Obsessive Compulsive Disorder (OCD) is an anxiety disorder. Individuals with OCD suffer with recurrent unwanted thoughts or images that are disturbing and cause significant anxiety and distress. Most of these thoughts or images are intrusive.
In an attempt to reduce distress and anxiety, individuals with OCD may perform compulsive rituals such as counting, checking, or repeating words in a very specific way. These behaviors can be both time-consuming and unproductive. This is in contrast to individuals with Obsessive Compulsive Personality, who are perfectionists not distressed by their thoughts and behaviors because they align with their values and beliefs (ego syntonic).
One of the most debilitating aspects of OCD is the insatiable nature of the compulsive behavior that never quite reaches an acceptable level of reassurance. This leads to tortuous repetition of the compulsive acts despite the individual recognizing their irrational nature (ego dystonic).
A persistent feeling of doubt and the need for reassurance are the prominent features of OCD. Individuals with OCD may exhibit irrational thinking, called “magical thinking,” whereby things need to be performed or thought about in a specific way for fear that something unrelated will happen.
Example: “If I don’t pet my dog three times every morning, something bad will happen.” All of the Obsessive Compulsive and related disorders likely involve similar neurological substrates supported by overlap in symptoms and behavior patterns, neuroimaging studies, and the high comorbidity in individuals with OCD.
What is an obsession?
An obsession is a recurrent and intrusive thought, feeling, idea, or sensation. Obsessions are mental events. This can include worries about contamination (germs), health problems (e.g., worrying about having cancer or some other devastating disease without any clinical evidence that it exists), sexual thoughts (e.g., worrying about being a pedophile, sex offender, or fear of molesting others when there is no evidence or history to support it), perfectionism or “just right” obsessions, moral OCD (e.g., worrying about being an immoral or horrible person), among others.
What is a compulsion?
A compulsion is a conscious, standardized, recurrent behavior, such as counting, checking, or avoiding. Compulsions are mental and/or behavioral events. Compulsive acts are carried out in an attempt to relieve the anxiety associated with the obsession. Sometimes it works, sometimes it doesn’t work. Resisting a compulsive act increases anxiety. Compulsions include checking to make sure the door is locked numerous times despite knowing it is locked, counting, banging or hitting yourself, skin picking, tongue biting, repeating a sentence, saying something out loud, constantly seeking reassurance (e.g., asking friends, visiting numerous doctors), among others.
In OCD, obsessions and compulsions are ego-dystonic (i.e., we are disturbed by them)
A Disorder of Pathological Doubt
OCD can be thought of as a disorder of doubt. There are numerous symptom “clusters” that can occur. Many have more than one “type” of OCD.
OCD is the 4th most common outpatient psychiatric diagnosis with approximately 10% of people having the diagnosis in psychiatric clinics. Epidemiological studies in Europe, Asia, and Africa have confirmed these rates across cultural boundaries. Females are slightly more affected than males in adulthood whereas boys are 2-3 times more affected than girls in childhood. Mean age of onset is approximately 19.5 years old. Males typically have an earlier age of onset than females. It is important to note that OCD rarely develops after age 35.
Risk factors for developing OCD include genetic factors and environmental factors (e.g., psychosocial stressors, developmental problems, trauma, abuse, perinatal complications, infections). Controversy and debate continue about whether childhood streptococcal infections increase the risk of developing obsessive compulsive disorder (see PANDAS below).
Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS): PANDAS is a controversial autoimmune disorder believed to develop in children after group A beta hemolytic streptococcal infections. Antibodies to GABHS also attack health brain regions causing acute and rapid onset of tics and other OCD symptoms.
About 90% of patients with OCD suffer from other disorders such as anxiety disorders, depression, bipolar disorder, Impulse control disorders, substance use disorders, and Tic disorder. Up to 50% of children suffering with OCD also suffer from attention deficit hyperactivity disorder, separation anxiety disorder, specific phobias, generalized anxiety disorder, Tourette’s disorder (tic disorder).
Other Disorders related to OCD
Body Dysmorphic Disorder (BDD)
Body Dysmorphic Disorder is a type of OCD-related disorder whereby individuals are preoccupied with an imagined defect in appearance which causes clinically significant distress. If a slight physical anomaly is actually present, the individual’s concern with the anomaly is excessive and bothersome. BDD is often accompanied by compulsions such as Mirror checking, Excessive grooming, and Comparing appearance to others. Women are more commonly affected than men and the age of onset is typically between 15 years old and 30 years old. Individuals with BDD often suffer with mood disorders, anxiety disorders, and psychotic disorders. Individuals with BDD are more commonly seen in Plastic Surgery Clinics, Dermatology Clinics, and/or Primary Care Clinics.
Hoarding Disorder is another type of OCD-related disorder whereby individuals acquire and “hoard” unimportant possessions with little or no value due to an obsessive fear that may be needed in the future. This is a disorder of distorted beliefs about the importance of possessions. There is often excessive emotional attachment to possessions. The hoarding behavior leads to Cluttering, Unsanitary living conditions, Health risks (falls, animal born diseases), and Fire risks. Hoarding Disorder is commonly diagnosed in single persons with social anxiety or dependent personality traits. However, Hoarding Disorder can occur as a manifestation of other disorders/diseases such as dementia, Cerebrovascular disease, and schizophrenia. Unfortunately, most individuals with Hoarding Disorder not present to mental health clinics because most lack insight into their illness (ego-syntonic).
Hair-Pulling Disorder (Trichotillomania)
Trichotillomania was coined by a French dermatologist Francois Hallopeau in 1889 and is a chronic disorder characterized by repetitive hair pulling which results in hair loss. There is increased tension prior to hair pulling and relief of tension or gratification after the hair pulling. Women are affected more than men (10:1). Roughly 35%-40% of individuals with Trichotillomania chew or swallow their hair. Swallowing hair increases the risk of Bezoars (hairballs in the GI tract) which can cause obstruction.
Excoriation (Skin-Picking) Disorder
Compulsive and repetitive picking of the skin. 1-5% lifetime prevalence. Women are affected more than Men. It is important to rule out stimulant-induced excoriation. Skin picking is most often seen on the Face but also Legs, Arms, Torso, Hands, Cuticles, Fingers, Scalp. Embarrassment leads to avoidance and social withdrawal. 12% of skin-picking patients have attempted suicide.
Olfactory Reference Syndrome
A false belief by the patient that he or she has a foul body odor. The odor is not perceived by others. Leads to excessive showering, changing clothes. May rise to level of somatic delusion (Delusional Disorder). It is important to rule out “organic” illnesses such as Temporal lobe epilepsy, Pituitary tumors, and Sinusitis. Currently there is little evidence for treatment.
Medication or Drug-Induced Obsessive-Compulsive Symptoms
The following medications/drugs have been associated with worsening or causing obsessive compulsive symptoms:
Synthetic Cathinones (“Bath Salts”)
Medical Problems associate with OCD Symptoms
The following medical problems/neurological disorders have been associated with obsessive compulsive symptoms as part of the natural course of the illness:
Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS)
Current evidence suggests the combination of medication and cognitive behavioral therapy/exposure response prevention therapy is the most effective approach to managing symptoms of OCD.
Problems with Treatment
20-30% of patients have significant improvement in symptoms with medication alone (this is increased when combined with therapy). 40-50% of patients have moderate improvement. Higher doses of SSRIs may be required to alleviate symptoms in OCD compared to depression. Higher doses of SSRIs means greater likelihood for developing side effects from these medications.
American Psychiatric Association (APA) Treatment Algorithm for OCD
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