What are the symptoms of OCD?
OCD involves ongoing obsessions and compulsions that interfere with daily life. Obsessions are unwanted ideas, thoughts, impulses, or images cause anxiety or distress. Obsessions are usually in one or more of six areas including: aggression, contamination, sex, hoarding/saving, religion, and symmetry/exactness.
However, the content alone is not enough for an OCD diagnosis. In fact, nearly 90% of the general population experiences similar obsessions. What distinguishes OCD obsessions from non-clinical obsessions are the greater frequency, intensity, and discomfort. OCD sufferers attach much greater meaning and threat to these thoughts than most people. What separates OCD patients from people with a delusional or thought disorder is that they usually realize the obsessions are unrealistic and a product of their own minds. Only 4% of OCD patients believe with absolute certainty that their feared consequences will actually occur, and most realize that their reactions to the thoughts are excessive. OCD thoughts, impulses, or images are not simply excessive worries about real-life problems and are not consistent with the individual’s self-perception.
In addition to frequent obsessions, most individuals with OCD engage in actions, called compulsions or rituals, to reduce the anxiety from the obsessions. As in the case of obsessions, compulsions are also often categorized into six categories including: cleaning, checking, repeating, counting, ordering/arranging, and hoarding/collecting. The most common compulsion reported by people with OCD is checking. See the Table for other common obsessions and compulsions.
It is usually the case that at some point the compulsions were logically linked to the obsessions. For example, a person with a fear of contamination may resort to washing their hands excessively or use antibacterial gels to the point of skin irritation. Another frequent compulsion is excessive checking. Interestingly, these patients often report memory problems driving them to re-check tasks. However, research suggests this low confidence in memory is not associated with actual memory impairment.
Who gets OCD?
It is estimated that between 2 and 3 million people are suffering from OCD in the United States. The National Comorbidity Survey Replication (NCS-R) showed that about 1.6% of the United States population reported obsessive-compulsive disorder at some point in their lives, with 1% of the sample experiencing obsessive-compulsive disorder within the last year. The prevalence of OCD appears to be about the same among ethnic and national groups across the US and internationally. For example, a recent study of African Americans showed an OCD lifetime prevalence of 1.6%. Interestingly, while prevalence rates of OCD among African Americans were identical to the overall prevalence in the NCS-R, age of onset was later (about 32 years old), and use of mental health services was much lower, resulting in greater disability.
Unlike many other anxiety disorders, males and females get OCD in equal numbers. However, age of onset is often earlier in males (13-15) than females (20-24). Age of OCD onset can be as young as 2 years old but usually occurs in early adolescence or young adulthood.
What causes OCD?
The exact cause of OCD is uncertain. Some behavioral scientists believe that overprotective or unusually rigid childhood family relationships may be a factor, but there is not yet adequate research to support his theory. As is the case of several mental disorders, OCD often appears to coincide with major stressors. Approximately 60% of OCD cases follow a stressful experience, traumatic life experience, or pregnancy and childbirth. But there is increasing evidence that genetic and biological factors are significant causes of OCD as well. OCD tends to run in families, and OCD patients have been shown to have deficits of the brain chemical serotonin, which regulates our sense of emotional and psychological well-being. Brain scans of persons with OCD clearly show differences in brain circuit activity versus those without OCD. Most likely, persons with OCD are best understood as having inherited a genetic biological vulnerability to the disorder which may be triggered often during times of stress and transition such as a job change, going off to college, childbirth, or divorce.
Unfortunately, research suggests that without treatment the natural course of OCD is chronic. A notable exception is among some children with OCD, whose symptoms appear abruptly with the onset of strep or other infections. These OCD manifestations are known as pediatric autoimmune neuropsychiatric disorders or PANDAS. OCD symptoms in these cases decrease with treatment of the infection and may increase upon recurrence of infection.
Impact of OCD
OCD results in severe personal distress and interferes with employment, relationships, and the daily activities of living in adults, children, and adolescents. Between 80 and 100 percent of people with severe OCD report major difficulties at home (100%), work (80%), relationships (87%), and social life (87%). One study showed that 22% of treatment-seeking participants with OCD were unemployed compared to the 6% unemployment rate for the US general population at the time. Another study showed an even higher unemployment rate (40%) among patients with OCD. OCD patients are also overrepresented in health care populations. One survey showed that OCD patients saw dermatologists and cardiologists more often than the general public and even more than individuals with panic disorder or generalized anxiety. Such high medical use, unemployment, and lost productivity due to OCD cost the US economy billions of dollars each year. It is estimated that in 1990 the direct and indirect cost of OCD to the US economy was $8.4 billion. OCD is considered one the top ten causes of disability worldwide.
Individuals with OCD may suffer with obsessions and compulsions for up to 17 hours a day or more. Not surprisingly, this time commitment and distress often interferes with interpersonal relationships. Half of OCD sufferers report losing friends and a quarter say that OCD caused the end of an intimate relationship. This is consistent with other findings that about 60% of OCD patients report difficulty maintaining relationships. Celibacy rates are also higher in OCD populations even relative to other anxiety disorders, and approximately half of married patients with OCD report marital distress.
How is OCD diagnosed?
Assessment of OCD is usually accomplished through a series clinical interviews with an experienced OCD professional and OCD self-report measures. Here we only cover the most common assessment tools.
Yale-Brown Obsessive-Compulsive Scale
The most widely used test to measure OCD is the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). It is a semistructured interview that takes approximately 30 minutes to complete. The Y-BOCS consists of a checklist of obsessions and compulsions and a 10-item severity scale. The checklist is most often administered before treatment and helps in treatment planning. The obsessions are listed in the categories mentioned above including: aggressive, contamination, sexual, hoarding/saving, religious, symmetry or exactness, body focused, and miscellaneous. The compulsions list is organized in categories including: cleaning/washing, checking, repeating, counting, ordering/arranging, hoarding/collecting, and miscellaneous. The separate severity scale rates the time spent on obsessions and compulsions, how much they interfere with functioning, how much distress they cause, attempts to resist, and level of control. Items are rated on a 5-point scale ranging from 0 (no symptoms) to 4 (severe symptoms). The severity scale is usually administered before treatment and again periodically throughout treatment. The total score is calculated by adding items 1 through 10, yielding scores between 0 and 40. The Y-BOCS shows good reliability and validity. Scores above 16 may be considered in the clinical range and the average OCD patients is 21.9 (SD = 8). Scores for healthy people without OCD are quite low (on average less than 1). Try the Y-BOCS checklist online…
Obsessive-Compulsive Inventory-Revised (OCI-R)
The Obsessive-Compulsive Inventory-Revised (OCI-R) is an 18 item self-report measure of distress from obsessions and compulsions. The total score ranges between 0 and 72. The questionnaire also includes six subscales including: washing, checking, ordering, obsessing, hoarding, and neutralizing. The subscale scores range between 0 and 12. The OCI-R has shown good internal consistency, test-retest reliability, and discriminant validity.
Maudsley Obsessional Compulsive Inventory (MOC or MOCI)
The Maudsley Obsessional Compulsive Inventory (MOC or MOCI) contains 30 dichotomously scored (true/false) items that assess obsessive-compulsive symptoms in the areas of contamination fears and washing behaviors, checking, and worries. The MOC takes 5-minutes to complete and scores can range from 0 to 30. The means for OCD patients and student samples are 13.67 (SD = 6.0) and 6.32 (SD = 3.9) respectively. The reliability and validity are acceptable.
PADUA Inventory – Washington State University Revision (PI-WSUR)
The original Padua Inventory contained 60 items about obsessions and compulsions on a 5-point rating scale in four main areas: contamination fears, checking, impaired control over mental activities, and worries about losing control over one’s behaviors. Two revised versions of the scale have been published including the 41-item PI-R and the 39-item PI-WSUR. Reliability and validity for the scale are good to excellent. The mean total score for individuals with OCD is 54.9 (SD = 16.7). The scale takes approximately 10-minutes to complete.
OCD and other mental disorders
Comorbidity (having more than one mental disorder) among patients with OCD is more the rule than the exception. The most recent finding is that a full 90% of people with OCD have at least one additional psychiatric disorder. See table for lifetime comorbidity of OCD with other psychiatric disorders.
Anxiety disorders were the most common additional diagnosis (76%) followed by mood disorders (63%), impulse-control disorders (56%), and substance use disorders (39%). Eating disorders are also common among women with OCD. Ten percent of women with OCD have a history of anorexia. Likewise, 33% of women with bulimia have a history of OCD. Although effective treatment improves the quality of life among individuals with OCD, it is common for people with OCD to suffer many years before receiving adequate treatment. For example, one study showed OCD patients suffered for an average of 8 years before seeking treatment. Also, only a minority of patients (29%) receive treatment specifically for OCD.