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Health and Disease

Obsessive-Compulsive Disorder (OCD): More Than Being Obsessively Neat and Tidy

Many mental illnesses are misconstrued by the media, and Obsessive-Compulsive Disorder, or OCD, is not an exception. While you may think of OCD as being obsessively neat and tidy, the fact is that it’s much more than that.

Abstract

Obsessive-Compulsive Disorder (OCD) is the fourth most common psychiatric illness (Fitzgerald). According to the Anxiety and Depression Association of America, 1 in 40 adults and 1 in 100 children in the U.S. are affected by OCD. OCD is a two-part mental disorder beginning with an obsession over certain thoughts and leading to the repetition of certain actions in a continuous cycle that impairs daily life. The process begins with obsessive thoughts (obsessions) that cause anxiety and lead to the individual repeating a behavior (compulsions). This could look like visualizing the spread of germs contaminating one’s hands, leading to excessive hand washing. Following through with compulsions only grants temporary relief from anxiety before the individual encounters another OCD trigger. However, if the individual does not follow through with the compulsion, it could result in anxiety and panic attacks. Both the obsessions and compulsions are involuntary. 

Types of OCD

OCD has many faces, and while every case is different, a person’s OCD commonly falls into one of these five categories.

  1. Checking

Checking is when someone with OCD “makes sure” of something, whether that’s if they left the stove on, if they turned off the bathroom lights, if they locked the front door, etc. It’s accompanied by fears of a dreadful event, such as the person’s home burning down or the death of someone close to them or even themselves (“Types of OCD”). The anxiety disorder side of OCD is what fuels this fear. The individual must check if they forgot their wallet; otherwise, their two-year old niece will be diagnosed with an incurable disease. These thought processes and the resulting compulsions—in this case, checking for a wallet—commonly impede the person’s daily life. It can result in someone being unable to leave their house until they check (and then check again), causing delays in a person’s day that they cannot do anything about.

  1. Contamination / Mental Contamination

The obsessions of someone with contamination related OCD is tied to a fear of harm to themselves or a loved one. It is also associated with a fear of germs and dirt. People with contamination OCD often avoid objects, places, or other people in fear of contamination through germs, dirt, etc. They may avoid public spaces, door knobs, shaking hands, among other things. Compulsions may be repeatedly washing hands until they’re raw, brushing teeth, showering, or laundering clothes immediately after returning home. They follow through with these compulsions to ensure that they don’t become ill or cause others to become ill (“Types of OCD”).

In addition, there is also a mental side to contamination related OCD. It is similar to physical contamination with the exception that people with this subtype of OCD perceive the contamination as happening internally, inside their body. They also feel the urge to clean out the contaminants, which in this case are negative thoughts or things they’ve heard, instead of the usual germs or debris. Similar to contamination OCD, they do this by showering and washing (“Types of OCD”). The key difference between contamination and mental contamination OCD is the presence of a physical object versus a human. The source of germs and dirt in contamination OCD is a physical object. However, the “germs and dirt” of mental contamination OCD—aka the negative things they’ve heard—originates from another human.

  1. Hoarding

Hoarding is not unique to OCD; it can be a mental disorder on its own or a symptom of another mental illness such as OCD or OCPD (“Hoarding: The Basics”). Hoarding is when someone is unwilling to discard certain possessions and, instead, feels the need to save them, resulting in an excessive accumulation of clutter that impairs their daily life. That need to save possessions can be for a number of reasons, and, in some cases, is linked to OCD and anxiety. For instance, some people with hoarding OCD believe that items that touch the floor are contaminated; therefore, no one should touch these items else they also become contaminated (“OCD Symptoms: OCD-Related Hoarding”). These obsessive thoughts are similar to those of someone with contamination related OCD. This thought process renders the person physically and mentally unable to dispose of the item, leading to excessive accumulation as the cycle continues.

  1. Rumination and Intrusive Thoughts

Both rumination and intrusive thoughts in OCD revolve around certain thoughts in an individual’s head. In the context of OCD, rumination is when an individual spends an excessive amount of time focusing on a question or thought. They can be focusing on a religious or philosophical topic such as life and death. However, they don’t arrive at a conclusion that satisfies them, leaving them to ponder for excessive amounts of time (“Types of OCD”).

For someone with OCD, intrusive thoughts are when disturbing thoughts reappear over and over in an individual’s mind. These thoughts are involuntary, and someone with OCD may begin believing these thoughts. Anxiety stems from the fear that they may act on the repugnant thoughts or impulses. These thoughts may be related to violence, sexual harm, relationships, etc. An example of an intrusive thought would be obsessing over the thought of harming other people with kitchen knives or other sharp objects, and the compulsion would be locking away those objects so as not to harm anyone (“Types of OCD”). The individual may question why they are having these thoughts or be consumed by the thought that they have already performed the violent action (even though they haven’t).

  1. Symmetry

People with symmetry-related OCD feel uncomfortable when objects are not aligned symmetrically or if an action isn’t done symmetrically. They become fixated on the positions of objects—such as books or clothes—and cannot move on until those objects are arranged in the “right” way (“Types of OCD”). People with OCD can also feel this way about certain actions; they have to perform an action on both sides or any number of sides to maintain balance and symmetry. For example, if someone with symmetry-related OCD scratches the left side of their face, they must scratch the right side to avoid a feeling of discomfort (Fitzgerald). This can be tied to a fear of harm to the person themself or someone close to them, but it can also just be to avoid the unease that they experience before satisfying a compulsion.

Causes

Symptoms of OCD commonly begin to appear in the pre-adolescent and early adulthood stages of life. The most common age range in which people start to experience the symptoms of OCD is between the ages of 10 and 24, but OCD can start at any age (Fitzgerald). The causes behind OCD are not crystal clear, but they may be linked to biological, genetic, and environmental factors. 

Cases of OCD have been linked to family in many ways. For instance, immediate family members of a person with OCD have a 25% chance of also developing the disorder (Ford-Martin). This means that the parents, siblings, and children of someone with OCD have increased chances of also having OCD, hinting that the disorder is somehow connected to family lines. This pattern may be a result of learning from and watching the behaviors of a family member with OCD (“Obsessive-compulsive disorder (OCD)” [NCH Healthcare System]). Part of the answer may also lie in genetics. Some twin studies have revealed that identical twins—twins that come from the same egg and therefore share all of their genes—are more likely to both develop OCD than fraternal twins. Genetics is not the only determiner though, as the rate for both identical twins exhibiting OCD is not 100% (Fitzgerald)

Some suggest that abnormal brain activity that differs from those without a mental illness or disorder may also be responsible for the obsessions and compulsions of OCD. Researchers have found that the orbital cortex of the brain is hyperactive in people with OCD, which may be responsible for the feelings of “alarm” that push people toward fulfilling compulsions (Ford-Martin). Abnormally low levels of serotonin in the brain may also play a role in OCD, as serotonin aids in communication between the frontal lobe and other parts of the brain that are connected to OCD compulsions (Ford-Martin).

Diagnosis

OCD can only be diagnosed by a mental health professional such as a psychiatrist or psychologist. It is usually done through an interview-like process in which a series of questions are asked to identify if the core aspects of OCD are present and therefore warrants a diagnosis. Examples of questions that a professional may ask are if the patient frequently cleans, if the patient checks things a lot, if the patient is bothered by thoughts they can’t rid themselves of, etc. Professionals take into account the effect of the symptoms on the patient’s life, whether the symptoms are time-consuming (taking up more than an hour each day), cause distress, impede function in daily life, etc. (“Diagnosing OCD”). One commonly used assessment is the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), which has five questions each for obsessions and compulsions; the Y-BOCS assesses the factors mentioned above (Fitzgerald).

Treatment

OCD is usually treated with cognitive-behavioral therapy (CBT) and medications.

Cognitive-behavioral therapy is a type of psychotherapy that has proven to be effective in treating certain mental illnesses. More specifically, the technique of exposure and response prevention (ERP) is the most effective in treating OCD; it helps reduce symptoms in 75%-80% of OCD patients (Fitzgerald). In ERP, the patient and therapist create a list of the patient’s obsessions and compulsions, starting with something mild and getting more extreme—these tasks look different for every patient based on their OCD. The idea is to expose the patient to OCD-triggers without having them give into compulsions. Patients start at a mild level where they will be able to tolerate not giving in to a compulsion. With each CBT session, the patient moves up the list with more difficult, OCD-inducing tasks. The tasks are repeated, and with each exposure, the anxiety associated with an obsession is reduced until the patient finds it manageable. One example of ERP is if a patient with contamination OCD is tasked with touching contaminated objects with increasing time between when they make contact and when they’re allowed to wash their hands (or give in to their compulsion).

OCD can also be treated by medication that increases levels of serotonin (selective serotonin reuptake inhibitors or SSRIs). These are fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram, and escitalopram. Clomipramine and venlafaxine are antidepressants that may also be prescribed for OCD patients; risperidone and haloperidol are antipsychotics that are an option for severe cases of OCD (Ford-Martin).

The last resort for OCD patients that don’t respond to CBT or medication is brain surgery. The operation removes a part of the brain called the “cingulate cortex” (Ford-Martin). The surgery is beneficial to 30% of OCD patients who receive it, resulting in lessened symptoms (Fitzgerald).

Conclusion

Obsessive-Compulsive Disorder is a mental disorder that significantly interferes with the daily lives of sufferers through a series of obsessions and compulsions; it is much more than the media’s portrayal of OCD being obsessively neat or tidy. OCD can look different for every patient, and the exact cause of the disorder hasn’t been determined. However, treatment through CBT and medication can help lessen symptoms, and it is important that people with OCD are not misunderstood and seek the professional help they need.

Michelle Li, Youth Medical Journal 2020

References

“Diagnosing OCD.” OCD-UK, http://www.ocduk.org/ocd/diagnosing-ocd/. Accessed 28 Sept. 2020.

Fitzgerald, Jane A., et al. “Obsessive-compulsive and Related Disorders.” The Gale Encyclopedia of Mental Health, edited by Brigham Narins, 4th ed., vol. 3, Gale, 2019, pp. 1149-56. Gale Health and Wellness, link.gale.com/apps/doc/CX2491200351/HWRC?u=mlin_m_newtnsh&sid=HWRC&xid=5cfaa5d0. Accessed 28 Sept. 2020.

Ford-Martin, Paula, and Lisa C. DeShantz-Cook. “Obsessive–Compulsive Disorder.” The Gale Encyclopedia of Alternative Medicine, edited by Deirdre S. Hiam, 5th ed., vol. 4, Gale, 2020, pp. 1942-45. Gale Health and Wellness, link.gale.com/apps/doc/CX7947800639/HWRC?u=mlin_m_newtnsh&sid=HWRC&xid=492d0698. Accessed 28 Sept. 2020.

“Hoarding: The Basics.” Anxiety and Depression Association of America, ADAA, adaa.org/understanding-anxiety/obsessive-compulsive-disorder-ocd/hoarding-basics. Accessed 23 Sept. 2020.

“Obsessive Compulsive Disorder.” Georgia Behavioral Health Professionals, http://www.mygbhp.com/condition/obsessive-compulsive-disorder/. Accessed 28 Sept. 2020.

“Obsessive-compulsive Disorder.” National Alliance on Mental Illness, http://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Obsessive-compulsive-Disorder. Accessed 28 Sept. 2020.

“Obsessive-Compulsive Disorder.” National Institute of Mental Health, http://www.nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd/index.shtml. Accessed 28 Sept. 2020.

“Obsessive-Compulsive Disorder (OCD).” Anxiety and Depression Association of America, ADAA, adaa.org/understanding-anxiety/obsessive-compulsive-disorder-ocd. Accessed 24 Sept. 2020.

“Obsessive-compulsive disorder (OCD).” NCH Healthcare System, http://www.nchmd.org/education/mayo-health-library/details/CON-20199571. Accessed 23 Sept. 2020.

“OCD Symptoms: OCD-Related Hoarding.” BeyondOCD.org, beyondocd.org/information-for-individuals/symptoms/ocd-related-hoarding. Accessed 28 Sept. 2020.

“Types of OCD.” OCD-UK, http://www.ocduk.org/ocd/types/. Accessed 27 Sept. 2020.

“What Is Obsessive-Compulsive Disorder?” American Psychiatric Association, http://www.psychiatry.org/patients-families/ocd/what-is-obsessive-compulsive-disorder. Accessed 28 Sept. 2020.

By Michelle Li

Michelle Li is a high school junior in Massachusetts. She hopes to pursue medicine in the future and is especially interested in pediatrics.

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