of a useful task. Compulsions are repetitive acts you may perform in an attempt to reduce the distress.

OCD is an anxiety disorder, a category that includes post-traumatic stress disorder, social anxiety disorder (social phobia) and panic disorder.

OCD should not be confused with obsessive-compulsive personality disorder (OCPD). Despite its name, OCPD does not involve obsessions and compulsions. It is a personality pattern that involves being preoccupied with order, and traits such as perfectionism and inflexibility. Only a few people with OCD have OCPD.

What causes OCD?

There is no single, proven cause of OCD. It is likely that both genetic and environmental factors are involved.

Research suggests that OCD is related to faulty communication between the front part of the brain (the orbital cortex) and deeper structures (the basal ganglia). These brain structures use serotonin, a neurotransmitter (chemical "messenger" between nerve cells).

Another theory is that OCD involves various auto-immune reactions (in which the body's disease-fighting mechanism attacks normal tissue). Evidence to support this is that OCD sometimes starts in childhood in association with strep throat (a sore throat caused by infection with Streptococcus bacteria).

Research suggests that genetics play a role in development of the disorder in some cases, and a number of genes may contribute to its development.

Who gets OCD and who is at risk?

OCD is a fairly common disorder, affecting between 2% and 3% of people.

Onset can begin any time from preschool age to adulthood (usually before age 40). Men most commonly start having symptoms as teenagers; women start in their early 20s. One-third to one-half of adults with OCD report that their illness started in childhood. It is just about equally common in men and women.

When a parent has OCD, there is a slightly increased risk that a child will develop the condition. However, similar rituals are not inherited. Thus a child may have checking rituals, while her mother washes compulsively.

OCD is not primarily related to stress or psychological conflict, and can be seen in all kinds of personality types.

OCD often occurs along with mood disorders such as depression and bipolar affective disorder (manic depression).

Symptoms and signs of OCD

OCD usually involves both obsessions and compulsions, although in rare cases, one may be present without the other.

Obsessions:

Obsessions are defined as recurrent and persistent thoughts, impulses or images that you feel unable to control or prevent. You will usually experience these as senseless, disturbing and intrusive, and try to ignore or suppress them. Obsessions are often accompanied by anxiety, fear, disgust or doubt.

Common Obsessions:

  • Worrying excessively about dirt or germs and that you may become contaminated or contaminate others
  • Imagining you have harmed yourself or others; having doubts about safety issues (such as whether you have turned off the stove)
  • Fearing something terrible will happen or that you will do something terrible
  • Preoccupations with symmetry, or a need to have things "just so"
  • Intrusive sexual thoughts
  • Intrusive violent or repulsive images
  • Excessive religious or moral doubt or guilt; intrusive blasphemous images
  • Excessive doubting or indecision: "should I - shouldn't I?"
  • A need to tell, ask or confess

Compulsions:

Compulsions on the other hand, are defined as repetitive and ritualistic behaviour or mental acts, often performed according to certain "rules".

Common compulsions:

  • Washing or cleaning: such as showering repeatedly or washing your hands until the skin is red and painful
  • Checking: such as repeatedly checking that you have turned off the stove or locked the front door
  • Repeating: such as repeating a name or phrase many times to ease anxiety
  • Completing: performing a series of steps in an exact order or repeating them until you feel they are done perfectly
  • Repetitive ordering, arranging or counting of objects
  • Hoarding: collecting useless items you may repeatedly count or order
  • Excessive and repetitive praying
  • Repetitive touching

Unlike compulsive drinking or gambling, OCD compulsions are not pleasurable, but are often are performed to obtain relief from obsessions. For example, you may repeatedly check that you have turned off the stove because of an obsession about burning the house down or you may count certain objects repeatedly because of an obsession about losing them.

Not all obsessive-compulsive behaviours are OCD. Some rituals (such as religious practices, exercise routines) are part of daily life. Normal worries, such as contamination fears, may increase during times of stress, such as when someone in the family is sick.

You may have OCD if your obsessions or compulsions:

  • Cause you marked distress
  • Persist and take up a lot of time (over an hour a day). People with OCD may spend hours each day performing compulsive acts
  • Significantly interfere with your normal routine, work, social activities or relationships
  • Are senseless

People with OCD are usually aware that their obsessions or compulsions are excessive or senseless, and are more than just normal worries. "OCD with poor insight" is diagnosed when someone with OCD does not recognise that his or her beliefs and actions are unreasonable.

OCD symptoms usually have a "waxing and waning" course, i.e. tend to come and go over time, and vary in intensity. Some symptoms may be mild and fairly easy to ignore; others cause severe distress and disability.

People with OCD also often have depression or depressive symptoms, including:

  • Guilt
  • Sadness
  • Low self-esteem
  • Anxiety
  • Fatigue

How is OCD diagnosed?

OCD tends to be under-diagnosed. Because of the stigma of mental illness, people may hide symptoms and avoid seeking professional help. People with OCD may also be unaware that they have a recognisable and treatable illness. Thanks to recent awareness campaigns and destigmatisation efforts by the media and mental health organisations, this situation is improving. Some health professionals are, however, still unfamiliar with OCD symptoms.

There are no laboratory tests for OCD; diagnosis is based on assessment of your symptoms. Your doctor will ask you, and often people close to you, about your symptoms, and pose specific questions about the type of obsessions or compulsions you experience.

Your doctor will also check that a medication or drug is not making your symptoms worse.

How is OCD treated?

Combining antidepressant medication and cognitive-behavioural therapy (CBT) has been found to be the most effective treatment for OCD. Both kinds of treatment may take several months to be effective, but a good response is often seen in time.

Medication

Medications most commonly prescribed for OCD are antidepressants called selective serotonin reuptake inhibitors (SSRIs), notably, fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Aropax), fluvoxamine (Luvox), and citalopram (Cipramil).

Another medication used is clomipramine (Anafranil), which is a non-selective SRI, meaning it affects other neurotransmitters besides serotonin, and might have more side effects.

The SSRIs are usually easier for people to tolerate. All these antidepressants are equally effective, although for any particular person one agent may be better than another.

Most people notice some benefit from these medications after four to six weeks, but it is necessary to try the medication for 10 to 12 weeks to see whether it works or not. If you do experience distressing side-effects, your doctor can try reducing the dose, or adding or switching to a different medicine. Indeed, when the medication (an SSRI) has proved ineffective after 10 to 12 weeks, a different SSRI can be tried. Alternatively, another medication can be added to the first, or adding CBT may render treatment more effective.

Very importantly: Before deciding that a treatment has failed, your therapist needs to be sure that the treatment has been given in a large enough dose for a sufficient period of time.

Fewer than 20% of people treated with medication alone will have their symptoms resolved completely, so medication is often combined with CBT for better results. The need for medication depends on the severity of your OCD and your age. In milder OCD, CBT alone may be used initially, but medication may be added if CBT proves ineffective. People with severe OCD or complicating conditions (such as depression) often start with medication, adding CBT once the medicine has provided some relief. In younger patients doctors are more likely to use CBT alone. However, if a trained cognitive-behavioral psychotherapist is unavailable, medication may be used.

Cognitive-behavioural therapy (CBT)

Behaviour therapy helps you learn to change your behaviour and feelings by changing your thoughts. Behaviour therapy for OCD involves exposure and response prevention (E/RP), and cognitive therapy.

Exposure involves gradually exposing yourself to feared stimuli. For example, people with contamination obsessions are encouraged to touch "dirty" objects (like money) until their anxiety recedes. Anxiety tends to decrease after repeated exposure until the contact is no longer feared.

Exposure is most effective if combined with response or ritual prevention, in which rituals or avoidance behaviours are blocked. If, for example, you wash your hands compulsively, your therapist may stand at the sink with you and prevent you from washing your hands until the anxiety recedes.

Cognitive therapy, the other component in CBT, is often added to E/RP to help reduce the exaggerated thoughts and sense of responsibility that often occurs in OCD. Cognitive therapy helps you challenge the faulty assumptions of your obsessions, and so bring anxiety and the urge to respond with compulsive behaviour under control.

Gradual CBT involves practice with the therapist once or twice a week and doing daily E/RP "homework". Homework is necessary because many of the elements that trigger OCD occur in your own environment and often cannot be reproduced in the therapist’s office. According to research, people who complete CBT have a 50%–80% reduction in symptoms after 12–20 sessions. Intensive CBT, which involves two to three hours of therapist-assisted E/RP daily for three weeks, may work even more quickly. In rare cases where OCD is very severe or complicated by another illness, or involves severe depression or aggressive impulses, hospitalisation may be recommended for intensive CBT.

Other techniques, such as thought stopping and distraction (suppressing or "switching off" OCD symptoms) may sometimes be helpful.

Other treatments

In adults with very severe OCD, neurosurgery to interrupt specific malfunctioning brain circuits may be recommended.

People with OCD may have substance-abuse problems, sometimes as a result of attempts at self-medication, and this usually also needs specific treatment.

Maintenance treatment

Once OCD symptoms are eliminated or greatly reduced, these gains must be maintained. Most experts recommend monthly follow-up visits for at least six months and continued treatment for at least a year before trying to stop medication or CBT.

Relapse is common when medication is withdrawn, particularly if you have not had CBT. It is recommended that you continue medication if you don't have access to CBT.

People who have repeated episodes of OCD may need to receive long-term prophylactic medication.

Discontinuing treatment

If you don't need long-term medication, most experts recommend gradual discontinuation of medication, while receiving CBT booster sessions to prevent relapse. It is harder to get OCD under control than to keep it there, so don’t risk a relapse by reducing or stopping your treatment without your doctor's advice.

Education and family support

Include your family in your therapy, and educate all concerned about the illness. This will help you manage your OCD and ensure you get the best treatment. Consider joining a support group: this helps you feel less alone and learn new strategies for coping with OCD. (The OCD Association of South Africa or the Mental Health Information Centre (MHIC) can give information about support groups in your area.)

When someone with OCD denies the problem or refuses to be treated, family members can help by ensuring the person has access to information about the disorder and explaining that there are effective treatments.

OCD can cause considerable disruption for other family members, who may get drawn into the ill person's rituals. The therapist can help family members learn how to become gradually disengaged from these.

A calm, supportive family can help improve treatment outcome. Ordering someone with OCD to simply stop their compulsive behaviour is seldom helpful and can make the person feel worse. Instead, praise any successful attempts to resist OCD, and focus on positive elements in the person’s life. Treat people normally once they have recovered, but be alert for telltale signs of relapse. Point out any early symptoms in a caring manner.

What is the outcome of OCD?

Without treatment, the disorder may last a lifetime, becoming less severe from time to time, but rarely resolving completely. In some people, OCD occurs in episodes, with years free of symptoms before a relapse.

Even with treatment however, OCD can come and go many times during your lifetime. Although OCD is completely curable only in some individuals, most people achieve relief with comprehensive treatment.

OCD symptoms often create problems in daily living and relationships. In extreme cases, people become totally disabled and cannot leave home because they spend their time engaged in rituals or obsessive thoughts.

In children and adolescents, OCD may worsen or cause disruptive behaviours, exaggerate a pre-existing learning disorder or cause problems with attention and concentration. These disruptive behaviours will often resolve or improve when the OCD is successfully treated.

When to call the doctor

See your doctor if you:

  • Suspect you or a family member may be developing symptoms of OCD.
  • Experience worsening OCD symptoms that aren’t relieved by strategies you learned in CBT.
  • Experience changes in medication side effects.
  • Have new symptoms that may indicate development of another disorder (such as panic or depression).
  • Are going through a life crisis that might worsen your OCD.

Can OCD be prevented?

At present there is no known prevention for OCD. However, early diagnosis and correct treatment can help people avoid the suffering associated with the condition and lessen the risk of developing other problems, such as depression or relationship and work difficulties.

For more information contact the MRC Unit on Anxiety Disorders at 021 938 9229, the Obsessive-Compulsive Association of SA at 011 786 7030, or the Mental Health Information Centre at 021 938 9212.

Reviewed by Christine Lochner, Coordinator: Genetics and Anxiety Disorders Research, MRC Unit on Anxiety Disorders.

 

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Depression expert

Michael Simpson has been a senior psychiatric academic, researcher, and Professor in several countries, having worked at London University in the UK; McMaster University in Canada; Temple University in Philadelphia, USA.; and the University of Natal in South Africa.

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