Obsessive–compulsive disorder
Obsessive–compulsive disorder is a mental disorder in which an individual has intrusive thoughts and feels the need to perform certain behaviors repeatedly to relieve the distress caused by the obsession, to the extent where it impairs general function.
Obsessions are persistent unwanted thoughts, mental images, or urges that generate feelings of anxiety, disgust, or discomfort. Some common obsessions include fear of contamination, obsession with symmetry, the fear of acting blasphemously, sexual obsessions, and the fear of possibly harming others or themselves. Compulsions are repetitive actions performed in response to obsessions to reduce anxiety, such as washing, checking, counting, reassurance seeking, and situational avoidance.
Compulsions occur often and typically take up at least one hour per day, impairing one's quality of life. Compulsions temporarily relieve distress but reinforce obsessions over time. Many adults with OCD recognize their rituals as irrational yet continue them to reduce anxiety. For this reason, thoughts and behaviors in OCD are usually considered egodystonic.
The exact causes of OCD are unknown, but there is evidence for the presence of a genetic component to the disorder. A variety of social and environmental factors can also contribute to the development of OCD. Diagnosis is based on clinical presentation; rating scales such as the Yale–Brown Obsessive–Compulsive Scale assess severity. OCD is associated with a general increase in suicidality. The term obsessive–compulsive or OCD is often used informally to describe someone overly meticulous or fixated, but OCD can present in many ways, and not all sufferers focus on cleanliness or symmetry.
OCD is chronic and long-lasting with periods of severe symptoms followed by periods of improvement. Treatment can improve ability to function and quality of life, and is usually reflected by improved Y-BOCS scores. First-line treatment for OCD typically consists of either exposure and response prevention or pharmacotherapy with selective serotonin reuptake inhibitors, or both in combination. Some patients fail to improve after treatment with SSRIs alone; these cases qualify as treatment-resistant and can require second-line treatment such as clomipramine or atypical antipsychotic augmentation. Recent evidence for treatment-resistant OCD also supports adjunctive use of deep brain stimulation, neurosurgical ablation, and repetitive transcranial magnetic stimulation.
Signs and symptoms
OCD can present with a wide variety of symptoms. Certain groups of symptoms usually occur together as dimensions or clusters, which may reflect an underlying process. The standard assessment tool for OCD, the Yale–Brown Obsessive–Compulsive Scale, has 13 predefined categories of symptoms. These symptoms fit into three to five groupings. A meta-analytic review of symptom structures found a four-factor grouping structure to be most reliable: symmetry factor, forbidden thoughts factor, cleaning factor and hoarding factor. The symmetry factor correlates highly with obsessions related to ordering, counting and symmetry, as well as repeating compulsions. The forbidden thoughts factor correlates highly with intrusive thoughts of a violent, religious or sexual nature. The cleaning factor correlates highly with obsessions about contamination and compulsions related to cleaning. The hoarding factor only involves hoarding-related obsessions and compulsions, and was identified as being distinct from other symptom groupings.When examining the onset of OCD, one study suggests that there are differences in the age of onset between males and females, with the average age of onset of OCD being 9.6 years for boys and 11.0 years for girls. Children with OCD often have other mental disorders, such as ADHD, depression, anxiety and disruptive behavior disorder. Continually, children are more likely to struggle in school and experience difficulties in social situations. When looking at both adults and children, a study found the average ages of onset to be 21 and 24 for males and females respectively. While some studies have shown that OCD with earlier onset is associated with greater severity, other studies have not been able to validate this finding. Looking at women specifically, a different study suggested that 62% of participants found that their symptoms worsened at a premenstrual age. Across the board, all demographics and studies showed a mean age of onset of less than 25.
Some OCD subtypes have been associated with improvement in performance on certain tasks, such as pattern recognition and spatial working memory. Subgroups have also been distinguished by neuroimaging findings and treatment response, though neuroimaging studies have not been comprehensive enough to draw conclusions. Subtype-dependent treatment response has been studied and the hoarding subtype has consistently been least responsive to treatment.
While OCD is considered a homogeneous disorder from a neuropsychological perspective, many of the symptoms may be the result of comorbid disorders. For example, adults with OCD have exhibited more symptoms of attention deficit hyperactivity disorder and autism spectrum disorder than adults without OCD.
In regards to the cause of onset, researchers asked participants in one study what they felt was responsible for triggering the initial onset of their illness. 29% of patients answered that there was an environmental factor in their life that did so. Specifically, the majority of participants who answered with that noted their environmental factor to be related to an increased responsibility.
Obsessions
Obsessions are stress-inducing thoughts that recur and persist, despite efforts to ignore or confront them. People with OCD frequently perform tasks, or compulsions, to seek relief from obsession-related anxiety. Within and among individuals, initial obsessions vary in clarity and vividness. A relatively vague obsession could involve a general sense of disarray or tension, accompanied by a belief that life cannot proceed as normal while the imbalance remains. A more intense obsession could be a preoccupation with the thought or image of a close family member or friend dying, or intrusive thoughts related to relationship rightness. Other obsessions concern the possibility that someone or something other than oneself—such as God, the devil or disease—will harm either the patient or the people or things the patient cares about. Others with OCD may experience the sensation of invisible protrusions emanating from their bodies or feel that inanimate objects are ensouled. Another common obsession is scrupulosity, the pathological guilt/anxiety about moral or religious issues. In scrupulosity, a person's obsessions focus on moral or religious fears, such as the fear of being an evil person or the fear of divine retribution for sin, for example going to Hell. Mysophobia, a pathological fear of contamination and germs, is another common obsession theme.Some people with OCD experience sexual obsessions that may involve intrusive thoughts or images of various sexual acts with strangers, acquaintances, relatives, animals, or religious figures and can include heterosexual or homosexual contact with people of any age. Similar to other intrusive thoughts or images, some disquieting sexual thoughts are normal at times, but people with OCD may attach extraordinary significance to such thoughts. For example, obsessive fears about sexual orientation can appear to the affected individual, and even to those around them, as a crisis of sexual identity. Furthermore, the doubt that accompanies OCD leads to uncertainty regarding whether one might act on the troubling thoughts, resulting in self-criticism or self-loathing.
Pedophilia-themed obsessive–compulsive disorder is an OCD subtype regarding reocurring compulsions and obsessions over one being a pedophile.
Most people with OCD understand that their thoughts do not correspond with reality; however, they feel that they must act as though these ideas are correct or realistic. For example, someone who engages in compulsive hoarding might be inclined to treat inorganic matter as if it had the sentience or rights of living organisms, despite accepting that such behavior is irrational on an intellectual level. There is debate as to whether hoarding should be considered an independent syndrome from OCD.
Compulsions
Some people with OCD perform compulsive rituals because they inexplicably feel that they must do so, while others act compulsively to mitigate the anxiety that stems from obsessive thoughts. The affected individual might feel that these actions will either prevent a dreaded event from occurring or push the event from their thoughts. In any case, their reasoning is so idiosyncratic or distorted that it results in significant distress, either personally or for those around the affected individual. Excessive skin picking, hair pulling, nail biting and other body-focused repetitive behavior disorders are all on the obsessive–compulsive spectrum. Some individuals with OCD are aware that their behaviors are not rational, but they feel compelled to follow through with them to fend off feelings of panic or dread. Furthermore, compulsions often stem from memory distrust, a symptom of OCD characterized by insecurity in one's skills in perception, attention and memory, even in cases where there is no clear evidence of a deficit.Common compulsions may include hand washing, cleaning, checking things, repeating actions, ordering items in a certain way and requesting reassurance. Although some individuals perform actions repeatedly, they do not necessarily perform these actions compulsively; for example, morning or nighttime routines and religious practices are not usually compulsions. Whether behaviors qualify as compulsions or mere habit depends on the context in which they are performed. For instance, arranging and ordering books for eight hours a day would be expected of someone who works in a library, but this routine would seem abnormal in other situations. In other words, habits tend to bring efficiency to one's life, while compulsions tend to disrupt it. Furthermore, compulsions are different from tics and stereotyped movements, which are usually not as complex and not precipitated by obsessions. It can sometimes be difficult to tell the difference between compulsions and complex tics, and about 10–40% of people with OCD also have a lifetime tic disorder.
People with OCD rely on compulsions as an escape from their obsessive thoughts; however, they are aware that relief is only temporary and that intrusive thoughts will return. Some affected individuals use compulsions to avoid situations that may trigger obsessions. Compulsions may be actions directly related to the obsession, such as someone obsessed with contamination compulsively washing their hands, but they can be unrelated as well. In addition to experiencing the anxiety and fear that typically accompanies OCD, affected individuals may spend hours performing compulsions every day. In such situations, it can become difficult for the person to fulfill their work, familial or social roles. These behaviors can also cause adverse physical symptoms; for example, people who obsessively wash their hands with antibacterial soap and hot water can make their skin red and raw with dermatitis.
Individuals with OCD often use rationalizations to explain their behavior; however, these rationalizations do not apply to the behavioral pattern, but to each individual occurrence. For example, someone compulsively checking the front door may argue that the time and stress associated with one check is less than the time and stress associated with being robbed, and checking is consequently the better option. This reasoning often occurs in a cyclical manner and can continue for as long as the affected person needs it to in order to feel safe.
OCD sometimes manifests in mental instead of overt compulsions. This manifestation may be termed "primarily obsessional OCD" and typically involves mental compulsions, such as mental avoidance or excessive rumination. OCD without overt compulsions could, by one estimate, characterize as many as 50–60% of OCD cases.