Obsessive-compulsive disorder (OCD) is a common and serious mental illness characterized by the presence of obsessions and/or compulsions that cause intense discomfort and disrupt the sufferer’s daily life.
OCD Symptoms
Obsessive-compulsive disorder can be effectively treated with both medication and psychotherapeutic intervention. Obsessions are thoughts, images, fears, doubts, or urges that intrude on the patient’s mind. The latter experiences them as uninvited, unwanted, or stupid, and they cause him anxiety and discomfort. He has difficulty controlling and getting rid of them. The content of the obsessions is varied, and the patient may have many different obsessions, although usually one or two themes predominate. The most common obsessions include:
- Fear of contamination from dirty objects, chemicals, body fluids, or germs.
- Doubts and fears about the occurrence of something bad (the stove was left on and the house could catch fire, the door is unlocked and burglars will enter, etc.).
- Excessive preoccupation with precision, order, and symmetry.
- Blasphemous thoughts with religious content.
- Sexual thoughts or images.
- Violent thoughts or images.
- Tendency to collect and hoard various useless items in case they are ever needed.
It should be emphasized that thoughts similar to the above occur occasionally in almost all people without causing particular anxiety. In contrast, OCD patients attribute a different meaning to these thoughts. They believe that they have the power to cause harm to someone and, at the same time, the responsibility to prevent such harm. For example, when the sufferer thinks of himself attacking somebody, he believes that he is indeed dangerous and tries hard to prevent harm by resorting to compulsions and avoidance behaviors. The core of the problem in obsessive-compulsive disorder is a pathologically heightened sense of personal responsibility and the consequent efforts to avoid harming oneself or others.
Compulsions and obsessions
Compulsions are actions or thoughts that are repeated over and over in response to an obsession. Their goal is to prevent harm. They temporarily reduce the anxiety caused by the obsessions, and their repetition lasts until the patient feels that things are “just as they should be.” Common compulsions are:
- Repeated and excessive washing and cleaning of hands, bodies, and objects in response to contamination obsessions.
- Constant and repeated control (faucets are turned off, doors are locked) in response to obsessive doubts.
- Persistent arranging of objects in a strictly defined manner in response to obsessions of order and symmetry.
- Mental compulsions (specific words, phrases, prayers, or numbers that the sufferer repeats to themselves) or other behaviors such as looking at or touching objects in a specific way.
Although most OCD patients are aware of the exaggerated and irrational nature of their symptoms, there is a small minority of sufferers who are fully convinced of the accuracy and genuineness of their obsessions. Patients usually experience intense anxiety, guilt, and shame about their symptoms, and often try to keep them a secret, even from their own people. Other times, they require their family members to comply with specific rules dictated by the symptoms of the illness.
Obsessive-compulsive disorder can cause great mental pain, severe disability, and adversely affect all aspects of life. Compared to patients suffering from anxiety or depressive disorders, OCD patients are less likely to be married and more likely to be unemployed or socially functional.
Epidemiology
Obsessive compulsive disorder affects 2-3% of the population. The male/female ratio is 1/1. The onset is usually gradual and occurs in late adolescence or early adulthood. In most cases, the disease is chronic, with exacerbations and remissions of symptoms. Obsessive-compulsive disorder is often underdiagnosed and undertreated. On average, it takes a decade from the onset of symptoms until a correct diagnosis is made. Patients may fear that they will be called crazy if they disclose their symptoms, or may not realize that they are part of a specific medical condition for which there are effective treatments. On the other hand, many health professionals are not familiar with recognizing the symptoms.
Causes and rationale
The causes of OCD are not fully understood. Genetic factors play a role, as shown by the increased incidence of OCD in first degree relatives of patients compared to the general population. Genetic factors are even more important in cases of early-onset OCD in childhood or early adolescence. Disrupted regulation of the serotonin neurotransmitter system in the brain, as well as altered patterns of activity in specific brain regions, appear to be associated with the disease. These disorders return to normal levels with successful treatment, which means that there is no permanent brain damage in OCD.
Various life events can act as triggers for the onset or worsening of symptoms. Examples of such events are the birth of a child, a change of job, an interpersonal conflict, but also events of a biological nature such as a head injury or the use of cocaine or amphetamines.
According to the cognitive/behavioral model, obsessive-compulsive symptoms are established and maintained when the patient attributes personal and threatening meaning to unwanted intrusive thoughts that occur frequently in daily life and are not in themselves pathological. For example, the impulse “to push someone standing on the platform waiting for the train” may occur in a healthy person who experiences it as unpleasant but completely stupid and bypasses it without further complications. On the contrary, the person suffering from obsessive-compulsive disorder considers that the above impulse signals a real danger, that he may lose his self-control and actually push someone onto the train tracks.
The above compulsive and avoidant behaviors momentarily reduce anxiety and prevent the sufferer from seeing the groundlessness of his fears (staying at a distance from the man on the dock he cannot see that nothing bad will happen if he gets closer and stands next to him). Thus, the compulsions are strengthened and consolidated. In addition, their execution by the patient acts as a reminder of his obsessions and reinforces his false belief that nothing bad happened precisely because he gave in to the compulsions. In this way, a vicious cycle is created that perpetuates the disorder.
Treatment of OCD
Drug treatment of obsessive-compulsive disorder is based on selective serotonin reuptake inhibitors (SSRIs). The doses used are usually higher than those for depression and anxiety disorders, and the time required for the onset of action is longer. In case of a partial response of the symptoms, the treatment can be strengthened with small doses of antipsychotics. The duration of the treatment is 1-2 years, after which and on the condition that a remission of the symptoms has been achieved, a gradual reduction and discontinuation can be attempted.
Cognitive/behavioral therapy is the best-studied and most effective psychological intervention for obsessive-compulsive disorder. It involves systematic and prolonged exposure of the patient to the stimuli and situations that trigger obsessions and anxiety. At the same time, the patient refrains from performing self-compulsions. The goal of treatment is to show the sufferer that the obsessive-compulsive disorder does not persist indefinitely, but softens with familiarity and that compulsions are not necessary to avoid harm. In addition, an attempt is made to reduce the overestimation of risk and personal responsibility for its prevention that often dominates the way of thinking of people with obsessive-compulsive disorder. Many times, medication and cognitive/behavioral therapy are combined for best results.