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Obsessive-Compulsive
Disorder
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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.
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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 al, 1994).
- 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.
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Obsessions
- These 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.
Compulsions
- In 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.
Insight
- People 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.
Resistance
- Most 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 Secrecy
- OCD 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 the rituals.
Long-lasting Symptoms
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.
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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 cognitive processes.
- 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.
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Do I Have OCD? (screening test)
- 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.
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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.
Pharmacotherapy
- Clinical 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 Therapy
- Traditional 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, determined attitude.
- 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.
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How to Get Help for OCD
- If you think that you have OCD, you should seek the help of a mental
health professional. Family physicians, clinics, and health maintenance
organizations may be able to provide treatment or make referrals to mental
health centers and specialists. Also, the department of psychiatry at a
major medical center or the department of psychology at a university may
have specialists who are knowledgeable about the treatment of OCD and are
able to provide therapy or recommend another doctor in the area.
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What the Family Can Do to Help
- OCD affects not only the sufferer but the whole family. The family often
has a difficult time accepting the fact that the person with OCD cannot stop
the distressing behavior. Family members may show their anger and
resentment, resulting in an increase in the OCD behavior. Or, to keep the
peace, they may assist in the rituals or give constant reassurance.
- Education about OCD is important for the family. Families can learn
specific ways to encourage the person with OCD to adhere fully to behavior
therapy and/or pharmacotherapy programs. Self-help books are often a good
source of information. Some families seek the help of a family therapist who
is trained in the field. Also, in the past few years, many families have
joined one of the educational support groups that have been organized
throughout the country.
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