Understanding and Learning to Cope with Obsessive Compulsive Disorder
What is Obsessive Compulsive Disorder?
Obsessive compulsive disorder is defined as a chronic, neuropsychiatric illness that can often be debilitating and cause considerable distress to the affected person. It is a complex anxiety disorder which affects approximately 2.3% of the population and manifests itself in a variety of ways, some of which can go unrecognized by those who are not directly affected by the disorder. Obsessive compulsive disorder (also known as OCD) has two main components which set it apart from other anxiety disorders: obsessions and compulsions. Obsessions are characterized as repeated thoughts, urges, or mental images that cause anxiety, while compulsions are repetitive tasks or behaviors that a person who has OCD feels the urge to do in response to their obsessive thoughts.
Generally speaking, OCD follows a fairly set pattern that is informally deemed “The OCD Cycle” for the purposes of this article. This cycle consists of obsessions, anxiety, compulsions, and relief. When an obsession arises, it is often what the person gives the most attention to until it is relieved. Because the obsession takes precedence over other things that are simultaneously occurring, the person is overwhelmed by the obsession and begins to feel anxious. In order to negate this anxiety, a person with OCD will perform a compulsion, and temporary relief will set in until the obsession reemerges.
“I am so OCD about having my clothes organized.”
Before talking about the main types of obsessive compulsive disorder, one issue must be clarified: being particular about cleanliness or organization and having OCD are not the same thing. It is all too common that the term “OCD” is misused by the general public. There is a significant difference between liking to have things neatly organized and keeping a house immaculately clean in order to avoid or resolve extreme anxiety. One key difference between “being so OCD” about something and actually having the neuropsychiatric disorder is that the obsessions and compulsions of a person who has the disorder severely impact quality of life. In fact, those affected by obsessive compulsive disorder often experience “distress and impairment in social, academic, and/or family functioning” as a result of the immense amount of time that performing compulsions to relieve obsessions can consume. There is little joy or true benefit that comes from performing compulsions, but not carrying out these actions can lead people with OCD to become anxious and upset. Differentiating OCD-driven behaviors from non-OCD-driven behaviors which seem to mimic OCD-driven behaviors is key because the behaviors which fall into the latter category do yield satisfaction and/or benefit and do not consume an individual’s life or cause distress if they are prolonged or not completed.
Types of OCD
Typically, when one thinks of OCD, they imagine a person who performs some of the more common compulsions such as checking certain items many more times than is logically necessary, frequent hand-washing, or organizing items to the extent of pristine perfection. Contrary to popular belief, not all forms of obsessive compulsive disorder focus on checking, washing, or organizing compulsions. While these tend to be some of the more visible symptoms associated with the disorder, there are several types of OCD which downplay or are missing these symptoms altogether.
1. Checking
Many people double- or even triple-check to make sure that things are done or that they were put in the correct place, but a person who falls into this category of OCD checks to the point of exhaustion. This need, or compulsion, to check things stems from an obsession, most commonly a fear of causing an undesirable effect such as damage to items or harm to other people. For checking, the OCD cycle mentioned before is often repeated multiple times, sometimes lasting for several hours before the person feels enough relief to stop checking.
2. [Mental] Contamination
Contamination as a type of obsessive compulsive disorder has two subtypes: physical and mental. The first of the two is what most people think of when they are asked to describe OCD symptoms, but oddly enough, physical contamination is the least prevalent of the main types of OCD. Physical contamination consists of an obsessive fear that something near the person is contaminated and/or that it may cause illness or the death of a loved one or to the person with the obsession. To counteract this obsession, people who fall into the physical contamination category generally have a compulsion associated with cleaning, washing, or otherwise avoiding situations in which they could become contaminated. Cleaning or washing compulsions are often carried out numerous times and are occasionally accompanied by additional rituals of repetitive cleaning until the person believes or feels that the object is clean, as opposed to someone without OCD who would wash or clean the object until they saw that it was clean. This cycle can be detrimental to a person’s physical health because they are constantly scrubbing and cleaning, which will negatively impact their skin and hands.
Mental contamination is a much lesser-known sub-type of contamination. It shares some similarities with physical contamination, but the main difference between this type of contamination and the traditional type is the source of anxiety. With physical contamination, the source of the obsessive-compulsive cycle is generally physical contact with inanimate objects. In mental contamination, however, the source is almost always other humans. In a study conducted at the University of Reading, UK, roughly 46% of participants stated that they experienced feeling dirty because of emotional violations such as degradation, betrayal, or abuse. Similar to physical contamination, people who experience mental contamination will engage in compulsive attempts to wash the internal uncleanliness away by showering or washing themselves until they feel that they are clean.
3. Intrusive Thoughts
In the context of obsessive compulsive disorder, intrusive thoughts are defined as thoughts that are repetitive, disturbing, and frequently appalling in nature. Because intrusive thoughts are repetitive in nature and are not voluntarily made by the person experiencing them, they can cause the person to become distressed, as they are horrified by the fact that they are able to produce such thoughts. While these thoughts can be graphic and potentially dangerous if acted upon, a person with obsessive compulsive disorder would most likely not act on them because they tend to go to great lengths to avoid them and to prevent them from happening.
There are several sub-types of intrusive thoughts, two of which are body focused obsessions (also known as sensorimotor OCD) and violent intrusive thoughts. The first of these sub-types is associated with a hyperawareness of a particular bodily sensation. This sub-type of OCD is not to be confused with body dysmorphic disorder (BDD), in which the person is obsessed with perceived faults in their bodies. The second of these sub-types is violent intrusive thoughts. These are characterized by obsessive fears of committing violent acts against loved ones or other people. Most people who experience this type of intrusive thought generally label themselves as bad people simply because they have had bad thoughts. They believe that because they are able to have these thoughts, they are also capable of acting upon them. Because of this, people with violent intrusive thoughts are often reluctant to open up to health professionals who may be able to help them for fear that these people will also label them as bad.
4. Symmetry and Orderliness
This type of obsessive compulsive disorder is characterized by the need to have everything symmetrical or ordered “just right” in order to prevent discomfort or, in some cases, harm. For some people, symmetry OCD can be characterized by the need to repeat every action that affects one side of their body on the other side. Samantha Pena, one person who falls into this category of OCD, was willing to hurt herself so severely for the sake of symmetry that she had to attend physiotherapy afterward. In the video below, Samantha discusses her life with OCD at a TEDx youth conference.
Neurobiology of Obsessive Compulsive Disorder
Although the pathophysiology of OCD is not yet fully understood, there has been evidence in the last few years suggesting that abnormalities in the fronto-cortico-striatal-thalamo-cortical (CSTC) circuitry caused by an imbalance of activity in opposing basal ganglia pathways are partially to blame for this disorder. A review published in the Indian Journal of Psychological Medicine in September 2016 revealed that there are four CSTC circuits that are suggested to play a role in OCD pathophysiology. These circuits include: (1) One involving projections from the sensorimotor cortex via the putamen, (2) one involving projections from the paralimbic cortex via the nucleus accumbens, (3) projections from the orbitofrontal cortex to the ventromedial caudate nucleus, and (4) projections from the dorsolateral prefrontal cortex (DLPFC) via the dorsolateral caudate nucleus. These circuits are thought to play a part in the manifestation of OCD because of their tendency to include two serial inhibitory signals. The same study published in the Indian Journal of Psychological Medicine states: “[The] orbitofrontal and cingulate cortex send robust excitatory (glutaminergic) projections to [the] ventral striatum and [the] caudate nucleus. The caudate nucleus sends GABA-ergic projections to [the] globus pallidus which, in turn, sends inhibitory projections to [the] thalamus. Two serial inhibitory outputs suggest the possibility of [a] reverberating circuit. This abnormality is thought of as inherent to the function neruopathology of OCD.”
Along with defects in the CSTC circuits discussed above, it is suggested that people with OCD may have abnormal metabolic activity in several areas of the brain. Those with increased metabolic rates that are mentioned in the September 2016 review are the orbitofrontal cortex and parts of the prefrontal cortex, which are part of the CSTC circuit.
Overall, the authors of the 2016 review conclude that various neuroimaging studies broadly implicate four regions in the pathophysiology of OCD symptoms: the orbitofrontal cortex, the cingulate cortex, the thalamus, and the head of the caudate nucleus. These four regions form a circuit that is hyperactive in OCD, and this circuit’s dysfunction plays an important role in implicit processing deficits and intrusive symptoms.
Coping with Obsessive Compulsive Disorder
There are several ways in which OCD can be managed. As with most anxiety disorders, obsessive compulsive disorder is commonly treated with medications, cognitive behavioral therapy, or a combination of the two.
1. Medication
Obsessive compulsive disorder has a highly selective response to serotonergic medications. That is to say, OCD can be picky with what medication it prefers. The initial line of pharmacotherapy for obsessive compulsive disorder is treatment with a medication from the SSRI family, particularly fluoxetine (Prozac), fluvoxamine (Luvox), paroxeine (Paxil), and sertraline (Zoloft). These four drugs have been approved by the FDA for the treatment of OCD, but citalopram (Celexa) and escitalopram (Lexapro), medications often used to treat anxiety, are also commonly used. Because of the nature of OCD, higher doses of these medications are generally needed in order for them to be an effective treatment than would be necessary if they were being used to treat their respective main targets.
If SSRIs on their own aren’t effective in treating OCD symptoms, the next line of treatment is to add an antipsychotic, a class of medication which typically focuses on altering dopamine levels in the brain. According to a review published in the journal Dialogues in Clinical Neuroscience in 2010, when antipsychotics such as risperidone, haloperidol, olanzapine, and quetiapine are used in combination with an SSRI, they are more effective in treatment-resistant cases of OCD than SSRI pharmacotherapy alone.
2. Cognitive Behavioral Therapy
Cognitive behavioral therapy (or CBT) has proven to be beneficial for those who live with obsessive compulsive disorder, even if they are not subsequently taking medication. One particular type of therapy that has been shown to help negate symptoms of OCD is graded exposure and response therapy, or ERT. The first step of ERT is to recognize the link among obsessions, compulsions, and anxiety. In a person who is diagnosed with OCD, compulsions are repeated to reduce the anxiety caused by the obsessions, but the more these compulsions are performed, the stronger the need to continue the OCD cycle will be. With the help of ERT, people with OCD begin to understand what happens when they resist a compulsion. If done correctly and with a compulsion that is not too strong to begin with, resisting a compulsion over a period of hours will result in reduced anxiety surrounding the obsession as well as a reduced urge to give in to the compulsion. ERT is often a long and uncomfortable process, but it eventually helps many people work out their obsessions and compulsions until there is no more anxiety surrounding them.
