Obsessive Compulsive Disorder in Adults

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Obsessive Compulsive Disorder in Adults

by Glenn Brynes, PhD, MD
© January 2001

Description of OCD Symptoms

"Imagine you are getting up in the morning. You know you will need to go to the bathroom, but the thought of accidentally touching the doorknob is frightening. There may be dangerous bacteria on it. Of course you cleaned the entire bathroom yesterday, including the usual series of disinfectant spraying, washing and rinsing. As usual it took a couple of hours to do it the right way. Even then you weren't sure whether you had missed an area, so you had to re-wash the floor. Naturally the doorknob was sprayed and rubbed three times with a bactericidal spray. Now the thought that you could have missed a spot on the doorknob makes you very nervous. Maybe you should have cleaned it another time? Carefully you put on your laundered slippers and think to yourself repeatedly, "The Lord will protect me from all germs; I will fear no evil", and cross the floor to the bathroom, careful to do it in exactly 10 steps. On some days you spend so much of your time checking, cleaning and arranging things, there is little time left for other matters."

This description might give you some sense of the tormented and anxious world that people with Obsessive Compulsive Disorder (OCD) live in. It is a world filled with dangers from outside and from within. Often elaborate rituals and thoughts are used to ward off feared events, but no amount of mental or physical activity seems adequate, so doubt and anxiety are often present.

(Read this description of what it's like living with OCD)

Obsessions are thoughts or images that seem to intrude into a person's mind. While he generally knows they are his own thoughts, he can't control them, and finds them very disturbing. They may take the form of fears of something terrible happening to himself, his friends or family, often as a result of his own actions or neglect.

Compulsions are behaviors that usually are repetitive and stereotyped. They may take the form of actions or thoughts. The compulsive behaviors are intended to reduce the anxiety engendered by obsessions. People who do not have OCD may perform behaviors in a ritualistic way, repeating, checking, or washing things out of habit or concern. Generally this is done without much if any worry. What distinguishes OCD as a psychiatric disorder is that the experience of obsessions, and the performance of rituals, reaches such an intensity or frequency that it causes significant psychological distress and interferes in a significant way with psychosocial functioning. The guideline of at least one hour spent on symptoms per day (American Psychiatric Association 1994; Goodman et al. 1989b) is often used as a measure of "significant interference." However, among patients who try to avoid situations that bring on anxiety and compulsions, the actual symptoms may not consume an hour. Yet the quantity of "time lost" from having to avoid objects or situations would clearly constitute interfering with functioning. Consider, for instance, a welfare mother who throws out more than $100 of groceries a week because of contamination fears. Although this behavior has a major effect on her functioning, it might not consume one hour per day.

Patients with OCD describe their experience as having thoughts (obsessions) that they associate with some danger. The sufferer generally recognizes that it is his own thought, rather than something imposed by someone else (as in some paranoid schizophrenic patients). However the disturbing thought cannot be dismissed, and simply nags at him. Something must then be done to relieve the danger and mitigate the fear. This leads to actions and thoughts that are intended to neutralize the danger. These are the compulsions. Because these behaviors seem to give the otherwise "helplessly anxious" person something to combat the danger, they are temporarily reassuring. However, since the "danger" is typically irrational or imaginary, it simply returns, thereby triggering another cycle of the briefly reassuring compulsions. From the standpoint of classic conditioning, this pattern of painful obsession followed by temporarily reassuring compulsion eventually produces an intensely ingrained habit. It is rare to see obsessions without compulsions.

The two most common obsessions are fears of contamination and fear of harming oneself or others. The two most common compulsions are checking and cleaning (Foa and Kozak 1995).

OCD Can Mimic Other Disorders

An OCD sufferer with an intense fear of contamination might avoid the object of his fear by staying home, and thus become housebound as in agoraphobia. The distinction becomes apparent when the reason for staying home is investigated.

Obsessive Compulsive Disorder may manifest with fears of contracting severe illnesses, such as cancer, venereal diseases or AIDS. These somatic obsessions may resemble hypochondria. Despite the similarities, the OCD patient will often have a typical history of various obsessions and compulsive symptoms that are not primarily somatic (e.g. fears of hitting someone, compulsions to count or check).

OCD can result in depression as well as avoidant behavior that resembles specific or social phobias. The degree of anxiety experienced in connection with the obsessions may be so pervasive that it can resemble generalized anxiety disorder.

Genetics of OCD

The prevalence of OCD in the United States is estimated to be 2-3%. Thus 5-7 million Americans have this illness. Studies of OCD patients and their families have established a 10% prevalence of OCD in first degree relatives (an additional 8% have a subclinical degree of OCD symptoms). The genetic connection seems to be higher if the onset of OCD is before age 14. In studies of twins, there is a 63% concordance rate for OCD in identical twins.

Treatment of OCD

Prior to studies in the 1980's, the usual view of OCD was that it was a relatively rare disorder with a poor prognosis. However, in addition to it being now recognized to be much more common (2-3% prevalence rate), it is generally seen to be treatable, with some 60%–80% of patients showing at least some response to treatment.

It is generally thought that the serotonin system in the brain is involved in the pathology of OCD, since the pharmacological agents that have been shown to be effective in the treatment of ocd generally increase the availability of this neurotransmitter. These include the serotonin re-uptake inhibitors: clomipramine, fluoxetine, sertraline, paroxetine, fluvoxamine, and citalopram.

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Behavioral therapy - specifically ERP [Exposure and Response Prevention] - has been successfully used for the treatment of OCD. The idea behind ERP is that compulsions provide only a temporary reduction of the anxiety produced by obsessions. Furthermore, the only way to experience more permanent relief is to habituate (grow tolerant of…"used to") the anxiety caused by the obsession without performing the compulsion. Habituation is the key factor, and clinicians proceed by first identifying triggers for and situations that bring on obsessional thoughts and compulsive behaviors and then developing a graduated hierarchy of anxiety based on the patient's report. The patient "challenges" him- or herself with the least anxiety-provoking items first and then moves up the hierarchy. In addition to exposure, the patient is instructed to refrain from carrying out the associated rituals.

Heidi was afraid of germs and dirt. She felt very uncomfortable whenever she had to go into a bathroom. She carried tissues with which to open the bathroom door, and had to wash her hands several times before leaving the bathroom. The door was then opened with a paper towel. If she accidentally touched the door, she had to wash all over again.

For her ERP treatment, Heidi was told to spent 10 minutes sitting on a chair in her bathroom without washing her hands. This was to be repeated each day for a week. Initially she felt very uncomfortable, and greatly wished to clean her hands. She found herself thinking of the dirt and "germs" that she felt must be everywhere in the bathroom. However with much effort she was able to tolerate this. Once she had 'mastered' this she was told to increase the time from 10 to 20 minutes. She was still uncomfortable, but was a bit surprised that spending twice as long didn't mean being twice as uncomfortable. Indeed after about 10 minutes, she felt somewhat relieved that nothing terrible had occurred. Further extending the time to 30 minutes simply led to her feeling that nothing was going to happen if she spent more time not washing. Once Heidi had mastered this, she was told to touch the inside of the sink, and not wash her hands for 10 minutes. Since she regarded the sink as one of the moderately dirty places in the bathroom, this presented a new challenge for her. As she mastered one level of discomfort, she was moved on to the next more challenging level, until she finally was able to use the bathroom without intolerable anxiety and without her usual rituals.

An added benefit of behavioral treatment is its long-term efficacy. Unlike pharmacotherapy, whose beneficial effects do not last in the great majority of patients after medication is withdrawn, behavioral therapy has shown continued efficacy in follow-up studies ranging from 1 to 6 years, although booster sessions may be required.

Summary

Obsessive Compulsive Disorder is more common than generally believed 20 years ago. It appears to be largely a neuropsychiatries condition, rather than a product of overly strict upbringing (as was once believed). Although OCD can have a paralyzing impact if not properly diagnosed and treated, there are fortunately behavioral and pharmacological approaches available that can help many of the sufferers from this potentially devastating illness.

Obsessions may often involve thoughts which seem unacceptable to the individual, so that he or she feels ashamed. Because of this, many people keep their thoughts a secret and suffer silently. In the past decade, there have been advances in the behavioral and pharmacological treatment of Obsessive Compulsive Disorder. For helpful mental health links, please see the links below.

Obsessive Compulsive Disorder in Adults

Description of OCD Symptoms

OCD Can Mimic Other Disorders

Genetics of OCD

Treatment of OCD

Summary

More Links related to OCD

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