Obsessive-compulsive disorder

Definition

Obsessive-compulsive disorder (OCD) is a type of anxiety disorder characterized by distressing repetitive thoughts, impulses, or images that are intense, frightening, absurd, or unusual. These thoughts are followed by ritualized actions that are usually bizarre and irrational. These ritual actions, known as compulsions, help reduce anxiety caused by the individual's obsessive thoughts. Often described as the "disease of doubt," the sufferer usually knows the obsessive thoughts and compulsions are irrational but, on another level, fears they may be true.

Description

Almost one out of every 40 people will suffer from obsessive-compulsive disorder at some time in their lives. The condition is two to three times more common than either schizophrenia or manic depression , and strikes men and women of every ethnic group, age, and social level. Because the symptoms are so distressing, sufferers often hide their fears and rituals but cannot avoid acting on them. OCD sufferers are often unable to decide if their fears are realistic and need to be acted upon.

Most people with obsessive-compulsive disorder have both obsessions and compulsions, but occasionally a person will have just one or the other. The degree to which this condition can interfere with daily living also varies. Some people are barely bothered, while others find the obsessions and compulsions to be profoundly traumatic and spend a great deal of time each day in compulsive actions.

Obsessions are intrusive, irrational thoughts that keep popping up in a person's mind, such as, "My hands are dirty, I must wash them again." Typical obsessions include fears of dirt, germs, contamination, and violent or aggressive impulses. Other obsessions include feeling responsible for others' safety, or an irrational fear of hitting a pedestrian with a car. Additional obsessions may involve intrusive sexual thoughts. The patient may fear acting out the strong sexual thoughts in a hostile way. People with obsessive-compulsive disorder may have an intense preoccupation with order and symmetry, or be unable to throw anything out.

Compulsions usually involve repetitive rituals such as excessive washing (especially handwashing or bathing), cleaning, checking and touching, counting, arranging, or hoarding. As the person performs these acts, he may feel temporarily better, but there is no long lasting sense of satisfaction or completion after the act is performed. Often, a person with obsessive-compulsive disorder believes that if the ritual isn't performed, something dreadful will happen. While these compulsions may temporarily ease stress , short-term comfort is purchased at a heavy price—time spent repeating compulsive actions and a long-term interference with life.

The difference between OCD and other compulsive behavior is that while people who have problems with gambling, overeating, or substance abuse may appear to be compulsive, these activities also provide pleasure to some degree. The compulsions of OCD, on the other hand, are never pleasurable.

OCD may be related to some other conditions, such as the continual urge to pull out body hair (trichotillomania); fear of having a serious disease (hypochondriasis), or preoccupation with imagined defects in personal appearance disorder (body dysmorphic disorder). Some people with OCD also have Tourette syndrome , a condition featuring tics and unwanted vocalizations (such as swearing). OCD is often linked with depression and other anxiety disorders.

Causes & symptoms

The tendency to develop obsessive-compulsive dis-order appears to be inherited. In the summer of 2002, researchers at the University of Michigan identified a segment of human chromosome 9p as containing genes for susceptibility to OCD. Other chromosomes that may also be linked to OCD are 19q and 6p.

There are several theories behind the cause of OCD. Some experts believe that OCD is related to a chemical imbalance within the brain that causes a communication problem between the front part of the brain (frontal lobe) and deeper parts of the brain responsible for the repetitive behavior. Research has shown that the orbital cortex located on the underside of the brain's frontal lobe is overactive in OCD patients. This may be one reason for the feeling of alarm that pushes the patient into compulsive, repetitive actions. The higher-than-average rate of concurrent eating disorders in patients diagnosed with OCD has been attributed to the fact that hyperactivity in the orbital cortex is associated with both disorders. It is possible that people with OCD experience overactivity deep within the brain that causes the cells to get "stuck," much like a jammed transmission in a car damages the gears. This could lead to the development of rigid thinking and repetitive movements common to the disorder. The fact that drugs which boost the levels of serotonin (a brain chemical linked to emotion) in the brain can reduce OCD symptoms may indicate that to some degree OCD is related to brain serotonin levels.

Recently, scientists have identified an intriguing link between childhood episodes of strep throat and the development of OCD. It appears that in some vulnerable children, strep antibodies attack a certain part of the brain. Antibodies are cells that the body produces to fight specific diseases. That attack results in the development of excessive washing or germ phobias . A phobia is a strong but irrational fear. In this instance the phobia is fear of disease germs present on commonly handled objects. These symptoms would normally disappear over time, but some children who have repeated infections may develop full-blown OCD. Treatment with antibiotics has resulted in lessening of the OCD symptoms in some of these children.

If one person in a family has obsessive-compulsive disorder, there is a 25% chance that another immediate family member has the condition. It also appears that stress and psychological factors may worsen symptoms, which usually begin during adolescence or early adulthood.

Some studies indicate that the nature of parent-child interactions is an important factor in the development of OCD. Observers have often remarked that parents and children in OCD families can be differentiated from members of other types of families on the basis of behavior. One Australian study described the parents of children with OCD as "..less confident in their child's ability, less rewarding of independence, and less likely to use positive problem solving."

OCD has also sometimes been linked to religion, in that the symptoms of some persons diagnosed with OCD reflect religious beliefs or practices. Christian clergy have been trained since the Middle Ages to recognize a specific spiritual problem known as scrupulosity, in which a person is troubled by excessive fears of God's punishment or fears of having sinned and offended God. A new inventory for measuring scrupulosity in devout Jews as well as Protestants and Catholics has been tested at the University of Pennsylvania and appears to be a reliable instrument for evaluating OCD symptoms that take religious forms. Scrupulosity has been traditionally treated in both Judaism and Christianity by consultation with a rabbi, priest, or pastor who is able to correct the distorted beliefs that underlie the obsessions or compulsions. In some cases the clergyperson may also use an appropriate religious ritual in treating scrupulosity.

Diagnosis

People with obsessive-compulsive disorder feel ashamed of their problem and often try to hide their symptoms. They may avoid seeking treatment. Because they can be very good at keeping their problem from friends and family, many sufferers do not get the help

they need until the behaviors are deeply ingrained habits and harder to change. As a result, the condition is often misdiagnosed or underdiagnosed. All too often, it can take more than a decade between the onset of symptoms and proper diagnosis and treatment.

While scientists seem to agree that OCD is related to a disruption in serotonin levels, there is no blood test for the condition. Instead, doctors diagnose OCD after evaluating a person's symptoms and history.

Treatment

Because OCD sometimes responds to selective serotonin reuptake inhibitors (SSRI) antidepressants, herbalists believe a botanical medicine called St. John's wort (Hypericum perforatum ) might have some beneficial effect as well. Known popularly as "Nature's Prozac," St. John's wort is prescribed by herbalists for the treatment of anxiety and depression. They believe that this herb affects brain levels of serotonin in the same way that SSRI antidepressants do. Herbalists recommend a dose of 300 mg, three times per day. In about one out of 400 people, St. John's wort (like Prozac) may initially increase the level of anxiety. Homeopathic constitutional therapy can help rebalance the patient's mental, emotional, and physical well-being, allowing the behaviors of OCD to abate over time.

Other alternative treatments for OCD are intended to lower the patient's anxiety level; some are thought to diminish the compulsions themselves. Alternative recommendations include the following:

• Bach flower remedies : White chestnut, for obsessive thoughts and repetitive thinking.
• Traditional Chinese medicine: a mixture of bupleurum and dong quai , to strengthen the spleen and regulate the liver. In Chinese medicine, obsessive-compulsive disorder is due to liver stagnation and a weak spleen.
• Aromatherapy: a mixture of lavender, rosemary , and valerian for relaxation.
• Yoga: Yogis in India developed a special technique of yogic breathing specifically for OCD. The specific yogic technique for treating OCD requires blocking the right nostril with the tip of the thumb; slow deep inspiration through the left nostril; holding the breath; and slow complete expiration through the left nostril. This is followed by a long breath-holding out period.
• Schuessler tissue salts: for OCD, 10 tablets of Ferrum phosphorica 30X and 10 tablets of Kali phosphorica 200X, twice daily.
• Massage therapy: with special emphasis on loosening the muscles in the neck, back, and shoulders.

Cognitive-behavioral therapy (CBT) teaches patients how to confront their fears and obsessive thoughts by making the effort to endure or wait out the activities that usually cause anxiety without compulsively performing the calming rituals. Eventually their anxiety decreases. People who are able to alter their thought patterns in this way can lessen their preoccupation with the compulsive rituals. At the same time, the patient is encouraged to refocus attention elsewhere, such as on a hobby.

Allopathic treatment

Obsessive-compulsive disorder can be effectively treated by a combination of cognitive-behavioral therapy and medication that regulates the brain's serotonin levels. Drugs that are approved to treat obsessive-compulsive disorder include fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft), all SSRIs that affect the level of serotonin in the brain. Drugs should be taken for at least 12 weeks before deciding whether or not they are effective.

In a few severe cases where patients have not responded to medication or behavioral therapy , brain surgery may be attempted to relieve symptoms. Surgery can help up to a third of patients with the most severe form of OCD. The most common operation involves removing a section of the brain called the cingulate cortex. The serious side effects of this surgery for some patients include seizures, personality changes, and decreased ability to plan.

Expected results

Obsessive-compulsive disorder is a chronic disease that, if untreated, can last for decades, fluctuating from mild to severe and worsening with age. When treated by a combination of drugs and behavioral therapy, some patients go into complete remission. Unfortunately, not all patients have such a good response. About 20% of people cannot find relief with either drugs or behavioral therapy. Hospitalization may be required in some cases.

Resources

BOOKS

Dumont, Raeann. The Sky is Falling: Understanding and Coping with Phobias, Panic and Obsessive-Compulsive Disorders. New York: W.W. Norton & Co., 1996.

Pelletier, Kenneth R., MD. The Best Alternative Medicine, Part II, "CAM Therapies for Specific Conditions: Anxiety." New York: Simon & Schuster, 2002.

Schwartz, Jeffrey. Brain Lock. New York: HarperCollins, 1996.

Schwartz, Jeffrey. Free Yourself from Obsessive-Compulsive Behavior: A Four-Step Self-Treatment Method to Change Your Brain Chemistry. New York: HarperCollins, 1996.

Swedo, S.E., and H. L. Leonard. It's Not All In Your Head. New York: HarperCollins, 1996.

PERIODICALS

Abramowitz, J. S., J. D. Huppert, A. B. Cohen, et al. "Religious Obsessions and Compulsions in a Non-Clinical Sample: The Penn Inventory of Scrupulosity (PIOS)." Behaviour Research and Therapy 40 (July 2002): 825-838.

Barrett, P., A. Shortt, and L. Healy. "Do Parent and Child Behaviours Differentiate Families Whose Children Have Obsessive-Compulsive Disorder from Other Clinic and Non-Clinic Families?" Journal of Child Psychology and Psychiatry 43 (July 2002): 597-607.

Hanna, G. L., J. Veenstra-Vanderweele, N. J. Cox, et al. "Genome-Wide Linkage Analysis of Families with Obsessive-Compulsive Disorder Ascertained through Pediatric Probands." American Journal of Medical Genetics 114 (July 8, 2002): 541-552.

Lin, H., C. B. Yeh, B. S. Peterson, et al. "Assessment of Symptom Exacerbations in a Longitudinal Study of Children with Tourette's Syndrome or Obsessive-Compulsive Dis-order." Journal of the American Academy of Child and Adolescent Psychiatry 41 (September 2002): 1070-1077.

Pelchat, M. L. "Of Human Bondage: Food Craving, Obsession, Compulsion, and Addiction." Integrative Physiological and Behavioral Science 76 (July 2002): 347-352.

Sica, C., C. Novara, and E. Sanavio. "Religiousness and Obsessive-Compulsive Cognitions and Symptoms in an Italian Population." Behaviour Research and Therapy 40 (July 2002): 813-823.

Stein, D. J. "Obsessive-Compulsive Disorder." Lancet 360 (August 3, 2002): 397-405.

Talan, Jamie. "A Link to Strep, Behavior: The Infection May Trigger Obsessive-Compulsive Symptoms." Newsday (May 21, 1996): B31.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007. (202) 966-7300. Fax: (202) 966-2891. <www.aacap.org.>.

American Psychiatric Association. 1400 K Street, NW. Washington, DC 20005. (202) 682-6220. <www.psych.org.>.

Anxiety Disorders Association of America. 11900 Parklawn Dr., Ste. 100, Rockville, MD 20852. (301) 231-9350. http://adaa.org.

National Alliance for the Mentally Ill (NAMI). 200 N.Glebe Rd., #1015, Arlington, VA 22203-3728. (800) 950-NAMI. http://www.nami.org.

National Anxiety Foundation. 3135 Custer Dr., Lexington, KY 40517. (606) 272-7166. http://www.lexington-online.com/naf.html.

National Institutes of Mental Health (NIMH). Information Resources and Inquires Branch. 5600 Fishers Lane, Rm.7C-02, MSC 8030, Bethesda, MD20892. (301) 443-4513. http://www.nimh.nih.gov.

Paula Ford-Martin

Rebecca J. Frey, PhD

Obsessive-compulsive disorder

Definition

Obsessive-compulsive disorder (OCD) is a type of anxiety disorder. Anxiety disorder is the experience of prolonged, excessive worry about circumstances in one's life. OCD is characterized by distressing repetitive thoughts, impulses, or images that are intense, frightening, absurd, or unusual. These thoughts are followed by ritualized actions that are usually bizarre and irrational. These ritual actions, known as compulsions, help reduce anxiety caused by the individual's obsessive thoughts. Often described as the "disease of doubt," the sufferer usually knows the obsessive thoughts and compulsions are irrational but, on another level, fears they may be true.

Description

Most people with obsessive-compulsive disorder have both obsessions and compulsions, but occasionally a person will have just one or the other. The degree to which this condition can interfere with daily living also varies. Some people are barely bothered, while others find the obsessions and compulsions to be profoundly traumatic and spend much time each day in compulsive actions. Because the symptoms are so distressing, sufferers often hide heir fears and rituals but cannot avoid acting on them. OCD sufferers are often unable to decide if their fears are realistic and need to be acted upon.

Obsessions are intrusive, irrational thoughts that keep popping up in a person's mind, such as the urgency to wash one's hands again. Typical obsessions include fears of dirt, germs, contamination, and violent or aggressive impulses. Other obsessions include feeling responsible or others' safety or an irrational fear of hitting a pedestrian with a car. Additional obsessions can involve excessive religious feelings or intrusive sexual thoughts. The patient may need to confess frequently to a religious counselor or may fear acting out the strong sexual thoughts in a hostile way. People with obsessive-compulsive disorder may have an intense preoccupation with order and symmetry or may be unable to throw anything out.

Compulsions usually involve repetitive rituals such as excessive washing (especially hand washing or bathing), cleaning, checking and touching, counting, arranging, and/or hoarding. As the person performs these acts, he may feel temporarily better, but there is no long-lasting sense of satisfaction or completion after the act is performed. Often, a person with obsessive-compulsive disorder believes that if the ritual is not performed, something dreadful will happen. While these compulsions may temporarily ease stress, short-term comfort is purchased at a heavy price—time spent repeating compulsive actions and a long-term interference with life.

The difference between OCD and other compulsive behavior is that while people who have problems with gambling, overeating, or with substance abuse may appear to be compulsive, these activities also provide pleasure to some degree. The compulsions of OCD, on the other hand, are never pleasurable.

OCD may be related to some other conditions, such as the continual urge to pull out body hair (trichotillomania ); fear of having a serious disease (hypochondriasis); or preoccupation with imagined defects in personal appearance disorder (body dysmorphia). Some people with OCD also have Tourette syndrome , a condition featuring tics and unwanted vocalizations (such as swearing). OCD is often linked with depression and other anxiety disorders.

Demographics

Almost one out of every 40 people suffers from obsessive-compulsive disorder at some time in their lives. The condition is two to three times more common than either schizophrenia or manic depression and strikes men and women of every ethnic group, age, and social level.

If one person in a family has obsessive-compulsive disorder, there is a 25 percent chance that another immediate family member has the condition. It also appears that stress and psychological factors may worsen symptoms, which usually begin during adolescence or early adulthood.

Causes and symptoms

Research suggests that the tendency to develop obsessive-compulsive disorder is inherited. There are several theories behind the cause of OCD. OCD may be related to a chemical imbalance within the brain that causes a communication problem between the front part of the brain (frontal lobe) and deeper parts of the brain responsible for the repetitive behavior. The orbital cortex located on the underside of the brain's frontal lobe is overactive in OCD patients. This may be one reason for the feeling of alarm that pushes the patient into compulsive, repetitive actions. It is possible that people with OCD experience overactivity deep within the brain that causes the cells to get "stuck," much like a jammed transmission in a car damages the gears. This could lead to the development of rigid thinking and repetitive movements common to the disorder. The fact that drugs which boost the levels of serotonin, a brain messenger substance linked to emotion and many different anxiety disorders, in the brain can reduce OCD symptoms may indicate that to some degree OCD is related to levels of serotonin in the brain.

There may also be a link between childhood episodes of strep throat and the development of OCD. In some vulnerable children, strep antibodies attack a certain part of the brain. Antibodies are cells that the body produces to fight specific diseases. That attack results in the development of excessive washing or germ phobias . A phobia is a strong but irrational fear. In this instance the phobia is fear of disease germs present on commonly handled objects. These symptoms would normally disappear over time, but some children who have repeated infections may develop full-blown OCD. Treatment with antibiotics , immunoglobulin, or blood cleansing procedures can decrease the circulating anti-strep antibodies in the blood, thus lessening the OCD symptoms in some of these children.

Diagnosis

People with obsessive-compulsive disorder feel ashamed of their problem and often try to hide their symptoms. They avoid seeking treatment. Because they can be very good at keeping their problem from friends and family, many sufferers do not get the help they need until the behaviors are deeply ingrained habits and hard to change. As a result, the condition is often misdiagnosed or underdiagnosed. All too often, it can take more than a decade between the onset of symptoms and proper diagnosis and treatment.

OCD appears to be related to a disruption in serotonin levels, there is no blood test for the condition. Instead, doctors diagnose OCD after evaluating a person's symptoms and history.

Treatment

Obsessive-compulsive disorder can be effectively treated by a combination of cognitive-behavioral therapy and medication that regulates the brain's serotonin levels. Drugs that are approved to treat obsessive-compulsive disorder include fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft), all selective serotonin reuptake inhibitors (SSRIs) that affect the level of serotonin in the brain. Older drugs include the antidepressant clomipramine (Anafranil), a widely studied drug in the treatment of OCD, but one that carries a greater risk of side effects. Drugs should be taken for at least 12 weeks before a person decides whether they are effective.

Cognitive-behavioral therapy (CBT) teaches patients how to confront their fears and obsessive thoughts by making the effort to endure or wait out the activities that usually cause anxiety without compulsively performing the calming rituals. Eventually their anxiety decreases. People who are able to alter their thought patterns in this way can lessen their preoccupation with the compulsive rituals. At the same time, the patient is encouraged to refocus attention elsewhere, such as on a hobby.

In a few very severe cases in which patients have not responded to medication or behavioral therapy, brain surgery may be tried as a way of relieving the unwanted symptoms. Surgery can help up to one third of patients with the most severe form of OCD. The most common operation involves removing a section of the brain called the cingulate cortex. The serious side effects of this surgery for some patients are seizures, personality changes, and less ability to plan.

Prognosis

Obsessive-compulsive disorder is a chronic disease that, if untreated, can last for decades, fluctuating from mild to severe and worsening with age. When treated by a combination of drugs and behavioral therapy, some patients go into complete remission. Unfortunately, not all patients have such a good response. About 20 percent of people cannot find relief with either drugs or behavioral therapy. Hospitalization may be required in some cases.

Despite the crippling nature of the symptoms, many successful doctors, lawyers, business people, performers, and entertainers function well in society despite their condition. Nevertheless, the emotional and financial cost of obsessive-compulsive disorder can be quite high.

Parental concerns

Some people have referred to obsessive-compulsive disorder as "the great pretender," because its symptoms can mimic a number of other disorders. Furthermore, children may become skilled at hiding the more embarrassing features of their condition. Because of these characteristics of the disorder, obsessive-compulsive disorder may go undiagnosed for some time.

KEY TERMS

Anxiety disorder —A mental disorder characterized by prolonged, excessive worry about circumstances in one's life. Anxiety disorders include agoraphobia and other phobias, obsessive-compulsive disorder, post-traumatic stress disorder, and panic disorder.

Cognitive-behavioral therapy —A type of psychotherapy in which people learn to recognize and change negative and self-defeating patterns of thinking and behavior.

Compulsion —A repetitive or ritualistic behavior that a person performs to reduce anxiety. Compulsions often develop as a way of controlling or "undoing" obsessive thoughts.

Obsession —A persistent image, idea, or desire that dominates a person's thoughts or feelings.

Selective serotonin reuptake inhibitors (SSRIs) —A class of antidepressants that work by blocking the reabsorption of serotonin in the brain, thus raising the levels of serotonin. SSRIs include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil).

Serotonin —A widely distributed neurotransmitter that is found in blood platelets, the lining of the digestive tract, and the brain, and that works in combination with norepinephrine. It causes very powerful contractions of smooth muscle and is associated with mood, attention, emotions, and sleep. Low levels of serotonin are associated with depression.

Resources

BOOKS

Herbert, Fredrick B. "Obsessive-Compulsive Disorder in Children and Adolescents." In Psychiatric Secrets. Edited by James L. Jacobson et al. Philadelphia: Hanley and Belfus, 2001.

Stafford, Brian, et al. "Anxiety Disorders." In Nelson Textbook of Pediatrics. Edited by Richard E. Behrman et al. Philadelphia: Saunders, 2004.

PERIODICALS

Barrett, P. "Cognitive-behavioral family treatment of childhood obsessive-compulsive disorder: a controlled trial." Journal of the American Academy of Child and Adolescent Psychiatry 43 (January 2004): 46–62.

Storch, E. A. "Behavioral treatment of a child with PANDAS." Journal of the American Academy of Child and Adolescent Psychiatry 86 (May 2004): 510–1.

ORGANIZATIONS

Anxiety Disorders Association of America. 11900 Park Lawn Drive, Suite 100, Rockville, MD 20852. Web site: <www.adaa.org>.

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA 22201–3042. Web site: <www.nami.org>.

National Anxiety Foundation. 3135 Custer Dr., Lexington, KY 40517. Web site: <www.lexington-on-line.com/naf.html>.

Carol A. Turkington Rosalyn Carson-DeWitt, MD

Obsessive-Compulsive Disorder

Definition

Obsessive-compulsive disorder (OCD) is a type of anxiety disorder. Anxiety disorder is the experience of prolonged, excessive worry about circumstances in one's life. OCD is characterized by distressing repetitive thoughts, impulses or images that are intense, frightening, absurd, or unusual. These thoughts are followed by ritualized actions that are usually bizarre and irrational. These ritual actions, known as compulsions, help reduce anxiety caused by the individual's obsessive thoughts. Often described as the "disease of doubt," the sufferer usually knows the obsessive thoughts and compulsions are irrational but, on another level, fears they may be true.

Description

Almost one out of every 40 people will suffer from obsessive-compulsive disorder at some time in their lives. The condition is two to three times more common than either schizophrenia or manic depression, and strikes men and women of every ethnic group, age and social level. Because the symptoms are so distressing, sufferers often hide their fears and rituals but cannot avoid acting on them. OCD sufferers are often unable to decide if their fears are realistic and need to be acted upon.

Most people with obsessive-compulsive disorder have both obsessions and compulsions, but occasionally a person will have just one or the other. The degree to which this condition can interfere with daily living also varies. Some people are barely bothered, while others find the obsessions and compulsions to be profoundly traumatic and spend much time each day in compulsive actions.

Obsessions are intrusive, irrational thoughts that keep popping up in a person's mind, such as "my hands are dirty, I must wash them again." Typical obsessions include fears of dirt, germs, contamination, and violent or aggressive impulses. Other obsessions include feeling responsible for others' safety, or an irrational fear of hitting a pedestrian with a car. Additional obsessions can involve excessive religious feelings or intrusive sexual thoughts. The patient may need to confess frequently to a religious counselor or may fear acting out the strong sexual thoughts in a hostile way. People with obsessive-compulsive disorder may have an intense preoccupation with order and symmetry, or be unable to throw anything out.

Compulsions usually involve repetitive rituals such as excessive washing (especially handwashing or bathing), cleaning, checking and touching, counting, arranging or hoarding. As the person performs these acts, he may feel temporarily better, but there is no long-lasting sense of satisfaction or completion after the act is performed. Often, a person with obsessive-compulsive disorder believes that if the ritual is not performed, something dreadful will happen. While these compulsions may temporarily ease stress, short-term comfort is purchased at a heavy price—time spent repeating compulsive actions and a long-term interference with life.

The difference between OCD and other compulsive behavior is that while people who have problems with gambling, overeating or with substance abuse may appear to be compulsive, these activities also provide pleasure to some degree. The compulsions of OCD, on the other hand, are never pleasurable.

OCD may be related to some other conditions, such as the continual urge to pull out body hair (trichotillomania) fear of having a serious disease (hypochondriasis ) or preoccupation with imagined defects in personal appearance disorder (body dysmorphia). Some people with OCD also have Tourette syndrome, a condition featuring tics and unwanted vocalizations (such as swearing). OCD is often linked with depression and other anxiety disorders.

Causes and symptoms

While no one knows for sure, research suggests that the tendency to develop obsessive-compulsive disorder is inherited. There are several theories behind the cause of OCD. Some experts believe that OCD is related to a chemical imbalance within the brain that causes a communication problem between the front part of the brain (frontal lobe) and deeper parts of the brain responsible for the repetitive behavior. Research has shown that the orbital cortex located on the underside of the brain's frontal lobe is overactive in OCD patients. This may be one reason for the feeling of alarm that pushes the patient into compulsive, repetitive actions. It is possible that people with OCD experience overactivity deep within the brain that causes the cells to get "stuck," much like a jammed transmission in a car damages the gears. This could lead to the development of rigid thinking and repetitive movements common to the disorder. The fact that drugs which boost the levels of serotonin, a brain messenger substance linked to emotion and many different anxiety disorders, in the brain can reduce OCD symptoms may indicate that to some degree OCD is related to levels of serotonin in the brain.

Recently, scientists have identified an intriguing link between childhood episodes of strep throat and the development of OCD. It appears that in some vulnerable children, strep antibodies attack a certain part of the brain. Antibodies are cells that the body produces to fight specific diseases. That attack results in the development of excessive washing or germ phobias. A phobia is a strong but irrational fear. In this instance the phobia is fear of disease germs present on commonly handled objects. These symptoms would normally disappear over time, but some children who have repeated infections may develop full-blown OCD. Treatment with antibiotics has resulted in lessening of the OCD symptoms in some of these children.

If one person in a family has obsessive-compulsive disorder, there is a 25% chance that another immediate family member has the condition. It also appears that stress and psychological factors may worsen symptoms, which usually begin during adolescence or early adulthood.

Diagnosis

People with obsessive-compulsive disorder feel ashamed of their problem and often try to hide their symptoms. They avoid seeking treatment. Because they can be very good at keeping their problem from friends and family, many sufferers do not get the help they need until the behaviors are deeply ingrained habits and hard to change. As a result, the condition is often misdiagnosed or underdiagnosed. All too often, it can take more than a decade between the onset of symptoms and proper diagnosis and treatment.

While scientists seem to agree that OCD is related to a disruption in serotonin levels, there is no blood test for the condition. Instead, doctors diagnose OCD after evaluating a person's symptoms and history.

Treatment

Obsessive-compulsive disorder can be effectively treated by a combination of cognitive-behavioral therapy and medication that regulates the brain's serotonin levels. Drugs that are approved to treat obsessive-compulsive disorder include fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft), all selective serotonin reuptake inhibitors (SSRIs) that affect the level of serotonin in the brain. Older drugs include the antidepressant clomipramine (Anafranil), a widely-studied drug in the treatment of OCD, but one that carries a greater risk of side effects. Drugs should be taken for at least 12 weeks before deciding whether or not they are effective.

Cognitive-behavioral therapy (CBT) teaches patients how to confront their fears and obsessive thoughts by making the effort to endure or wait out the activities that usually cause anxiety without compulsively performing the calming rituals. Eventually their anxiety decreases. People who are able to alter their thought patterns in this way can lessen their preoccupation with the compulsive rituals. At the same time, the patient is encouraged to refocus attention elsewhere, such as on a hobby.

In a few severe cases where patients have not responded to medication or behavioral therapy, brain surgery may be tried as a way of relieving the unwanted symptoms. Surgery can help up to a third of patients with the most severe form of OCD. The most common operation involves removing a section of the brain called the cingulate cortex. The serious side effects of this surgery for some patients include seizures, personality changes and less ability to plan.

Alternative treatment

Because OCD sometimes responds to SSRI antidepressants, a botanical medicine called St. John's wort (Hypericum perforatum ) might have some beneficial effect as well, according to herbalists. Known popularly as "Nature's Prozac," St. John's wort is prescribed by herbalists for the treatment of anxiety and depression. They believe that this herb affects brain levels of serotonin in the same way that SSRI antidepressants do. Herbalists recommend a dose of 300 mg., three times per day. In about one out of 400 people, St. John's wort (like Prozac) may initially increase the level of anxiety. Homeopathic constitutional therapy can help rebalance the patient's mental, emotional, and physical well-being, allowing the behaviors of OCD to abate over time.

Prognosis

Obsessive-compulsive disorder is a chronic disease that, if untreated, can last for decades, fluctuating from mild to severe and worsening with age. When treated by a combination of drugs and behavioral therapy, some patients go into complete remission. Unfortunately, not all patients have such a good response. About 20% of people cannot find relief with either drugs or behavioral therapy. Hospitalization may be required in some cases.

Despite the crippling nature of the symptoms, many successful doctors, lawyers, business people, performers and entertainers function well in society despite their condition. Nevertheless, the emotional and financial cost of obsessive-compulsive disorder can be quite high.

Resources

ORGANIZATIONS

Anxiety Disorders Association of America. 11900 Park Lawn Drive, Ste. 100, Rockville, MD 20852. (800) 545-7367. 〈http://www.adaa.org〉.

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd., Ste. 300, Arlington, VA 22201-3042. (800) 950-6264. 〈http://www.nami.org〉.

National Anxiety Foundation. 3135 Custer Dr., Lexington, KY 40517. (606) 272-7166. 〈http://www.lexington-on-line.com/naf.html〉.

Obsessive-Compulsive Anonymous. P.O. Box 215, New Hyde Park, NY 11040. (516) 741-4901. 〈west24th@aol.com〉 〈http://members.aol.com/west24th/index.html〉.

Obsessive-Compulsive Foundation. P.O. Box 70, Milford, CT 06460. (203) 874-3843. 〈JPHS28A@Prodigy.com〉 〈http://pages.prodigy.com/alwillen/ocf.html〉.

KEY TERMS

Anxiety disorder— This is the experience of prolonged, excessive worry about circumstances in one's life. It disrupts daily life.

Cognitive-behavior therapy— A form of psychotherapy that seeks to modify behavior by manipulating the environment to change the patient's response.

Compulsion— A rigid behavior that is repeated over and over each day.

Obsession— A recurring, distressing idea, thought or impulse that feels "foreign" or alien to the individual.

Selective serotonin reuptake inhibitors (SSRIs)— A class of antidepressants that work by blocking the reabsorption of serotonin in brain cells, raising the level of the chemical in the brain. SSRIs include Prozac, Zoloft, Luvex, and Paxil.

Serotonin— One of three major neurotransmitters found in the brain that is related to emotion, and is linked to the development of depression and obsessive-compulsive disorder.

Obsessive-Compulsive Disorder

BIBLIOGRAPHY

Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by recurrent and intrusive obsessions and/or compulsions that are excessive or unreasonable, are time-consuming, and cause marked distress for the individual and/or significant impairment in global functioning. Obsessions are defined as recurrent and persistent thoughts, impulses, or images that are intrusive and inappropriate. Compulsions are defined as repetitive behaviors or mental acts that are performed in response to an obsession or according to rigid rules in order to prevent or reduce distress.

Common obsessions seen in individuals suffering from OCD are fear of contamination from germs, dirt, and environmental toxins; doubts about safety—having harmed the self or others; the need for symmetry, exactness, and order—having things “just right”; fear of making mistakes and acting socially inappropriate; intrusive sexual thoughts or urges; excessive religious or moral doubts—having “forbidden thoughts”; and the need to tell, ask, or confess. Common compulsions include washing and cleaning, checking, ordering and arranging, hoarding and collecting, repeating, touching, praying, counting, reassurance seeking, making mental lists, and retracing past memories.

People with OCD are sometimes overwhelmed by their disturbing obsessions, which seem uncontrollable and cause intense anxiety. To reduce the discomfort generated by the obsessions, an OCD sufferer avoids the feared situation and/or engages in compulsions repeatedly and ritualistically, which may relieve the discomfort but only temporarily. This pattern eventually develops into a vicious cycle of obsessions and a complicated web of compulsions. However, not all people with obsessions perform compulsions.

About 2 to 3 percent of Americans, as many as seven million people, have OCD at some point in their lives. OCD can happen to anyone and usually begins in adolescence or early adulthood, but the disorder can also occur in children. Seventy-five percent of those who develop it show symptoms by age thirty. OCD starts earlier in boys than in girls. In adults, men and women are affected in equal numbers. In some cases, OCD begins after a trauma. Cases involving the interplay of OCD and posttraumatic stress disorder (PTSD) precipitated by trauma need to be treated by addressing both disorders. OCD may co-occur with conditions such as Tourette’s syndrome, attention deficit disorder, other obsessive-compulsive spectrum disorders, and other anxiety disorders. Depression is often a secondary symptom to OCD.

Like many psychiatric disorders, OCD appears to result from a combination of biological and psychological factors. Some people may have a biological predisposition to experience anxiety. Research suggests that abnormal levels of the neurotransmitter serotonin may play a role in OCD. Brain scans of OCD sufferers have revealed abnormalities in the activity level of the orbital cortex, cingulated cortex, and caudate nucleus. OCD tends to develop when these biological factors are combined with a psychological vulnerability to anxiety. Some individuals may have learned that the world is a potentially dangerous place over which one has little control. This learned belief of danger is then overvalued and misattributed to one’s lack of control over the environment.

OCD can have disabling effects on a sufferer’s life. Individuals with severe cases of OCD may need hospitalization to treat their obsessions and compulsions. People with OCD must allow a great deal of extra time to complete seemingly routine tasks. Individuals may avoid going to certain places or engaging in certain activities due to their own embarrassment about their compulsive behavior. Furthermore, family members of individuals with OCD may feel anger, frustration, and/or guilt when the sufferer’s compulsive behaviors interfere with family functioning. OCD is a chronic illness that, like other psychiatric illnesses, has periods of exacerbation followed by periods of relative improvements, though a completely symptom-free interval is generally unusual. With appropriate treatment, most sufferers show considerable improvements.

Exposure and response prevention (ERP), a form of cognitive-behavioral therapy, is the most effective type of psychotherapy for OCD. Essentially, OCD sufferers are repeatedly exposed to those anxiety-provoking thoughts and situations that they fear, but are prevented from engaging in their compulsive rituals and avoidance behaviors. The basis for ERP allows an individual the opportunity to learn that simply tolerating the obsessions without avoidance or compulsions will gradually lead to reduction in anxiety and extinction of obsessive fears. In turn, the occurrence of obsessions is reduced, and the vicious cycle eventually dissipates. Intensive ERP alone is often effective enough for many individuals with OCD.

OCD treatment using certain medications may be beneficial, but generally is not as effective as intensive ERP. Medications considered for the treatment of OCD are usually antidepressants known as selective serotonin reuptake inhibitors (SSRIs), which are often effective without severe side effects. These SSRIs, which include fluvoxamine (Luvox), fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) increase the serotonin available in the brain. Clomipramine (Anafranil), a tricyclic antidepressant, is another Food and Drug Administration–approved OCD medication that is more effective than SSRIs but has unpleasant side effects. In more resistant cases of OCD, an SSRI and clomipramine may be combined. Finally, although psychotherapy using ERP is commonly integrated with the use of medication, this treatment combination has not been established as generally superior to intensive ERP alone.

BIBLIOGRAPHY

American Psychiatric Association. 1994. Diagnostic and Statistical Manual of Mental Disorders ( DSM -IV). 4th ed. Washington, DC: Author.

Gorbis, Eda. 1996. Effects of Trauma, on Assessment and Treatment of Obsessive Compulsive Disorder. Ph.D. diss., California Graduate Institute, Los Angeles, CA.

Kozak, Michael J., and Edna Foa. 1997. Mastery of Obsessive Compulsive Disorder: Therapist Guide. San Antonio, TX: Psychological Corp.

March, John S., Allen Frances, Daniel Carpenter, and David A. Kahn. 1997. The Expert Consensus Guideline Series: Treatment of Obsessive-Compulsive Disorder. Journal of Clinical Psychiatry 58 (4): 65–72.

Yip, Jenny C. 2005. An Integrated Approach for the Family Treatment of OCD in Children and Adolescents. Psy.D. diss., Argosy University, Washington, DC.

Eda Gorbis

Obsessive-compulsive disorder

Mental illness characterized by the recurrence of intrusive, anxiety-producing thoughts (obsessions) accompanied by repeated attempts to suppress these thoughts through the performance of certain irrational, often ritualistic, behaviors (compulsions).

Obsessive-compulsive disorder (OCD) is classified as a mental illness , and is characterized by the recurrence of intrusive, anxiety-producing thoughts (obsessions). The person with obsessive-compulsive disorder repeatedly and consistently tries to suppress these thoughts through the performance of certain irrational, often ritualistic, behaviors (compulsions).

Symptoms

Although there are marked similarities between cases, no two people experience this anxiety disorder in exactly the same way. In one common form of obsessive-compulsive disorder, an exaggerated fear of contamination (the obsession) leads to washing one's hands so much that they become raw (the compulsion). Other common manifestations of OCD involve sorting, checking, and counting compulsions. Checking compulsions seem to be more common among men, whereas washing is more common among women. Another type of OCD is trichotillomania, the compulsion to pull hair. The compulsive behavior is usually not related in any logical way to the obsessive fear, or else it is clearly excessive (as in the case of hand-washing).

Everyone engages in these types of behavior to a certain extent—counting steps as we walk up them, double-checking to make sure we've turned off the oven or locked the door—but in a person with OCD, such behaviors are so greatly exaggerated that they interfere with relationships and day-to-day functioning at school or work. A child with a counting compulsion, for example, might not be able to listen to what the teacher is saying because he or she is too busy counting the syllables of the teacher's words as they are spoken.

These are some of the signs that a child might be suffering from OCD:

• Avoidance of scissors or other sharp objects. A child might be obsessed with fears of hurting herself or others.
• Chronic lateness or the appearance of dawdling. A child could be performing checking rituals (e.g., repeatedly making sure all her school supplies are in her bookbag).
• Daydreaming or preoccupation. A child might actually be counting or balancing things mentally.
• Inordinate amounts of time spent in the bathroom. A child could be involved in a hand-washing ritual.
• Late schoolwork. A child might be repeatedly checking her work.
• Papers with holes erased in them. This might also indicate a checking ritual.
• Secretive and defensive behavior. People with OCD will go to extreme lengths in order not to reveal or give up their compulsions.

Although people with OCD realize that their thought processes are irrational, they are unable to control their compulsions, and they become painfully embarrassed when a bizarre behavior is discovered. Usually certain behaviors called rituals are repeated in response to an obsession. Rituals only temporarily reduce discomfort or anxiety caused by an obsession, and thus they must be repeated frequently. However, the fear that something terrible will happen if a ritual is discontinued often locks OCD sufferers into a life ruled by what appears to be superstition .

Causes

Sigmund Freud attributed obsessive-compulsive disorder to traumatic toilet training and, although not supported by any empirical evidence, this theory was widely accepted for many years. Current research, however, indicates that OCD is neurobiological in origin, and researchers have found physical differences between the brains of OCD sufferers and those without the disorder. Specifically, neurons in the brains of OCD patients appear to be overly sensitive to serotonin, the chemical which transmits signals in the brain . A recent study at the National Institute of Mental Health suggests a link between childhood streptococcal infections and the onset of OCD. Other research indicates that a predisposition for OCD is probably inherited. It is possible that physical or mental stresses can precipitate the onset of OCD in people with a predisposition towards it. Puberty also appears to trigger the disorder in some people.

Prevalence

Once considered rare, OCD is now believed to affect between 5 and 6 million Americans (2-3% of the population), which makes it almost as common as asthma or diabetes mellitus. Among mental disorders, OCD is the fourth most prevalent (after phobias, substance abuse, and depression ). In more than one-third of cases, onset of OCD occurs in childhood or adolescence . Although the disorder occurs equally among adults of both genders, among children it is three times more common in boys than girls.

Treatment

Fewer than one in five OCD sufferers receive professional help; the typical OCD patient suffers for seven years before seeking treatment. Many times, OCD is diagnosed when a patient sees a professional for another problem, often depression. Major depression affects close to one-third of patients with obsessive-compulsive disorder.

In recent years, a new family of antidepressant medications called selective serotonin reuptake inhibitors (SSRIs) has revolutionized the treatment of obsessive-compulsive disorder. These drugs include clomipramine (Anafranil), fluoxetine (Prozac), fluvoxamine (Luvox), and sertraline (Zoloft). They work by altering the level of serotonin available to transmit signals in the brain. Thanks to these medications, the over-whelming majority of OCD sufferers (75-90%) can be successfully treated.

In addition to medication, an extreme type of behavior therapy is sometimes used in patients with OCD. In exposure-response prevention therapy, a patient slowly gives up his or her compulsive behaviors with the help of a therapist. Someone with a hand-washing compulsion, for example, would have to touch something perceived as unclean and then refrain from washing his/her hands. The resulting extreme anxiety eventually diminishes when the patient realizes that nothing terrible is going to happen.

Further Reading

Rapoport, Judith L. The Boy Who Couldn't Stop Washing: The Experience and Treatment of Obsessive-Compulsive Disorder. New York: E.P. Dutton, 1989.

Further Information

The Obsessive-Compulsive Foundation Inc. P.O. Box 70, Milford, CT 06460–0070, (203) 878–5669, (800) NEWS-4-OCD.

Obsessive Compulsive Anonymous (OCA). P.O. Box 215, New Hyde Park, NY 11040, (516) 741–4901.

The Obsessive Compulsive Information Center. Dean Foundation for Health, Research and Education, 8000 Excelsior Drive, Suite 302, Madison, WI 53717-1914, (608) 836–8070. http://www.fairlite.com/ocd.

OBSESSIVE-COMPULSIVE DISORDER

DEFINITION

Obsessive-compulsive disorder (OCD) is a type of anxiety disorder. A person with an anxiety disorder worries excessively about the circumstances of his or her life over a long period of time. OCD is characterized by distressing thoughts that never seem to go away. These thoughts are often accompanied by images that are powerful, unusual, frightening, or absurd.

A person with OCD deals with these thoughts and feelings with ritualized actions. A ritualized action is a behavior that is performed again and again in exactly the same way. Patients believe that these actions will protect them from the terrible thoughts in their minds. Ritualized actions are often unusual and meaningless. They are also called compulsions or compulsive behaviors.

OCD is sometimes known as the "disease of doubt." The patient often knows that his or her obsessive thoughts and ritualized actions are not rational (make no logical sense). Yet he or she may still worry that the fears may be true.

DESCRIPTION

About one out of every forty people will experience obsessive-compulsive disorder at some time in their lives. It occurs with equal frequency among men and women, all ages, and all ethnic groups. Many people with the disorder try to hide their condition from other people. Yet they are unable to avoid acting out their compulsions.

Most people with OCD have both obsessions and compulsions. Some people may have only obsessions or only compulsions. The extent to which OCD affects a person's daily life varies. Some people are barely bothered. Others are terribly troubled by their obsessions. They may spend a large part of the day carrying out their compulsive behaviors.

An obsession is an irrational thought that occurs again and again. As an example, a person might think, "My hands are dirty, and I must wash them again." The person's hands may be (and probably are) totally clean. Yet the person cannot get the thought out of his or her mind that the hands are still dirty.

Some typical obsessions include:

• Fear of dirt, germs, or contamination
• A desire to perform violence on other people
• A feeling of responsibility for other people's safety
• Fear of hitting a pedestrian with a car
• Excessive religious feelings
• Intense sexual thoughts

A compulsion is a particular behavior that is performed repeatedly to protect against an obsession. Some common compulsions are excessive washing (especially hand washing or bathing); housecleaning; and touching, counting, arranging, or hoarding objects. The patient may feel better while performing these actions. But that sense of satisfaction does not last long. Soon, the person will feel the need to do the action again.

Obsessive-Compulsive Disorder: Words to Know

Anxiety disorder:

An experience of prolonged, excessive worry about the circumstances of one's life.

Cognitive-behavioral therapy:

A form of psychological counseling in which patients are helped to understand the nature of their disorder and reshape their environment to help them function better.

Compulsion:

A ritualistic behavior that is repeated again and again.

Neurotransmitter:

A chemical that occurs in the brain and that helps electrical signals travel from one nerve cell to another.

Obsession:

A troubling thought that occurs again and again and causes severe distress in a person.

For a person with OCD, a compulsive behavior is a form of protection. He or she feels that something terrible will happen if the behavior

is not repeated. The behavior may relieve stress for a short time, but it does not bring any kind of pleasure to the patient.

OCD is sometimes related to other emotional disorders. For example, some people feel a constant urge to pull hair out of their bodies. Others are constantly afraid of catching some terrible disease. Still others worry that there is something wrong with the way their bodies look. OCD is often linked with depression (see depressive disorders entry) and other anxiety disorders.

CAUSES

The cause of obsessive-compulsive disorder has not yet been found. Many researchers believe that it may be inherited. If one person in a family has OCD, there is a 25 percent chance that another family member will also have the condition. Stress and other psychological factors may also contribute to the development of OCD.

One popular theory is that OCD is caused by low levels of seratonin (pronounced sihr-uh-TOE-nun), a neurotransmitter. Neurotransmitters are chemicals that occur in the brain. They are responsible for delivering electrical signals from one nerve cell to another and help control many of the mental activities that occur in the brain.

Some researchers think that OCD develops when the brain produces too much or too little of some particular neurotransmitter. In such a case, nerve messages cannot travel smoothly from one part of the brain to another. They may begin to recycle—that is, to travel again and again across the same set of nerves. This constant repetition of nerve messages might be responsible for the repetitive behavior characteristic of compulsions.

Another theory is that OCD may be related to childhood episodes of strep throat (see strep throat entry), a bacterial infection. In some children, strep throat antibodies attack a certain part of the brain. Antibodies are chemicals produced by the immune system. Their job is to fight off infections. But antibodies can sometimes cause damage to the body itself. Researchers think that damage to the brain caused by strep throat antibodies may lead to obsessions and compulsions such as fear of germs and excessive hand washing. Some children with OCD have benefited from treatment with antibiotics.

SYMPTOMS

While some children may experience OCD, symptoms usually begin when a person reaches adolescence. While everyone has a tendency to double check to make sure that the doors are locked or the stove is turned off when leaving the house, the compulsions of OCD sufferers are so great that they may interfere with daily life. Individuals with the disorder have been known to wash their hands for hours at a time or to rearrange and clean their household several times throughout a day. They usually recognize that their behavior is irrational, but they have no control over their actions.

DIAGNOSIS

Psychiatrists diagnose obsessive-compulsive disorder based on the described symptoms. No blood tests or other kinds of laboratory tests are available for diagnosing OCD. Many people with the condition are never diagnosed or are diagnosed only after many years. The delay in diagnosis is due to the shame that many patients feel about their condition. They become skillful at hiding their symptoms from other people.

TREATMENT

Two forms of treatment are used with obsessive-compulsive behavior: drugs and cognitive-behavioral therapy. The drugs used with OCD are designed to alter the amount of neurotransmitters in the brain. They include fluoxetine (pronounced floo-AHK-suh-teen, trade name Prozac), paroxetine (pronounced par-AHK-suh-teen, trade name Paxil), and sertraline (pronounced SIR-truh-leen, trade name Zoloft). An older drug that is sometimes used is clomipramine (pronounced KLO-mip-ruh-meen, trade name Anafranil). However, Clomipramine has more side effects than the newer drugs listed.

Cognitive-behavioral therapy is a form of counseling conducted by trained medical professionals. The goal is to help patients understand the basis of their disorder. They are encouraged to accept the fact that they have fears and obsessive thoughts. Then they are helped to find ways to tolerate the conditions that cause their anxiety and avoid performing the ritualistic activities of their compulsions. Patients sometimes find it helpful to think about other things by taking up a hobby or finding activities of interest.

Some patients do not benefit from drugs or cognitive-behavioral therapy. Brain surgery is the treatment of last resort with these patients. Surgery involves removing the small part of the brain that controls compulsive behavior. The surgery is successful in about a third of all cases. It may have very serious side effects, however, including seizures, personality changes, and loss of some mental functions.

Alternative Treatment

St. John's wort is sometimes recommended as a treatment for OCD. St. John's wort is an herb that has long been used to treat anxiety and depression. Some practitioners believe that the herb has the same effect on neurotransmitters as the conventional drugs described. Research suggests that a very small fraction of people with OCD may benefit from the use of St.-John's-wort.

Some people believe that homeopathic treatments can help people with OCD. They try to rebalance a patient's mental, emotional, and physical wellbeing, allowing compulsive behaviors to disappear over time.

PROGNOSIS

The prognosis for obsessive-compulsive disorder varies widely among patients. If left untreated, the condition can last for decades. People go through periods when symptoms alternate between mild and severe. The symptoms usually get worse with age.

Treatment with drugs and cognitive-behavioral therapy can be very helpful. Some people recover from the disorder completely. They may need to stay on some type of treatment program for many years, however, or even for life. About 20 percent of all OCD patients do not respond to any form of treatment. These individuals may require hospitalization.

Many people with OCD can eventually live happy and productive lives. They find success in nearly every career field, from doctors and lawyers to businesspeople and entertainers. Keeping the condition under control can be very difficult, however. It may require a considerable emotional effort and a serious financial investment.

PREVENTION

There are no known ways to prevent obsessive-compulsive disorder.

FOR MORE INFORMATION

Books

Dumont, Raeann. The Sky Is Falling: Understanding and Coping with Phobias, Panic, and Obsessive-Compulsive Disorder. New York: W. W. Norton & Company, 1996.

Foa, E., and R. Wilson. Stop Obsessing! How to Overcome Your Obsessions and Compulsion. New York: Bantam Books, 1991.

Schwartz, Jeffrey. Free Yourself from Obsessive-Compulsive Behavior: A Four-Step Self-Treatment Method to Change Your Brain Chemistry. New York: HarperCollins, 1996.

Swedo, S. E., and H. L. Leonard. It's Not All in Your Head. New York: HarperCollins, 1996.

Organizations

Anxiety Disorders Association of America. 11900 Parklawn Drive, Suite 100, Rockville, MD 20852. (301) 231-9350. http://www.adaa.org.

National Alliance for the Mentally Ill. 200 N. Glebe Road, #1015, Arlington, VA 22203-3728. (800) 950-NAMI. http://www.nami.org.

National Mental Health Association. 1021 Prince Street, Alexandria, VA 22314-2971. (800) 969-NMHA. http://www.nmha.org.

Obsessive-Compulsive Anonymous. PO Box 215, New Hyde Park, NY 11040. (516) 739-0662. http://members.aol.com/west24th.

Obsessive-Compulsive Disorder

What Is Obsessive-Compulsive Disorder?

What Causes Obsessive-Compulsive Disorder?

What Are Obsessions?

What Are Compulsions?

How Is Obsessive-Compulsive Disorder Treated?

Resources

Obsessive-compulsive (ob-SES-iv-kom-PUL-siv) disorder (OCD) causes people to become trapped in a pattern of repeated, unwanted thoughts, called obsessions (ob-SESH-unz), and a pattern of repetitive behavior, called compulsions (kom-PUL-shunz). Thoughts that feel impossible to control cause distress and anxiety (ang-ZY-e-tee) that is often neutralized, or offset, by the particular compulsive behavior patterns.

KEYWORDS

for searching the Internet and other reference sources

Anxiety disorders

Brain chemistry (neurochemistry)

Compulsion

Obsession

Many people knock on wood to ward off bad luck. Others may walk around, rather than under, ladders, or they may step over, rather than on, cracks in the sidewalk. These are familiar examples of superstitions. Superstitions are irrational beliefs resulting from false ideas, fear of the unknown, or trust in magic or chance. Superstitions are common in everyday life. However, for people with OCD, rituals go much further than that. People with this disorder may feel driven to wash their hands until they bleed, count objects for hours on end, or go through a complex, 30-minute routine before leaving the house.

These Pandas Are a Bear

PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections) is a term for unusual, OCD-like symptoms that arise in a small number of children after strep throat, a common throat infection caused by bacteria. The behavior of the children usually changes quite suddenly. Almost overnight, they develop obsessions, compulsions, or tics; uncontrollable muscle twitches; or verbal outbursts. The cause is still unknown. One theory, though, is that a strep infection in childhood prompts the body to form antibodies (AN-ti-bo-deez), substances in the blood that fight bacteria and other foreign matter. The next time strep develops, the body is ready to fight back. It releases a barrage of antibodies, but some miss their mark and head for the part of the brain that is thought to affect behavior and movement—resulting in OCD symptoms.

What Is Obsessive-Compulsive Disorder?

People with OCD can become trapped in a pattern of repeated, unwanted behaviors and thoughts that are senseless and upsetting but that seem impossible to control. The behaviors and thoughts can take up so much time and energy that people have trouble getting on with their daily lives. The problem often begins with disturbing thoughts, called obsessions. People then go through repeated rituals, called compulsions, in an effort to prevent these thoughts or make the distress caused by the thoughts go away. For example, people may wash their hands, count objects on a shelf, or check a door lock over and over again. For people with OCD, there is no pleasure in doing these things. There is only short-lived relief from the upsetting thoughts (for example, that the house will catch on fire or that a close relative is sick), which all too soon return.

Most people have a few odd habits. For example, they may check an oven to be sure it is off and then recheck it a few seconds later. Such behaviors are signs of OCD only when they take considerable amounts of time each day, cause much distress, and interfere with other activities.

What Causes Obsessive-Compulsive Disorder?

About 2 percent of adults in the United States have OCD in any given year. OCD usually begins during childhood or the teenage years, and it affects men and women equally. In the past, it was believed that OCD was due mainly to family problems or attitudes learned as children. Today, however, researchers stress the link between biological factors and life experiences. Brain imaging studies (special brain “x-rays”) have shown that people with OCD have patterns of brain activity that differ from the patterns of people with other mental disorders and of people with no disorders at all.

OCD occurs more often than average in people with certain other conditions that affect the brain and nervous system*. For example, there is an increased risk of OCD in people with Tourette (tu-RET) syndrome, an inherited nervous system disorder that causes repeated, uncontrollable muscle twitches and verbal outbursts. Researchers now are trying to find out if there is a genetic* link between OCD and Tourette syndrome.

* nervous system

is a network of specialized tissue made of nerve cells, or neurons, that processes messages to and from different parts of the human body.

* genetic

(je-NE-tik) pertains to genes, which are chemicals in the body that help determine a person’s characteristics, such as hair or eye color. They are inherited from a person’s parents and are contained in the chromosomes, threadlike structures inside the cells of the body.

What Are Obsessions?

Obsessions are unwanted ideas or wishes that repeatedly well up in the minds of people with OCD. The thoughts create constant worry and fear. People who do not experience OCD believe that the worry is silly or strange. People with OCD also can agree that the worry is needless; however, they cannot stop feeling the worry that comes with the thoughts. Interestingly, thoughts and behaviors may not be related. The thought “I might get sick” could be followed by the behavior of counting to seven. Common obsessions include:

Compelling Reading

The word “compulsive” has more than one meaning in the mental health world. When people talk about obsessive-compulsive disorder, they are using the word in a formal way to refer to a specific kind of repeated ritual. When people talk about compulsive gambling or compulsive internet use, however, they are using the word in a less strict sense to refer to people who have an intense craving that is out of control.

• worries about germs and dirt, for example, worrying about getting germs from shaking hands
• repeated doubts, for example, worrying about leaving a door unlocked
• worries about keeping things in order, for example, becoming very upset when things are out of place
• violent impulses, for example, thinking repetitively about hurting someone
• sexual impulses, for example, thinking repetitively about a sexual act.

What Are Compulsions?

People try to keep these unwanted thoughts in check with repeated actions that they feel driven to perform. Some people have set routines, while others have complex, changing rituals. The actions provide some relief from worry, but only temporarily. Common compulsions include:

• Washing: For example, people worried about germs and dirt may spend hours washing their hands.
• Checking: For example, people with repeated doubts about leaving a door unlocked may check the lock over and over.
• Ordering: For example, people worried about keeping things in order may arrange and rearrange the objects on a shelf.
• Counting: For example, people with disturbing violent or sexual thoughts may block them out by counting to 11 again and again.

Teenagers and adults with OCD know that their behavior is pointless, but the distress is so great that they feel unable to stop the behavior. At times, they may even start to believe their own unreasonable fears. People with OCD may be able to keep their behavior under control at school or at work for a while. They often are afraid to tell others, believing that they will be thought of as “weird.” Without treatment, though, the problem may get worse over time. For some individuals, the constant worries and time-consuming rituals can take over their lives.

How Is Obsessive-Compulsive Disorder Treated?

Medications

Studies have shown that medicines that affect a brain chemical called serotonin* can reduce the symptoms of OCD. While medicines may help control OCD, the symptoms may return once people stop taking medication. For this reason, doctors often recommend a combination of prescription medication and visits to a behavior therapist. Some individuals whose OCD is not significantly debilitating* might choose behavior therapy alone as the preferred treatment.

* serotonin

(ser-o-TO-nin) is a neurotransmitter, a substance that helps transmit information from one nerve cell to another.

* debilitating

(de-BI-li-tay-ting) means making weak or sap-ping strength.

Behavioral therapy

Behavioral (be-HAY-vyor-al) therapy helps people change specific unwanted behaviors. For OCD, this often means using an approach called exposure and response prevention. In this approach, people purposely are exposed to a feared object or idea, either directly or through imagination. Then they prevent themselves from carrying out the usual response (the compulsion), instead using other methods to manage the anxiety they feel. For example, people with a handwashing compulsion might be encouraged to touch objects that they believe to be dirty. Then with the therapist’s help, they resist the compulsion to wash for several hours. During this time, the anxiety associated with the obsession decreases and so does the compulsion to wash. Research has shown that this approach can be effective for treating OCD. People who remain in therapy may gradually learn to worry less about their obsessive thoughts, and eventually they may learn to go for long periods of time without falling back on their old compulsive actions. With exposure and response prevention, thoughts and compulsions frequently (and sometimes quickly) disappear or become manageable.

See also

Anxiety and Anxiety Disorders

Brain Chemistry (Neurochemistry)

Habits and Habit Disorders

Therapy

Tourette Syndrome

Resources

Book

Rapoport, Judith L. The Boy Who Couldn’t Stop Washing. New York: Plume, reissued 1990. One of the first books to bring obsessive-compulsive disorder to public attention.

Organizations

Anxiety Disorders Association of America, 11900 Parklawn Drive, Suite 100, Rockville, MD 20852. This nonprofit group promotes public awareness of OCD. Telephone 301-231-9350 http://www.adaa.org

Anxiety Disorders Education Program, U.S. National Institute of Mental Health, 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. This government program provides reliable information about OCD. Telephone 888-8ANXIETY http://www.nimh.nih.gov/anxiety

Obsessive-Compulsive Foundation, 337 Notch Hill Road, North Branford, CT 06471. This organization is for people with OCD and others with an interest in the disorder. Telephone 203-315-2190 http://ocfoundation.org