WHAT IS OBSESSIVE-COMPULSIVE DISORDER?

BASIC FACTS • SYMPTOMS • FAMILIES • TREATMENTS

RT P SE A Mental Illness Research, Education and Clinical Center E C I D F

I A C VA Desert Pacific Healthcare Network

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R E E Long Beach VA Healthcare System N T T N A E L C IL L LN A E IC S IN Education and Dissemination Unit 06/116A S R CL ESE N & ARCH, EDUCATIO 5901 E. 7th Street | Long Beach, CA 90822 2 WHAT IS OBSESSIVE COMPULSIVE DISORDER? - MIRECC - FALL 2017 ee o svr eog t wrat n C danss Females lence ratesinternationallyare similartothatoftheU.S. diagnosis. OCD an der isfoundacross all levelsofeducationand income. The preva- warrant to enough experience OCD at a slightly higher rate thanmales, and the disor severe not were compulsions at some point in their lifetime, buttheirsymptoms over aquarterofpeoplereported experiencingobsessions and/or meet fullcriteriaforthedisorder. Onelarge-scale studyfoundthat er, itis also very common to experienceOCDsymptoms and not thoughts anddoesritualisticbehaviorfrom timetotime.Howev- their lifetime.Virtuallyeveryone experiencesoccasionalunwanted Between2-3% of people willhave OCD atsome point during Prevalence locks orthestovebecomesfocusoftheirattention. es, whereas othersstruggle toleavethehousebecausechecking or impuls- to counteract“bad”thoughts heads compulsivelytotry images that they struggle tocontrol. Some might count in their whereas another person might have disturbing violentor sexual nation and spends excessive amounts of time washing or cleaning, one personmightbeexcessivelyconcernedwithgermsorcontami- es of OCD vary greatly in terms of specific symptoms. For example, need to do, usually in response to an obsession. People’s experienc- are repetitive behaviorsormentalactsthatapersonfeelslikethey distress .significant and cause and unwanted Compulsions sions. Obsessionsare repeated thoughts,images,orurgesare that presencethe der characterizedby ofobsessionsand/orcompul- but manymore OCD symptoms andnotmeetfull peoplewillexperience 2-3% ofpeoplewillhaveOCDatsomepointintheirlifetime, Between People’s experiences of OCD vary greatly in terms of specific symptoms. OCD ischaracterizedbythepresenceand/or compulsions. ofobsessions basic facts Obsessive-compulsive disorder (OCD)isapsychiatricdisor criteria forthedisorder. - - Causes ety ormooddisorders. least oneco-occurring disorder. OCDtendstoco-occur with anxi- women with ahistoryof OCD. Most people withOCDalso have at creased risk of developing OCDor a worsening of symptoms for pregnancy andthepostpartumperiod are associated with anin- stress, butthenthesymptomsremit afteraperiodoftime.Both people mightexperienceacuteOCDepisodes during timesof Some time. over fluctuating severity symptom with often dition, common in males. If leftuntreated, OCDtendstobeachronic con- ter ofcases emerge before age14. An earlierageofonsetismore However, OCDcanbeginasearlychildhood, and aboutaquar Course ofOCD males, hormones appeartobestronglyrelated toOCD;onsetand circuits, as compared to thosewithoutthedisorder. Forsome fe- brain in functioning abnormal and structure brain in differences ther,people withOCDhave brainimagingstudieshavefoundthat OCD, suchanimbalanceinbrainchemicals (e.g., glutamate).Fur a biologicalcontributiontothedevelopmentandmaintenanceof symptoms atayoungerage. genes playagreaterthat thought role inpeoplewhohaveOCD disorder.development ofthe to the genes contribute multiple is It about therole ofgenesinthedevelopmentOCD,itislikelythat and environmental stressors. orders, biological factors,psychologicalvulnerability, life events, dis- anxiety of OCD orother or familyhistory include agenetic al factorsmayplayapartintheonsetofdisorder. These might begin asearlychildhood. Most peoplewithOCDalsohaveatleastone 20’s.The averageageofonsetOCDislateteens/early However, itcan There is nosimpleanswertowhatcauses OCD becausesever The average ageof onset intheU.S. is late teens/early20’s. In addition to genetics, many scientists believe that therethat In additiontogenetics,manyscientistsbelieve is Although there isnotan“OCDgene,”andmuchunknown co-occurring disorder. - - - explained byanothermental health disorder. of asubstanceoranothermedical conditionandcannotbebetter effects the to Further,due day). be a cannot hour symptoms these one least (at time-consuming very be and/or distress, significant enough tointerfere withaperson’s day-to-day functioning,cause a symptom. considered be to excessive be must compulsion the fire, a of fears related totheobsession, such ascheckingthestovetocounteract act theintrusive thoughtofharmingothers.If thecompulsion is to theobsession.Forexample,apersonmightcountcounter from occurring. Thecompulsive act isnotalwayslogicallyrelated iety ordistress ortoprevent somehorriblepercieved outcome set forthemselves.Compulsions are usuallydonetoreduce anx- of rigidrulessponse toanobsessionoraset individualshave that apersonfeelscompelled to do. Compulsions are ofteninre- lock checking)ormentalacts(e.g.,countingrepeating words) Compulsions are repetitive behaviors(e.g.,handwashingand tralizing withanotherthought,orbyperformingacompulsion. to getridofthem,eitherthrough ignoring,suppressing, orneu- tress or anxiety. Obsessions are usuallyaccompanied by attempts unwanted andintrusive.degree Theseusuallycauseahigh ofdis- persistent thoughts,urges, orimages that apersonexperiencesas have just one or the other. Obsessions are defined as recurrent and diagnosis have both typesof symptoms, but there are some who sions and/or compulsions. The majority of people withanOCD causes forthesymptoms. terference. A physical exam isalso important torule outmedical the symptoms of OCDandthedegree ofrelated distress and in- is withaclinicalinterview, inwhichtheinterviewerwillaskabout other biological or laboratorytest.The only waytodiagnose OCD they perceive asbad(e.g.,ablasphemousreligious thought). that a thought dismissing difficulties have also might wrong and ly, thosewhoare highlymoralistic and haveastrong senseofright (compulsions). Similar or behaveinwaystocounteractit thought upsetting, intrusiveto activelysuppressmight try thoughts.Instead,they the dismissing difficulty have of lot a experience to sively guilty, orhighlymoralistic. For example,peoplewho tend opment ofOCDare tendenciestobeoverlysuperstitious,exces- arefactors that sions. Otherpersonality devel- the associatedwith meaning ofthesethoughts,leadingtothedevelopmentobses- easily, thosewhogoontodevelopOCDtendworryandmake sexual impulses.Whilemost people candismiss these thoughts For example,a person may have violent thoughts or distressing to haveout-of-characterandintrusive thoughtsfrom timetotime. a riskfactor.can alsobe ing thoughts Itisnormalforeverybody ament are atincreased risk.Thewayapersonresponds todistress- a moreOCD. Individualswith risk ofdeveloping anxioustemper and thepostpartumperiod. worsening of symptoms are related to menstruation, pregnancy, the interviewer will askaboutthesymptoms ofOCDandthedegreethe interviewer of The onlywaytodiagnoseOCD is withaclinicalinterview, inwhich To be diagnosed with OCD, these symptoms must be severe An OCDdiagnosis is characterized bythepresence of obses- OCD cannotbediagnosed with abloodtest,CAT-scan, or any There areincrease severalpersonalityfactorsthat aperson’s related distress andinterference. diagnosis andsymptoms - - - the causeisnotcompletelyunderstood. though even OCD for treatments effective are there that mind in are likely to be different for different people. It is important to keep there arecould playarole; manypossiblefactorsthat these factors OCD butcanworsensymptomssignificantly. promotedting atwork.Stressful eventsdonotappeartocause married, havingababy,positive lifeevents,suchasgetting orget- significant include also can They job. a of loss or stress, financial include negativeeventssuchasadeathoflovedone,divorce, or abusestressfulStressful lifeeventsasanadult. lifeevents tributors aswell.Thesefactorscanincludechildhood loss, trauma, OCD. Stressful lifeeventsandenvironmental factorsare oftencon- disorders, biological factors, psychological vulnerability,and life events, Although muchisunknownabouthowOCDcaused,riskfactors basic facts(cont’d) might includeageneticorfamilyhistoryofOCDotheranxiety In sum,althoughitisunclearexactlyhowOCDcaused, None oftheseriskfactorsalonearethe solecauseof likely environmental stressors. 3 WHAT IS OBSESSIVE COMPULSIVE DISORDER? - MIRECC - FALL 2017 4 WHAT IS OBSESSIVE COMPULSIVE DISORDER? - MIRECC - FALL 2017 overlap insymptoms,courseofillness,andriskfactors.Re professionals consider to be related to OCD because of their involves helping people tograduallyconfront whattheyare afraid vention (ERP), is akeycomponentoftreatment. Thisintervention Thebehavioralcomponent ofCBT, exposure andresponse pre- immorally orviolently. as acting about sexorviolenceisnot the samething a thought obsessional thoughts,thetherapist willhelpthemseethathaving example, if a person believes that they willact on their disturbing OCD changehowtheythinkabout theirobsessional thoughts. For and beliefs andisoftenusedtohelppeoplewith son’s thoughts ThecognitivetherapycomponentofCBTfocuses on aper cle. sions, reassurance-seeking, andavoidance)feedintotheOCDcy- develop andare maintained,andhowOCDbehaviors (compul- obsessions how address Specifically, will symptoms. therapist the specific person’s the to it tailor provideand OCD about education Using informationfrom theassessment,therapistwill then concepts. CBTstartswithathorough assessment of symptoms. also beinvolvedinthetreatment andcanhelpreinforce treatment delivered inanindividualorgroup format.Familymembers can therapies: cognitivetherapyand behavioral therapyand can be of types two of blend a is CBT OCD. or treatment effective most Research shows that cognitivebehavioral therapy(CBT) is the Cognitive BehavioralTherapy(CBT) to treat OCD. Know” (pages6-7)provides informationaboutmedicationsused Thesectioncalled“MedicationsforOCD:What You Should Medication dence-based practices. evi- be to considered are They OCD. with people for effective be The treatments listed here are ones which research has shown to tions. For many, a combination of the two might be most effective. those with more severe symptoms might also benefit from medica milder case of OCD, psychotherapy alone might be effective, while OCD, includingmedicationsandpsychotherapy. Forthosewitha Generalized anxietydisorder ischaracterizedbyexcessive food andweight,aneatingdisorder mightbediagnosed. ric disorders. Ifaperson’sobsessionsare solelysurrounding that OCDistreated. disorders, however, are notnecessarilytreated thesameway also considered tobeOCD-related disorders. These related (compulsive hairpulling)andexcoriation(skinpicking)are diagnosed withbodydysmorphicdisorder. Trichotillomania are solely related to an aspect of their appearance might be roundings. A personwithobsessionsandcompulsionsthat in difficulty extremediscarding them,resulting inalotofclutterone’ssur and belongings of collection pulsive For example, hoarding disorder is characterized by a com petitive behaviorsare alsoacomponentofthesedisorders. treatment similar psychiatricdisorders Different types of treatments are available for people with for areavailable of treatments types Different There are afewpsychiatricdisorders thatmentalhealth OCD alsoshares symptomswithnon-related psychiat ------alcohol orsubstanceusedisorders. are alsoseeninseveralothermentalhealthdisorders, suchas involuntary and occur very quickly. Compulsive behaviors OCD compulsionsinthatticsare oftenexperiencedasbeing and rapid motor movements or vocalizations. differ from is sometimes confused with OCD,is characterized by sudden distressing andintrusive thanobsessions. disorder, which similar toobsessions.Ruminations,however, tendtobeless is oftencharacterizedbyruminations whichalsomayseem be lessrealistic andmore unusual.Majordepressive disorder tend tobeaboutreal lifeconcerns, while obsessionstendto ference isthatwithgeneralizedanxietydisorder, theworries with fearfulthoughts,compulsions, andavoidancebehaviors. to simplyobservetheirsymptoms, ratherthanfeedingintothem thoughts andemotions.Mindfulness canteachpeoplewithOCD less judgmental and reactive, and more accepting of their negative present. Peoplewho regularly practice mindfulness can learn tobe arewho they asa person. moreACT alsousesmindfulnesstobe on badly reflect not does thoughts negative having that learn and them. Peoplepracticedisengagingfrom the obsessive thoughts against fighting than rather obsessions unpleasant their accepting support livinginlinewiththesevalues.In ACT, peoplefocus on social relationships, andcommunity, andhelpthem takeactionto lives, suchasfamily,value mostintheir they what identify work, far are promising. An overarching goalof ACT istohelppeople on ACT andOCD,butthestudiesthathave beenconducted thus ment thathasbeenusedforOCD.There hasbeenlimitedresearch Acceptance and commitment therapy(ACT) is anewertreat- Acceptance andCommitmentTherapy to toleratetheiranxiety. will beaskedtorefrain from reassurance-seeking sotheycanlearn learn abouthowreassurance contributes totheOCD cycle. They door locked”or“AmIabadperson?”).InCBT, thepersonwill ManypeoplewithOCDaskothersforreassurance (e.g.,“Isthe instructed todoexposure betweensessionshomework. as therapy symptoms. To get more practicedoing exposures, people are often and distress andwilleventuallyexperienceadecrease inOCD pulsive behaviors,peoplelearnthattheycantoleratetheanxiety to feared thoughtsandsituations,combinedwithresisting com fortable and anxiety-producing. However, withrepeated exposure (in vivo)and/orthrough imagination.ERP canbeveryuncom- checking thelock.Exposures canbedoneintheactualsituation resist theurge toengageinthecompulsion,thiscaserepeatedly of, suchasleavingtheirhomeunlocked,andthenhelpingthem worry, whichmightseemsimilartoanobsession.Thedif course of illness, andriskfactors.OCD also shares symptomswith to berelatedconsider toOCDbecauseoftheiroverlapinsymptoms, There are afewpsychiatricdisordersthatmentalhealthprofessionals treatment forOCD.There isrecent research thatsupportsanewer Cognitive behaviortherapyisthe mosteffectivepsychosocial treatment calledacceptanceandcommitment therapy. non-related psychiatricdisorders. - - OCD.” Infamilies where plansoften changebecauseofOCDbe- and I’m not goingto give it to you because it feeds into the cycle of family memberscangentlysay, “youare askingforreassurance, their relativeexample, whenaskedby withOCDforreassurance, OCD. Howcanfamilymembers eliminate accommodation? For member does not learnhow to tolerateanxietyassociated with the types of behaviors reinforce the OCD cycle, and the affected family ily accommodation, themore severe theOCDsymptoms. These things worse.Infact,research hasfoundthatthegreater thefam- ing thesetypesofaccommodations, thesebehaviorsactuallymake aremembers mightfeellikethey “helping”theirrelative bymak- of personal and family routines due to theOCD. Although family reassurance, helpingwithavoidancebehaviors,and/orchanging modation refers toassistingwithrituals/compulsions, providing gage inaccommodation of their relative’s OCD symptoms. Accom Treatment Concepts Eliminate AccommodationandReinforce transportation totheclinic. remindersgiving appointments by psychotherapy andproviding attendance to members canalsosupport medications. Family their it. Familymembers can helpencourageandremind them totake betimes might when a person does not wantto take itor just might forget –there totake difficult be can medication Taking that. regular times,thefamilymembercanhelpgivesupportaround son with OCDisprescribed medications that needtobetakenat tend tohelpanswerquestions and to provide support. If the per thorough evaluation.Ifpossible,familymemberscouldalsoat- a for professional health mental a visit first to OCD with person low apersontoregain control overtheirlife.Itisimportantfora and medications can help alleviatethesymptoms of OCD and al- Encourage Treatment OCD can affect the entire family. Family members often en- often members family. Family entire the affect can OCD OCD isatreatable problem. Psychotherapy(especiallyCBT) how familymemberscanhelp - - al ifneeded. They can’t.should get thehelpofamentalhealthprofession should notfeelresponsible forsolvingtheproblem themselves. cope withalovedone’sOCD.Finally,better familymembers or therapygroup. Counselingcanoftenhelpfamilyand friends Family membersmayalsoconsiderjoiningasupport well-being. or with otherfamilymembers or friends is important for their own with OCDtomonopolizealloftheirtime,andspendingtimealone ways todo this. Familymembers should not allowtheirrelative portant thattheytakecare of themselves as well. There are many Take Care ofThemselves accommodation andencouragingexposure. relatives canhelpreinforce some of these concepts by eliminating at home. Even if aperson is not receiving psychotherapyfor OCD, practice such in join to offer can members treatment,family the of part is mindfulness If relevant. if help, to offer and practice, sure encourage theirrelative toengageinthehomework, such as expo- CBT is comprised ofhomeworkassignments;familymemberscan commodation and provide support of the treatment. Forexample, with the therapist to learn specifics about how they can reduce ac- relativeIf their guilt. isreceivingCBT, familymemberscantalk cognitive-behavioral model of OCD can help reduce feelings of their relative’s symptoms,buthavinganunderstandingofthe to docompulsions. can insistthatplansmustgoonas scheduled regardless of urges haviors (e.g.,duetotimespentoncompulsions), family members ment, eliminating accommodation, and reinforcing treatment concepts. relativecan helptheir Family members treat withOCDbyencouraging - Family membersshouldalsoremember totakecare ofthemselves. Given thechallengesthatfamilymembers may face, it is im- about notaccommodating Family membersoftenfeelguilty - 5 WHAT IS OBSESSIVE COMPULSIVE DISORDER? - MIRECC - FALL 2017 6 WHAT IS OBSESSIVE COMPULSIVE DISORDER? - MIRECC - FALL 2017 • • • • • medication: whatyoushouldknow effects. Contact your doctor immediately if youexperience one ormore severe symptoms. if immediately doctor your Contact effects. ersome. Inrare cases, these medicationscancausesevere side both- become or persist effects side if doctor your with Check experience aretypically and subsideinafewdays. tolerable people effects side The effects. side minor or effects side no All medications may cause side effects, but many people have medication orcombinationofmedications! ifyoursymptoms know have notimproved anddonotgiveupsearching fortheright doctor your Let fit. a good find to another medicationorcombinationofmedications to trying well foronepersonmaynotdoasanother. Beopen works What symptoms. OCD your in improvements nificant sig- to lead not may try first you medication the Sometimes glutamate. and mood,includingserotonin,ulate anxiety dopamine,and These medications work on neurotransmitters believed toreg- but theycanbehelpfulwhenaddedtoSRIs. These medications are not effective for OCD when used alone, second generation antipsychoticsandglutamatemodulators. SRI medications,othermedications are oftenadded, such as For patientswhose OCD symptoms do notrespond well to pressants thatare notSRIsare noteffective. are therefore considered second-line treatments. Otherantide- they havenotbeenFDA-approved for treatment of OCD, and for serotonin-norepinephrine reuptakeinhibitors (SNRIs),but pressiondisorders. orotheranxiety There issomeevidence are considerablyhigherthanthoseusedfortreatment ofde- es ofSRImedications that are neededfortreatment ofOCD serotonin , whichalsohasstrong SRIproperties. Thedos- selective the both reuptake(SSRIs) andthetricyclicantidepressantinhibitors include These medications. sant tonin reuptake inhibitors (SRIs), a specific class of antidepres- areeffective that for OCD.The primary medications used for OCDareof medications sero- types different are There or treatmentandisnotintendedasmed patient, mustdeterminedosagesandthe the medicinesmentioned.Thisinforma for makinganevaluationastotherisks and benefitsoftakingaparticularmed not coverallpossibleuses,actions,pre tion doesnotconstitutemedicaladvice ication. Thetreatingphysician,relying cautions, sideeffects,orinteractionsof obsessive-compulsive disorder. Itdoes ical adviceforindividualproblemsor on experienceandknowledgeofthe This handoutprovidesonlygeneral information aboutmedicationfor best treatmentforthepatient. - - - - TRICYCLICS AND TETRACYCLICS(TCA INHIBITORS (SNRI SEROTONIN ANDNOREPINEPHRINE REUPTAKE SELECTIVE SEROTONINREUPTAKE INHIBITORS(SSRIs) • • • • Medications Clomipramine (Anafranil) (Effexor) (Pristiq) (Zoloft) (Paxil) (Luvox) (Prozac) (Lexapro) (Celexa) on thoseyouhaveforgotten. time. sume takingyourmedicationatthenextregularlyscheduled should havebeentaken,justskiptheforgotten doseandre- medication. If ithasbeenmore than three hoursafterthedose time youwere supposedtotakeyourmedication, pressant medication: ifit has beenthree from hoursorless the Here isasaferule ofthumbifyoumissadoseyourantide- your doctorabouthowtocorrectly stopit. your medication,talkto pervision. Ifyouwanttostoptaking su- Medication should onlybestoppedunderyourdoctor’s feeling better. Stoppingyourmedicationcancausearelapse. do not abruptly stoptakingyourmedications, even ifyouare To prevent OCDsymptoms from coming back orworsening, might recommend longertermtreatment. symptoms. If youhaveamore severe case of OCD,thedoctor years. Discontinuingtreatmentearlier mayleadtoarelapse of tinue treatment. Itistypicalfortreatment tocontinuefor1-2 Once youhaveresponded to treatment, itisimportanttocon- tion becauseyouthinkit’snotworking.Giveittime! changes inyoursymptoms. So don’tstoptakingyourmedica es forupto12weeksbefore youcanexpecttoseepositive SRI medicationsmustbetakenatfull,anti-obsessionaldos Never doubleupondosesof your antidepressant to“catchup” s) s ANDTECA ) - - FIRST-GENERATION ATYPICAL ANTIPSYCHOTICS • • • Medications Fluphenazine (Prolixin) (Haldol) (Geodon) (Seroquel) Olanzapine (Zyprexa) (Risperdal) (Abilify) on thoseyouhaveforgotten. time. sume takingyourmedicationatthenextregularlyscheduled should havebeentaken,justskiptheforgotten doseandre- medication. Ifithasbeenmore thansixhoursafterthedose time youwere supposedtotakeyourmedication, forget totakeadose: if ithasbeensixhoursorlessfrom the to betakentwiceaday, here isasaferule ofthumbifyou up” onthedoseyoumissed.Ifyourmedicationisprescribed take yourmedication,donotdoubleupthenextdayto“catch Most antipsychoticsare prescribed oncedaily.forget Ifyou to medication becauseyouthinkit’snotworking.Giveittime! your you don’tstoptaking symptoms. Itisimportantthat They often take several weeks to have their full effect on OCD All antipsychoticmedications must be takenasprescribed. medications andare usuallyprescribed inlowdoses. served for patientswho do not have a good response to SRI times behelpfulinreducing OCDsymptoms. They are re- treatmentchotic medicationstoongoing SRIs cansome- with Although OCDisnotapsychoticdisorder, addingantipsy- Never double up on doses of your antipsychoticto “catch up” 7 WHAT IS OBSESSIVE COMPULSIVE DISORDER? - MIRECC - FALL 2017 RT P SE A E C I D F

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R E E N T T N A E L C IL L LN A E IC SS IN R CL ESE N & ARCH, EDUCATIO

MENTAL ILLNESS RESEARCH, EDUCATION AND CLINICAL CENTER VA Desert Pacific Healthcare Network Long Beach VA Healthcare System Education and Dissemination Unit 06/116A 5901 E. 7th Street Long Beach, CA 90822

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Bonnie Zucker, PhD 1 Noosha Niv, PhD 1, 2 Jonathan Abramowitz, PhD 3 Sanjaya Saxena, MD 4

1VA Desert Pacific Mental Illness Research, Education and Clinical Center (MIRECC) 2UCLA, Department of and Biobehavioral Sciences 3UNC-Chapel Hill, Department of Psychology and Neuroscience 4UCSD Department of Psychiatry