Obsessive Compulsive Disorder
What is OCD?
Obsessive-compulsive disorder (OCD), one of the anxiety disorders,
is a potentially disabling condition that can persist throughout
a person's life. The individual who suffers from OCD becomes trapped
in a pattern of repetitive thoughts and behaviors that are senseless
and distressing but extremely difficult to overcome. OCD occurs
in a spectrum from mild to severe, but if severe and left untreated,
can destroy a person's capacity to function at work, at school,
or even in the home.
The case histories in this brochure are typical for those who
suffer from obsessive-compulsive disorder--a disorder that can be
effectively treated. However, the characters are not real.
How Common Is OCD?
For many years, mental health professionals thought of OCD as
a rare disease because only a small minority of their patients had
the condition. The disorder often went unrecognized because many
of those afflicted with OCD, in efforts to keep their repetitive
thoughts and behaviors secret, failed to seek treatment. This led
to underestimates of the number of people with the illness. However,
a survey conducted in the early 1980s by the National Institute
of Mental Health (NIMH)--the Federal agency that supports research
nationwide on the brain, mental illnesses, and mental health--provided
new knowledge about the prevalence of OCD. The NIMH survey showed
that OCD affects more than 2 percent of the population, meaning
that OCD is more common than such severe mental illnesses as schizophrenia,
bipolar disorder, or panic disorder. OCD strikes people of all ethnic
groups. Males and females are equally affected. The social and economic
costs of OCD were estimated to be $8.4 billion in 1990 (DuPont et
Although OCD symptoms typically begin during the teenage years
or early adulthood, recent research shows that some children develop
the illness at earlier ages, even during the preschool years. Studies
indicate that at least one-third of cases of OCD in adults began
in childhood. Suffering from OCD during early stages of a child's
development can cause severe problems for the child. It is important
that the child receive evaluation and treatment by a knowledgeable
clinician to prevent the child from missing important opportunities
because of this disorder.
ObsessionsThese are unwanted ideas or impulses that repeatedly well up in
the mind of the person with OCD. Persistent fears that harm may
come to self or a loved one, an unreasonable concern with becoming
contaminated, or an excessive need to do things correctly or perfectly,
are common. Again and again, the individual experiences a disturbing
thought, such as, "My hands may be contaminated--I must wash
them"; "I may have left the gas on"; or "I am
going to injure my child." These thoughts are intrusive, unpleasant,
and produce a high degree of anxiety. Sometimes the obsessions are
of a violent or a sexual nature, or concern illness.
CompulsionsIn response to their obsessions, most people with OCD resort to
repetitive behaviors called compulsions. The most common of these
are washing and checking. Other compulsive behaviors 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,
such as mentally repeating phrases, listmaking, or checking are
also common. These behaviors generally are intended to ward off
harm to the person with OCD or others. Some people with OCD have
regimented rituals while others have rituals that are complex and
changing. Performing rituals may give the person with OCD some relief
from anxiety, but it is only temporary.
InsightPeople with OCD show a range of insight into the senselessness
of their obsessions. Often, especially when they are not actually
having an obsession, they can recognize that their obsessions and
compulsions are unrealistic. At other times they may be unsure about
their fears or even believe strongly in their validity.
ResistanceMost people with OCD struggle to banish their unwanted, obsessive
thoughts and to prevent themselves from engaging in compulsive behaviors.
Many are able to keep their obsessive-compulsive symptoms under
control during the hours when they are at work or attending school.
But over the months or years, resistance may weaken, and when this
happens, OCD may become so severe that time-consuming rituals take
over the sufferers' lives, making it impossible for them to continue
activities outside the home.
Shame and SecrecyOCD sufferers often attempt to hide their disorder rather than
seek help. Often they are successful in concealing their obsessive-compulsive
symptoms from friends and coworkers. An unfortunate consequence
of this secrecy is that people with OCD usually do not receive professional
help until years after the onset of their disease. By that time,
they may have learned to work their lives--and family members' lives--around
OCD tends to last for years, even decades. The symptoms may become
less severe from time to time, and there may be long intervals
when the symptoms are mild, but for most individuals with OCD,
the symptoms are chronic.
What Causes OCD?
The old belief that OCD was the result of life experiences has
been weakened before the growing evidence that biological factors
are a primary contributor to the disorder. The fact that OCD patients
respond well to specific medications that affect the neurotransmitter
serotonin suggests the disorder has a neurobiological basis. For
that reason, OCD is no longer attributed only to attitudes a patient
learned in childhood--for example, an inordinate emphasis on cleanliness,
or a belief that certain thoughts are dangerous or unacceptable.
Instead, the search for causes now focuses on the interaction of
neurobiological factors and environmental influences, as well as
OCD is sometimes accompanied by depression, eating disorders,
substance abuse disorder, a personality disorder, attention deficit
disorder, or another of the anxiety disorders. Co-existing disorders
can make OCD more difficult both to diagnose and to treat.
In an effort to identify specific biological
factors that may be important in the onset or persistence of OCD,
NIMH-supported investigators have used a device called the positron
emission tomography (PET) scanner to study the brains of patients
with OCD. Several groups of investigators have obtained findings
from PET scans suggesting that OCD patients have patterns of brain
activity that differ from those of people without mental illness
or with some other mental illness. Brain-imaging studies of OCD
showing abnormal neurochemical activity in regions known to play
a role in certain neurological disorders suggest that these areas
may be crucial in the origins of OCD. There is also evidence that
treatment with medications or behavior therapy induce changes in
the brain coincident with clinical improvement.
Recent preliminary studies of the brain using magnetic resonance
imaging showed that the subjects with obsessive-compulsive disorder
had significantly less white matter than did normal control subjects,
suggesting a widely distributed brain abnormality in OCD. Understanding
the significance of this finding will be further explored by functional
neuroimaging and neuropsychological studies (Jenike et al, 1996).
Symptoms of OCD are seen in association with some other neurological
disorders. There is an increased rate of OCD in people with Tourette's
syndrome, an illness characterized by involuntary movements and
vocalizations. Investigators are currently studying the hypothesis
that a genetic relationship exists between OCD and the tic disorders.
Other illnesses that may be linked to OCD are trichotillomania
(the repeated urge to pull out scalp hair, eyelashes, eyebrows or
other body hair), body dysmorphic disorder (excessive preoccupation
with imaginary or exaggerated defects in appearance), and hypochondriasis
(the fear of having--despite medical evaluation and reassurance--a
serious disease). Genetic studies of OCD and other related conditions
may enable scientists to pinpoint the molecular basis of these disorders.
Other theories about the causes of OCD focus on the interaction
between behavior and the environment and on beliefs and attitudes,
as well as how information is processed. These behavioral and cognitive
theories are not incompatible with biological explanations.
Do I Have OCD?
A person with OCD has obsessive and compulsive behaviors that
are extreme enough to interfere with everyday life. People with
OCD should not be confused with a much larger group of individuals
who are sometimes called "compulsive" because they hold
themselves to a high standard of performance and are perfectionistic
and very organized in their work and even in 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.
Treatment of OCD; Progress Through Research
Clinical and animal research sponsored by NIMH and other scientific
organizations has provided information leading to both pharmacologic
and behavioral treatments that can benefit the person with OCD.
One patient may benefit significantly from behavior therapy, while
another will benefit from pharmacotherapy. Some others may use both
medication and behavior therapy. Others may begin with medication
to gain control over their symptoms and then continue with behavior
therapy. Which therapy to use should be decided by the individual
patient in consultation with his or her therapist.
PharmacotherapyClinical trials in recent years have shown that drugs that affect
the neurotransmitter serotonin can significantly decrease the symptoms
of OCD. The first of these serotonin reuptake inhibitors (SRIs)
specifically approved for the use in the treatment of OCD was the
tricyclic antidepressant clomipramine (AnafranilR). It
was followed by other SRIs that are called "selective serotonin
reuptake inhibitors" (SSRIs). Those that have been approved
by the Food and Drug Administration for the treatment of OCD are
flouxetine (ProzacR), fluvoxamine (LuvoxR),
and paroxetine (PaxilR). Another that has been studied
in controlled clinical trials is sertraline (ZoloftR).
Large studies have shown that more than three-quarters of patients
are helped by these medications at least a little. And in more than
half of patients, medications relieve symptoms of OCD by diminishing
the frequency and intensity 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 SRI may give a better response. For patients
who are only partially responsive to these medications, research
is being conducted on the use of an SRI as the primary medication
and one of a variety of medications as an additional drug (an augmenter).
Medications are of help in controlling the symptoms of OCD, but
often, if the medication is discontinued, relapse will follow. Indeed,
even after symptoms have subsided, most people will need to continue
with medication indefinitely, perhaps with a lowered dosage.
Behavior TherapyTraditional psychotherapy, aimed at helping the patient develop
insight into his or her problem, is generally not helpful for OCD.
However, a specific behavior therapy approach called "exposure
and response prevention" is effective for many people with
OCD. 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
ritualizing, with support and structure provided by the therapist,
and possibly by others whom 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 greatly 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 behavior therapy for OCD have found it to be a successful
treatment for the majority of patients who complete it. For the
treatment to be successful, it is important that the therapist be
fully trained to provide this specific form of therapy. It is also
helpful for the patient to be highly motivated and have a positive,
The positive effects of behavior therapy endure once treatment
has ended. A recent compilation of outcome studies indicated that,
of more than 300 OCD patients who were treated by exposure and response
prevention, an average of 76 percent still showed clinically significant
relief from 3 months to 6 years after treatment (Foa & Kozak,
1996). Another study has found that incorporating relapse-prevention
components in the treatment program, including follow-up sessions
after the intensive therapy, contributes to the maintenance of improvement
(Hiss, Foa, and Kozak, 1994).
One study provides new evidence that cognitive-behavioral therapy
may also prove effective for OCD. This variant of behavior therapy
emphasizes changing the OCD sufferer's beliefs and thinking patterns.
Additional studies are required before the promise of cognitive-behavioral
therapy can be adequately evaluated. The ongoing search for causes,
together with research on treatment, promises to yield even more
hope for people with OCD and their families.