Obsessive–compulsive disorder

Obsessive–compulsive disorder (OCD) is a mental and behavioral disorder in which an individual has intrusive thoughts (an obsession) and feels the need to perform certain routines (compulsions) repeatedly to relieve the distress caused by the obsession, to the extent where it impairs general function.^[1][2][7]

Obsessions are persistent unwanted thoughts, mental images, or urges that generate feelings of anxiety, disgust, or discomfort.^[8] Some common obsessions include fear of contamination, obsession with symmetry, the fear of acting blasphemously, the sufferer's sexual orientation, and the fear of possibly harming others or themselves.^[1][9] Compulsions are repeated actions or routines that occur in response to obsessions to achieve a relief from anxiety. Common compulsions include excessive hand washing, cleaning, counting, ordering, repeating, avoiding triggers, hoarding, neutralizing, seeking assurance, praying, and checking things.^[1][9][10] People with OCD may only perform mental compulsions such as needing to know or remember things. While this is sometimes referred to as primarily obsessional obsessive–compulsive disorder (Pure O), it is also considered a misnomer due to associated mental compulsions and reassurance seeking behaviors that are consistent with OCD.^[11]

Compulsions occur often and typically take up at least one hour per day, impairing one's quality of life.

Obsessive–compulsive disorder affects about 2.3% of people at some point in their lives, while rates during any given year are about 1.2%.[2]^[6] More than three million Americans suffer from OCD.^[32] According to Mercy, approximately 1 in 40 U.S. adults and 1 in 100 U.S. children have OCD.^[33] Although possible at times with triggers such as pregnancy, onset rarely occurs after age 35, and about 50% of patients experience detrimental effects to daily life before age 20.^{[1][16][2][34]} While OCD occurs worldwide,^[1][2] a recent meta-analysis showed that women are 1.6 times more likely to experience OCD.^[35] Based on data from 34 studies, the worldwide prevalence rate is 1.5% in women and 1% in men.^[35]

Signs and symptoms

OCD can present with a wide variety of symptoms. Certain groups of symptoms usually occur together as dimensions or clusters, which may reflect an underlying process. The standard assessment tool for OCD, the

When looking into the onset of OCD, one study suggests that there are differences in the age of onset between males and females, with the average age of onset of OCD being 9.6 for male children and 11.0 for female children.[38]Children with OCD often have other mental disorders, such as ADHD, depression, anxiety, and disruptive behavior disorder. Continually, children are more likely to struggle in school and experience difficulties in social situations (Lack 2012).When looking at both adults and children a study found the average ages of onset to be 21 and 24 for males and females respectively.^[39] While some studies have shown that OCD with earlier onset is associated with greater severity, other studies have not been able to validate this finding.^[40] Looking at women specifically, a different study suggested that 62% of participants found that their symptoms worsened at a premenstrual age. Across the board, all demographics and studies showed a mean age of onset of less than 25.^[41]

Some OCD subtypes have been associated with improvement in performance on certain tasks, such as

In regards to the cause of onset, researchers asked participants in one study[41] what they felt was responsible for triggering the initial onset of their illness. 29% of patients answered that there was an environmental factor in their life that did so. Specifically, the majority of participants who answered with that noted their environmental factor to be related to an increased responsibility.

Obsessions

Obsessions are stress-inducing thoughts that recur and persist, despite efforts to ignore or confront them.

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 contact with people of any age.^[52] Similar to other intrusive thoughts or images, some disquieting sexual thoughts are normal at times, but people with OCD may attach extraordinary significance to such thoughts. For example, obsessive fears about sexual orientation can appear to the affected individual, and even to those around them, as a crisis of sexual identity.^[53][54] 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.^[52]

Most people with OCD understand that their thoughts do not correspond with reality; however, they feel that they must act as though these ideas are correct or realistic. For example, someone who engages in

Some people with OCD perform compulsive rituals because they inexplicably feel that they must do so, while others act compulsively to mitigate the anxiety that stems from obsessive thoughts. The affected individual might feel that these actions will either prevent a dreaded event from occurring, or push the event from their thoughts. In any case, their reasoning is so idiosyncratic or distorted that it results in significant distress, either personally, or for those around the affected individual. Excessive skin picking, hair pulling, nail biting, and other body-focused repetitive behavior disorders are all on the obsessive–compulsive spectrum.^[2] Some individuals with OCD are aware that their behaviors are not rational, but they feel compelled to follow through with them to fend off feelings of panic or dread.^[56] Furthermore, compulsions often stem from memory distrust, a symptom of OCD characterized by insecurity in one's skills in perception, attention, and memory, even in cases where there is no clear evidence of a deficit.^[57]

Common compulsions may include hand washing, cleaning, checking things (such as locks on doors), repeating actions (such as repeatedly turning on and off switches), ordering items in a certain way, and requesting reassurance.

People with OCD rely on compulsions as an escape from their obsessive thoughts; however, they are aware that relief is only temporary, and that intrusive thoughts will return. Some affected individuals use compulsions to avoid situations that may trigger obsessions. Compulsions may be actions directly related to the obsession, such as someone obsessed with contamination compulsively washing their hands, but they can be unrelated as well.[9] In addition to experiencing the anxiety and fear that typically accompanies OCD, affected individuals may spend hours performing compulsions every day. In such situations, it can become difficult for the person to fulfill their work, familial, or social roles. 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.^[63]

Individuals with OCD often use rationalizations to explain their behavior; however, these rationalizations do not apply to the behavioral pattern, but to each individual occurrence. For example, someone compulsively checking the front door may argue that the time and stress associated with one check is less than the time and stress associated with being robbed, and checking is consequently the better option. This reasoning often occurs in a cyclical manner, and can continue for as long as the affected person needs it to in order to feel safe.^[64]

In

OCD sometimes manifests without overt compulsions, which may be termed "primarily obsessional OCD." OCD without overt compulsions could, by one estimate, characterize as many as 50–60% of OCD cases.[69]

Insight and overvalued ideation

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), identifies a continuum for the level of insight in OCD, ranging from good insight (the least severe) to no insight (the most severe). Good or fair insight is characterized by the acknowledgment that obsessive–compulsive beliefs are not or may not be true, while poor insight, in the middle of the continuum, is characterized by the belief that obsessive–compulsive beliefs are probably true. The absence of insight altogether, in which the individual is completely convinced that their beliefs are true, is also identified as a delusional thought pattern, and occurs in about 4% of people with OCD.^[70][71] When cases of OCD with no insight become severe, affected individuals have an unshakable belief in the reality of their delusions, which can make their cases difficult to differentiate from psychotic disorders.^[72]

Some people with OCD exhibit what is known as overvalued ideas, ideas that are abnormal compared to affected individuals' respective cultures, and more treatment-resistant than most negative thoughts and obsessions.^[73] After some discussion, it is possible to convince the individual that their fears are unfounded. It may be more difficult to practice exposure and response prevention therapy (ERP) on such people, as they may be unwilling to cooperate, at least initially.^[74] Similar to how insight is identified on a continuum, obsessive-compulsive beliefs are characterized on a spectrum, ranging from obsessive doubt to delusional conviction. In the United States, overvalued ideation (OVI) is considered most akin to poor insight—especially when considering belief strength as one of an idea's key identifiers.^[75] Furthermore, severe and frequent overvalued ideas are considered similar to idealized values, which are so rigidly held by, and so important to affected individuals, that they end up becoming a defining identity.^[73] In adolescent OCD patients, OVI is considered a severe symptom.^[76]

Historically, OVI has been thought to be linked to poorer treatment outcome in patients with OCD, but it is currently considered a poor indicator of prognosis.^[76][77] The Overvalued Ideas Scale (OVIS) has been developed as a reliable quantitative method of measuring levels of OVI in patients with OCD, and research has suggested that overvalued ideas are more stable for those with more extreme OVIS scores.^[78]

Cognitive performance

Though OCD was once believed to be associated with above-average intelligence, this does not appear to necessarily be the case.

Specific subtypes of symptom dimensions in OCD have been associated with specific cognitive deficits.[82] For example, the results of one meta-analysis comparing washing and checking symptoms reported that washers outperformed checkers on eight out of ten cognitive tests.^[83] The symptom dimension of contamination and cleaning may be associated with higher scores on tests of inhibition and verbal memory.^[84]

Video game addiction

Pediatric OCD

Approximately 1–2% of children are affected by OCD.^[86] There is a lot of similarity between the clinical presentation of OCD in children and adults, and it is considered a highly familial disorder, with a phenotypic heritability of around 50%.^[38][87] Obsessive–compulsive disorder symptoms tend to develop more frequently in children 10–14 years of age, with males displaying symptoms at an earlier age, and at a more severe level than females.^[88] In children, symptoms can be grouped into at least four types, including sporadic and tic-related OCD.^[36]

The Children's Yale–Brown Obsessive–Compulsive Scale (CY-BOCS) is the gold standard measure for assessment of pediatric OCD.^[89] It follows the Y-BOCS format, but with a Symptom Checklist that is adapted for developmental appropriateness. Insight, avoidance, indecisiveness, responsibility, pervasive slowness, and doubting, are not included in a rating of overall severity. The CY-BOCS has demonstrated good convergent validity with clinician-rated OCD severity, and good to fair discriminant validity from measures of closely related anxiety, depression, and tic severity.^[89] The CY-BOCS Total Severity score is an important monitoring tool as it is responsive to pharmacotherapy and psychotherapy.^[90][91] Positive treatment response is characterized by 25% reduction in CY-BOCS total score, and diagnostic remission is associated with a 45%-50% reduction in Total Severity score (or a score <15).^[89]

CBT is the first line treatment for mild to moderate cases of OCD in children, while medication plus CBT is recommended for moderate to severe cases.

It has been found that between 18 and 34% of females currently experiencing OCD scored positively on an inventory measuring disordered eating.[98] Another study found that 7% are likely to have an eating disorder,^[98] while another found that fewer than 5% of males have OCD and an eating disorder.^[99]

Individuals with OCD have also been found to be affected by

OCD frequently occurs comorbidly with both bipolar disorder and major depressive disorder. Between 60 and 80% of those with OCD experience a major depressive episode in their lifetime. Comorbidity rates have been reported at between 19 and 90%, as a result of methodological differences. Between 9–35% of those with bipolar disorder also have OCD, compared to 1–2% in the general population. About 50% of those with OCD experience cyclothymic traits or hypomanic episodes. OCD is also associated with anxiety disorders. Lifetime comorbidity for OCD has been reported at 22% for specific phobia, 18% for social anxiety disorder, 12% for panic disorder, and 30% for generalized anxiety disorder. The comorbidity rate for OCD and ADHD has been reported to be as high as 51%.^[106]

Causes

The cause of OCD is unknown.

4) Clinically induces distress or impairment in social, occupational, or other important areas of functioning. [109]^{[110][111][112][113]}

Genetics

There appear to be some

Research has found there to be a genetic correlation between anorexia nervosa and OCD, suggesting a strong etiology.[116]^[117][118] First and second hand relatives of probands with OCD have a greater risk of developing anorexia nervosa as genetic relatedness increases.^[116]

A

A systematic review found that while neither allele was associated with OCD overall, in Caucasians, the L allele was associated with OCD.^[120] Another meta-analysis observed an increased risk in those with the homozygous S allele, but found the LS genotype to be inversely associated with OCD.^[121]

A

The relationship between OCD and Catechol-O-methyltransferase (COMT) has been inconsistent, with one meta-analysis reporting a significant association, albeit only in men, and another meta analysis reporting no association.^[124][125]

It has been postulated by evolutionary psychologists 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 the result of a high number of predisposing genes.^[126]

Brain structure and functioning

A controversial hypothesis is that some cases of rapid onset of OCD in children and adolescents may be caused by a syndrome connected to Group A streptococcal infections (GABHS), known as pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).^{[130][131][132]} OCD and tic disorders are hypothesized to arise in a subset of children as a result of a post-streptococcal autoimmune process.^{[133][134][135]} The PANDAS hypothesis is unconfirmed and unsupported by data, and two new categories have been proposed: PANS (pediatric acute-onset neuropsychiatric syndrome) and CANS (childhood acute neuropsychiatric syndrome).^[134][135] The CANS and PANS hypotheses include different possible mechanisms underlying acute-onset neuropsychiatric conditions, but do not exclude GABHS infections as a cause in a subset of individuals.^[134][135] PANDAS, PANS, and CANS are the focus of clinical and laboratory research, but remain unproven.^{[133][134][135]} Whether PANDAS is a distinct entity differing from other cases of tic disorders or OCD is debated.^{[136][137][138][139]}

A review of studies examining anti-basal ganglia antibodies in OCD found an increased risk of having anti-basal ganglia antibodies in those with OCD versus the general population.^[140]

Environment

OCD may be more common in people who have been bullied, abused, or neglected, and it sometimes starts after a significant life event, such as childbirth or

Neuroimaging

Functional neuroimaging during symptom provocation has observed abnormal activity in the

Generally, two categories of models for OCD have been postulated. The first category involves deficits in executive dysfunction and is based on the observed structural and functional abnormalities in the dlPFC, striatum and thalamus. The second category involves dysfunctional modulatory control and primarily relies on observed functional and structural differences in the ACC, mPFC, and OFC.^[149][150]

One proposed model suggests that dysfunction in the OFC leads to improper valuation of behaviors and decreased behavioral control, while the observed alterations in amygdala activations leads to exaggerated fears and representations of negative stimuli.^[151]

Due to the

Another model proposes that affective dysregulation links excessive reliance on habit-based action selection[153] with compulsions. This is supported by the observation that those with OCD demonstrate decreased activation of the ventral striatum when anticipating monetary reward, as well as increased functional connectivity between the VS and the OFC. Furthermore, those with OCD demonstrate reduced performance in Pavlovian fear-extinction tasks, hyperresponsiveness in the amygdala to fearful stimuli, and hyporesponsiveness in the amygdala when exposed to positively valanced stimuli. Stimulation of the nucleus accumbens has also been observed to effectively alleviate both obsessions and compulsions, supporting the role of affective dysregulation in generating both.^[151]

Neurobiological

From the observation of the efficacy of antidepressants in OCD, a serotonin hypothesis of OCD has been formulated. Studies of peripheral markers of serotonin, as well as challenges with proserotonergic compounds have yielded inconsistent results, including evidence pointing towards basal hyperactivity of

Abnormalities in glutamatergic neurotransmission have been implicated in OCD. Findings such as increased cerebrospinal glutamate, less consistent abnormalities observed in neuroimaging studies, and the efficacy of some glutamatergic drugs (such as the glutamate-inhibiting riluzole) have implicated glutamate in OCD.^[158] OCD has been associated with reduced N-Acetylaspartic acid in the mPFC, which is thought to reflect neuron density or functionality, although the exact interpretation has not been established.^[160]

Diagnosis

Formal diagnosis may be performed by a psychologist, psychiatrist, clinical social worker, or other licensed mental health professional. OCD, like other mental and behavioral health disorders, cannot be diagnosed by a medical exam,^[7] nor are there any medical exams that can predict if one will fall victim to such illnesses. To be diagnosed with OCD, a person must have obsessions, compulsions, or both, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM notes that there are multiple characteristics that can turn obsessions and compulsions from normalized behavior to "clinically significant". There has to be recurring and strong thoughts or impulsive that intrude on the day-to-day lives of the patients and cause noticeable levels of anxiousness.^[2]

These thoughts, impulses, or images are of a degree or type that lies outside the normal range of worries about conventional problems.^[161] A person may attempt to ignore or suppress such obsessions, neutralize them with another thought or action, or try to rationalize their anxiety away. People with OCD tend to recognize their obsessions as irrational.

Compulsions become clinically significant when a person feels driven to perform them in response to an obsession, or according to rules that must be applied rigidly, and when the person consequently feels or causes significant distress. Therefore, while many people who do not have OCD may perform actions often associated with OCD (such as ordering items in a pantry by height), the distinction with clinically significant OCD lies in the fact that the person with OCD must perform these actions to avoid significant psychological distress. These behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these activities are not logically or practically connected to the issue, or, they are excessive.

Moreover, the obsessions or compulsions must be time-consuming, often taking up more than one hour per day, or cause impairment in social, occupational, or scholastic functioning.

In regards to diagnosing, the health professional also looks to make sure that the signs of obsessions and compulsions are not the results of any drugs, prescription or recreational, that the patient may be taking.[164]

There are several types of obsessive thoughts that are found commonly in those with OCD. Some of these include fear of germs, hurting loved ones, embarrassment, neatness, societally unacceptable sexual thoughts etc.^[164] Within OCD, these specific categories are often diagnosed into their own type of OCD.^[2]

OCD is sometimes placed in a group of disorders called the obsessive–compulsive spectrum.^[165]

Another criterion in the DSM is that a person's mental illness does not fit one of the other categories of a mental disorder better. That is to say, if the obsessions and compulsions of a patient could be better described by trichotillomania, it would not be diagnosed as OCD.^[2] That being said, OCD does often go hand in hand with other mental disorders. For this reason, one may be diagnosed with multiple mental disorders at once.^[166]

A different aspect of the diagnoses is the degree of insight had by the individual in regards to the truth of the obsessions. There are three levels, good/fair, poor and absent/delusional. Good/fair indicated that the patient is aware that the obsessions they have are not true or probably not true.^[2] Poor indicates that the patient believes their obsessional beliefs are probably true.^[2] Absent/delusional indicates that they fully believe their obsessional thoughts to be true.^[2] Approximately 4% or fewer individuals with OCD will be diagnosed as absent/delusional.^[2] Additionally, as many as 30% of those with OCD also have a lifetime tic disorder, meaning they have been diagnosed with a tic disorder at some point in their life.^[2]

There are several different types of tics that have been observed in individuals with OCD. These include but are not limited to, "grunting", "jerking" or "shrugging" body parts, sniffling, and excessive blinking.^[164]

There has been a significant amount of progress over the last few decades, and as of 2022 there is statically significant improvement in the diagnostic process for individuals with OCD. One study found that of two groups of individuals, one with participants under the age of 27.25 and one with participants over that age, those in the younger group experienced a significantly faster time between the onset of OCD tendencies and their formal diagnoses.^[167]

Differential diagnosis

OCD is often confused with the separate condition obsessive–compulsive personality disorder (OCPD). OCD is egodystonic, meaning that the disorder is incompatible with the individual's self-concept.^[168][169] As egodystonic disorders go against a person's self-concept, they tend to cause much distress. OCPD, on the other hand, is egosyntonic, marked by the person's acceptance that the characteristics and behaviors displayed as a result are compatible with their self-image, or are otherwise appropriate, correct, or reasonable.

As a result, people with OCD are often aware that their behavior is not rational, and are unhappy about their obsessions, but nevertheless feel compelled by them.^[170] By contrast, people with OCPD are not aware of anything abnormal; they will readily explain why their actions are rational. It is usually impossible to convince them otherwise, and they tend to derive pleasure from their obsessions or compulsions.^[170]

Management

One specific CBT technique used is called

For example, a patient might be asked to touch something very mildly contaminated (exposure), and wash their hands only once afterward (response prevention). Another example might entail asking the patient to leave the house and check the lock only once (exposure), without going back to check again (response prevention). After succeeding at one stage of treatment, the patient's level of discomfort in the exposure phase can be increased. When this therapy is successful, the patient will quickly habituate to an anxiety-producing situation, discovering a considerable drop in anxiety level.^[174]

ERP has a strong evidence base, and is considered the most effective treatment for OCD.^[174] However, this claim was doubted by some researchers in 2000, who criticized the quality of many studies.^[175] While ERP can lead a majority of clients to improvements, many do not reach remission or become asymptomatic;^[176] some therapists are also hesitant to use this approach.^[177]

The recent development of remotely technology-delivered CBT is increasing access to therapy options for those living with OCD and remote versions appear to equally as effective as in-person therapy options. The development of smartphone interventions for OCD that utilize CBT techniques are another alternative that is expanding access to therapy while allowing therapies to be personalized for each patient.^[178]

Acceptance and commitment therapy (ACT), a newer therapy also used to treat anxiety and depression, has also been found to be effective in treatment of OCD.^[179][180] ACT uses acceptance and mindfulness strategies to teach patients not to overreact to or avoid unpleasant thoughts and feelings but rather "move toward valued behavior."^[181][182]

Inference-based therapy (IBT) is a form of cognitive therapy specifically developed for treating OCD.^[183] The therapy posits that individuals with OCD put a greater emphasis on an imagined possibility than on what can be perceived with the senses, and confuse the imagined possibility with reality, in a process called inferential confusion.^[184] According to inference-based therapy, obsessional thinking occurs when the person replaces reality and real probabilities with imagined possibilities.^[185] The goal of inference-based therapy is to reorient clients towards trusting the senses and relating to reality in a normal, non-effortful way. Differences between normal and obsessional doubts are presented, and clients are encouraged to use their senses and reasoning as they do in non-obsessive-compulsive disorder situations.^[186][183] Research on Inference-Based Cognitive-Behavior Therapy (I-CBT) suggests it can lead to improvements for those with OCD.^[187]

A 2007 Cochrane review found that psychological interventions derived from CBT models, such as ERP, ACT, and IBT, were more effective than non-CBT interventions.^[26] Other forms of psychotherapy, such as psychodynamics and psychoanalysis, may help in managing some aspects of the disorder. However, in 2007, the American Psychiatric Association (APA) noted a lack of controlled studies showing their efficacy, "in dealing with the core symptoms of OCD."^[188] For body-focused repetitive behaviors (BFRB), behavioral interventions such as habit-reversal training and decoupling are recommended.^[67][68]

Psychotherapy in combination with psychiatric medication may be more effective than either option alone for individuals with severe OCD.^{[189][190][191]} ERP coupled with weight restoration and serotonin reuptake inhibitors has proven the most effective when treating OCD and an eating disorder simultaneously.^[192]

Medication

The medications most frequently used to treat OCD are antidepressants, including selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs).^[4] Sertraline and fluoxetine are effective in treating OCD for children and adolescents.^{[193][194][195]}

SSRIs help people with OCD by inhibiting the reabsorption of serotonin by the nerve cells after they carry messages from neurons to synapse; thus, more serotonin is available to pass further messages between nearby nerve cells.^[129]

SSRIs are a second-line treatment of adult OCD with mild functional impairment, and as first-line treatment for those with moderate or severe impairment. In children, SSRIs can be considered as a second-line therapy in those with moderate to severe impairment, with close monitoring for psychiatric adverse effects.^[171] Patients treated with SSRIs are about twice as likely to respond to treatment as are those treated with placebo, so this treatment is qualified as efficacious.^[196][197] Efficacy has been demonstrated both in short-term (6–24 weeks) treatment trials, and in discontinuation trials with durations of 28–52 weeks.^{[198][199][200]}

Clomipramine, a medication belonging to the class of tricyclic antidepressants, appears to work as well as SSRIs, but has a higher rate of side effects.^[4]

In 2006, the National Institute for Health and Care Excellence (NICE) guidelines recommended augmentative second-generation (atypical) antipsychotics for treatment-resistant OCD.^[5] Atypical antipsychotics are not useful when used alone, and no evidence supports the use of first-generation antipsychotics.^[28][201] For OCD treatment specifically, there is tentative evidence for risperidone, and insufficient evidence for olanzapine. Quetiapine is no better than placebo with regard to primary outcomes, but small effects were found in terms of Y-BOCS score. The efficacy of quetiapine and olanzapine are limited by an insufficient number of studies.^[202] A 2014 review article found two studies that indicated that aripiprazole was "effective in the short-term", and found that "[t]here was a small effect-size for risperidone or anti-psychotics in general in the short-term"; however, the study authors found "no evidence for the effectiveness of quetiapine or olanzapine in comparison to placebo."^[5] While quetiapine may be useful when used in addition to an SSRI/SNRI in treatment-resistant OCD, these drugs are often poorly tolerated, and have metabolic side effects that limit their use. A guideline by the American Psychological Association suggested that dextroamphetamine may be considered by itself after more well-supported treatments have been attempted.^[203]

Procedures

Electroconvulsive therapy (ECT) has been found to have effectiveness in some severe and refractory cases.^[204] Transcranial magnetic stimulation has shown to provide therapeutic benefits in alleviating symptoms.^[205]

Therapeutic treatment may be effective in reducing ritual behaviors of OCD for children and adolescents.[210] Similar to the treatment of adults with OCD, cognitive behavioral therapy stands as an effective and validated first line of treatment of OCD in children.^[211] Family involvement, in the form of behavioral observations and reports, is a key component to the success of such treatments.^[212] Parental interventions also provide positive reinforcement for a child who exhibits appropriate behaviors as alternatives to compulsive responses. In a recent meta-analysis of evidenced-based treatment of OCD in children, family-focused individual CBT was labeled as "probably efficacious," establishing it as one of the leading psychosocial treatments for youth with OCD.^[211] After one or two years of therapy, in which a child learns the nature of their obsession and acquires strategies for coping, they may acquire a larger circle of friends, exhibit less shyness, and become less self-critical.^[213] Trials have shown that children and adolescents with OCD should begin treatment with the combination of CBT with a selective serotonin reuptake inhibitor or CBT alone, rather than only an SSRI.^[93][95]

Although the known causes of OCD in younger age groups range from brain abnormalities to psychological preoccupations, life stress such as bullying and traumatic familial deaths may also contribute to childhood cases of OCD, and acknowledging these stressors can play a role in treating the disorder.^[214]

Prognosis

Quality of life is reduced across all domains in OCD. While psychological or pharmacological treatment can lead to a reduction of OCD symptoms and an increase in reported quality of life, symptoms may persist at moderate levels even following adequate treatment courses, and completely symptom-free periods are uncommon.^[215][216] In pediatric OCD, around 40% still have the disorder in adulthood, and around 40% qualify for remission.^[217] The risk of having at least one comorbid personality disorder in OCD is 52%, which is the highest among anxiety disorders and greatly impacts its management and prognosis.^[218]

Epidemiology

Obsessive–compulsive disorder affects about 2.3% of people at some point in their life, with the yearly rate about 1.2%.^[6] OCD occurs worldwide.^[2] It is unusual for symptoms to begin after the age of 35 and half of people develop problems before 20.^[1][2] Males and females are affected about equally.^[1] However, there is an earlier age for onset for males than females.^[219]

History

Plutarch, an ancient Greek philosopher and historian, describes an ancient Roman man who possibly had scrupulosity, which could be a symptom of OCD or OCPD. This man is described as "turning pale under his crown of flowers," praying with a "faltering voice," and scattering "incense with trembling hands."^{[220][221][222]}

In the 7th century AD, John Climacus records an instance of a young monk plagued by constant and overwhelming "temptations to blasphemy" consulting an older monk, who told him: "My son, I take upon myself all the sins which these temptations have led you, or may lead you, to commit. All I require of you is that for the future you pay no attention to them whatsoever."^[223]: 212 The Cloud of Unknowing, a Christian mystical text from the late 14th century, recommends dealing with recurring obsessions by attempting to ignore them, and, if that fails, to "cower under them like a poor wretch and a coward overcome in battle, and reckon it to be a waste of your time for you to strive any longer against them", a technique now known as emotional flooding.^[223]: 213

Abu Zayd Al-Balkhi, the 9th century Islamic polymath, was likely the first to classify OCD into different types and pioneer cognitive behavioral therapy, in a fashion unique to his era and which was not popular in Greek medicine.^[224] In his medical treatise entitled Sustenance of the Body and Soul, Al-Balkhi describes obsessions particular to the disorder as "Annoying thoughts that are not real. These intrusive thoughts prevent enjoying life, and performing daily activities. They affect concentration and interfere with ability to carry out different tasks."^[225] As treatment, Al-Balkhi suggests treating obsessive thoughts with positive thoughts and mind-based therapy.^[224]

From the 14th to the 16th century in Europe, it was believed that people who experienced blasphemous, sexual or other obsessive thoughts were

The English term obsessive–compulsive arose as a translation of German Zwangsvorstellung (obsession) used in the first conceptions of OCD by Karl Westphal. Westphal's description went on to influence Pierre Janet, who further documented features of OCD.^[71] In the early 1910s, Sigmund Freud attributed obsessive–compulsive behavior to unconscious conflicts that manifest as symptoms.^[226] Freud describes the clinical history of a typical case of "touching phobia" as starting in early childhood, when the person has a strong desire to touch an item. In response, the person develops an "external prohibition" against this type of touching. However, this "prohibition does not succeed in abolishing" the desire to touch; all it can do is repress the desire and "force it into the unconscious."^[228] Freudian psychoanalysis remained the dominant treatment for OCD until the mid-1980s, even though medicinal and therapeutic treatments were known and available, because it was widely thought that these treatments would be detrimental to the effectiveness of the psychotherapy.^{[223]: 210–211} In the mid-1980s, this approach changed, and practitioners began treating OCD primarily with medicine and practical therapy rather than through psychoanalysis.^[223]: 210

One of the first successful treatments of OCD, exposure and response prevention, emerged during the 1960s, when psychologist Vic Meyer exposed two hospitalized patients to anxiety-inducing situations while preventing them from performing any compulsions. Eventually, both patients' anxiety level dropped to manageable levels. Meyer devised this procedure from his analysis of fear extinguishment in animals via flooding.^[229] The success of ERP clinically and scientifically has been summarized as "spectacular" by prominent OCD researcher Stanley Rachman decades following Meyer's creation of the method.^[230]

In 1967, psychiatrist Juan José López-Ibor reported that the drug clomipramine was effective in treating OCD. Many reports of its success in treatment followed, and several studies had confirmed its effectiveness by the 1980s.^[231][232] However, clomipramine was subsequently displaced by new SSRIs developed in the 1970s, such as fluoxetine and sertraline, which were shown to have less side effects.^[4][232]

Obsessive-compulsive symptoms worsened during the early stages of the COVID-19 pandemic, particularly for individuals with contamination-related OCD.^[233]

Notable cases

John Bunyan (1628–1688), the author of The Pilgrim's Progress, displayed symptoms of OCD (which had not yet been named). During the most severe period of his condition, he would mutter the same phrase over and over again to himself while rocking back and forth.^{[223]: 53–54} He later described his obsessions in his autobiography Grace Abounding to the Chief of Sinners, stating, "These things may seem ridiculous to others, even as ridiculous as they were in themselves, but to me they were the most tormenting cogitations."^{[223]: 53–54} He wrote two pamphlets advising those with similar anxieties.^{[223]: 217–218} In one of them, he warns against indulging in compulsions: "Have care of putting off your trouble of spirit in the wrong way: by promising to reform yourself and lead a new life, by your performances or duties".^{[223]: 217–218}

British poet, essayist and lexicographer Samuel Johnson (1709–1784) also had OCD. He had elaborate rituals for crossing the thresholds of doorways, and repeatedly walked up and down staircases counting the steps.^{[234][223]: 54–55} He would touch every post on the street as he walked past, only step in the middle of paving stones, and repeatedly perform tasks as though they had not been done properly the first time.^[223]: 55

The "Rat Man", real name Ernst Lanzer, a notable patient of Sigmund Freud, suffered from what was then called "obsessional neurosis". Lanzer's illness was characterised most famously by a pattern of distressing intrusive thoughts in which he feared that his father or a female friend would be subjected to a purported Chinese method of torture in which rats would be encouraged to gnaw their way out of a victim's body by a hot poker.^[235]

American aviator and filmmaker Howard Hughes is known to have had OCD, primarily an obsessive fear of germs and contamination.^[236] Friends of Hughes have also mentioned his obsession with minor flaws in clothing.^[237] This was conveyed in The Aviator (2004), a film biography of Hughes.^[238]

English singer-songwriter George Ezra has openly spoken about his life-long struggle with OCD, particularly primarily obsessional obsessive–compulsive disorder (Pure O).^[239]

World renowned Swedish climate activist Greta Thunberg is also known to have OCD, among other mental health conditions.^[240]

American actor James Spader has also spoken about his OCD. In 2014, when interviewed for Rolling Stone he said: "I'm obsessive-compulsive. I have very, very strong obsessive-compulsive issues. I'm very particular. ... It's very hard for me, you know? It makes you very addictive in behavior, because routine and ritual become entrenched. But in work, it manifests itself in obsessive attention to detail and fixation. It serves my work very well: Things don't slip by. But I'm not very easygoing.^[241]

In 2022 the president of Chile Gabriel Boric stated that he had OCD, saying: "I have an obsessive–compulsive disorder that's completely under control. Thank God I've been able to undergo treatment and it doesn't make me unable to carry out my responsibilities as the President of the Republic."^[242]

In a documentary released in 2023, David Beckham shared details about his compelling cleaning rituals, need for symmetry in the fridge, and the impact of OCD on his life.^[243]

Society and culture

Art, entertainment and media

Movies and television shows may portray idealized or incomplete representations of disorders such as OCD.

• The play and film adaptations of The Odd Couple based around the character of Felix, who shows some of the common symptoms of OCD.^[247]
• In the film As Good as It Gets (1997), actor Jack Nicholson portrays a man with OCD who performs ritualistic behaviors that disrupt his life.^[248]
• The film Matchstick Men (2003) portrays a con man named Roy (Nicolas Cage) with OCD who opens and closes doors three times while counting aloud before he can walk through them.^[249]
• In the television series Monk (2002–2009), the titular character Adrian Monk fears both human contact and dirt.^[250][251]
• The one-man show The Life and Slimes of Marc Summers (2016), a stage adaptation of Marc Summers' 1999 memoir which recounts how OCD affected his entertainment career.^[252]
• In the novel Turtles All the Way Down (2017) by John Green, teenage main character Aza Holmes struggles with OCD that manifests as a fear of the human microbiome. Throughout the story, Aza repeatedly opens an unhealed callus on her finger to drain out what she believes are pathogens. The novel is based on Green's own experiences with OCD. He explained that Turtles All the Way Down is intended to show how "most people with chronic mental illnesses also live long, fulfilling lives".^[253]
• The British TV series
  primarily obsessional obsessive compulsive disorder.^[254]

External links

Wikimedia Commons has media related to Obsessive–compulsive disorder.

• Obsessive–compulsive disorder at
  Curlie
• National Institute Of Mental Health
• American Psychiatric Association
• APA Division 12 treatment page for obsessive-compulsive disorder
• Davis LJ (2008). Obsession: A History. University of Chicago Press.
  ISBN 978-0-226-13782-7
  .