What is Obsessive Compulsive Disorder? Symptoms, Treatment, and More

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. 

Prevalence

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.

Associated Features

Suicide Risk

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 

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.

Dysfunctional beliefs

For example

• 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.”

Diagnosis 

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). 

Differential Diagnosis

1. 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. 
2. Major depressive  disorder
3. Body  dysmorphic disorder
4. Eating disorders
5. 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
6. Psychotic  disorders.    
7. Compulsive sexual  behaviour and substance abuse   
8. 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.

Management

Pharmacotherapy

Psychotherapy – Cognitive behavioral therapy, Exposure and response prevention therapy

Pharmacotherapy

• 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.

Psychotherapy

COGNITIVE-BEHAVIORAL THERAPY

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.