Obsessive-compulsive disorder (OCD)

Definition

Obsessive-compulsive disorder (OCD) – coding according to DSM 5: 300.3/ICD 10: F42 – is a psychiatric disorder where patients feel the urge to perform repetitive actions or rituals and/or have repeating thoughts. During the course of the illness, the actions could evolve to sometimes very complex rituals. When the patient resists performing such actions, he develops severe anxiety. In some patients, the OCD creates only compulsive thoughts, which the patient is not able to resist. The most disturbing aspect of the compulsions is that the person affected is not able to stop them despite the knowledge that the compulsions are irrational. The patient feels that the compulsion is overwhelming him and does not depend on his will. The OCD rituals/intrusive thoughts usually run in cycles frequently taking a big part of the day interfering with normal life activities. The untreated obsessive-compulsive disorder tends to increase in severity trapping the patients in a vicious cycle of reciprocal rituals and intrusive thoughts, which can lead to full debilitation. In contrast to patients affected by schizophrenia, who are usually not able to recognize that their behavior/thinking is irrational, patients with OCD are fully aware of the fact that their thoughts/actions don’t make any sense and that they are – so to say- over imposed on them.

02 Diagnostic Criteria OCD01 Diagnostic Criteria OCD (2)

Diagnosis

Using a careful clinical interview and taking into consideration the above listed diagnostic criteria, a psychiatrist or psychologist can make a diagnosis.  A person must have obsessions, compulsions, or both, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM), to be diagnosed with OCD. The Quick Reference to the 2000 edition of the DSM states that several features characterize clinically significant obsessions and compulsions. Such obsessions, the DSM says, “are recurrent and persistent thoughts, impulses or images that are experienced as intrusive and that cause marked anxiety or distress. These thoughts, impulses or images are of a degree or type that lies outside the normal range of worries about conventional problems” (p. 75). A person may attempt to ignore or suppress such obsessions, or to neutralize them with some other thought or action, and will tend to recognize the obsessions as idiosyncratic or irrational.

The compulsions can also be developed by healthy individuals, such as when they order or collect items, are highly organized, have a restrictive daily routine and compulsive thoughts. The compulsions become clinically relevant if the person feels urged to perform them as an effect of an obsession, or the compulsions appear with a particular rigidity significantly affecting the patient’s life. The compulsions can be qualified as a psychiatric disorder (OCD) if the person must perform these actions to avoid severe distress.  Another important criterion is that the compulsions are time-consuming (according to DSM 5 taking up more than one hour per day) and/or cause impairment of the patient’s social and professional functioning.

Symptoms

Obsessive-compulsive disorder can appear as variety of symptoms, such as washing compulsions, checking things countless times (e.g., locks on doors), performing rituals, arranging objects in a certain way, repeating words and phrases, or experiencing reciprocal thoughts often with disturbing content.  Other symptoms are counting in certain way, or performing some actions/rituals before being able to move to the normal life routine.

The obsessive-compulsive disorder symptoms are related to such themes as symmetry, cleanliness, collecting and grouping objects, as well as forbidden thought contents.  The symptoms related to symmetry correlate with obsessional ordering, counting, and grouping objects in a certain – perfect and highly symmetric – way. The thought contents related to taboo subjects include intrusive and distressing thoughts of violent, sexual or blasphemous content. The symptoms grouped around cleanliness correlate with obsessions related to washing hands or excessive bathing up to dozens of times per day, cleaning objects and fears of contamination. The hoarding compulsion and obsessions appears as obsessive collection of items that often have no value.

Patients with OCD perform tasks, rituals, or follow the intrusive thoughts to escape the unbearable anxiety in case they would try to stop the compulsion.

Some patients with obsessive-compulsive disorder could experience sexual obsessions with intrusive thoughts, or images related to sexuality. Those obsessive thoughts can question a patient’s sexual orientation, or create highly disturbing images of sexual relationship with parents, children, family members or friends.   Patients never put sexual compulsions in action and they are unrelated to the patient’s sexual orientation or preferences. These patients could be extremely scared doubting themselves regarding whether they might act upon their inappropriate ideas.

Causes

The causes of the obsessive-compulsive disorder are multifactorial:   Genetic, biological and environmental factors play a role.

The genetic factors: Twin studies showed that the appearance of OCD happens more often by identical twins compared to non-identical twins. There is further evidence supporting the influence of genetics on OCD prevalence: individuals who suffer from OCD more frequently have first-degree family members affected by the same disorder. About 25% of OCD patients have an immediate family member with the same disorder.  The OCD symptoms can be passed on from parents to children. This means that the biological vulnerability to OCD can be inherited.

The neurobiological factors, such as the brain structure and – on a deeper level – the neurotransmitters, are interlinked with genetics. Using neuroimaging technologies allows brain mapping, including the detection of functions in certain brain areas. Neuroimaging studies have shown that particular areas of the brain function differently in people with OCD as compared to a control group without OCD.  This research suggests that OCD symptoms are related to communication errors among different parts of the brain in particular the frontal part of the brain such as the orbitofrontal and the anterior cingulate cortex. OCD could be caused by errors in the brain pathways, which link areas responsible for judgment and planning with those involved in the autonomous reactions linked to the brain structure called amygdala. OCD sufferers also show abnormalities in neurotransmitter systems especially the serotonergic, dopaminergic and glutamate system.

Environmental factors: There are environmental stressors which can trigger the onset of OCD. These stressors include: majorly stressful changes in living situations, illnesses, death of a loved one, professional or school-related problems or relationship concerns.

Differential diagnosis

Obsessive- compulsive disorder is often confused with other impulse control disorders, such as Obsessive Compulsive Personality Disorder (OCPD), Trichotillomania and some phobias.

In comparison to Obsessive Compulsive Personality Disorder (OCPD), OCD is ego-dystonic which means that the compulsions are incompatible with patient’s ego consciousness (self-concept of patient’s personality), while in Obsessive Compulsive Personality Disorder they are ego-syntonic which means that the content of the compulsions goes along with patient’s self-concept. Patients suffering from Obsessive Compulsive Personality Disorder are not able to recognize that there is something abnormal about their behavior.

Another disorder with symptoms resembling OCD is Trichotillomania. Trichotillomania (TTM) is also known under the description:  Hair pulling disorder (TTM). The patients with TTM experience a long- term urge to pulling out their hair, and they are not able to resist the impulse.

Some phobias are also accompanied by impulse control and/or other body focused repetitive behaviors. One of such phobia is Body Dysmorphic Disorder (Dysmorphophobia). Patients with Body Dysmorphic Disorder (BDD) are preoccupied with an imagined defect of their physical appearance. The patients can spend hours checking and rechecking their appearance in the mirror. They frequently undergo surgery trying to reach a perfect appearance of their face or body. They tend to repeat the surgery, because they remain unhappy with the effect. The series of surgeries often end with a devastating effect of a full body deformation.

Prevalence

OCD is the fourth most common psychiatric disorder after depression, substance abuse (alcohol and drugs abuse) and anxiety disorders.  The life prevalence of OCD (the probability of developing OCD during the entire life) varies in different countries and societies between 1 and 2 %. Half of people develop OCD before age twenty. There is no gender difference in people affected by this disorder. OCD frequently co-occurs with other psychiatric disorders, such as bipolar and major depressive disorder, anxiety disorder (social phobia, generalized anxiety and panic disorder), as well as ADHD.

Treatment

The treatment of Obsessive-Compulsive Disorder – especially such with very severe life changing symptoms- can be long and difficult. Evidence based studies show that the best treatment results can be achieved by using psychiatric medication in combination with psychotherapy.

Medication

Historically the first effective medication used in the treatment of OCD was a tricyclic antidepressant called clomipramine. Nowadays the first line medications are the antidepressants belonging to the group of selective serotonin reuptake inhibitors (SSRIs). Recent research also showed good efficacy of some antidepressants from the group of selective serotonin- norepinephrine reuptake inhibitors (SNRIs). There is also evidence that atypical antipsychotics can be helpful. In severe cases, in order to suppress the OCD symptoms, a combination of an antidepressant, antipsychotic and/or mood stabilizer could be necessary.

Psychotherapy

The main therapeutic technique used in treatment of OCD is a variation of Cognitive Behavioral Therapy (CBT) called Exposure and Response Prevention (ERP).  ERP gradually exposes the patients to situations triggering the compulsions trying to block the usual compulsive act associated with the obsession. During the course of treatment, the level of exposure is increased and the patient has to learn how to suppress the compulsion and tolerate the discomfort and anxiety caused by not following the compulsion (“response prevention”). ERP has a strong evidence base, and is considered the most effective treatment for OCD.

In the past, psychoanalytical/psychodynamic psychotherapy has been used with good effect, but there is little evidence based data related to this psychotherapeutic technique.