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Obsessive Compulsive Disorder

What is OCD?

OCD is a common, and frequently chronic, disorder characterized by uncontrollable obsessions or compulsions.  Obsessions are persistent, intrusive and unwanted thoughts, images, or urges that cause significant discomfort and distress. Compulsions are repetitive behaviors or mental acts that the person feels driven to perform in response to an obsessive thought.

Although OCD is a common condition, effecting 1.2% of adults in any given year, because the obsessions and compulsions in OCD often seem to the person experiencing them to be illogical or irrational, they may be reluctant to discuss their symptoms and may experience a great deal of shame.  About 50% of people effected by OCD have a severe condition which markedly impacts their functioning, but even in the other 50% with moderate and mild forms of OCD, the distress can be significant.

What are typical obsessions in OCD?

There is a wide range of intrusive and distressing thoughts that people with OCD may experience.  Common obsessions include fears of contamination or germs, intrusive thoughts of harming others or themselves, unwanted or taboo thoughts or images involving sex or religious beliefs, and preoccupation with symmetry or having things in a perfect order. Someone with OCD can’t control their thoughts, even when they perceive these thoughts as unwarranted.

What are typical compulsions in OCD?

Compulsions are repetitive actions that people with OCD engage in so as to reduce the anxiety and distress triggered by obsessive thoughts.  Common compulsions include handwashing and cleaning, checking and rechecking (such as checking multiple times to see if the door is locked or the stove is turned off), and ordering and arranging objects in a precise way.  People with OCD may also engage in mental rituals which may include counting, praying, and reviewing in order to undo or neutralize intrusive thoughts.  Sometimes people with OCD involve others in their compulsions, by getting them to do specific actions for them, or by repeatedly seeking reassurance.

Not all habits or repetitive behaviors are OCD.  For example, almost everyone does a certain amount of double checking, such as checking the alarm before going to bed, especially on the night before an important meeting.  However, when the amount of time spent in repetitive, compulsive behaviors, or caught up in distressing obsessions, becomes excessive, or interferes with functioning, an OCD diagnosis may be warranted.

What causes OCD?

The causes are unknown but are believed to be a combination of factors, including genetic factors, environmental factors, and certain brain structural or functional features. A family history of OCD is present in about 45% of adult cases, likely reflecting shared genetic and environmental risk factors within families. Some studies also report associations with trauma during childhood, however whether or not this can be a causative factor is unclear.  For people with OCD, symptoms can wax and wane over time and may be triggered by or worsen during periods of increased stress.

Neuroimaging studies have demonstrated some structural differences in the brains of subjects with OCD compared to control subjects without OCD, however the significance of these findings is not yet clear.  In some cases, it even seems that a childhood infection may trigger the onset of OCD, suggesting the possibility of autoimmune factors in the onset of the condition.  Certain psychological features, such as a particular difficulty coping with uncertainty, an increased sense of responsibility, and what is called “magical thinking”, may also be risk factors for OCD.

How is it diagnosed?

There is no laboratory or neuroimaging test that is required or particularly helpful in diagnosing OCD.  Rather, a formal diagnosis according to diagnostic guidelines is made during an evaluation with a clinician trained in making the diagnosis.  The formal diagnosis requires that the person spend more than one hour per day consumed by obsessions and compulsions, or that their obsessions and compulsions cause significant daily stress or interfere with their lives.

Other psychiatric diagnosis not infrequently occur along with OCD.  Examples of more common co-occurring diagnoses include anxiety disorders, depression, hoarding disorder, hair pulling called Trichotillomania, skin picking disorder called Excoriation, tic disorders including Tourette syndrome, substance use disorders, and sometimes autism or schizophrenia.  Self-medication with alcohol or other substances may lead to additional problems.  OCD is a risk factor for suicide as well, so asking if you have any suicidal thoughts is part of an evaluation for OCD.

Given the potential for these co-occurring disorders, and the degree of distress or impairment that people with OCD often experience, it is important to seek treatment.  Unfortunately, most people with OCD delay treatment up to 11 years, perhaps because of their shame or embarrassment about their intrusive thoughts.

What are the treatments?

Treatment for OCD generally involves the use of medications, psychotherapy, or some combination of the two.  The most frequently effective medications for OCD are a specific class of antidepressants called SSRIs (Selective Serotonin Reuptake Inhibitors), such as Zoloft, Lexapro, Prozac, and others.  Although some patients respond quickly to antidepressants, pharmacological treatment of OCD often requires somewhat higher doses of medication, for longer periods of time, than is generally the case when those medications are used only to treat major depression.  Sometimes additional medications are needed to maximize the clinical response.

Psychotherapy for OCD is also a very effective treatment modality.  However, although most people get significant benefit from psychotherapy, frequently some level of symptoms remain. Therefore, a combination of psychotherapy and medication is often the best approach.

Specific types of psychotherapy that are used to treat OCD include Cognitive Behavioral Therapy (CBT) generally, and various subtypes of CBT, such as Exposure and Response Prevention (ERP), or related psychotherapies, such as Acceptance and Commitment Therapy (ACT).  Other approaches to psychotherapy can be effective as well.

For people with significant compulsions, ERP is perhaps the most widely researched treatment. It involves having the person spend time in a situation which triggers the urge to do the compulsion but then resist acting on the urge.  Over time, this has the impact of lessening the drive to engage in these behaviors and can result as well in a decrease in time spent or distress involved with obsessive thoughts.

Optimally, treatment, whether medication, psychotherapy, or some combination of the two, is customized for each individual person.  Customization is based on each person’s specific circumstances, co-occurring conditions, such as other forms of anxiety or depression if present, and preferred treatment modalities and goals.

OCD is a surprisingly common, and potentially lifelong, condition, yet one that often remains untreated.  At The Midtown Practice, we are a team of psychopharmacologists, psychiatrists and psychotherapists skilled and experienced in treating OCD.   If you are considering whether or not you or someone you know has OCD, or you are thinking of reaching out for an evaluation or treatment, contact us to schedule a consultation to learn about all options that would be right for you or your loved one.  All inquiries are treated with the utmost compassion, privacy, and concern.


Resources

  • https://www.nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd/index.shtml
  • Fenske JN, Petersen K. Obsessive-Compulsive Disorder: Diagnosis and Management. Am Fam Physician. 2015 Nov 15;92(10):896-903.
  • Krebs G, Heyman I. Obsessive-compulsive disorder in children and adolescents. Arch Dis Child. 2015 May;100(5):495-9. [PMC free article] [PubMed] [Reference list]
  • Chacon P, Bernardes E, Faggian L, Batistuzzo M, Moriyama T, Miguel EC, Polanczyk GV. Obsessive-compulsive symptoms in children with first degree relatives diagnosed with obsessive-compulsive disorder. Braz J Psychiatry. 2018 Oct-Dec;40(4):388-393
  • Bhikram T, Abi-Jaoude E, Sandor P. OCD: obsessive-compulsive … disgust? The role of disgust in obsessive-compulsive disorder. J Psychiatry Neurosci. 2017 Sep;42(5):300-306.
  • Bowen R, Rahman H, Dong LY, Khalaj S, Baetz M, Peters E, Balbuena L. Suicidality in People With Obsessive-Compulsive Symptoms or Personality Traits. Front Psychiatry. 2018;9:747.
  • https://www.nimh.nih.gov/health/statistics/obsessive-compulsive-disorder-ocd.shtml

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