OCD Defined

OCD is the fourth most common psychiatric diagnosis. The onset of symptoms is usually gradual, but some patients report a sudden onset. A few people recall a precipitating event, while others do not. Precipitating events can include emotional stress at work or at home, increased levels of responsibility, health problems and bereavement. Pregnancy, the birth of a child and termination of pregnancy may be linked to the onset or worsening of OCD symptoms.

The DSM-IV-R (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) states that "the essential features of Obsessive-Compulsive Disorder are recurrent obsessions or compulsions that are severe enough to be time consuming (i.e., they take more than 1 hour a day) or cause marked distress or significant impairment. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable." Adults usually realize their obsessions and compulsions are unreasonable or excessive, but children are not as likely to recognize this.

Obsessions are persistent images, impulses, thoughts or ideas that are experienced as inappropriate and intrusive, and cause marked anxiety. People with OCD have a sense that the thoughts are not within their control and not the kind of thoughts they would expect to have. We are able to understand that the obsessions are products of our own minds and are not imposed from without.

Trying to ignore the thoughts or impulses, or to neutralize them with other thoughts or actions, people develop compulsions. Compulsions are mental acts, such as repeating words silently, praying or counting, or are repetitive behaviors such as ordering, checking or hand washing. The goal is to reduce or prevent anxiety, not to provide gratification or pleasure. The person usually feels driven to perform the compulsion to prevent some dreaded situation or to reduce the distress accompanying an obsession. Compulsions are either not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

Almost everyone worries, at times excessively. OCD is considered as a diagnosis if it interferes with one's life or causes distress. The worries of OCD are usually irrational. Ignoring them makes one feel anxious and nervous. Excessive worrying that is rational, but excessive, may be a symptom of depression. Many people are compulsive, but do not have OCD. They give careful attention to details and procedure. The compulsions of the people with OCD are useless, repetitive behaviors and are performed to dispel the anxiety that accompanies an obsession.

People with obsessive thoughts or compulsive rituals that are not distressing or particularly time-consuming may have subclinical OCD. They have OCD symptoms that are of concern, but are too mild to diagnose OCD. The same principles used to treat OCD may be helpful for subclinical OCD.

What Causes OCD?
By Cherry Pedrick, RN
Reprinted from Suite101.com, March 2, 1999, revised

Brain research is in its infancy. What we think we know about obsessive-compulsive disorder and other neurobiological disorders today will likely change tomorrow. Researchers around the world are piecing together the puzzle of OCD.

Certain antidepressants, such as Prozac, Luvox, Zoloft, Paxil, Anafranil, Celexa, and Lexapro, are effective in controlling OCD. This leads us to believe that serotonin regulation is involved in the cause of OCD. Serotonin is one of the brain’s vital chemical messengers and plays a role in many biological processes, including mood, aggression, impulse control, sleep, appetite, body temperature, and pain.

In addition to the problem with serotonin regulation, brain imaging studies have shown abnormalities in several parts of the brains of people with OCD. These include the caudate nucleus, (part of the basil ganglia), the thalamus, orbital cortex and cingulate gyrus.

Discovering that specific abnormalities in the way my brain works helped me realize that OCD was "all in my head." But not in the way we usually think of this cliche. It is our brains that aren’t working right. So does that mean we are without hope? Lost in our obsessive thoughts and compulsive behaviors?

No way! As I mentioned, several medications help to correct the serotonin imbalance and relieve symptoms of OCD. But the news gets better. Studies have found that cognitive-behavior therapy can bring about changes in brain structure and function. With his colleagues at UCLA, Jeffrey Schwartz, author of Brain Lock, demonstrated, with PET scans, actual changes in energy use in specific parts of the brain after patients underwent behavior therapy.

So what is cognitive-behavior therapy? The word, "cognitive" in cognitive-behavior therapy (CBT) refers to techniques that help change the faulty beliefs common to people with OCD. "Behavior" refers to techniques that help change actions. The most effective cognitive-behavior therapy technique for OCD is called exposure and ritual prevention (ERP). It is also referred to as exposure and response prevention.

I’ll explain exposure and ritual prevention further in the section,"Help and HOpe for OCD.". Simply put, it means to expose yourself to the thoughts you fear, and prevent the rituals you now use to alleviate the fear. It sounds scarey, and often it is. But it is worth the effort to break free from OCD. I’ll end with a few quotes. I love quotes. They make me stop and think.

There is perhaps nothing so bad and so dangerous in life as fear.
Jawaharlail Nehru

Almost OCD?
by Cherry Pedrick, RN
Reprinted from Suite101.com, October 26, 1999

Many people have compulsive rituals which do not necessarily interfere with their lives. John Ratey, MD and Catherine Johnson, Ph.D. call this a “shadow syndrome” in their book, Shadow Syndromes. They have obsessive-compulsive symptoms that are of concern, but are too mild to diagnose OCD.

People with “shadow syndromes” are functional, but often struggle with life. Like those of us with OCD, their behavior is influenced by the structure and chemistry of their brains. This is not an excuse for negative behavior. We are not imprisoned by our biology – there is much we can do to influence the neurochemistry of our brains.

So what is the difference between someone with OCD and someone who just has obsessive-compulsive traits? Let’s look at the definition of OCD to find the answer.

The DSM-IV-R (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) states that “the essential features of obsessive-compulsive disorder are recurrent obsessions or compulsions that are severe enough to be time consuming (i.e., they take more than 1 hour a day) or cause marked distress or significant impairment. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable.”

What if the obsessions and compulsions don’t take up that much time and cause only moderate distress and impairment? Maybe you check your school papers three times before handing them in and it takes you two hours to do a one hour assignment. But once it is turned in you don’t worry about it. You could sure use that extra hour though.

Or maybe you’re like someone I worked with years ago. She admitted that she washed her towels after each shower. She said she didn’t want to dry her face on the same towel she used on the rest of her body. Imagine the amount of laundry she had! The rest of my coworkers agreed that this was excessive. Years later, when I was diagnosed with OCD, I wondered if she had OCD, and if she had other symptoms. Was she successfully keeping obsessive thoughts, compulsive behavior and anxiety a secret?

Perhaps you like to keep an organized pantry. All the cans need to be facing the same direction so the labels are easily read. Soups on the right, in alphabetical order, fruit on the left, mushrooms and tuna in the middle. Do you get upset when someone disturbs your neatly stacked cans? Your obsessive-compulsive behavior may not be bothering you, but it might be exasperating your family. This is a very good reason to tackle obsessive-compulsive behavior, even if you don’t have OCD.

Finally, do you avoid certain activities to escape inevitable anxiety? Do you avoid school zones because you worry you might hit a child? Do you make certain you aren’t the last one to leave the office so you won’t worry about locking the door? Think of all you might be missing out on because of your avoidance!

In Shadow Syndromes, Ratey and Johnson ask, “Ultimately, the question is: why should the person with a very mild disorder accept his problems as simply his lot in life? If it is possible to treat a mild and hidden disorder by means of natural or medical intervention, then it is desirable. Even a mild disorder, given time, can damage a life, can drain away joy and hope.” The same treatments used for OCD may be helpful for sub-clinical OCD.

OCD’s Related Disorders
by Cherry Pedrick, RN
Reprinted from Suite101.com, September 14, 1999, revised

We all have those bothersome relatives. The pesky ones that make our life more difficult. OCD has annoying relatives too. Other disorders include obsessive compulsive symptoms such as intrusive thoughts or repetitive behaviors. These are often called OC spectrum disorders and include trichotillomania, monosymptomatic hypochondriasis, body dysmorphic disorder, and some eating disorders. I will discuss some of these disorders in the coming months. Other disorders are seen frequently in people with OCD. These are called comorbid disorders because they coexist with OCD. The most common comorbid disorder is depression.

Trichotillomania (TTM) is characterized by chronic, repetitive pulling of bodily hair. People with trichotillomania can have urges to pull hair from their scalp, eyelashes, eyebrows, axillary, body, and pubic area. They experience increasing tension that is relieved by pulling out a hair. Hair pulling brings about feelings of pleasure, gratification and relief. Further research into the cause of TTM is needed, but it is thought to be related to abnormalities in brain function. Find out more about trichotillomania at http://www.trich.org

Body dysmorphic disorder (BDD) is another OC spectrum disorder. It is characterized by preoccupation with a minor bodily defect or imagined defect which is believed to be conspicuous to others. About 90% of people with BDD perform one or more repetitive and often time-consuming behaviors intended to examine, improve, or hide imagined defects. This can include mirror checking, grooming, shaving, washing, skin picking, weight lifting, and comparing self with others. If you are struggling with BDD, you may find helpful a book I coauthored with James Claiborn: The BDD Workbook.

Trichotillomania and body dysmorphic disorder can both be treated with medication and cognitive behavior therapy. As with OCD, there is much hope for people with these disorders.

Depression is the most common disorder that coexists with OCD. Is it a separate disease, independent from OCD, or a secondary disease, caused by the OCD itself? Further research will help us answer that question. Treatment of depression is an important part of treating OCD.

More OCD Relatives
by Cherry Pedrick, RN
Reprinted from Suite101.com, September 28, 1999, revised

I discussed trichotillomania, body dysmorphic disorder and depression in my last article. Now, let’s look at disorders sometimes found in children with OCD. The disorders seen most often in children and teens with OCD are ADHD, learning disorders, disruptive disorders, Tourette syndrome, tic disorders, depression and other anxiety disorders.

Team work is important in the treatment of children with more than one disorder. Doctors, therapists, teachers, counselors and parents need to work together to coordinate the treatment and education plans.

Tourette Syndrome

Tourette syndrome (TS) affects one out of every two thousand children. Symptoms begin before age 21 and last at least one year. Children with TS have tics, which are repeated involuntary body movements and vocal sounds. Many children – about 15 percent – have transient tics. Their tics come and go.

Tics are sudden urges to make a sound or movement and can include arm thrusting, shoulder shrugging, neck jerking, arm flailing, kicking movements, foot stomping, jumping, repeated throat clearing, sniffing, eye blinking, squinting, lip smacking, nail biting, barking, coughing, hissing, humming, stuttering, swearing, voicing short, often meaningless phrases and sudden changes of voice tone, tempo or volume.

When children have TS or a tic disorder and OCD, it becomes important to distinguish between tics and OCD rituals. Why? Because the treatments differ. A thought precedes OCD rituals, while a sensory feeling precedes a tic.

Attention Deficit/Hyperactivity Disorder (ADD and ADHD)

ADHD affects 3% to 5% of children and occurs four to nine times as often in boys. It is the most common neuropsychiatric disorder in children. Children with ADD have difficulty keeping attention focused on one thing and are more easily distracted. ADHD adds hyperactivity to the equation. Children with ADHD have excessive, uncontrollable fidgetiness and have difficulty sitting still.

ADD and ADHD are diagnosed when symptoms are chronic and present more often than not, are present at home and school, cause significant problems for the child, and are present before the age of seven. If symptoms begin after the age of seven, the doctor will consider other disorders, such as anxiety disorders, depression and P.A.N.D.A.S.

Children and adults with OCD often seem inattentive and distracted. We are focusing on obsessive thoughts or mental rituals. Children with OCD are often misdiagnosed with ADD or ADHD because they seem preoccupied and distracted. And of course, some children have both OCD and ADD/ADHD.

P.A.N.D.A.S.

What do Pandas have to do with OCD and ADHD? P.A.N.D.A.S. is an acronym for Pediatric Autoimmune Neurological Disorder Associated with Streptococci. You can see why it’s easier to say P.A.N.D.A.S. Researchers at the National Institute of Mental Health have linked some behavior problems in children to strep throat infections. These include anxiety, obsessive-compulsive symptoms, hyperactivity, inattention and motor and vocal tics.

Researchers aren’t quite sure precisely how strep infections are involved, but it is thought that the body forms antineuronal antibodies against the streptococcal bacteria. These antibodies interact with tissue in the basal ganglia part of the brain. This leads to the behavior problems. This seems to be rare, but it is good incentive to have sudden changes in behavior checked by a doctor. And good incentive to have strep infections treated promptly.

Trichotillomania Learning Center - http://www.trich.org/