Obsessive-compulsive disorder (OCD) is an anxiety disorder in which people have unwanted and repeated thoughts, feelings, images, and sensations (obsessions) and engage in behaviors or mental acts in response to these thoughts or obsessions. Often the person carries out the behaviors to reduce the impact or get rid of the obsessive thoughts, but this only brings temporary relief. Not performing the obsessive rituals can cause great anxiety. A person’s level of OCD can be anywhere from mild to severe, but if left untreated, it can limit his or her ability to function at work or school or even to lead a comfortable existence at home or around others.
Causes of Obsessive Compulsive Disorder
The cause of the obsessive-compulsive disorder is concerned with identifying the biological risk factors involved in the expression of obsessive-compulsive disorder (OCD) symptomology. The leading hypotheses propose the involvement of the orbitofrontal cortex, basal ganglia, and/or the limbic system, with discoveries being made in the fields of neuroanatomy, neurochemistry, neuroimmunology, neurogenetics, and neuroethology.
Symptoms of Obsessive Compulsive Disorder
Just because you have obsessive thoughts or perform compulsive behaviors does NOT mean that you have obsessive-compulsive disorder. With OCD, these thoughts and behaviors cause tremendous distress, take up a lot of time (at least one hour per day), and interfere with your daily life and relationships.
Most people with the obsessive-compulsive disorder have both obsessions and compulsions, but some people experience just one or the other.
Common obsessive thoughts in OCD include
- Fear of being contaminated by germs or dirt or contaminating others
- Fear of losing control and harming yourself or others
- Intrusive sexually explicit or violent thoughts and images
- Excessive focus on religious or moral ideas
- Fear of losing or not having things you might need
- Order and symmetry: the idea that everything must line up “just right”
- Superstitions; excessive attention to something considered lucky or unlucky
Common compulsive behaviors in OCD include
- Excessive double-checking of things, such as locks, appliances, and switches
- Repeatedly checking in on loved ones to make sure they’re safe
- Counting, tapping, repeating certain words, or doing other senseless things to reduce anxiety
- Spending a lot of time washing or cleaning
- Ordering or arranging things “just so”
- Praying excessively or engaging in rituals triggered by religious fear
- Accumulating “junk” such as old newspapers or empty food containers.
Obsessive Compulsive Disorder is diagnosed when the Obsessions and Compulsions
- Consume excessive amounts of time (approximately an hour or more).
- Cause significant distress and anguish.
- Interfere with daily functioning at home, school, or work; or interfere with social activities/ family life/relationships.
Many compulsions are similar to body tics, and up to 40% of people with the obsessive-compulsive disorder have a tic disorder. Some examples of compulsion include:
- Hand washing
- Cleaning themselves or things around them
- Doing something (like turning lights on and off) a certain number of times
- Putting objects in certain orders
- Counting to a certain number
- Checking that they did some action, usually checking a certain number of times
People with obsessive-compulsive disorder usually know that their compulsions do not make sense, but do them anyways to stop the feelings of panic or anxiety. People with obsessive-compulsive disorder may do their compulsions for hours every day. Their compulsions can also hurt them, such as compulsive hand washing making their hands red and cut.
Types of Obsessive Compulsive Disorder
Checking – the need to check is the compulsion, the obsessive fear might be to prevent damage, fire, leaks or harm. Common checking includes:
- Memory (checking ones memory to ‘make sure’ an intrusive thought is just a thought and didn’t really happen).
- Gas or electric stove knobs (fear of causing explosion and therefore the house to burn down).
- Water taps (fear of flooding property and damaging irreplaceable treasured items).
- Door locks (fear of allowing a burglar to break in and steal or cause harm).
- House alarm (fear of allowing a burglar to break in and steal or cause harm).
- Windows (fear of allowing a burglar to break in and steal or cause harm).
- Appliances (fear of causing the house to burn down).
- House lights (fear of causing the house to burn down).
- Car doors (fear of car being stolen).
- Re-reading postal letters and greetings cards before sealing / mailing (fear of writing something inappropriate or offensive).
- Candles (fear of causing the house to burn down).
- Route after driving (fear of causing an accident).
- Wallet or purse (fear of losing important bank cards or documents).
- Illnesses and symptoms online (fear of developing an illness, constant checking of symptoms).
- People – Calling and Texting (fear of harm happening to a loved one).
- Reassurance (fear of saying or doing something to offend or upset a loved one).
- Re-reading words or lines in a book over and over again (fear of not quite taking in the information or missing something important from the text).
- Schizophrenia Symptoms – (fear that OCD is a precursor to Schizophrenia which will cause them to lose control).
The checking is often carried out multiple times, sometimes hundreds of times, and for hours on end, resulting in the person being late for work, dates and other appointments. This can have a serious impact on a person’s ability to hold down jobs and relationships. The checking can also cause damage to objects that are constantly being checked.
Contamination – the need to clean and wash is the compulsion, the obsessive fear is that something is contaminated and/or may cause illness, and ultimately death, to a loved one or oneself.
- Using public toilets (fear of contracting germs from other people).
- Coming into contact with chemicals (fear of contamination).
- Shaking hands (fear of contracting germs from other people).
- Touching door knobs/handles (fear of contracting germs from other people).
- Using public telephones (fear of contracting germs from other people).
- Waiting in a GP’s surgery (fear of contracting germs from other people).
- Visiting hospitals (fear of contracting germs from other people).
- Eating in a cafe/restaurant (fear of contracting germs from other people).
- Washing clothes in a launderette (fear of contracting germs from other people).
- Touching bannisters on staircases (fear of contracting germs from other people).
- Touching poles (fear of contracting germs from other people).
- Being in a crowd (fear of contracting germs from other people).
- Avoiding red objects and stains (fear of contracting HIV/AIDS from blood like stains).
- Clothes (having to shake clothes to remove dead skin cells, fear of contamination).
- Excessive Tooth Brushing (fear of leaving minute remains of mouth disease).
- Cleaning of Kitchen and Bathroom (fear of germs being spread to family).
Diagnosis of Obsessive Compulsive Disorder
There are four DSM diagnostic criteria for obsessive–compulsive disorder
- The person has to have obsessions, compulsions, or both. The DSM defines obsessions as thoughts that happen multiple times that the person does not want. The person has to try to get rid of the thoughts. The DSM defines compulsions as actions done multiple times because of an obsession. These actions are done to reduce the stress caused by an obsession.
- The obsessions or compulsions take a lot of time or cause lots of problems in the person’s life.
- The symptoms are not caused by a drug or a different medical problem.
- The problems are not closer to the problems caused other mental disorders such as an anxiety disorder or body dysmorphic disorder.
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a widely used manual for diagnosing mental disorders, defines obsessive–compulsive personality disorder (in Axis II Cluster C) as an extensive pattern of preoccupation with perfectionism, orderliness, and interpersonal and mental control, at the cost of efficiency, flexibility and openness. Symptoms must appear by early adulthood and in multiple contexts. At least four of the following should be present
- Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.
- Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met).
- Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).
- Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).
- Is unable to discard worn-out or worthless objects even when they have no sentimental value.
- Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things.
- Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.
- Shows rigidity and stubbornness.
Since the DSM-IV-TR was published in 2000, some studies have found fault with its OCPD coverage. A 2004 study challenged the usefulness of all but three of the criteria: perfectionism, rigidity and stubbornness, and miserliness. A study in 2007 found that OCPD is etiologically distinct from avoidant and dependent personality disorders, suggesting it is incorrectly categorized as a Cluster C disorder.
The World Health Organization’s ICD-10 uses the term anankastic personality disorder . Anankastic is derived from the Greek word ἀναγκαστικός (Anankastikos: “compulsion”).
It is characterized by at least four of the following
- feelings of excessive doubt and caution;
- preoccupation with details, rules, lists, order, organization, or schedule;
- perfectionism that interferes with task completion;
- excessive conscientiousness, scrupulousness, and undue preoccupation with productivity to the exclusion of pleasure and interpersonal relationships;
- excessive pedantry and adherence to social conventions;
- rigidity and stubbornness;
- unreasonable insistence by the individual that others submit exactly to his or her way of doing things or unreasonable reluctance to allow others to do things;
- intrusion of insistent and unwelcome thoughts or impulses.
- compulsive and obsessional personality (disorder)
- obsessive-compulsive personality disorder
Also, it excludes
- obsessive-compulsive disorder
It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.
Theodore Millon identified five subtypes of the compulsive personality (2004). Any compulsive personality may exhibit one or more of the following:
|Conscientious compulsive||Including dependent features||Rule-bound and duty-bound; earnest, hardworking, meticulous, painstaking; indecisive, inflexible; marked self-doubts; dreads errors and mistakes.|
|Bureaucratic compulsive||Including narcissistic features||Empowered in formal organizations; rules of group provide identity and security; officious, high-handed, unimaginative, intrusive, nosy, petty-minded, meddlesome, trifling, closed-minded.|
|Puritanical compulsive||Including paranoid features||Austere, self-righteous, bigoted, dogmatic, zealous, uncompromising, indignant, and judgmental; grim and prudish morality; must control and counteract own repugnant impulses and fantasies.|
|Parsimonious compulsive||Including schizoid features||Miserly, tight-fisted, ungiving, hoarding, unsharing; protects self against loss; fears intrusions into vacant inner world; dreads exposure of personal improprieties and contrary impulses.|
|Bedeviled compulsive||Including negativistic features||Ambivalences unresolved; feels tormented, muddled, indecisive, befuddled; beset by intrapsychic conflicts, confusions, frustrations; obsessions and compulsions condense and control contradictory emotions.|
Treatment of Obsessive Compulsive Disorder
Treatment for OCPD includes psychotherapy, cognitive behavioral therapy, behavior therapy or self-help. Medication may be prescribed. In behavior therapy, a person with COPD discusses with a psychotherapist ways of changing compulsions into healthier, productive behaviors. Cognitive analytic therapy is an effective form of behavior therapy
Behavioral therapy and cognitive behavioral therapy are used to help people with obsessive–compulsive disorder. The therapy works by making people be in places where they have their obsessive thoughts. They are then made to not do their compulsion. Over time, the person becomes used to the place or things that causes them to have their obsessive thoughts. An example of this is someone who is afraid of dirt having dirt put on their hands without being able to wash it off.
The medicines that are usually used are called “selective serotonin reuptake inhibitors”, or SSRIs. These medicines work by stopping a chemical in the brain called serotonin from working. This causes the obsessive thoughts to happen less. In adults, SSRIs are used for people with moderate or severe issues. In children, SSRIs are used after or with therapy for people with severe issues.
If SSRIs do not work, it is possible for a doctor to give someone with obsessive–compulsive disorder anti-psychotic medicines. Doctors may use both medication and counseling for those with the disorder, and they find that this approach works best.
The medications most frequently used are the selective serotonin reuptake inhibitors (SSRIs). Clomipramine, a medication belonging to the class of tricyclic antidepressants, appears to work as well as SSRIs but has a higher rate of side effects.
SSRIs are a second line treatment of adult obsessive compulsive disorder (OCD) with mild functional impairment and as first line treatment for those with moderate or severe impairment. In children, SSRIs can be considered as a second line therapy in those with moderate-to-severe impairment, with close monitoring for psychiatric adverse effects. SSRIs are efficacious in the treatment of OCD; people treated with SSRIs are about twice as likely to respond to treatment as those treated with placebo. Efficacy has been demonstrated both in short-term (6–24 weeks) treatment trials and in discontinuation trials with durations of 28–52 weeks
Surgery can be used to help people if other treatments do not work. In the United States, surgery is not done unless medicine and therapy have not worked multiple times. In the United Kingdom, surgery cannot be done unless cognitive behavioral therapy has not worked.
Electroconvulsive therapy (ECT) – has been found to have effectiveness in some severe and refractory cases.
Surgery – may be used as a last resort in people who do not improve with other treatments. In this procedure, a surgical lesion is made in an area of the brain (the cingulate cortex). In one study, 30% of participants benefitted significantly from this procedure.
Deep-brain stimulation – and vagus nerve stimulation are possible surgical options that do not require destruction of brain tissue. In the United States, the Food and Drug Administration approved deep-brain stimulation for the treatment of OCD under a humanitarian device exemption requiring that the procedure is performed only in a hospital with specialist qualifications to do so.
In the United States, psychosurgery for OCD is a treatment of last resort and will not be performed until the person has failed several attempts at medication (at the full dosage) with augmentation, and many months of intensive cognitive–behavioral therapy with exposure and ritual/response prevention. Likewise, in the United Kingdom, psychosurgery cannot be performed unless a course of treatment from a suitably qualified cognitive–behavioral therapist has been carried out.
Therapy can be used to reduce the compulsions in children and young adults. Family involvement is very important in treating children. The family also gives the children positive reinforcement for children who do not follow their compulsive behaviors and find better ways to stop their obsessive thoughts.
In 2006, the National Institute of Clinical and Health Excellence (NICE) guidelines recommended antipsychotics for OCD that does not improve with SSRI treatment. For OCD the evidence for the atypical antipsychotic drugs risperidone is tentative with insufficient evidence for olanzapine. While quetiapine is no better than placebo with regard to primary outcomes, but small effects were found in terms of YBOCS score. The efficacy of quetiapine and olanzapine are limited by the insufficient number of studies.
A 2014 review article found two studies that indicated that aripiprazole was “effective in the short-term” and found that there was a small effect-size for risperidone or antipsychotics in general in the short-term”; however, the study authors found “no evidence for the effectiveness of quetiapine or olanzapine in comparison to placebo.
While quetiapine may be useful when used in addition to an SSRI in treatment-resistant OCD, these drugs are often poorly tolerated and have metabolic side effects that limit their use. None of the atypical antipsychotics appear to be useful when used alone. Another review reported that no evidence supports the use of first-generation antipsychotics in OCD.
A guideline by the APA suggested that dextroamphetamine may be considered by itself after more well-supported treatments have been tried.
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