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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. Click here to see the DSM-IV 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, 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: clomipramine (Anafranil), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), and escitalopram (Lexapro).
For more detailed information about the symptoms and treatment of OCD, go to www.ocfoundation.org
*Please note that all details are disguised to protect the privacy of the individual.
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 extra curricular 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). When Dan learned that EX/RP 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 with an experienced therapist.
Remaining on the SRI, Dan participated in 17 EX/RP 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.
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