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Obsessive-Compulsive Disorder

What is Obsessive Compulsive Disorder?

Obsessive-compulsive disorder is a mental health disorder defined by a combination of anxiety-causing thoughts and behaviors.

OCD disrupts an individual’s sense of well-being by acting like an overactive defense mechanism: under OCD, somewhat concerning stimuli (e.g. tracking dirt inside your house) can bring about a great deal of anxiety. This can lead the individual to focus their thoughts on the stressor that triggered their distress and try to calm themselves down by carrying out a certain pattern of behavior (e.g. washing their shoes). Unfortunately, OCD-related actions often end up doing the opposite (e.g. cleaning one’s shoes is perceived as having “infected” the rag you used to clean them with, your hands and overall body), thereby feeding your anxiety in a continuous loop.

Obsessive Thoughts

Though there are endless examples of OCD-related thoughts, the more common ones can be divided into four categories, appearing either on their own or together with one another:

  • Contamination or cleanliness concerns (e.g. picking up an illness from touching a door handle).
  • Worry over disaster striking (e.g. taking a different way to work may end up in a car accident).
  • A focus on symmetry, organization, counting, or “just right” thinking (e.g. folding and refolding your laundry until every item is “perfectly” neat).
    Taboo or “immoral” thoughts and rituals (e.g. having a violent thought about causing harm to someone you care about).

OCD-related thoughts are experienced as unwanted, intrusive, and greatly distressing. They can severely impair an individual’s daily life and cause them a substantial amount of worry, guilt or frustration.

Compulsive Behavior

OCD-related compulsions are the actions the individual carries out in an effort to quell their rising anxiety. Despite this initial motivation, the compulsive behavior that arises ends up increasing the level of experienced anxiety, while also negatively affecting the individual’s physical, mental, social, and emotional well-being.

Examples of OCD-related compulsive behaviors are varied and may include constant hand-washing, repeatedly making sure your gas stove is safely turned off, rearranging your bookshelf to fit a perceived “ideal” order, or trying to dispel a distressing thought about a loved one falling in harm’s way by repeating the same hand gesture.

Such compulsive actions are performed to achieve a momentary relief, but in the long run fail to actually ward off obsessive thoughts. As they go through repeated, OCD-related behavior, many individuals start contending with self-doubt: did they really turn off the lights four times as they meant to do, or did they miss one? Did they remember to wash both of their thumbs, or not? To be on the safe side, they repeat their action once more, and then again, until they can be sure they have carried it out flawlessly. Such actions quickly become an exhausting, energy-depleting and extremely frustrating ritual, all without alleviating the OCD-related anxiety that triggered them.

Insight and Tic Disorder Specifiers

In addition to noting symptoms of obsessive thoughts and compulsive behaviors, an OCD diagnosis includes two specifiers: assessing the individual’s level of insight into their condition, and whether they also have a tic disorder. A patient’s insight attests to how aware they are that they are suffering from OCD, with the vast majority of patients—over 96%—falling between “good or fair insight” to “poor insight.” In fact, many OCD sufferers may rationalize their thoughts or behavior as personality quirks, unworthy of diagnosis or treatment. The existence of a tic disorder, referring to sudden involuntary twitches, movements, or sounds that are performed repeatedly, is also considered, since over 30% of individuals with OCD also face a tic disorder.

OCD-Related Disorders

Obsessive compulsive disorder is actually included among a range of what is referred to in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (or DSM-V) as OCD-related disorders, which are also known as OCD-spectrum disorders. The conditions in this group include disorders that, like OCD, involve an obsessive thought pattern combined with an unwanted action or ceremony intended to ward off feelings of anxiety.

OCD-related disorders include the following:

Body dysmorphic disorder: A preoccupation with a perceived or minor physical flaw, body dysmorphic disorder causes the individual to carry out repeated actions (e.g. looking in the mirror) or mental acts (e.g. comparing their appearance to others’).  Individuals with this condition will often seek out numerous cosmetic procedures to try to improve their perceived physical flaw.  While many of the symptoms are similar to those of eating disorders, patients diagnosed with BDD does not necessarily involve considerations of eating or weight.

Hoarding: A difficulty throwing away or parting with physical items, regardless of their actual value, due to a strong perceived need to save them and feelings of distress at the thought of discarding them.  Hoarders often have little insight into the severity of their condition, even when their home is no longer a livable space and social or family relationships are damaged.

Excoriation: Characterized by picking one’s skin to remove perceived or actual small irregularities, leading to skin lesions.

Trichotillomania: Defined by repeatedly pulling out of one’s hair, which may result in eventual hair loss.

Substance/Medication-Induced Obsessive-Compulsive and Related Disorder: Consists of obsessive-compulsive symptoms that are due to substance intoxication, withdrawal or relating to medication.

Obsessive Compulsive and Related Disorder Due to Another Medical Condition: Obsessive compulsive symptoms linked to OCD and related disorders that do not amount to an official diagnosis.

While not an OCD-related disorder, PANDAS, or Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections, are a group of conditions unique to children, in which OCD or a tic disorder suddenly develops or becomes exacerbated following strep throat or scarlet fever.

Prognosis and Epidemiology

2.3% of US adults and 1%-2.3% of US children and adolescents will contend with OCD. These statistics do not include the many individuals who face subclinical OCD, due to not meeting the requirements for an official OCD diagnosis.

OCD can develop at any age, with symptoms commonly appearing between the age of ten and early adulthood. Despite this, on average patients are only diagnosed and begin receiving treatment from ages 14-17. This is because OCD can be challenging to diagnose, and can often be rationalized as a personal eccentricity, rather than an official mental health condition.

OCD Medication Treatment: Efficacy Counterbalanced by Side Effects

Several psychiatric medications have been shown to offer symptom relief for patients with OCD. Five types of medication have been FDA-approved to treat this condition. Out of the five medications FDA-approved for treating OCD, four are selective serotonin reuptake inhibitors (SSRIs) and one is from the tricyclics (TCA) family.

Though many patients report a reduction in symptom severity and frequency when taking them, OCD medications have also been known to cause possible side effects.

SSRIs: Selective serotonin reuptake inhibitors are presently considered to be a first-line obsessive-compulsive disorder treatment, in addition to cognitive behavioral treatment (CBT). The medications included in this family keep the neurotransmitter serotonin active for a longer time, which increases its efficacy.  Current FDA-approved SSRIs for OCD include sertraline (Zoloft), fluoxetine (Prozac), fluvoxamine (Luvox) and paroxetine (Paxil).

SSRIs are more commonly known as antidepressants, and are also a very popular treatment for major depressive disorder. However, SSRIs and in fact all antidepressants are also considered anxiolytics, due to their ability to inhibit anxiety, in addition to depression. Since OCD is an anxiety-centered disorder, SSRIs were eventually found to help alleviate OCD symptoms, as well.

But while SSRIs are considered effective and relatively well-tolerated, some patients find their accompanying side effects to be adverse, and discontinue treatment as a result. Weight gain, nausea and sexual dysfunction are among their more common side effects.

In addition, 40%-60% of patients with OCD show little-to-no symptom improvement from first-line medication. As a result, many patients continue searching for a treatment option that works for them.

Clomipramine: The tricyclic medication clomipramine is considered a second-line treatment for OCD, and was more frequently prescribed to treat this condition during the ‘80s. This medication works to prevent the reuptake process of both serotonin and norepinephrine. Due to its more severe side effects, these days clomipramine is less frequently prescribed.