Obsessive-Compulsive Disorder: Symptoms, Causes, and Management

Obsessive-Compulsive Disorder is a pervasive disorder characterized by uncontrollable and recurrent thoughts termed as obsessions along with repetitive behaviours referred to as compulsions to combat anxiety-provoking thoughts. This causes significant distress to the individual who is affected along with disruptions in their occupational and personal lives. OCD impacts 1-3% of the global population and the lifetime prevalence of OCD among Indian citizens as reported by the National Health Portal of India is 2-3%, lower than most of the countries. The prevalence of OCD is 0.6% in India.

OCD-Related Disorders

Another new class of disorders in DSM-5 brings together several disorders that share several characteristics, such as driven repetitive behaviours and some other symptoms, and a similar course and treatment response. In DSM-IV, these disorders were categorized separately. Along with obsessive-compulsive disorder (OCD), which was previously classified as an anxiety disorder, this group now includes hoarding disorder, body dysmorphic disorder (formerly listed under somatoform disorders), and trichotillomania (previously classified under impulse control disorders). Additionally, excoriation (skin picking) disorder is a new addition to this category. 

• Excoriation: pulling out skin
• Trichotillomania: excessive hair pulling or eating
• Body dysmorphic disorder: preoccupation with one’s body
• Hoarding disorder: collecting things or difficulty in discarding belongings that have no financial or personal value

History of Obsessive-Compulsive Disorder

The current terminology of OCD described in our manuals was contributed by Karl Friedrich Otto Westphal (1833–1890) in 1877 as Zwangsvorstellung which was of German origin. OCD was historically perceived as stemming from demonic possession or moral shortcomings. Esquirol (1772-1840) described OCD as a form of monomania in his 1838 textbook. He wavered between viewing it as a disorder of the intellect and of the will. Much of Freud’s ideas on obsessive neurosis were shaped in 1909, when he shed a detailed psychoanalytic treatment of a 29-year-old man who, since childhood, had developed compulsive impulses (Zwangsvorstellung) in response to aggressive and sexual obsessions.

This concept encompassed intellectualization and isolation, strategies aimed at diminishing the emotional effects of unacceptable thoughts and impulses. It also included the process of “undoing,” where compulsions were carried out to counteract these troubling ideas, as well as reaction formation, where individuals developed traits that were contrary to their feared impulses.

Obsessions

Obsessions are recurrent and intrusive images, urges, fears or thoughts that trigger anxiety-inducing symptoms. It can be characterized as involuntary, irrational and perturbing in context to the affected individual. Individuals recognize that these thoughts are irrational and cannot be comprehended through simple logic or reasoning. People attempt to manage their obsessions by engaging in repetitive behaviours known as compulsions, which temporarily alleviate the anxiety or distress caused by unwanted intrusive thoughts. Some types of obsessions are:

• Unpleasant sexual urges 
• Thoughts of cleanliness or disgust
• Concern about morality- right or wrong
• Preoccupied with existential themes like death
• Fear of causing accidents, fire or terrible events
• Conscious about bodily sensations- breathing or blinking
• Fear of harming oneself or others and losing one’s control
• Thoughts about one’s sexual orientation or gender identity 
• Fear of forgetting things or losing things-problem in discarding things
• Discomfort when belongings are not in symmetry or perfect order and balance 
• Blasphemous sexual images of God or unpleasant thoughts related to one’s religion
• Constant worry about unlocked doors and locks or electrical appliances switched on
• Fear of contamination or bring in the vicinity of dirt or germs or body fluids like urine or feces

Compulsions

Compulsions are ritualistic behaviours or actions done in response to obsessions or unpleasant cognitions that lead to a feeling of anxiety or distress. Engaging in these activities alleviates the distress or anxiety caused by the irrational, recurrent thoughts, urges or fears.

The individual does not derive pleasure from these compulsions but rather provides temporary relief from the anxious thoughts. An individual with a fear of contamination may compulsively wash and clean to alleviate the anxiety triggered by their irrational fear, while someone with safety-related anxiety might repeatedly check whether doors are securely locked or appliances are switched off.

However, when a person resists performing these ritualistic compulsive behaviours to relieve their distress, it can heighten their anxiety, leading to negative effects on their physical, social, and psychological well-being. Some of the common compulsions include:

• Praying or chanting
• Compulsive counting in certain patterns
• Performing daily tasks in a strict routine
• Repetitively narrating the same phrases or words
• Seeking assurance or approval if they have harmed anyone
• Engaging in excessive cleaning, brushing, grooming and bathing
• Hoarding things even if they have no purpose or personal value
• Preoccupied with numbers, patterns or following a rigid routine
• Repeated checking or reassurance – doors, locks or electrical appliances
• Frequently washing hands throughout the day to avoid contamination or germs
• Perfection – placing things in the correct sequence to maintain order and balance

Compulsions vs Addiction

Addiction is characterized by a persistent desire to use a psychoactive substance or indulge in a behaviour that provides natural rewards, despite its harmful consequences. When an individual consumes a specific substance or participates in an activity, it stimulates the brain’s reward system, leading to feelings of pleasure. Compulsions are repetitive behaviours that individuals get involved in to relieve themselves of the anxiety caused by obsessions – unwanted and irrational thoughts. The individual recognizes the irrationality of their thoughts or fears but feels helpless, leading them to engage in certain behaviours to alleviate the anxiety.

Compulsions vs Rituals

All repetitive behaviours are not rituals. Following daily routines like brushing, defecating taking a bath or chanting religious prayers are some repetitive activities, people perform every day but they are not compulsions as they are not conducted in response to alleviate anxiety, instead, they are executed for positive functioning of daily life. Similarly, a person working in a library who arranges and organizes the books on the shelves for hours daily is not diagnosed with OCD (Obsessive-Compulsive Disorder). 

Obsessions vs Being Obsessed or Preoccupied with Urges/Thoughts

Obsessing is a terminology we use in our everyday life. It does not lead to disruption in our day-to-day activities – occupational or personal. An individual can be obsessed with a song they heard on social media, although despite this obsession one is capable of performing their routine tasks without any hindrance.

Thoughts about the death of loved ones, concerns for personal safety, or fears of getting sick are common worries we all experience, but we typically move past them and continue with our daily functioning tasks. However, a person having OCD (Obsessive-Compulsive Disorder) might face difficulty carrying out daily tasks despite these obsessions. Moreover, the frequency of these irrational thoughts is much higher in amount in people affected with OCD (Obsessive-Compulsive Disorder). 

What causes OCD?

• Childhood trauma, neglect and isolation might predispose an individual to this disorder.
• Evolutionary preparedness: Displacement behaviours like grooming or nesting under frustration are carried out by animals under high arousal situations which have a close correlation to OCD.
• Genetic predisposition: First-degree relatives of individuals having OCD or Tourette’s syndrome might be prone to contracting OCD. Additionally, the disorder typically begins in childhood and is marked by chronic motor tics, resembling Tourette’s syndrome. Twin studies have also demonstrated that OCD has a high degree of heritability.
• Neurotransmitter abnormalities: Increased serotonin activity makes the brain structures sensitive to serotonin which might contribute to the pathology of OCD. Although antidepressants like clomipramine or fluoxetine used in the treatment of OCD increase serotonin levels its long-term effects reduce the serotonin levels and are visible after 6-12 weeks of the drug administration.
• Two process theories of avoidance learning: Neutral stimuli like shaking hands or touching a doorknob when becomes associated with frightening thoughts of being exposed to germs or contamination elicit anxiety through classical conditioning. To reduce that anxiety one engages in activities like washing hands or sanitizing which further gets reinforced and is performed even when other anxiety-provoking stimulus comes in the vicinity. 
• The orbital frontal cortex handles primary urges related to sex, aggression, and hygiene. These urges are subsequently processed by the caudate nucleus and transmitted to the thalamus. When the cortico-basal-ganglionic-thalamic circuit is disrupted, it can result in repetitive behaviours or compulsions. Even though individuals might be aware of the irrational nature of their thoughts or fears, they often feel powerless, leading them to engage in specific behaviours to alleviate the anxiety driven by their obsessions. 
• Children affected by Streptococcus pyogenes are reported to develop disruptions in their personality, behaviour and movement. PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infections) affects children with scarlet fever or strep throat. Studies have displayed that OCD (Obsessive-Compulsive Disorder) have been linked to PANDAS syndrome. Moreover, if the child is diagnosed with PANDAS, they are more likely to be prone or have contracted OCD (Obsessive-Compulsive Disorder).
• Cognitive factors: Individuals affected with OCD often try to suppress their obsessive thoughts which reinforces the same. These individuals have an inflated sense of responsibility for the harm they may have caused which motivates them to engage in compulsive behaviors to reduce their likelihood of harmful acts. Moreover, they have an attentional bias towards disturbing material relevant to their obsessions. Additionally, memory deficits, inhibitory motor responses and reduced ability to block irrelevant information lead to repetitive behaviours.

Negative symptoms of Obsessive-Compulsive Disorder

• Low self-esteem
• Suicide ideation
• Social isolation
• Negative affect on education
• Poor interpersonal relationships
• Legal consequences of risky and aggressive behaviours
• Unemployment due to impairment in cognitive abilities like judgment and reasoning leading to financial crisis
• Health-related issues like chronic fatigue due to performing repetitive activities or dermatitis due to compulsive hand-washing

Difference between OCD and OCPD:

OCPD or Obsessive-Compulsive Personality Disorder is a cluster C personality disorder that is characterized by anxiety and fearfulness. Individuals affected with this disorder have excessive concern with order, rules and trivial details. They tend to be perfectionists, lacking emotional expressiveness and warmth. They are devoted to work and productivity and exclude leisure activities.

Whereas, OCD or Obsessive-Compulsive Disorder is characterized by obsessions (irrational thoughts) and compulsions (repetitive behaviours) which cause hindrance to daily functioning both occupationally and personally. In OCD the behaviours fluctuate according to the anxiety-provoking stimulus whereas, in OCPD the behavioural patterns are pervasive and persistent.

Diagnosis of Obsessive-Compulsive Disorder

Clinicians assess OCD in an individual by the amount of time spent, interference or distress caused, efforts used to resist and level of control over obsessive thoughts and compulsive behaviours. Various scales that are available to assess obsessive-compulsive behaviours, including self-report measures that evaluate the duration, intensity, and frequency of symptoms are: 

• The Vancouver Obsessional Compulsive Inventory is a 55-item scale with six subscales that measure cognitive and behavioural aspects of OCD: contamination, checking, obsessions, hoarding, just right, and indecisiveness.
• The Obsessive-Compulsive Inventory is a 42-item self-report tool that measures the frequency of OCD symptoms and the distress caused by them over the past month. The total possible score is 168, and a score of 42 or higher indicates the presence of OCD.
• The Obsessive-Compulsive Trait Core Dimensions Questionnaire is a 20-item self-report tool designed to assess compulsive behaviours in OCD, focusing on harm avoidance and incompleteness. It features two subscales, each with 10 items rated on a 5-point Likert scale.
• The Contamination Cognitions Scale (CCS) evaluates the overestimation of threat from potentially contaminated objects. It includes 13 common items associated with germs (such as door handles and toilet seats) and asks clients to rate the likelihood and severity of contamination if they were to touch each object without washing their hands.
• The Obsessional Beliefs Questionnaire is an 87-item, 7-point Likert scale designed to assess beliefs associated with obsessive thinking. It includes subscales covering cognitive domains relevant to OCD, such as control over thoughts (14 items), importance of thoughts (14 items), responsibility (16 items), intolerance of uncertainty (13 items), and perfectionism (16 items).
• The Yale-Brown Obsessive-Compulsive Scale is a 10-item, 5-point Likert scale that assesses the severity and frequency of obsessions and compulsions experienced in a day. It includes two subscales—obsessions and compulsions—with scores ranging from zero (no symptoms) to 40 (extreme symptoms). This scale evaluates severity by considering time spent, interference, distress, resistance, and control over obsessive-compulsive symptoms.

Treatment of Obsessive-Compulsive Disorder

• Anxiety management techniques: like box-breathing, muscle relaxation, visualization, yoga, meditation and grounding techniques help control one’s anxiety.
• DBS (Deep Brain Stimulation): This is an invasive procedure that involves placing an electrode in the brain structure which activates the neighbouring neural circuits. It is typically used when both medication and psychotherapy prove ineffective for the individual.
• Medications: SSRIs (Selective Serotonin Reuptake Inhibitors) like fluoxetine, fluvoxamine, paroxetine and sertraline – initially increase serotonin levels but if administered for 6-12 weeks reduce the same. SSRIs are commonly used to treat depression, but in the case of OCD, a higher dosage is often required.
• TMS (Transcranial Magnetic Stimulation): Repetitive transcranial magnetic stimulation is provided to the orbitofrontal cortex and prefrontal cortex – areas that are depicted as overstimulated in OCD patients. This technique is a non-invasive therapy that uses magnetic pulses to repeatedly stimulate targeted areas of the brain with low intensity.
• Cognitive-Behavioural Therapy: CBT helps change maladaptive behaviour and thoughts into rational ones with the help of logical reanalysis. Cognitive Behavioral Therapy (CBT) helps individuals challenge negative thoughts, understand how they influence emotions and behaviours, and replace self-destructive patterns with healthier ones.
• ERP (Exposure and response prevention): During the treatment course, the individual is exposed to their anxiety-provoking stimulus, which initially increases their distress and anxiety. However, when coupled with response prevention where clinicians advise the patients to not engage in their compulsive behaviours to alleviate the anxiety, the OCD client realizes the irrationality of their thoughts, which makes them cope with their obsessions or anxiety-causing stimuli without indulging in their compulsive behaviours, eventually leading to decreased anxiety. 

Self-Care Tips

• Engaging in physical activity or exercising, eating a healthy diet and ensuring quality sleep time.
• Support groups help individuals with OCD cope with the stigma of the disorder and empower themselves.
• Education: One should have adequate information about their treatment plan and the trajectory of their recovery. 
• Catering to one’s needs: People affected with OCD might have other psychological issues like anxiety, depression, substance-use disorders or suicide ideation. One should be aware of its symptoms and consult a clinician.
• Vigilance: A person affected with OCD should look out for triggering stimuli that might activate their compulsive behaviours or provoke anxious thoughts and urges. OCD disrupts an individual’s occupational and personal life, they should acknowledge and appreciate their success as well as anticipate setbacks as it’s an ongoing journey.