Obsessive Compulsive Disorder (OCD) is an anxiety disorder characterized by obsessional thoughts which the individual experiences as disturbing.  These thoughts are accompanied by compulsive thoughts or behavior which temporary relieve the individual's anxiety.  Obsessions are intrusive thoughts, images or impulses that the individual perceives as senseless for at least some part of the disorder.  Compulsions are repetitive intentional behaviors or mental acts performed in response to an obsession, and specifically function to suppress or neutralize discomfort and/or anxiety.

Persons who suffer from this disorder fear of contamination from a variety of sources--germs, insecticides, or disease (with changing times feared diseases have changed from syphilis and herpes to AIDS).  They may fear of disastrous event, i.e., burglary or fire.  Or they may fear engaging in an impulsive act, or one that the person feels is morally wrong, such as hurting themselves, child abuse, grabbing person of the opposite sex.

Compulsions may be washing repeatedly to remove contamination; checking (stove, locks on doors, clothes for evidence of contamination--”spots of red”); or seeking reassurance that a feared event has not or will not happen.

For a first-person account by one of my patients of his struggle with OCD and his progress in treatment, click here.

Click here for strategies to cope with OCD in the workplace.

Click here for a comment on how cognition is affected by OCD.

From time to time, all of us have fears which in retrospect we might see as unreasonable, and manage these fears by checking or fixing overmuch.  OCD behavior is differentiated from normal behavior by examining the characteristics of potential problem behavior: 1) Frequency—how often the thought or behavior occurs, 2)   Intensity—the degree to which attention is focused on the fear or compulsion 3)    Duration—how long the fear or compulsion persists.  High levels on these dimensions, resulting distress, low self esteem and impaired social and work functioning add up to a diagnosis of OCD.  People with OCD are often capable of work, but many have reduced capacity for work or are unable to work at all.

OCD is often characterized by avoidance of circumstances which trigger obsessive compulsive activity.  People may avoid dirt or the perception of a soiled surface by not beginning to clean, by not turning lights on, avoid leaving home, avoid social contact, or if they have an obsessional fear of impulsively harming others, they avoid behavior which individual feels might injure another (carrying bags in hands in order to avoid striking others while walking; avoid holding a child; avoid using knives or tools when others are around).

OCD occurs at the rate of two percent of the population, and possibly more.  The ratio of males to females is 1 to 1.  Men become symptomatic earlier in their course, have a higher level of symptomatology overall and overall may achieve fewer milestones such as marriage. The fourth most common psychiatric disorder in the U.S.  Most people with OCD develop symptoms as teenagers, 30% show symptoms as children, and few develop symptoms after the age of 35. 

Listed as number ten on the World Health Organization’s list of disorders responsible for disability worldwide (major depression is #1, chronic obstructive pulmonary disease is #4, arthritis #8).

Average length of time between first appearance of symptoms and seeking treatment is ten years. 

Cognitive behavioral therapy (CBT) has consistently been found to be more effective than other psychotherapies.  This treatment is often given along with drug treatment.

Important treatment components of CBT for OCD include:

1) Education of the patient about OCD and the rationale for the treatment

2) Development of a hierarchy of anxiety-producing obsessional fears and/or rituals  

3) Exposure and response prevention (E/RP):

    In vivo exposure to anxiety-producing situations and thoughts   

    Abstinence from ritualized compulsive responses to obsessive thoughts.  Reduction of anxiety in the absence of artificial means.  That is, without compulsions, the patient finds that anxiety goes away on its own.  This allows the body’s natural return to homeostasis--or normal, balanced functioning--following arousal.

Exposure and response prevention is a fundamental element of anxiety treatment.  The goal is to bring about reduction in subjective and physiological experience of anxiety within the therapy session.  The treatment brings about reduction in anxiety across sessions as well.  This is associated with more overall change during and after treatment. 

E/RP requires focus on obsessive concerns during exposure.  This requires prevention of ritualizing in imagination. For instance, the patient may promise himself that he will be able to wash his hands after the session.  This amounts to using a mental compulsion to reduce anxiety, rather than allowing full exposure to his obsessive fears, which is the therapeutic goal.

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