At Its Worst, OCD Impairs Daily Function

The primary symptom of obsessive-compulsive disorder is the presence of intrusive, unwanted thoughts. The person having those thoughts knows them to be abnormal and obsessive, but cannot stop them from occurring.

In some people, obsessive thoughts lead to compulsive behaviors. For example, a common obsession is a fear of contamination from touching any variety of objects; the resulting compulsion is repeated, unstoppable hand washing.

Many people who have obsessive-compulsive disorder live with it for years, until their unwanted behaviors begin to take over their lives.

"The structure of the obsessive-type of thinking followed by the compulsive behavior to ward off the doubt and worry related with the thought can take any form," said Juan Hernandez, MD, Medical College of Wisconsin Assistant Professor of Psychiatry and Behavioral Medicine. Dr. Hernandez practices at the Zablocki VA Medical Center.

Severity of Illness Varies
The severity of obsessive-compulsive disorder and the domain in which it occurs can vary. An obsessive-compulsive disorder can range from a simple repeated behavior to one that involves repeated checking, cleaning, rearranging and reordering. The disorder is also notorious for changing over time.

People who have obsessive-compulsive disorder often also suffer from phobias or panic attacks, depression, attention deficit hyperactivity disorder, eating disorders or learning disorders such as dyslexia.

OCD is driven by out-of-control doubt, Hernandez said. In addition to fear of contamination, another common form of obsession/compulsion involves "just so" behaviors, in which objects have to be placed in very specific ways in order for the person to achieve comfort, for instance, books might have to be in precise order, smallest to largest, on a shelf, or pens have to be lined up in a certain pattern in a certain desk drawer.

"To somebody that is orderly, it feels right. For the OCD sufferer, it feels either excessive or strange or it interferes with life. It feels excessive to the subject having these thoughts," Hernandez said. "That's a major difference." The behaviors can be the source of a great deal of shame.

Many people with OCD have an extremely difficult time leading normal lives; for instance, a person might leave for work, only to return home again and again to make sure the oven is turned off. This person might arrange to spend hours every day getting to a job that is just miles away.

"It's remarkable how well people can function despite being plagued by many of these thoughts," said Dr. Hernandez.

To be classified as having an obsessive-compulsive disorder, a person has to be impaired in their social, occupational, and interpersonal functioning.

Redefining the Condition
During the last 25 years obsessive-compulsive disorder has gone from a rarely-discussed problem that was seen as strange and highly stigmatized to one that is considered a common neuropsychiatric condition affecting the brain. This transformation has led to new hope for those who deal everyday with the disorder.

"Fairly effective treatment has emerged as OCD has been reframed as a disease of the brain," Hernandez said. "What's exciting is the search for newer and more effective treatments and ultimately the cause."

Sources Unknown
The causes of obsessive-compulsive disorder remain unknown. There are a small number of cases that are correlated with streptococcal infections in childhood. A low amount of serotonin in the brain also has been labeled a potential cause of obsessive-compulsive disorder. Serotonin is a neurotransmitter; that is, it carries messages from one nerve to another in the brain.

In the past, obsessive-compulsive disorder was treated with long-term psychotherapy that addressed psychological defenses. There were no objective measurements used to diagnose obsessive-compulsive disorder and there were no medications to assist patients.

Practitioners now use the Yale Brown Obsessive-Compulsive Scale that involves an interview with the subject, who is asked at what frequency they have obsessive thoughts and compulsive behavior. The result of the scale is a number that is used to quantify the patient's condition before and during treatment.

Patients also have access to medication such as serotonin, antidepressants, anti-anxiety medicines, and beta-blockers.

"The improvement is quite objective and you can measure it and see it," Dr. Hernandez said.

Other treatment consists of behavioral approaches in which the patient must face and confront the doubt and must deal with the anxiety associated with not going ahead with the compulsive behavior.

If the patient's compulsive behavior includes washing their hands 40 times a day, then treatment would involve slowly decreasing the number of hand washes a day. A patient might also be asked to reflect on their thoughts and behavior through writing.

"Therapists prescribe specific times during the day to worry," Hernandez said. "Worry could be limited to an hour in the morning and an hour in the afternoon. The patient is instructed to stop worrying at other times. That's called response prevention."

Creative techniques might also include the patient being asked to visualize a stop sign or clap their hands loudly when they begin have obsessive thought.

About 2.2 million adults in the United States have Obsessive Compulsive Disorder, which tends to begin in childhood. Similar numbers of men and women are suffer from the disorder.

Brendan O'Brien
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.