Obsessive-Compulsive Disorder (OCD)

Topic Overview

What is obsessive-compulsive disorder (OCD)?

Obsessive-compulsive disorder (OCD) is a type of mental illness that causes repeated unwanted thoughts. To get rid of the thoughts, a person does the same tasks over and over. For example, you may fear that everything you touch has germs on it. So to ease that fear, you wash your hands over and over again.

OCD is a chronic, or long-term, illness that can take over your life, hurt your relationships, and limit your ability to work or go to school.

What causes OCD?

Experts don't know the exact cause of obsessive-compulsive disorder. Research suggests that there may be a problem with the way one part of the brain sends information to another part. Not having enough of a brain chemical called serotonin may help cause the problem.

Some experts believe that a problem related to infections, such as strep throat or scarlet fever, can suddenly bring on the disorder or make its symptoms worse in some children.

What are the symptoms?

Symptoms of obsessive-compulsive disorder tend to come and go over time and range from mild to severe. Anxiety is the most common symptom. For example, you may have an overall sense that something terrible will happen if you don't do a certain task, such as check again and again to see whether the stove is on. If you fail to check, you may suddenly feel tense or anxious or have a nagging sense that you left something undone.

Symptoms of the disorder include:

• Obsessions. These are unwanted thoughts, ideas, and impulses that you have again and again. They won't go away. They get in the way of your normal thoughts and cause anxiety or fear. The thoughts may be sexual or violent, or they may make you worry about illness or infection. Examples include:
  • A fear of harm to yourself or a loved one.
  • A driving need to do things perfectly or correctly.
  • A fear of getting dirty or infected.
• Compulsions. These are behaviors that you repeat to try to control the obsessions. Some people have behaviors that are rigid and structured, while others have very complex behaviors that change. Examples include:
  • Washing, or checking that something has been done.
  • Counting, often while doing another compulsive action, such as hand-washing.
  • Repeating things or always moving items to keep them in perfect order.
  • Hoarding.
  • Praying.

The obsessions or compulsions usually take up a lot of time-more than 1 hour a day. They greatly interfere with your normal routine at work or school, and they affect social activities and relationships.

Sometimes people may understand that their obsessions and compulsions are not real. But at other times they may not be sure, or they may believe strongly in their fears.

How is OCD diagnosed?

Your doctor can check for obsessive-compulsive disorder by asking about your symptoms and your past health. He or she may also do a physical exam. It's important to talk to your doctor if you think you have OCD. Many people with the disorder go without treatment because they are afraid or embarrassed to talk to a doctor.

How is it treated?

Treatment includes medicines and counseling. Using both often works best.

Antidepressant medicines called selective serotonin reuptake inhibitors (SSRIs) are most commonly used. Examples of these medicines include Prozac and Zoloft. You may begin to feel better in about 1 to 3 weeks after you start taking medicine. But it can take as long as 12 weeks to see more improvement. If you have concerns about your medicine, or if you do not start to feel better by 3 weeks, talk to your doctor. He or she may increase the dose or change to a different medicine.

Counseling for the disorder includes a type of cognitive-behavioral therapy called exposure and response prevention. This therapy slowly increases your contact with the thing that causes worries or false beliefs. For example, if you were worried about getting germs from things you touch, you would touch an object you believe has germs and then not wash your hands afterward. You would keep doing that until you could do it without feeling anxious. This can be hard at first. But with the help of a counselor, this therapy can reduce your symptoms over time.

Other cognitive therapy may also help change the false beliefs that lead to OCD behaviors.

Treatment can make your symptoms less severe. But you may still have some mild symptoms after you begin treatment.

Frequently Asked Questions

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	Should I take medicines to treat obsessive-compulsive disorder (OCD)?

Cause

Researchers have yet to pinpoint the exact cause of obsessive-compulsive disorder (OCD), but brain abnormalities, genetic (family) influences, and environmental factors are being studied. Brain scans of people with OCD have shown that they have different patterns of brain activity than people without OCD and that abnormal functioning of circuitry within a certain part of the brain (striatum) may cause the disorder. Abnormalities in other parts of the brain and an imbalance of brain chemicals, especially serotonin, may also contribute to OCD.¹

Some experts believe that a problem related to infections, such as strep throat or scarlet fever, can suddenly bring on the disorder or make its symptoms worse in some children.

Symptoms

Obsessive-compulsive disorder (OCD) is a chronic or long-term illness, and without treatment, symptoms typically come and go over time and may significantly interfere with your ability to work and have a family. Treatment can reduce the severity of the illness. And although some symptoms may linger after treatment, you should be able to have an active social life, raise a family, and work.

Anxiety is the most prominent symptom of OCD. For example, you may have an overall sense that something terrible will happen if you don't follow through with a particular ritual, such as repeatedly checking to see whether the stove is on. If you don't perform the ritual, you may have immediate anxiety or a nagging sense of incompleteness.

Symptoms of OCD vary with each person and include the following:^{2, 3}

Obsessive thoughts

• Fear of dirt or germs or overconcern about body smells/secretions or the proper functioning of the body
• Overconcern with order, neatness, and exactness
• Fear of thinking bad thoughts or doing something embarrassing
• Constantly thinking of certain sounds, words, or numbers, or a preoccupation with counting or checking
• Constant need for approval or the need to apologize
• Fear that something terrible will happen or fear of harming yourself or someone else

Compulsive behaviors

• Frequently washing hands, showering, or brushing teeth or the overuse of items to hide body smells
• Constantly cleaning, straightening, and ordering certain objects
• Repeatedly checking zippers and buttons on clothing
• Checking lights, appliances, or doors again and again to be sure they are turned off or closed
• Repeating certain physical activities, such as sitting down and getting up from a chair
• Hoarding objects, such as newspapers
• Asking the same question or saying the same thing over and over
• Avoiding public places or taking extreme measures to prevent harm to yourself or others
• Religious rituals, such as constant silent praying

It is common for children with OCD to need to repeat actions until they feel 'just right,' such as going back and forth through a door, going up and down stairs, touching things with their right hand and then their left (symmetrical touch), or rereading or rewriting school assignments.⁴ Children with OCD may not want to go to school or may be afraid to leave someone they trust.

You may experience suicidal feelings if you have depression along with OCD. Warning signs of suicide include talking about death or giving away possessions.

What Happens

With obsessive-compulsive disorder (OCD), you develop disturbing, obsessive thoughts that cause fear or anxiety. In order to rid yourself of these thoughts and relieve the fear, you perform rituals, such as repeated hand-washing or checking that something has been done. Unfortunately, the relief is only temporary. The thoughts return and you repeat the rituals.

The rituals or behaviors become time-consuming and have a significant impact on your daily life. If your particular fear involves unfamiliar situations, it is possible for you to become so obsessed by the fears that you stop going outside of your home. Quality of life can be substantially lowered by OCD since it can greatly affect your ability to work and have relationships.

Many people are too embarrassed by their symptoms to seek treatment, and they go for years before seeing a doctor. Symptoms of OCD can be reduced with treatment.

OCD can have a negative effect on those who care about you. Family members can become angry and frustrated at the strain the rituals or behaviors put on them. Talk to your doctor about ways your family members can help with OCD.

What Increases Your Risk

If you have a parent or sibling with obsessive-compulsive disorder (OCD), your chance of developing OCD is increased.⁵

Your risk for developing OCD is greatest from childhood to middle adulthood.⁵

When To Call a Doctor

It is important to seek treatment for obsessive-compulsive disorder (OCD) as soon as you suspect you have it. Treatment will improve your quality of life, as well as the lives of your loved ones.

If you have OCD (especially with depression) and are feeling suicidal, or if you know someone with OCD who is feeling suicidal, call a doctor or 911 right away. Warning signs of suicide include talking about death or giving away possessions.

Watchful Waiting

Waiting to treat OCD is not appropriate. OCD should be treated as soon as you suspect that you or someone you care about has the disorder.

Who To See

Although there are many health professionals who can treat or monitor obsessive-compulsive disorder (OCD), you may want to partner with a health professional who has had specific training in OCD management. Health professionals who can diagnose, treat, or monitor the progress of OCD include:

• Psychiatrist.
• Family medicine doctor.
• Internist.
• Psychiatric nurse practitioner.

Other health professionals who can provide ongoing counseling and support for OCD but cannot prescribe medicines include:

• Psychologist.
• Licensed mental health counselor.
• Social worker.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

A diagnosis of obsessive-compulsive disorder (OCD) is based on your symptoms, medical history, and a physical examination. Your doctor may also want a mental health assessment, which is an evaluation of your emotional functioning and your ability to think, reason, and remember (cognitive functioning). A mental health assessment may include an examination of your nervous system, written or verbal tests, and laboratory tests (such as blood and urine tests) as well as a review of your appearance, mood, behavior, thinking, reasoning, memory, and ability to express yourself.

Many people with OCD live with the condition for years before being diagnosed, or they go without treatment because they are afraid or embarrassed to talk about their symptoms. Answers to three initial questions may help your health professional diagnose whether you have OCD:⁶

• Do you have repeated thoughts that cause anxiety and that you cannot get rid of no matter how hard you try?
• Do you wash your hands frequently or keep things extremely clean and neat?
• Do you excessively check things?

If your health professional suspects you have OCD, he or she will look for a full range of symptoms that will confirm the diagnosis, including:¹

• Recurrent and persistent thoughts, impulses, or images that are intrusive and inappropriate, cause anxiety or distress, and are not simply excessive worries about real-life issues.
• Attempts to suppress or ignore the thoughts or get rid of them with other thoughts or actions.
• A recognition that the obsessions are created in your own mind and don't make sense.
• Repetitive behaviors, such as hand-washing, ordering, praying, or checking that you're driven to do in response to the obsession. The behaviors are aimed at preventing or reducing distress or preventing a dreaded event.

For a diagnosis of OCD, the obsessions or compulsions must be time-consuming (more than 1 hour a day) or greatly interfere with your normal routine at work or school and affect social activities and relationships.

Early Detection

Early detection and proper treatment is very important in improving the course of OCD. This disorder is often a long-lasting (chronic) condition that will need to be monitored throughout your life.

Treatment Overview

The earlier you seek treatment for obsessive-compulsive disorder (OCD), the better. Early treatment of OCD can reduce symptoms and reduce the disruption the illness can create in your life. Unfortunately, research shows that most people see an average of 3 to 4 health professionals and spend more than 9 years seeking treatment for OCD before they are correctly diagnosed.⁶ Their diagnoses are complicated by their being embarrassed or secretive about their symptoms and by other conditions they may have along with OCD, such as depression.

Treatment includes a combination of professional counseling and medicines.

Initial treatment

Depending on the severity of your symptoms, your doctor may prescribe only counseling or counseling and an antidepressant, such as fluoxetine (for example, Prozac), fluvoxamine (Luvox), or sertraline (Zoloft). For severely ill people who cannot function in a job or in social situations because of their symptoms, it is recommended that medicines be tried first before counseling.⁶

Should I take medicines to treat my OCD?

• Counseling:

A type of cognitive-behavioral therapy called exposure and response prevention is considered the most effective type of counseling for OCD.⁶ With exposure and response prevention therapy, you repeatedly expose yourself to an obsession, such as something you fear is contaminated, and deny yourself the ritual compulsive act, which in this case would be washing your hands. This therapy is done with a therapist or on your own with direction from your therapist.

In the beginning of exposure and response prevention therapy, your therapist may ask you to write a list of your obsessions, rituals (compulsions), and things that you avoid and then have you rank the amount of anxiety each of the obsessions causes from highest to lowest. You might begin exposing yourself to an obsession that causes a moderate amount of anxiety and then work your way up the list to the obsession that causes the most anxiety.

Therapists often combine exposure and response prevention therapy with cognitive-behavioral therapy to help overcome the faulty beliefs (such as fear of contamination) that lead to OCD behaviors.

• Medicines

Your doctor may first prescribe an antidepressant called a selective serotonin reuptake inhibitor (SSRI), such as fluoxetine (for example, Prozac), or a tricyclic antidepressant, such as clomipramine. You may start to feel better within 1 to 3 weeks of taking an SSRI. But it can take as many as 12 weeks to see more improvement. If you have questions or concerns about your medicines, or if you do not notice any improvement by 3 weeks, talk to your doctor. Your doctor may increase the dosage of your medicine or change to another SSRI if the first medicine prescribed doesn't help.

Ongoing treatment

Ongoing treatment for OCD includes monitoring the dosage and effectiveness of your medicines. Your doctor may want you to stay on one medicine for at least 10 to 12 weeks before trying a different antidepressant. Although antidepressants are considered the most effective medicine for OCD, researchers are studying whether other medicines, such as dopamine antagonists, can be combined with antidepressants for better results.

If you are in counseling, your doctor will monitor your progress and, if necessary, modify the amount or type of counseling you're receiving. Research shows that those who receive the most counseling have the best results and that longer sessions (at least 90 minutes) of exposure and response prevention therapy are more effective for reducing anxiety than short sessions.⁶ Between 13 and 20 sessions may be needed to relieve symptoms. Your health professional may also advise family members to participate in therapy with you or on their own.

Treatment if the condition gets worse

Deep brain stimulation, which uses surgically implanted electrodes in the brain, and magnetic stimulation of parts of the brain may be tried in rare cases of OCD when other treatment has not been successful.

What To Think About

Consistency is important for both counseling and medicines. People who don't take their medicines regularly or stop altogether often have their symptoms return (relapse). With therapy, it is important to work with your doctor to determine when, or if, you should stop.

If you need help deciding whether to see your doctor, see some reasons why people don't get help and how to overcome them.

Prevention

You cannot prevent obsessive-compulsive disorder (OCD) from starting, but the best way to prevent a relapse of OCD symptoms is by staying with your therapy and taking any medicines exactly as they have been prescribed.

Home Treatment

Taking care of yourself every day is important in dealing with obsessive-compulsive disorder (OCD). This includes taking your medicines as directed every day and doing the homework your therapist gives you to do at home, such as self-directed exposure and response prevention exercises. With exposure and response prevention therapy, you repeatedly expose yourself to an obsession, such as something you fear is contaminated, and deny yourself the ritual compulsive act, which in this case would be washing your hands.

It's also important to involve family members and loved ones in your treatment, especially if your health professional suggested you participate in therapy together. Keeping lines of communication open may help you deal with relationships that have become strained during your illness.

Reducing overall stress in your life, although not proven treatment for OCD symptoms, may help you cope. Stress- and anxiety-relieving tips include:

• Taking slow, deep breaths.
• Soaking in a warm bath.
• Listening to soothing music.
• Taking a walk or doing some other exercise.
• Taking a yoga class.
• Having a massage or back rub.
• Drinking a warm, nonalcoholic, noncaffeinated beverage.

Eating a healthy, balanced diet and avoiding certain foods or drinks may also help you reduce stress.

• Avoid or limit caffeine. Coffee, tea, some soda pop, and chocolate contain caffeine. Caffeine can make stressful situations seem more intense. If you drink a lot of caffeine, reduce the amount gradually. Stopping use of caffeine suddenly can cause headaches and make it hard to concentrate.
• If you drink alcohol, do so in moderation. If you are feeling very stressed, you might be turning to alcohol for relief more often than you realize. If you drink, limit yourself to 2 drinks a day for men and 1 drink a day for women.
• Make mealtimes calm and relaxed. Try not to skip meals or eat on the run. Skipping meals can cause your blood sugar to drop, which will make other stress-related symptoms worse, such as headaches or stomach tension. Eating on the run can cause indigestion. Use mealtime to relax, enjoy the flavor of your meal, and reflect on your day.
• Avoid eating to relieve stress. Some people turn to food to comfort themselves when they are under stress. This can lead to overeating and guilt. If this is a problem for you, try to replace eating with other actions that relieve stress, like taking a walk, playing with a pet, or taking a bath.

For more information, see the topic Stress Management.

Medications

After you are diagnosed with obsessive-compulsive disorder (OCD), your doctor will likely prescribe antidepressants known as selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (for example, Prozac). Antidepressants are thought to help balance neurotransmitters (such as serotonin) in your brain.

In some cases it takes time to adjust the dosage or find the right medicine that will work for you. You may start to feel better within 1 to 3 weeks of taking an SSRI. But it can take as many as 12 weeks to see more improvement. If you have questions or concerns about your medicines, or if you do not notice any improvement by 3 weeks, talk to your doctor. Your doctor may increase the dosage of your medicine, change to another SSRI, or use another medicine known as clomipramine if the medicine first prescribed does not help. Clomipramine, a tricyclic antidepressant, has been used for years to treat OCD, but it may have more side effects than SSRIs.

Your doctor may prescribe other medicines if you have other conditions along with OCD.

Medication Choices

Antidepressants (SSRIs) such as fluoxetine (for example, Prozac), fluvoxamine (Luvox), and sertraline (Zoloft) are commonly prescribed to treat OCD. These medicines are taken as tablets or capsules. The medicine venlafaxine can also help symptoms of OCD. The tricyclic antidepressant clomipramine (Anafranil) is sometimes used as well.

Antidepressants are used to relieve the obsessive thoughts and subsequent compulsive behaviors in those who have OCD. By increasing the level of serotonin in the brain, antidepressants help to regulate the communication between different parts of the brain.

Other medicines (such as antipsychotics) are sometimes used to treat OCD.

What To Think About

A person with OCD may also have other anxiety disorders that complicate treatment and require using other medicines.

For children and adolescents with OCD, treatment combining cognitive-behavioral therapy with antidepressants (SSRIs), such as sertraline, works better than only taking medicine. Cognitive-behavioral therapy alone also works well, but it works better if it is combined with medicine.⁷

Surgery

In rare cases, deep brain stimulation, which uses surgically implanted electrodes in the brain, and magnetic stimulation of parts of the brain are done for severe obsessive-compulsive disorder (OCD) that does not respond to other treatments.

Other Treatment

Current research indicates that behavioral therapy can be as effective as medicine for the treatment of obsessive-compulsive disorder (OCD).⁶ But you and your doctor will need to decide whether you will be treated only with therapy or with therapy in addition to medicine.

Types of counseling that have proved effective in treating OCD include:

• Exposure and response prevention (ERP) therapy, a type of cognitive-behavioral therapy in which you repeatedly expose yourself to an obsession, such as something you fear is contaminated, and deny yourself the ritual compulsive act, which in this case may be washing your hands.
• Cognitive therapy may also be used to help overcome the faulty beliefs (such as fear of contamination) that lead to OCD behaviors.

You and your loved ones may choose to go to family therapy. During family therapy, the counselor teaches the family about the condition, offers them support, and gives them suggestions on how to help you with OCD. Family therapy may be very important for other family members who are having difficulty coping with the effects of your illness.

Other Places To Get Help

Organizations

Related Information

• Anorexia Nervosa
• Anxiety
• Bulimia Nervosa
• Depression
• Social Anxiety Disorder

References

Citations

1. Stein DJ (2002). Obsessive-compulsive disorder. Lancet, 360(9330): 397-405.

2. Soomro GM (2007). Obsessive compulsive disorder, search date July 2006. Online version of BMJ Clinical Evidence. Available online: http://www.clinicalevidence.com.

3. American Psychiatric Association (2000). Obsessive-compulsive personality disorder. In Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text rev., pp. 725-729. Washington, DC: American Psychiatric Association.

4. King RA, et al. (1998). Practice parameters for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 37(10, Suppl): 27S-45S.

5. Sadock BJ, Sadock VA (2007). Obsessive-compulsive disorder. In Kaplan and Sadock's Synopsis of Psychiatry, Behavioral Sciences/Clinical Psychiatry, 10th ed., pp. 604-612. Philadelphia: Lippincott Williams and Wilkins.

6. Jenike MA (2004). Clinical practice: Obsessive-compulsive disorder. New England Journal of Medicine, 350(3): 259-265.

7. Pediatric OCD Treatment Study (POTS) Team (2004). Cognitive-behavioral therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: The Pediatric OCD Treatment Study (POTS) randomized controlled trial. JAMA, 292(16): 1969-1976.

Other Works Consulted

• Geller DA, et al. (2002). Attention-deficit/hyperactivity disorder in children and adolescents with obsessive-compulsive disorder: Fact or artifact? Journal of the American Academy of Child and Adolescent Psychiatry, 41(1): 52-58.

• Mataix-Cols D, et al. (2002). Symptom stability in adult obsessive-compulsive disorder: Data from a naturalistic two-year follow-up study. American Journal of Psychiatry, 159(2): 263-268.

• McCracken JT (2005). Obsessive-compulsive disorder in children section of Anxiety disorders in children. In BJ Sadock, VA Sadock, eds., Kaplan and Sadock's Comprehensive Textbook of Psychiatry, 8th ed., vol. 2, pp. 3280-3286. Philadelphia: Lippincott Williams and Wilkins.

• Pine DS, McClure EB (2005). Anxiety disorders: Clinical features section of Anxiety disorders. In BJ Sadock, VA Sadock, eds., Kaplan and Sadock's Comprehensive Textbook of Psychiatry, 8th ed., vol. 1, pp. 1768-1780. Philadelphia: Lippincott Williams and Wilkins.

• Riddle MA, et al. (2001). Fluvoxamine for children and adolescents with obsessive-compulsive disorder: A randomized, controlled, multicenter trial. Journal of the American Academy of Child and Adolescent Psychiatry, 40(2): 222-229.

• Sadock BJ, Sadock VA (2007). Obsessive-compulsive disorder of infancy, childhood, and adolescence. In Kaplan and Sadock's Synopsis of Psychiatry, Behavioral Sciences/Clinical Psychiatry, 10th ed., pp. 1270-1273. Philadelphia: Lippincott Williams and Wilkins.

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