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Although once thought to be a relatively rare condition, obsessive-compulsive disorder (OCD) is now recognized to be a common and often debilitating form of mental illness. Two to three percent of the population experience OCD during their life. OCD affects people throughout the world, regardless of the culture in which they live. In adults more women than men experience OCD, but in children, it is almost twice as likely to affect boys.
There are two different times that OCD manifests itself initially, and they are distinguishable onset patterns. For the early-onset group, OCD begins on average at about age 11. The late-onset OCD group first experiences the condition in their early 20s. Early-onset OCD occurs in about three-quarters of the individuals who suffer from the disorder. In the current classification system for mental health problems, OCD is no longer considered an anxiety condition but is grouped with several other problems considered to have important similarities to OCD. OCD is understood to involve the frequent experience of obsessions, compulsions, or both. Most people who experience OCD have both obsessions and compulsions. Obsessions are unwanted or distressing thoughts, images, or urges. Compulsions are defined as repetitive behaviors or thoughts (e.g., having a “good” thought to cancel out a “bad” thought) people feel driven to do to reduce distress. Often compulsions are intended to reduce distress related to obsessions (e.g., repetitive washing in response to concerns about germs and disease). While periodic negative thoughts are a common experience for all people, OCD is defined by the related significant distress and life interference that results from these thoughts.
What Are Obsessions?
Obsessions are ideas, thoughts, images, or impulses that are senseless and “get in the way.” They continue even though a person may try to ignore or forget about them. They are experienced as unpleasant and unwanted and may provoke anxiety, guilt, shame, or other uncomfortable emotions.
The most common obsessions are concerns that objects or other people might be “contaminated” by contact with germs, disease, dirt, chemicals, or some other source. The feeling of contamination is accompanied by an urge to wash or to clean. Other obsessions focus on fears that doors or windows have been left unlocked, appliances have been left on, important papers have been thrown away, mistakes have been made, and so forth.
Frightening thoughts about burglary, fire, and other losses often accompany these fears, forming part of the obsessive ideas. Some obsessive thoughts concern accidents or unfortunate events that might occur unless one superstitiously repeats particular actions or thoughts to prevent the disaster. Other obsessions take the form of unwanted urges or impulses to do something harmful, such as to stab one’s child with a kitchen knife. Some people experience horrific or upsetting images having to do with religious figures.
Obsessions can take many forms. Ordinary people are concerned by many of the ideas, thoughts, images, or impulses underlying obsessive fears. Most of us are concerned about AIDS and other diseases, and about harmful chemicals in the environment. We are careful not to leave hot appliances near materials that might catch fire. We periodically experience odd impulses or form upsetting images. However, for those with OCD, the fear and guilt or other unpleasant emotions are out of proportion to the actual risk of danger or harm, driving them to carry out compulsions to rid themselves of the worry.
What Are Compulsions?
Compulsions, also called rituals, are usually actions that are repeated, but sometimes are thought patterns that are performed to rid oneself of a disturbing obsession. Rituals are usually carried out according to certain rules or in a rigid fashion and are clearly excessive. The person recognizes that the rituals are not reasonable but feels unable to control them. Most compulsions are logically related to the type of obsessive ideas they attempt to reduce or prevent, although this is not always true. Because they temporarily reduce discomfort, rituals become habitual, and the person with OCD often has difficulty controlling them.
Examples of compulsions include hand-washing, showering, or cleaning to remove “contamination”; checking to prevent feared dangers such as theft, fire, or loss of important things; repeating actions or thoughts to prevent a catastrophic event from happening; having to arrange objects in a particular way before beginning an activity; or needing repeated reassurance from others that a feared event has not or cannot happen. Some compulsions are performed mentally without any behavioral manifestation. Examples include praying to relieve guilt about an unwanted idea and repeating phrases or images in one’s mind to prevent a catastrophe.
Those who suffer from obsessions and compulsions vary widely in their personality characteristics, life circumstances, and the degree to which their lives are disrupted by these symptoms. Thus, it is difficult to make general statements about their habits. Some researchers have suggested that those with OCD tend to come from more perfectionistic and possibly more moralistic upbringings. They are more concerned with avoiding mistakes than are people who do not get so anxious.
Many OCD sufferers appear to overestimate the risk involved in their obsessive concern, and some dislike taking even small risks of any type. Many doubt their own decision-making ability and request reassurance from others to confirm their choices. On the other hand, many people with OCD do not exhibit these traits, but appear to be quite normal in their social, recreational, and work lives.
While obsessions and related compulsions can take a near infinite number of forms, there are several symptom patterns that are regularly seen in OCD. A common type of OCD involves contamination obsessions and associated washing and/or cleaning compulsions. Another variation of OCD symptoms involves obsessions about bad things happening (e.g., leaving something cooking on the stove and inadvertently causing a fire). To prevent harm from occurring, the individual becomes stuck respectively checking. Other people with OCD experience distress when things are not ordered or arranged in a particular manner, while others are troubled by constant concerns about morality and the implications it might have for their behavior. The heterogeneous nature of OCD, and its frequent occurrence with anxiety, depression, and other problems, can present challenges to its identification by health and mental health professionals.
There is no clear understanding of what causes OCD, although research over the last several decades indicates that multiple factors are involved. There is a significant genetic component with people closely related to those with OCD being more likely to have or develop the condition. Some models of the development of OCD emphasize differences in specific brain neurotransmitters and abnormalities in specific brain circuits. In behavioral models of OCD, specific types of learning and conditioning experiences are emphasized. The cognitive model of OCD emphasizes the common nature of negative intrusive thoughts and the important role the misappraisal of these thoughts has in the condition’s development. For example, having a thought that a loved one could be in a car accident can be understood as a passing negative thought and is easily dismissed. Alternatively, the thought could be inaccurately appraised as an indication that an accident is more likely to occur, in which case one would be obligated to prompt the person to drive carefully. The latter appraisal, understood as driven by specific types of dysfunctional beliefs, is believed to play an important role in OCD development and the continuation of symptoms.
A number of treatments help. One includes a specific form of behavior therapy, exposure and response (ritual) prevention (ERP). OCD has also been effectively treated by a form of cognitive-behavior therapy focused on how negative intrusive thoughts are understood. Most mental health professionals and scientists with expertise in OCD see ERP as a critical treatment for the condition. ERP first involves careful identification of the individual’s obsessions and the related distress- reducing compulsions or avoidance behaviors. Often people’s obsessional concerns and compulsions are highly idiosyncratic. Once obsessions and related compulsions are understood, an exposure hierarchy is structured. The exposure hierarchy is a listing of less difficult to more difficult OCD-related activities. For example, for a person with contamination concerns, touching and not washing might begin with a table used by others at home and progress to touching a sink in a public restroom. It is very important that during each exposure exercise the individual be guided to continue the activity until they experience a significant reduction in anxiety or distress. Individuals willing to complete this treatment often experience significant symptom reduction in several weeks.
Unfortunately, many health and mental health professionals are not expert in the identification of OCD, or in its treatment using ERP. Professional organizations such as ABCT provide listings of practitioners expert in cognitive-behavioral therapy, including providers who specialize in treating OCD. You can visit the ABCT website and click on “Find a CBT Therapist” to find treatment providers in your area who treat OCD (https://www.abct.org/Help/?m=mFindHelp &fa=dFindHelp). Additionally, there are several international, national, or regional organizations that provide information about health care professionals’ expertise in treating OCD, information about OCD broadly, and advice on screening OCD treatment providers. The International OCD Foundation provides information about OCD and related problems and information on where to find treatment (https://iocdf.org/about-ocd/treatment/). The Anxiety and Depression Association of America also provides information about OCD and its treatment (https://www.adaa.org/sites/default/files/Relief-from-OCD.pdf). Beyond OCD is a provider of information and treatment for OCD in Chicago and the Midwest (http://beyondocd.org/).