Treatment of OCD (Obsessive Compulsive Disorder). Introduction
OCD (Obsessive-Compulsive-Disorder) is a serious psychiatric illness that affects millions of people around the world. The disorder is characterized by the urge to perform repetitive actions or rituals, or by having repeating thoughts.
The obsessions experienced by individuals with OCD are outside of the normal range of worries and concerns and tend to be recognized as irrational by the individual.
A person with OCD may try to ignore or suppress the obsessions or neutralize them with some other thought or action.
Compulsions, which can also be present in healthy individuals, become clinically relevant in OCD when they are performed in response to an obsession or have a particular rigidity that significantly affects the individual’s life.
In this article we shade light on different aspects of Obsessive-Compulsive Disorder with the main focus on its diagnosis and treatment.
Is OCD a Frequent Disorder?
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.
Symptoms of Obsessive-Compulsive Disorder
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.
Intrusive Thoughts and Rituals
In many cases, the repetitive actions can evolve into complex rituals, and when patients resist performing them, they can experience severe anxiety. In some patients, OCD only manifests as compulsive thoughts that the individual is unable to resist.
Despite being aware that the compulsive thoughts and actions are irrational, they are so overwhelming that the patient feels powerless to stop them.
The intrusive thoughts and rituals can take up a significant portion of the day and interfere with normal life activities. This can result in a vicious cycle, where the untreated OCD only becomes more severe, leading to full debilitation. This is a stark contrast to patients affected by schizophrenia, who are usually not able to recognize that their behaviour and thinking is irrational.
Other OCD Related Themes
OCD 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 appear as obsessive collection of items that often have no value.
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.
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.
How Does Obsessive-Compulsive Disorder Progress?
Obsessive-compulsive disorder usually develops gradually. Over time, individuals may notice they spend a lot of time on compulsive actions or struggle to shake off obsessive thoughts. OCD can lead to problems at work, in relationships, or within the family. It becomes difficult to fulfill everyday obligations, and hobbies may become less enjoyable. Eventually, the compulsions can take over daily life.
OCD typically follows a chronic course, with periods of milder or more severe symptoms. There can also be periods without symptoms. The nature of the obsessions and compulsions may change over time.
How Is OCD Diagnosed?
Obsessive-compulsive disorder (OCD) is a mental health condition characterized by persistent and intrusive thoughts, images, or impulses (obsessions) and repetitive behaviours or mental acts (compulsions) that a person feels driven to perform. In Europe, Obsessive-Compulsive Disorders are diagnosed according to the ICD-10 (International Classification of Diseases). Diagnostic criteria from the American Diagnostic Manual, DSM 5 may also be considered. To make a diagnosis of OCD, the below listed DSM 5 criteria must be met.
DSM 5 Diagnostic Criteria for Obsessive-Compulsive Disorder (OCD):
- Obsessions: Recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress.
- Compulsions: Repetitive behaviours or mental acts that an individual feels driven to perform in response to an obsession or in accordance with rules that must be applied rigidly.
- The obsessions or compulsions are time-consuming (taking up more than an hour a day) or cause significant distress or impairment in social, occupational, or other important areas of functioning.
- The obsessions or compulsions are not due to the physiological effects of a substance or another medical condition.
- The obsessive-compulsive symptoms are not better accounted for by another mental disorder.
In addition to the presence of obsessions and compulsions, the DSM criteria for OCD also include the requirement that the symptoms are not due to the effects of a substance or medical condition and are not better accounted for by another mental disorder.
Diagnosis Process of OCD
The diagnosis process begins with gathering medical history (anamnesis), including questions about symptoms and life history (e.g., stressful crises, other illnesses, medications, etc.). Clinical psychological assessment may also be useful. Physical causes for the disorder (e.g., dementia or stroke) must be ruled out by a physician (e.g., through neurological examination or MRI).
The diagnosis of OCD should be made based on a comprehensive evaluation, including a thorough medical and psychological assessment and by ruling out any other underlying conditions that may be contributing to the symptoms.
Distinguishing OCD from Other Mental Health Disorders
There are other mental illnesses that can resemble OCD, such as:
Generalized Anxiety Disorder (GAD)
Involves excessive worry and fear about various life situations.
Tic Disorders
can also resemble OCD or occur together, especially if the condition begins in childhood.
Trichotillomania (TTM)
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.
Body Dysmorphic Disorder (BDD)
Some phobias are also accompanied by impulse control and/or other body focused repetitive behaviours. One of such phobias 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.
Obsessive Compulsive Personality Disorder (OCPD)
In rare cases, Obsessive-Compulsive Disorder may be confused with other impulse control disorders, such as Obsessive Compulsive Personality Disorder (OCPD).
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 behaviour.
What Are the Causes of Obsessive-Compulsive Disorder?
In professional circles, it’s believed that OCD has various causes, which can also interact. These may include genetic predisposition, psychological stressors, or difficult life circumstances or crises. Personality factors, such as being particularly conscientious, can also play a role.
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.
Neurobiological Factors
Thes factors are related to the brain structure and – on a deeper level – to the neurotransmitters. The neurobiological factors are closely 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 a malfunction in communication in 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.
Models Explaining the Development of OCD
There are different models explaining the development of OCD, such as:
Neurobiological Models
Research suggests that OCD may involve dysfunction in certain parts of the brain (frontal cortex, basal ganglia, and limbic system). There may also be disruptions in brain metabolism related to the neurotransmitter serotonin.
Learning Theoretical Models
These propose that individuals try to avoid or reduce anxiety and tension through compulsive rituals. Additionally, the strong negative evaluation of obsessive thoughts leads to feelings of guilt, creating a vicious cycle of anxiety and compulsion.
Psychodynamic Models
These view potential causes of OCD in internal, often unconscious conflicts.
Treatment of Obsessive-Compulsive Disorder
It is important to seek help and treatment for OCD, as it can have a devastating impact on one’s life. OCD left untreated can become more severe, leading to debilitation. However, with proper treatment and support, individuals with OCD can live fulfilling and productive lives. In milder cases the use of psychotherapy helps patients to get insight into their behaviours and learn how to manage them. In more severe cases it’s necessary, in addition to psychotherapy, to treat the patient with medication helping to suppress the compulsions.
Treatment of OCD with Medication
The main medication used in treatment for OCD are antidepressants. Historically the first effective medication used in the treatment of OCD was a tricyclic antidepressant called clomipramine.
OCD Treatment with SSRIs and SNRIs
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 serotonine- norepinephrine reuptake inhibitors (SNRIs).
OCD Treatment with Atypical Antipsychotics
There is also evidence that atypical antipsychotics can be helpful. In cases where antidepressants are insufficiently effective, augmentation with a low-dose atypical antipsychotic is recommended. Augmentation refers to adding substances to an antidepressant that individually show little or no antidepressive or, in this case, “anti-OCD” effects. When combined with an antidepressant, these substances enhance the antidepressant’s effectiveness against OCD symptoms, leading to an overall improved effect. This augmentation is successful in approximately one-third of patients who did not respond to monotherapy with an antidepressant.
OCD Treatment with Mood Stabilizers
In severe cases, in order to suppress the OCD symptoms, a combination of an antidepressant, antipsychotic and/or mood stabilizer could be necessary.
Dosage and Treatment Duration
SSRI dosage for OCD should generally be in the upper range, but dosage should always be discussed with the treating physician. It may take at least 4 weeks for the medication to take effect and 8-12 weeks to reach its maximum effect. Discontinuation should always be gradual, particularly following the course of additional cognitive-behavioral therapy.
Considering long-term effects, medication therapy should always be combined with cognitive-behavioral therapeutic measures.
Treatment of OCD with Psychotherapy
The main psychotherapeutic technique used in treatment of OCD is a variation of CBT (Cognitive Behavioral Therapy) 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 Exposure and Response Prevention, the patient gradually confronts triggering stimuli under the guidance of a therapist and learns to manage the arising unpleasant feelings without performing compulsive actions. Ideally, exposure to triggering situations should occur in the patient’s everyday environment (e.g., at home). Through this process, the patient realizes that the feared consequences of the situation do not occur and that they can cope with the unpleasant feelings, leading to a decrease in anxiety, disgust, or tension over time, even without performing compulsions.
Given the complexity of the disorder, multimodal cognitive-behavioral therapy approaches are typically used for moderate to severe cases of OCD. These approaches include additional cognitive-behavioral therapeutic methods, as well as systemic, psychodynamic, and/or mindfulness-based elements.
The functionality of the obsessive symptoms is also considered in treatment. For instance, compulsions may serve to compensate for intense self-doubt or regulate relationships with close individuals. Involving family members in therapy is recommended, especially if they are involved in the rituals.
In the past, psychoanalytical/psychodynamic psychotherapy has been used with good effect, but there is little evidence-based data related to this psychotherapeutic technique.
Treatment of OCD (Obsessive-Compulsive Disorder). Summary
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, mostly antidepressants, in combination with psychotherapy.
The most effective psychotherapeutic approach is Cognitive Behavioral Therapy (CBT) with Exposure and Response Prevention (ERP). 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.
Early intervention is crucial to prevent the numerous consequences of the disorder. Even if the illness has persisted for decades, the right therapy can still be highly successful. While symptoms may not completely disappear for all patients, many experience a significant increase in quality of life as the intensity of obsessions and compulsions diminishes.