Facts about Obsessive-Compulsive Disorder

What is Obsessive-Compulsive Disorder?
Obsessive-compulsive disorder (OCD) is a major psychiatric disorder that can affect all aspects of a person’s
functioning, including his or her relationships with others, the ability to work, and recreational activities.  Clients with
OCD typically experience anxiety related to severe obsessions (repeated worries that are difficult to let go of) or
compulsions (recurrent behaviors or thoughts that must be frequently repeated to reduce anxiety).  Clients with OCD
often understand that their obsessions are unrealistic or their compulsions are excessive, but they feel powerless to
change.  Some individuals with OCD lack insight into the senselessness of the obsessions and compulsions.

How Common Is OCD?
OCD is a relatively common psychiatric disorder.  Between two and three out of every one hundred persons (2-3
percent) develop OCD at some time during their life.

How Is the Disorder Diagnosed?
OCD can only be diagnosed by a clinical interview.  The purpose of the interview is to determine whether the client has
experienced specific "symptoms" of the disorder and whether these symptoms have been present long enough to merit
the diagnosis.  OCD cannot be diagnosed with a blood test, an X ray, a CAT scan, or any other laboratory test.

The Characteristic Symptoms of OCD
    The symptoms of OCD can be broadly divided into three different categories: obsessions, compulsions, and other
symptoms
.  Clients with OCD can have either severe obsessions or severe compulsions, although the majority of clients
have both types of symptoms.  Regardless of which symptoms the client has, they cause significant distress and
disruption to his or her life.  Specific symptoms of OCD are described below.

Obsessions.  Obsessions are recurrent thoughts, impulses, or images that cause anxiety and are disturbing to the
client, such as the impulse to kill a loved child or the thought that one has somehow been exposed to a fatal disease.  
The insight clients have into the true basis of their concerns varies from one client to the next, ranging from a
recognition that the obsessions are unrealistic to fully believing that the obsessions are realistic.  However, regardless
of the client's insight, obsessions cause distress, which leads to efforts to avoid, suppress, or neutralize these
thoughts.  These efforts provide temporary relief, but then the obsessions return again.

Compulsions.  Compulsions are the urge to engage repeatedly in behaviors or thoughts in order to reduce anxiety
related to an obsession or because the person finds it difficult to resist the behavior.  These stereotyped behavior
patterns serve no useful purpose, except to fend off anxiety.  The compulsions can be so pervasive that the person
repeats them innumerable times throughout the day.  Several types of specific compulsive symptoms include:

  
  Washing and Cleaning.  Fear of dirt, disease, and contamination are quite common among clients with OCD, and
one natural consequence of this fear is compulsions about cleanliness.  Hand washing is common, to the point where
the client may wash more than fifty to one hundred times per day, with resulting chaffing, redness, and bleeding of skin.  
Vigorous body scrubbing, washing of clothes, and excessive use of disinfectants may occur.  The person may spend
hours in the bathroom washing, attending to dental hygiene, etc., making it difficult to live a "normal" life.  The fear of
contamination may also lead clients to avoid many situations or touching commonplace objects.
    
    
Checking.  The client may repeatedly check on things, such as making sure the door is locked, windows are shut,
electrical appliances are turned off, or a task has been done correctly.  The person may check something many times in
a row, just to make sure there is no safety risk or error.  Even though the client knows he or she just checked
something, the fear of possible catastrophe leads to checking again and again.

    
Ordering.  An excessive level of order in the home or at work is maintained (such as requiring symmetry of objects,
insisting on a particular organization of the house or workplace).  The client spends a considerable amount of time
keeping this order and may become anxious or angry if others upset the order.

    
Repeating.  The client repeats specific actions over and over because of a "magical" belief that it will protect him or
her in some way.  For example, a client repeatedly dresses and undresses until a thought about her loved ones being
hurt disappears.  Unlike washing, cleaning, and checking rituals, repeating rituals are not "logically" related to the
concerns the person has; rather, the behaviors are simply repeated until the undesired thought or feeling goes away,
sometimes after numerous repetitions.

    
Hoarding.  The client has difficulty throwing things away, forming idiosyncratic collections of no value (such as
scraps of paper, old newspapers, etc.).  The major reason given by clients for saving the objects is that they may need
them sometime in the future, although the need never seems to rise.

    
Thinking Rituals.  The client develops thinking rituals that stop the obsession and neutralize the anxiety associated
with it.  These rituals may need to be repeated many times before the obsession is stopped.  For example, a religious
person with recurrent blasphemous thoughts may develop an elaborate set of specific prayers that are repeated over
and over until the thought has ceased.

    
Other Symptoms
    In addition to anxiety, which is present in most clients with OCD, a variety of other symptoms may also occur.  
Depression is a common problem for many clients, as the obsessions and compulsions take control of their life.  Alcohol
and drug abuse problems may occur as clients try to escape the ever-present obsessions or compulsions.  Sometimes
clients with OCD have quite bizarre obsessions that seem quite real to the person, and there are thus delusions (or
"false beliefs").  For example, one client was genuinely terrified of carpets because he was afraid of getting tacked
under the carpet.

What Is the Course of the Disorder?
The course of OCD varies from one client to the next.  OCD often develops in late adolescence or early adulthood,
although onset during childhood and later in adulthood also occurs.  For some clients, OCD is a chronic and debilitating
disorder that lasts throughout much of their lives.  Many clients are capable of recovering substantially from OCD,
especially when they have received appropriate treatments for the disorder.

What Causes OCD?
The precise causes of OCD are not understood at this time, although there are several theories.  The most prominent
theories of OCD involve learning and altered brain chemistry.  According to learning theory, obsessions and
compulsions develop gradually over a period of time.  First, the person experiences a minor distressing thought, image,
or impulse, which results in anxiety.  The person tries to think about something different or engages in a particular
behavior as a distraction from the thought, thereby lowering his or her anxiety.  However, the thought or image is likely
to occur again, since no method of distraction is permanent.  Gradually, the person spends more and more time
anticipating (and experiencing) these distressing thoughts (obsessions) and developing increasingly elaborate cognitive
strategies (thinking rituals) and behaviors (compulsions) for lowering his or her anxiety.  As a result, much of the
person's time becomes occupied with these obsessions and compulsions, with his or her anxiety steadily worsening.  
    Biological theories of OCD suggest that the disorder may result from differences in brain neurotransmitters
(chemicals in the brain).  One particular neurotransmitter has been linked to OCD - serotonin.  However, the nature of
the abnormality is not known.  Both learning and biological factors may be involved in OCD.

Are There Factors That Might Increase the Likelihood of Relapse?
OCD symptoms often wax and wane over time, usually in response to life stress.  Symptoms tend to worsen under
periods of life change or stress, or when going off prescribed medication against the doctor's advice.

How is OCD Treated?
Two primary treatments can improve or eliminate the symptoms of OCD: behavior therapy and medication.  Two specific
techniques of behavior therapy are especially effective at reducing obsessions and compulsions: exposure to the
feared stimuli (such as situations, thoughts, etc.) and response prevention to stop behavior patterns that reduce
anxiety.  When clients permit themselves to confront feared thoughts, places, or objects for extended periods of time,
their anxiety gradually subsides.  Teaching clients to refrain from rituals and compulsions breaks the vicious cycle of
repeated behaviors, providing relief.  Most behavior therapy programs for OCD require several weeks of intensive
treatment or longer periods of less intensive therapy.  Family treatment can help lower the stress on clients with OCD
and their relatives, improving the long-term outcome of the disorder.  Pharmacological treatment with antidepressant
medications also improves the symptoms of OCD.  There is evidence that antidepressants with a primary effect on
serotonin (such as Anafranil, Prozac, Zoloft, or Paxil) have the most beneficial effect on OCD.  Medication usually
requires at least ten weeks to be effective.  A combination of behavior therapy and medication may also be helpful.




Recommended Readings

Foa, E.B. & Wilson, R. (1991), Stop Obsessing!  How to Overcome Your Obsessions and Compulsions.  New York:
Bantam.

Rapoport, J.L. (1989),
The Boy Who Couldn't Stop Washing: The Experience and Treatment of Obsessive Compulsive
Disorder.
 New York: Dutton.

Steketee, G. & White, K. (1990),
When Once Is Not Enough: Help for Obsessive Compulsives.  Oakland, CA: New
Harbinger.

*Note:  This handout is taken from the book Behavioral Family Therapy for Psychiatric Disorders (1999) by Kim T.
Meuser and Shirley M. Glynn, published by New Harbinger Publications.  Used with permission.
Consult a mental health professional (such as a psychiatrist, social worker, or
psychiaric nurse) about any questions you have concerning this handout.