Obsessive-Compulsive Disorder

September 20, 2011

Obsessions and compulsions are fairly common mental phenomena that most people have experienced, but they can become severe enough to interfere with one’s functioning. At this point they are known as a disorder. Obsessions are repeated intrusive thoughts, usually unwelcome to the thinker, and may include ideas of a harmful, violent, sexual, or religious nature. Frequently the ideas are not those the individual can accept and they cause anxiety or tension. They may relate to contamination or the fear that something terrible will happen if the person does not perform perfectly some act that will take away the idea. These acts are called rituals. Compulsions are behaviors or thoughts that must be done in order to undo the terrible ideas. They may include frequent hand washing, saying certain numbers, checking the stove or windows and doors, arranging furniture or objects in a certain way, cleaning, hoarding, or other acts. Individuals who suffer from these conditions know that the obsessions and compulsions are not real, but they cannot refrain from experiencing them and they can consume a considerable amount of time taken from ordinary life.

Obsessions and compulsions must be distinguished from excessive worrying about real-life events and often there is a fine line between them. Adults usually have some insight into the realization that the ideas and behaviors are excessive, while children may not. Often these disorders occur along with other psychiatric problems such as major depressive illnesses, anxiety disorders such as phobias or posttraumatic stress disorders, and drug and alcohol abuse. Often people experiencing these disorders have obsessive-compulsive personalities that have been very helpful in organizing their lives and have contributed to their successful management of difficult situations, but the disorder becomes sufficient to meet the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition of the American Psychiatric Association. The definition in this book requires that for the diagnosis, the person must experience the obsessions and compulsions for at least over 1 hour a day and that they interfere with functioning such as work, school, social relationships, and self-care. It is important to find out that they are not due to the use of drugs or alcohol, or due to another medical condition. It is also important to distinguish them from the delusions of a psychotic condition such as is noted in schizophrenia, the manic thoughts in bipolar disease, or the excessive preoccupation with food and body image in eating disorders. Certain other preoccupations with body image are also distinguished from this. Sometimes it is hard to tell the difference between delusions and obsessions and compulsions or specific phobias, but careful discussion with a trained mental health professional can clarify this, which is important because of treatment considerations.

CAUSES

The exact causes of obsessive-compulsive disorders (OCDs) are not known at this time, although extensive research is being done. Special interest has been in the genetics of the disease. In some cases a family history can be found and studies show an autosomal dominant mode of inheritance with incomplete penetrance. In some cases there is an association with Tourette’s syndrome (a disorder in which individuals experience involuntary tics among other symptoms). Certain brain pathways and structures are affected including the orbitofrontal cortex, the caudate nucleus, and the cingulate cortex. There is a disturbance in the function of serotonin transmission in the orbital cortex and caudate nucleus. Recent research has suggested some cases may be due to autoimmune problems such as infection with betahemolytic streptococcal infection in children. Brain imaging techniques have helped greatly in clarifying more of these causes.

COURSE

While the mean onset of this disorder is usually between ages 20 and 24, many cases occur in childhood or adolescence and some later in life, though usually before age 35. Men and women have similar prevalence rates of obsessive-compulsive disorder, although men seem to have an earlier age of onset. The disorder starts often after a very stressful life event, but for women it may very well begin or be exacerbated during or after a pregnancy. Women are often very loathe to tell their doctors or midwives about their condition because it may include ideas about harming their babies. They know that they would not hurt them but their fears are major. They are usually relieved when a knowledgeable trained person can help. They are to be distinguished from women who are psychotic with delusional ideas about harming themselves or their fetuses and babies. Women tend to have depression associated with obsessive-compulsive disorder more than men and the depression may resolve while the obsessive-compulsive disorder persists. Gender differences in the expression of the disorder include the finding that women tend to have more hand washing rituals while men tend to have more checking rituals. Men seem to be more treatment resistant. Many individuals may keep their symptoms secret so there is often a long lag between onset and presentation of the troublesome symptoms to the attention of any professional person. Onset often happens after a very stressful life event or frequently during or after a pregnancy in women.

Treatment usually requires the integration of a few different types of therapies. These include behavioral therapy, use of serotonin reuptake inhibitor drugs such as fluoxetine (Prozac) or sertraline (Zoloft), other antidepressant or antianxiety medications, and making sure that all helpful approaches are used. Behavioral therapies include exposing the person to the feared objects or situation and trying to help the person resist the ritual. This is often called exposure therapy. In the most difficult cases neurosurgery has occasionally been used. There have been tremendous advances in this area in the past 30 years. Treatment has improved, as we understand more of the underlying neurobiological and psychosocial causes.

SEE ALSO: Anxiety disorders, Depression

Suggested Reading

  • Sadock, J. B., & Sadock, V. S. (2000). Comprehensive textbook of psychiatry (7th ed.). Philadelphia: Lippincott, Williams & Wilkins.

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