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Obsessive-compulsive disorder (OCD) is comprised of obsessions, compulsions, or both. Obsessions are intrusive thoughts, urges, or images, and compulsions form as a result of these obsessions. The Diagnostic and Statistical Manual of Mental Disorders ed. 5 (DSM-V) groups OCD with other obsessive and compulsive disorders. These include body dysmorphia, hoarding, trichotillomania (hair-pulling), excoriation (skin-picking), and OCD related to medications or medical conditions. All of the related disorders contain an obsessive and/or compulsive component, although their exact nature varies. These disorders are grouped together because they have strong clinical relations; meaning they seem to stem from the same thought processes.

The average onset of OCD is at 19 years old. It is less common for children to develop OCD, but those who do normally see symptoms by age 14. Similarly, onset after age 35 is uncommon. Symptoms of OCD normally appear gradually. That is, most people will not find a complete switch in behavior from one day to the other.

As with any disorder, OCD has varying severity. In severe cases, it can be debilitating and restrict social and professional development. Some people find themselves unable to leave their house or interact with others due to their obsessions and compulsions. Treatment is a necessity to overcome OCD; without it, the remissions rates are exceptionally low, at around 20%.

WHAT ARE THE SYMPTOMS OF OCD?

OCD symptoms can be divided into obsessions and compulsions. Obsessions are defined by unwanted and intrusive thoughts, images, or urges. They normally induce distress or anxiety, which will cause the individual to neutralize the obsessions with another thought or action (a compulsion).

Compulsions are defined as repetitive behaviors or mental acts that the individual feels obligated to perform due to an obsession. They are meant to reduce anxiety or prevent a traumatic event. However, compulsions have no real connection to what they are meant to prevent and are very excessive. Below are examples of both compulsions and obsessions.

OBSESSIONS:

• Organizing
• Symmetry
• Checking
• Forbidden thoughts (ex. Aggressive, sexual, or religious obsessions)
• Counting
• Harm
• Orderliness
• Cleaning

COMPULSIONS:

• Turning a light switch on and off repeatedly
• Repeating a word, phrase, or prayer
• Locking and unlocking the door for a set amount of times before leaving the house
• Hand washing until skin becomes raw or burned
• Repeatedly taking showers or washing clothes

After identifying the presence of obsessions and/or compulsions, OCD is diagnosed based on the following criteria:

• The obsessions and compulsions are time-consuming, cause significant distress to the individual, or cause social, professional, or other impairment
• The obsessive-compulsive symptoms are not attributed to substance use or another medical condition
• The symptoms are not better explained by another mental disorder

ARE THERE GENDER DIFFERENCES IN OCD?

The DSM-V outlines some differences between men and women with OCD. Males tend to develop OCD more frequently than women. Males also have a higher tendency of a co-occurring tic disorder than women. (A tic is defined as a sudden, rapid and recurring movement or vocalization. This can be eye blinking, throat clearing, or a repeated word.)

There also seems to be a gender difference in symptom focus. Women’s obsessions and compulsions focus more around cleaning, while men’s focus more on symmetry or forbidden thoughts. Women with OCD may experience peripartum symptoms as well; for instance, forbidden or aggressive thoughts surrounding the baby that may result in infant avoidance.

WHAT DISORDERS CAN CO-OCCUR WITH OCD?

Disorders that occur together are called co-morbid disorders. The most common co-morbid disorders for OCD are anxiety and mood disorders. These include panic disorders, generalized anxiety, specific phobias, major depressive disorder, bipolar depression. For those who develop a co-morbid anxiety disorder, the anxiety is normally present before the OCD. The reverse is true for depression; OCD is often diagnosed prior to a mood disorder diagnosis.

Trichotillomania (hair-pulling), excoriation (skin-picking), body dysmorphic disorder and eating disorders occur more frequently in people with OCD than those without. This is attributed to the ease at which additional obsessions or compulsions may be developed when another is already present. People with schizophrenia, schizoaffective disorder, and Tourette’s disorder also have a higher comorbidity rate for OCD.

HOW IS OCD TREATED?

OCD treatment generally revolves around therapy and medication. The most common type of therapy treatment is CBT; more specifically, a subset of CBT called Exposure and Response Prevention (ERP). There are two parts to ERP. The first, exposure, refers to bringing forth anything that triggers your obsessions. These include thoughts, situations, actions, or feelings that cause you to become anxious. The second part, response, refers to refraining from compulsive behaviors once the obsessions have started. This is all done with the guidance of a professional, but eventually, you will learn the skills to begin ERP on your own. The end goal of ERP is for patients to become less anxious upon refraining from compulsions.

Selective serotonin reuptake inhibitors (SSRI) are the most common types of medication used in OCD treatment. Most people recognize SSRI’s as depression medication, but they are very effective in the treatment of other disorders. Medication treatment is often used in conjunction with therapy; especially because ERP can lead to an increase in anxiety during the exposure phase. Fluoxetine (Prozac), clomipramine (Anafranil), and sertraline (Zoloft) are the frequently prescribed medication to treat OCD.

In rare cases, and as a last resort, neurosurgery may be performed on patients with OCD. There are two types of surgeries; both target areas of the brain thought to involve obsessive and compulsive thoughts. In an anterior cingulotomy, a neurosurgeon will take a probe and burn away part of the anterior cingulate, a part of the brain that houses impulse control and decision. An anterior capsulotomy is similar to the prior surgery but is focused on the anterior limb of the internal capsule. Patients who do not respond to therapy or medication may benefit from surgery, but there are times where the risks outweigh the benefits.

Other forms of neurosurgery include deep brain stimulation and gamma ventral capsulotomy. Deep brain stimulation (DBS) has been used since the 1980’s to treat movement disorders, like Parkinson’s, and is now being used to treat a variety of other disorders, like OCD. The procedure involves placing electrodes and a device called an implantable neurostimulator under the skin. The electrodes are placed on certain parts of the brain, and the implantable neurostimulator is placed somewhere nearby under the skin, usually around the collarbone. The neurosurgeon is then able to use a remote and a special computer to communicate with the implantable neurostimulator and send electrical impulses to the electrodes on the brain. These electrical impulses alter how the nearby neurons communicate and are what makes the treatment effective.

Gamma ventral capsulotomy, or gamma knife, is the least invasive procedure. There is no traditional surgery involved, and general anesthesia is not required. During a gamma knife procedure, the patients head will be placed in an instrument called a stereotactic frame and gamma rays will be passed through the skull to hit a specific part of the brain. An individual gamma-ray will pass through the brain harmlessly; but when many rays intersect, they are able to damage brain tissue. Using high-tech 3D imaging and diagnostic tools, your neurosurgeon will find the appropriate place for the gamma rays to converge. Only the area of the brain hit by the gamma rays will be treated; the tissue in surrounding areas will not be harmed.

If you find yourself suffering from symptoms of OCD, New Milford Counseling Center can help you receive the treatment you need. Feel free to contact us by phone at 860-740-2228, or by email at info@nmccct.com.