Obsessive–compulsive disorder

For other things named "OCD", see OCD (disambiguation). For other types of "obsession", see obsession (disambiguation). For other types of "compulsion", see compulsion (disambiguation).

Obsessive-compulsive disorder (OCD) is a brain disorder, and more specifically, an anxiety disorder. OCD is manifested in a variety of forms, but is most commonly characterized by a subject's obsessive drive to perform a particular task or set of tasks, compulsions commonly termed rituals.

OCD should also be distinguished from the similarly named but notably different obsessive-compulsive personality disorder, which psychiatric guidelines define as a personality characteristic rather than an anxiety disorder.

The phrase "obsessive-compulsive" has worked its way into the wider English lexicon, and is often used in an offhand sense to describe someone who is meticulous or absorbed in a cause. Such casual references should not be confused with obsessive-compulsive disorder. It is also important to distinguish OCD from other types of anxiety, including the routine tension and stress that appear throughout life. A person who shows signs of infatuation or fixation with a subject, or displays traits such as perfectionism, is not necessarily stricken with OCD, a specific and well-defined disorder.

Symptoms and prevalence

Modern research has revealed that OCD is much more common than previously thought. An estimated two to three percent of the population of the United States is thought to have OCD or display OCD-like symptoms. Because of the condition's personal nature, and the lingering stigma that surrounds it, there may be many unaccounted OCD sufferers, and the above percentages could be even higher.

The typical OCD sufferer performs tasks (or compulsions) to seek relief from obsessions. To others, these tasks may appear simple and unnecessary. But for the sufferer, such tasks can feel critically important, and must be performed in particular ways for fear of dire consequences and to stop the stress build up. Examples of these tasks: repeatedly checking that one's parked car has been locked before leaving it; turning lights on and off a set number of times before exiting a room; repeatedly washing hands at regular intervals throughout the day.

OCD rituals are often bound up with intricate detail — detail that may seem arbitrary to outsiders. A smoker with OCD, for instance, may argue with herself that quitting cigarettes is possible only on the 13th or 27th of a month, and only when she has possession of four cigarettes at noon.

Obsessions are thoughts and ideas that the sufferer cannot stop thinking about. Common OCD obsessions include fears of acquiring disease, getting hurt or causing harm to someone. Obsessions are typically automatic, frequent, distressing, and difficult to control or put an end to by themselves. A sufferer will almost always obsess over something which he or she is most afraid of. People with OCD who obsess over hurting themselves or others are actually less likely to do so than the average person.

Compulsions refer to actions that the person performs, usually repeatedly, in an attempt to make the obsession go away. For an OCD sufferer who obsesses about germs or contamination, for example, these compulsions often involve repeated cleansing or meticulous avoidance of trash and mess. Most of the time the actions become so regular that it is not a noticeable problem. Common compulsions include excessive washing and cleaning; checking; hoarding; repetitive actions such as touching, counting, arranging and ordering; and other ritualistic behaviors that the person feels will lessen the chances of provoking an obsession. Compulsions can be observable — washing, for instance — but they can also be mental rituals such as repeating words or phrases, or counting.

Most OCD sufferers are aware that such thoughts and behavior are not rational, but feel bound to comply with them to fend off fears of panic or dread. Because sufferers are consciously aware of this irrationality but feel helpless to push it away, OCD is often regarded as one of the most vexing and frustrating of the major anxiety disorders.

Other people with OCD are not aware of anything abnormal with them; they will readily explain why their actions are rational, and it is usually impossible to convince them otherwise. This form of OCD resembles delusional disorder. Eventually their obsessions will become so severe they need help to overcome what began as an irritating, time wasting problem. It should be noted that not all people in this category necessarily have any desire to perform their actions; they may simply feel they are necessary as an onerous duty. For example, a compulsive checker may argue that, although they have a memory of having previously performed the check, that memory - or the check - may be in error and asserting that it is not would be irrational, since everybody makes mistakes sometimes.

Equally frequently, these rationalisations do not apply to the overall behaviour, but to each instance individually, as in addiction: for example, a person compulsively checking their front door may argue that the time taken and stress causes by one more check of the front door is considerably less than the time and stress associated with being burgled, and thus the check is the better option. In practice, after that check, the compulsive is still not sure, and it is still better in terms of time and stress to do one more check, and this reasoning can continue as long as necessary. And again, the compulsive may be aware that they are engaging in circular reasoning, but argue that this does not alter the fact that each and every check is rationally justified ("just because checking again won't make me feel sure, doesn't mean that the house is definitely safe now")

Not all OCD sufferers engage in compulsive behavior. Recent years have seen increased diagnoses of Pure Obsessional OCD, or "Pure O." This form of OCD is manifested entirely within the mind, and involves obsessive ruminations triggered by certain thoughts. These mental "snags" can be debilitating, often tying up a sufferer for hours at a time. At this writing (2004), Pure O is considered the trickiest form of OCD to treat, though headway continues to be made by specialists such as Dr. Steven Phillipson [1].

OCD is different from behaviors such as gambling addiction and overeating. People with these disorders typically experience at least some pleasure from their activity; OCD sufferers do not actively want to perform their compulsive tasks, and experience no tangible pleasure in doing so.

OCD is placed in the anxiety class of mental illness, but like many chronic stress disorders it can lead to depression over time. The constant stress of the condition can cause sufferers to develop a deadening of spirit, a numbing frustration, or sense of hopelessness. OCD's effects on day-to-day life — particularly its substantial consumption of time — can produce difficulties with work, finances and relationships.

Causes and related disorders

Recent research has revealed a possible genetic mutation that could be the cause of OCD. Researchers funded by the National Institutes of Health have found a mutation in the human serotonin transporter gene, hSERT, in unrelated families with OCD.

Violence is rare among OCD sufferers, but the disorder is often debilitating to the quality of life. Also, the psychological self-awareness of the irrationality of the disorder can be painful. For people with severe OCD, it may take several hours a day to carry out the compulsive acts. To avoid perceived obsession triggers, they also often avoid certain situations or places altogether.

Some people with OCD also suffer from conditions such as Tourette syndrome, attention deficit disorder, trichotillomania and hypochondria. Other minor side problems that come along with these disorders are scratching, picking, and nail biting.

Some cases are thought to be caused at least in part by childhood streptococcal infections and are termed PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcus). The streptococcal antibodies become involved in an autoimmune process.

OCD in men at least may be partially caused by low oestrogen levels (external link about this is below).

Treatment

OCD can be treated with behavioral therapy (BT) or Cognitive therapy (CBT) and with a variety of medications. According to the Expert Consensus Guidelines for the Treatment of Obsessive-Compulsive Disorder (Journal of Clinical Psychiatry, 1995, Vol. 54, supplement 4), the treatment of choice for most OCD is behavior therapy or cognitive behavior therapy. Medications can help make the treatment go faster and easier, but most experts regard BT/CBT as clearly the best choice. Medications generally do not produce as much symptom control as BT/CBT, and symptoms invariably return if the medication is ever stopped.

The specific technique used in BT/CBT is called Exposure and Ritual Prevention (also known as Exposure and Response Prevention) or ERP; this involves gradually learning to tolerate the anxiety associated with not performing the ritual behavior. At first, for example, someone might touch something only very mildly "contaminated" (such as a tissue that has been touched by another tissue that has been touched by the end of a toothpick that has touched a book that came from a "contaminated" location, such as a school). That is the "exposure." The "ritual prevention" is not washing. Another example might be leaving the house and checking the lock only once (exposure) without going back and checking again (ritual prevention). The person fairly quickly habituates to the (formerly) anxiety-producing situation and discovers that their anxiety level has dropped considerably; they can then progress to touching something more "contaminated" or not checking the lock at all — again, without performing the ritual behavior of washing or checking.

Medication treatments include selective serotonin reuptake inhibitors such as paroxetine (Paxil, Aropax), sertraline (Zoloft), fluoxetine (Prozac), and fluvoxamine (Luvox) as well as the tricyclic antidepressants, and in particular clomipramine (Anafranil). Some medications like Gabapentin have also been found to be useful in the treatment of OCD. Symptoms tend to return, however, once the drugs are discontinued.

Recent research has found increasing evidence that opioids may significantly reduce OCD symptoms, though the addictive property of these drugs likely stands as an obstacle to their sanctioned approval for OCD treatment. Anecdotal reports suggest that some OCD sufferers have successfully self-medicated with opioids such as Ultram and Vicodin, though the off-label use of such painkillers is not encouraged, again because of their addictive qualities.

Hallucinogens, such as psilocybin (an active ingredient in "magic mushrooms") and LSD, have also shown promise — reducing symptoms for up to several months after ingestion in some people. The US FDA has approved a study to determine their effectiveness that is being conducted at the University of Arizona.

OCD in literature and film

The media's portrayal of OCD sufferers as eccentric and overtly neurotic is a contributing factor in the continuting public misconception of the disorder. Contrary to popular belief, however, OCD sufferers will rarely exhibit their compulsive behaviours in public, and are often very adept at hiding or camouflaging their rituals. To the outside observer, the person with OCD will often seem completely normal. In fact, the more visible traits of OCD are actually ones that are encouraged and even admired in society, such as perfectionism, attention to detail, and cleanliness. The popular media rarely portrays sufferers as how they truely are - locked in a debilitating cycle of meaningless rituals that they feel compelled to perform despite recognizing their senselessness.

Justin Green's 1972 comic book Binky Brown Meets the Holy Virgin Mary was based on the artist's childhood experience of what was later diagnosed as OCD. Green suffered from arranging, cleansing, and avoidance compulsions related to intrusive religious and sexual fears.

The science fiction novel Xenocide by Orson Scott Card portrays a planet on which people with a form of OCD are revered as religious figures.

Richard Briers' character Martin Bryce from the sitcom Ever Decreasing Circles was cleary sufferring from advanced OCD and this manifested itself in organising all the local events, societies and charities of The Close. His home and daily routines also had to be spotless. One running gag was the repetitive straightening of the telephone cable, a trait which he eventually passed on to his wife.

Adrian Monk (played by Tony Shalhoub), the title character of the American television series Monk, is a detective whose OCD is alternatively beneficial and detrimental to his line of work.

The 1997 film As Good as it Gets starred Jack Nicholson as a theoretically obsessive-compulsive author. Nicholson received an Oscar for the performance. The film is notorious for its unrealistic, Hollywood portrayal of OCD symptoms.

In the book series Everworld, Jalil Sherman's OCD is particularly painful, as his mind is otherwise rigidly bound to science and logic. It also serves as the basis for his connection to Senna.

The 2003 film Matchstick Men featured Nicolas Cage as a con artist suffering from OCD-style symptoms.

The 2004 book by Steve Martin, The Pleasure of my Company is told from the point of view of a juvenile but charming mathematical genius with OCD.

The 2004 film The Aviator starred Leonardo DiCaprio as reclusive genius Howard Hughes, who was believed to have suffered from OCD.

In the 2005 film Elektra, the title character (played by Jennifer Garner) suffers from OCD, despite her own claims not to.

In the TV show Joey, Joey Tribbiani's executive producer, Lauren (played by Lucy Liu), suffers from OCD. She goes crazy when she thinks she left her oven on and when someone knocks, Lauren has to knock on something.

In the TV show Desperate Housewives, Bree Van De Kamp (played by Marcia Cross), suffers from OCD. She is highly sensitive about objects being in order (as well as her emotional life).

The Riddler, a DC Comics supervillain, is portrayed as having OCD in most modern interpretations. He is unable to commit a crime without sending a riddle to either the Gotham police force or Batman that reveals the crime's nuances. Ironically, most of the crimes would be unsolvable if not for the riddles he sends.

Episodes twelve and thirteen of season three of the TV series Scrubs featured a guest character played by Michael J. Fox that suffered from OCD. This is particularly interesting because Michael J. Fox was, only a few years prior, diagnosed with Parkinson's disease.

Famous/celebrity OCD sufferers

These figures have either publicly talked about their OCD, or otherwise been identified with the disorder:

References

The Boy Who Couldn't Stop Washing, ISBN 0451172027, by Judith L. Rapoport. A highly readable introduction to OCD, with case histories.
Edna B. Foa & Reid Wilson, Stop Obsessing! How To Overcome Your Obsessions And Compulsions, Bantam Books, 1st Edition (July 2001), ISBN 0553381172. A self-help text for OCD patients, clear, precise and practical.

Books on OCD

The Mind and the Brain : Neuroplasticity and the Power of Mental Force[2] by Jeffrey M. Schwartz, Sharon Begley.
Brain Lock : Free Yourself from Obsessive-Compulsive Behavior[3] by Jeffrey M. Schwartz.

External links