Obsessive Compulsive Disorder (OCD)

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Signs and Symptoms

Early indications of OCD can be seen in children and teenagers. The disease usually begins gradually and worsens with age. Symptoms of OCD can be mild or severe. Some people have only obsessive thoughts without compulsive behavior.

Most people, especially children, do not perceive obsessions and compulsive behaviors as irrational or ridiculous. For example, children do not mind avoiding cracks in the sidewalk. And though adults might brood over their problems, they usually do so because their problems and solutions are meaningful to adult life. But all people with OCD realize that in addition to being excessive and disruptive, their obsessions and compulsions are excessive, compulsive, and unreasonable.

This realization is characteristic of the disease and is accounted for in the American Psychiatric Association's (APA) criteria for diagnosis. Moreover, it distinguishes OCD from obsessive-compulsive personality disorder (OCPD), once thought to be closely related to OCD. People with OCPD are usually undisturbed by their obsessive-compulsive behavior.

People with OCD often feel embarrassed and ashamed of their illness and rarely reveal their symptoms, if they can help it. Many people hide their symptoms from family and friends for years. These people recognize the absurdity of their behaviors, but without intervention, they often learn to live with them.

Typical Obsessions
Obsessions are recurrent, intrusive, and unwanted thoughts, impulses, or images that cause significant anxiety. At first the obsession may be experienced as relatively benign. Over time, the person associates it with fear and disabling anxiety. Obsessions fall into the following common thematic categories:

• Fear of contamination with dirt, germs, or poisons
• Fear of having a serious illness
• Fear that one's actions hurt other people or cause bad things to happen
• Inability to discard useless items (hoarding)
• Inappropriate sexual and aggressive thoughts and images
• Need for symmetry, order, or exactness

People who fear contamination may obsess about shaking hands or touching public doorknobs. Those who obsess about the implications of their actions often fear they endanger others. They may feel they have left a door unlocked or hit someone while driving. Obsessions with symmetry and order may cause significant anxiety over furniture arrangement, eating habits, or clothing. Inappropriate sexual impulses and pornographic images, often of an aggressive nature, can dominate a person's mind. Obsessions of aggression can also center on violent emotions, shouting out in public, or harming others. Hoarding useless items, like outdated catalogs or clothing, is common in OCD and may coincide with an obsession over order.

People suffering from OCD realize that they create their obsessions. They feel that the content of their obsessions is out of their control, inappropriate, not indicative of their character, and something they wouldn't normally think or communicate to others. Thus, their anxiety is intensified not only by recurrent obsessions, but also by the strangeness of the obsessions.

Typical Compulsions
Compulsions are repetitive, often ritualized behaviors that are intended to suppress the anxiety caused by obsessions. Compulsions common in OCD are the following:

• Asking for assurances
• Avoiding places or situations
• Cleaning
• Counting
• Doing certain tasks slowly and deliberately
• Doubting and checking, e.g., locks, lights, and ovens
• Hoarding possessions
• Ordering or arranging
• Repeating behaviors, including speech and action
• Washing, e.g., excessive hand-washing or bathing

Compulsive washing and cleaning are subsequent to the obsessive fear of germs or contamination. Compulsive people have been known to shower for 4 hours, or to wash their hands until they are raw. Others make sure their bath towels are arranged by some exact design, or that the soap is dry before they leave it. People may check the lock on a door several times an hour, or repetitively return home to make sure the oven is off. Some people count incessantly in an attempt to distract or soothe aggressive thoughts. Others depend on patterned behavior to control anxiety, such as avoiding traffic intersections or avoiding a change in routine.

A general theme of compulsive behavior is adherence to some often elaborate set of rules or routine. People with OCD will go to great lengths to satisfy the requirements of a routine, which often results in patterned, idiosyncratic behavior, e.g., slowly and meticulously preparing a bathroom for a shower that lasts for several hours. People who know OCD sufferers may call them perfectionists, especially if they only get a glimpse of the compulsive behavior.

Obsessive-compulsive behavior often leads to secondary avoidance behavior. For example, people who obsess about germs compulsively wash their hands, and may also compulsively avoid places and situations that cause their anxiety in the first place, like public restrooms, doorknobs, and handshaking. Avoidance-related anxiety prohibits some people from leaving the house. And compulsive washing can lead to dermatological problems.

The fact that compulsive behavior can consume most of a person's time makes OCD a particularly devastating disease, especially when behavior becomes daily routine. In fact, the time aspect is stipulated in the criterion for diagnosis. Ironically, behavior that is intended to suppress anxiety usually causes greater distress, prohibits concentration, and interferes with normal daily activities.

Adult sufferers recognize the futility of their compulsive behavior, but they are powerless to change it and cannot provide reason for their compulsive behavior. Some people lack this insight, a factor that is specified in the criteria for diagnosis.

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