Are you OC-OC?

We all use the words "obsessive" and "compulsive" loosely to describe people who worry too much, spend too much time on details, or become deeply immersed in a single activity to the exclusion of everything else. That’s the obsessive-compulsive personality: conscientious, orderly, morally rigid, fussy about details, indecisive, perfectionist.

What psychiatrists mean by obsessive compulsive disorder (OCD), however, is not identical and is more specific. "Obsession" comes from a Latin root meaning "besieged," which is how people with OCD feel. Their obsessions are repetitious thoughts, urges, and images fueled by doubts, fears, a need for symmetry and order or aggressive and sexual impulses. And the most common obsessions involve cleanliness and fear of disease. Another source of obsessions is doubt whether something has been done correctly or safely.

Under siege, people take refuge. The tension or anxiety produced by obsessions is relieved, temporarily, by compulsive acts – often called rituals, because they must be performed according to rigid rules. Compulsions include washing, checking (often with demands for reassurance), arranging, straightening and ordering, hoarding, and repetitious thoughts (silent prayer, counting, silently repeating magic words and phrases).

The symptoms come and go unpredictably, vary from person to person, and may change over time in any given individual. A man washes for hours every day or every time he touches anything slightly dirty, and uses a whole roll of toilet paper for one bowel movement. A woman avoids the LRT for fear that she will push someone off the platform. Others count backwards from 100 repeatedly to suppress the urge to shout obscenity in public or check and double-check to make sure the baby is still breathing. A man feels obliged to do everything twice or has to dress always in the same clothes and in exactly the same order, starting over after any minor mistake. Some people accumulate so much junk that they barely have space to eat and sleep. Almost always, they know that these obsessions and compulsions are irrational, but they can’t help themselves: "I see that the door is locked and the stove turned off, but I don’t get the feeling of certainty that it’s so."

The Origins Of OCD

No one knows exactly what causes OCD. It affects about 2.5 percent of the population, and at least 20 percent of sufferers have a family member who is also affected. Even when more than one family member has OCD, their obsessions and compulsions can be quite different, so it’s not as simple as a child learning fears and behaviors from a parent or sibling. There’s almost certainly a hereditary component; probably more than one gene is involved, in combination with environment triggers. OCD usually begins before age 25 and often in childhood but in about 15 percent of people, it starts after age 35. Diagnosis may be delayed if a person keeps his suffering a secret and arranges his life to accommodate his symptoms.

Many experts believe that OCD is a result of abnormal brain chemistry – in particular, problems with serotonin, a neurotransmitter involved in various psychological and physical functions. According to Dr. Michael Jenike, professor of psychiatry at Harvard Medical School, certain areas of the brain become hyperactive when people who have OCD are having symptoms (see illustration). Research also suggests that OCD can develop following certain kinds of infections, brain tumors or physical trauma.

Depression and OCD often occur together, particularly in adults. Depression can worsen OCD symptoms, and the struggle to cope with untreated OCD can lead to depression. Likewise, certain factors can exacerbate symptoms, such as the stress of marital separation, bereavement or retirement. In women, OCD symptoms may emerge for the first time – or worsen – in response to hormonal shifts that occur as part of the menstrual cycle, during pregnancy or often delivery. During perimenopause or menopause, OCD symptoms worsen in some women and subside in others.

reatment Approaches

T OCD is usually treated with medications and cognitive behavioral therapy (CBT). Some people do well with medication, some with CBT, but most do best with a combination of the two. Sometimes, another kind of psychotherapy is added to help a patient better understand his situation and the connections between his thoughts and behaviors.

"Although CBT is the core treatment," explains Dr. Ellen Blumenthal, a psychiatrist at Massachusetts General Hospital, "traditional therapy may provide additional support by encouraging a person to cope with his illness and pursue treatment, deal with life stresses that can worsen symptoms of OCD, and learn to create a satisfying life and relationships incorporating OCD and its treatment."

• Medications. Six medications have been found effective for treating OCD. Five are selective serotonin reuptake inhibitors (SSRI) and antidepressants: fluoxetine (Prozac), fluvoxamine (Faverin), sertraline (Zoloft), paroxetene (Seroxat), and citalopram (Lupram). The sixth, which has been used the longest, is the tricyclic antidepressant clomipramine (Anafranil). These drugs increase the amount of serotonin that’s available to receptors on nerve cells and, within a few weeks, seem to induce changes in the receptors themselves.

The antidepressants given to treat OCD generally take several weeks to work. Side effects (which subside with time) include dry mouth, increased dreaming, a small amount of weight gain, tiredness, and lowered libido. If side effects are intolerable, your physician may lower the dose or suggest a different drug. If you don’t respond to a particular drug, your psychiatrist may switch you to a different one; add a second drug; or suggest CBT if you aren’t already receiving it.

• Cognitive behavioral therapy. The basic behavioral treatment strategy is exposure and response prevention (ERP). It helps by breaking OCD’s characteristic cycle of obsessive thoughts, anxiety in response to those thoughts, and rituals performed to relieve the anxiety.

During the CBT session, the patient is exposed to the feared thought or situation but isn’t allowed to perform his usual ritual. The exposure can be real (he’s asked to touch something dirty and is prevented from washing his hands) or imaginary (he’s asked to imagine fire that could occur if he didn’t check and recheck the stove). During an exposure, the therapist will teach him how to control his anxiety. Between sessions (which are usually once or twice a week), the patient will be given exposure homework.

ERP takes advantage of a normal cognitive process called habituation. Just as you become accustomed to traffic noise if you live in an urban area, a person with OCD can gradually learn to tolerate a feared situation or thought without becoming overly anxious. The rituals he performs to relieve his anxiety start to lose their power as he learns to master his anxiety without them.

The length of therapy depends on the severity of OCD and the intensity of treatment and practice. Afterwards, the patient must continue to practice and apply the skills he has learned, particularly at times of stress or if symptoms begin to reemerge.

Brain imaging techniques have shown that CBT can change brain function. For example, by measuring blood flow in different parts of the brain, researchers have shown that the caudate nucleus, a region believed to be involved in intrusive thoughts, is overactive in people with OCD but calms down after successful cognitive behavioral therapy.

Outcome

In a 40-year follow-up of patients admitted to hospitals with OCD, Swedish researchers found that more than 80 percent improved but only about 20 percent made a complete recovery. Most of the improvement occurred early in the course of the illness, and about 50 percent continued to have OCD for more than 30 years, although they often learned to cope with the symptoms. Those were severe cases. In the average person with obsessive-compulsive symptoms, however, one can reasonably hope for a better long-term outcome.