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obsessive compulsive disorder

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Order, Symmetry.... obsessions
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compulsions.....

Obsessive-Compulsive Disorder

"I couldn't do anything without rituals. They invaded every aspect of my life. Counting really bogged me down. I'd wash my hair 3 times as opposed to once because 3 was a good luck number & one wasn't. It took me longer to read because I'd count the lines in a paragraph. When I set my alarm at night, I had to set it to a number that wouldn't add up to a "bad" number."

"Getting dressed in the morning was tough because I had a routine & if I didn't follow the routine, I'd get anxious & would have to get dressed again. I always worried that if I didn't do something, my parents were going to die. I'd have these terrible thoughts of harming my parents. That was completely irrational, but the thoughts triggered more anxiety & more senseless behavior. Because of the time I spent on rituals, I was unable to do a lot of things that were important to me."

"I knew the rituals didn't make sense & I was deeply ashamed of them, but I couldn't seem to overcome them until I had therapy."

Obsessive-compulsive disorder, or OCD, involves anxious thoughts or rituals you feel you can't control. If you have OCD, you may be plagued by persistent, unwelcome thoughts or images, or by the urgent need to engage in certain rituals.

You may be obsessed with germs or dirt, so you wash your hands over & over. You may be filled with doubt & feel the need to check things repeatedly. You may have frequent thoughts of violence & fear that you'll harm people close to you. You may spend long periods touching things or counting; you may be preoccupied by order or symmetry; you may have persistent thoughts of performing sexual acts that are repugnant to you; or you may be troubled by thoughts that are against your religious beliefs.

The disturbing thoughts or images are called obsessions & the rituals that are performed to try to prevent or get rid of them are called compulsions. There's no pleasure in carrying out the rituals you're drawn to, only temporary relief from the anxiety that grows when you don't perform them.

A lot of healthy people can identify with some of the symptoms of OCD, such as checking the stove several times before leaving the house. But for people with OCD, such activities consume at least an hour a day, are very distressing & interfere with daily life.

Most adults with this condition recognize that what they're doing is senseless, but they can't stop it. Some people, though, particularly children with OCD, may not realize that their behavior is out of the ordinary.

Obsessive-compulsive disorder (OCD) is the 4th most common mental disorder in the US, with an estimated lifetime prevalence of 2.3%.1,2

The disorder is often chronic & disabling. Although effective treatments exist, OCD is underdiagnosed & undertreated. More than 1/2 of OCD patients (54.9%) in the US receive no treatment at all; worldwide the figure is 59.5%.3

Due to important advances in pharmacologic treatment, many patients with OCD can be treated in primary care settings.

At this time the 2 first-line treatments for OCD are selective serotonin reuptake inhibitors (SSRIs) & cognitive-behavioral therapy (CBT). Many believe that a combination of these is ideal.

1/3 of adults with OCD report having experienced their first symptoms as children. The course of the disease is variable -symptoms may come & go, they may ease over time, or they can grow progressively worse. Research evidence suggests that OCD might run in families.3

Depression or other anxiety disorders may accompany OCD,2,4 & some people with OCD also have eating disorders.6

In addition, people with OCD may avoid situations in which they might have to confront their obsessions, or they may try unsuccessfully to use alcohol or drugs to calm themselves.4,5

If OCD grows severe enough, it can keep someone from holding down a job or from carrying out normal responsibilities at home.

OCD generally responds well to treatment with medications or carefully targeted psychotherapy.

 

 

"Take everything you like seriously, except yourselves."


Rudyard Kipling

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"OCD is a medical brain disorder that causes problems in information processing. It's not your fault or the result of a "weak" or unstable personality."
 

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"I couldn't do anything without rituals. They invaded every aspect of my life. Counting really bogged me down. I would wash my hair 3 times as opposed to once because 3 was a good luck number & 1 wasn't. It took me longer to read because I'd count the lines in a paragraph. When I set my alarm at night, I had to set it to a number that wouldn't add up to a "bad" number."

The disturbing thoughts or images are called obsessions & the rituals performed to try to prevent or get rid of them are called compulsions. There is no pleasure in carrying out the rituals you're drawn to, only temporary relief from the anxiety that grows when you don't perform them.

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A large body of scientific evidence suggests that OCD results from a chemical imbalance in the brain.

For years, mental health professionals incorrectly assumed OCD resulted from bad parenting or personality defects.

Clinical researchers have implicated certain brain regions in OCD. They have discovered a strong link between OCD & a brain chemical called serotonin. Serotonin is a neurotransmitter that helps nerve cells communicate.

Scientists have also observed that people with OCD have increased metabolism in the basal ganglia & the frontal lobes of the brain. This, scientists believe, causes repetitive movements, rigid thinking & lack of spontaneity.

Successful treatment with medication or behavior therapy produces a decrease in the over activity of this brain circuitry. People with OCD often have high levels of the hormone vasopressin.

In layperson's terms, something in the brain is stuck, like a broken record. Judith Rapoport, M.D., describes it in her book, The Boy Who Couldn't Stop Washing, as "grooming behaviors gone wild."

Characteristics & Course

OCD is characterized by obsessions & compulsions. However, it isn't the only disorder with these symptoms. Obsessions are recurring thoughts, urges or images; in OCD these are experienced as alien, intrusive & distressing.

Compulsions are repetitive behaviors (rituals) that patients feel compelled to perform.

Obsessions & compulsions can take many forms. In recent years, public awareness of OCD has been raised by movies & television shows featuring characters with OCD contamination obsessions & typical cleaning & hand-washing compulsions.

Another familiar set of symptoms is an obsessive fear accompanied by a compulsion to check (e.g., fearing burglars & repeatedly checking that doors & windows are locked shut).

However, not all obsessions & compulsions come in neat, sensible pairings.

Typical obsessions are listed in Table 1; these include preoccupation with contamination, unacceptable violent or sexual thoughts, doubting, concern about asymmetry or imperfections & thoughts that something will go wrong.

Typical rituals are listed in Table 2; these include washing, cleaning, checking, counting, repeating & arranging. Although some patients may have obsessions without any compulsions, often the compulsive behaviors are simply not recognized as they can be mental acts or very subtle behaviors.

An OCD patient might need to have specific thoughts or mental images in order to counter an obsession (e.g., the image of a loved one being harmed might be countered by picturing something good happening to the person).

Patients who have fearful thoughts may hold their breath until the thought passes, shake their head, or blink. Patients generally perform rituals to reduce anxiety created by thoughts of fearful consequences.

However, some patients perform rituals simply because of a general sense of foreboding or because it feels wrong if they do not.

OCD patients usually have good insight. They recognize that their fears are unrealistic,4 yet, their distress compels them to perform rituals.

In their worst moments, insight may waver & fears may seem not only realistic but inevitable unless the ritual is performed.

Although in severe cases of OCD insight may be lost, it must have been present at some time to meet diagnostic criteria.5 It's normal to have occasional unwanted thoughts or perform repetitive or superstitious behaviors accompanied by transient anxiety, but an OCD diagnosis requires that symptoms cause marked distress, be time consuming (≥1 hour/day), or significantly interfere with functioning.5

OCD onset is often in late adolescence or young adulthood, though it can begin at any age. Childhood onset isn't rare. Onset is earlier in males than in females. The course is chronic & waxes & wanes in severity, often in response to stress.

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OCD strikes people of all ethnic groups w/males & females equally affected.

The social & economic costs of OCD were estimated to be $8.4 billion in 1990 (DuPont et al, 1994).

People can be so ashamed of their compulsions & obsessions that they refuse to seek treatment or allow anyone to know they're dealing w/ OCD.

OCD symptoms usually begin during the teen years or in early adulthood & recent research shows that some children develop the illness at earlier ages, even during the preschool years.

Studies also indicate that at least 1/3 of the cases of OCD in adults began in childhood.

Experiencing OCD during early stages of a child's development can cause severe problems for the child. It's important that the child receive evaluation & treatment by an experienced mental health professional to prevent the child from missing important opportunities because of this disorder.

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OCD is a medical brain disorder that causes problems in information processing. It's not your fault or the result of a "weak" or unstable personality.
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"Symptoms"
of
Obsessive Compulsive Disorder

OCD is a very real, chronic, often severe condition that's associated w/recurrent intrusive thoughts that cause extreme discomfort or anxiety (obsessions) &/or senseless repetitive actions (compulsions) that are performed in an effort to try to reduce discomfort & anxiety.

OCD's symptoms can range from:

  • Excessive house cleaning

  • Excessive Hand washing

  • Object hoarding

  • Counting things over & over

In today's society the symptoms are often confused w/highly driven individuals who're in total control of their environment.

Personal hygiene, domestic cleanliness & perfectionism are usually regarded as virtues:

  • Perfect grooming turns heads

  • A spotless house wins praise

  • Corporate culture rewards organizational skills

  • Counting objects is a common obsession

What are some common obsessions?

The following are some common obsessions:

  • Fear of dirt or germs
  • Disgust with bodily waste or fluids
  • Concern with order, symmetry (balance) & exactness
  • Worry that a task has been done poorly, even when the person knows this is not true
  • Fear of thinking evil or sinful thoughts
  • Thinking about certain sounds, images, words or numbers all the time
  • Need for constant reassurance
  • Fear of harming a family member or friend

Copyright © 1994-2005 American Academy of Family Physicians
Permission is granted to print and photocopy this material for nonprofit educational uses. Written permission is required for all other uses, including electronic uses

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While those experiencing OCD continue on their way, obsessing & performing their compulsions, many people who are unaware of the OCD, praise them for their efficiency & organizational skills.

There's such a thing as too much of a good thing though!

Individuals with OCD feel more like someone mysteriously enslaved by incomprehensible forces beyond his or her control. The urges to continually fulfill their tasks can often cause further problems, such as:

  • skin rashes from too much hand washing

  • a loss of hair from continual hair pulling 

  • the loss of a job because they're so compulsive in their quest for perfection that they can't fulfill their full job responsibilities
more symptoms

  • Persistent, unpleasant, & unwelcome mental images, often with a violent theme

  • Uncontrollable urges to count, touch or reorganize everything in sight

  • Washing hands until they're raw to placate an excessive fear of germs
  • Repeatedly checking that the door is locked or the stove is turned off because you're convinced that disaster will strike unless you do so

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"I knew the rituals didn't make sense & I was deeply ashamed of them, but I couldn't seem to overcome them until I had therapy."

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Most Common
Obsessive Intrusive Thoughts

Fear of Contamination

Fearing dirt, germs, cancer, AIDS, bodily waste, asbestos, chemicals, radiation, sticky substances - causing common compulsions, i.e. - ritualistic hand washing

Fear of Causing Harm to Others:

Putting poison in food, spreading illness, smothering a child, pushing a stranger in front of a car, running over a pedestrian - common compulsion that occurs - repeating or checking behavior

Imagining losing control of aggressive urges - common compulsion that occurs - checking

Fear of Making a Mistake:

Setting fire to the house, flooding the house, losing something valuable, bankrupting the company - common compulsion that occurs - praying

Fear of Behaving in a Socially Unacceptable Manner:

Swearing, making sexual advances, saying the wrong thing - common compulsion that occurs - touching

Excessive religious or moral doubt - common compulsion that occurs - counting

A need to have things "just so" - common compulsion that occurs Hoarding or saving

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OCD has been described as, "hiccups of the mind."

Obsessions: recurrent or persistent mental images, thoughts or ideas, which may result in compulsive behaviors, repetitive, rigid & self-prescribed routines that are intended to prevent the manifestation of the obsession.

OCD often co-exists with depression & anxiety. Individuals recognize that the obsessive thoughts & ritualized behavior patterns are senseless & excessive although they can't stop them, in spite of strenuous efforts to ignore or suppress the thoughts or actions.

Obsessions & compulsions don't always coexist; over 1/2 of OCD sufferers have obsessive thoughts without ritualistic behavior. There's some evidence that the symptoms improve over time & that nearly 1/2 will eventually recover completely or have only minor symptoms.

OCD is time-consuming, distressing & can disrupt normal functioning. Much research suggests that a critical feature in this disorder is an overinflated sense of responsibility, in which the patient's thoughts center around possible dangers & an urgent need to do something about it.

The obsessive thoughts or images can range from mundane worries about whether one has locked a door to bizarre & frightening fantasies of behaving violently toward a loved one.

The compulsive acts triggered by such obsessions might include repetitive checking for locked doors or unlit stove burners or calls to loved ones at frequent intervals to be sure they're safe.

Some people are compelled to wash their hands every few minutes or spend inordinate amounts of time cleaning their surroundings in order to subdue the fear of contagion.

Certain other obsessive disorders, including body dysmorphic disorder (BDD), trichotillomania & Tourette's syndrome, may be part of the OCD spectrum.

  • In BDD, people are obsessed believing they're extremely ugly.
  • People with trichotillomania continually pull their hair, leaving bald patches.
  • Symptoms of Tourette's syndrome include jerky movements, tics & uncontrollably uttering obscene words.

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OCD shouldn't be confused w/obsessive-compulsive personality, which defines certain character traits (e.g., being a perfectionist, excessively consciousness, morally rigid & preoccupied w/rules & order).

These traits don't necessarily occur in people w/obsessive-compulsive disorder, which is a psychiatric condition.

Common Compulsive Ritualistic Behaviors
Associated w/OCD

Cleaning/Washing

Hand washing, showering or cleaning oneself repeatedly

Checking/Questioning

Checking to see if light switches, appliances & faucets are off; if doors are locked; numbers are correct

Collecting/Hoarding

Collecting old objects, mail or trash to the point of filling up one's home

Counting/Repeating

Counting to a certain number or counting objects over & over; repeatedly performing a movement or set of movements before being able to move on.

Arranging/Organizing
Arranging items in perfect symmetry or in a particular order (i.e., cans or books on shelves)

What are some common compulsions?

The following are some common compulsions:

  • Cleaning & grooming, such as washing hands, showering or brushing teeth over & over again
  • Checking drawers, door locks & appliances to be sure they are shut, locked or turned off
  • Repeating, such as going in & out of a door, sitting down & getting up from a chair, or touching certain objects several times
  • Ordering & arranging items in certain ways
  • Counting over & over to a certain number
  • Saving newspapers, mail or containers when they're no longer needed
  • Seeking constant reassurance & approval

Copyright © 1994-2005 American Academy of Family Physicians
Permission is granted to print and photocopy this material for nonprofit educational uses. Written permission is required for all other uses, including electronic uses.

Negative comments or criticism from family members often make OCD worse, while a calm, supportive family can help improve the outcome of treatment.
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Co-existing Disorders

OCD is sometimes accompanied by:

A person having more than one disorder find that OCD is often more difficult to diagnose & treat.

Symptoms of OCD can also coexist & may even be part of a spectrum of neurological disorders, such as Tourette's syndrome.
 
Appropriate diagnosis & treatment of other disorders are important to successful treatment of OCD.

People w/OCD experience unwanted obsessions, which cause anxiety. Severe anxiety produces feelings of dread, worry, fright & apprehension (see generalized anxiety disorder GAD).
 
Certain behaviors are performed compulsively in an attempt to lessen this anxiety. Although they realize their obsessions are excessive & their behavior is unreasonable, they feel powerless to control either. In fact, their symptoms can overwhelm them & result in severe impairment & dysfunction, which can begin at an early age.

How do people w/OCD typically react to their disorder?

People w/OCD generally attempt to hide their problem rather than seek help. Often they are remarkably successful in concealing their obsessive-compulsive symptoms from friends & co-workers.

An unfortunate consequence of this secrecy is that people w/OCD generally don't receive professional help until years after the onset of their disease.

By that time, the obsessive-compulsive rituals may be deeply ingrained & very difficult to change.

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Other mental illnesses possibly linked to OCD are:

Genetic studies of OCD & 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 & the environment, on beliefs & attitudes, as well as how information is processed. These behavioral & cognitive theories aren't incompatible w/biological explanations.

Are other illnesses associated with OCD?

People with OCD often have other kinds of anxiety, like phobias (i.e., fear of spiders or flying) or panic attacks.

They may also may have:

Having one or more of these disorders can make diagnosis & treatment more difficult, so it's important to talk to your doctor about any symptoms you have, even if you're embarrassed.

Copyright © 1994-2005 American Academy of Family Physicians
Permission is granted to print and photocopy this material for nonprofit educational uses. Written permission is required for all other uses, including electronic uses.

Treatment of OCD

Researchers have found that clomipramine (Anafranil), an antidepressant medication, helps alleviate painful, intrusive thoughts & repetitive behaviors. Clomipramine has a powerful effect on the neurotransmitter serotonin & helps increase the amount of this important brain chemical to improve communication between the nerve cells.

2 other antidepressant medications, sertraline (Zoloft) <click the underlined link, left, to read info included w/the purchase of Zoloft - difficult reading> & fluoxetine (Prozac), have also been shown to be effective in easing symptoms.

Researchers are currently investigating 2 other medications, paroxetine & fluvoxamine, that may be equally effective in alleviating obsessions & compulsions. Like clomipramine, these medications affect the level of neurotransmitters in the brain & have shown great promise in treating obsessive-compulsive disorder.

As w/all medications, antidepressants have some side effects. The most common side effects are:

  • Sedation
  • Hand tremors