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Obsessive-compulsive disorder (OCD) describes a syndrome of persistent and recurring obsessions or compulsive behaviors. Obsessions are ideas (including thoughts and images), while compulsions are behaviors such as touching doorknobs while walking down a hall.
In OCD, the thoughts or behaviors are intended to prevent anxiety and unwelcome thoughts/actions from occurring, but instead they create a significant negative impact on the individual’s life. They may be time consuming and interfere with daily activities and functioning in school or work. Individuals with OCD usually understand that their thoughts and actions are irrational, and consequently they may carry a great deal of shame and embarrassment. On the other hand, individuals with poor insight might not recognize the irrational nature of their obsessions and compulsions.
It’s important to distinguish between obsessive-compulsive disorder and obsessive-compulsive personality disorder. Although the two sound similar, obsessive-compulsive personality disorder describes a perfectionist, preoccupied with rules and order, morally rigid, controlling, workaholic. In contrast, individuals with obsessive-compulsive disorder can be seen as tortured by forces that they cannot control.
Obsessions are recurrent intrusive thoughts, ideas, impulses or images that are seen as wrong, grotesque, or illicit. These obsessions produce extreme anxiety and distress and are termed “ego-alien” or “ego-dystonic” because they seem alien and foreign to the individual. Obsessions are perceived as uncontrollable, and the individual fears losing control and acting on their impulses.
The obsessive thoughts can range from worries about turning off the stove burners to frightening images of violent acts toward a loved one. Most frequently, individuals report distressing thoughts about contamination, doubts about having done some action (like locking the door), an overpowering need to have things well ordered and symmetrical, violent urges, or a repeated sexual image. Individuals with obsessive thoughts will often try to manage their anxiety with behaviors that can become compulsions.
Compulsions are repetitive, rigid routines and rituals that are intended to avert some feared outcome or reduce distress. Compulsions include both behaviors, such as hand washing, and mental acts such as counting or praying. The person feels driven to perform their compulsive action, although they usually do not have any understanding of why. Individuals with obsessions of contamination may be compelled to wash their hands every few minutes or to spend disproportionate amounts of time cleaning their surroundings to reduce the fear of contagion. Some individuals express compulsions with a need to count. To be considered a compulsion, the activity must be clearly excessive or not related to the situation it is attempting to prevent. Common compulsions include washing and cleaning, counting, repeating, and checking. Hording, asking for reassurance, and ritualistic touching are also common compulsions.
Research suggests that a critical characteristic in OCD is an overinflated sense of responsibility, in which the individual’s thoughts focus on potentials dangers and an urgent need to take action against those dangers.
Obsessive thoughts are more common than compulsive behavior. More than 50 percent of patients with OCD do not express compulsive behavior. However, OCD is often diagnosed concurrently with depression or other anxiety disorders.
Associated Obsessive Disorders
These disorders are strongly associated with OCD.
- Body dysmorphic disorder: an obsession with the belief that individuals are ugly or that part of their bodies are abnormally shaped.
- Hypochondriasis: denotes an excessive fear of having a serious illness.
- Anorexia nervosa: Individuals with this eating disorder frequently manifest OCD symptoms as well. The compulsive behavior focuses on limited food intake and weight.
- Trichotillomania: describes a condition where individuals continually pull their hair, leaving bald spots.
- Tourette syndrome: Tourette syndrome features jerky movements, tics, and uncontrollably stating indecent words. Up to 50 percent of people with Tourette disorder develop OCD.
- Compulsive shoplifting is also related to OCD.
Obsessive-compulsive disorder occurs in approximately 2.4 percent of the general population and is equally distributed among men and women. Obsessive-compulsive disorder typically begins for males in adolescence to young adult life, but for females it usually originates in the early 20s. Severity fluctuates with life stress.
Symptoms in children may be mistaken for behavioral problems (taking too long to do homework because of perfectionism or refusing to perform a chore because of fear of germs). Children do not usually recognize that their obsessions or compulsions are excessive.
The most effective treatment consists of exposure and response prevention therapy. In this treatment, the patient is exposed to his obsessions and then prevented from making compulsive corresponding action. Before this therapy can begin, there must be a clear understanding of the severity of the OCD and the patient’s anxiety level. Usually therapy starts with low exposure, then moves to more exposure and response prevention as the patient allows. The goal is to keep the anxiety level in manageable ranges and ensure anxiety falls at the end of each treatment. Treatments can take up to two hours, but the length of treatment is relatively short, for approximately 10 sessions.
Therapy may also include cognitive restructuring, designed to refute irrational thoughts and replace them with realistic and functional ones. Other techniques include stress management, assertiveness and social skills training, and strategies for better relationships.