Questions about OCD

Obsessive-compulsive disorder (OCD) is an illness that causes people to have distressing, intrusive, irrational thoughts, images or impulses (i.e., obsessions) and to perform repetitive behavioral or mental acts (i.e., compulsions) aimed at reducing distress or preventing some dreaded situation. Read the DSM-5 Criteria for OCD.

Although everyone with OCD has obsessions and/or compulsions, the content varies from person to person. Typical obsessions include repetitive fears of causing harm or being harmed, fears of contamination and illness, fears of making mistakes, intrusive distressing sexual or religious imagery, or fears of losing things. Typical compulsions include repetitive washing and cleaning, excessive checking, excessive ordering, and arranging, or extreme hoarding and saving. Some people with OCD have only one type of obsession or compulsion; others have several types of obsessions and compulsions.

OCD occurs in 1-3 percent of the population with its onset typically occurring in adolescence or young adulthood (although it can start in childhood). The course is often chronic.

When obsessions and compulsions cause marked distress, are time-consuming (for example, take more than one hour a day), or interfere with functioning, treatment is recommended. Two treatments significantly reduce the symptoms of OCD: cognitive-behavioral therapy (CBT) using exposure and ritual prevention and pharmacotherapy with serotonin reuptake inhibitors (SRIs) clomipramine (Anafranil), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), and escitalopram (Lexapro).

Obsessions

• Obsessions are persistent and recurrent thoughts, urges, impulses, or images that are inappropriate and intrusive. These thoughts can cause feelings of anxiety, distress, or disgust
• Obsessions are not just excessive worries about real-life problems
• The patient tries to suppress or ignore the obsessions or to neutralize them with a different thought or behavior
• The patient recognizes that the obsessions are not based on reality

Examples of Obsessions

• Fears of contamination or germs
• Fears of harming oneself or others
• Concerns about order and symmetry
• Unwanted sexual or religious thoughts

Compulsions 

• Compulsions are repetitive behaviors or mental acts that the patient feels driven to perform according to strict rules, or to bring down anxiety, or to prevent a feared event or situation
• The compulsions are clearly excessive or are not connected in a realistic way with what they are supposed to neutralize or prevent

Examples of Compulsions

• Excessive hand washing or cleaning
• Excessive checking (e.g., locks, doors, stoves, etc.)
• Ordering and arranging
• Counting, praying or repeating words silently to oneself

In adults, the lifetime prevalence of OCD is approximately 2.5%, and the 1-year prevalence is between 0.5%-2.1%. Research shows that the prevalence of OCD is similar in many different cultures around the world.

OCD most often begins in adolescence or early adulthood, but for many, it begins in childhood. OCD is typically a chronic disorder, with waxing and waning symptoms that can worsen due to stress.

The first-line treatments for OCD are medication with serotonin reuptake inhibitors (SRIs), therapy with Cognitive Behavioral Therapy (CBT), or their combination. Our center offers both types of treatment. We encourage patients to select the treatment that they feel most comfortable with.

• Serotonin Reuptake Inhibitors (SRIs): Serotonin reuptake inhibitors (SRIs) are the most effective pharmaceutical treatment for OCD. SRIs are antidepressants that block the re-absorption of serotonin in the brain. Although SRIs are commonly prescribed for depression, studies have found that they can be effective for patients with OCD. The doses required for treating OCD are often higher than the doses required for treating depression. Common side effects of SRIs include: nausea, diarrhea, sexual dysfunction, and headaches. Not all patients respond to SRIs and some who do still experience bothersome symptoms. For these patients, we recommend adding Cognitive-Behavioral Therapy (CBT).
• Cognitive-Behavioral Therapy (CBT): Cognitive-Behavioral Therapy (CBT) that includes Exposure and Ritual Prevention (or Exposure and Response Prevention; EX/RP, ERP) has been shown to be the most effective psychotherapy for OCD. The goal of CBT is to change dysfunctional thoughts, emotions, and behaviors. To do this, the therapist helps the patient repeatedly approach situations that trigger OCD-related anxiety or distress (exposure), while refraining from performing compulsions or rituals (ritual prevention). By doing this, the patient learns that their anxiety and distress will go down, and that feared consequences will not occur, even if they don’t do their rituals. CBT with EX/RP (ERP) is typically completed in 17-25 ninety-minute sessions.

Obsessive-compulsive personality disorder (OCPD) is a chronic maladaptive pattern of excessive perfectionism, preoccupation with orderliness and detail, and need for control over one's environment that leads to significant distress or impairment, particularly in areas of interpersonal functioning. Individuals with this disorder are often characterized as rigid and overly controlling. They may find it difficult to relax, feel obligated to plan out their activities to the minute and find unstructured time intolerable.

According to recent studies, about a quarter to a third of individuals with OCD meet criteria for OCPD. There is also evidence of a familial association between OCPD and OCD with studies showing increased frequencies of OCPD traits in the first degree relatives of individuals with OCD. Despite the apparent relationship between the disorders and some similarities in their symptoms, there are distinct differences between the conditions. OCD is characterized by intrusive and distressing obsessions; in contrast, OCPD traits and symptomatic behaviors are viewed by affected individuals as appropriate and correct, though they can lead to significant distress due to the associated need for control.

OCD Case Examples

C.D.*, a 27-year old woman, complained of excessive checking. Her symptoms dated back to her childhood when she spent hours on homework because of a need to have each page perfect with no erasures or cross-outs and hours arranging her room so that it was in perfect order before sleeping. By high school, she couldn't complete assignments until after the term had ended and did not participate in any extracurricular activities because her time was spent checking work assignments. When C.D. entered college she developed new checking rituals to assure herself that she had not caused harm to anyone around her (e.g., checking electrical appliances for fear that she had started a fire, faucets for fear that she had left them running, and door locks for fear that she had left them open). These rituals began to consume several hours a day leading her to be late for class or to miss it entirely. Although she sought therapy, she did not tell the therapist about her obsessions and rituals for fear she would be labeled "crazy." Her bedtime rituals grew to three to four hours, leaving her practically no time to sleep or study. Her appetite and mood plummeted and she stopped attending class. She left college and returned home. Her parents, alarmed at the changes in their daughter, took her to a psychiatrist who diagnosed depression and started her on a standard dosage of a serotonin reuptake inhibitor. After six weeks on the medication, her mood was slightly improved but her rituals were unchanged. Her medication was changed to a second serotonin reuptake inhibitor, also at a low dosage, with no better results. A second opinion was sought and C.D. felt comfortable enough to admit to her "crazy" thoughts. Obsessive Compulsive Disorder (OCD) was diagnosed. Her serotonin reuptake inhibitor dose was raised and her obsessions decreased in intensity, reducing the amount of time spent checking to an hour a day. On the medication, she was able to return and complete college.

D.S., a 35-year-old male, complained of elaborate cleaning and washing rituals. His particular concerns were with bodily waste or secretions (especially urine, feces, saliva, and semen). His specific feared consequences were about contracting HIV disease and/or spreading the HIV virus to others. His rituals included elaborate handwashing routines, prolonged and stereotyped showers, and lengthy wiping and cleaning rituals after using the toilet. The possibility that he might contract HIV disease and/or that he might spread it to others dominated his waking hours, and he only really felt safe when he was at home washing.

On initial evaluation, Dan was told about the two proven treatments for OCD: pharmacotherapy with a serotonin reuptake inhibitor (SRI) and cognitive-behavioral therapy consisting of exposure and ritual prevention (EX/RP or ERP). When Dan learned that EX/RP (ERP) treatment would require exposure to feared contaminants, he chose SRI treatment instead. After about 6 weeks on fluoxetine 60 mg per day, Dan reported that he was much less bothered by his obsessions, and he was more able to delay or stop his rituals. On the other hand, he continued to obsess about 3 hours per day about contaminants and to wash excessively. Thus, he was referred to twice-weekly EX/RP (ERP) with an experienced therapist.

Remaining on the SRI, Dan participated in 17 EX/RP (ERP) sessions. With the therapist's expert guidance, he confronted feared contaminants in session and at home without ritualizing. He started with situations that he found moderately distressing (e.g., touching the floor in the therapists office), progressed to situations that he found more distressing (e.g., touching the floor in public bathrooms), and finished with situations that were highly distressing (e.g., imagining contracting HIV disease and giving it to his whole family). Although the treatment triggered a lot of anxiety, he persisted, and he became less fearful over time as he repeatedly confronted his fears without ritualizing. By the end, his OCD symptoms were minimal, his work and his social functioning had improved, and he felt optimistic about his future.

OCPD Case Example

Mrs. B. is a 30-year old school teacher without previous treatment. She described having a book collection that she dusted daily and would not let anyone else, including her husband, touch. She insisted that her husband get into bed at night before her so that she could make sure that nothing in the house had been moved after she went to bed. If they were late for an engagement, she was unable to modify her routine of getting ready. Both at work and at home, she refused to allow others to do any tasks that might be helpful to her, as she felt that only she could perform these tasks correctly. When leaving the house, she insisted on driving or walking a predetermined route despite any obstacles, such as traffic, that presented themselves along the way. She was critical and outspoken about "shortcuts" that she thought other teachers took in their work. These patterns of behavior and attitudes caused major marital conflict and conflict with other teachers.

*Please note that all details are disguised to protect the privacy of the individual.