Obsessive-compulsive disorder (OCD) features a pattern of unwanted thoughts and fears (obsessions) that leads one to do repetitive behaviours (compulsions). These obsessions and compulsions interfere with daily activities and cause significant distress.
A person may try to ignore or stop these obsessions, but that only increases her/his distress and anxiety. Ultimately, she/he feels driven to perform compulsive acts to try to ease her/his stress. Despite efforts to ignore or get rid of bothersome thoughts or urges, they keep coming back. This leads to more ritualistic behaviour — the vicious cycle of OCD.
Signs and Symptoms
People with OCD may have symptoms of obsessions, compulsions, or both. These symptoms can interfere with all aspects of life, such as work, school, and personal relationships.
Obsessions are repeated thoughts, urges, or mental images that cause anxiety.
Common symptoms include:
- Fear of germs or contamination
- Unwanted forbidden or taboo thoughts involving sex, religion, or harm
- Aggressive thoughts towards others or self
- Having things symmetrical or in a perfect order
Compulsions are repetitive behaviours that a person with OCD feels the urge to do in response to an obsessive thought.
Common compulsions include:
- Excessive cleaning and/or handwashing
- Ordering and arranging things in a particular, precise way
- Repeatedly checking on things, such as repeatedly checking to see if the door is locked or that the oven is off.
- Compulsive counting
Not all rituals or habits are compulsions. Everyone double-checks things sometimes.
But a person with OCD generally:
- Can’t control his or her thoughts or behaviours, even when those thoughts or behaviours are recognized as excessive.
- Spends at least 1 hour a day on these thoughts or behaviours.
- Doesn’t get pleasure when performing the behaviours or rituals but may feel brief relief from the anxiety the thoughts cause.
- Experiences significant problems in their daily life due to these thoughts or behaviours
Some individuals with OCD also have a tic disorder. Motor tics are sudden, brief, repetitive movements, such as eye blinking and other eye movements, facial grimacing, shoulder shrugging, and head or shoulder jerking. Common vocal tics include repetitive throat-clearing, sniffing, or grunting sounds.
Symptoms may come and go, ease over time, or worsen. People with OCD may try to help themselves by avoiding situations that trigger their obsessions, or they may use alcohol or drugs to calm themselves. Although most adults with OCD recognize that what they are doing doesn’t make sense, some adults and most children may not realize that their behaviour is out of the ordinary. Parents or teachers typically recognize OCD symptoms in children.
OCD usually begins in the teen or young adult years, but it can start in childhood. Symptoms usually begin gradually and tend to vary in severity throughout life. The types of obsessions and compulsions that one experiences can also change over time. Symptoms generally worsen when a person experiences greater stress. OCD, usually considered a lifelong disorder, can have mild to moderate symptoms or be so severe and time-consuming that it becomes disabling.
Twin and family studies have shown that people with first-degree relatives (such as a parent, sibling, or child) who have OCD are at a higher risk for developing OCD themselves. The risk is higher if the first-degree relative developed OCD as a child or teen. Ongoing research continues to explore the connection between genetics and OCD and may help improve OCD diagnosis and treatment.
Brain Structure and Functioning
Imaging studies have shown differences in the frontal cortex and subcortical structures of the brain in patients with OCD. There appears to be a connection between OCD symptoms and abnormalities in certain areas of the brain, but that connection is not clear. Research is still underway. Understanding the causes will help determine specific, personalized treatments to treat OCD.
An association between childhood trauma and obsessive-compulsive symptoms has been reported in some studies. More research is needed to understand this relationship better.
In some cases, children may develop OCD or OCD symptoms following a streptococcal infection—this is called Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS).
Steps to help diagnose obsessive-compulsive disorder may include:
- Psychological evaluation – This includes discussing your thoughts, feelings, symptoms, and behaviour patterns to determine if you have obsessions or compulsive behaviours that interfere with your quality of life. With your permission, this may include talking to your family or friends.
- Diagnostic criteria for OCD – Your doctor may use criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.
- Physical exam – This may be done to help rule out other problems that could be causing your symptoms and to check for any related complications.
It’s sometimes difficult to diagnose OCD because symptoms can be like those of obsessive-compulsive personality disorder, anxiety disorders, depression, schizophrenia, or other mental health disorders. And it’s possible to have both OCD and another mental health disorder. Work with your doctor so that you can get the appropriate diagnosis and treatment.
Obsessive-compulsive disorder treatment may not result in a cure, but it can help bring symptoms under control so that they don’t rule your daily life. Depending on the severity of OCD, some people may need long-term, ongoing, or more intensive treatment.
Sometimes people with OCD also have other mental disorders, such as anxiety, depression, and body dysmorphic disorder, a disorder in which someone mistakenly believes that a part of their body is abnormal. It is important to consider these other disorders when making decisions about treatment.
The two main treatments for OCD are psychotherapy and medications. Often, treatment is most effective with a combination of these.
Psychotherapy can be an effective treatment for adults and children with OCD. Research shows that certain types of psychotherapy, including cognitive behaviour therapy (CBT) and other related therapies (e.g., habit reversal training) can be as effective as medication for many individuals.
Research also shows that a type of CBT called Exposure and Response Prevention (EX/RP)—spending time in the very situation that triggers compulsions (e.g., touching dirty objects) but then being prevented from undertaking the usual resulting compulsion (e.g., handwashing)—is effective in reducing compulsive behaviours in OCD, even in people who did not respond well to SRI medication.
As with most mental disorders, treatment is usually personalized and might begin with either medication or psychotherapy or with a combination of both. For many patients, EX/RP is the add-on treatment of choice when SRIs or SSRIs medication does not effectively treat OCD symptoms or vice versa for individuals who begin treatment with psychotherapy.
Certain psychiatric medications can help control the obsessions and compulsions of OCD. Most commonly, antidepressants are tried first.
However, your doctor may prescribe other antidepressants and psychiatric medications.
Sometimes, psychotherapy and medications aren’t effective enough to control OCD symptoms. In treatment-resistant cases, other options may be offered:
- Intensive outpatient and residential treatment programs – Comprehensive treatment programs that emphasize ERP therapy principles may be helpful for people with OCD who struggle with being able to function because of the severity of their symptoms. These programs typically last several weeks.
- Deep brain stimulation (DBS) – DBS is approved by the FDA to treat OCD in adults age 18 years and older who don’t respond to traditional treatment approaches. DBS involves implanting electrodes within certain areas of your brain. These electrodes produce electrical impulses that may help regulate abnormal impulses.
- Transcranial magnetic stimulation (TMS) – The FDA approved a specific device (BrainsWay Deep Transcranial Magnetic Stimulation) to treat OCD in adults ages 22 to 68 years, when traditional treatment approaches have not been effective. TMS is a noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of OCD. During a TMS session, an electromagnetic coil is placed against your scalp near your forehead. The electromagnet delivers a magnetic pulse that stimulates nerve cells in your brain.