Obsessive-Compulsive Disorder (OCD)

by Karen M. Stufflebeam, M.A., Doctoral student at MSPP and Clinician at Family Service Inc.

Obsessive-Compulsive Disorder (OCD) is categorized as an anxiety disorder according to the American Psychological Association and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. One in fifty adults currently struggle with OCD, which equals out to about one to two percent of the United States population. OCD typically presents itself between the ages of eight and twelve and either re-emerges or presents itself for the first time in the late teens/mid twenties, but can present itself for the first time as late as forty years of age. OCD presents itself equally among adult men and women, but is typically more prevalent in males during the childhood years. OCD symptoms wax and wane over the years, with significant distress from symptoms occurring around stressful times in the individual's life.

What Is Obsessive-Compulsive Disorder?

Although we all worry about things throughout the day, an anxiety disorder such as OCD takes our typical day-to-day worries to the extreme. Obsessions are characterized by persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause anxiety or distress. Compulsions are repetitive behaviors or mental acts, the goal of which is to prevent or reduce anxiety or distress, not to provide pleasure or gratification.

OCD symptoms typically take up a significant amount of the sufferers time (more than an hour a day) and/or significantly interfere with the person’s work, relationships, or social life. Those suffering from OCD recognize their obsessions and compulsions to be unreasonable.

Can I Be/Have I Been Misdiagnosed?

OCD is distinguishable from Post-Traumatic Stress Disorder in that OCD is not caused by a terrible event. Other diagnoses that lay along the OCD spectrum are Body Dysmorphic Disorder, Tic Disorders (such as Tourette’s Disorder), Trichotillomania (compulsive hair pulling) and habit disorders, such as nail biting or skin picking.

Common Symptoms of OCD

Obsessions:

  • Contamination fears of germs, dirt, etc.
  • Imagining having harmed oneself or others
  • Imagining losing control or having aggressive urges
  • Intrusive sexual thoughts or urges
  • Excessive religious or moral doubt
  • Forbidden thoughts
  • A need to have things “just so”
  • A need to tell, ask, or confess

Compulsions:

  • Washing
  • Checking
  • Repeating
  • Mental reviewing
  • Touching
  • Counting
  • Praying (to reduce anxiety)
  • Avoiding
  • Reassurance seeking

What Causes Obsessive-Compulsive Disorder?

Although there is no known cause for OCD, there are several theories at the forefront of the OCD research that indicate some of the main contributing factors in the onset and maintenance of OCD.

History

Obsessive-Compulsive disorder has a long history of documentation, going as far back as three-hundred years. During the late seventeenth century and early nineteenth century writers have indicated OCD to be caused by Satan (17th century) and also called “The Doubting Madness” (19th century). During the twentieth century OCD was viewed primarily through a psychodynamic lens indicating symptoms reflecting maladaptive responses to unresolved conflicts from early stages of psychological development. OCD has also been viewed through an evolutionary lens, indicating that during a time when physical threat was imminent, “obsessing” about germs and the safety of one’s family was “adaptive”; this system has since broken down and has become maladaptive.

Thought-Action Fusion (TAF) and Thought Suppression

Those suffering from OCD have a heightened awareness of their thoughts and a catastrophic misinterpretation of the significance of their thoughts resulting in the thoughts becoming very important, personally significant, revealing, and threatening. This phenomenon is summarized as Thought-Action Fusion: people tend to regard their thoughts as being psychologically equivalent to the corresponding action, and/or to believe that their thoughts of possible misfortunes actually increase the likelihood that the misfortune will occur.

Suppression is the willful attempt to move unwanted thoughts away from one’s consciousness. Volitional thought suppression has been found to produce an immediate increase in cognitive intrusions, an enhancement effect, or an increase in intrusions following suppression. In other words, the more one tries to suppress a thought the more frequently the thought occurs.

The Brain           

Research on the brains of those suffering from OCD has been extremely useful in explaining this disorder. The Frontal Cortex is involved in motor function, problem solving, spontaneity, memory, language, initiation, judgment, impulse control, and social and sexual behavior. The latest research indicates that there is abnormal metabolic activity in this area of the brain of those struggling with OCD, more specifically, in the anterior cingulated cortex, the caudate nucleus, and the orbital frontal cortex.

The neurological pathway primarily involved in OCD is the cortico-striato-thalamic pathway. It has been found through neuroimaging studies that at rest, those struggling with OCD have increased activity in the cortico-striato-thalamic pathway. For example, the orbital frontal cortex is involved in decision making, and if this region is overactive, the evaluation of consequences of actions might be increased (a.k.a. “over-thinking”).

Hyperactivity in the dorsal region of the anterior cingulate cortex could keep an individual’s focus on his or her thoughts when making a decision (obsessional thinking) and hyperactivity in the ventral region could keep his or her attention on internal emotional states, leading to a feeling of unease or guilt.

The ventral region of the caudate nucleus controls stopping and starting behaviors in procedural learning, and if this information is not integrated properly, some behavior may function in loops, leading to repetitive thoughts, emotional experiences, and behaviors.

Treatment of Obsessive-Compulsive Disorder

Many treatments have been tried and failed, but the latest research indicates the following as the most effective forms of treatment available.

Exposure and Response Prevention Therapy (ERP)

The body cannot remain in the “fight or flight” response for long periods of time, which is typically the feeling one has when facing a trigger (i.e. what makes one anxious). The body, through evolution, is designed to calm itself down (a.k.a. the parasympathetic nervous system). Otherwise, the “fight or flight” response can actually damage the body. Compulsions get in the way of the body’s natural ability to calm itself down, thus the purpose of ERP is to allow the body the time it needs to do just that.

In order to reduce the fear one must face the fear. The purpose of ERP is to expose the individual to his or her trigger and through the initial guidance of a “coach” the individual is prompted to prevent his or her ritual(s). By facing the trigger and not performing the compulsion, the body naturally reduces its own anxiety. Over time, the body habituates to the initial trigger, meaning that the individual eventually comes to experience little/no anxiety with that trigger.

These triggers are placed on a hierarchy and treatment is designed in a collaborative manner between the client and the therapist. One of the many reasons ERP is so effective is that it can be tailored to each individual’s specific set of symptoms, thus making treatment unique and personalized to that individual.

Pharmacotherapy

Serotonin appears to be a key player in the successful treatment of Obsessive-Compulsive Disorder. Although many anti-depressants have been experimented with, only a few have been shown to consistently have a positive effect: clomipramine (up to 250mg a day), fluvoxamine (up to 300mg a day), paroxetine (up to 60mg a day) and fluoxetine (up to 80mg a day).

Clomipramine (Anafranil) is the most thoroughly studied drug for OCD and was the first to receive FDA approval for this indication.

The information in the article above was drawn from the following sources:

Additional Sources of Information

Disclaimer: Material on the Project INTERFACE web site is intended as general information. It is not a recommendation for treatment, nor should it be considered medical or mental health advice. Project INTERFACE urges families to discuss all information and questions related to medical or mental health care with a health care professional.