Obsessive–compulsive disorder

Obsessive–compulsive disorder
Obsessive–compulsive disorder
Specialty	Psychiatry, psychology

For other uses, see OCD (disambiguation), obsession (disambiguation) or compulsion (disambiguation).

Obsessive-compulsive disorder (OCD) is a psychiatric disorder, 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; see clinomorphism. 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/object, or displays traits such as perfectionism, is not necessarily suffering from 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-for OCD sufferers, and the actual 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. Smokers with OCD, for instance, may argue with themselves that quitting cigarettes is possible only on the 13th or 27th of a month, and only when they are in possession of four cigarettes at noon.

Another symptom of the disease is fear of contamination, some suffers may fear the presence of human body secretion such as saliva,sweat, tears or mucus, or excretions such as urine or feces. Some OCD suffers even fear the soap they're using is contaminated.(Source)

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. 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.

People who suffer from the separate and unrelated condition obsessive compulsive personality disorder 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. People who suffer with OCPD tend to derive pleasure from their obsessions or compulsions. Those with OCD do not derive pleasure but are ridden with anxiety. This is a significant difference between these disorders.

Equally frequently, these rationalisations do not apply to the overall behavior, but to each instance individually; for example, a person compulsively checking their front door may argue that the time taken and stress caused by one more check of the front door is considerably less than the time and stress associated with being robbed, and thus the check is the better option. In practice, after that check, the individual 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.

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. As of 2004, headway continues to be made by specialists. It is believed by many that Pure O OCD is in fact more prevalent than other types of OCD, although it is likely the most underreported as it is not visibly apparent, and sufferers tend to suffer in silence. In Pure O, the sufferer tries to "disprove" the anxious thoughts through logic and reasoning, yet in doing so becomes further entrapped by the obsessions. Pure O OCD is thought to be the most difficult form of OCD to treat.

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.

However, some people still maintain successful careers and relationships as many do find they can hide or suppress their obsessive-compulsive behaviour due to feeling unnecessarily ashamed of this debilitating disorder.

The illness ranges widely in severity.

Causes and related disorders

There are many different theories about the cause of obsessive compulsive disorder. Some research has discovered a type of size abnormality in different brain structures. The majority of researchers believe that there is some type of abnormality in the neurotransmitter serotonin, among other possible psychological or biological abnormalities; however, it is possible that this activity is the brain's response to OCD, and not its cause.

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.

A popular explanation for OCD is that offered in the book 'Brain Lock', which suggests that OCD is caused by the part of the brain that is responsible for translating complex intentions (e.g., "I will pick up this cup") into fundamental actions (e.g., "move arm forward, rotate hand 15 degrees, etc.") failing to correctly communicate the chemical message that an action has been completed. This is perceived as a feeling of doubt and incompleteness which then leads the individual to attempt to consciously deconstruct their own prior behavior - a process which induces anxiety in most people, even those without OCD.

Violence is rare among OCD sufferers, but the disorder is often debilitating and detrimental to their 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.

Sufferers are generally of above-average intelligence, as the very nature of the disorder necessitates complicated thinking patterns.

Some people with OCD also suffer from conditions such as Tourette's syndrome, compulsive skin picking, body dysmorphic disorder and trichotillomania. It is also interesting to note that there is some research demonstrating a link between drug addiction and obsessive compulsive disorder as well. There is a higher risk of drug addiction among those with any anxiety disorder (possibly as a way of coping with the heightened levels of anxiety), but drug addiction among obsessive compulsive patients may serve as a type of compulsive behavior and not just as a coping mechanism. Depression is also extremely prevalent among sufferers of OCD. One idea for the high depression rate among OCD populations was posited by Mineka, Watson and Clark (1998), who explained that people with OCD (or any other anxiety disorder for that matter) may feel depressed because of an "out of control" type of feeling.

Some cases are thought to be caused at least in part by childhood streptococcal infections and are termed P.A.N.D.A.S (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.

Pharmacologic treatments include selective serotonin reuptake inhibitors such as paroxetine (Paxil, Aropax), sertraline (Zoloft), fluoxetine (Prozac), and fluvoxamine (Luvox) as well as the tricyclic antidepressants, in particular clomipramine (Anafranil). Other medications like gabapentin (Neurontin), lamotrigine (Lamictal), and the newer atypical antipsychotics olanzapine (Zyprexa) and risperidone (Risperdal) have also been found to be useful as adjuncts in the treatment of OCD. Symptoms tend to return, however, once the drugs are discontinued.

The naturally occurring sugar inositol has been found in double-blind studies to be an effective treatment for obsessive-compulsive disorder (OCD). It is equal in effectiveness to SSRI's and is virtually free from side effects. (Source: a summary of research on inositol in treatment of OCD can be found at http://www.standardprocess.com/lit/monographs/InositolL9005.pdf#search='inositol%20OCD')

Research performed by the Research Group for Mind-Body Dynamics, Institute for Nonlinear Science, University of California, San Diego, indicates that a particular type of yogic breathing may be an effective treatment for OCD. See references here: http://www.theinternetyogi.com/html/publications.html

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 in some people. There is an ongoing US FDA-approved study being conducted at the University of Arizona to determine their effectiveness.

Studies have also been done that show nutrition deficiencies may also be a probable cause for OCD and other mental disorders. Certain vitamin and mineral supplements such as EM Power Plus aid in such disorders and provide the nutrients necessary for proper mental functioning.

Neuropsychiatry

OCD primarily involves the brain regions of the striatum and the cingulate cortex, especially the striatum. OCD involves several different receptors, mostly H2, M4, nk1, NMDA, and non-NMDA glutamate receptors. The receptors 5-HT1D, 5-HT2C, and the mu opioid receptor exert a secondary effect. The H2, M4, nk1, and non-NMDA glutamate receptors are active in the striatum, whereas the NMDA receptors are active in the cingulate cortex.

The activity of certain receptors is positively correlated to the severity of OCD, whereas the activity of certain other receptors is negatively correlated to the severity of OCD. Those correlations are as follows:

activity positively correlated to severity:

H2
M4
nk1
non-NMDA glutamate receptors

activity negatively correlated to severity:

NMDA
mu opioid
5-HT1D
5-HT2C

The central dysfunction of OCD involves the receptors nk1, non-NMDA glutamate receptors, and NMDA, whereas the other receptors exert secondary modulatory effects.

Pharmaceuticals that act directly on those core mechanisms are aprepitant (nk1 antagonist), riluzole (glutamate release inhibitor), and tautomycin (NMDA receptor sensitizer). The drugs that are popularly used to fight OCD lack efficacy because they do not act upon the core mechanisms.

OCD in literature and film

The media's portrayal of OCD sufferers as eccentric and overtly neurotic is a contributing factor in the continuing public misconception of the disorder. Contrary to popular belief, OCD sufferers will rarely exhibit their compulsive behaviours in public, often becoming 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 truly are — locked in a debilitating cycle of meaningless rituals that they feel compelled to perform despite recognizing their senselessness.

Rosalie, in Takin' Over the Asylum, has an OCD about cleanliness.
In Alfred Hitchcock's Vertigo, Scottie (played by James Stewart) seems to show the OCD characteristics of inflexibility; preoccupation with details, rules, and lists; reluctance to allow others to do things; and restrictive expression of affection in the scenes when he remakes Judy (played by Kim Novak) into Elster's wife, Madeline.
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 Children of the Mind 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 clearly suffering from advanced OCD and this manifested itself in organizing 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.
Matthew Roman (played by Matthew Lawrence), the character of Brotherly Love thinks he has OCD, but it remains false and a running joke. (His character somewhat looks like a happy maniac when he thinks he has OCD)
In "A Plague of Tics", the second chapter of his 1997 memoir Naked, humorist David Sedaris describes the tragicomic impact of OCD on his childhood. Sedaris's other works make passing references to the disorder.
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 has been criticized 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 (among other more serious conditions).
In the 2005 film Elektra, the title character (played by Jennifer Garner) is said to suffer from OCD, despite her own claims not to. The film itself makes almost no physical reference to this fact, other than a scene in which Elektra is shown to be cleaning a floor as a "compulsion" and a scene where she arranges and rearranges the objects in a house she is staying in. The movie was criticized by OCD-experts and sufferers for this unrealistic treatment.
In the 2005 film Deuce Bigalow: European Gigolo, Deuce's girlfriend, Eva, suffers from acute obsessive-compulsive disorder. She does things like bite people when a horn is honked, smells herself when she hears sirens, slaps herself three times when someone sneezes, etc.
In the TV show Joey, Joey Tribbiani's executive producer, Lauren (played by Lucy Liu), suffers from OCD. She compulsively checks to ensure that her oven is not left on at home, and feels the need to knock upon hearing a knocking noise.
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.
Malcolm McDowell plays an OCD sufferer in the show Shadow Realm whose rituals keep the entire universe in working order.
In the British comedy series Blackadder The Third, in the episode "Sense and Senility", the two actors who visit the prince appear to suffer from a form of OCD in which they feel obliged to complete a ritual whenever Macbeth is mentioned.
The character of "Cameron" in the British teen soap opera Hollyoaks has OCD - his story lines often delt with the difficultys surrounding the disease.
In Ken Kesey's novel "One Flew Over the Cuckoo's Nest", clinic patient George Sorensen suffered from acute OCD. In the book he is described like "the water freak, who grins and shies back from that unsanitary hand" and he says things like "Those boats awful dirty any more — everything awful dirty." He behaves accordingly.

Famous/celebrity OCD sufferers

These figures have been identified as having the disorder:

References

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.
Mineka, S., Watson, D. & Clark, L. A. (1998). "Comorbidity of Anxiety and Unipolar Mood Disorders." Annu. Rev. Psychol., 49, 377-412. Peer reviewed journal article offering a possible explanation for the high comorbidity rate of anxiety disorders and certain mood disorders.
Rachman, Stanley & De Silva, Padmal Obsessive Compulsive Disorders: The Facts, Oxford University Press, 2nd edition (January 15, 1998), ISBN 0192628607. Book for patients and their families. Includes assessment and evaluation, treatment, effect on family, work, and social life, practical advice, and its relationship to other disorders.
Rapoport, Judith, L. The Boy Who Couldn't Stop Washing : The Experience and Treatment of Obsessive-Compulsive Disorder (1991), ISBN 0451172027, A highly readable introduction to OCD, with case histories.

References.

OCD and Contaminationaccesed January 26th 2006.

External links

OCD Action and OCD-UK are national charities for people who are affected by Obsessive-Compulsive Disorder (OCD)
Ken Williams Complete OCD Page
Symptoms of Obsessive-Compulsive Disorder
The Obsessive-Compulsive Foundation (OCF)
The Austin Center for the Treatment of Obsessive-Compulsive Disorder (ACTOCD)
The OCD Centre, UK
National Institute of Mental Health (NIMH)
OCD mutant gene found
University of Arizona Psilocybin Study Protocol (maps.org)
Twelve FAQs about OCD
Obsessive behaviour linked to low oestrogen levels
Neurochemistry of OCD
Obsessive Compulsive Disorder Research Clinic, New York State Psychiatric Institute