By Christine Haran
While many of us may find ourselves checking and rechecking the alarm clock the night before an early morning flight or job interview, the lives of people living with obsessive-compulsive disorder (OCD) are dominated by such repetitive behaviors, as well as by obsessive, unwanted thoughts.
Obsessive-compulsive disorder is an anxiety disorder that affects approximately 3.3 million American adults. Below, Gerald Nestadt, MD, a professor of psychiatry at the Johns Hopkins Medical School in Baltimore, discusses the symptoms of OCD and how treatment can alleviate the need to carry out unnecessary rituals and help free someone of their obsessive thoughts.
What is obsessive-compulsive disorder (OCD)?
Obsessive-compulsive disorder is the presence of either an obsession or a compulsion that individuals may have that ultimately interferes with their life, either by taking up too much time or impairing their ability to function adequately.
An obsession is an unwanted thought that pops into the mind that one wants to dispel but cannot do so with any ease. A compulsion is the same thing, except that it is a behavior that one does that one would prefer not doing but cannot prevent oneself from doing.
What are some examples of obsessions and compulsions?
An example of an obsession may be a young mother who has the thought that she's going to stab her young child. She has no desire to do so and is disturbed by the thought but cannot get it out of her mind. As a consequence, she might avoid knives, for instance, and sometimes even avoid her young child. Another example would be the fear that by touching something one will be contaminated by germs. Therefore, they will avoid touching anything, even though they recognize that it's irrational.
Examples of compulsions include checking your stove or not being able to leave anywhere without unplugging all sorts of items. We all may do that for safety, but the individual with the compulsion will need to go back and check several times even when they recall they have pulled out a plug or switched off a light. Other compulsions involve counting in one's head for no apparent reason, say in multiples of three; the need to wash one's hands after touching something considered contaminated; ordering and arranging things or making sure that if you touch something on the left side, you touch it on the right side.
Compulsions may make people feel foolish, or worse, out of control or terrified that something bad is about to happen if they don't perform the ritual. Although compulsions can feel like the only way to get relief from obsessive thoughts, they only escalate the problem, making the thoughts recur and triggering doubts that the compulsion may not have been done correctly.
Another symptom that people don't often recognize as problematic, though their relatives and neighbors do, is hoarding behaviors, which may or may not be a similar syndrome. People can horde immense quantities of useless items, taking up their homes and their garages and even rental spaces.
What causes OCD?
We're not entirely sure. There may be a dysfunction of the brain circuitry between two parts of the brain: the orbital cortex and the basal ganglion. When children have OCD, parents are often concerned that it's their fault—that they raised the child incorrectly or badly and that has resulted in the development of this condition. We have no evidence to that degree at all.
Does OCD run in families?
We've demonstrated that these symptoms and disorders do seem to run in families. There's an eight-fold increased risk in the first-degree relatives of individuals who have the condition.
What are other risk factors?
The other risk factors include a condition called PANDAS (pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections). It usually affects children who contract a streptoccocal infection like a strep throat; they abruptly develop symptoms of obsessive-compulsive disorder after infection. There are other medical conditions that can bring about obsessive-compulsive disorder, from rare things such as carbon monoxide poisoning to strokes. People with certain neurological conditions such as Tourette's syndrome and Huntington's disease also have an increased risk.
There's no doubt that there are also environmental factors. It's difficult, though, to delineate them with great accuracy. A very important one is pregnancy. A woman can either have the onset or a substantial aggravation of the syndrome during pregnancy or immediately post-partum. There can also be exacerbations during the menstrual period. People can also develop obsessions and compulsions with post-traumatic stress syndrome, which is a condition that develops following a traumatic event.
How is OCD diagnosed?
Unfortunately, the only way to diagnose obsessive-compulsive disorder is by a clinical examination in which the health professional develops a real understanding of the experiences of the individual they are evaluating. The criteria are the presence of obsessions and/or compulsions and impairment of one's life. There are no blood tests as yet or brain imaging tests that are used routinely to diagnose obsessive-compulsive disorder.
At what age does the condition usually appear?
It varies considerably and can occur throughout the lifespan. The age of 12 seems to be a particularly common age for the onset, but people describe the onset as early as three, four years of age, and then very occasionally there are individuals who have onset at a very late age. A lot of the literature suggests that females have the onset later than males: in the late teens, early 20s.
Does OCD manifest itself differently in children than it does in adults?
It seems that children have more compulsive behaviors early on—such as checking, hoarding, counting and repeating behaviors—rather than obsessions, whereas older people tend to have obsessions more frequently than compulsions.
If untreated, does OCD get worse over time?
Generally, it's a rather persistent condition that goes through life getting worse and getting better, often exacerbated by stress. There are fewer cases where it follows an episodic course, that is, it's present and goes away and may recur at a later time. And there are even fewer cases where you will have the onset of the condition and then it abates spontaneously and doesn't return.
Is OCD affiliated with other mental health conditions?
There does seem to be an association with a variety of other psychiatric or psychological conditions. In our own work, up to 60 to 70 percent of individuals who we diagnose with OCD will also have at least one episode of major depression at some stage in their life. There are also a variety of the anxiety conditions that seem to co-occur with obsessive-compulsive disorder, such as generalized anxiety, which is a free-floating syndrome where one worries excessively and has other physical and mental sensations of anxiety.
Clearly people who have obsessive-compulsive disorder get very distressed by it, and it seems very understandable that they would become depressed or demoralized. However, we don't know whether it's actually a physiological relationship or a psychological relationship.
How is OCD treated?
The treatment for OCD is two-fold. One treatment is medications, usually in the antidepressant group, such as the selective serotonin reuptake inhibitors (SSRIs), which help 60 percent to 70 percent of individuals. The SSRIs increase the availability of the serotonin in the brain, and OCD seems to be related to this brain chemical. One doesn't stay on the medication indefinitely; usually one tries to wean off the medication under the supervision of a health professional.
There are also behavioral therapies: both exposure and response prevention, and cognitive behavioral therapies. The cognitive-behavioral therapy involves understanding where the thought is coming from and recognizing that you are not in danger, so that you can learn to stop obsessing. With the exposure and response prevention, if you're worried about contamination, for example—say touching things that are red because you think they may be blood—the idea is to proceed with touching them but not allow yourself to go and wash your hands or do any of the behaviors that you usually do to reduce the anxiety related to the touching. Even though that sounds rather scary to individuals, with professional help you can get through it and actually abolish the fear or the behavior.
When should someone who thinks they might have OCD seek help?
You should seek help if you find that you are having thoughts or have behaviors that you recognize as being burdensome and you can't rid yourself of them and they're in any way interfering with your life. For example, if they're taking up more than an hour a day or causing you to be slow in accomplishing tasks. There is treatment for people with OCD, so people should not just assume that nothing will change or that this is integral to their personality.
We have a collaborative group of researchers around the country who are trying to understand the genetics behind obsessive-compulsive disorder. We hope to identify genes that are related to this particular condition. If we know what genes are related, the next step will be to understand what's happening physiologically in the brain and, ultimately, develop treatments that make sense based on physiology, not just chance.
©2007 Healthology, Inc.