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Anxiety: Obsessive Compulsive Disorder
 

Signs & Symptoms

Possibly the most infamous example of a person with obsessive compulsive disorder was U.S. millionaire playboy Howard Hughes. In his latter years, Hughes became a virtual recluse, where he drank only pure spring water and ate only food prepared by his servants according to elaborate instructions to avoid contamination. So great was Hughes' horror of being contaminated from normal tap water that he rarely washed, and in his reclusive hotel room, every object was placed on layers of tissues and newspapers to protect it from contamination by the floor or table.

Hughes suffered from a very severe obsessive compulsive disorder (OCD), but more common manifestations of the same disorder make life difficult for up to 3% of the population who suffer from OCD.

The disorder actually has two sides - intrusive, unwanted thoughts, images or impulses (obsessions), and repetitive behaviours (compulsions) that generally reduce the distress and anxiety provoked by obsessions. Equally likely to occur in men as in women, OCD appears to occur more often in the upper classes and in people of high intelligence. The most common obsessions include fears of contamination or making oneself or others ill by touching things; fear of harming oneself or another person (even though the person with OCD never would), and the need for orderliness, cleanliness or exactness.

But people can also be fearful that they might be responsible for something terrible like a fire or burglary, and repeatedly check to make sure that they really did turn the stove off or check the door. One person, a male in his early 30s, spent practically every weekend in his apartment, fearful that going out would involve an endless series of checking where he had to confirm that his apartment door was locked - again and again and again.

An increasingly common obsession today is a preoccupation with contacting the virus leading to AIDS. People are often aware that their thoughts and behaviors are completely irrational, but the only way they can relieve the unbearable anxiety that arises from their fears is to give in to the ritualistic behaviour.

People can have obsessive thoughts alone without following through with compensatory rituals - and vice versa. A young woman who sought professional help because she wanted to stab herself in the eye every time she saw a pen is one example of obsessive thoughts people can have which are not followed by any ritual. Alternatively, ritualistic hair-pulling may not be accompanied by any obsessive thoughts prior to the person engaging in the activity; once the hair-pulling starts, the person can spend hours doing it before the urge subsides.

Often, thoughts which are characteristic of OCD are disturbingly violent and they can make people feel as if they are crazy as well as dangerous to themselves or to others. People with OCD may recognize that their compulsions - repeated handwashing, repeated checking of the appliances or doors - are excessive or unnecessary, and this realization, too, can make them feel as if they are going crazy. In fact, people tend to keep their obsessive thoughts and rituals to themselves, fearful that if others find out, they'll be judged by others as "crazy" too. Some people with OCD have been so long caught up in their obsessions and thoughts that they don't recognize there is anything particularly abnormal about them.

Others can be so tormented by the disorder that alcohol and other drug abuse or even suicide seem like the only way out.

Even in it's mildest forms, OCD can interfere with a person's ability to enjoy life, form intimate relationships and have normal social interactions. Depression also affects about one-third of people with OCD, while other types of anxiety disorders along with alcohol abuse not infrequently co-exist with OCD as well.

Although some people recover without treatment, OCD tends to be a chronic illness and symptoms can change as the illness progresses.

OCD Checklist

At some point, people with either obsessions or compulsions or both need to realize that their thoughts and behaviors are causing severe distress; that they take up time (more than an hour per day); and that they are interfering with the person's usual routines or personal interactions.

In addition, all of the following must be present to have a diagnosable obsessive disorder:

Obsessive Disorder Checklist
A person must have recurring, persisting thoughts, impulses or images which intrude on normal thinking and which cause marked distress. These thoughts also must be more than extreme worries about ordinary problems.
A person must be trying to ignore or supress these thoughts or neutralize them with other thoughts or behaviours.
A person must be aware that the ideas are coming from their own mind and not someone else's.


To have a diagnosable compulsive disorder, all of the following must be present

Compulsive Disorder Checklist
A person must feel compelled to repeat certain behaviours.
These behaviours must occur as a response to an obsession
The aim of all these behaviours must be to reduce or eliminate distress or to prevent something that is dreaded.
The behaviours must be either not realistically related to the events they are supposed to neutralize or are clearly excessive for that purpose.

 
 
Treatment

Just as it is in depression and anxiety, the serotonin system is implicated in OCD as well. Consequently, treatment for OCD is the same as it is for depression and the selective serotonin reuptake inhibitors (SSRIs) are generally considered first. How the SSRIs work to resolve obsessions and compulsions is unclear, but thinking is that serotonin activity in the brain is overstimulated in people with OCD.

When an SSRI which further stimulates serotonin activity is given, the brain may compensate by dampening down the hyperactive serotonin system, effectively bringing activity levels closer to normal. Early reports suggest that venlafaxine (Effexor) may prove useful in OCD as well, while the older monoamine oxidase inhibitors (MAOIs), though helpful, are no longer widely used.

An important additional treatment of OCD is cognitive behavioral therapy (CBT). By teaching people specific techniques aimed at getting them to "unlearn" and reverse obsessive, compulsive behaviour, CBT is often successful in helping defuse obsessions and compulsions so that even if troubling thoughts intrude, people no longer feel compelled to respond to them.

An example of how CBT might work would go like this. Say a person who fears contamination is being treated for his or her fears of contamination and subsequent ritualistic handwashing. A therapist may ask that person to first list all the tasks that provoke anxiety for them, and then rank each task according to the degree of difficulty they associate with it. These tasks might include touching a handrail, pushing an elevator button or using a public toilet. All of these tasks may trigger contamination fears and ritualistic handwashing but some more powerfully so than others. From this list, and using CBT learned techniques, the person is asked to do the task that is easiest for them - like pushing an elevator button.

Although the task may still make them anxious, the conscious effort it takes to touch that elevator button or handrail, and not give into the handwashing immediately afterward helps people learn to control their obsessive/compulsive behavior. Simultaneously, treatment with an SSRI is usually given to decrease the intensity of intrusive thoughts and urges.

OCD can be difficult to resolve and the use of medication plus CBT may not fully banish all obsessive thoughts and ritualistic behaviors. But for 60 to 80% of people with OCD, treatment will diminish the intensity of the disorder and allows people to have a life - often for the first time in many years.

Treatment of OCD often takes longer than it does for depression, and the doses of medication used often have to be higher. Encouraged to stick with it, the majority of people with OCD can look forward to a time when the distressing thoughts and rituals so long kept secret diminish and even disappear.

In Canada, currently recommended treatments for OCD include: Cognitive behavioural therapy, SSRIs, clomipramine (Anafranil), MAOIs. (For more information, please see Panic Disorder).


Up to 3% of the population suffer from obsessive compulsive disorder, consisting of intrusive, unwanted thoughts, images or impulses (obsessions) on the one hand, and repetitive behaviours (compulsions) that generally reduce the distress and anxiety provoked by obsessions on the other.


 
The combination of an antidepressant medication and cognitive behavioural therapy helps between 60 to 80% of people with OCD gain control over their obsessions and compulsions and live a more normal life.