Obsessions are recurrent and persistent thoughts, images, or impulses. Obsessions are usually experienced as being intrusive or inappropriate; patients often describe them as being different from normal thoughts. Indeed, the word ‘obsession’ comes from a Latin root meaning ‘to besiege’ or ‘to occupy’, which captures this unwanted, intrusive character. Obsessions typically involve significant anxiety or distress, which leads sufferers to try to suppress, avoid, or neutralize them. Obsessions can vary broadly, but they often fall into particular categories. Common types of obsessions include concerns about contamination or symmetry, fears that harm will come to oneself or others, and unwanted or inappropriate violent, sexual, or blasphemous thoughts, impulses, or images.
Compulsions are repetitive behaviors or mental acts that are performed in an effort to control anxiety or distress or to prevent a dreaded event or situation. They are sometimes performed in very precise, almost ritualized ways. Common compulsions include repetitive washing, checking rituals, praying, superstitious rituals, mental rituals such as counting or reciting, seeking reassurance, and repetitive touching or tapping.
Obsessions and compulsions can occur independently of one another, but they usually occur together, and they are usually related. Compulsions are typically efforts to control the anxiety caused by obsessions – for example, repeated washing may be a response to obsessions about germs or contamination. While this may temporarily succeed, the relief is often brief, and other obsessions arise, which prompt further compulsive behavior. Unfortunately, performing compulsions can actually strengthen the obsessive-compulsive cycle. The distressing and time-consuming cycle of obsessions and compulsions can interfere significantly with patients’ functioning and quality of life.
Obsessions and compulsions are quite common in the general population; in a recent survey, they were reported in over 28% of people (Ruscio et al, 2010). OCD is only diagnosed when obsessions and compulsions are common and severe enough that they cause significant distress or interfere with an individual’s ability to function. Diagnosable OCD is found in 1.6-2.5% of the population, though only a fraction of that number actually receive a diagnosis and get treatment.
Most people with OCD are well aware that their obsessions and compulsions are irrational. Indeed, this is part of the torment of OCD – their insight does little to weaken the obsessional distress or to make compulsive behaviors easier to resist, and the understanding that these thoughts and behaviors are irrational heightens the distress. This can lead to a high degree of shame, embarrassment, and isolation.
The emotional areas of the brain are making the person feel as if, for example, their hands are contaminated with deadly germs, or that they may have accidentally hit someone with their car, or that they left the iron on and their house might burn down as a result. The distress that arises doesn’t stop until they perform their compulsive behaviors of (respectively) perhaps scrubbing their hands with soap and hot water, or retracing the entire route they just drove checking for a struck pedestrian, or driving back home to check that the iron is off.
OCD is associated with particular abnormalities in the brain – in particular, hyperactivity in a set of brain regions known as the basal ganglia, the anterior thalamus, the anterior cingulate cortex, and the orbitofrontal cortex. Treatments that improve symptoms generally also improve these brain abnormalities.
But OCD is, at the same time, a psychological condition, influenced by life experience. Specialized psychotherapy is as effective as medication in many cases – perhaps more effective in some. The relationship between brain abnormalities and psychological symptoms is one of the great mysteries of psychiatry.
It is not clear whether one comes ‘first’ – whether there is a core brain abnormality, perhaps based in the genes, that leads to the symptoms, or whether a pattern of obsessional and compulsive behavior develops and is reflected in brain function. The answer is probably both – underlying genetic and other biological factors probably set the stage and determine why one person is at more risk than another for developing OCD, but life experiences may then contribute to who develops the disorder and who does not, and to what form their symptoms take.
We don’t know what causes OCD.
We do know that it can run in families. Researchers are actively searching genetic variations that may help explain why one person gets OCD and another does not. Genes are not the whole story, though: even identical twins, who have identical genetic material, can differ, with one having OCD and the other not.
Environmental causes of OCD are not clear. Some cases, especially among children, may be related to an autoimmune reaction to infection, though this remains unclear in most instances. Stressful life events can cause symptoms to appear or to worsen; it is not clear whether they actually cause OCD in a susceptible person, or whether they just worsen or amplify a condition that was already there. Hormonal fluctuations may also influence OCD; onset is common during adolescence, and some women report symptoms worsening with their menstrual cycle or around the time of pregnancy.
This isn’t necessarily OCD. It might be OCD if someone knows that their greater-than-average concern about neatness or germs is excessive, if they wish it would stop, and if it causes them distress. But if an individual just likes things neat and is comfortable with that, then that is best understood as a part of their personality, and not as OCD.
The term “OCD” has become a part of the common lexicon to describe people with patterns of behavior such as in these examples. You’ve probably heard this before: “I’m so OCD about _________.” From a psychiatrist’s or psychologist’s perspective, this is a misuse of the term.
Some obsessions can have disturbing violent content. Like all other obsessions, these are involuntarily experienced and completely unwanted. People with OCD typically do NOT seek to act out violent or aggressive obsessions; rather, they are highly disturbed by them, and experience them as separate and contrary to their sense of self (this is called “ego dystonic”).
Compulsions performed to combat such obsessions do NOT involve acting out the obsessions. On the contrary, the compulsions are based on efforts to neutralize or undo the obsessions, or checking to ensure that no person has been hurt.
The word ‘obsessed’ is sometimes used to describe someone with a single-minded preoccupation with a person or an idea, or even with stalking. This is very different from the obsessions seen in patients with OCD.
Both psychotherapy and medication, when properly used, can substantially improve OCD symptoms in a majority of patients – up to 60-70%.
A mission of our clinic is to find ways to help those who are not significantly helped by existing treatments. Please see our 'Research' page for more information.