Obsessive-Compulsive Disorder: When You Can't Stop Intrusive Thoughts and Rituals
Since his early twenties, Joe was often plagued by seemingly senseless fears. For awhile he had been terrified of getting sick and spent several hours a day washing his hands to be sure they were germ-free. The washing took a lot of time and made his hands red and raw. But he felt too embarrassed to tell anyone.
Joe, a high school English teacher praised by students and colleagues alike, finally decided to confide in his doctor when his thoughts became more frightening. He was constantly afraid that he had run someone over in his car. His heightened anxiety and the pressing need to return to the site of the "accident" to check if the person was okay was making him late for work. He was also unable to focus on his teaching. The doctor suspected Joe had obsessive-compulsive disorder (OCD). A psychiatrist confirmed the diagnosis and started Joe on treatment that has significantly reduced his fears and enabled him to return to his successful teaching career.
How Do You Know It's OCD?
Most people occasionally get stuck in a thought, worry over and over about a particular problem, get totally preoccupied with something they're doing, or triple-check to make sure they locked their house or car door. But that's not OCD. The hallmark of OCD is becoming so stuck in an unwanted thought or repetitive action that your daily life is disrupted. Other indications that suggest OCD are if the preoccupations or compulsions add up to an hour or more each day, and are very distressing.
OCD is a condition that is characterized by intrusive, unwanted, recurrent, and unpleasant thoughts (obsessions) that cause anxiety and repetitive, ritualistic behaviors (compulsions). Victims feel driven to carry out these obsessions to reduce their anxiety. But the compulsions only provide short-term and often incomplete relief before an obsession strikes again.
Although the thoughts and behaviors in OCD may seem "crazy," people with OCD are not "crazy." They are aware that their obsessions and compulsions are excessive and senseless. They don't want to act them out, but they have little or no control. As a result, they may feel embarrassed, hide their symptoms, and remain alone and unsupported with their disorder.
In a given year, over two million adults have OCD in the US. Both men and women are affected in approximately equal numbers, and there is some evidence that OCD may run in families. OCD sometimes occurs in children, as well.
According to Wayne Brunell, MD, a psychiatrist at the Obsessive-Compulsive Disorders Clinic, Massachusetts General Hospital in Boston, "With the treatments we have available now, people can experience significant improvement in their symptoms." Brunell, along with people such as Joe who have been successfully diagnosed and treated, strongly encourage anyone who thinks he or she may have OCD to seek help from a professional with experience treating OCD.
Are There "Typical" Obsessions and Compulsions?
People with OCD may have many or just a few typical obsessions and compulsions. The specific ones and their severity tend to change over time. Most people have both obsessions and compulsions, but a small percentage just have obsessions.
- Fears related to contamination from items such as dirt, germs, bodily wastes, and chemicals
- Fears about causing harm to someone else, such as killing a beloved family member or running over a pedestrian
- Fears of having done something wrong even when you know you've done it right
- Intense need to have things in a certain order, place, or position
- Disturbing thoughts that may involve religious or sexual behaviors, and fears of acting on them
- Excessive washing or cleaning, particularly handwashing or bathing
- Repeatedly checking (for example, that the door is locked or the stove is turned off)
- Arranging or organizing things in a certain order
- Collecting things like newspapers or mail to the point of filling your home
- Repetitive actions, such as touching something over and over
- Mental compulsions, such as repeatedly counting to a certain number or counting all the books in a bookcase
What Causes OCD?
Although the exact causes of OCD are not known, researchers believe that OCD may be caused by a kind of "faulty wiring" in the brain. Studies using positron emission tomography (PET) scans have showed that people with OCD have brain activity patterns that differ from people who do not have OCD. These PET scans have also been able to track the activation of certain parts of the brain when a person begins to experience OCD symptoms. Not surprisingly, these active areas are those which help us process anxiety (commonly referred to as the "worry circuit"). The brain appears to get "locked into" a runaway circuit that is self-perpetuating.
Additionally, research increasingly suggests that imbalances in one or more chemicals in the brain, including serotonin and possibly dopamine, are also involved. These imbalances may be inherited. Stress and other psychological factors can trigger the onset of OCD and heighten symptoms.
PANDAS, which refers to Pediatric Autoimmune Neuropsychiatric Disorders associated with Streptococcal Infections, is a term that refers to a group of children who have OCD and/or a tic disorder, which gets worse or is related to strep throat. Researchers are studying what causes this, for example, antibodies in the body may interact with the brain.
Are There Related or Simultaneous Disorders?
Some people may experience other disorders, such as depression , eating disorders, attention deficit disorder (ADD), or other anxiety disorders, simultaneously with OCD. This may make diagnosis of OCD more complicated.
There has also been a noted link between symptoms of OCD and tic disorders; for example, OCD is often present in people who suffer from Tourette syndrome. Other illnesses, such as trichotillomania (the repeated urge to pull out scalp and other body hair), body dysmorphic disorder (preoccupation with, or distorted image of, the body), and hypochondriasis (fear of serious illness, even when testing proves negative), may also be related to OCD.
What Is the Treatment?
As of yet, OCD cannot be completely cured. However, treatment can help most people experience significant improvement. Behavior therapy and medication are the two primary approaches.
"For most people it is best to combine behavior therapy with medication," says Dr. Brunell. Most people with OCD need professional help to achieve substantial improvement, but some with mild symptoms can improve on their own using self-help books about exposure and response prevention therapy.
Behavior therapy is a term that covers a number of treatment techniques designed to change undesirable behaviors. Exposure and response prevention is the only type of behavior therapy that has been shown to be effective in treating OCD. People with OCD learn to confront their fears and decrease their anxiety (exposure) without performing the compulsive rituals (response prevention). Cognitive therapy, which can help cope with fears and anxiety, is sometimes used in conjunction with exposure and response prevention.
The medications that are most effective in treating OCD are the ones that help normalize the balance of serotonin. They are:
- Clomipramine (Anafranil)
- Fluoxetine (Prozac)
- Fluvoxamine (Luvox)
- Paroxetine (Paxil)
- Sertraline (Zoloft)
- Citalopram (Celexa)
- Buspirone (BuSpar)
- Lithium—This medication may be used along with fluvoxamine. There are mixed reports, though, on how helpful it is in reducing symptoms.
These medications help reduce obsessions and compulsions. However, the risk of side effects and severity of symptoms needs to be considered in deciding whether to take medication and which one to take.
***Please note: In March 2004, the Food and Drug Administration (FDA) issued a Public Health Advisory that cautions physicians, patients, families and caregivers of patients with depression to closely monitor adults, teens, and children receiving certain antidepressant medications. The FDA is concerned about the possibility of worsening depression and/or the emergence of suicidal thoughts at the beginning of treatment or when there’s an increase or decrease in the dose. The medications of concern—mostly SSRIs (Selective Serotonin Re-uptake Inhibitors)—are: Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Luvox (fluvoxamine), Celexa (citalopram), Lexapro (escitalopram), Wellbutrin (bupropion), Effexor (venlafaxine), Serzone (nefazodone), and Remeron (mirtazapine). Of these, only Prozac (fluoxetine) is approved for use in children and adolescents for the treatment of major depressive disorder. Prozac (fluoxetine), Zoloft (sertraline), and Luvox (fluvoxamine) are approved for use in children and adolescents for the treatment of obsessive compulsive disorder. Evidence available through 2006 suggests an excess risk of suicidal thoughts or actions among children and adolescents, but does not yet clearly confirm that risk for adults. For more information, please visit http://www.fda.gov/cder/drug/antidepressants.
If you suspect you might have OCD, remember that are you are not alone. You don't need to keep your frightening thoughts and ritualistic behaviors a secret. Seek out diagnosis and treatment from a professional experienced in treating OCD. Consider joining a support group of people with OCD. If you know someone who may have the condition and is not diagnosed or receiving treatment, encourage him to get professional help. Remember that OCD is an illness and deserves the same treatment and consideration that you would give to any other medical condition.
National Institute of Mental Health
Canadian Psychiatric Association
Canadian Psychological Association
McDougle CJ, Price LH, Goodman WK, Charney DS, Heninger GR. A controlled trial of lithium augmentation in fluvoxamine-refractory obsessive-compulsive disorder: lack of efficacy. J Clin Psychopharmacol. 1992;12:65-66.
The numbers count: mental disorders in America. National Institute of Mental Health website. Available at: http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america.shtml. Updated June 2008. Accessed August 6, 2008.
PANDAS. National Institute of Mental Health website. Available at: http://intramural.nimh.nih.gov/pdn/web.htm. Updated April 2008. Accessed August 6, 2008.
Last reviewed June 2008 by Theodor B. Rais, MD
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