Obsessive/Compulsive Disorder (OCD)

Obsessive-Compulsive Disorder (OCD) is an intriguing and often debilitating neurobiological condition where an individual suffers with repetitive intrusive, unwanted thoughts, feelings, urges or mental images that cause anxiety (obsessions) and develop the subsequent need to perform certain repetitive behaviors or mental acts in response to the thoughts (compulsions) in an effort to relieve the anxiety. OCD affects both men and women and people of all races and socioeconomic backgrounds. It usually appears in childhood, adolescence or early adulthood and is a chronic condition. The onset of OCD is usually a gradual process, however, in some cases it can start abruptly, particularly following trauma. Typically speaking symptoms of OCD worsen with age. OCD is estimated to among the top 20 causes of illness-related disability worldwide for people aged 15-44. Currently, there is no “cure” for OCD as it appears to be a chronic life-long condition.

Despite a wealth or research, the exact cause of OCD is not known. Some speculate that there is a neurobiological basis, as neuroimaging shows differences in brain functioning with people with OCD. There is a link between OCD and the neurotransmitter serotonin. There are genetic, behavioral, cognitive, neurological and environmental contributors to this condition. Individuals may have symptoms of obsessions, compulsions or both.

Characteristics of the OCD include:

• Not being able to control one’s thoughts or behaviors, even when one is aware that they are irrational and/or excessive.
• Spending at least one hour a day on these thoughts and behaviors.
• Not getting pleasure when performing the rituals, but one does experience some relief from the anxiety associated with the thoughts.
• Experiences significant interference with social and occupational functioning related to this pattern.

Common Obsessions include:

• Fear of contamination such as germs, viruses, body fluids, chemicals or dirt.
• Fear of losing control of oneself by acting on thoughts or impulses, such as harming someone, blurting out swear words, stealing or being violent and harming self or others.
• Unwanted intrusive sexually explicit or violent thoughts and images.
• Excessive thoughts regarding religious or moral conditions.
• A fixation on certain numbers and/or colors being good or bad, right or wrong.

Common Compulsions include:

• Excessive cleaning and/or hand washing.
• Repeatedly checking the door, coffee pot or oven to be sure they are locked or off.
• Counting objects, letters, words or anything.
• Doing routine activities repeatedly, like going up the stairs to turn the light on and then down the stairs to turn the light back off.

Not all rituals or habits are compulsions. With OCD, the individual’s thoughts cause them to feel out of control, as well as to experience significant anxiety, fear, disgust and/or guilt. This then
causes the repetitive behaviors to occur over and over again, possibly for hours on end, in order to relieve their anxiety. A client presenting for help with OCD is diagnosed by presentation of symptoms and clinical history.

Clients have an assortment of presentations, however, typically speaking they present with one or an assortment of the following:

• Checking – The need to repeatedly check things such as those things that might pose threat (door unlocked), harm (coffee pot not turned off), leaks (gas or carbon monoxide), damage or
  fire.
• Mental or Physical Contamination – excessive washing, brushing of teeth, cleansing to get emotions to go away.
• Hoarding – The inability to throw away used or useless possessions.
• Rumination – Extended and unfocused obsessive train of thought that focuses on wide-ranging topics such as “life after death”. No satisfactory conclusion is ever achieved.
• Intrusive Thoughts – Often violent, horrific, obsessional thoughts that involve hurting a loved one.
• Symmetry and orderliness – Person obsesses about objects being lined up to avoid discomfort.

Clinically, the obsessions and compulsions cause marked distress, are time consuming and interfere with a person’s normal routine. While the struggles of OCD are fairly consistent over the life span, how the symptoms present for help and other contributing causes may vary.

OCD in children is more common in boys than in girls, as the typical onset of symptoms is later in females than males. It is estimated that one in every 100 children struggle with OCD. There are as many children with OCD as there are children with diabetes Children don’t always talk about the fears and behaviors OCD causes. They often feel embarrassed or confused about their fear and will keep it to themselves. They also try to hide their rituals. Children are typically going to present their obsessions as “bad thoughts” or fears or worries. A child will often have difficulty describing their thoughts or putting them into words. For Example: A child may have a reoccurring fear of their mother getting killed and insist on a particular “good by” when parting, and the insistence on confirming the safety and location of the mother at all times, and may experience tremendous fear or panic if unable to locate the mother. Although fears of harm, germs, washing and checking are very common of OCD in children, the symptoms may manifest in a variety of ways. Children often experience uncomfortable feelings or urges regarding something having to be “just right”, rather than specific detailed obsessions. This child may put on and take off the same sure repeatedly until it “feels right”. Because children OCD often try to hide their struggle, it’s important for parents to keep an eye on other areas that might indicate a problem.

These include:

• Does the child have difficulty concentrating or enjoying activities?
• Does the child feel or act irritable, upset or anxious?
• Does the child seem to question if things are “OK”?
• Does the child take enormous amounts of time for everyday tasks such as getting ready, organizing their room, taking a shower or completing school assignments?
• Does the child react negatively or lose their temper if things are out of place?
• Does the child insist that the parent say or do something in an exact manner?

All of the above can be signs that there may be a bigger problem to assess. OCD in the elderly will have similar presentations, to those at other ages. However, it is important to note that anxiety and OCD symptoms that emerge in an elderly person could be related to Alzheimer’s disease or dementia. Seniors with Alzheimer’s and frontotemporal dementia may experience obsessive thoughts and develop ritualistic behaviors that baffles caregivers. This is important to differentiate as if the cause is either of the conditions above, the treatment will differ from that of OCD.
One of the most difficult things to deal with when diagnosed with OCD is that it is quite challenging to treat. While there is a broad range regarding severity of symptoms, when one has severe chronic OCD, treatment is varied and somewhat unpredictable. The challenge for treatment effectiveness several components. First, clients often hide their symptoms due to embarrassment and stigma. Second, there is a lack of training in health professionals. Lastly, it can be difficult finding local therapists who can effectively treat OCD.

The most common treatments are Cognitive Behavioral Therapy, exposure and response prevention, and psychotropic medications such as SSRIs or antipsychotics. Reports indicate that about 70% of clients with OCD will benefit from Cognitive Behavioral Therapy or medication. However, it can often take multiple medication trials to find relief and even then only about 45-45% of those struggle with find significant relief with medication. Moreover, for those who do find relief with therapeutic treatment and medication it is typically a life-long challenge that is affected by acute stress, hormones, physical condition and illness. A person might find stability for years only to have symptoms emerge again. While some people are able to find significant relief, most struggle at some level on a regular basis with the symptoms and unwanted thoughts.

OCD myths and misconceptions include:

• There is only one type of OCD.
• OCD is just about cleaning, hand washing and being a germaphobe.
• People with OCD are “neat and tidy” – people with OCD wash because they are concerned and have fears of contamination. Additionally, 2?3 or people with OCD are hoarders, i.e. they accumulate unneeded items and garbage.
• OCD is caused by developmental injuries in childhood – this is a neurobiological condition.
• When a person has OCD it’s obvious.
• Religion makes people compulsive.
• People with OCD are intense, weird, neurotic and just need to relax.
• “We are all a little OCD at times”.
• “OCD is not that big of a deal, people need to just relax and not worry so much”.
• Stress causes OCD.

In conclusion, OCD is a complex and challenging condition that effects people across the lifespan. With early diagnosis and treatment, many clients can find relief. However, the treatment is complex and requires a skilled treatment team which ideally includes the client, their family, a therapist and a medical professional.

Lisa Day, R.N.,Ph.D.

Dr. Lisa Day is the host of Meier Clinics Podcast on Mental Health News Radio Network. She is a registered nurse, clinical psychologist, and director of the Meier Clinics Idaho office. For more information about Dr. Day visit www.meierclinicspodcast.com.