Obsessive-Compulsive Disorder (OCD)

Obsessions and compulsions

Obsessions are repeated, unwanted thoughts, images or urges that cause anxiety, disgust or a feeling that something is "not right". People with OCD usually recognize that these thoughts are excessive, but cannot simply dismiss them.

Compulsions are behaviors or mental acts done to reduce that distress or prevent a feared event. They bring brief relief, which reinforces the cycle and makes obsessions stronger over time.

Compulsions are not always visible. Mental compulsions, such as silently repeating phrases, praying, counting or reviewing memories, are common.

Intrusive thoughts

Almost everyone has occasional strange or disturbing thoughts. In OCD, the person reacts to these thoughts with intense alarm, attaches great meaning to them, and tries hard to neutralize them. Having violent or taboo intrusive thoughts in OCD does not mean a person wants to act on them; these thoughts are distressing precisely because they go against the person's values.

Causes and risk factors

• Genetics: OCD runs in families, especially early-onset OCD.
• Brain circuits: differences in communication between the frontal cortex and deeper brain structures (the basal ganglia).
• Stressful or traumatic life events can trigger or worsen symptoms.
• Pregnancy and the postpartum period: a known time of onset or worsening.
• PANDAS/PANS: in some children, a sudden onset of OCD symptoms after a strep or other infection is thought to be immune-related. This is an area of ongoing research.

Related conditions

OCD often occurs with depression, generalized anxiety disorder, tic disorders and Tourette syndrome, and ADHD. Related "obsessive-compulsive spectrum" conditions include body dysmorphic disorder, hoarding disorder, trichotillomania (hair pulling) and skin-picking disorder. Illness anxiety disorder shares some features.

OCD in children

Children may not recognize their thoughts as excessive. Signs include long bedtime or bathroom rituals, repeated questions for reassurance, distress if routines are changed, redoing homework, and avoiding touching certain things. Parents often get pulled into rituals. Early treatment with ERP adapted for children is very effective.

Diagnosis

A primary care doctor, psychologist or psychiatrist diagnoses OCD through a clinical interview. Questionnaires such as the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) measure severity. The diagnosis requires obsessions, compulsions or both that are time-consuming (over an hour a day) or cause significant distress or impairment, and are not better explained by another condition or substance.

Treatment

Exposure and response prevention (ERP)

ERP is a type of cognitive behavioral therapy and the most effective psychological treatment. With a therapist, you gradually face feared situations or thoughts (exposure) while resisting compulsions (response prevention). Anxiety rises and then falls without the ritual, and the brain learns that the feared outcome does not happen or can be tolerated. Typical courses involve 12 to 20 sessions, plus practice between sessions.

Medicines

• SSRIs (selective serotonin reuptake inhibitors) such as fluoxetine, fluvoxamine, sertraline and paroxetine are first-line. OCD often needs higher doses than depression, and benefits may take 8 to 12 weeks.
• Clomipramine, an older antidepressant, is effective but has more side effects.
• Augmentation: for partial response, adding a low dose of certain antipsychotics or other medicines under specialist care.

Combining ERP and medicines is often best for moderate to severe OCD.

Severe and treatment-resistant OCD

Options include intensive outpatient or residential ERP programs, transcranial magnetic stimulation (deep TMS is FDA-cleared for OCD), and, rarely, deep brain stimulation.

Living with OCD

• learn about OCD and how reassurance-seeking feeds it
• family members can support by not participating in rituals, with guidance from the therapist
• look after sleep, exercise and stress
• connect with support organizations such as the International OCD Foundation

Outlook

OCD is often long-term, with symptoms that wax and wane, but most people improve significantly with ERP and medicines. Many achieve good control and full lives.

Frequently asked questions

What are the main symptoms of OCD?

OCD involves obsessions, which are unwanted, distressing thoughts, images or urges, and compulsions, which are repetitive behaviors or mental acts done to reduce anxiety. Common examples include fears of contamination with excessive washing, and doubts about safety with repeated checking.

What are the types of OCD?

OCD is usually described by themes: contamination and cleaning, harm and checking, symmetry and ordering, unwanted taboo thoughts with mental rituals, and hoarding-like behaviors. Many people have more than one theme, and themes can change over time.

Can OCD go away on its own?

OCD rarely disappears without treatment, though symptoms can fluctuate with stress. With exposure and response prevention therapy and medicines, most people experience significant, lasting improvement.

Do intrusive thoughts mean I want to act on them?

No. In OCD, intrusive thoughts about harm or taboo topics are unwanted and distressing because they conflict with your values. People with OCD are not more likely to act on them. Therapy helps you respond to these thoughts without fear.

What is the best treatment for OCD?

Exposure and response prevention, a form of cognitive behavioral therapy, is the most effective therapy. SSRI medicines are the first-line medicines. Many people do best with both, especially for moderate to severe OCD.