What is Obsessive Compulsive Disorder? Symptoms, Treatment, and MoreJanuary 10, 2023 5:42 pm
What is obsessive compulsive disorder?
Disorder characterized by the presence of obsessions, compulsions, or both.
Obsessions are defined as recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).
Compulsions are defined as repetitive behaviors (e.g., hand washing, ordering, checking) that the individual feels driven to perform in response to an obsession. Such behaviors or mental acts are aimed at preventing or reducing distress.
Other specific characteristics
- The obsessions or compulsions are time-consuming (should take more than 1 hour per day), can cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- The symptoms are not attributable to the physiological effects of a substance or another medical condition.
- The disturbance is not better explained by the symptoms of another mental disorder.
- Most individuals with OCD have both obsessions and compulsions. Compulsions are typically performed in response to an obsession (e.g., thoughts of contamination leading to washing rituals)
Symptoms Supporting Diagnosis
- Cleaning (contamination obsessions and cleaning compulsions)
- Symmetry (symmetry obsessions and repeating, ordering and counting compulsions)
- forbidden or taboo thoughts (e.g., aggressive, sexual, or religious obsessions and related compulsions).
- Harm (e.g., fears of harm to oneself or others and checking compulsions).
- Hoarding – difficulty in discarding and ends up in accumulating objects as a consequence of typical obsessions and compulsions.
It is common for individuals with the disorder to avoid people, places, and things that trigger obsessions and compulsions.
The 12-month prevalence of OCD internationally is (1.1%-1.8%).
Females are affected more than males in adulthood, although males are more commonly affected in childhood.
Development and Course
Onset after age 35 years is unusual – males have an earlier age at onset than females.
The onset of symptoms is typically gradual; onset in childhood or adolescence can lead to a lifetime of OCD. 40% of individuals with onset of OCD in childhood or adolescence may experience remission by early adulthood.
Without treatment, remission rates in adults are low.
Risk and Prognostic Factors
- Temperamental – Greater internalizing symptoms, higher negative emotionality, and behavioral inhibition in childhood
- Environmental – Physical and sexual abuse in childhood and other traumatic events
- Genetic and physiological – The rate of OCD among first-degree relatives of adults with OCD is approximately two times that among first-degree relatives of those without the disorder.
Suicidal thoughts occur at some point in as many as about half of individuals with OCD. The presence of comorbidities like major depressive disorder increases the risk.
Avoidance behaviors are often pervasive and severely restrict functioning. Individuals with OCD avoid people, places, or things that trigger obsessions and compulsions. For example, individuals with contamination fear void public places eg public restrooms, to reduce exposure to feared contaminants. Individuals with intrusive thoughts about causing harm to others may avoid social interactions.
- Inflated responsibility and the tendency to overestimate threat
- Perfectionism and the intolerance of uncertainty
- Overvaluing the importance of thoughts (eg, believing that having a forbidden thought is as bad as acting on it) and the need to control thoughts
Level of insight
Individuals with OCD differ in the degree to which they believe that their obsessions and compulsions are excessive or unreasonable. Insight can vary within an individual over the course of the illness.
Response to symptoms
Individuals with OCD may experience affective responses to their obsessions or compulsions and the response to the symptom may lead to further psychosocial distress. As an example, some individuals may experience marked anxiety or recurrent panic attacks.
The distress may persist until the individual attains a sense of “completeness” or until things look, feel, or sound “just right.”
This diagnostic approach is in accordance with the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria for OCD
- A. Presence of obsessions, compulsions, or both:
Obsessions as defined by both:
- 1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
- 2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (ie, by performing a compulsion).
Compulsions as defined by both:
- 1. Repetitive behaviors (eg, hand washing, ordering, checking) or mental acts (eg, praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession, or according to rules that must be applied rigidly.
- 2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.
- B. The obsessions or compulsions are time-consuming (eg, take more than one hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication) or another medical condition.
- D. The disturbance is not better explained by the symptoms of another mental disorder, for example:
- Excessive worries, as in generalized anxiety disorder
- Preoccupation with appearance, as in body dysmorphic disorder
- Difficulty discarding or parting with possessions, as in hoarding disorder
- Hair pulling, as in trichotillomania (hair-pulling disorder)
- Skin picking, as in excoriation (skin-picking) disorder
- Stereotypies, as in stereotypic movement disorder
- Ritualized eating behavior, as in eating disorders
- Preoccupation with substances or gambling, as in substance-related and addictive disorders
- Preoccupation with having an illness, as in illness anxiety disorder
- Sexual urges or fantasies, as in paraphilic disorders
- Impulses, as in disruptive, impulse-control, and conduct disorders
- Guilty ruminations, as in major depressive disorder
- Thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders
- Repetitive patterns of behavior, as in autism spectrum disorder
Specifiers for OCD in DSM-5 – Specifiers for the disorder include assessments of the patient’s insight and presence/history of a tic disorder.
- Patient’s degree of insight into the illness
- With good or fair insight – The individual recognizes that OCD beliefs are definitely or probably not true or that they may or may not be true.
- With poor insight – The individual thinks OCD beliefs are probably true.
- With absent insight/delusional beliefs – The individual is completely convinced that OCD beliefs are true.
- Tic-related – The individual has a current or past history of a tic disorder.
Functional Consequences of OCD
- OCD is associated with reduced quality of life as well as high levels of social and occupational impairment.
- Impairment can be caused by the time spent obsessing and doing compulsions.
- Avoidance of situations that can trigger obsessions or compulsions can also severely restrict functioning.
- Obsessions about symmetry can derail the timely completion of school or work projects because the project never feels “just right,” potentially resulting in school failure or job loss.
- Health consequences can occur. For e.g. individuals with contamination concerns may avoid hospitals because of fears of exposure to germs or develop dermatological problems (e.g., skin lesions due to excessive washing).
- Anxiety disorders – 76 percent of individuals have a co morbid anxiety disorder including panic disorder, social anxiety disorder, generalized anxiety disorder (30 percent) and specific phobia.
- Major depressive disorder
- Body dysmorphic disorder
- Eating disorders
- Tics (in tic disorder) and stereotyped movements. A tic is a sudden, rapid, recurrent, nonrhythmic motor movement or vocalization ( e.g., eye blinking, throat clearing). A stereotyped movement is a repetitive, seemingly driven, nonfunctional motor behavior
- Psychotic disorders.
- Compulsive sexual behaviour and substance abuse
- Neurological disorders – OCD is described in basal ganglia dysfunction such as Huntington disease, Sydenham chorea, and Parkinson disease. It has also been described in temporal lobe epilepsy.
Psychotherapy – Cognitive behavioral therapy, Exposure and response prevention therapy
- Selective serotonin re-uptake inhibitors – Fluoxetine, Sertraline, Escitalopram etc.
- Serotonin-norepinephrine re-uptake inhibitors – Desvenlaflaxine, Duloxetine, Venlaflaxine etc.
When medication is used, SSRIs are recommended as first-line treatment. The SSRIs have a superior side effect profile compared with others. The choice among the SSRIs can be made on the basis of prior treatment response, drug side effects and their acceptability to the patient, and the potential for drug interactions.
Cognition – this requires that the patient must also be able to implement treatment procedures on their own and consolidate information they learn using the techniques. This may be difficult for those who are very concrete in their thinking, developmentally disabled, or cognitively impaired.
Insight – Patients with poor insight into the senselessness of their OCD symptoms show an attenuated response to CBT because of reluctance to engage in exposure and response prevention and difficulty consolidating information learned in CBT.
Providing CBT for OCD requires specialized training and experience.