Obsessive–compulsive disorder

Obsessive–compulsive disorder (OCD) is a mental disorder where people feel the need to check things repeatedly, perform certain routines repeatedly (called "rituals"), or have certain thoughts repeatedly. People are unable to control either the thoughts or the activities for more than a short period of time. Common activities include hand washing, counting of things, and checking to see if a door is locked. Some may have difficulty throwing things out. These activities occur to such a degree that the person's daily life is negatively affected. Often they take up more than an hour a day. Most adults realize that the behaviors do not make sense. The condition is associated with tics, anxiety disorder, and an increased risk of suicide.
The cause is unknown. There appear to be some genetic components with both identical twins more often affected than both non-identical twins. Risk factors include a history of child abuse or other stress inducing event. Some cases have been documented to occur following infections. The diagnosis is based on the symptoms and requires ruling out other drug related or medical causes. Rating scales such as the Yale–Brown Obsessive Compulsive Scale can be used to assess the severity. Other disorders with similar symptoms include anxiety disorder, major depressive disorder, eating disorders, tic disorders, and obsessive–compulsive personality disorder.
Treatment involves counselling, such as cognitive behavioral therapy (CBT), and sometimes medication, typically selective serotonin reuptake inhibitors (SSRIs). CBT for OCD involves increasing exposure to what causes the problems while not allowing the repetitive behavior to occur. While clomipramine appears to work as well as SSRIs, it has greater side effects. Atypical antipsychotics may be useful when used in addition to an SSRI in treatment-resistant cases but are also associated with an increased risk of side effects. Without treatment, the condition often lasts decades.
Obsessive–compulsive disorder affects about 2.3% of people at some point in their life. Rates during a given year are about 1.2% and it occurs worldwide. It is unusual for symptoms to begin after the age of thirty-five, and half of people develop problems before twenty. Males and females are affected about equally. In English the phrase "obsessive–compulsive" is often used in an informal manner unrelated to OCD to describe someone who is excessively meticulous, perfectionistic, absorbed, or otherwise fixated.
Obsessions are thoughts that recur and persist despite efforts to ignore or confront them. People with OCD frequently perform tasks, or compulsions, to seek relief from obsession-related anxiety. Within and among individuals, the initial obsessions, or intrusive thoughts, vary in their clarity and vividness. A relatively vague obsession could involve a general sense of disarray or tension accompanied by a belief that life cannot proceed as normal while the imbalance remains. A more intense obsession could be a preoccupation with the thought or image of someone close to them dying or intrusions related to "relationship rightness." Other obsessions concern the possibility that someone or something other than oneself—such as God, the Devil, or disease—will harm either the person with OCD or the people or things that the person cares about. Other individuals with OCD may experience the sensation of invisible protrusions emanating from their bodies, or have the feeling that inanimate objects are ensouled.
Some people with OCD experience sexual obsessions that may involve intrusive thoughts or images of "kissing, touching, fondling, oral sex, anal sex, intercourse, incest and rape" with "strangers, acquaintances, parents, children, family members, friends, coworkers, animals and religious figures", and can include "heterosexual or homosexual content" with persons of any age. As with other intrusive, unpleasant thoughts or images, some disquieting sexual thoughts at times are normal, but people with OCD may attach extraordinary significance to the thoughts. For example, obsessive fears about sexual orientation can appear to the person with OCD, and even to those around them, as a crisis of sexual identity. Furthermore, the doubt that accompanies OCD leads to uncertainty regarding whether one might act on the troubling thoughts, resulting in self-criticism or self-loathing.
People with OCD understand that their notions do not correspond with reality; however, they feel that they must act as though their notions are correct. For example, an individual who engages in compulsive hoarding might be inclined to treat inorganic matter as if it had the sentience or rights of living organisms, while accepting that such behavior is irrational on a more intellectual level.
OCD sometimes manifests without overt compulsions. Nicknamed "Pure-O", or referred to as Primarily Obsessional OCD, OCD without overt compulsions could, by one estimate, characterize as many as 50 percent to 60 percent of OCD cases. Primarily obsessional OCD has been called one of the most distressing and challenging forms of OCD. People with this form of OCD have distressing and unwanted thoughts emerging frequently, and these thoughts typically center on a fear that one may do something totally uncharacteristic of oneself, possibly something potentially fatal to oneself or others. The thoughts may likely be of an aggressive or sexual nature.
Rather than engaging in observable compulsions, the person with this subtype might perform more covert, mental rituals, or might feel driven to avoid the situations in which particular thoughts seem likely to intrude. As a result of this avoidance, people can struggle to fulfill both public and private roles, even if they place great value on these roles and even if they had fulfilled the roles successfully in the past. Moreover, the individual's avoidance can confuse others who do not know its origin or intended purpose, as it did in the case of a man whose wife began to wonder why he would not hold their infant child. The covert mental rituals can take up a great deal of a person's time during the day.
Some people with OCD perform compulsive rituals because they inexplicably feel they have to, others act compulsively so as to mitigate the anxiety that stems from particular obsessive thoughts. The person might feel that these actions somehow either will prevent a dreaded event from occurring, or will push the event from their thoughts. In any case, the individual's reasoning is so idiosyncratic or distorted that it results in significant distress for the individual with OCD or for those around them. Excessive skin picking, hair-pulling, nail biting, and other body-focused repetitive behavior disorders are all on the obsessive–compulsive spectrum. Some individuals with OCD are aware that their behaviors are not rational, but feel compelled to follow through with them to fend off feelings of panic or dread.
Some common compulsions include hand washing, cleaning, checking things (e.g., locks on doors), repeating actions (e.g., turning on and off switches), ordering items in a certain way, and requesting reassurance. Compulsions are different than tics (such as touching, tapping, rubbing, or blinking) and stereotyped movements (such as head banging, body rocking, or self-biting), which usually aren't as complex as compulsions and aren't precipitated by obsessions. It can sometimes it may be difficult to tell the difference between compulsions and complex tics. About 10% to 40% of individuals with OCD also have a lifetime tic disorder.
People rely on compulsions as an escape from their obsessive thoughts; however, they are aware that the relief is only temporary, that the intrusive thoughts will soon return. Some people use compulsions to avoid situations that may trigger their obsessions. Although some people do certain things over and over again, they do not necessarily perform these actions compulsively. For example, bedtime routines, learning a new skill, and religious practices are not compulsions. Whether or not behaviors are compulsions or mere habit depends on the context in which the behaviors are performed. For example, arranging and ordering DVDs for eight hours a day would be expected of one who works in a video store, but would seem abnormal in other situations. In other words, habits tend to bring efficiency to one's life, while compulsions tend to disrupt it.
In addition to the anxiety and fear that typically accompanies OCD, sufferers may spend hours performing such compulsions every day. In such situations, it can be hard for the person to fulfill their work, family, or social roles. In some cases, these behaviors can also cause adverse physical symptoms. For example, people who obsessively wash their hands with antibacterial soap and hot water can make their skin red and raw with dermatitis.
People with OCD can use rationalizations to explain their behavior; however, these rationalizations do not apply to the overall behavior but to each instance individually. For example, a person compulsively checking the front door may argue that the time taken and stress caused by one more check of the front door is much less than the time and stress associated with being robbed, and thus checking is the better option. In practice, after that check, the person is "still" not sure and deems it is "still" better to perform one more check, and this reasoning can continue as long as necessary.
Some people with OCD exhibit what is known as "overvalued ideas". In such cases, the person with OCD will truly be uncertain whether the fears that cause them to perform their compulsions are irrational or not. After some discussion, it is possible to convince the individual that their fears may be unfounded. It may be more difficult to do ERP therapy on such people because they may be unwilling to cooperate, at least initially. There are severe cases in which the person has an unshakeable belief in the context of OCD that is difficult to differentiate from psychotic disorders.
A 2013 meta-analysis confirmed people with OCD to have mild but wide-ranging cognitive deficits; significantly regarding spatial memory, to a lesser extent with verbal memory, fluency, executive function and processing speed, while auditory attention was not significantly affected. People with OCD show impairment in formulating an organizational strategy for coding information, set-shifting, motor and cognitive inhibition.
People with OCD may be diagnosed with other conditions, as well or instead of OCD, such as the aforementioned obsessive–compulsive personality disorder, major depressive disorder, bipolar disorder, generalized anxiety disorder, anorexia nervosa, social anxiety disorder, bulimia nervosa, Tourette syndrome, Asperger syndrome, attention deficit hyperactivity disorder, dermatillomania (compulsive skin picking), body dysmorphic disorder, and trichotillomania (hair pulling). In 2009 it was reported that depression among those with OCD is particularly alarming because their risk of suicide is high; more than 50 percent of people experience suicidal tendencies, and 15 percent have attempted suicide. Individuals with OCD have also been found to be affected by delayed sleep phase syndrome at a substantially higher rate than the general public. Moreover, severe OCD symptoms are consistently associated with greater sleep disturbance. Reduced total sleep time and sleep efficiency have been observed in people with OCD, with delayed sleep onset and offset and an increased prevalence of delayed sleep phase disorder.
Behaviorally, there is some research demonstrating a link between drug addiction and the disorder as well. For example, there is a higher risk of drug addiction among those with any anxiety disorder (possibly as a way of coping with the heightened levels of anxiety), but drug addiction among people with OCD may serve as a type of compulsive behavior and not just as a coping mechanism. Depression is also extremely prevalent among people with OCD. One explanation for the high depression rate among OCD populations was posited by Mineka, Watson, and Clark (1998), who explained that people with OCD (or any other anxiety disorder) may feel depressed because of an "out of control" type of feeling.
Someone exhibiting OCD signs does not necessarily have OCD. Behaviors that present as (or seem to be) obsessive or compulsive can also be found in a number of other conditions as well, including obsessive–compulsive "personality" disorder (OCPD), autism, disorders where perseveration is a possible feature (ADHD, PTSD, bodily disorders or habit problems), or sub-clinically.
Some with OCD present with features typically associated with Tourette's syndrome, such as compulsions that may appear to resemble motor tics; this has been termed "tic-related OCD" or "Tourettic OCD".