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Obsessive Compulsive Disorder (OCD)

Obsessive Compulsive Disorder (OCD)

Obsessive Compulsive Disorder (OCD)

What is Obsessive Compulsive Disorder?

The defining features of Obsessive Compulsive Disorder (OCD) are the presence of obsessions and compulsions. Obsessions are unwanted, unwelcome ideas, images, thoughts or impulses that repeatedly enter your mind against your will. You may find them repugnant, senseless and totally against your personality. Compulsions are behaviors or thoughts that you feel driven to do or think even though you may recognize that they make no sense. Typically the obsession generates strong feelings of discomfort, usually anxiety but not necessarily (the obsession may generate other feelings such as disgust or guilt in addition to, or instead of the anxiety), and the compulsion is designed to reduce the discomfort/anxiety.

A classic example of OCD might be an obsession that after having touched a doorknob one's hands are covered in germs and unless the germs are washed off quickly sickness (and even death) are sure to follow. The compulsion might then be to wash one's hands to remove the feared germs. Unfortunately, with OCD one can never be certain that all the germs were properly washed off and so the washing is repeated and repeated often many times over in an often futile attempt to be certain that the germs have been washed away. Other times the compulsion does not appear to be so logically related to the obsession, but the person with OCD performs the compulsion anyway because it somehow reduces their distress (If I tap my foot a certain way as I get out of bed in the morning, my parents will not die today). To fully qualify for the diagnosis of OCD, the obsessions and compulsions must cause marked distress and take up an hour or more per day or significantly interfere with the person's normal routine, occupational or academic functioning, or usual social activities or relationships.

Obsessive Compulsive Disorder is more common than people realize.

Prior to 1983, OCD was thought to be a relatively rare disorder. Usual estimates for the prevalence of OCD in the general population were in the range of .05%, which would mean that between 125,000 and 150,000 people in the United States would have OCD. In 1983 the National Institutes of Health conducted a national survey to ascertain the frequency of occurrence of various mental health disorders, including OCD. Researchers went from door to door in five different areas of the country and interviewed 18,500 people. With regards to OCD, the results were stunning. The actual prevalence of OCD was found to be between 1.9% and 3.3% of the population, which translates into between 5,700,000 and 9,900,000 people with OCD. It was clear that the prevalence of OCD had been grossly underestimated. We now know that OCD is actually one of the more common mental health disorders, in fact it is the fourth most common disorder behind phobias, substance abuse and depression. While there has been some disagreement about the actual prevalence of OCD in the general population, there is general agreement that it is about 1% to 2%. Surveys in other countries have found similar prevalence rates.

Even today, close to 40 years after the above survey, there seems to be little awareness about OCD. Other less common disorders are better known to the general public. For example, schizophrenia's prevalence rate is between 0.5% and 1.0%, about one-half of that of OCD, but it seems to be better known. Perhaps part of the problem is that people with OCD are more likely to suffer in silence. People with OCD are often ashamed to admit that they have the disorder, fearing that they will be labeled "crazy" and keep their symptoms hidden. Thanks in part to greater awareness among professionals of the prevalence of OCD and also in some measure to movies such as "As Good as it Gets" and television shows like "Monk", people are becoming more aware of OCD, yet it still remains what Michael Jenike of Harvard University has called a "hidden epidemic".

Do I have Obsessive Compulsive Disorder?

Only an evaluation by a qualified mental health professional can properly answer that question, but by answering the following questions you can get some idea of where you stand.

Self-Screen for OCD

If you answer "Yes" to any of the following questions, it is suggested that you consider getting a professional consultation to determine whether you may be suffering from OCD.

  1. Are you frequently troubled by repetitive thoughts that are unwanted, intrusive, and that cause you to feel anxious?

  2. Do you tend to wash or clean yourself or your possessions excessively?

  3. Do you have unreasonably strong fears of germs, dirt, chemicals, or radioactivity?

  4. Is your living space filled or cluttered with excessive amounts of possessions or useless items that you are unable to throw away?

  5. Are you frequently troubled by thoughts of acting inappropriately toward others in violent or sexual ways?

  6. Do you frequently feel the urge to check things over and over, for fear of having done something careless that could harm either yourself or others?

  7. Do you constantly question others or seek reassurance that you have not behaved badly in some way?

  8. Do you constantly question others or seek reassurance that some bad event will or will not happen to yourself or others?

  9. Do you feel that at times, you must perform special repetitive behaviors or think in special ways in order to prevent bad things from happening to yourself or others, or to cancel out bad luck?

  10. Are you frequently bothered by blasphemous or irreligious thoughts, or are you constantly concerned that you are not observing the beliefs or laws of your religion perfectly enough?

  11. Do you spend excessive amounts of time trying to order or arrange things in your environment, in order to make them perfect or symmetrical in some way?

  12. Do you feel overly responsible for the well being and safety of others (even strangers), to the point of constantly checking on them and worrying about them?

  13. Are you constantly troubled by serious doubts, and do you have great difficulty in making decisions.

  14. Are you overly concerned with lucky or unlucky numbers, or do you have to perform particular actions a special number of times to prevent bad things from happening?

Questions reprinted with permission of Fred Penzel, Ph.D., Western Psychological Services, Huntington, NY

Are there different types of Obsessive Compulsive Disorder?

Yes there are. To paraphrase Joseph Campbell, OCD is the "Disorder with a Thousand Faces". Despite this, however, there are some categories of obsessions and compulsions that are frequently seen. The most common obsessions involve contamination, safety concerns, pathological doubt, aggressive and sexual thoughts, somatic concerns and the need for symmetry and precision. The most common compulsions (or "rituals" as they are also called) are checking, cleaning, and counting. Though it is not a type of OCD, depression frequently accompanies OCD. Depression is often secondary to the OCD and usually clears up once the OCD is under control. Sometimes, however, the depression is severe enough to interfere with the treatment process for the OCD or it persists beyond the resolution of the OCD and requires treatment above and beyond that provided for the OCD.

What causes Obsessive Compulsive Disorder?

The short answer is that we don't really know. There is general consensus that it is a neurobiological disorder, which in plain English means that OCD is caused by a glitch in how your brain works. It is as if a circuit refuses to close and the person with OCD cannot break out of an endless loop. Some people have referred to this as a "brain hiccup". We used to think OCD was related to unresolved inner conflicts or from poor parenting, but these theories have not received much research support.

How is Obsessive Compulsive Disorder treated?

There are two treatments for OCD that have proven to be effective: Cognitive Behavior Therapy/Exposure and Response Prevention (CBT/ERP) and medications. The backbone of behavioral treatment for OCD is Exposure and Response or Ritual Prevention (or ERP). The sufferer is exposed to what they are afraid of (which triggers the obsession and creates anxiety) and then does not perform the usual compulsion/ritual to reduce the anxiety. For example, to follow up on the example used above of the hand washer, the person would touch a door knob and then not wash their hands. Recall that the obsession is that their hands are now covered in germs and they or a loved one are surely going to get sick and may die. It is easy to see how this belief could cause anxiety! In the past the sufferer has used washing their hands to relieve the anxiety, but now they have entered treatment and are not going to wash their hands. What they discover is that if they can wait long enough, the anxiety does eventually go away and no one gets sick and dies. The principle that ERP is based on is habituation. If you jump into a swimming pool of cold water, the water would feel very cold at first, but if you stayed in the water you would gradually get used to it and eventually the water would not feel so cold. Touching the doorknob and not washing you hands is equivalent to jumping into the cold water and staying there. In the same way that you "adjust" to the cold water, you also "adjust" to the idea of having touched the doorknob. You also, of course, notice that the feared outcome did not occur and that helps speed along the "getting used to it" process. While the general principles of ERP are somewhat easy to explain, it is often very difficult to do the exposures. Again, if you look at it from the perspective of the person with OCD and they truly believe they or a loved one are going to die if they don't wash their hands, not washing their hands would be extremely difficult.

Depending upon how severe the OCD is, you could consider trying to do ERP on your own. There are a number of excellent self-help books available and some of the ones I recommend are listed on my recommended books page. If you decide to seek CBT/ERP therapy it will be important to find someone who is trained to do ERP. The International Obsessive Compulsive Disorder Foundation (www.iocdfoundation.org) provides a service you can use to locate a therapist in your area. Be aware that there is somewhat of a national shortage of properly trained therapists who treat OCD (especially OCD in children) and so you may have difficulty finding someone. I recently wrote a short e-book on the topic of finding a therapist to treat anxiety disorders (provide link) which might be helpful.

Medication is the other validated treatment for OCD. The practice guidelines for treating OCD suggest that CBT/ERP be tried first and if that is not successful, then try adding medication. Research outcome studies have shown that two-thirds of people benefit considerably from ERP alone without medication.