Learn More About OCD
What is OCD?
Obsessive-compulsive disorder (OCD) is an illness that affects thoughts and actions and is believed to be rooted in faulty information processing in certain brain circuits. OCD is classified as an anxiety disorder in the Diagnostic and Statistical Manual (DSM-IV) of the American Psychiatric Association, published in 1994, and is characterized by recurrent and disturbing thoughts (called obsessions) and/or repetitive, ritualized behaviors that the person feels driven to perform (called compulsions). Obsessions can also take the form of intrusive images or unwanted impulses. Individuals with OCD usually try to actively dismiss the obsessions or neutralize them by engaging in compulsions or avoiding situations that trigger them. In most cases, compulsions serve to alleviate anxiety. However, it is common for the compulsions themselves to engender anxiety, especially when they become very demanding.
A hallmark of OCD is that the affected individual recognizes that his/her thoughts or behaviors are senseless or excessive. However, the discomfort and drive can be so powerful that the person gives in to the compulsion even though he/she knows it makes no sense.
Diagnostic features of OCD
- Classified as an anxiety disorder
- Recurrent unwanted and distressing thoughts (obsessions) and/or repetitive irresistible behaviors (compulsions)
- Majority have both obsessions and compulsions
- Insight present: person acknowledges senselessness or excessiveness of symptoms
- Compulsions usually reduce anxiety, but are not pleasurable
- Symptoms produce subjective distress, are time-consuming (less than 1 hour per day), or interfere with function
Examples of obsessions and compulsions
Common types of obsessions include concerns with contamination (e.g., fear of dirt, germs, or illness), safety/harm (being responsible for a fire), unwanted acts of aggression (unwanted impulse to harm a loved one), and the need for symmetry or exactness.
Common compulsions include excessive cleaning (e.g., ritualized hand washing), checking, ordering and arranging rituals, counting, repeating routine activities (going in/out of a doorway), and hoarding (collecting useless items). While most compulsions are observable behaviors (e.g., hand washing), some are performed as unobservable mental rituals (silent recitation of nonsense words to vanquish a horrific image).
Depression is a common complication of OCD. Approximately 75% of patients with OCD report that they have suffered from symptoms of depression, including feelings of despair, inability to experience pleasure, disturbed sleep, loss of energy, weight loss (or gain), decreased sexual drive, and suicidal thoughts.
Uncontrollable hair pulling or trichotillomania is present in some patients with OCD.
Several lines of evidence suggest a relationship between OCD and the childhood-onset disorder Tourette's syndrome (TS). About 50% of patients with TS develop obsessive-compulsive symptoms during the course of their illness.
How common is OCD?
Studies suggest that 2%-3% of the population (roughly 5 million Americans) may suffer from OCD at some point during their lifetimes.
Who is affected and when does it start?
The onset of OCD is usually in adolescence or early adulthood. Nearly one half of all cases begin in childhood and it is rare to see onset after age 35 years. In adults with OCD, men and women are almost equally affected by OCD. In childhood OCD, boys outnumber girls and their age of onset is earlier.
OCD strikes people from all walks of life and all levels of educational background. Factors that predispose to the development of OCD have not been identified.
What is the course of OCD?
If untreated, OCD is usually chronic and follows a waxing and waning course. Only about 5%-10% of OCD sufferers enjoy a spontaneous remission in which all symptoms of OCD go away for good. Another 5%-10% experience progressive deterioration in their symptoms. Stress can make OCD worse, but trying to eliminate all stress is unlikely to quell OCD. If untreated, approximately one third to one half of children and adolescents with OCD continue to have OCD in adulthood. Early recognition and intervention is, therefore, very important.
How do I know if I have OCD?
There is no reliable diagnostic test for OCD. The diagnosis is almost entirely based on a thorough face-to-face interview conducted by an experienced mental health professional.
The content of OCD can be so disagreeable and so private it is very difficult to share with anyone, including loved one’s and trained professionals. A simple device we use to reduce the shame of sharing such sensitive material is to administer a checklist featuring examples of obsessive-compulsive behaviors. It is best to do this in person, but some people actually prefer to fill out a questionnaire initially on their own. That way it is just between you and the piece of paper or the computer.
As a beginning to your inquiry into OCD, the Florida Obsessive-Compulsive Inventory (FOCI) is a relatively short self-administered screening instrument. The FOCI has its limitations and it is not a substitute for a face-to-face clinical interview.
Assessing severity of OCD
One of the most widely used instruments for assessing OCD includes a symptom checklist that includes about 75 examples of obsessions and compulsions. This instrument, called the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), is ordinarily used by trained professionals to evaluate OCD. The scale, developed by Wayne Goodman, MD (Icahn School of Medicine), Steven Rasmussen, MD (Brown University), and Lawrence Price, MD (Brown University), contains two parts: 1) the Symptom Checklist and 2) the 10-item severity measure. The psychometric properties of the Y-BOCS have been extensively studied (Goodman et al 1989; Goodman et al 1989).
More recently, the original developers along with Eric Storch, PhD, of the University of South Florida (Storch et al, 2010), created a new version of the Y-BOCS (referred to as the Y-BOCS II). Both the Y-BOCS and the Y-BOCS II are copyrighted and cannot be copied, distributed, or modified without the written permission of Dr. Goodman. To obtain a complete copy of the Y-BOCS, Y-BOCS II, or FOCI, please e-mail Dr. Goodman.
Treatment of OCD
Studies consistently demonstrate the efficacy of cognitive behavioral therapy (CBT) and serotonin reuptake inhibitors (SRIs) in the treatment of OCD. The most broadly effective treatment for OCD appears to be a combination of CBT and an SRI.
The medications that consistently work in the treatment of OCD are antidepressants (SRIs) that interact with the brain chemical serotonin. Serotonin is one of the brain's many chemical messengers (neurotransmitters) that allow nerve cells (neurons) to communicate with each other. SRIs, like clomipramine (Anafranil®) that block the serotonin pump in neurons and increase the availability of serotonin where neurons meet (synapse). In addition to clomipramine, several selective serotonin reuptake inhibitors (SSRIs) have also proven effective in treating OCD, including fluvoxamine (Luvox®), fluoxetine (Prozac®), sertraline (Zoloft®), and paroxetine (Paxil®).
All five of these medications are approved by the Federal Drug Administration (FDA) to treat OCD in both adults and children. Other SRIs have been found to be effective in treating OCD, as well as the addition of other medications to “augment” the effects of SRIs.
CBT is a type of therapy that focuses on the interplay between thoughts, feelings, and behaviors. Specifically, a CBT technique known as Exposure and Response Prevention (ERP) is the gold standard treatment used for OCD. This treatment does not focus on the meaning of the obsessions; rather it targets the thinking process. The OCD thinking pattern can be described as the following: one gets an intrusive thought, image, or impulse, which is accompanied with discomfort and/or anxiety. To relieve the painful emotion, a person engages in either a ritual or avoidance. This pattern works in the short run, but not for the long term, and it serves to strengthen the OCD.
In the past, many therapists told their patients “to just stop thinking about it”, but as anyone who has OCD will tell you, that strategy only leads to more obsessive thinking and compulsive behavior. ERP is the exact opposite of “thought stopping”, which is why it works. This technique involves confronting one’s fears without performing rituals. Following repeated exposures, the link weakens between obsessions and anxiety through a process called habituation. Habituation occurs when one stays in an anxiety-producing situation long enough for the anxiety to eventually reduce on its own. However, the process only works if one does not engage in any type of rituals or reassurance-seeking behaviors. As it may sound., this is the difficult part of treatment, which is why our program augments the exposure and response prevention with the most cutting edge techniques to help people face their fears.
Mindfulness/acceptance based techniques, writing scripts, imaginable exposure, motivational techniques, and cognitive therapy are all techniques that our program uses to enhance ERP. It is our mission to provide the most comprehensive care for our patients, and to tailor the treatment to the specific needs of the patient. We will combine techniques as needed to ensure that the OCD is being treated in the most effective way.
Deep Brain Stimulation (DBS)
For patients with intractable, treatment-resistant OCD, the FDA has provided a humanitarian device exemption (FDE) since January 2010 for treatment with Deep Brain Stimulation (DBS). DBS is a neurosurgical technique, already approved and effective for the treatment of Parkinson’s disease, tremors and dystonia, that involves the implantation and stimulation of electrodes in brain regions known to be involved in these disorders. Studies have demonstrated that placement in and stimulation of the ventral striatum (an area of the brain implicated in the pathophysiology of OCD) can reduce the frequency and severity of OCD symptoms. DBS is available at our program but is only an option for patients who have failed multiple SRI trials, including the addition of other medications (augmentation), as well as CBT.
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