“Obsessive-compulsive” is one of the many medical terms that have entered our everyday language. It denotes people who like things neat and orderly. They are reliably on-time and organized. But the disorder this term comes from takes it to an extreme degree.
Patients with Obsessive-Compulsive Disorder spend great amounts of time and energy on irrational, intrusive ideas and on behaviors intended to quell those thoughts. The disorder can be incredibly disruptive to everyday life, with patients devoting multiple hours every day to their obsessions and compulsions. They also change their behavior to avoid any possible symptom triggers.
Patients who obsess over order are often delayed in finishing projects for work or school because they are not, in the patient’s estimation, perfect. Unwanted thoughts about harming others lead many patients to seclude themselves, even from friends and family. Someone with checking compulsions may be unable to leave the home without checking that the door is locked or the alarm set not just once or twice, but tens or hundreds of times. Patients may even impede their own treatment by avoiding doctors’ offices because they fear exposure to germs. Those who focus on cleanliness can cause harm to themselves from repetitive washing.
Patients’ families may also participate in the disorder with them. They may perform compulsions with them, do errands for a home bound patient, or change their routines to fit the rules set out by the patient. Children with the disorder have difficulty socializing and making friends. When the disorder starts in adolescence, patients may avoid moving out of the house and struggle to be independent. The disorder follows a vacillating, chronic course if it goes untreated, and even with treatment, remission, rather than a complete cure, should be expected.
Causes and Risk Factors
In a given year, 1.2% of American adults are diagnosed with Obsessive-Compulsive Disorder. The average age at diagnosis is 19, and the vast majority of those who will ever be diagnosed are by age 35. The disorder lasts 9 years on average. Twenty-five percent of diagnoses are made by age 14, but when just looking at males, that age drops to 10.
Ninety percent of these patients have another mental health diagnosis. About 76% have an anxiety disorder, 63% have depression or Bipolar Disorder, 56% have an impulse control disorder (like Pyromania, Intermittent Explosive Disorder, or Kleptomania), and 39% have a substance use disorder. Thirty percent of these patients also have a tic disorder, and this phenomenon is most common in child-onset Obsessive Compulsive Disorder in males.
The risk of developing Obsessive Compulsive Disorder is twice the average for first degree family members of a patient with the disorder. However, that risk increases to 10 times the average if the patient was diagnosed as a child or adolescent. Lifetime risk of the disorder increases with increasing number of different types of obsessions and compulsions. Estimates of heritability from twin studies range from 29% to 65%. About half of those genetics are shared with anxiety disorders, and the other half are unique to Obsessive Compulsive Disorder.
Streptococcal infection in childhood can bring sudden onset Obsessive Compulsive Disorder, a phenomenon known as Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections.
Personality and environment
Obsessive-Compulsive Disorder in adulthood is associated with physical and sexual abuse in childhood. Furthermore, a withdrawn temperament and lack of peer relationships in childhood increase the risk for developing the disorder in adulthood. These qualities are associated with the personality trait neuroticism, which describes people who tend to expect generally negative outcomes wherever possible and is another risk factor for OCD.
Diagnosing Obsessive-Compulsive Disorder
Making the diagnosis
Patients have either obsessions, compulsions, or both. The obsessions and compulsions either disrupt school, work, or home life, or they take at least an hour of the patient’s time each day.
Obsessions are relentless, invasive thoughts, mental pictures, or impulses that cause significant disturbance and anxiety in most patients. Patients try to contain or tune out these thoughts, replace them with other thoughts, or offset them by acting out a compulsion.
Compulsions are repetitive physical (like hand washing, organizing, or checking) or mental (like counting or praying) actions. These people feel they must perform these actions either to quell an obsession or to follow a precise set of self-imposed rules. They do it to reduce their own anxiety or to ward off a feared event. In the second case, though, the actions do not have a logical association with avoiding the event in question.
Patients can have a wide range of levels of insight into their disorder, from full understanding that their thoughts and associations are illogical to the point of complete delusions. The vast majority of patients have good levels of insight; only 2-4% of patients have delusions.
Types of obsessions and compulsions
There are five general topics on which most obsessions and compulsions focus. One of the most well-known types is about symmetry and organization, where patients focus on counting and arranging objects. Another common topic is the fear of being dirty, which leads to compulsive cleaning of oneself and objects. Patients can also feel it is their duty to prevent negative events from happening to themselves and those around them. They can obsess over distressing, culturally taboo thoughts about sex, violence, or religious mores. Patients may also exhibit hoarding behaviors related to the obsessions, but this has to be differentiated from Hoarding Disorder.
Treating Obsessive-Compulsive Disorder
Both Cognitive Behavioral Therapy and medication therapy are considered possible first-line treatments by the American Psychiatric Association, given patient preference, the patient’s medical history, and any coexisting problems.
Cognitive Behavioral Therapy and exposure
The psychotherapy with the most supporting evidence and best response rates is CBT with Exposure and Ritual Prevention (EX/RP). CBT with EX/RP therapy is based on the idea that patients misunderstand non-threatening events to be dangerous and that therapists can use conditioning to help patients change these psychological patterns.
The key to this treatment is that patients experience the anxiety-provoking situations in a controlled environment, but they do not try to escape or perform any compulsive acts to quell their distress. Instead, they experience the distress and are ultimately confronted with the fact that their fears are unfounded. After weekly, hour-long sessions for two to four months, patients learn new, non-distressing responses to the previously feared situations.
CBT and medication
CBT is especially helpful for patients in whom medication alone is unsuccessful. In this population specifically, the strategy of combination of CBT and antidepressants increases response rates two to four times compared to patients on medication-only treatment. However, when all OCD patients are taken into account, this benefit largely disappears, and CBT with EX/RP is superior to medication – be it clomipramine or SSRIs – and equal to CBT with EX/RP plus medication.
The American Psychiatric Association considers all selective serotonin reuptake inhibitors (SSRIs) to be equally effective in treating OCD. The Food and Drug Administration has approved the SSRIs, Prozac (fluoxetine), Luvox (fluvoxamine), Paxil (paroxetine), and Zoloft (sertraline), and the older, tricyclic antidepressant, Anafranil (clomipramine), to treat OCD.
The antipsychotic Risperdal (risperidone) is helpful in cases of coexisting OCD and Tic Disorder. A few small studies have demonstrated that administration of D-cycloserine 2 hours before CBT sessions decreases the time required before patients saw a response to therapy.
Managing Obsessive-Compulsive Disorder
Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections
PANDAS is a disorder where the immune system confuses human brain cells with an infection and, in fighting the infection, also causes psychiatric issues. It can bring on obsessive compulsive symptoms, ADHD symptoms, separation anxiety, mood instability, trouble sleeping, motor skills alterations, and joint pains. As soon as the episode is diagnosed, the streptococcal infection should be treated with an appropriate course of antibiotics. For the psychiatric consequences, standard treatment is appropriate except that SSRI medication doses should be started lower than normal and raised slowly because these patients are especially sensitive to side effects.
Managing severe cases
Although 70% of patients benefit from either medication or CBT with EX/RP, 50.6% of patients have “severe” OCD. These cases have associated suicide attempts, inability to work, psychosis, or substance use disorders. Half of OCD patients contemplate suicide, and a quarter attempt it.
These patients are more likely to be in the minority who do not see much benefit with the first line treatments. These cases may be suited to more intensive treatment that can only be offered at day programs (several hours of daily treatment, five days a week), residential programs (patients live in an unlocked facility and receive treatment there), or inpatient programs (locked psychiatric hospital units).
Resources for friends and family
If a patient does not want treatment, family members, especially those who live with the patient, should seek the help of support groups. These are available online or in person and help participants to learn strategies to deal with the affected relative and not to enable the disorder.
Spotting the disorder in kids
Compulsions, which are usually obvious to observers, are much more easily diagnosed in children than obsessions, which children often have difficulty articulating. However, children are just as likely to have both obsessions and compulsions as adults are, and a clinician with pediatric experience will help elucidate the whole picture.