Obsessive-Compulsive Disorder: A Summary of Diagnosis and Treatment
Lily Shearer
Kalamazoo College
Most people have repetitive thoughts and worries, and many have little actions that provide them with some sort of relief. However, when these thoughts and behaviors cross the line, become constant, and interfere with everyday life, the person can be classified as having obsessive-compulsive disorder, or OCD. OCD is characterized by repetitive and unwanted thoughts, known as obsessions, and actions, known as compulsions. Common obsessions include fear of uncleanliness, concern with order and exactness, and fear of tragedy; some of the accompanying common compulsions include excessive hand washing or grooming, repeating rituals, and checking things like appliances, vehicle damage, or doors. On average, OCD onsets at 19 years of age, and affects about 1% of the adult population (Kessler, Chiu, Demler, & Walters, 2005). It is more common in teens and young adults, and although it is equally present in males and females, it typically onsets at a younger age for men than women. OCD is often difficult to diagnose because of its similar characteristics with other anxiety and depression disorders (Mayo Clinic, 2016). OCD can have severe impacts on daily life; while the person often knows their feelings are irrational, the never-ending cycle of indulging one's anxiety with a compulsion is haunting, time consuming, and makes functioning very difficult.
While OCD has been present for centuries, the modern definition of OCD originated in the nineteenth century. Psychiatrists slowly began to distinguish obsessions from delusions and compulsions from impulsions, and OCD developed into a unique disorder (Stanford Medicine, 2016). Nowadays, the definition of OCD comes from the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, (DSM-5). The DSM-5 was published in 2013 and has four major criteria for the diagnosis of OCD: the presence of obsessions and/or compulsions, the obsessions or compulsions are time-consuming or cause significant stress that may impair social and occupational functioning, the disorder is not the result of a substance (i.e. drugs or alcohol), and it is not the result of another mental disorder (American Psychiatric Association, 2013). OCD was formerly classified as a type of anxiety disorder, but was separated in the DSM-5 and is now classified as a separate mental disorder that involves anxiety (Myers and Dewall, 2015).
OCD manifests in a variety of ways, but typically follows a cycle; an anxious and obsessive thought occurs, a compulsion is performed that relieves anxiety, temporary relief is experienced, and then obsession over the thought occurs again. Therefore, a never-ending cycle is created. Symptoms often have to do with cleanliness and order, but can include a wide range of obsessions and compulsions. Obsessions with taboo topics like religion and sex occur, as well as thoughts of aggression. Compulsions can include repeatedly checking on things, touching items, or counting things (National Institute of Mental Health, 2016). Typically, doctors and psychiatrists perform a variety of tests to see if one fits into the diagnostic criteria. Physical examinations and lab tests are often done to rule out other problems that may be causing symptoms and check for related physical complications. Then, a psychological examination must be given to determine if the obsessions and compulsions are occurring at a severity that warrants diagnosis. This examination is usually given in the form of a structured clinical interview by a trained health professional (Mayo Clinic, 2016).
The major symptoms for OCD may seem straightforward, but it is often difficult to diagnose, especially in younger patients. OCD exhibits many similar symptoms to other mental disorders such as schizophrenia, generalized anxiety disorder, and Tourette's syndrome (Greenberg, 2017). Schizophrenia is a mental disorder that is characterized by the inability to identify what is real. The obsessions someone with OCD may experience may not be realistic, and can be confused with schizophrenic delusions. However, people with OCD typically understand their obsessions are from their own mind and can distinguish reality from imagination (Greenberg, 2017). Generalized anxiety disorder (GAD) occurs when a person has uncontrollable and constant worry. It is distinguished from OCD in that the worries of someone with generalized anxiety disorder are more realistic and common. In addition to this, someone with GAD typically does not have ritualistic behaviors to cope with anxiety. For example, someone with GAD may just be extremely nervous for an upcoming test, while someone with OCD believes that they must count up to a certain number before the test in order to do well. (Abramowitz and Foa, 1998). Tourette's syndrome involves repetitive movements and vocal tics, and these often resemble the compulsions of OCD. However, people with OCD repeat behaviors to relieve specific thoughts, and people with Tourette's do not perform actions to relieve an obsession (Lombroso and Scahill, 2008).
Although OCD is separate from all of these by its own specific criteria, many of these and other mental disorders occur alongside OCD. Attention deficit/hyperactivity disorder (ADHD), body dysmorphic disorder, eating disorders, depression, and bipolar disorder are often linked to OCD (Mayo Clinic, 2016). The ability to distinguish OCD from these disorders and identify when they are occurring together is not easy, and takes a trained psychologist familiar with symptoms to diagnose. Not all clinicians and physicians can accomplish a correct diagnosis. Additionally, alcohol and drugs can mimic symptoms of OCD, making it difficult to diagnose in some (National Institute of Mental Health, 2016).
The exact cause of OCD is not known, but there are risk factors that increase the likelihood of OCD. OCD is strongly linked to an imbalance of neurotransmitters in the brain, specifically serotonin and glutamate. Serotonin is linked to sleep, mood, and attention to negative images, and an excess of glutamate can cause alarm centers of the brain to become overactive (Myers and Dewall, 2015). Twin and family studies have shown that genetics is a factor in the development of OCD; a review of 14 twin studies that was done in 2011 concluded there was a strong genetic basis for OCD (Myers and Dewall, 2015). About 25% of people with OCD have an immediate family member with the disorder; it is estimated that genetics contribute 45-65% of the risk of developing the disorder (Beyond OCD, 2017). Traumatic brain injuries and severe viral or bacterial infections have been associated with the onset of OCD, and people who have experienced childhood abuse or other trauma have an increased risk of developing OCD (Beyond OCD, 2017). These environmental, biological, and psychological factors all contribute to OCD, giving researchers insight to what the cause of this disorder may be.
One of the most famous people recognized for his struggles with OCD is Howard Hughes, a film director, entrepreneur, pilot, and philanthropist. He was born in 1905. During his life, he was known as one of the most financially successful individuals. He struggled with OCD, and his symptoms manifested in his everyday life and career. He was obsessed with cleanliness and order; he picked up objects with tissues to protect himself from germs. As a film director, he was obsessed with making the smallest of details perfect, and he assigned his staff lengthy tasks to relieve his compulsions. When he was filming The Outlaw, he became extremely fixated on bunches in the blouse of Jane Russell. He wrote a lengthy memorandum to the crew with a demand to fix it. Hughes also gave his staff very specific instructions on how to handle all of the objects; for example, two tissues had to be wrapped around a spoon by an employee before he would use it. His symptoms got worse and worse, and would eventually involve him watching a single movie on repeat for days and only eating milk and chocolate bars. His declining health due to his behaviors as well as injuries from multiple plane crashes caused his death in 1976 (Wolf, 2011). Leonardo DiCaprio portrayed Hughes in the 2004 film The Aviator, which chronicled his life and his struggles with OCD. DiCaprio also has a mild form of OCD, and as a child he had significant obstacles due to the disorder. One of his compulsions included stepping on cracks and then walking back blocks to step on the same crack or gum stains. His OCD does not plague him in the same way it once did and does not result in as severe behaviors as Hughes, but is still something he has to deal with in his everyday life (Murray, 2016).
For mental disorders, there are two main types of treatments: psychotherapy and medication. Cognitive behavioral therapy (CBT) is the most common type of psychotherapy used for mental disorders, and is used to treat OCD. Cognitive behavioral therapy focuses on altering the way people think and behave by creating awareness of irrational thinking and practicing a positive approach to reduce harmful behaviors (Myers and Dewall, 2015). A type of CBT that is targeted to those with OCD is known as exposure and response prevention, or ERP. Under the guidance of a therapist, the person is exposed to objects or situations that make them anxious and trigger obsessive thoughts. Then, the compulsion that is typically used to relieve anxiety is prevented. This is done gradually, and by breaking the cycle of obsessions and compulsions repeatedly, anxiety levels will drop over time. ERP is currently considered the most effective treatment for OCD by psychologists, but typically a combination of cognitive behavioral therapy and medication is used (National Institute of Mental Health, 2016).
Medication is commonly prescribed to people with OCD to balance the level of neurotransmitters in the brain. Selective serotonin reuptake inhibitors (SSRIs) are a type of antidepressant that are prescribed to those with OCD. They prevent the reabsorption of serotonin into the presynaptic cell, and therefore increase the level of serotonin that can bind to postsynaptic receptors and send specific signals through the body. They are particularly effective for patients with OCD because an imbalance of serotonin is especially prevalent for those with OCD (Mayo Clinic, 2016). The SSRIs that are approved by the Food and Drug Administration (FDA) are Prozac (fluoxetine), Luvox (fluvoxamine), Paxil (paroxetine hydrochloride), and Zoloft (sertraline). The tricyclic antidepressant Anafranil (clomipramine) is the other medication that is prescribed for those with OCD. It works by not only increasing serotonin in the brain, but also norepinephrine, a neurotransmitter that triggers energy in times of stress (Greenberg, 2017).
A wide range of clinical and experimental tests have been done to determine the successfulness of medications to treat OCD, but new studies are constantly being done to challenge existing treatments and come up with better ones. Clomipramine has proven to be effective by researchers in reducing OCD symptoms (Foa, Liebowitz, Kozak, Davies, Campeas, Franklin, Huppert, Kjernisted, Rowan, Schmidt, Simpson, & Tiu, 2005). However, another comprehensive review has concluded from case studies that the significant side effects from clomipramine outweigh the potential benefits and are therefore inferior to SSRIs (Abramowitz, 2007). These results and the effectiveness of clomipramine is still debated today and the medication is evaluated on an individual basis. While clomipramine is still prescribed to those with OCD, it is prescribed and used much less than it once was, and SSRIs are favored by most psychiatrists (Greenberg 2017).
It was widely believed that exposure and response prevention is the most successful therapy for those with OCD. However, some studies doubt this claim and the degree of the success of ERP. Donald Klein reviews a wide array of studies and meta-analyses and examines the fault in the overall claims of the success of ERP, stating that these statements are not as comprehensive as many might say and much of the research done to make these meta-analyses is flawed (Klein, 2000). Another study examines the individual successes of ERP, and concludes that due to psychiatric errors ERP is often not as successful as believed (Gillihan, Williams, Malcoun, Yadin, & Foa, 2012). These studies contradict the more widely accepted idea that is stated in another journal that reviews literature and definitively concludes that ERP is the most successful treatment for those with OCD (Huppert and Roth, 2003). Overall, ERP is still an extremely important and helpful therapy to combat OCD that should still be widely used, but caution is advised when making large assumptions of its success and it has to be implemented in the right way.
There are many layers and components of obsessive compulsive disorder, and while the basic criteria of OCD is simple to understand, the wide variety of obsessions and compulsions may make it often difficult to identify and understand. There has been a large amount of research on OCD and treatments to relieve one of obsessions and compulsions, and more research continues to be done to make sure as many people as possible can overcome this disorder. OCD affects each individual differently; each person with OCD requires a specific set of treatments to cope with everyday life. The success of treatments varies based on each person, but typically therapies and/or medications reduce symptoms of OCD. In a 40 year study of 144 people, almost all obsessions and compulsions lessened overtime, and 1 in 5 people had completely recovered from OCD symptoms (Myers and Dewall, 2015). While OCD can seem like a void of endless obsessions and compulsions, the treatments that have been developed by researchers can be effective in making living with OCD manageable.
References
Abramowitz, J. S. (2007). Effectiveness of psychological and pharmacological treatments for obsessive-compulsive disorder: A quantitative Review. Journal of Consulting and Clinical Psychology, 65(1), 44-52. http://dx.doi.org/10.1037/0022-006X.65.1.44
Abramowitz J.S., Foa, E.B. (1998). Worries and obsessions in individuals with obsessive-compulsive disorder with and without a comorbid generalized anxiety disorder. Behav Res Ther, 36: 695-700. https://www.ncbi.nlm.nih.gov/pubmed/9682525
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Foa, E.B., Liebowitz, M.R., Kozak, M.J., Davies, S., Campeas, R., Franklin, M.E., Huppert, J.D., Kjernisted, K., Rowan, V., Schmidt, A.B., Simpson, H.B., & Tiu, X. (2005). Randomized, Placebo-Controlled Trial of Exposure and Ritual Prevention, Clomipramine, and Their Combination in the Treatment of Obsessive-Compulsive Disorder. American Journal of Psychiatry; 162: 151-161. http://ajp.psychiatryonline.org/doi/abs/10.1176/appi.ajp.162.1.151
Gillihan, S. J., Williams, M. T., Malcoun, E., Yadin, E., & Foa, E. B. (2012). Common Pitfalls in Exposure and Response Prevention (EX/RP) for OCD. Journal of Obsessive-Compulsive and Related Disorders, 1(4), 251–257. http://doi.org/10.1016/j.jocrd.2012.05.002
Greenberg, W. M. (2017). Obsessive-Compulsive Disorder Medication. Medscape. Retrieved November 1, 2017, from https://emedicine.medscape.com/article /1934139-medication
History of OCD. (2016). Stanford Medicine. Retrieved November 02, 2017, from http://ocd.stanford.edu/treatment/history.html
Huppert, J. D., & Roth, D. A. (2003). Treating Obsessive-Compulsive Disorder with Exposure and Response Prevention. The Behavior Analyst Today, 4(1), 66-70. http://psycnet.apa.org/fulltext/2014-44018-008.pdf
Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, Severity, and Comorbidity of Twelve-month DSM-IV Disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 62(6), 617–627. http://doi.org/10.1001/archpsyc.62.6.617
Klein, D.F. (2000). Flawed meta-analyses comparing psychotherapy with pharmacotherapy. American Journal of Psychiatry; 157:1204–1211. http://ajp.psychiatryonline.org/doi/citedby/10.1176/appi.ajp.157.8.1204
Lombroso, P. J., & Scahill, L. (2008). TOURETTE SYNDROME AND OBSESSIVE-COMPULSIVE DISORDER. Brain & Development, 30(4), 231–237. http://doi.org/10.1016/j.braindev.2007.09.001
Murray, R. (2016, February 17). Leonardo DiCaprio Talks About "The Aviator". Thought Co. Retrieved November 1, 2017, from https://www.thoughtco.com/leonardo-dicaprio-discusses-the-aviator-2430281
Myers, D. G., & Dewall, C. N. (2015). Psychology (Eleventh ed.). New York: Worth.
Obsessive-compulsive disorder (OCD). (2016, September). Mayo Clinic. Retrieved November 1, 2017, from https://www.mayoclinic.org/diseases-conditions/obsessi ve-compulsive-disorder/diagnosis-treatment/drc-20354438
Obsessive-Compulsive Disorder. (2016, January). National Institute of Mental Health. Retrieved November 1, 2017, from https://www.nimh.nih.gov/health/topics/obsess ive-compulsive-disorder-ocd/index.shtml
What Causes OCD. (2017). Beyond OCD. Retrieved November 03, 2017, from http://beyondocd.org/information-for-individuals/what-causes-ocd
Wolf, R. (2011, July). How OCD Affected Howard Hughes. Health Guide Info. Retrieved November 1, 2017, from http://www.healthguideinfo.com/living-with-ocd/p122480/