Obsessive Compulsive Disorder

Description

In the mental illness called obsessive-compulsive disorder (OCD), a person becomes trapped in a pattern of repetitive thoughts and behaviors that are senseless and distressing but extremely difficult to overcome. For example:

• Troubled by repeated thoughts that she may have contaminated herself by touching doorknobs and other "dirty" objects, a teenage girl spends hours every day washing her hands. Her hands are red and raw, and she has little time for social activities, but the washing continues.

• A middle-aged man is tormented by the notion that he may injure others through carelessness. He has difficulty leaving his home because he must first go through a lengthy ritual of checking and rechecking the gas jets and water faucets to make certain that they are turned off.

• Several times a day, a young mother is seized by the fearful thought that she is going to harm her child. However hard she tries, she cannot get rid of this painful and worrisome idea. She even refuses to touch the kitchen knives and other sharp objects because she is afraid that she may use them as weapons.

If OCD becomes severe enough, it can destroy a person's capacity to function in the home, at work, or at school.

Obsessions

Obsessions usually involve doubt, worry, and/or fear of contamination or of one's own aggression. These intrusive thoughts or urges run through a person's mind repeatedly.

Common obsessions include:

• Repeatedly wondering whether you have locked a door or turned off an appliance.

• Believing that you will be contaminated by touching anyone else.

• Fearing unrealistically that you have hurt someone.

• Having the persistent urge to be violent toward a loved one.

• Worrying incessantly that something has been lost or misplaced.

• Experiencing the intrusion of nonsensical sounds, words, numbers, images, or blasphemous thoughts if you are a religious person.

Compulsions

Compulsions are the acts repeated in response to obsessions, or according to strict rules.

These patterns of action usually take the form of excessive or unrealistic attempts to prevent some dreaded event, such as getting a disease or being robbed. They are either distressing, or so time consuming that they interfere with the daily routine.

Common compulsions include:

• Endlessly checking to be sure that doors are locked or appliances turned off.

• Washing your hands over and over or showering, bathing, or grooming excessively.

• Repeatedly retracing an automobile route to be sure that your car has not struck a pedestrian.

• Taking irrational measures, like hanging clothes in a certain way or putting all sharp objects out of sight, to prevent harm to yourself or others.

• Having to go through a door several times before you leave.

• Counting the number of times you do something.

Diagnosis

The diagnosis of obsession is valid only if the four following features are present:

• Recurrent ideas, impulses, or images considered to be intrusive and senseless.

• Attempts to ignore, suppress, or neutralize these thoughts with other thoughts or with actions.

• Recognition by the patient that the troublesome thoughts are a product of his or her own mind, not imposed from without.

• Symptoms not accounted for by another mental disorder, such as guilty thoughts in major depression or a longing for drugs in psychoactive substance use disorder.

The diagnosis of compulsion is valid only if the three following features are present:

• Repetitive, purposeful, and intentional behaviors performed in response to an obsession, according to certain rules, or in a stereotyped manner.

• Behaviors aimed at preventing discomfort or some dreaded situation but designed in a way that is unrealistic or excessive.

• Recognition by the patient that the behaviors are unreasonable.

The diagnosis of obsessive-compulsive disorder is valid only if an obsession and/or compulsion (as just defined) causes marked distress, is time-consuming (1 hr./day), or significantly interferes with normal routine, work, or relationships.

Behavior Therapy

There is little evidence that psychotherapy is effective in patients with obsessive-compulsive disorder. Behavior therapy, on the other hand, is of proven benefit in obsessive-compulsive disorder.

Improvement of symptoms has been shown to persist over time, with a parallel improvement in depressive symptoms and overall functioning in family and work settings.

Treatment consists of exposure and response prevention, directed primarily toward the patient's compulsions, since it is more difficult to gain access to a patient's obsessions.

Behavior therapy is generally considered the treatment of first choice, because it has been shown to be at least as effective as psychopharmacologic interventions in reducing the symptoms of obsessive-compulsive disorder.

However, as many as 15 percent of patients refuse behavior therapy, and another 10 percent are unable to comply with the suggested regimen for exposure and response prevention.

A number of patients simply do not improve, despite a high level of compliance. A few patients also have severe depressive symptoms that warrant drug therapy. These facts, as well as the occasional unavailability of behavior therapy and its time-consuming nature, make drug therapy an attractive option for many patients.

Drug Therapy

Psychotherapy, behavior therapy, and various drugs have been used to treat obsessive-compulsive disorder without much success. The FDA has approved the prescription drug clomipramine for the treatment of severe obsessive-compulsive disorder. Clomipramine is the first substantially effective drug treatment.

The drug's most serious side effect is seizure, which may occur in about 1.5 percent of treated patients each year. Other possible side effects include dry mouth, constipation, increased appetite, decreased sex drive, ejaculation failure, and impotence.

The drug is manufactured by Ciba-Geigy Pharmaceuticals of Summit, NJ, marketed under the trade name Anafranil.

Questions to Ask Your Doctor

What type of treatment do you recommend?

What type of therapy do you recommend?

How successful is the therapy with this behavior?

How long does it take before some improvement is seen?

How long will therapy be needed?

Will this disorder return? Can some other form of behavior of OCD develop later?

Will you be prescribing any medications? What are the side effects?