Obsessive-Compulsive Disorder (OCD)

obsessive-compulsive disorder OCD Dr Jonathan Haverkampf psychiatry psychotherapy

Obsessive-compulsive disorder (OCD) is a mental disorder where people feel the need to

  • check things repeatedly
  • perform certain routines repeatedly (called “rituals”), or
  • have certain thoughts repeatedly.

Obsessive–compulsive disorder affects about 2.3% of people at some point in their life. [8] Rates during a given year are about 1.2% and it occurs worldwide. [2] Half of people develop problems before twenty, and it is rare to occur for the first time after age thirty-five. [1][2] Males and females are affected about equally. [1]

The helplessness of having OCD

You may feel quite helpless when experiencing OCD. You may have intrusive thoughts, thoughts that you feel you need to think or that in a sense force themselves on you. Or you may feel the need to do certain things over and over again, like washing your hands or praying or counting all of the blue tiles on the wall or steps on a staircase or all the stones on the ground. You may also experience both, intrusive thoughts and the need to engage in safety routines or safety behaviours. Over time, your brain learns to only feel safe if you think certain things or act in certain ways. A classic example is counting to a specific number, such as 3, 5 or 6, or touching a railing or a desk or a wall a certain number of times. Intrusive thoughts can, for example, be thoughts of driving off the Golden Gate Bridge whenever you cross it in your car. The last one is a classic example that is often used to describe OCD. Typical of OCD is also that when you try to suppress those thoughts or routines you feel tenser and more anxious, and it feels as if there is a need to quickly reengage with the thoughts or the behaviours that are part of the OCD. We call the thoughts ego-dystonic to differentiate them from thoughts that feel ego-syntonic. The former feel as if they do not come from me or within me, they don’t feel like they are mine. This is how people often describe their OCD thoughts or OCD behaviours. Sometimes it helps to imagine a monkey sitting on one shoulder who continuously blabbers, and this is what the obsessive thoughts really are. Compulsive behaviours, such as hand washing or the need to walk a certain way or take to take the first step only with the left or the right foot or cleaning something repeatedly or looking at someone a certain number of times or tapping objects a certain number of times, are safety behaviours that we may have learned early in life too self soothe and two deal with conflicting or painful emotions.

OCD and control

You may feel unable to suppress your intrusive thoughts or your routine safety behaviours for more than a short period of time. Often nervousness, anxiety and uneasiness occur when one tries to suppress them.

The problem with control is that the perceived need for more control is usually counterproductive. We may see this often in everyday life, that if we try to control something we actually control it less. Yielding control often gets us more control over something or even over our own emotions. For example, if I tell myself not to feel sad, I will continuously be reminded of the sadness and experience it until I yield control by accepting the sadness, going through it, and finding its resolution. With OCD, this is quite similar. The more I control my OCD, the more I try to control my feeling of a need for control, the worse the OCD symptoms often get. In therapy, there are many techniques to work with OCD, but the fundamental one is to help you to let go of scrambling for control of the uncontrollable and let you experience greater control over the things you can control. Instead of less of you, there needs to be more of you.

It is important to identify if some thoughts could really be a risk such as suicidal thoughts that can be quite common if one feels low or suffers from another mental health condition. It is then particularly important to work with a mental health professional to identify the thoughts and the risk and create a safe environment.

Ritual (compulsive) behaviors

Common activities include hand washing, counting of things, and checking to see if a door is locked. But they can be virtually anything, from cleaning things to walking in a certain pattern when approaching the office. Some may have difficulty throwing things out. The activities interfere with one’s quality of life and can take more than an hour a day. Most adults realize that the behaviors do not make sense. [1] The condition is associated with tics, anxiety disorder, and an increased risk of suicide. [2][3] However, often the rituals have common themes, that can frequently by traced to a patient’s individual history or current situation. This is then the task of psychotherapy.

Causes of OCD

The cause of OCD is unknown. [1] There appear to be some genetic components with both identical twins more often affected than both non-identical twins. Risk factors include a history of child abuse or other stress inducing event, but it is more the subjective perception of a life event that matters, than the actual facts. Some cases of OCD have been documented to occur following infections, and then frequently in a more severe form.

As in many other mental health condition three factors play a role also in OCD:

  • biology (e.g. genetics)
  • psychology (e.g. individual life experiences and coping strategies)
  • social (e.g. communication at the workplace and at home and one’s social network)

There appears to a heritable quality. In general, genetic factors account for 45–65% of the variability in OCD symptoms in children diagnosed with the disorder. [31] Recent evidence supports the possibility of a heritable predisposition for neurological development favoring OCD. [32]

Identical twins are more often affected than non-identical twins, which also supports the hypothesis of a genetic predisposition. [2] Further, individuals with OCD are more likely to have first-degree family members exhibiting the same disorders than do matched controls. In cases where OCD develops during childhood, there is a much stronger familial link in the disorder than cases in which OCD develops later in adulthood.

A mutation has been found in the human serotonin transporter gene, hSERT, in unrelated families with OCD. [33]

There may be an evolutionary benefit to moderate versions of compulsive behavior. These individuals might have had an advantage over their peers and were so able to pass on these traits. Examples would be moderate constant checking of hygiene, the hearth, or the environment for enemies, or the hoarding of supplies.

Brain scans of people with OCD have shown that they have different patterns of brain activity than people without OCD and that different functioning of circuitry within a certain part of the brain, the striatum, may cause the disorder. Differences in other parts of the brain and neurotransmitter dysregulation, especially serotonin and dopamine, may also contribute to OCD. [34] Independent studies have consistently found unusual dopamine and serotonin activity in various regions of the brain in people with OCD. These can be defined as dopaminergic hyperfunction in the prefrontal cortex (mesocortical dopamine pathway) and serotonergic hypofunction in the basal ganglia. [35] Dysregulation of glutamate, a cotransmitter with dopamine in dopamine pathways that project out of the ventral tegmental area, has also been the subject of recent research, [36] although the role of glutamate in the disorder’s etiology is not yet clear.

People with OCD have shown a greater probability for increased grey matter volumes in bilateral lenticular nuclei, extending to the caudate nuclei, with decreased grey matter volumes in bilateral dorsal medial frontal/anterior cingulate gyri. These findings contrast with those in people with other anxiety disorders, who have shown decreases in grey matter volumes in bilateral lenticular / caudate nuclei, while also decreased grey matter volumes in bilateral dorsal medial frontal/anterior cingulate gyri. Orbitofrontal cortex overactivity is attenuated in people who have successfully responded to SSRI medication, a result believed to be caused by increased stimulation of serotonin receptors 5-HT2Aand 5-HT2C. [37] The striatum, linked to planning and the initiation of appropriate actions, has also been implicated; mice genetically engineered with a striatal abnormality exhibit OCD-like behavior, grooming themselves three times as frequently as ordinary mice.

In any case, no matter what the specific peculiarities in OCD are, the vast majority of cases can be treated, often with a combination of psychotherapy/counselling and medication.

Diagnosis of OCD

The diagnosis should always be made by an experienced mental health professional. The diagnosis is based on the symptoms and requires ruling out other drug related or medical causes. [2] Rating scales such as the Yale–Brown Obsessive Compulsive Scale can be used to assess the severity. [4] Other disorders with similar symptoms include anxiety disorder, major depressive disorder, eating disorders, tic disorders, and obsessive–compulsive personality disorder. [2]

Treatment of OCD

Treatment involves psychotherapy and counselling, such as psychodynamic (psychoanalytic) psychotherapy and cognitive behavioral therapy (CBT) and, and sometimes medication, typically selective serotonin reuptake inhibitors (SSRIs). [5][6] One should always see an experienced mental health professional for treatment of OCD. Psychotherapy has been shown repeatedly to be an effective approach to treating OCD. In OCD a combination of psychodynamic and cognitive-behavioral approaches seems especially valuable. Medication can be added to speed up the recovery process.

Psychodynamic (psychoanalytic) psychotherapy looks at possible causes for the OCD. Often, there are intrapsychic processes that maintain the rituals and obsessive thoughts. In most cases, people are not aware of repressed emotions or inner conflicts that maintain the OCD. In therapy they can be made aware, which often leads to a substantial or full collapse of the OCD.

CBT for OCD involves increasing exposure to what causes the problems while not allowing the repetitive behavior to occur. [5]

On the medication side, selective serotonin reuptake inhibitors (SSRIs) are frequently considered first line of treatment. The tricyclic antidepressant clomipramine appears to work as well as the SSRIs, but it has greater side effects than the SSRIs [5], probably because it is less selective than these, and there are no real reasons anymore for using it. Atypical antipsychotics may be useful when used in addition to an SSRI in treatment-resistant cases but are also associated with an increased risk of side effects. [6][7]

Without treatment, the condition often lasts decades. [2]

Obsessions are thoughts that recur and persist despite efforts to ignore or confront them.[10] People with OCD frequently perform tasks, or compulsions, to seek relief from obsession-related anxiety. Within and among individuals, the initial obsessions, or intrusive thoughts, vary in their clarity and vividness. A relatively vague obsession could involve a general sense of disarray or tension accompanied by a belief that life cannot proceed as normal while the imbalance remains. A more intense obsession could be a preoccupation with the thought or image of someone close to them dying[10][11] or intrusions related to “relationship rightness.”[12] Often people with OCD feel overly responsible for the well-being of other people and themselves. They may have fears to contaminate objects, so that others may contract a severe disease, or attempt to make things ‘undone’ that to other people do not seem dangerous or even risky. A person with OCD builds a personal scaffolding to hold the own emotions in check. In therapy, once people get in touch with their emotions and can describe and explain them, the fears, anxieties, and thus the OCD itself, often subside considerably.

Obsessive Thoughts

Some people with OCD experience sexual obsessions that may involve intrusive thoughts or images of “kissing, touching, fondling, oral sex, anal sex, intercourse, incest and rape” with “strangers, acquaintances, parents, children, family members, friends, coworkers, animals and religious figures”, and can include “heterosexual or homosexual content” with persons of any age.[13] As with other intrusive, unpleasant thoughts or images, some disquieting sexual thoughts at times are normal, but people with OCD may attach extraordinary significance to the thoughts. For example, obsessive fears about sexual orientation can appear to the person with OCD, and even to those around them, as a crisis of sexual identity.[14][15] Furthermore, the doubt that accompanies OCD leads to uncertainty regarding whether one might act on the troubling thoughts, resulting in self-criticism or self-loathing.[13] Often, in therapy the patient discovers that there are some other fears or themes below these disquieting thoughts that might only be very superficially connected to them. This can lead to a great sense of relief and a decrease in the anxieties and fears.

People with OCD understand that their notions do not correspond with reality; however, they feel that they must act as though their notions are correct. For example, an individual who engages in compulsive hoarding might be inclined to treat inorganic matter as if it had the sentience or rights of living organisms, while accepting that such behavior is irrational on a more intellectual level.

Someone exhibiting OCD signs does not necessarily have OCD. Behaviors that present as (or seem to be) obsessive or compulsive can also be found in a number of other conditions as well, including obsessive–compulsive personality disorder (OCPD), autism, disorders where perseveration is a possible feature (ADHD, PTSD, bodily disorders or habit problems). [16] or sub-clinically.

Some with OCD present with features typically associated with Tourette’s syndrome, such as compulsions that may appear to resemble motor tics; this has been termed “tic-related OCD” or “Tourettic OCD”. [17][18]

There is tentative evidence that OCD may be associated with above-average intelligence or at least a small increase in intelligence.[19][20]

OCD sometimes manifests without overt compulsions [21] and is referred to as Primarily Obsessional OCD, OCD without overt compulsions could, by one estimate, characterize as many as 50 percent to 60 percent of OCD cases. [22] People with this form of OCD have distressing and unwanted thoughts emerging frequently, and these thoughts typically center on a fear that one may do something totally uncharacteristic of oneself, possibly something potentially fatal to oneself or others. [23] The thoughts may be of an aggressive or sexual nature. [23]

Rather than engaging in observable compulsions, the person with this subtype might perform more covert, mental rituals, or might feel driven to avoid the situations in which particular thoughts seem likely to intrude. [24] As a result of this avoidance, people can struggle to fulfill their roles at home and in the workplace, even if they place great value on these roles and even if they had fulfilled the roles successfully in the past. [24] The covert mental rituals can take up a great deal of a person’s time during the day.

Compulsive Behaviors

Some people with OCD perform compulsive rituals because they inexplicably feel they have to, others act compulsively so as to mitigate the anxiety that stems from particular obsessive thoughts. The person might feel that these actions somehow either will prevent a dreaded event from occurring, or will push the event from their thoughts. In any case, the individual’s reasoning is so idiosyncratic or distorted that it results in significant distress for the individual with OCD or for those around them. Excessive skin picking, hair-pulling, nail biting, and other body-focused repetitive behavior disorders are all on the obsessive–compulsive spectrum. [2] Some individuals with OCD are aware that their behaviors are not rational, but feel compelled to follow through with them to fend off feelings of panic or dread. [2][25]

Some common compulsions include hand washing, cleaning, checking things (e.g., locks on doors), repeating actions (e.g., turning on and off switches), ordering items in a certain way, and requesting reassurance. Compulsions are different than tics (such as touching, tapping, rubbing, or blinking) and stereotyped movements (such as head banging, body rocking, or self-biting), which usually aren’t as complex as compulsions and aren’t precipitated by obsessions. It can sometimes it may be difficult to tell the difference between compulsions and complex tics. [2] About 10% to 40% of individuals with OCD also have a lifetime tic disorder. [26]

Associated Diagnoses

People with OCD may be diagnosed with other conditions, as well or instead of OCD, such as the aforementioned obsessive–compulsive personality disorder, major depressive disorder, bipolar disorder, [27] generalized anxiety disorder, anorexia nervosa, social anxiety disorder, bulimia nervosa, Tourette syndrome, Asperger syndrome, attention deficit hyperactivity disorder, dermatillomania (compulsive skin picking), body dysmorphic disorder, and trichotillomania (hair pulling). One explanation for the high depression rate among OCD populations was posited by Mineka, Watson, and Clark (1998), who explained that people with OCD (or any other anxiety disorder) may feel depressed because of an “out of control” type of feeling. [28]

Individuals with OCD have been found to be affected by delayed sleep phase syndrome at a substantially higher rate than the general public. [29] Moreover, severe OCD symptoms are consistently associated with greater sleep disturbance. Reduced total sleep time and sleep efficiency have been observed in people with OCD, with delayed sleep onset and offset and an increased prevalence of delayed sleep phase disorder. [30]

Obsessive-compulsive personality disorder (OCPD)

OCD is egodystonic, meaning that the disorder is incompatible with the sufferer’s self-concept. [38] Because ego dystonic disorders go against a person’s self-concept, they tend to cause much distress. OCPD, on the other hand, is egosyntonic—marked by the person’s acceptance that the characteristics and behaviours displayed as a result are compatible with their self-image, or are otherwise appropriate, correct or reasonable. By contrast people for people with OCPD their actions seem to them normal and there is no motivation to change anything because they feel it is just the way things ought to be done.

 

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References

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[15] Mark-Ameen Johnson, I’m Gay and You’re Not : Understanding Homosexuality Fears brainphysics.com.

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Links to further material of interest on OCD:

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