By Jannsen-Claig
Obsessive-compulsive disorder (OCD)
Obsessive-compulsive disorder (OCD) is an anxiety disorder. It is a condition that can last throughout a person's life. People with OCD can become trapped in a pattern of repetitive thoughts and behaviours that are senseless and distressing, but extremely difficult to overcome. Their symptoms can range from mild to severe, and when untreated, severe OCD can destroy a person's ability to function at work, at school, or even at home.
Obsessive-compulsive disorder involves anxious thoughts (obsessions) or rituals (compulsions) which you feel you can't control. People with OCD are often plagued by persistent, unwelcome thoughts or images, or by the urgent need to engage in certain rituals. For example, a person with OCD might be obsessed with germs or dirt, and wash his or her hands over and over. Another person may check things repeatedly or be preoccupied by thoughts of violence and fear. Obsessive counting is often seen in people with OCD.
For many years, doctors thought that OCD was a rare disease, because they saw very few patients with the condition. However, many sufferers were not identified, because people with OCD will try to keep their repetitive thoughts and behaviours secret, and so tend not to seek treatment. It is now thought that about two people in a hundred are affected, meaning that OCD is more common than mental illnesses like schizophrenia, bipolar disorder, or panic disorder. OCD strikes people of all ethnic groups, and males and females are equally affected.
OCD symptoms usually begin in the teenage years or early adulthood, but some children develop the illness at earlier ages, even in the pre school years. At least one-third of adults with OCD first developed the disease in childhood. OCD tends to last for years, even decades. The symptoms may become less severe from timeto time, and there may be long intervals when the symptoms are mild, but for most individuals, the symptoms are chronic.
Symptoms of OCD
Obsessions
Obsessions are unwanted ideas or impulses that repeatedly well up in the mind of the person with OCD. Sufferers often fear that harm may come to themselves or a loved one, have unreasonable concerns about becoming contaminated, or an excessive need to do things correctly or perfectly. Again and again, the person experiences a disturbing thought, such as, "My hands may be contaminated--I must wash them" or "I may have left the gas on" or "I am going to injure my child." These distressing thoughts intrude on the patients other thoughts, and cause anxiety. Sometimes the obsessions are of a violent or a sexual nature, or concern illness.
Compulsions
In response to their obsessions, most people with OCD resort to repetitive behaviours called compulsions. The most common of these are washing and checking. Other compulsive behaviours include counting (often while performing another compulsive action such as hand washing), repeating, hoarding, and endlessly rearranging objects in an effort to keep them in precise alignment with each other. Mental problems are also common, such as mentally repeating phrases and list making. These behaviours are generally intended to ward off harm to the person with OCD or others. Some people with OCD have regimented rituals; others have rituals that are complex and changing. Performing these rituals provides only temporary relief from anxiety, but not performing them increases the person's anxiety.
Insight
People with OCD may realise that their obsessions and compulsions are senseless and unrealistic (i.e., they show insight), especially when their obsessional thoughts are under control. At other times they may be unsure about their fears, or may even believe strongly that their thoughts are reasonable.
Resistance
Most people with OCD struggle to banish their unwanted obsessive thoughts, and to prevent themselves from engaging in compulsive behaviours. Many are able to keep their obsessive-compulsive symptoms under control when they are at work or school, but over months or years, their resistance may weaken. When this happens, the symptoms may become so severe that time-consuming rituals take over their lives, making it impossible for them to continue activities outside the home.
Shame and secrecy
OCD sufferers often attempt to hide their disorder rather than seek help, and they are often they are successful in concealing their obsessive-compulsive symptoms from friends and co-workers. Unfortunately, this means that people with OCD usually do not receive professional psychiatric help until years after the onset of their disease. By that time, they may have learned to work their lives, and those of their relatives and friends, around the rituals.
People with OCD should not be confused with people who may be called 'compulsive' because they hold themselves to a high standard of performance and are perfectionist and very organised in their work and recreational activities. This type of compulsiveness often serves a valuable purpose, contributing to a person's self-esteem and success on the job. In that respect, it differs from the life-wrecking obsessions and rituals of the person with OCD.
Illnesses which coexist with OCD
Some people with OCD may also suffer from depression, eating disorders, substance abuse, attention deficit hyperactivity disorder (ADHD), or other anxiety disorders. When a person has other disorders, OCD is often more difficult to diagnose and treat. Symptoms of OCD are also seen in other brain disorders, such as Tourette's syndrome. Correct diagnosisand treatment of these disorders is important for successful treatment of OCD.
In the past it was thought that OCD was caused by life experiences, but there is now increasing evidence that biological factors are involved. and that OCD is related to an abnormality in the function of circuits of nerve cells in specific areas of the brain. OCD is not caused by family problems or attitudes learned in childhood, such as an emphasis on cleanliness, or a belief that certain thoughts are dangerous or unacceptable. Using techniques which allow them to look at events in the brain in living people, such as positron emission tomography (PET), doctors have compared people with and without OCD. People with OCD have patterns of brain activity that differ from people with other mental illnesses or people with no mental illness. In addition, PET scans show that in patients with OCD, both behavioural therapy and drugs produce changes in the brain. These changes may be an explanation for the clinical improvements produced by both psychotherapy and medication. Other studies of brain structure using magnetic resonance imaging (MRI) showed that people with OCD had less white matter than normal subjects, suggesting a widely distributed brain abnormality.
Other theories about the causes of OCD emphasise the importance of the interaction between behaviour and the environment, and on beliefs and attitudes, as well as how information is processed. Both the behavioural and cognitive theories and the biological explanations are important explanations of different aspects of how the illness might arise.
Drug treatment
Drugs which affect the actions of the neurotransmitter serotonin (5-HT) in the brain can significantly reduce the symptoms of OCD. Several drugs (clomipramine, fluoxetine, fluvoxamine, sertraline, and paroxetine) have been proven effective. More than three-quarters of patients are helped by these medications at least a little, and in more than a half of patients, medications relieve symptoms of OCD by reducing the frequency and severity of the obsessions and compulsions. Improvement usually takes at least three weeks or longer. If a patient does not respond well to one of these medications, or has unacceptable side effects, another drug may give a better response. Medications help in controlling the symptoms of OCD, but often, if the patient stops taking their medication, a relapse of symptoms will follow. Even after symptoms have subsided, most people will need to continue with medication indefinitely, perhaps with a lowered dosage.
Behaviour therapy
Traditional psychotherapy, aimed at helping the patient develop insight into his or her problem, is generally not helpful for OCD. However, a specific behaviour therapy approach called 'exposure and response prevention' is effective for many people. In this approach, the patient deliberately and voluntarily confronts the feared object or idea, either directly or by imagination. At the same time the patient is strongly encouraged to refrain from ritualising, with support and structure provided by the therapist, and possibly by others who the patient recruits for assistance. For example, a compulsive hand washer may be encouraged to touch an object believed to be contaminated, and then urged to avoid washing for several hours until the anxiety provoked has decreased. Treatment then proceeds on a step-by-step basis, guided by the patient's ability to tolerate the anxiety and control the rituals. As treatment progresses, most patients gradually experience less anxiety from the obsessive thoughts and are able to resist the compulsive urges.
Studies of behaviour therapy for OCD have found it to be a successful treatment for the majority of patients who complete it. It is helpful for the patient to be highly motivated and have a positive, determined attitude. The positive effects of behaviour therapy remain once treatment has ended.
Cognitive-behavioural therapy (CBT) may be effective for OCD. This form of behaviour therapy emphasises changing the OCD sufferer's beliefs and thinking patterns.
The effect of OCD on families
OCD affects not only the individual sufferer but also their relatives and friends. Families often have a difficult time accepting the fact that the person with OCD cannot stop the distressing behaviour. If relatives show their anger and resentment, this may lead to an increase in the OCD behaviour. Otherwise, to keep the peace, they may assist in the rituals or give constant reassurance. However, families can learn ways to encourage the person with OCD to persist with the behaviour therapy and/or medication programs.
1. Classification and definition of disorders causing hypertonia in childhood
TD Sanger, MR Delgado, D Gaebler-Spira, M Hallett, JW Mink, Task Force on Childhood Motor Disorders
Pediatrics 2003;111:e89-e97
A consensus conference on hypertonic movement disorders in children proposes the following definitions:
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NIMH
Obsessive-Compulsive Disorder, OCD, is an anxiety disorder and is characterized by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions). Repetitive behaviors such as handwashing, counting, checking, or cleaning are often performed with the hope of preventing obsessive thoughts or making them go away. Performing these so-called "rituals," however, provides only temporary relief, and not performing them markedly increases anxiety.
Signs & Symptoms
People with OCD may be plagued by persistent, unwelcome thoughts or images, or by the urgent need to engage in certain rituals. They may be obsessed with germs or dirt, and wash their hands over and over. They may be filled with doubt and feel the need to check things repeatedly.
Treatment
Effective treatments for obsessive-compulsive disorder are available, and research is yielding new, improved therapies that can help most people with OCD and other anxiety disorders lead productive, fulfilling lives. more>>
Getting Help: Locate Services
Locate mental health services in your area, affordable healthcare, NIMH clinical trias, and listings of professionals and organizations.
Related Information
Obsessive-Compulsive Disorder Information from NLM's MedlinePlus, in English and Spanish
Some mental illnesses also carry an increased risk for suicide.
TREATMENT
Psychotherapy, Medications Best for Youth With Obsessive Compulsive Disorder
Children and adolescents with Obsessive Compulsive Disorder (OCD) respond best to a combination of both psychotherapy and an antidepressant, a major clinical trial has found. Supported by the National Institutes of Health's (NIH) National Institute of Mental Health, the study recommends that treatment begin with cognitive behavior therapy (CBT), either alone or with a serotonin reuptake inhibitor (SSRI) antidepressant. The research spotlights the need for improved access to CBT, since most young people with OCD currently receive only the antidepressant, often combined with an antipsychotic medication. John March, M.D., Duke University, Edna Foa, Ph.D., University of Pennsylvania, and colleagues report on the findings of the Pediatric OCD Treatment Study (POTS) in the October 27, 2004 Journal of the American Medical Association (JAMA).
Ninety-seven 7-17 year-olds with OCD completed 12 weeks of treatment with either CBT, the SSRI sertraline, the combination treatment, or a placebo. Independent evaluators, blind to their treatment status, assessed each patient every four weeks. Patients in the study were typical of patients seen in clinical practice. For example, while industry-sponsored trials commonly exclude patients with more than one condition, 80 percent of study participants had at least one additional psychiatric disorder.
Combining sertraline and CBT was more effective than treatment with just one or the other. CBT alone did prove superior to sertraline, which, in turn, was better than a placebo. By the end of the trial, the remission rates were 53.6 percent for combined treatment, 39.3 percent for CBT, 21.4 percent for sertraline, and 3.6 percent for placebo.
CBT alone was more effective in the University of Pennsylvania site than at Duke University site, but the combination treatment was equally effective at both sites, suggesting that it may be less susceptible to setting-specific variations. The strong showing of CBT at the University of Pennsylvania led the researchers to recommend it as "a first line option" for initial treatment. They point out, however, that "only a small minority" of children and adolescents with OCD receives such state-of- the-art care.
"In the Treatment of Adolescents with Depression Study, which compared CBT with an SSRI and combination treatment, for teens with depression, the medication proved superior to CBT. In this case the reverse was true, but in both studies, combination was superior. This underscores that different disorders in adolescents respond to different treatments," noted NIMH Director Thomas Insel, M.D.
"We believe that the results of this study will contribute to the appreciation by non-physician mental health clinicians of the strengths and limitations of pharmacological treatments and to the appreciation by physicians of the evidence-based psychosocial treatments," states the article. "It is imperative that the focus of research turn to identifying and testing dissemination strategies for CBT," the researchers add.
There were no episodes of mania, suicidality, or other serious adverse events during the course of the study.
Also participating in the study were Pat Gammon, Ph.D., Allan Chrisman, M.D., John Curry, Ph.D., David Fitzgerald, Ph.D., and Kevin Sullivan, BA, all from Duke University Medical Center; Martin Franklin, Ph.D., Jonathan Huppert, Ph.D., MoiraRynn, M.D., Ning Zhao, Ph.D., and Lori Zoellner, Ph.D., from the University of Pennsylvania; and Henrietta Leonard, M.D., Abbe Garcia, Ph.D., and Jennifer Freeman, Ph.D., from Brown University. The principal statistician was Xin Tu, Ph.D. (University of Pennsylvania).
NIMH is part of the National Institutes of Health (NIH), the Federal Government's primary agency for biomedical and behavioral research. NIH is a component of the U.S. Department of Health and Human Services.
To learn more, visit:
Obsessive Compulsive Disorder (OCD)
Treatment of Adolescents with Depression Study (TADS)
Child and Adolescent Mental Health
Jannsen-Claig
Role of family and friends in treatment
Families and friends can play important supporting roles in combating anxiety disorder in a family member. Although the patient is the most important focus of treatment, family members and friends can help by taking part in the treatment program. With appropriate training they can accompany the patient into anxiety-producing situations. They can offer support and encouragement, and help create an environment that promotes healing.
Family members and friends can help by:
recognising and praising small achievements by patients
modifying patients' expectations during stressful periods
measuring progress on the basis of the improvements made by the individual, not set against some rigid external standards
being flexible and trying to maintain a normal routine.
Family members and friends can often play an active role in the treatment of anxiety disorders. The precise type of assistance they can provide will vary depending on the disorder and the relationship between the patient and the family member. In addition to providing psychological therapy and drug treatment, doctors are increasingly recommending treatment programs that include family members. In general, the more severe the disorder, the more likely that family and/or marital issues will need to be addressed by the therapy program.
In one common approach to family therapy, doctors rely on the involvement of a spouse or other family member or friend as a co-therapist. Involving family members or friends as part of the treatment team will be likely to reduce the possibility of tension surrounding the therapy program. The provision of educational materials for family members also promotes understanding
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