Signs and symptoms
Obsessions
Main article: Intrusive thoughts
Obsessions are thoughts that recur and persist despite efforts to ignore or confront them.[8] People with OCD frequently perform tasks, orcompulsions, to seek relief from obsession-related anxiety. Within and among individuals, the initial obsessions, or intrusive thoughts, vary in their clarity and vividness. A relatively vague obsession could involve a general sense of disarray or tension accompanied by a belief that life cannot proceed as normal while the imbalance remains. A more intense obsession could be a preoccupation with the thought or image of someone close to them dying[9][10] or intrusions related to "relationship rightness."[11] Other obsessions concern the possibility that someone or something other than oneself—such as God, the Devil, or disease—will harm either the person with OCD or the people or things that the person cares about. Other individuals with OCD may experience the sensation of invisible protrusions emanating from their bodies, or have the feeling that inanimate objects are ensouled.[12]
Some people with OCD experience sexual obsessions that may involve intrusive thoughts or images of "kissing, touching, fondling, oral sex, anal sex, intercourse, incest and rape" with "strangers, acquaintances, parents, children, family members, friends, coworkers, animals and religious figures", and can include "heterosexual or homosexual content" with persons of any age.[13] As with other intrusive, unpleasant thoughts or images, most "normal" people have some disquieting sexual thoughts at times, but people with OCD may attach extraordinary significance to the thoughts. For example, obsessive fears about sexual orientation can appear to the person with OCD, and even to those around them, as a crisis of sexual identity.[14][15] Furthermore, the doubt that accompanies OCD leads to uncertainty regarding whether one might act on the troubling thoughts, resulting in self-criticism or self-loathing.[13]
People with OCD understand that their notions do not correspond with reality; however, they feel that they must act as though their notions are correct. For example, an individual who engages in compulsive hoarding might be inclined to treat inorganic matter as if it had the sentience or rights of living organisms, while accepting that such behavior is irrational on a more intellectual level.
Primarily obsessional
Main article: Primarily Obsessional OCD
OCD sometimes manifests without overt compulsions.[16] Nicknamed "Pure-O",[17] or referred to as Primarily Obsessional OCD, OCD without overt compulsions could, by one estimate, characterize as many as 50 percent to 60 percent of OCD cases.[18] Primarily obsessional OCD has been called "one of the most distressing and challenging forms of OCD."[19] People with this form of OCD have "distressing and unwanted thoughts pop into [their] head frequently", and the thoughts "typically center on a fear that you may do something totally uncharacteristic of yourself, something ...potentially fatal...to yourself or others."[19] The thoughts "quite likely, are of an aggressive or sexual nature."[19]
Rather than engaging in observable compulsions, the person with this subtype might perform more covert, mental rituals, or might feel driven to avoid the situations in which particular thoughts seem likely to intrude.[17] As a result of this avoidance, people can struggle to fulfill both public and private roles, even if they place great value on these roles and even if they had fulfilled the roles successfully in the past.[17] Moreover, the individual's avoidance can confuse others who do not know its origin or intended purpose, as it did in the case of a man whose wife began to wonder why he would not hold their infant child.[17] The covert mental rituals can take up a great deal of a person's time during the day.
Compulsions
Main article: Compulsive behavior
Some people with OCD perform compulsive rituals because they inexplicably feel they have to, others act compulsively so as to mitigate the anxiety that stems from particular obsessive thoughts. The person might feel that these actions somehow either will prevent a dreaded event from occurring, or will push the event from their thoughts. In any case, the individual's reasoning is so idiosyncratic or distorted that it results in significant distress for the individual with OCD or for those around them. Excessive skin picking (i.e., dermatillomania) or hair plucking (i.e., trichotillomania) and nail biting (i.e., onychophagia) are all on the Obsessive-Compulsive Spectrum. Individuals with OCD are aware that their thoughts and behavior are not rational,[20] but they feel bound to comply with them to fend off feelings of panic or dread.
Some common compulsions include counting specific things (such as footsteps) or in specific ways (for instance, by intervals of two), and doing other repetitive actions, often with atypical sensitivity to numbers or patterns. People might repeatedly wash their hands[21] or clear their throats, make sure certain items are in a straight line, repeatedly check that their parked cars have been locked before leaving them, constantly organize in a certain way, turn lights on and off, keep doors closed at all times, touch objects a certain number of times before exiting a room, walk in a certain routine way like only stepping on a certain color of tile, or have a routine for using stairs, such as always finishing a flight on the same foot.
The compulsions of OCD must be distinguished from tics; movements of other movement disorders such as chorea, dystonia, myoclonus; movements exhibited in stereotypic movement disorder or some people with autism; and the movements of seizure activity.[22] There may exist a notable rate of comorbidity between OCD and tic-related disorders.[22]
People rely on compulsions as an escape from their obsessive thoughts; however, they are aware that the relief is only temporary, that the intrusive thoughts will soon return. Some people use compulsions to avoid situations that may trigger their obsessions. Although some people do certain things over and over again, they do not necessarily perform these actions compulsively. For example, bedtime routines, learning a new skill, and religious practices are not compulsions. Whether or not behaviors are compulsions or mere habit depends on the context in which the behaviors are performed. For example, arranging and ordering DVDs for eight hours a day would be expected of one who works in a video store, but would seem abnormal in other situations. In other words, habits tend to bring efficiency to one's life, while compulsions tend to disrupt it.[23]
In addition to the anxiety and fear that typically accompanies OCD, sufferers may spend hours performing such compulsions every day. In such situations, it can be hard for the person to fulfill their work, family, or social roles. In some cases, these behaviors can also cause adverse physical symptoms. For example, people who obsessively wash their hands with antibacterial soap and hot water can make their skin red and raw with dermatitis.[24]
People with OCD can use rationalizations to explain their behavior; however, these rationalizations do not apply to the overall behavior but to each instance individually. For example, a person compulsively checking the front door may argue that the time taken and stress caused by one more check of the front door is much less than the time and stress associated with being robbed, and thus checking is the better option. In practice, after that check, the person is still not sure and deems it is still better to perform one more check, and this reasoning can continue as long as necessary.
Associated conditions
People with OCD may be diagnosed with other conditions, as well or instead of OCD, such as the aforementioned obsessive–compulsive personality disorder, major depressive disorder, bipolar disorder,[29] generalized anxiety disorder, anorexia nervosa, social anxiety disorder,bulimia nervosa, Tourette syndrome, Asperger syndrome, attention deficit hyperactivity disorder, dermatillomania (compulsive skin picking), body dysmorphic disorder, and trichotillomania (hair pulling). In 2009 it was reported that depression among those with OCD is particularly alarming because their risk of suicide is high; more than 50 percent of patients experience suicidal tendencies, and 15 percent have attempted suicide.[30]Individuals with OCD have also been found to be affected by delayed sleep phase syndrome at a substantially higher rate than the general public.[31] Moreover severe OCD symptoms are consistently associated with greater sleep disturbance. Reduced total sleep time and sleep efficiency have been observed in OCD patients, with delayed sleep onset and offset and an increased prevalence of delayed sleep phase disorder.[32]
Causes
Main article: Cause of obsessive-compulsive disorder
Scholars generally agree that both psychological and biological factors play a role in causing the disorder, although they differ in their degree of emphasis upon either type of factor.
Psychological
An evolutionary psychology view is that moderate versions of compulsive behavior may have had evolutionary advantages. Examples would be moderate constant checking of hygiene, the hearth, or the environment for enemies. Similarly, hoarding may have had evolutionary advantages. In this view OCD may be the extreme statistical "tail" of such behaviors possibly due to a high amount of predisposing genes.[35]
Biological
Main article: Biology of obsessive–compulsive disorder
OCD has been linked to abnormalities with the neurotransmitter serotonin, although it could be either a cause or an effect of these abnormalities. Serotonin is thought to have a role in regulating anxiety. To send chemical messages from one neuron to another, serotonin must bind to the receptor sites located on the neighboring nerve cell. It is hypothesized that the serotonin receptors of OCD sufferers may be relatively understimulated. This suggestion is consistent with the observation that many OCD patients benefit from the use of selective serotonin reuptake inhibitors (SSRIs), a class of antidepressant medications that allow for more serotonin to be readily available to other nerve cells.[36]
A possible genetic mutation may contribute to OCD. A mutation has been found in the human serotonin transporter gene, hSERT, in unrelated families with OCD.[37] Moreover, data from identical twins supports the existence of a "heritable factor for neurotic anxiety".[38] Further, individuals with OCD are more likely to have first-degree family members exhibiting the same disorders than do matched controls. In cases where OCD develops during childhood, there is a much stronger familial link in the disorder than cases in which OCD develops later in adulthood. In general, genetic factors account for 45–65% of OCD symptoms in children diagnosed with the disorder.[39] Environmental factors also play a role in how these anxiety symptoms are expressed; various studies on this topic are in progress and the presence of a genetic link is not yet definitely established.
People with OCD evince increased grey matter volumes in bilateral lenticular nuclei, extending to the caudate nuclei, while decreased grey matter volumes in bilateral dorsal medial frontal/anterior cingulate gyri.[40][41] These findings contrast with those in people with other anxiety disorders, who evince decreased (rather than increased) grey matter volumes in bilateral lenticular / caudate nuclei, while also decreased grey matter volumes in bilateral dorsal medial frontal/anterior cingulate gyri.[41] Orbitofrontal cortex overactivity is attenuated in patients who have successfully responded to SSRI medication, a result believed to be caused by increased stimulation of serotonin receptors 5-HT2A and 5-HT2C.[42] The striatum, linked to planning and the initiation of appropriate actions, has also been implicated; mice genetically engineered with a striatal abnormality exhibit OCD-like behavior, grooming themselves three times as frequently as ordinary mice.[43] Recent evidence supports the possibility of a heritable predisposition for neurological development favoring OCD.[44]
Rapid onset of OCD in children and adolescents may be caused by a syndrome conntected to Group A streptococcal infections (PANDAS)[45][46]or caused by immunologic reactions to other pathogens (PANS).[47]
Neurotransmitters
Researchers have yet to pinpoint the exact cause of OCD, but brain differences, genetic influences, and environmental factors are being studied. Brain scans of people with OCD have shown that they have different patterns of brain activity than people without OCD and that different functioning of circuitry within a certain part of the brain, the striatum, may cause the disorder. Differences in other parts of the brain and neurotransmitter dysregulation, especially serotonin and dopamine, may also contribute to OCD.[48] Independent studies have consistently found unusual dopamine and serotonin activity in various regions of the brain in individuals with OCD. These can be defined as dopaminergichyperfunction in the prefrontal cortex and serotonergic hypofunction in the basal ganglia.[49][50][51] Glutamate dysregulation has also been the subject of recent research,[52][53] although its role in the disorder's etiology is not yet clear.
Society and culture
Movies and television often portray idealized representations of disorders such as OCD. These depictions may lead to increased public awareness, understanding, and sympathy for such disorders.[82]
- British poet, essayist, and lexicographer Samuel Johnson is an example of a historical figure with a retrospective diagnosis of OCD. He had elaborate rituals for crossing the thresholds of doorways, and repeatedly walked up and down staircases counting the steps.[83]
- American aviator and filmmaker Howard Hughes is known to have suffered from OCD. Friends of Hughes have mentioned his obsession with minor flaws in clothing and he is reported to have had a great fear of germs, common among OCD patients.[84]
- English footballer David Beckham has been outspoken regarding his struggle with OCD. He said that he has to count all of his clothes, and his magazines have to lie in a straight line.[85]
- Canadian comedian, actor, television host, and voice actor Howie Mandel, best known for hosting the game show Deal or No Deal, wrote an autobiography, Here's the Deal: Don't Touch Me, describing how OCD andmysophobia (fear of germs) affect his life.[86]
- American game show host Marc Summers wrote Everything in Its Place: My Trials and Triumphs with Obsessive Compulsive Disorder, describing the effect of OCD on his life.[87]
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