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.
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.
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.
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
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.
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.
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.
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Rebecca J. Frey, PhD