What Is Obsessive-Compulsive Disorder (OCD)?

Repeated Unwanted Thoughts or Routines Causing Distress

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Obsessive-compulsive disorder (OCD) is considered a chronic (long-term) mental health condition. This neuropsychiatric disorder is characterized by obsessive, distressful thoughts and ritualistic behaviors. Those with obsessive-compulsive disorder are known to have a variety of symptoms and traits, some of which are not distinctly defined.

Neuropsychology is a field of psychology pertaining to the brain and behavior. A person with OCD commonly performs the same rituals (such as handwashing) over and over and may feel a loss of control over performing such practices. These repetitive behaviors are often performed in an effort to reduce distress and anxiety.

The Diagnostic and Statistical Manual-5 defines obsessive-compulsive disorder as the presence of obsessions, compulsions, or both. Obsessions are recurrent and persistent thoughts, urges, or images that are unwanted and intrusive and cause anxiety or distress. Compulsions are repetitive behaviors or mental acts the person feels they must do in response to an obsession or rigid rules.

Obesessive-compulsive disorder may display cleaning rituals
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Characteristics / Traits / Symptoms

The symptoms of OCD may involve characteristics of obsessions, behaviors that would indicate compulsions, or both. Symptoms are often associated with feelings of shame and concealment (secretiveness).

Common Obsessive Symptoms

In OCD, obsessions are defined as repetitive thoughts, urges, impulses, or mental images that cause anxiety or distress. These obsessions are considered intrusive and unwanted.

The person attempts to ignore or suppress the thoughts, urges, or images via some other thought or action (such as performing compulsive actions).

Common obsessions exhibited by those with OCD may include:

  • Fear of getting germs by touching items perceived as being contaminated (exhibited by fear of touching things that others have touched, the fear of shaking hands, and more)
  • A strong need for order exhibited by feelings of extreme anxiety when things are out of order or asymmetrical or when objects are moved by someone else and/or difficulty leaving the house (or the room) until objects are deemed perfectly placed
  • Taboo thoughts which often involve very troubling thoughts about topics such as sex or religion
  • Aggressive thoughts which often involves fear of harming others or self and may manifest as compulsive behaviors, such as being obsessed with news reports about violence
  • Severe self-doubt or fear of making mistakes, which commonly involves having a high need for reinforcement from others

Common Compulsive Symptoms of OCD

Compulsions can be defined as specific types of repetitive behavior or mental rituals that a person with OCD often engages in (to the point of being ritualistic). These repetitive behaviors help reduce distress that comes from obsessive thoughts.

There is a very strong compulsion to perform these repetitive actions and behaviors, and over time, they become automatic. A person feels driven to perform these repetitive behaviors as a way of either lowering anxiety or preventing a dreaded event from occurring. 

Compulsive behaviors may include repeatedly checking things, handwashing, praying, counting, and seeking reassurance from others.

Specific examples of common compulsions in people with OCD include:

  • Excessive handwashing or cleaning (which may include taking repetitive showers or baths each day)
  • Excessive organizing (putting things in exact order or having a strong need to arrange things in a very precise manner).
  • Ritualistic counting (such as counting the numbers on the clock, counting the number of steps taken to reach a certain place or counting floor or ceiling tiles)
  • Repetitively checking on things (such as checking doors and windows to ensure they are locked or checking the stove to make sure it’s turned off)

Most people (even those without OCD) have some mild compulsions—such as the need to check the stove or the doors a time or two before leaving the house—but with OCD, there are some specific symptoms that go along with these compulsions such as:

  • The inability to control the behaviors (even when the person with OCD is able to identify the thoughts or behaviors as abnormal)
  • Spending at least one hour each day on the obsessive thoughts or behaviors or engaging in behavior that results in distress or anxiety or erodes the normal function of important activities in life (such as work or social connections).
  • Engaging in rituals that do not engender a positive feeling (they may provide short-term relief from anxiety, but the emotional stress shortly returns, causing the person with OCD to repeatedly engage in compulsions. This is done in an effort to relieve the cycle of stress and anxiety that comes from obsessive thoughts.
  • Experiencing a negative impact in day-to-day life as a direct result of the ritualistic behaviors and obsessive thoughts
  • Having a motor tic—a sudden, quick, repetitive movement —like blinking the eye, facial grimacing, jerking of the head, or shoulder shrugging. Vocal tics that may be common in those with OCD include clearing the throat, sniffing and other sounds.

Common Traits of People With OCD

Some adults, and most children with OCD, are unaware that their behaviors and thoughts are abnormal. Young children are not usually able to explain the reason they have disturbing mental thoughts or why they perform ritualistic behaviors. In children, the signs and symptoms of OCD are usually detected by a teacher or a parents.

Commonly, people with OCD may use substances (such as alcohol or drugs) to lessen the stress and anxiety associated with their symptoms. The symptoms of OCD may change over time; for example, some symptoms will come and go, others may lesson or they may get worse over time.

If you or a loved one are struggling with obsessive-compulsive disorder, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-4357 for information on support and treatment facilities in your area.

For more mental health resources, see our National Helpline Database.

Diagnosis or Identifying OCD

There are no diagnostic lab tests, genetic tests, or other formal tests for diagnosing OCD. A diagnosis is made after an interview with a skilled clinician (a professional who has been trained in diagnosing mental health conditions). This could be a licensed clinical social worker, a licensed psychologist, or a psychiatrist (a medical doctor specializing in the field of psychiatry). 

The qualifications for who can make a formal diagnosis varies from state to state. For example, in some states, a diagnosis can be made by a licensed professional counselor (LPC) in addition to other licensed professionals. Be sure to check your state’s mandates on who can make a diagnosis in your geographic location.

Here are the traits and symptoms that a qualified clinician will look for when formulating a diagnosis of OCD:

  • Does the person have obsessions?
  • Does the person exhibit compulsive behaviors?
  • Do the obsessions and compulsions take up a significant amount of the person’s time/life?
  • Do the obsessions and compulsions interfere with important activities in life (such as working, going to school or socializing)?
  • Do the symptoms (obsessions and compulsions) interfere with a person’s values?

If the clinician finds that the obsessive, compulsive behaviors take up a lot of the person’s time and interfere with important activities in life, there may be a diagnosis of OCD.

If you suspect that you, or a friend or family member may have OCD, be sure to consult with your healthcare provider about the symptoms as soon as possible. When left untreated, OCD can impact all aspects of a person’s life. Also, keep in mind that early diagnosis and intervention equates to better treatment outcomes.

Causes

The exact cause of OCD is unknown, but new research is uncovering some strong evidence that points to why OCD occurs. This may help to provide insight into successful treatment of OCD in the future. 

Studies

A 2019 study discovered new data that enabled researchers to identify the specific areas of the brain and the processes associated with the repetitive behaviors of those with OCD.

Researchers examined hundreds of brain scans of people with OCD and compared them with the brain scans of those who did not have OCD. This is what the researchers discovered:

  • MRI brain scans revealed structural and functional differences in neuronal (nerve) circuits in the brains of those with OCD.
  • The brains of those with OCD were unable to use normal stop signals to quit performing the compulsive behaviors (even when the person with OCD knew they should stop).
  • Error processing and inhibitory control are important processes that were altered in the brain scans of those with OCD. These functions (error processing and inhibitory control) normally enable a person to detect and respond to the environment and adjust behaviors accordingly.

According to the lead study author, Luke Norman, Ph.D., “These results show that, in OCD, the brain responds too much to errors, and too little to stop signals. By combining data from 10 studies, and nearly 500 patients and healthy volunteers, we could see how brain circuits long hypothesized to be crucial to OCD are indeed involved in the disorder,” says Norman.

Treatment

Early identification and prompt treatment of OCD is important. There are some specific types of treatment as well as medication that may be more effective when the disease is diagnosed early on.

But, in many instances, a diagnosis of OCD is delayed. This is because the symptoms of OCD often go unrecognized, partially because of the wide range of diverse symptoms. Also, many manifestations (such as obsessive thoughts) are kept secret by the person with OCD.

In fact, according to ­­­­­­­­­an older study published in the Journal of Clinical Psychiatry, it takes a person on average of 11 years to start treatment after meeting the diagnostic criteria for the disease.

A 2014 study, published by the Journal of Affective Disorders, discovered that early detection and treatment are known to result in better treatment outcomes. 

Often, people with OCD realize significant improvement in symptoms with proper and timely treatment, some people even achieve remission.

Cognitive Therapy

There are a variety of cognitive therapy modalities used to treat OCD.

Exposure and Response Prevention (ERP)

Exposure and response prevention is one type of cognitive therapy that is used to treat OCD. This type of therapy encourages people with OCD to face their fears without engaging in compulsive behaviors. ERP aims to help people break the cycle of obsessions and compulsions to help improve the overall quality of life for those with OCD. 

Exposure and response therapy begins with helping people confront situations that cause anxiety. When a person has repeated exposure, it helps to lower the intensity of anxious feelings associated with certain situations that normally engender distress.

Starting with situations that cause mild anxiety, the therapy involves moving on to more difficult situations (the ones that cause moderate and then severe anxiety).

Cognitive Behavioral Therapy (CBT)

Cognitive behavioral therapy is a type of therapy offers elements of ERT, but also includes cognitive therapy, so it’s considered a more all-inclusive type of treatment, compared to ERT alone.

Cognitive therapy is a type of psychotherapy that helps people change their problematic thoughts, emotions, and behaviors, improving skills such as emotional regulation and coping strategies. This helps people to more effectively deal with current problems or issues.

The therapy can include 1-to-1 sessions with a therapist or group therapy; it’s also offered online by some providers.

Motivational Interviewing

Using motivational interviewing is thought to increase engagement in therapy and improve outcomes for people with OCD.

In contrast to cognitive therapy, psychotherapy has not been proven effective in the treatment of OCD.

Medication

There are several types of medication commonly prescribed to treat OCD. Selective serotonin reuptake inhibitors (SSRIs) are the preferred initial pharmacotherapy for OCD. This is because studies have shown that SSRIs are effective at treating OCD and they have fewer side effects than tricyclic antidepressants.

SSRIs include Prozac (fluoxetine), Zoloft (sertraline), and Paxil (paroxetine). Tricyclic antidepressants such as Anafranil (clomipramine) may be used.

When taking SSRI’s, there are some basic guidelines that apply, these include:

  • People with OCD need a higher dosage of SSRIs compared to those with other types of diagnoses.
  • The dosage should start low and gradually increase over a four- to six-week time span until the maximum dosage is reached. 
  • Careful monitoring by the prescribing physician is important (particularly when higher than usual dosages are given).
  • The medication should be given for a trial period of eight to 12 weeks (with at least six weeks of taking the maximum dose). It usually takes at least four to six weeks and sometimes up to 10 weeks to see any type of significant improvement.

If first line treatment (such as Prozac) is not effective for symptoms of OCD, it’s advisable to consult with a psychiatrist (a doctor who specializes in treating mental illness and who can prescribe medications). Other medications, such as clomipramine may be given to help potentiate the SSRI medication regime.

If you are prescribed medication for OCD, it’s important to:

  • Be closely monitored by a health care provider (such as a psychiatrist) for side effects and symptoms of comorbidities (having two or more psychiatric illnesses at one time) such as depression, as well as being monitored for suicidal ideation (thoughts of suicide).
  • Refrain from suddenly stopping your medication without the approval of your healthcare provider.
  • Understand the side effects and the risks/benefits of your medication. You can find some general information about these medications on the NIMH (Mental Health Medications) website.
  • Report any side effects to your healthcare provider as soon as they are noticed, you may need to have your medication change,

Coping

As with any type of mental health condition, coping with OCD can be challenging, for the person who is diagnosed with OCD, as well as for the family members. Be sure to reach out for support (such as participating in an online support group) or talk to your healthcare provider or therapist about your needs.

You may need to educate friends and family members about OCD. Keep in mind that according to the study authors in a 2018 study, OCD is not some type of dark behavioral problem, but rather, a medical problem that is not the fault of anyone who is diagnosed with the disorder.

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