• HOW COMMON IS OBSESSIVE COMPULSIVE DISORDER (OCD)?

For many years, mental health professionals thought of OCD as a rare disease because only a small minority of their patients had the condition. The disorder often went unrecognized because many of those afflicted with OCD, in efforts to keep their repetitive thoughts and behaviours secret, failed to seek treatment. This led to underestimates of the number of people with the illness. However, a survey conducted in the early 1980s by the National Institute of Mental Health (NIMH)--the Federal agency that supports research nationwide on the brain, mental illnesses, and mental health--provided new knowledge about the prevalence of OCD.

The NIMH survey showed that OCD affects more than 2 percent of the population, meaning that OCD is more common than such severe mental illnesses as schizophrenia, bipolar disorder, or panic disorder. OCD strikes people of all ethnic groups. Males and females are equally affected. The social and economic costs of OCD were estimated to be $8.4 billion in 1990 (DuPont et al, 1994).

Although OCD symptoms typically begin during the teenage years or early adulthood, recent research shows that some children develop the illness at earlier ages, even during the preschool years. Studies indicate that at least one-third of cases of OCD in adults began in childhood. Suffering from OCD during early stages of a child's development can cause severe problems for the child. It is important that the child receive evaluation and treatment by a knowledgeable clinician to prevent the child from missing important opportunities because of this disorder.

• OBSESSIONS

These are unwanted ideas or impulses that repeatedly well up in the mind of the person with OCD. Persistent fears that harm may come to self or a loved one, an unreasonable concern with becoming contaminated, or an excessive need to do things correctly or perfectly, are common. Again and again, the individual experiences a disturbing thought, such as, "My hands may be contaminated--I must wash them"; "I may have left the gas on"; or "I am going to injure my child." These thoughts are intrusive, unpleasant, and produce a high degree of anxiety. Sometimes the obsessions are of a violent or a sexual nature, or concern illness.

• COMPULSIONS

In response to their obsessions, most people with OCD resort to repetitive behaviours called compulsions. The most common of these are washing and checking. Other compulsive behaviours include counting (often while performing another compulsive action such as hand washing), repeating, hoarding, and endlessly rearranging objects in an effort to keep them in precise alignment with each other. Mental problems, such as mentally repeating phrases, list making, or checking are also common. These behaviours generally are intended to ward off harm to the person with OCD or others. Some people with OCD have regimented rituals while others have rituals that are complex and changing. Performing rituals may give the person with OCD some relief from anxiety, but it is only temporary.

• INSIGHT

People with OCD show a range of insight into the senselessness of their obsessions. Often, especially when they are not actually having an obsession, they can recognize that their obsessions and compulsions are unrealistic. At other times they may be unsure about their fears or even believe strongly in their validity.

• RESISTANCE

Most people with OCD struggle to banish their unwanted, obsessive thoughts and to prevent themselves from engaging in compulsive behaviours. Many are able to keep their obsessive-compulsive symptoms under control during the hours when they are at work or attending school. But over the months or years, resistance may weaken, and when this happens, OCD may become so severe that time-consuming rituals take over the sufferers' lives, making it impossible for them to continue activities outside the home.

• SHAME AND SECRECY

OCD sufferers often attempt to hide their disorder rather than seek help. Often they are successful in concealing their obsessive-compulsive symptoms from friends and co-workers. An unfortunate consequence of this secrecy is that people with OCD usually do not receive professional help until years after the onset of their disease. By that time, they may have learned to work their lives--and family members' lives--around the rituals.

• LONG-LASTING SYMPTOMS

OCD tends to last for years, even decades. The symptoms may become less severe from time to time, and there may be long intervals when the symptoms are mild, but for most individuals with OCD, the symptoms are chronic.

• WHAT CAUSES OCD?

The old belief that OCD was the result of life experiences has been weakened before the growing evidence that biological factors are a primary contributor to the disorder. The fact that OCD patients respond well to specific medications that affect the neurotransmitter serotonin suggests the disorder has a neurobiological basis. For that reason, OCD is no longer attributed only to attitudes a patient learned in childhood--for example, an inordinate emphasis on cleanliness, or a belief that certain thoughts are dangerous or unacceptable. Instead, the search for causes now focuses on the interaction of neurobiological factors and environmental influences, as well as cognitive processes.

OCD is sometimes accompanied by depression, eating disorders, substance abuse disorder, a personality disorder, attention deficit disorder, or another of the anxiety disorders. Co-existing disorders can make OCD more difficult both to diagnose and to treat.

In an effort to identify specific biological factors that may be important in the onset or persistence of OCD, NIMH-supported investigators have used a device called the positron emission tomography (PET) scanner to study the brains of patients with OCD. Several groups of investigators have obtained findings from PET scans suggesting that OCD patients have patterns of brain activity that differ from those of people without mental illness or with some other mental illness. Brain-imaging studies of OCD showing abnormal neurochemical activity in regions known to play a role in certain neurological disorders suggest that these areas may be crucial in the origins of OCD.

There is also evidence that treatment with medications or behaviour therapy induce changes in the brain coincident with clinical improvement.

Recent preliminary studies of the brain using magnetic resonance imaging showed that the subjects with obsessive-compulsive disorder had significantly less white matter than did normal control subjects, suggesting a widely distributed brain abnormality in OCD. Understanding the significance of this finding will be further explored by functional neuroimaging and neuropsychological studies (Jenike et al, 1996).

Symptoms of OCD are seen in association with some other neurological disorders. There is an increased rate of OCD in people with Tourette's syndrome, an illness characterized by involuntary movements and vocalizations. Investigators are currently studying the hypothesis that a genetic relationship exists between OCD and the tic disorders.

Other illnesses that may be linked to OCD are Trichotillomania (the repeated urge to pull out scalp hair, eyelashes, eyebrows or other body hair), body dysmorphic disorder (excessive preoccupation with imaginary or exaggerated defects in appearance), and hypochondriasis (the fear of having--despite medical evaluation and reassurance--a serious disease). Genetic studies of OCD and other related conditions may enable scientists to pinpoint the molecular basis of these disorders.

Other theories about the causes of OCD focus on the interaction between behaviour and the environment and on beliefs and attitudes, as well as how information is processed. These behavioural and cognitive theories are not incompatible with biological explanations.

• DO I HAVE OCD?

A person with OCD has obsessive and compulsive behaviours that are extreme enough to interfere with everyday life. People with OCD should not be confused with a much larger group of individuals who are sometimes called "compulsive" because they hold themselves to a high standard of performance and are perfectionistic and very organized in their work and even in recreational activities. This type of "compulsiveness" often serves a valuable purpose, contributing to a person's self-esteem and success on the job. In that respect, it differs from the life-wrecking obsessions and rituals of the person with OCD.

• TREATMENT OF OCD; PROGRESS THROUGH RESEARCH

Clinical and animal research sponsored by NIMH and other scientific organizations has provided information leading to both pharmacologic and behavioural treatments that can benefit the person with OCD. One patient may benefit significantly from behaviour therapy, while another will benefit from pharmacotherapy. Some others may use both medication and behaviour therapy. Others may begin with medication to gain control over their symptoms and then continue with behaviour therapy. Which therapy to use should be decided by the individual patient in consultation with his or her therapist.

• PHARMACOTHERAPY

Clinical trials in recent years have shown that drugs that affect the neurotransmitter serotonin can significantly decrease the symptoms of OCD. The first of these serotonin reuptake inhibitors (SRIs) specifically approved for the use in the treatment of OCD was the tricyclic antidepressant Clomipramine (Anafranil). It was followed by other SRIs that are called "selective serotonin reuptake inhibitors" (SSRIs). Those that have been approved by the Food and Drug Administration for the treatment of OCD are Fluoxetine (Prozac and Lovan), Fluvoxamine (Luvox), and Paroxetine (Aropax). Another that has been studied in controlled clinical trials is Sertraline (Zoloft). Large studies have shown that more than three-quarters of patients are helped by these medications at least a little. And in more than half of patients, medications relieve symptoms of OCD by diminishing the frequency and intensity of the obsessions and compulsions.

Improvement usually takes at least three weeks or longer. If a patient does not respond well to one of these medications, or has unacceptable side effects, another SRI may give a better response. For patients who are only partially responsive to these medications, research is being conducted on the use of an SRI as the primary medication and one of a variety of medications as an additional drug (an augmenter).

Medications are of help in controlling the symptoms of OCD, but often, if the medication is discontinued, relapse will follow. Indeed, even after symptoms have subsided, most people will need to continue with medication indefinitely, perhaps with a lowered dosage.

• BEHAVIOUR THERAPY

Traditional psychotherapy, aimed at helping the patient develop insight into his or her problem, is generally not helpful for OCD. However, a specific behaviour therapy approach called "exposure and response prevention" is effective for many people with OCD. In this approach, the patient deliberately and voluntarily confronts the feared object or idea, either directly or by imagination. At the same time the patient is strongly encouraged to refrain from ritualizing, with support and structure provided by the therapist, and possibly by others whom the patient recruits for assistance.

For example, a compulsive hand washer may be encouraged to touch an object believed to be contaminated, and then urged to avoid washing for several hours until the anxiety provoked has greatly decreased. Treatment then proceeds on a step-by-step basis, guided by the patient's ability to tolerate the anxiety and control the rituals. As treatment progresses, most patients gradually experience less anxiety from the obsessive thoughts and are able to resist the compulsive urges.

Studies of behaviour therapy for OCD have found it to be a successful treatment for the majority of patients who complete it. For the treatment to be successful, it is important that the therapist be fully trained to provide this specific form of therapy. It is also helpful for the patient to be highly motivated and have a positive, determined attitude.

The positive effects of behaviour therapy endure once treatment has ended. A recent compilation of outcome studies indicated that, of more than 300 OCD patients who were treated by exposure and response prevention, an average of 76 percent still showed clinically significant relief from 3 months to 6 years after treatment (Foa & Kozak, 1996).

Another study has found that incorporating relapse-prevention components in the treatment program, including follow-up sessions after the intensive therapy, contributes to the maintenance of improvement (Hiss, Foa, and Kozak, 1994).

One study provides new evidence that cognitive-behavioral therapy may also prove effective for OCD. This variant of behaviour therapy emphasizes changing the OCD sufferer's beliefs and thinking patterns. Additional studies are required before the promise of cognitive-behavioral therapy can be adequately evaluated. The ongoing search for causes, together with research on treatment, promises to yield even more hope for people with OCD and their families.
How to Get Help for OCD

If you think that you have OCD, you should seek the help of a mental health professional. Family physicians, clinics, and health maintenance organizations may be able to provide treatment or make referrals to mental health centers and specialists. Also, the department of psychiatry at a major medical centre or the department of psychology at a university may have specialists who are knowledgeable about the treatment of OCD and are able to provide therapy or recommend another doctor in the area.

• WHAT THE FAMILY CAN DO TO HELP

OCD affects not only the sufferer but the whole family. The family often has a difficult time accepting the fact that the person with OCD cannot stop the distressing behaviour. Family members may show their anger and resentment, resulting in an increase in the OCD behaviour. Or, to keep the peace, they may assist in the rituals or give constant reassurance.

Education about OCD is important for the family. Families can learn specific ways to encourage the person with OCD to adhere fully to behaviour therapy and/or pharmacotherapy programs. Self-help books are often a good source of information. Some families seek the help of a family therapist who is trained in the field. Also, in the past few years, many families have joined one of the educational support groups that have been organized throughout the country.

• CONTINUING RESEARCH

Research into treatment for OCD is ongoing in several areas--ways of increasing availability of effective behaviour therapy; cognitive therapy; relapse prevention; methods of reducing medication in patients who have a history of being unable to tolerate medication, such as small, liquid doses of Fluoxetine or the use of intravenous Clomipramine; and neurosurgery, a new approach to treatment-refractory OCD. In the very few centers where neurosurgery has been performed as a clinical procedure, candidates are generally restricted to those who have failed to respond to conventional treatments, including behaviour therapy and pharmacotherapy.

In addition to research into treatment modalities, NIMH researchers are conducting studies into possible linkage of OCD to some autoimmune diseases (diseases in which infection-fighting cells, or antibodies, turn against the body, trying to destroy it). Other NIMH-supported studies compare behaviour therapy, pharmacotherapy, and a combination of both.

Anecdotal reports of the successful use of electroconvulsive therapy (ECT) in OCD have been published over the past several decades. Most often, the benefit from ECT has been short lived, and this treatment is now generally restricted to instances of treatment-resistant OCD accompanied by severe depression.
Obsessive-compulsive disorder is characterized by either obsessions or compulsions:


• OBSESSIONS AS DEFINED BY:

1.Recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
2.The thoughts, impulses, or images are not simply excessive worries about real-life problems
3.The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action
4.The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)

• COMPULSIONS AS DEFINED BY:

1.Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
2.The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive
--- AND: ---
At some point during the course of the disorder, the adult has recognized that the obsessions or compulsions are excessive or unreasonable (not applicable to children).

The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual social activities or relationships.

If another disorder is present, the content of the obsessions or compulsions is not restricted to it. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.


USEFUL WEB SITES FOR FURTHER INFORMATION

National Institute of Mental Health
www.nimh.nih.gov/

SANE Australia
www.sane.org/information/factsheets-podcasts

Royal Australian and New Zealand College of Psychiatrists
www.ranzcp.org/resources/clinical-practice-guidelines.html

The Royal College of Psychiatrists
www.rcpsych.ac.uk/

Internet Mental Health
www.mentalhealth.com/

Beyondblue Australia
www.beyondblue.org.au

Black Dog Institute
www.blackdoginstitute.org.au

Australian Psychological Society
www.psychology.org.au/

Mental Health in Multicultural Australia (MHiMA)
www.mhima.org.au