What is OCD?
Obsessive-Compulsive Disorder (OCD) is a chronic mental disorder that manifests as obsessive thoughts that cause distress in the sufferer and compulsions to perform certain behaviors to lessen the anxiety caused by the obsessive thoughts. Although obsessions and compulsions are everyday experiences even for people who don’t have OCD, the thoughts and behaviors in diagnosed cases of OCD rise to a level of severity that is disruptive to the daily life of the sufferer.
People with OCD may experience either obsessions or compulsions or experience both at the same time in an irresistible cycle of behaviors.
The obsessive thoughts experienced by OCD sufferers are more than mere repetitive ideas or notions. They may be full-fledged thoughts, or they may be relatively simple mental images or urges that occur repeatedly, and sufferers feel as if they have no control over when the obsessions begin or end.
Obsessions often bring negative feelings with them, including fear, doubt, or disgust. They may be accompanied by the feeling that only doing things a certain way will make the negative emotions go away. OCD sufferers often understand that their obsessive thoughts are not rational, but they remain powerless to stop the obsessions. As a result, the obsessions and their effects become disruptive to the person’s daily functioning.
Common OCD obsessions include:
- Fear of contamination by germs, chemicals, dirt, or other contaminants
- Unwanted sexual thoughts, often about taboo or prohibited sexual behavior
- Fear of doing something harmful to yourself or others, or being responsible for harm coming to someone
- Obsession with doing things perfectly, or a fear of being imperfect
- Obsession with following religious or moral rules
Again, the compulsions experienced by people with OCD differ from the common ritualistic or habitual behaviors that most people engage in. For OCD sufferers, compulsions are behaviors that provide some relief from the negative feelings brought about by obsessions, and the sufferer indulges in the compulsion to feel better, if only for a short time. Sometimes compulsive behaviors are rituals meant to avoid the situation that produces the obsession in the first place.
As is the case with obsessions, OCD sufferers are typically aware that their compulsive behaviors are not rational. Still, because they produce some relief from the anxiety produced by these obsessions, the compulsions are tolerated. The person with OCD likely would prefer not to be driven by the compulsion, but there seems to be no other way out.
Common OCD compulsions include:
- Excessive cleanliness, including repeated handwashing, bathing, or housecleaning
- Repetitive checking to be sure that you haven’t harmed yourself or others
- Repeating or redoing actions over and over, or repeating actions (such as tapping or touching an object) a particular number of times
- Mentally constructing thoughts in a particular way (such as counting while doing something) as a ritual to prevent harm from coming to anyone.
- Arranging or ordering objects obsessively
What Causes OCD?
Doctors and researchers have not yet determined the exact causes of OCD, but they have identified several risk factors that increase an individual’s likelihood of developing the disorder.
- Genetic Predisposition. Studies of families in which OCD is present, including studies of identical twins, suggest that there may be a genetic component that is a risk factor for the disorder. Having a parent, sibling, or child who has been diagnosed with OCD increases the chance that you will also be diagnosed with the condition. Researchers have made some progress in identifying the genes that may play a role in developing OCD, but more research is necessary to determine the precise genetic connections.
- Neurological Causes. Some brain imaging research has noted differences in parts of the brain structure, including the frontal cortex and subcortical structures, between people who have OCD and those who don’t. However, how these differences may play a role in developing the disorder is not yet understood.
- Environmental Factors. Symptoms of OCD often first occur before adulthood, and they often seem to be triggered by stress. Research has shown a connection between a history of physical or sexual abuse in childhood and the development of OCD. Other childhood traumas may also be a risk factor for the development of the disorder.
- Bacterial Infections. Some children develop OCD, or symptoms consistent with OCD, after having had a streptococcal infection.
Is OCD Hereditary?
Researchers have long suspected that biological factors rather than environmental factors primarily cause OCD. Studies of families in which the disorder occurs strongly suggest that a genetic component may be responsible.
- One early study found that among patients who had been diagnosed with OCD, 37% of the parents of the patients and 21% of their siblings were also diagnosed with the disorder.
- Another study found that participants with OCD had a first-degree relative (a parent, child, or sibling) with the disorder, as compared to 1.9% in the case of participants without OCD.
- Studies have also found that having a first-degree relative who experienced the onset of OCD during childhood or adolescence increases the risk of developing the disorder.
How Is OCD Detected?
Because the onset of OCD often occurs in childhood or adolescence, detecting the early signs of the disorder often falls on parents. Pediatric OCD generally develops gradually over time, so spotting the earliest warning signs may be difficult. Eventually, the obsessive and compulsive symptoms will become so severe that they interfere with the child’s functioning, but they may be subtle at first.
OCD can first manifest at any age, but the most common age ranges for the development of pediatric OCD are in the pre-adolescent years (between the ages of 8 and 12) and the post-adolescent period between the late teens and early 20s.
Potential early signs of OCD include:
- Frequent worries about illness, germs, or death
- Frequent worries about being imperfect or doing things incorrectly
- Frequent worries about harming others
- Unwanted thoughts about sex
- Excessive washing or cleaning
- Excessive concerns about safety issues (e.g., whether the door is locked or the oven is turned off)
- Excessive need for reassurance or approval
- Repetitive actions or ritualistic behavior
- Excessive focus on religious or moral rules
- Excessive focus on “lucky” behaviors, numbers, or rituals
How Is OCD Diagnosed?
Diagnosis of OCD can be tricky, given that the disorder can sometimes appear similar to other physical or mental illnesses, and it may be coincident with additional conditions in the same patient. Proper diagnosis requires physical and psychiatric assessments, as well as observation and evaluation of current symptoms.
In general, a mental health professional will first determine if the patient is experiencing obsessive thoughts, if the obsessive thoughts are coincident with compulsive behaviors, and if the combination of obsessions and compulsions interferes with the patient’s typical daily functioning. If these criteria are met, there is reason to suspect that OCD is present.
Further diagnostic steps may include:
- A physical exam. This exam will focus on ruling out physical conditions that could be causing the symptoms.
- Blood tests. These tests will look at the patient’s blood chemistry for issues such as thyroid function. Screenings for drugs and alcohol may also be conducted to rule out symptoms possibly caused by substance abuse.
- Psychological assessments. These assessments may take the form of questionnaires or talk sessions with a mental health professional to assess the patient’s mood, mental state, and mental health history. Family members or caregivers may also be asked to participate in these assessments.
The psychological assessment results will be compared to the diagnostic criteria for OCD in the Diagnostic and Statistical Manual of Mental Disorders. Comparing these criteria will help a psychiatrist decide whether the symptoms indicate OCD or another psychiatric problem (such as obsessive-compulsive personality disorder, anxiety disorders, depression, and schizophrenia) whose symptoms sometimes look similar to those of OCD.
How Is OCD Treated?
OCD currently has no cure, but a combination of medications and psychotherapy has proven to be effective at reducing the severity of symptoms in many patients. In these patients, the impact of symptoms may be reduced to a level that minimizes their detrimental effect on daily functioning. Many sufferers, however, will need to continue treatment for the rest of their lives to manage their symptoms, and some patients may not respond to treatment at all.
Several different medications may be used to treat and manage the symptoms of OCD, and individual medication plans are dependent on the age of the patient, the patient’s responsiveness to treatments, and the severity of their symptoms.
- Antidepressants. These drugs are usually the medications that doctors try first as part of an overall treatment plan. Clomipramine is often prescribed to treat OCD symptoms in adults and children over the age of 10. Fluoxetine, fluvoxamine, and sertraline are sometimes prescribed for younger children, and paroxetine is typically only prescribed for adults.
- Antipsychotics. When OCD patients do not respond to treatment with antidepressants, doctors will sometimes prescribe an antipsychotic such as risperidone. The research into the effectiveness of these drugs in treating OCD is not yet conclusive.
- Other Medications. Because OCD sometimes is present alongside other mental disorders, medications to treat those disorders may also be part of a patient’s treatment plan.
While medications or psychotherapy are sometimes used alone in treating OCD, combining the two approaches is often most effective at lessening the symptoms’ severity. The most common therapeutic approach is cognitive-behavioral therapy (CBT). This process focuses on helping the patient identify a pattern of harmful thoughts and construct strategies and solutions for dealing with them that don’t interfere with functionality.
A more dynamic approach is exposure and response prevention (ERP) therapy. This is a type of CBT that involves gradually, and in a controlled way, exposing the patient to the triggers of their anxieties and compulsive behaviors and teaching them ways to cope with the triggers.
How Does OCD Progress?
The progression of OCD from the initial experience of obsessions and compulsions to a fully developed and disruptive manifestation of the disorder is usually a slow process over months or even years. Research has shown that several factors, such as the initial onset of symptoms and the amount of stress a sufferer experiences during the onset phase, seem to influence how the disorder progresses.
One study found that most participants experienced a slow progression of the disorder, with an average time of five years between the first signs of the condition and the development of full-blown OCD. A lengthy progression was consistent whether patients developed OCD early or late in life, but those with late-onset OCD tended to experience an even slower progression.
Slower progressions also seemed to be more common in women and people who experienced compulsions before they experienced obsessions.
In children who develop OCD symptoms in conjunction with a streptococcal infection, the progression may be very rapid.
How Is OCD Prevented?
OCD cannot be prevented, but early diagnosis and a consistent treatment plan can help manage symptoms and prevent them from becoming as disruptive as possible if left untreated. Faithful adherence to a treatment plan, especially if it’s working well, can also help to prevent a relapse into a state of severe symptoms. It’s essential for those diagnosed with OCD to seek regular evaluations from their mental health providers and stick to any prescribed medication plan.
OCD Caregiver Tips
One of the most important things that caregivers can do to support an OCD sufferer is educating themselves about the disorder. Education will help the caregiver identify what are symptoms of the disorder and what aren’t, understand what the sufferer is going through, and understand how they can (and can’t) help the sufferer.
Caregivers for someone with OCD should consider these tips to help the sufferer and themselves to cope with the disorder:
- First, learn as much as possible about the disorder.
- Seek out appropriate professional treatment for the sufferer.
- Do everything possible to support the sufferer in the pursuit of treatment.
- When a professional says it’s appropriate, disengage with the disorder by refusing to participate in rituals.
- Find ways to have positive experiences with the sufferer that don’t focus on the disorder.
- Find a support group for caregivers.
- Take time away from the sufferer when possible.
Many people with OCD also suffer from other brain and mental health-related issues, a condition called co-morbidity. Here are a few of the disorders commonly associated with OCD:
- At least a third of people with OCD also suffer from depression.
- About a quarter of people with bipolar disorder also have OCD.
- Many people with OCD also have some type of anxiety disorder, especially panic disorder.
- People with OCD are at increased risk of suicide, alcoholism, and substance use disorders.
- Personality disorders such as antisocial personality disorder and narcissistic personality disorder are more common in people with OCD.
- Schizophrenia is more common in people with OCD than in the general population.
OCD Brain Science
Researchers are currently working on studies with the goals of finding the causes of OCD (which could, in turn, lead to a cure), identifying the medications that work best to treat the disorder’s symptoms (and finding new medicines that are even more effective), and learning which therapies produce the best results in lessening the impact of symptoms.
Many studies on the genetic and neuroscience levels are being directed at the fundamental causes of the disorder:
- Researchers at Johns Hopkins University have identified particular chromosomes that seem to be connected to the development of OCD. They’ve found evidence that some of these chromosomal linkages are present in families with multiple members with the disorder. The team is continuing to look for specific genes that may be linked to the condition.
- Researchers are examining the effectiveness of deep brain stimulation (DBS) in OCD patients. This treatment involves inserting an electrode into a targeted part of the brain and delivering an electrical pulse to the area. The therapy has been used in patients with movement disorders, but it has shown promise in treating OCD resistant to other forms of treatment.
- A study comparing MRI images of the brains of people with OCD to those without the disorder has found areas of the brain that consistently appear to be different in OCD sufferers. The study found that the brain’s parietal lobe, which controls attention and planning, is often smaller in people with OCD.
Scientists are working on several research projects to expand on what is known about Obsessive-Compulsive Disorder (OCD). The research will improve knowledge about the factors that increase the risk for OCD and the causes and best treatments and aid people living with OCD and their caregivers.
Title: Brain Imaging for Individuals with OCD
Study Director: Helen Simpson, MD, PhD
Columbia University Department of Psychiatry
Additional Study Information:
The goal of the project is to identify brain signatures associated with obsessive-compulsive disorder (OCD) by comparing brain images of (1) individuals with OCD, (2) individuals without OCD, and (3) siblings of individuals with OCD. Eligible participants will be asked about their medical and psychiatric history, perform tasks on a computer, and receive a brain scan using Magnetic Resonance Imaging (MRI). The study requires one in-person visit and one assessment by telehealth. Participants will be compensated for their time and effort and may also be eligible for treatment (delivered via telehealth) at no cost with one of our OCD specialists.
Title: Brain Network Changes Accompanying and Predicting Responses to Pharmacotherapy
Yale School of Medicine – Department of Psychiatry
Additional Study Information:
Current treatments for OCD benefit about 60-70% of people, but many do not experience adequate relief. There is a need to identify predictors of treatment response. In this study, state-of-the-art neuroimaging will be used to identify predictors and correlates of response to a standard medication-based treatment for OCD. In clinical practice, this may aid proper treatment selection and improve outcomes. Identifying predictors of treatment response will also shed light on therapeutic change mechanisms and highlight potential targets for anatomically-based treatments, such as transcranial magnetic stimulation and neurofeedback.
This 18-week study is designed to examine whether brain scans can predict how well individuals will respond to standard medication treatment, and what changes in the brain over the course of treatment correspond to an improvement in symptoms. Participants will receive fluoxetine (also known as Prozac) and participate in a series of brain imaging and symptom assessments. Fluoxetine is a standard treatment for OCD, and has been approved by the U.S. FDA to treat OCD in both adults and children. Some participants will receive fluoxetine from the beginning of the study. Others will initially receive a placebo pill (which contains no active drug) for a period of time before beginning fluoxetine. Every participant will receive a proper trial of fluoxetine throughout this study. At the end of the study, participants can choose whether they wish to continue taking fluoxetine after consultation with study physicians and their own doctor.
This is a registered clinical trial (ClinicalTrials.gov identifier: NCT04131829)