disorder (OCD) is a psychiatric disorder characterised by obsessions and
are unwanted ideas, images or impulses, which repeatedly enter an individual's
mind; compulsions are repetitive behaviours or mental acts, often linked to
is growing evidence that certain parts of the brain (basal ganglia) and
specific brain chemicals (serotonin) are important in mediating OCD.
affects between 1% and 3.3% of people; it is one of the most common and
disabling of the psychiatric disorders.
antidepressant medication and cognitive behavioural therapy has been found to
be the most effective treatment for OCD.
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.
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
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 Streptococcusbacteria).
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.
gets OCD and who is at risk?
OCD is a fairly common disorder,
affecting between 1% 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).
and signs of OCD
OCD usually involves both obsessions
and compulsions, although in rare cases, one may be present without the other.
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.
excessively about dirt or germs and that you may become contaminated or
you have harmed yourself or others; having doubts about safety issues (such as
whether you have turned off the stove)
something terrible will happen or that you will do something terrible
with symmetry, or a need to have things "just so"
violent or repulsive images
religious or moral doubt or guilt; intrusive blasphemous images
doubting or indecision: "should I - shouldn't I?"
need to tell, ask or confess
Compulsions on the other hand, are
defined as repetitive and ritualistic behaviour or mental acts, often performed
according to certain "rules".
or cleaning: such as showering repeatedly or washing your hands until the skin
is red and painful
such as repeatedly checking that you have turned off the stove or locked the
such as repeating a name or phrase many times to ease anxiety
performing a series of steps in an exact order or repeating them until you feel
they are done perfectly
ordering, arranging or counting of objects
collecting useless items you may repeatedly count or order
and repetitive praying
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
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
you marked distress
and take up a lot of time (over an hour a day). People with OCD may spend hours
each day performing compulsive acts
interfere with your normal routine, work, social activities or relationships
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
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:
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.
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.
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-behavioural 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
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.
In adults with very severe OCD,
neurosurgery to interrupt specific malfunctioning brain circuits may be
People with OCD may have
substance-abuse problems, sometimes as a result of attempts at self-medication,
and this usually also needs specific 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.
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
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
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
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
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.
to call the doctor
See your doctor if you:
you or a family member may be developing symptoms of OCD.
worsening OCD symptoms that aren’t relieved by strategies you learned in CBT.
changes in medication side effects.
new symptoms that may indicate development of another disorder (such as panic
going through a life crisis that might worsen your OCD.
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 Dr Stefanie van Vuuren, MBChB (Stell), M
Med (Psig) (Stell), FC (Psych) SA, Psychiatrist in private practice, Durbanville Cape Town, February 2015.
Previously reviewed by
Christine Lochner, Coordinator: Genetics and Anxiety Disorders Research, MRC
Unit on Anxiety Disorders.