OCD

What is obsessive-compulsive disorder (OCD)?

Obsessive-compulsive disorder (OCD) is a condition in which you have frequent unwanted thoughts and
sensations (obsessions) that cause you to perform repetitive behaviors (compulsions). The repetitive
behaviors can significantly interfere with social interactions and performing daily tasks.
OCD is usually a life-long (chronic) condition, but symptoms can come and go over time.
Everyone experiences obsessions and compulsions at some point. For example, it’s common to occasionally
double-check the stove or the locks. People also often use the phrases “obsessing” and “obsessed” very
casually in everyday conversations. But OCD is more extreme. It can take up hours of a person’s day. It gets
in the way of normal life and activities. Obsessions in OCD are unwanted, and people with OCD don’t enjoy
performing compulsive behaviors.

Who does OCD affect?

OCD can affect anyone. The average age of onset is 19 years. About 50% of people with OCD begin to have
symptoms in childhood and adolescence.
It’s rare for someone to develop OCD after the age of 40.

How common is obsessive-compulsive disorder (OCD)?

Obsessive-compulsive disorder is relatively common. It affects 1.6% to 2.3% of the general U.S. population.

What are the symptoms of OCD?

The main symptoms of OCD are obsessions and compulsions that interfere with normal activities. For
example, symptoms may often prevent you from getting to work on time. Or you may have trouble getting
ready for bed in a reasonable amount of time.
You may know that these symptoms are problematic, but you can’t stop them. Symptoms of OCD may come
and go, ease over time or worsen over time.
If you or your child have symptoms of OCD that interfere with your/their daily life, you should talk to a
healthcare provider.

Obsessions in OCD
In OCD, obsessions are unwanted, intrusive thoughts or mental images that cause intense anxiety. People
with OCD can’t control these thoughts. Most people with OCD realize that these thoughts are illogical or
irrational.
Common examples include:
 Fear of coming into contact with perceived contaminated substances, such as germs or dirt.
 Fear of causing harm to yourself or someone else because you’re not careful enough or you’re going
to act on a violent impulse.
 Unwanted thoughts or mental images related to sex.
 Fear of making a mistake.
 Excessive concern with morality (“right or wrong”).
 Feelings of doubt or disgust.
 Need for order, neatness, symmetry or perfection.
 Need for constant reassurance.

Compulsions in OCD
In OCD, compulsions are repetitive actions that you feel like you have to do to ease or get rid of the
obsessions.
People with OCD don’t want to perform these compulsive behaviors and don’t get pleasure from them. But
they feel like they have to perform them or their anxiety will get worse. Compulsions only help temporarily,
though. The obsessions soon come back, triggering a return to the compulsions.
Compulsions are time-consuming and get in the way of important activities that you value. They don’t have
to match the content of your obsessions.

Examples include:
 Arranging things in a very specific way, such as items on your dresser.
 Bathing, cleaning or washing your hands over and over.
 Collecting or hoarding items that have no personal or financial value.
 Repeatedly checking things, such as locks, switches and doors.
 Constantly checking that you haven’t caused someone harm.
 Constantly seeking reassurance.
 Rituals related to numbers, such as counting, doing a task a specific amount of times, or excessively
preferring or avoiding certain numbers.
 Saying certain words or prayers while doing unrelated tasks.
Compulsions can also include avoiding situations that trigger obsessions. One example is refusing to shake
hands or touch objects that other people touch a lot, like doorknobs.

What causes OCD?

Researchers don’t know what exactly causes OCD. But they think several factors contribute to its
development, including:
 Genetics: Studies show that people who have a first-degree relative (biological parent or sibling)
with OCD are at a higher risk for developing the condition. The risk increases if the relative
developed OCD as a child or teen.
 Brain changes: Imaging studies have shown differences in the frontal cortex and subcortical
structures of the brain in people who have OCD. OCD is also associated with other neurological
conditions that affect similar areas of your brain, including Parkinson’s disease, Tourette’s
syndrome and epilepsy.
 PANDAS syndrome: PANDAS is short for “pediatric autoimmune neuropsychiatric disorders
associated with streptococcal infections.” It describes a group of conditions that can affect children
who have had strep infections, such as strep throat or scarlet fever. OCD is one of these conditions.
 Childhood trauma: Some studies show an association between childhood trauma, such as abuse or
neglect, and the development of OCD.
DSM-5 Diagnostic Criteria for Obsessive-Compulsive Disorder (OCD)
According to the DSM-5, the essential features of OCD are the presence of obsessions, compulsions, or
both. These are defined as follows:
A. Presence of Obsessions, Compulsions, or Both:
Obsessions are defined by:
 Recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted,
and that in most individuals cause marked anxiety or distress.
 The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them
with some other thought or action (i.e., by performing a compulsion).

Compulsions are defined by:

 Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting,
repeating words silently) that the individual feels driven to perform in response to an obsession or
according to rules that must be applied rigidly.
 The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing
some dreaded event or situation; however, these behaviors or mental acts are not connected in a
realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

B. The obsessions or compulsions are time-consuming (e.g., take more than one hour per day) or cause
clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g.,
a drug of abuse or medication) or another medical condition.
D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive
worries as in GAD, preoccupation with appearance in BDD, difficulty discarding items in hoarding disorder,
etc.).
Specify if:
 With good or fair insight
 With poor insight
 With absent insight/delusional beliefs
Specify if:
 Tic-related (the individual has a current or past history of a tic disorder)

Comorbidity of OCD
OCD frequently co-occurs with a number of other psychiatric disorders, both internalizing and externalizing.
Common comorbidities include:
 Anxiety Disorders- Generalized Anxiety Disorder, Panic Disorder, Social Anxiety Disorder, and
Specific Phobias often co-occur. The anxiety may precede or follow the onset of OCD.
 Depressive Disorders- Major Depressive Disorder is one of the most common comorbidities.
Depression may result from the chronic stress and impairment associated with OCD or co-develop
independently.
 Tic Disorders- Tourette’s Disorder and other chronic tic disorders are commonly comorbid, particularly
in early-onset OCD cases and in males.
 Obsessive-Compulsive and Related Disorders- Body Dysmorphic Disorder, Hoarding Disorder,
Trichotillomania (hair-pulling disorder), and Excoriation (skin-picking) Disorder may co-occur.
 Neurodevelopmental Disorders-Particularly in children and adolescents, there may be comorbidity
with ADHD or Autism Spectrum Disorder.
 Eating Disorders and Substance Use Disorders- Although less common, some individuals with OCD
may also struggle with eating disorders like Anorexia Nervosa or engage in substance use as a
maladaptive coping strategy.
Developmental Course of OCD
 Age of Onset- OCD typically begins in childhood, adolescence, or early adulthood. The average age of
onset is around 19 years, with 25% of cases starting by age 14. Onset before age 10 is more common in
males and is often associated with tic disorders.
 Course- The course of OCD can be variable. Some individuals have episodic symptoms, while others
experience chronic and persistent symptoms with waxing and waning in severity. Without treatment,
OCD tends to become chronic and may cause significant impairment. However, with appropriate
treatment (especially CBT and/or SSRIs), substantial improvement is possible.
 Childhood-Onset OCD- May be more likely to involve family history of OCD, greater prevalence in
males, and association with tic disorders. Insight may be limited in children, which can affect diagnosis
and treatment engagement.
 Insight and Severity- Insight may vary across the lifespan. Children and individuals with poor insight
may believe their obsessive thoughts are true, making it more difficult to recognize the disorder.
 Predictors of Poor Prognosis- Early onset, comorbid personality disorders, poor insight, longer
duration of illness before treatment, and severe compulsions tend to be associated with worse outcomes.

Differential Diagnosis of OCD

Several psychiatric and medical conditions can resemble OCD and should be carefully ruled out:
 Generalized Anxiety Disorder (GAD)- In GAD, worries are usually about real-life concerns and
are more pervasive and less intrusive. OCD obsessions are intrusive and often ego-dystonic
(inconsistent with the individual’s values or self-concept).
 Major Depressive Disorder-Ruminations in depression are typically mood-congruent and not
usually associated with compulsive behaviors or attempts to neutralize the thoughts.
 Body Dysmorphic Disorder (BDD)- In BDD, preoccupations are specifically about perceived
defects in physical appearance. In OCD, the obsessions are broader and more varied in content.
 Hoarding Disorder- While hoarding was once considered a subtype of OCD, it is now a distinct
diagnosis. In hoarding disorder, the distress is associated with discarding items, whereas in OCD,
hoarding may be done as a compulsion related to obsessional fears (e.g., fear of contamination).
 Trichotillomania and Excoriation Disorder- These involve repetitive behaviors but are not
typically performed in response to obsessions. The behaviors are more often driven by urges or
tension relief.
 Tic Disorders- Tics are sudden, rapid, recurrent motor movements or vocalizations. Compulsions,
by contrast, are more complex, intentional, and often follow obsessions.
 Psychotic Disorders (e.g., Schizophrenia)- Obsessions in OCD are intrusive and distressing but are
typically recognized as irrational by the individual (unless poor insight is present). In contrast,
delusions in psychosis are usually held with strong conviction.
 Eating Disorders- Rituals around eating may resemble compulsions but are motivated by body
image concerns rather than irrational obsessions unrelated to food or weight.
 Autism Spectrum Disorder (ASD)- Repetitive behaviors in ASD are typically related to restricted
interests and are not accompanied by obsessions or anxiety to the same extent as in OCD.

Diagnosis and Tests

How is OCD diagnosed?
There’s no test for OCD. A healthcare provider makes the diagnosis after asking you about your symptoms
and medical and mental health history. Providers use criteria explained in the Diagnostic and Statistical
Manual of Mental Disorders, 5th Edition (DSM-V) to diagnose OCD.

Management and Treatment

How is OCD treated?
The most common treatment plan for OCD involves psychotherapy (talk therapy) and medication.
If this treatment doesn’t help your OCD symptoms and your symptoms are severe, your provider may
recommend transcranial magnetic stimulation (TMS).

Psychotherapy for OCD

Psychotherapy, also called talk therapy, is a term for a variety of treatment techniques that aim to help you
identify and change unhealthy emotions, thoughts and behaviors. You work with a mental health
professional, such as a psychologist.
There are several types of psychotherapy. The most common and effective forms for treating OCD include:
 Cognitive behavioral therapy (CBT): During CBT, a therapist will help you examine and
understand your thoughts and emotions. Over several sessions, CBT can help alter harmful thoughts
and stop negative habits, perhaps replacing them with healthier ways to cope.
 Exposure and response prevention (ERP): ERP is a type of CBT. During ERP, a therapist exposes
you to your feared situations or images and has you resist the urge to perform a compulsion. For
example, your therapist may ask you to touch dirty objects but then stop you from washing your
hands. By staying in a feared situation without anything negative happening, you learn that your
anxious thoughts are just thoughts and not necessarily reality.
 Acceptance and commitment therapy (ACT): ACT helps you learn to accept obsessive thoughts as
just thoughts, taking the power away from them. An ACT therapist will help you learn to live a
meaningful life despite your OCD symptoms.
Mindfulness techniques such as meditation and relaxation can also help with symptoms.

Medication for OCD

Medications called serotonin reuptake inhibitors (SRIs), selective SRIs (SSRIs) and tricyclic antidepressants
may help treat OCD.
Healthcare providers most often recommend SSRIs for OCD and prescribe them at much higher doses than
they do for anxiety or depression. U.S. Food and Drug Administration (FDA)-approved SSRIs include:
 Fluoxetine.
 Fluvoxamine.
 Paroxetine.
 Sertraline.
It may take up to eight to 12 weeks for these medications to start working.

Outlook / Prognosis
What is the prognosis of OCD?
The prognosis (outlook) of OCD can vary. OCD is often a lifelong condition that can wax and wane.
People with OCD who receive appropriate treatment often experience increased quality of life and improved
social, school and/or work functioning.
If you don’t receive treatment, the cycle of obsessions and compulsions is more difficult to break and treat,
as structural changes in your brain take place. Because of this, it’s key to seek medical care as soon as
possible if you or your child experience symptoms.