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What follows is part 2 in a series of 3 articles. Part 1 focused on OCD in children. Part 3 will address an under-recognized, obsessive condition called olfactory reference disorder (ORD).
As a recognized condition within psychiatry, obsessive compulsive disorder (OCD) has morphed over the years. Earlier, it was considered a neurosis, and later, it was categorized as an anxiety disorder. Today, it is classified under the broad category of “obsessive compulsive and related disorders.”
Why does this matter? According to Dr. Katharine Phillips, professor of psychiatry and attending psychiatrist at Weill Cornell Medicine, the way OCD is defined and diagnosed has everything to do with how it’s treated.
In what follows, Dr. Phillips unpacks the complexities of OCD, from diagnosis to treatment and prospects for recovery. She also explains the differences between OCD and other mental health challenges as well as everyday worries and anxieties.
OCD has two major components. The obsessive piece involves unwanted, intrusive thoughts, which are very distressing for those who experience them. The compulsions—repetitive, ritualistic behaviors—are the sufferer’s attempt to alleviate that distress, and they can actually succeed in doing so, temporarily.
For example, someone with OCD may think, “If I touch the doorknob, I’m going to get sick.” Their compulsive behavior may take the form of excessive hand-washing. According to OCD logic, that makes sense. Fifteen minutes of hand-washing, as they see it, will protect them from getting sick.
More than an hour a day of misery-inducing obsessive thinking is one of the key symptoms of OCD, Dr. Phillips says. Rituals (compulsive and repetitive behaviors) are another.
The disorder often begins in adolescence or early adulthood. It’s also quite common, affecting roughly 1 to 2 percent of adults in the U.S. in a given year and 2.3 percent over their lifetime. Like a number of other mental health disorders, it’s caused by a combination of genetic and environmental factors.
The category encompasses a number of disorders that share some but not all of OCD’s characteristics, including:
If you check a couple of times to see whether you turned off the stove before you go out, that isn’t OCD. Nor is it feeling, periodically, that you’ve done something wrong.
Remember, OCD involves obsessive thoughts that are distressing or that significantly interfere with a person’s life for significant periods of time, every day. Taking a few minutes to make sure you’ve turned off the stove or set the alarm doesn’t earn you an OCD diagnosis, nor do feelings of guilt or regret over past actions, usually associated with depression.
Everyday worries, she says, are not OCD, a disorder that’s about an excessive need for symmetry or exactness. Emphasis on the word “excessive.”
OCD usually does trigger a lot of anxiety in its sufferers. The question is, which came first: the anxiety or the obsessive thoughts that trigger it? Psychiatrists today agree that in OCD, the obsessive thoughts start the process and cause anxiety, not the other way around.
Says Dr. Phillips, the diagnostic gold standard for OCD involves determining whether the symptoms meet the diagnostic criteria that are in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). The following checklist and follow-up questions can be helpful in making the diagnosis:
“It bears repeating that more than an hour a day of obsessive thoughts or rituals that are characteristic of OCD, or significant distress or impairment due to these obsessive thoughts or rituals, qualifies for an OCD diagnosis,” she says.
Treatment typically involves a specialized type of cognitive behavioral therapy called exposure and response prevention (ERP).
People undergoing ERP deliberately expose themselves to their obsessions without performing the usual rituals that bring short-term relief. They’ll agree, for example, to touch the doorknob or toilet seat and refrain from washing their hands afterwards. Over time, they learn that the dreaded consequence—getting sick—doesn’t happen.
“We often add cognitive approaches as well, focusing on the unrealistic, inaccurate thoughts that underlie obsessions. Along the way, patients learn that they habitually overestimate risk and threat. They learn to develop more accurate, helpful thoughts. But ERP is the key strategy.”
Psychiatrists prescribe an SSRI (selective serotonin reuptake inhibitor) for OCD. Medication is always recommended for severe OCD (along with ERP), and it can also be used for OCD that is milder or moderate in severity.
People with OCD frequently require higher-than-usual doses of these medications. It is often helpful to exceed the manufacturer’s maximum dose. However, that is not recommended for Celexa (citalopram) or Anafranil (clomipramine), she explains.
“SSRIs usually work very well, and they’re well tolerated in most patients. They gradually reduce the obsessions and the anxiety the obsessions cause, and they also reduce the urge to perform the compulsive rituals associated with OCD.”
Sometimes, she says, there may be a need to boost the effects of the SSRI by adding a neuroleptic like Risperdal (risperidone) or Abilify (aripiprazole), or an anti-anxiety medication like Buspar (buspirone).
Occasionally, an SSRI may stop working, as the patient has missed doses. Or your pharmacy may have replaced the generic SSRI it normally dispenses with another formulation. In that case, “I’ll ask my patient whether the pill looks different, and if it does, I’ll call the pharmacy and ask whether they’ve recently changed the generic they use to fill prescriptions. If so, I’ll ask whether they can get the former one back in stock and fill my patient’s next prescription with that formulation. Alternatively, we can try increasing the dose of the formulation they’re currently taking.
“My goal is to find a strategy that will work for the individual patient,” she continues. “If one SSRI doesn’t work, I’ll try another, or add an additional medication to boost its efficacy. We’ll often add cognitive behavioral therapy into the mix—ERP plus cognitive techniques. These treatments are very effective, and the vast majority of OCD sufferers get better. Over time, many even become symptom-free.”
Learn more about OCD through our On the Mind podcast and make an appointment at Weill Cornell Medicine here.
[MC1]Dr. Phillips has requested that we add a hyperlink to “Part I,” once it goes live.
