Obsessive-Compulsive Disorder

Obsessions are constant, intrusive, unwanted thoughts that cause distressing emotions such as anxiety or disgust. People experiencing obsessions recognize that these persistent images are a product of their own mind and are excessive or unreasonable. Yet, these intrusive thoughts cannot be settled by logic or reasoning. For example, some people may constantly fear bringing harm or injury to themselves or others or worry that they could violate social norms by swearing or making sexual advances. Others worry about germs and contamination.

Most people quickly become accustomed to an experience that only appears to be a threat. After repeated exposure to it, they eventually no longer feel threatened by it. People with OCD continue to experience these anxious feelings of threat and do not realize that the "threat" might be minuscule. Over the course of several months, these feelings develop into an obsession that becomes a threat on its own. Often, people with OCD find that repeated behaviors (rituals) decrease their concern, and so they feel compelled to repeat them in order to reduce their discomfort.

Compulsions are urges to do something to lessen discomfort, usually discomfort that is caused by an obsession. Rituals are the behaviors in which people engage in response to a compulsion. In the most severe cases, a constant repetition of rituals may fill the day, making a normal routine impossible. Compounding the anguish these rituals cause is the knowledge that the compulsions are irrational.

• Cleaning - Provoked by the fear that real or imagined germs, dirt, or chemicals will "contaminate" them, some spend hours and hours washing themselves or cleaning their surroundings.

• Repeating - To dispel anxiety, some utter a name, phrase, or behavior several times. They know these repetitions won’t actually guard against injury but fear harm will occur if they don’t do it.

• Completing - People with this compulsion must perform a series of complicated behaviors in an exact order or repeat them again and again until they are done perfectly.

• Checking - The fear of harming oneself or others by forgetting to lock the door or turn off the gas stove develops into the ritual of checking. Others repeatedly retrace routes they drive to be sure they haven’t hit anyone or caused any accidents.

• Being meticulous - While neatness and tidiness don’t signify a disorder, some individuals with OCD develop an overwhelming concern about where things go on a desk or the appearance of a room.

• Avoiding - Compulsive avoiders stay away from the cause of their anxiety and anything related to it. One patient became so anxious about chocolate that she avoided not only the candy but also anything else that was brown.

• Hoarding - One of the less common compulsions, hoarding involves the constant collection of useless items. People with this compulsion may collect anything - scraps, newspapers, clothing, containers, cans, stones, garbage, even excrement - to the point that rooms are filled, doorways are blocked, and health hazards develop.

• Slowness - Also a rather uncommon compulsion that strikes mostly men, this compulsion causes people to do certain tasks very, very slowly.

• Other varieties of compulsions include excessive and ritualized praying, counting, and list making.

One of the most effective treatments is a type of behavior therapy known as exposure and response prevention.

During treatment sessions, patients are exposed to the situations that give rise to their anxiety and provoke compulsive behavior or mental rituals. Through this exposure, the patients learn to decrease and then stop the rituals that plague their lives. They find that the anxiety arising from their obsessions lessens without their engaging in ritualistic behavior. For example, therapy for a compulsive cleaner who previously could not handle money without washing her hands might involve counting dollar bills without washing her hands.

This technique works well for patients whose compulsions focus on situations that can be re-created easily. A few engage in compulsive rituals because they fear catastrophic events that can’t be re-created. Therapy for these patients must rely more on imagining exposure to the anxiety-producing situations.

Throughout behavior therapy, the patient follows guidelines or a "contract" on which the psychiatrist and patient agree. For example, the contract may outline whether a patient can perform any part of his or her ritualistic behavior and, if so, for how long and under what circumstances. A compulsive washer may agree to shower for only 10 minutes a day. Compulsive checkers may be permitted to check door locks, gas stoves, or knives only once a day.

Careful studies show that behavior therapy can effectively reduce compulsive behavior and significantly lessen the chances for relapse. But behavior therapy depends on the patient’s willingness to participate and ability to keep his or her part of the treatment contract. Throughout therapy the psychiatrist coaches the patient to fight the compulsion. Often, family members also coach and support their loved ones in sticking with their therapy.

Various studies indicate that behavior therapy is successful for 50% to 90% of those with OCD. However, some patients will not agree to participate in behavior therapy because it can be difficult. Others also have depression which must be treated simultaneously.

Numerous studies have demonstrated that a class of medications known as serotonin reuptake inhibitors are often effective in the treatment of OCD.