Obsessive–compulsive disorder - Wikipedia

Obsessive–compulsive disorder (OCD) is a mental and behavioral disorder in which an individual has intrusive thoughts and/or feels the need to perform ... Obsessive–compulsivedisorder FromWikipedia,thefreeencyclopedia Jumptonavigation Jumptosearch Disorderthatinvolvesrepeatedthoughtsthatmakeapersonfeeldriventodosomething "OCD"redirectshere.NottobeconfusedwithObsessive–compulsivepersonalitydisorder.Forotheruses,seeOCD(disambiguation). MedicalconditionObsessive–compulsivedisorderFrequentandexcessivehandwashingoccursinsomepeoplewithOCD.SpecialtyPsychiatrySymptomsFeeltheneedtocheckthingsrepeatedly,performcertainroutinesrepeatedly,havecertainthoughtsrepeatedly[1]ComplicationsTics,anxietydisorder,suicide[2][3]UsualonsetBefore35years[1][2]RiskfactorsChildabuse,stress[2]DiagnosticmethodBasedonthesymptoms[2]DifferentialdiagnosisAnxietydisorder,majordepressivedisorder,eatingdisorders,obsessive–compulsivepersonalitydisorder[2]TreatmentCounseling,selectiveserotoninreuptakeinhibitors,clomipramine[4][5]Frequency2.3%[6] Obsessive–compulsivedisorder(OCD)isamentalandbehavioraldisorderinwhichanindividualhasintrusivethoughtsand/orfeelstheneedtoperformcertainroutinesrepeatedlytotheextentwhereitinducesdistressorimpairsgeneralfunction.[7][1][2]Asindicatedbythedisorder'sname,theprimarysymptomsofOCDareobsessionsandcompulsions.Obsessionsarepersistentunwantedthoughts,mentalimages,orurgesthatgeneratefeelingsofanxiety,disgust,ordiscomfort.[8]Commonobsessionsincludefearofcontamination,obsessionwithsymmetry,andintrusivethoughtsaboutreligion,sex,andharm.[1][9]Compulsionsarerepeatedactionsorroutinesthatoccurinresponsetoobsessions.Commoncompulsionsincludeexcessivehandwashing,cleaning,counting,ordering,hoarding,neutralizing,seekingassurance,andcheckingthings.[1][9][10]Washingisinresponsetothefearofcontamination.Orderingisthepreferencefortaskstobecompletedaspecificway(e.g.,organizingclothesaspecificway).Hoardingisthecollectingofunnecessaryobjects(e.g.,collectingfoodwrappers).Neutralizingistheactofengaginginaritualtomakeupforsupposedly"badbehavior".Checkingisthecompulsiontocheckparticularobjects/placestoensuretheyareacertainway(e.g.,checkingtoensurethewateristurnedoff).PeoplewithOCDtendtobeoverlycleanly,repeatedlycountobjects,andseekreassurancetoavoidmakingamistake.ManyadultswithOCDareawarethattheircompulsionsdonotmakesense,buttheyperformthemanywaytorelievethedistresscausedbyobsessions.[1][8][9][11]Compulsionsoccursooften,typicallytakingupatleastonehourperday,thattheyimpairone'squalityoflife.[1][9] ThecauseofOCDisunknown.[1]Thereappeartobesomegeneticcomponents,anditismorelikelyforbothidenticaltwinstobeaffectedthanbothfraternaltwins.Riskfactorsincludeahistoryofchildabuseorotherstress-inducingevents;somecaseshaveoccurredafterstreptococcalinfections.[1]Diagnosisisbasedonpresentedsymptomsandrequiresrulingoutotherdrug-relatedormedicalcauses;ratingscalessuchastheYale–BrownObsessiveCompulsiveScale(Y-BOCS)assessseverity.[2][12]Otherdisorderswithsimilarsymptomsincludegeneralizedanxietydisorder,majordepressivedisorder,eatingdisorders,ticdisorders,andobsessive–compulsivepersonalitydisorder.[2]Theconditionisalsoassociatedwithageneralincreaseinsuicidality.[3][13] TreatmentforOCDmayinvolvepsychotherapysuchascognitivebehavioraltherapy(CBT),pharmacotherapysuchasantidepressants,orsurgicalproceduressuchasdeepbrainstimulation.[4][5][14][15]CBTincreasesexposuretoobsessionsandpreventscompulsions,whilemetacognitivetherapyencouragesritualbehaviorstoaltertherelationshiptoone'sthoughtsaboutthem.[4][16]Selectiveserotoninreuptakeinhibitors(SSRIs)areacommonantidepressantusedtotreatOCD.SSRIsaremoreeffectivewhenusedinexcessoftherecommendeddepressiondosage;however,higherdosescanincreasesideeffectintensity.[17]CommonlyusedSSRIsincludesertraline,fluoxetine,fluvoxamine,paroxetine,citalopram,andescitalopram.[14]SomepatientsfailtoimproveaftertakingthemaximumtolerateddoseofmultipleSSRIsforatleasttwomonths;thesecasesqualifyastreatment-resistantandrequiresecond-linetreatmentsuchasclomipramineoratypicalantipsychoticaugmentation.[4][5][17][18]Surgerymaybeusedasafinalresortinthemostsevereortreatment-resistantcases,thoughmostproceduresareconsideredexperimentalduetothelimitedliteratureontheirsideeffects.[19]Withouttreatment,OCDoftenlastsdecades.[2] Obsessive–compulsivedisorderaffectsabout2.3%ofpeopleatsomepointintheirlives,whileratesduringanygivenyearareabout1.2%.[2][6]Itisunusualforsymptomstobeginafterage35,andaround50%ofpatientsexperiencedetrimentaleffectstodailylifebeforeage20.[1][2]Malesandfemalesareaffectedequally,andOCDoccursworldwide.[1][2]Thephraseobsessive–compulsiveissometimesusedinaninformalmannerunrelatedtoOCDtodescribesomeoneasexcessivelymeticulous,perfectionistic,absorbed,orotherwisefixated.[20] Contents 1Signsandsymptoms 1.1Obsessions 1.2Compulsions 1.3Insightandovervaluedideation 1.4Cognitiveperformance 1.5Children 1.6Associatedconditions 2Causes 2.1Drug-inducedOCD 2.2Genetics 2.3Brainstructureandfunctioning 2.4Autoimmune 2.5Environment 3Mechanisms 3.1Neuroimaging 3.2Cognitivemodels 3.3Neurobiological 4Diagnosis 4.1Differentialdiagnosis 5Management 5.1Therapy 5.2Medication 5.3Procedures 5.4Children 6Epidemiology 7Prognosis 8History 8.1Notablecases 9Societyandculture 9.1Art,entertainmentandmedia 10Research 11Otheranimals 12References 13Externallinks Signsandsymptoms OCDcanpresentwithawidevarietyofsymptoms.Certaingroupsofsymptomsusuallyoccurtogether;thesegroupsaresometimesviewedasdimensions,orclusters,whichmayreflectanunderlyingprocess.ThestandardassessmenttoolforOCD,theYale–BrownObsessiveCompulsiveScale(Y-BOCS),has13predefinedcategoriesofsymptoms.Thesesymptomsfitintothreetofivegroupings.[21]Ameta-analyticreviewofsymptomstructuresfoundafour-factorgroupingstructuretobemostreliable:asymmetryfactor,aforbiddenthoughtsfactor,acleaningfactor,andahoardingfactor.Thesymmetryfactorcorrelateshighlywithobsessionsrelatedtoordering,counting,andsymmetry,aswellasrepeatingcompulsions.Theforbiddenthoughtsfactorcorrelateshighlywithintrusiveanddistressingthoughtsofaviolent,religious,orsexualnature.Thecleaningfactorcorrelateshighlywithobsessionsaboutcontaminationandcompulsionsrelatedtocleaning.Thehoardingfactoronlyinvolveshoarding-relatedobsessionsandcompulsions,andwasidentifiedasbeingdistinctfromothersymptomgroupings.[22] SomeOCDsubtypeshavebeenassociatedwithimprovementinperformanceoncertaintasks,suchaspatternrecognition(washingsubtype)andspatialworkingmemory(obsessivethoughtsubtype).Subgroupshavealsobeendistinguishedbyneuroimagingfindingsandtreatmentresponse,thoughneuroimagingstudieshavenotbeencomprehensiveenoughtodrawconclusions.Subtype-dependenttreatmentresponsehasbeenstudied,andthehoardingsubtypehasconsistentlybeenleastresponsivetotreatment.[23] WhileOCDisconsideredahomogeneousdisorderfromaneuropsychologicalperspective,manyofthesymptomsmaybetheresultofcomorbiddisorders.Forexample,adultswithOCDhaveexhibitedmoresymptomsofattention–deficit/hyperactivitydisorder(ADHD)andautismspectrumdisorder(ASD)thanadultswithoutOCD.[24] Obsessions Mainarticle:Intrusivethought Seealso:Primarilyobsessionalobsessivecompulsivedisorder PeoplewithOCDmayfaceintrusivethoughts,suchasthoughtsaboutthedevil(shownisapaintedinterpretationofHell). Obsessionsarestress-inducingthoughtsthatrecurandpersist,despiteeffortstoignoreorconfrontthem.[25]PeoplewithOCDfrequentlyperformtasks,orcompulsions,toseekrelieffromobsession-relatedanxiety.Withinandamongindividuals,initialobsessionsvaryinclarityandvividness.Arelativelyvagueobsessioncouldinvolveageneralsenseofdisarrayortension,accompaniedbyabeliefthatlifecannotproceedasnormalwhiletheimbalanceremains.Amoreintenseobsessioncouldbeapreoccupationwiththethoughtorimageofaclosefamilymemberorfrienddying,orintrusivethoughtsrelatedtorelationshiprightness.[26][27]Otherobsessionsconcernthepossibilitythatsomeoneorsomethingotherthanoneself—suchasGod,thedevil,ordisease—willharmeitherthepatientorthepeopleorthingsthepatientcaresabout.OtherswithOCDmayexperiencethesensationofinvisibleprotrusionsemanatingfromtheirbodies,orfeelthatinanimateobjectsareensouled.[28] SomepeoplewithOCDexperiencesexualobsessionsthatmayinvolveintrusivethoughtsorimagesof"kissing,touching,fondling,oralsex,analsex,intercourse,incest,andrape"with"strangers,acquaintances,parents,children,familymembers,friends,coworkers,animals,andreligiousfigures,"andcanincludeheterosexualorhomosexualcontactwithpeopleofanyage.[29]Similartootherintrusivethoughtsorimages,somedisquietingsexualthoughtsarenormalattimes,butpeoplewithOCDmayattachextraordinarysignificancetosuchthoughts.Forexample,obsessivefearsaboutsexualorientationcanappeartotheaffectedindividual,andeventothosearoundthem,asacrisisofsexualidentity.[30][31]Furthermore,thedoubtthataccompaniesOCDleadstouncertaintyregardingwhetheronemightactonthetroublingthoughts,resultinginself-criticismorself-loathing.[29] MostpeoplewithOCDunderstandthattheirthoughtsdonotcorrespondwithreality;however,theyfeelthattheymustactasthoughtheseideasarecorrectorrealistic.Forexample,someonewhoengagesincompulsivehoardingmightbeinclinedtotreatinorganicmatterasifithadthesentienceorrightsoflivingorganisms,despiteacceptingthatsuchbehaviorisirrationalonanintellectuallevel.ThereisdebateastowhetherhoardingshouldbeconsideredanindependentsyndromefromOCD.[32] Compulsions Mainarticle:Compulsivebehavior Apersonexhibitingskin-pickingdisorder SomepeoplewithOCDperformcompulsiveritualsbecausetheyinexplicablyfeelthattheymustdoso,whileothersactcompulsivelytomitigatetheanxietythatstemsfromobsessivethoughts.Theaffectedindividualmightfeelthattheseactionswilleitherpreventadreadedeventfromoccurring,orpushtheeventfromtheirthoughts.Inanycase,theirreasoningissoidiosyncraticordistortedthatitresultsinsignificantdistress,eitherpersonally,orforthosearoundtheaffectedindividual.Excessiveskinpicking,hairpulling,nailbiting,andotherbody-focusedrepetitivebehaviordisordersareallontheobsessive–compulsivespectrum.[2]SomeindividualswithOCDareawarethattheirbehaviorsarenotrational,buttheyfeelcompelledtofollowthroughwiththemtofendofffeelingsofpanicordread.[33]Furthermore,compulsionsoftenstemfrommemorydistrust,asymptomofOCDcharacterizedbyinsecurityinone'sskillsinperception,attention,andmemory,evenincaseswherethereisnoclearevidenceofadeficit.[34] Commoncompulsionsmayincludehandwashing,cleaning,checkingthings(suchaslocksondoors),repeatingactions(suchasrepeatedlyturningonandoffswitches),orderingitemsinacertainway,andrequestingreassurance.[35]Althoughsomeindividualsperformactionsrepeatedly,theydonotnecessarilyperformtheseactionscompulsively;forexample,morningornighttimeroutinesandreligiouspracticesarenotusuallycompulsions.Whetherbehaviorsqualifyascompulsionsormerehabitdependsonthecontextinwhichtheyareperformed.Forinstance,arrangingandorderingbooksforeighthoursadaywouldbeexpectedofsomeonewhoworksinalibrary,butthisroutinewouldseemabnormalinothersituations.Inotherwords,habitstendtobringefficiencytoone'slife,whilecompulsionstendtodisruptit.[36]Furthermore,compulsionsaredifferentfromtics(suchastouching,tapping,rubbing,orblinking)andstereotypedmovements(suchasheadbanging,bodyrocking,orself-biting),whichareusuallynotascomplexandnotprecipitatedbyobsessions.[37]Itcansometimesbedifficulttotellthedifferencebetweencompulsionsandcomplextics,andabout10–40%ofpeoplewithOCDalsohavealifetimeticdisorder.[2][38] PeoplewithOCDrelyoncompulsionsasanescapefromtheirobsessivethoughts;however,theyareawarethatreliefisonlytemporary,andthatintrusivethoughtswillreturn.Someaffectedindividualsusecompulsionstoavoidsituationsthatmaytriggerobsessions.Compulsionsmaybeactionsdirectlyrelatedtotheobsession,suchassomeoneobsessedwithcontaminationcompulsivelywashingtheirhands,buttheycanbeunrelatedaswell.[9]InadditiontoexperiencingtheanxietyandfearthattypicallyaccompaniesOCD,affectedindividualsmayspendhoursperformingcompulsionseveryday.Insuchsituations,itcanbecomedifficultforthepersontofulfilltheirwork,familial,orsocialroles.Thesebehaviorscanalsocauseadversephysicalsymptoms;forexample,peoplewhoobsessivelywashtheirhandswithantibacterialsoapandhotwatercanmaketheirskinredandrawwithdermatitis.[39] IndividualswithOCDoftenuserationalizationstoexplaintheirbehavior;however,theserationalizationsdonotapplytothebehavioralpattern,buttoeachindividualoccurrence.Forexample,someonecompulsivelycheckingthefrontdoormayarguethatthetimeandstressassociatedwithonecheckislessthanthetimeandstressassociatedwithbeingrobbed,andcheckingisconsequentlythebetteroption.Thisreasoningoftenoccursinacyclicalmanner,andcancontinueforaslongastheaffectedpersonneedsittoinordertofeelsafe.[40] Incognitivebehavioraltherapy(CBT),OCDpatientsareaskedtoovercomeintrusivethoughtsbynotindulginginanycompulsions.TheyaretaughtthatritualskeepOCDstrong,whilenotperformingthemcausesOCDtobecomeweaker.[41]Thispositionissupportedbythepatternofmemorydistrust;themoreoftencompulsionsarerepeated,themoreweakenedmemorytrustbecomes,andthiscyclecontinuesasmemorydistrustincreasescompulsionfrequency.[42]Forbody-focusedrepetitivebehaviors(BFRB)suchastrichotillomania(hairpulling),skinpicking,andonychophagia(nailbiting),behavioralinterventionssuchashabitreversaltraininganddecouplingarerecommendedforthetreatmentofcompulsivebehaviors.[43][44] OCDsometimesmanifestswithoutovertcompulsions,whichmaybetermed"primarilyobsessionalOCD."OCDwithoutovertcompulsionscould,byoneestimate,characterizeasmanyas50–60%ofOCDcases.[45] Insightandovervaluedideation TheDSM-5[expandacronym]identifiesacontinuumforthelevelofinsightinOCD,rangingfromgoodinsight(theleastsevere)tonoinsight(themostsevere).Goodorfairinsightischaracterizedbytheacknowledgmentthatobsessive–compulsivebeliefsarenotormaynotbetrue,whilepoorinsight,inthemiddleofthecontinuum,ischaracterizedbythebeliefthatobsessive–compulsivebeliefsareprobablytrue.Theabsenceofinsightaltogether,inwhichtheindividualiscompletelyconvincedthattheirbeliefsaretrue,isalsoidentifiedasadelusionalthoughtpattern,andoccursinabout4%ofpeoplewithOCD.[46][47]WhencasesofOCDwithnoinsightbecomesevere,affectedindividualshaveanunshakablebeliefintherealityoftheirdelusions,whichcanmaketheircasesdifficulttodifferentiatefrompsychoticdisorders.[48] SomepeoplewithOCDexhibitwhatisknownasovervaluedideas,ideasthatareabnormalcomparedtoaffectedindividuals'respectivecultures,andmoretreatment-resistantthanmostnegativethoughtsandobsessions.[49]Aftersomediscussion,itispossibletoconvincetheindividualthattheirfearsareunfounded.Itmaybemoredifficulttopracticeexposureandresponsepreventiontherapy(ERP)onsuchpeople,astheymaybeunwillingtocooperate,atleastinitially.[citationneeded]Similartohowinsightisidentifiedonacontinuum,obsessive-compulsivebeliefsarecharacterizedonaspectrum,rangingfromobsessivedoubttodelusionalconviction.IntheUnitedStates,overvaluedideation(OVI)isconsideredmostakintopoorinsight—especiallywhenconsideringbeliefstrengthasoneofanidea'skeyidentifiers—butEuropeanqualificationshavehistoricallybeenbroader.Furthermore,severeandfrequentovervaluedideasareconsideredsimilartoidealizedvalues,whicharesorigidlyheldby,andsoimportanttoaffectedindividuals,thattheyendupbecomingadefiningidentity.[49]InadolescentOCDpatients,OVIisconsideredaseveresymptom.[50] Historically,OVIhasbeenthoughttobelinkedtopoorertreatmentoutcomeinpatientswithOCD,butitiscurrentlyconsideredapoorindicatorofprognosis.[50][51]TheOvervaluedIdeasScale(OVIS)hasbeendevelopedasareliablequantitativemethodofmeasuringlevelsofOVIinpatientswithOCD,andresearchhassuggestedthatovervaluedideasaremorestableforthosewithmoreextremeOVISscores.[52] Cognitiveperformance ThoughOCDwasoncebelievedtobeassociatedwithabove-averageintelligence,thisdoesnotappeartonecessarilybethecase.[53]A2013reviewreportedthatpeoplewithOCDmaysometimeshavemildbutwide-rangingcognitivedeficits,mostsignificantlythoseaffectingspatialmemoryandtoalesserextentwithverbalmemory,fluency,executivefunction,andprocessingspeed,whileauditoryattentionwasnotsignificantlyaffected.[54]PeoplewithOCDshowimpairmentinformulatinganorganizationalstrategyforcodinginformation,set-shifting,andmotorandcognitiveinhibition.[55] SpecificsubtypesofsymptomdimensionsinOCDhavebeenassociatedwithspecificcognitivedeficits.[56]Forexample,theresultsofonemeta-analysiscomparingwashingandcheckingsymptomsreportedthatwashersoutperformedcheckersoneightoutoftencognitivetests.[57]Thesymptomdimensionofcontaminationandcleaningmaybeassociatedwithhigherscoresontestsofinhibitionandverbalmemory.[58] Children Approximately1–2%ofchildrenareaffectedbyOCD.[59]Obsessive–compulsivedisordersymptomstendtodevelopmorefrequentlyinchildren10–14yearsofage,withmalesdisplayingsymptomsatanearlierage,andatamoreseverelevelthanfemales.[60]Inchildren,symptomscanbegroupedintoatleastfourtypes,includingsporadicandtic-relatedOCD.[21] Associatedconditions PeoplewithOCDmaybediagnosedwithotherconditionsaswell,suchasobsessive–compulsivepersonalitydisorder,majordepressivedisorder,bipolardisorder,generalizedanxietydisorder,anorexianervosa,socialanxietydisorder,bulimianervosa,Tourettesyndrome,transformationobsession,ASD,ADHD,dermatillomania,bodydysmorphicdisorder,andtrichotillomania.[61]Morethan50%ofpeoplewithOCDexperiencesuicidaltendencies,and15%haveattemptedsuicide.[12]Depression,anxiety,andpriorsuicideattemptsincreasetheriskoffuturesuicideattempts.[62] Ithasbeenfoundthatbetween18-34%offemalesarecurrentlyexperiencingorwillexperienceOCDintheirlifetime.[63]Ofthat18-34%,7%arelikelytohaveaneatingdisorder.[63]Roughly0-5%ofmaleshaveOCDandaneatingdisorder.[63] IndividualswithOCDhavealsobeenfoundtobeaffectedbydelayedsleepphasedisorderatasubstantiallyhigherratethanthegeneralpublic.[64][65]Moreover,severeOCDsymptomsareconsistentlyassociatedwithgreatersleepdisturbance.ReducedtotalsleeptimeandsleepefficiencyhavebeenobservedinpeoplewithOCD,withdelayedsleeponsetandoffset.[65] SomeresearchhasdemonstratedalinkbetweendrugaddictionandOCD.Forexample,thereisahigherriskofdrugaddictionamongthosewithanyanxietydisorder,likelyasawayofcopingwiththeheightenedlevelsofanxiety.However,drugaddictionamongpeoplewithOCDmaybeacompulsivebehavior.DepressionisalsoextremelyprevalentamongpeoplewithOCD.OneexplanationforthehighdepressionrateamongOCDpopulationswaspositedbyMineka,Watson,andClark(1998),whoexplainedthatpeoplewithOCD,oranyotheranxietydisorder,mayfeel"outofcontrol".[66] SomeoneexhibitingOCDsignsdoesnotnecessarilyhaveOCD.Behaviorsthatpresentasobsessive–compulsivecanalsobefoundinanumberofotherconditions,includingobsessive–compulsivepersonalitydisorder(OCPD),autismspectrumdisorder(ASD),ordisordersinwhichperseverationisapossiblefeature(ADHD,PTSD,bodilydisorders,orstereotypedbehaviors).[67]SomecasesofOCDpresentsymptomstypicallyassociatedwithTourettesyndrome,suchascompulsionsthatmayappeartoresemblemotortics;thishasbeentermedtic-relatedOCDorTouretticOCD.[68][69] OCDfrequentlyoccurscomorbidlywithbothbipolardisorderandmajordepressivedisorder.Between60and80%ofthosewithOCDexperienceamajordepressiveepisodeintheirlifetime.Comorbidityrateshavebeenreportedatbetween19and90%,asaresultofmethodologicaldifferences.Between9–35%ofthosewithbipolardisorderalsohaveOCD,comparedto1–2%inthegeneralpopulation.About50%ofthosewithOCDexperiencecyclothymictraitsorhypomanicepisodes.OCDisalsoassociatedwithanxietydisorders.LifetimecomorbidityforOCDhasbeenreportedat22%forspecificphobia,18%forsocialanxietydisorder,12%forpanicdisorder,and30%forgeneralizedanxietydisorder.ThecomorbidityrateforOCDandADHDhasbeenreportedtobeashighas51%.[70] OCD Both ED(s) obsessionsandcompulsionsbeyondfoodandbodyimage(e.g.,washing,checking,counting,etc.) neuroticism obsessionsandcompulsionsaroundfoodandbodyimage(e.g.,overexercising,countingcalories,bodychecking,etc.) excessiveandunreasonablebehaviors perfectionism disturbedbodyimage intrusivethoughts anxiety driveforthinness depression secretiveaboutbehaviorsandfeelings genetics Causes Mainarticle:Causeofobsessive-compulsivedisorder ThecauseofOCDisunknown.[1]Bothenvironmentalandgeneticfactorsarebelievedtoplayarole.Riskfactorsincludeahistoryofchildabuseorotherstress-inducingevents.[2] Drug-inducedOCD Somemedicationsandotherdrugs,suchasmethamphetamineorcocaine,caninduceobsessive-compulsivedisorder(OCD)inpeoplewithoutprevioussymptoms.[71] Someatypicalantipsychotics(second-generationantipsychotics)suchasolanzapine(Zyprexa)andclozapine(Clozaril)caninduceOCDinpeople,particularlyindividualswithschizophrenia.[72][73][74][75] Genetics ThereappeartobesomegeneticcomponentsofOCDcausation,withidenticaltwinsmoreoftenaffectedthanfraternaltwins.[2]Furthermore,individualswithOCDaremorelikelytohavefirst-degreefamilymembersexhibitingthesamedisordersthanmatchedcontrols.IncasesinwhichOCDdevelopsduringchildhood,thereisamuchstrongerfamiliallinkinthedisorderthanwithcasesinwhichOCDdevelopslaterinadulthood.Ingeneral,geneticfactorsaccountfor45–65%ofthevariabilityinOCDsymptomsinchildrendiagnosedwiththedisorder.[76]A2007studyfoundevidencesupportingthepossibilityofaheritableriskforOCD.[77] ResearchhasfoundtheretobeageneticcorrelationbetweenanorexianervosaandOCD,suggestingastrongetiology.[78][79][80]FirstandsecondhandrelativesofprobandswithOCDhaveagreaterriskofdevelopinganorexianervosaasgeneticrelatednessincreases.[78] AmutationhasbeenfoundinthehumanserotonintransportergenehSERTinunrelatedfamilieswithOCD.[81] AsystematicreviewfoundthatwhileneitherallelewasassociatedwithOCDoverall,inCaucasians,theLallelewasassociatedwithOCD.[82]Anothermeta-analysisobservedanincreasedriskinthosewiththehomozygousSallele,butfoundtheLSgenotypetobeinverselyassociatedwithOCD.[83] Agenome-wideassociationstudyfoundOCDtobelinkedwithsingle-nucleotidepolymorphisms(SNPs)nearBTBD3,andtwoSNPsinDLGAP1inatrio-basedanalysis,butnoSNPreachedsignificancewhenanalyzedwithcase-controldata.[84] Onemeta-analysisfoundasmallbutsignificantassociationbetweenapolymorphisminSLC1A1andOCD.[85] TherelationshipbetweenOCDandCatechol-O-methyltransferase(COMT)hasbeeninconsistent,withonemeta-analysisreportingasignificantassociation,albeitonlyinmen,andanothermetaanalysisreportingnoassociation.[86][87] Ithasbeenpostulatedbyevolutionarypsychologiststhatmoderateversionsofcompulsivebehaviormayhavehadevolutionaryadvantages.Exampleswouldbemoderateconstantcheckingofhygiene,thehearth,ortheenvironmentforenemies.Similarly,hoardingmayhavehadevolutionaryadvantages.Inthisview,OCDmaybetheextremestatisticaltailofsuchbehaviors,possiblytheresultofahighnumberofpredisposinggenes.[88] Brainstructureandfunctioning ImagingstudieshaveshowndifferencesinthefrontalcortexandsubcorticalstructuresofthebraininpatientswithOCD.ThereappearstobeaconnectionbetweentheOCDsymptomsandabnormalitiesincertainareasofthebrain,butsuchaconnectionisnotclear.[89]SomepeoplewithOCDhaveareasofunusuallyhighactivityintheirbrain,orlowlevelsofthechemicalserotonin,[90]whichisaneurotransmitterthatsomenervecellsusetocommunicatewitheachother,[91]andisthoughttobeinvolvedinregulatingmanyfunctions,influencingemotions,mood,memory,andsleep.[92] Autoimmune AcontroversialhypothesisisthatsomecasesofrapidonsetofOCDinchildrenandadolescentsmaybecausedbyasyndromeconnectedtoGroupAstreptococcalinfections(GABHS),knownaspediatricautoimmuneneuropsychiatricdisordersassociatedwithstreptococcalinfections(PANDAS).[93][94][95]OCDandticdisordersarehypothesizedtoariseinasubsetofchildrenasaresultofapost-streptococcalautoimmuneprocess.[96][97][98]ThePANDAShypothesisisunconfirmedandunsupportedbydata,andtwonewcategorieshavebeenproposed:PANS(pediatricacute-onsetneuropsychiatricsyndrome)andCANS(childhoodacuteneuropsychiatricsyndrome).[97][98]TheCANSandPANShypothesesincludedifferentpossiblemechanismsunderlyingacute-onsetneuropsychiatricconditions,butdonotexcludeGABHSinfectionsasacauseinasubsetofindividuals.[97][98]PANDAS,PANS,andCANSarethefocusofclinicalandlaboratoryresearch,butremainunproven.[96][97][98]WhetherPANDASisadistinctentitydifferingfromothercasesofticdisordersorOCDisdebated.[99][100][101][102] Areviewofstudiesexamininganti-basalgangliaantibodiesinOCDfoundanincreasedriskofhavinganti-basalgangliaantibodiesinthosewithOCDversusthegeneralpopulation.[103] Environment OCDmaybemorecommoninpeoplewhohavebeenbullied,abused,orneglected,anditsometimesstartsafterasignificantlifeevent,suchaschildbirthorbereavement.[90]Ithasbeenreportedinsomestudiesthatthereisaconnectionbetweenchildhoodtraumaandobsessive-compulsivesymptoms.Moreresearchisneededtounderstandthisrelationshipbetter.[89] Mechanisms Mainarticle:Biologyofobsessive–compulsivedisorder Neuroimaging SomepartsofthebrainshowingabnormalactivityinOCD Functionalneuroimagingduringsymptomprovocationhasobservedabnormalactivityintheorbitofrontalcortex(OFC),leftdorsolateralprefrontalcortex(dlPFC),rightpremotorcortex,leftsuperiortemporalgyrus,globuspallidusexternus,hippocampus,andrightuncus.Weakerfociofabnormalactivitywerefoundintheleftcaudate,posteriorcingulatecortex,andsuperiorparietallobule.[104]However,anoldermeta-analysisoffunctionalneuroimaginginOCDreportedthattheonlyconsistentfunctionalneuroimagingfindingwasincreasedactivityintheorbitalgyrusandheadofthecaudatenucleus,whileanteriorcingulatecortex(ACC)activationabnormalitiesweretooinconsistent.[105] Ameta-analysiscomparingaffectiveandnonaffectivetasksobserveddifferenceswithcontrolsinregionsimplicatedinsalience,habit,goal-directedbehavior,self-referentialthinking,andcognitivecontrol.Fornonaffectivetasks,hyperactivitywasobservedintheinsula,ACC,andheadofthecaudate/putamen,whilehypoactivitywasobservedinthemedialprefrontalcortex(mPFC)andposteriorcaudate.Affectivetaskswereobservedtorelatetoincreasedactivationintheprecuneusandposteriorcingulatecortex,whiledecreasedactivationwasfoundinthepallidum,ventralanteriorthalamus,andposteriorcaudate.[106]Theinvolvementofthecortico-striato-thalamo-corticalloopinOCD,aswellasthehighratesofcomorbiditybetweenOCDandADHD,haveledsometodrawalinkintheirmechanism.Observedsimilaritiesincludedysfunctionoftheanteriorcingulatecortexandprefrontalcortex,aswellasshareddeficitsinexecutivefunctions.[107]TheinvolvementoftheorbitofrontalcortexanddorsolateralprefrontalcortexinOCDissharedwithbipolardisorder,andmayexplainthehighdegreeofcomorbidity.[108]DecreasedvolumesofthedorsolateralprefrontalcortexrelatedtoexecutivefunctionhasalsobeenobservedinOCD.[109] PeoplewithOCDevinceincreasedgreymattervolumesinbilaterallenticularnuclei,extendingtothecaudatenuclei,withdecreasedgreymattervolumesinbilateraldorsalmedialfrontal/anteriorcingulategyri.[110][108]Thesefindingscontrastwiththoseinpeoplewithotheranxietydisorders,whoevincedecreased(ratherthanincreased)greymattervolumesinbilaterallenticular/caudatenuclei,aswellasdecreasedgreymattervolumesinbilateraldorsalmedialfrontal/anteriorcingulategyri.[108]IncreasedwhitemattervolumeanddecreasedfractionalanisotropyinanteriormidlinetractshasbeenobservedinOCD,possiblyindicatingincreasedfibercrossings.[111] Cognitivemodels Generally,twocategoriesofmodelsforOCDhavebeenpostulated.ThefirstcategoryinvolvesdeficitsinexecutivedysfunctionandisbasedontheobservedstructuralandfunctionalabnormalitiesinthedlPFC,striatumandthalamus.ThesecondcategoryinvolvesdysfunctionalmodulatorycontrolandprimarilyreliesonobservedfunctionalandstructuraldifferencesintheACC,mPFC,andOFC.[112][113] OneproposedmodelsuggeststhatdysfunctionintheOFCleadstoimpropervaluationofbehaviorsanddecreasedbehavioralcontrol,whiletheobservedalterationsinamygdalaactivationsleadstoexaggeratedfearsandrepresentationsofnegativestimuli.[114] DuetotheheterogeneityofOCDsymptoms,studiesdifferentiatingvarioussymptomshavebeenperformed.Symptom-specificneuroimagingabnormalitiesincludethehyperactivityofcaudateandACCincheckingrituals,whilefindingincreasedactivityofcorticalandcerebellarregionsincontamination-relatedsymptoms.Neuroimagingdifferentiatingcontentofintrusivethoughtshasfounddifferencesbetweenaggressiveasopposedtotaboothoughts,findingincreasedconnectivityoftheamygdala,ventralstriatum,andventromedialprefrontalcortexinaggressivesymptoms,whileobservingincreasedconnectivitybetweentheventralstriatumandinsulainsexualorreligiousintrusivethoughts.[115] Anothermodelproposesthataffectivedysregulationlinksexcessiverelianceonhabit-basedactionselection[116]withcompulsions.ThisissupportedbytheobservationthatthosewithOCDdemonstratedecreasedactivationoftheventralstriatumwhenanticipatingmonetaryreward,aswellasincreasedfunctionalconnectivitybetweentheVSandtheOFC.Furthermore,thosewithOCDdemonstratereducedperformanceinPavlovianfear-extinctiontasks,hyperresponsivenessintheamygdalatofearfulstimuli,andhyporesponsivenessintheamygdalawhenexposedtopositivelyvalancedstimuli.Stimulationofthenucleusaccumbenshasalsobeenobservedtoeffectivelyalleviatebothobsessionsandcompulsions,supportingtheroleofaffectivedysregulationingeneratingboth.[114] Neurobiological FromtheobservationoftheefficacyofantidepressantsinOCD,aserotoninhypothesisofOCDhasbeenformulated.Studiesofperipheralmarkersofserotonin,aswellaschallengeswithproserotonergiccompoundshaveyieldedinconsistentresults,includingevidencepointingtowardsbasalhyperactivityofserotonergicsystems.[117]Serotoninreceptorandtransporterbindingstudieshaveyieldedconflictingresults,includinghigherandlowerserotoninreceptor5-HT2AandserotonintransporterbindingpotentialsthatwerenormalizedbytreatmentwithSSRIs.Despiteinconsistenciesinthetypesofabnormalitiesfound,evidencepointstowardsdysfunctionofserotonergicsystemsinOCD.[118]OrbitofrontalcortexoveractivityisattenuatedinpeoplewhohavesuccessfullyrespondedtoSSRImedication,aresultbelievedtobecausedbyincreasedstimulationofserotoninreceptors5-HT2Aand5-HT2C.[119] AcomplexrelationshipbetweendopamineandOCDhasbeenobserved.Althoughantipsychotics,whichactbyantagonizingdopaminereceptors,mayimprovesomecasesofOCD,theyfrequentlyexacerbateothers.Antipsychotics,inthelowdosesusedtotreatOCD,mayactuallyincreasethereleaseofdopamineintheprefrontalcortex,throughinhibitingautoreceptors.Furthercomplicatingthingsistheefficacyofamphetamines,decreaseddopaminetransporteractivityobservedinOCD,[120]andlowlevelsofD2bindinginthestriatum.[121]Furthermore,increaseddopaminereleaseinthenucleusaccumbensafterdeepbrainstimulationcorrelateswithimprovementinsymptoms,pointingtoreduceddopaminereleaseinthestriatumplayingaroleingeneratingsymptoms.[122] AbnormalitiesinglutamatergicneurotransmissionhaveimplicatedinOCD.Findingssuchasincreasedcerebrospinalglutamate,lessconsistentabnormalitiesobservedinneuroimagingstudies,andtheefficacyofsomeglutamatergicdrugs(suchastheglutamate-inhibitingriluzole)haveimplicatedglutamateinOCD.[121]OCDhasbeenassociatedwithreducedN-AcetylasparticacidinthemPFC,whichisthoughttoreflectneurondensityorfunctionality,althoughtheexactinterpretationhasnotbeenestablished.[123] Diagnosis Formaldiagnosismaybeperformedbyapsychologist,psychiatrist,clinicalsocialworker,orotherlicensedmentalhealthprofessional.OCD,likeothermentalandbehavioralhealthdisorders,cannotbediagnosedbyamedicalexam.[7]Norarethereanymedicalexamsthatcanpredictifonewillfallvictimtosuchillnesses.TobediagnosedwithOCD,apersonmusthaveobsessions,compulsions,orboth,accordingtotheDiagnosticandStatisticalManualofMentalDisorders(DSM).TheDSMnotesthattherearemultiplecharacteristicsthatcanturnobsessionsandcompulsionsfromnormalizedbehaviorto"clinicallysignificant".Therehastoberecurringandstrongthoughtsorimpulsivethatintrudeonthedaytodaylivesofthepatientsandcausenoticeablelevelsofanxiousness.[2] Thesethoughts,impulses,orimagesareofadegreeortypethatliesoutsidethenormalrangeofworriesaboutconventionalproblems.[124]Apersonmayattempttoignoreorsuppresssuchobsessions,ortoneutralizethemwithsomeotherthoughtoraction,andwilltendtorecognizetheobsessionsasidiosyncraticorirrational. Compulsionsbecomeclinicallysignificantwhenapersonfeelsdriventoperformtheminresponsetoanobsession,oraccordingtorulesthatmustbeappliedrigidly,andwhenthepersonconsequentlyfeelsorcausessignificantdistress.Therefore,whilemanypeoplewhodonothaveOCDmayperformactionsoftenassociatedwithOCD(suchasorderingitemsinapantrybyheight),thedistinctionwithclinicallysignificantOCDliesinthefactthatthepersonwithOCDmustperformtheseactionstoavoidsignificantpsychologicaldistress.Thesebehaviorsormentalactsareaimedatpreventingorreducingdistressorpreventingsomedreadedeventorsituation;however,theseactivitiesarenotlogicallyorpracticallyconnectedtotheissue,or,theyareexcessive.Inaddition,atsomepointduringthecourseofthedisorder,theindividualmustrealizethathisorherobsessionsorcompulsionsareunreasonableorexcessive.[citationneeded] Moreover,theobsessionsorcompulsionsmustbetime-consuming,oftentakingupmorethanonehourperday,orcauseimpairmentinsocial,occupational,orscholasticfunctioning.[124]ItishelpfultoquantifytheseverityofsymptomsandimpairmentbeforeandduringtreatmentforOCD.Inadditiontotheperson'sestimateofthetimespenteachdayharboringobsessive-compulsivethoughtsorbehaviors,concretetoolscanbeusedtogaugetheperson'scondition.Thismaybedonewithratingscales,suchastheYale–BrownObsessiveCompulsiveScale(Y-BOCS;expertrating)[125]ortheobsessive-compulsiveinventory(OCI-R;self-rating).[126]Withmeasurementssuchasthese,psychiatricconsultationcanbemoreappropriatelydetermined,asithasbeenstandardized.[12] Inregardstodiagnosing,thehealthprofessionalalsolookstomakesurethatthesignsofobsessionsandcompulsionsarenottheresultsofanydrugs,prescriptionorrecreational,thatthepatientmaybetaking.[127] ThereareseveraltypesofobsessivethoughtsthatarefoundcommonlyinthosewithOCD.Someoftheseincludefearofgerms,hurtinglovedones,embarrassment,neatness,societallyunacceptablesexualthoughtsetc.[127].WithinOCD,thesespecificcategoriesareoftendiagnosedintotheirowntypeofOCD.[2] OCDissometimesplacedinagroupofdisorderscalledtheobsessive–compulsivespectrum.[128] AnothercriteriaintheDSMisthataperson'smentalillnessdoesnotfitoneoftheothercategoriesofamentaldisorderbetter.Thatistosay,iftheobsessionsandcompulsionsofapatientcouldbebetterdescribedbytrichotillomania,itwouldnotbediagnosedasOCD.[2]Thatbeingsaid,OCDdoesoftengohandinhandwithothermentaldisorders.Forthisreason,onemaybediagnosedwithmultiplementaldisordersatonceorevenmultipletypesofOCDatonce.[129] Adifferentaspectofthediagnosesisthedegreeofinsighthadbytheindividualinregardstothetruthoftheobsessions.Therearethreelevels,good/fair,poororabsent/delusional.Good/fairindicatedthatthepatientisawarethattheobsessionstheyhavearenottrueorprobablynottrue.[2]Poorindicatesthatthepatientbelievestheirobsessionalbeliefsareprobablytrue.[2]Absent/delusionalindicatesthattheyfullybelievetheirobsessionalthoughtstobetrue.[2]Approximately4%orfewerindividualswithOCDwillbediagnosedasabsent/delusional.[2]Additionally,asmanyas30%ofthosewithOCDalsohavealifetimeticdisorder,meaningtheyhavebeendiagnosedwithaticdisorderatsomepointintheirlife.[2] ThereareseveraldifferenttypesofticsthathavebeenobservedinindividualswithOCD.Theseincludebutarenotlimitedto,"grunting","jerking"or"shrugging"bodyparts,sniffling,andexcessiveblinking.[127] Therehasbeenasignificantamountofprogressoverthelastfewdecades,andasof2022thereisstaticallysignificantimprovementinthediagnosticprocessforindividualswithOCD.Onestudyfoundthatoftwogroupsofindividuals,onewithparticipantsundertheageof27.25andonewithparticipantsoverthatage,thoseintheyoungergroupexperiencedasignificantlyfastertimebetweentheonsetofOCDtendenciesandtheirformaldiagnoses.[130] Differentialdiagnosis OCDisoftenconfusedwiththeseparateconditionobsessive–compulsivepersonalitydisorder(OCPD).OCDisegodystonic,meaningthatthedisorderisincompatiblewiththeindividual'sself-concept.[131][132]Asegodystonicdisordersgoagainstaperson'sself-concept,theytendtocausemuchdistress.OCPD,ontheotherhand,isegosyntonic,markedbytheperson'sacceptancethatthecharacteristicsandbehaviorsdisplayedasaresultarecompatiblewiththeirself-image,orareotherwiseappropriate,correct,orreasonable. Asaresult,peoplewithOCDareoftenawarethattheirbehaviorisnotrational,andareunhappyabouttheirobsessions,butneverthelessfeelcompelledbythem.[133]Bycontrast,peoplewithOCPDarenotawareofanythingabnormal;theywillreadilyexplainwhytheiractionsarerational.Itisusuallyimpossibletoconvincethemotherwise,andtheytendtoderivepleasurefromtheirobsessionsorcompulsions.[133] Management Cognitivebehavioraltherapy(CBT)andpsychotropicmedicationsarethefirst-linetreatmentsforOCD.[1][134] Therapy Oneexposureandritualpreventionactivitywouldbetocheckthelockonlyonceandthenleave. ThespecificCBTtechniqueusediscalledexposureandresponseprevention(ERP),whichinvolvesteachingthepersontodeliberatelycomeintocontactwithsituationsthattriggerobsessivethoughtsandfears(exposure),withoutcarryingouttheusualcompulsiveactsassociatedwiththeobsession(responseprevention).Thistechniquecausespatientstograduallylearntotoleratethediscomfortandanxietyassociatedwithnotperformingtheircompulsions.Formanypatients,ERPistheadd-ontreatmentofchoicewhenselectiveserotoninreuptakeinhibitors(SSRIs)orserotonin-norepinephrinereuptakeinhibitors(SNRIs)medicationdoesnoteffectivelytreatOCDsymptoms,orviceversa,forindividualswhobegintreatmentwithpsychotherapy.[89] Forexample,apatientmightbeaskedtotouchsomethingverymildlycontaminated(exposure),andwashtheirhandsonlyonceafterward(responseprevention).Anotherexamplemightentailaskingthepatienttoleavethehouseandcheckthelockonlyonce(exposure),withoutgoingbacktocheckagain(responseprevention).Aftersucceedingatonestageoftreatment,thepatient'slevelofdiscomfortintheexposurephasecanbeincreased.Whenthistherapyissuccessful,thepatientwillquicklyhabituatetoananxiety-producingsituation,discoveringaconsiderabledropinanxietylevel.[135] ERPhasastrongevidencebase,andisconsideredthemosteffectivetreatmentforOCD.[135]However,thisclaimwasdoubtedbysomeresearchersin2000,whocriticizedthequalityofmanystudies.[136] Acceptanceandcommitmenttherapy(ACT),anewertherapyalsousedtotreatanxietyanddepression,hasalsobeenfoundtobeeffectiveintreatmentofOCD.[137][138]ACTusesacceptanceandmindfulnessstrategiestoteachpatientsnottooverreacttooravoidunpleasantthoughtsandfeelingsbutrather"movetowardvaluedbehavior."[139][140] A2007CochranereviewfoundthatpsychologicalinterventionsderivedfromCBTmodels,suchasERPandACT,weremoreeffectivethannon-CBTinterventions.[141]Otherformsofpsychotherapy,suchaspsychodynamicsandpsychoanalysis,mayhelpinmanagingsomeaspectsofthedisorder.However,in2007,theAmericanPsychiatricAssociation(APA)notedalackofcontrolledstudiesshowingtheirefficacy,"indealingwiththecoresymptomsofOCD."[142]Forbody-focusedrepetitivebehaviors(BFRB),behavioralinterventionssuchashabit-reversaltraininganddecouplingarerecommended.[43][44] PsychotherapyincombinationwithpsychiatricmedicationmaybemoreeffectivethaneitheroptionaloneforindividualswithsevereOCD.[143][144][145]ERPcoupledwithweightrestorationandserotoninreputakeinhibitorshasproventhemosteffectivewhentreatingOCDandaneatingdisordersimultaneously.[146] Medication AblisterpackofclomipramineunderthebrandnameAnafranil ThemedicationsmostfrequentlyusedtotreatOCDareantidepressants,includingselectiveserotoninreuptakeinhibitors(SSRIs)andserotonin-norepinephrinereuptakeinhibitors(SNRIs).Clomipramine,amedicationbelongingtotheclassoftricyclicantidepressants,appearstoworkaswellasSSRIs,buthasahigherrateofsideeffects.[4] SSRIshelppeoplewithOCDbyinhibitingthereabsorptionofserotoninbythenervecellsaftertheycarrymessagesfromneuronstosynapse;thus,moreserotoninisavailabletopassfurthermessagesbetweennearbynervecells.[92] SSRIsareasecond-linetreatmentofadultOCDwithmildfunctionalimpairment,andasfirst-linetreatmentforthosewithmoderateorsevereimpairment.Inchildren,SSRIscanbeconsideredasasecond-linetherapyinthosewithmoderatetosevereimpairment,withclosemonitoringforpsychiatricadverseeffects.[134]PatientstreatedwithSSRIsareabouttwiceaslikelytorespondtotreatmentasarethosetreatedwithplacebo,sothistreatmentisqualifiedasefficacious.[147][148]Efficacyhasbeendemonstratedbothinshort-term(6–24weeks)treatmenttrials,andindiscontinuationtrialswithdurationsof28–52weeks.[149][150][151] In2006,theNationalInstituteforHealthandCareExcellence(NICE)guidelinesrecommendedaugmentativesecond-generation(atypical)antipsychoticsfortreatment-resistantOCD.[5]Atypicalantipsychoticsarenotusefulwhenusedalone,andnoevidencesupportstheuseoffirst-generationantipsychotics.[18][152]ForOCDtreatmentspecifically,thereistentativeevidenceforrisperidone,andinsufficientevidenceforolanzapine.Quetiapineisnobetterthanplacebowithregardtoprimaryoutcomes,butsmalleffectswerefoundintermsofY-BOCSscore.Theefficacyofquetiapineandolanzapinearelimitedbyaninsufficientnumberofstudies.[153]A2014reviewarticlefoundtwostudiesthatindicatedthataripiprazolewas"effectiveintheshort-term",andfoundthat"[t]herewasasmalleffect-sizeforrisperidoneoranti-psychoticsingeneralintheshort-term";however,thestudyauthorsfound"noevidencefortheeffectivenessofquetiapineorolanzapineincomparisontoplacebo."[5]WhilequetiapinemaybeusefulwhenusedinadditiontoanSSRI/SNRIintreatment-resistantOCD,thesedrugsareoftenpoorlytolerated,andhavemetabolicsideeffectsthatlimittheiruse.AguidelinebytheAmericanPsychologicalAssociationsuggestedthatdextroamphetaminemaybeconsideredbyitselfaftermorewell-supportedtreatmentshavebeenattempted.[154] Procedures Electroconvulsivetherapy(ECT)hasbeenfoundtohaveeffectivenessinsomesevereandrefractorycases.[155] Surgerymaybeusedasalastresortinpeoplewhodonotimprovewithothertreatments.Inthisprocedure,asurgicallesionismadeinanareaofthebrain(thecingulatecortex).Inonestudy,30%ofparticipantsbenefittedsignificantlyfromthisprocedure.[156]Deepbrainstimulationandvagusnervestimulationarepossiblesurgicaloptionsthatdonotrequiredestructionofbraintissue.IntheUnitedStates,theFoodandDrugAdministrationapproveddeep-brainstimulationforthetreatmentofOCDunderahumanitariandeviceexemption,requiringthattheprocedurebeperformedonlyinahospitalwithspecialqualificationstodoso.[157] IntheUnitedStates,psychosurgeryforOCDisatreatmentoflastresort,andwillnotbeperformeduntilthepersonhasfailedseveralattemptsatmedication(atthefulldosage)withaugmentation,andmanymonthsofintensivecognitive–behavioraltherapywithexposureandritual/responseprevention.[158]Likewise,intheUnitedKingdom,psychosurgerycannotbeperformedunlessacourseoftreatmentfromasuitablyqualifiedcognitive–behavioraltherapisthasbeencarriedout. Children TherapeutictreatmentmaybeeffectiveinreducingritualbehaviorsofOCDforchildrenandadolescents.[159]SimilartothetreatmentofadultswithOCD,cognitivebehavioraltherapystandsasaneffectiveandvalidatedfirstlineoftreatmentofOCDinchildren.[160]Familyinvolvement,intheformofbehavioralobservationsandreports,isakeycomponenttothesuccessofsuchtreatments.[161]Parentalinterventionsalsoprovidepositivereinforcementforachildwhoexhibitsappropriatebehaviorsasalternativestocompulsiveresponses.Inarecentmeta-analysisofevidenced-basedtreatmentofOCDinchildren,family-focusedindividualCBTwaslabeledas"probablyefficacious,"establishingitasoneoftheleadingpsychosocialtreatmentsforyouthwithOCD.[160]Afteroneortwoyearsoftherapy,inwhichachildlearnsthenatureoftheirobsessionandacquiresstrategiesforcoping,theymayacquirealargercircleoffriends,exhibitlessshyness,andbecomelessself-critical.[162] AlthoughtheknowncausesofOCDinyoungeragegroupsrangefrombrainabnormalitiestopsychologicalpreoccupations,lifestresssuchasbullyingandtraumaticfamilialdeathsmayalsocontributetochildhoodcasesofOCD,andacknowledgingthesestressorscanplayaroleintreatingthedisorder.[163] Epidemiology Age-standardizeddisability-adjustedlifeyearestimatedratesforobsessive-compulsivedisorderper100,000 inhabitantsin2004  nodata  <45  45–52.5  52.5–60  60–67.5  67.5–75  75–82.5  82.5–90  90–97.5  97.5–105  105–112.5  112.5–120  >120 Obsessive–compulsivedisorderaffectsabout2.3%ofpeopleatsomepointintheirlife,withtheyearlyrateabout1.2%.[6]OCDoccursworldwide.[2]Itisunusualforsymptomstobeginaftertheageof35andhalfofpeopledevelopproblemsbefore20.[1][2]Malesandfemalesareaffectedaboutequally.[1] Prognosis QualityoflifeisreducedacrossalldomainsinOCD.WhilepsychologicalorpharmacologicaltreatmentcanleadtoareductionofOCDsymptomsandanincreaseinreportedqualityoflife,symptomsmaypersistatmoderatelevelsevenfollowingadequatetreatmentcourses,andcompletelysymptom-freeperiodsareuncommon.[164][165]InpediatricOCD,around40%stillhavethedisorderinadulthood,andaround40%qualifyforremission.[166] History Plutarch,anancientGreekphilosopherandhistorian,describesanancientRomanmanwhopossiblyhadscrupulosity,whichcouldbeasymptomofOCDorOCPD.Thismanisdescribedas"turningpaleunderhiscrownofflowers,"prayingwitha"falteringvoice,"andscattering"incensewithtremblinghands."[167][168][169] Inthe7thcenturyAD,JohnClimacusrecordsaninstanceofayoungmonkplaguedbyconstantandoverwhelming"temptationstoblasphemy"consultinganoldermonk,whotoldhim:"Myson,Itakeuponmyselfallthesinswhichthesetemptationshaveledyou,ormayleadyou,tocommit.AllIrequireofyouisthatforthefutureyoupaynoattentiontothemwhatsoever."[170]: 212 TheCloudofUnknowing,aChristianmysticaltextfromthelate14thcentury,recommendsdealingwithrecurringobsessionsbyattemptingtoignorethem,and,ifthatfails,to"cowerunderthemlikeapoorwretchandacowardovercomeinbattle,andreckonittobeawasteofyourtimeforyoutostriveanylongeragainstthem",atechniquenowknownasemotionalflooding.[170]: 213  Fromthe14thtothe16thcenturyinEurope,itwasbelievedthatpeoplewhoexperiencedblasphemous,sexualorotherobsessivethoughtswerepossessedbythedevil.[131][170]: 213 Basedonthisreasoning,treatmentinvolvedbanishingthe"evil"fromthe"possessed"personthroughexorcism.[171][172]Thevastmajorityofpeoplewhothoughtthattheywerepossessedbythedevildidnothavehallucinationsorother"spectacularsymptoms"but"complainedofanxiety,religiousfears,andevilthoughts."[170]: 213 In1584,awomanfromKent,England,namedMrs.Davie,describedbyajusticeofthepeaceas"agoodwife",wasnearlyburnedatthestakeaftersheconfessedthatsheexperiencedconstant,unwantedurgestomurderherfamily.[170]: 213  TheEnglishtermobsessive–compulsivearoseasatranslationofGermanZwangsvorstellung(obsession)usedinthefirstconceptionsofOCDbyCarlWestphal.Westphal'sdescriptionwentontoinfluencePierreJanet,whofurtherdocumentedfeaturesofOCD.[47]Intheearly1910s,SigmundFreudattributedobsessive–compulsivebehaviortounconsciousconflictsthatmanifestassymptoms.[171]Freuddescribestheclinicalhistoryofatypicalcaseof"touchingphobia"asstartinginearlychildhood,whenthepersonhasastrongdesiretotouchanitem.Inresponse,thepersondevelopsan"externalprohibition"againstthistypeoftouching.However,this"prohibitiondoesnotsucceedinabolishing"thedesiretotouch;allitcandoisrepressthedesireand"forceitintotheunconscious."[173]FreudianpsychoanalysisremainedthedominanttreatmentforOCDuntilthemid-1980s,eventhoughmedicinalandtherapeutictreatmentswereknownandavailable,becauseitwaswidelythoughtthatthesetreatmentswouldbedetrimentaltotheeffectivenessofthepsychotherapy.[170]: 210–211 Inthemid-1980s,thisapproachchanged,andpractitionersbegantreatingOCDprimarilywithmedicineandpracticaltherapyratherthanthroughpsychoanalysis.[170]: 210  Notablecases Thissectionneedsexpansionwith:peoplelistedinthenavigationtemplate.Youcanhelpbyaddingtoit.(August2022) JohnBunyan(1628–1688),theauthorofThePilgrim'sProgress,displayedsymptomsofOCD(whichhadnotyetbeennamed).Duringthemostsevereperiodofhiscondition,hewouldmutterthesamephraseoverandoveragaintohimselfwhilerockingbackandforth.[170]: 53–54 HelaterdescribedhisobsessionsinhisautobiographyGraceAboundingtotheChiefofSinners,stating,"Thesethingsmayseemridiculoustoothers,evenasridiculousastheywereinthemselves,buttometheywerethemosttormentingcogitations."[170]: 53–54 Hewrotetwopamphletsadvisingthosewithsimilaranxieties.[170]: 217–218 Inoneofthem,hewarnsagainstindulgingincompulsions:"Havecareofputtingoffyourtroubleofspiritinthewrongway:bypromisingtoreformyourselfandleadanewlife,byyourperformancesorduties".[170]: 217–218  Britishpoet,essayistandlexicographerSamuelJohnson(1709–1784)alsohadOCD.Hehadelaborateritualsforcrossingthethresholdsofdoorways,andrepeatedlywalkedupanddownstaircasescountingthesteps.[174][170]: 54–55 Hewouldtoucheverypostonthestreetashewalkedpast,onlystepinthemiddlesofpavingstones,andrepeatedlyperformtasksasthoughtheyhadnotbeendoneproperlythefirsttime.[170]: 55  TheAmericanaviatorandfilmmakerHowardHughesisknowntohavehadOCD.[175]FriendsofHugheshavealsomentionedhisobsessionwithminorflawsinclothing.[176]ThiswasconveyedinTheAviator(2004),afilmbiographyofHughes.[177] Englishsinger-songwriterGeorgeEzrahasopenlyspokenabouthislife-longstrugglewithOCD,particularly"PureOCD."[178] WorldrenownedSwedishclimateactivistGretaThunbergisalsoknowntohaveOCD,amongothermentalhealthconditions.[179] AmericanactorJamesSpaderisalsoknowntohaveOCD.[180] Societyandculture Thisribbonrepresentstrichotillomaniaandotherbody-focusedrepetitivebehaviors.ConceptfortheribbonwasstartedbyJenneSchrader.ColorswerevotedonbyaTrichotillomaniaFacebookcommunity,andmadeofficialbytheTrichotillomaniaLearningCenterinAugust2013.[improvecaption] Art,entertainmentandmedia MoviesandtelevisionshowsmayportrayidealizedorincompleterepresentationsofdisorderssuchasOCD.Compassionateandaccurateliteraryandon-screendepictionsmayhelpcounteractthepotentialstigmaassociatedwithanOCDdiagnosis,andleadtoincreasedpublicawareness,understandingandsympathyforsuchdisorders.[181][182] InthefilmAsGoodasItGets(1997),actorJackNicholsonportraysamanwithOCDwhoperformsritualisticbehaviorsthatdisrupthislife.[183] ThefilmMatchstickMen(2003)portraysaconmannamedRoy(NicolasCage)withOCDwhoopensandclosesdoorsthreetimeswhilecountingaloudbeforehecanwalkthroughthem.[184] InthetelevisionseriesMonk(2002–2009),thetitularcharacterAdrianMonkfearsbothhumancontactanddirt.[185][186] InthenovelTurtlesAlltheWayDown(2017)byJohnGreen,teenagemaincharacterAzaHolmesstruggleswithOCDthatmanifestsasafearofthehumanmicrobiome.Throughoutthestory,Azarepeatedlyopensanunhealedcallusonherfingertodrainoutwhatshebelievesarepathogens.ThenovelisbasedonGreen'sownexperienceswithOCD.HeexplainedthatTurtlesAlltheWayDownisintendedtoshowhow"mostpeoplewithchronicmentalillnessesalsolivelong,fulfillinglives".[187] TheBritishTVseriesPure(2019)starsCharlyCliveasa24-year-oldMarniewhoisplaguedbydisturbingsexualthoughts,asakindofprimarilyobsessionalobsessivecompulsivedisorder.[188] Research ThenaturallyoccurringsugarinositolhasbeensuggestedasatreatmentforOCD.[189] μ-Opioids,suchashydrocodoneandtramadol,mayimproveOCDsymptoms.[190]AdministrationofopiatetreatmentmaybecontraindicatedinindividualsconcurrentlytakingCYP2D6inhibitorssuchasfluoxetineandparoxetine.[191] Muchcurrentresearchisdevotedtothetherapeuticpotentialoftheagentsthataffectthereleaseoftheneurotransmitterglutamateorthebindingtoitsreceptors.Theseincluderiluzole,memantine,gabapentin,N-acetylcysteine,topiramateandlamotrigine.[192] Otheranimals Seealso:Animalpsychopathology§ Obsessivecompulsivedisorder(OCD) References ^abcdefghijklmnoTheNationalInstituteofMentalHealth(NIMH)(January2016)."WhatisObsessive-CompulsiveDisorder(OCD)?".U.S.NationalInstitutesofHealth(NIH).Archivedfromtheoriginalon23July2016.Retrieved24July2016. ^abcdefghijklmnopqrstuvwxyzDiagnosticandstatisticalmanualofmentaldisorders :DSM-5(5 ed.).Washington:AmericanPsychiatricPublishing.2013.pp. 237–242.ISBN 978-0-89042-555-8. ^abAngelakis,I;Gooding,P;Tarrier,N;Panagioti,M(25March2015)."Suicidalityinobsessivecompulsivedisorder(OCD):Asystematicreviewandmeta-analysis".ClinicalPsychologyReview.Oxford,England:PergamonPress.39:1–15.doi:10.1016/j.cpr.2015.03.002.PMID 25875222. 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Externallinks WikimediaCommonshasmediarelatedtoObsessive–compulsivedisorder. Obsessive–compulsivedisorderatCurlie NationalInstituteOfMentalHealth AmericanPsychiatricAssociation APADivision12treatmentpageforobsessive-compulsivedisorder Davis,LennardJ.(2008).Obsession:AHistory.UniversityofChicagoPress.ISBN 978-0-226-13782-7. ClassificationDICD-10:F42ICD-9-CM:300.3OMIM:164230MeSH:D009771DiseasesDB:33766ExternalresourcesMedlinePlus:000929eMedicine:article/287681 vteMentaldisorders (Classification)AdultpersonalityandbehaviorSexual Ego-dystonicsexualorientation Paraphilia Fetishism Voyeurism Sexualmaturationdisorder Sexualrelationshipdisorder Other Factitiousdisorder Munchausensyndrome Genderdysphoria Intermittentexplosivedisorder Dermatillomania Kleptomania Pyromania Trichotillomania Personalitydisorder ChildhoodandlearningEmotionalandbehavioral ADHD Conductdisorder ODD Emotionalandbehavioraldisorders Separationanxietydisorder Movementdisorders Stereotypic Socialfunctioning DAD RAD Selectivemutism Speech Cluttering Stuttering Ticdisorder Tourettesyndrome Intellectualdisability X-linkedintellectualdisability Lujan–Frynssyndrome Psychologicaldevelopment(developmentaldisabilities) Pervasive Specific Mood(affective) Bipolar BipolarI BipolarII BipolarNOS Cyclothymia Depression Atypicaldepression Dysthymia Majordepressivedisorder Melancholicdepression Seasonalaffectivedisorder Mania NeurologicalandsymptomaticAutismspectrum Autism Aspergersyndrome High-functioningautism PDD-NOS Savantsyndrome Dementia AIDSdementiacomplex Alzheimer'sdisease Creutzfeldt–Jakobdisease Frontotemporaldementia Huntington'sdisease Mildcognitiveimpairment Parkinson'sdisease Pick'sdisease Sundowning Vasculardementia Wandering Other Delirium Organicbrainsyndrome Post-concussionsyndrome Neurotic,stress-relatedandsomatoformAdjustment Adjustmentdisorderwithdepressedmood AnxietyPhobia Agoraphobia Socialanxiety Socialphobia Anthropophobia Specificsocialphobia Specificphobia Claustrophobia Other Generalizedanxietydisorder OCD Panicattack Panicdisorder Stress Acutestressdisorder PTSD Dissociative Depersonalization-derealizationdisorder Dissociativeidentitydisorder Fuguestate Psychogenicamnesia Somaticsymptom Bodydysmorphicdisorder Conversiondisorder Gansersyndrome Globuspharyngis Psychogenicnon-epilepticseizures Falsepregnancy Hypochondriasis Masspsychogenicillness Nosophobia Psychogenicpain Somatizationdisorder PhysiologicalandphysicalbehaviorEating Anorexianervosa Bulimianervosa Ruminationsyndrome Otherspecifiedfeedingoreatingdisorder Nonorganicsleep Hypersomnia Insomnia Parasomnia Nightterror Nightmare REMsleepbehaviordisorder Postnatal Postpartumdepression Postpartumpsychosis SexualdysfunctionArousal Erectiledysfunction Femalesexualarousaldisorder Desire Hypersexuality Hypoactivesexualdesiredisorder Orgasm Anorgasmia Delayedejaculation Prematureejaculation Sexualanhedonia Spontaneousorgasm Pain Nonorganicdyspareunia Nonorganicvaginismus Psychoactivesubstances,substanceabuseandsubstance-related Drugoverdose Intoxication Physicaldependence Reboundeffect Stimulantpsychosis Substancedependence Withdrawal Schizophrenia,schizotypalanddelusionalDelusional Delusionaldisorder Folieàdeux Psychosisandschizophrenia-like Briefreactivepsychosis Schizoaffectivedisorder Schizophreniformdisorder Schizophrenia Childhoodschizophrenia Disorganized(hebephrenic)schizophrenia Paranoidschizophrenia Pseudoneuroticschizophrenia Simple-typeschizophrenia Other Catatonia Symptomsanduncategorized Impulse-controldisorder Klüver–Bucysyndrome Psychomotoragitation Stereotypy vteObsessive–compulsivedisorderHistory DimensionalObsessive-CompulsiveScale Yale–BrownObsessiveCompulsiveScale BiologyNeuroanatomy Basalganglia(striatum) Orbitofrontalcortex Cingulatecortex Brain-derivedneurotrophicfactor Receptors 5-HT1Dβ 5-HT2A 5-HT2C μOpioid H2 NK1 M4 NMDA Symptoms Obsessions(associative diagnostic injurious scrupulous pathogenic sexual) Compulsions(impulses,rituals tics) Thoughtsuppression(avoidance) Hoarding(animals,books possessions) TreatmentSerotonergicsSelectiveserotoninreuptakeinhibitors Escitalopram Fluoxetine Fluvoxamine Paroxetine Sertraline Citalopram Nefazodone Monoamineoxidaseinhibitors Phenelzine Tricyclicantidepressants Clomipramine Atypicalantipsychotics Aripiprazole Other Inositol Behavioral Acceptanceandcommitmenttherapy Cognitivebehavioraltherapy(Exposureandresponseprevention) Inference-basedtherapy Metacognitivetherapy Notablepeople EdnaB.Foa WayneK.Goodman StanleyRachman AdamS.Radomsky JeffreyM.Schwartz JonathanAbramowitz SusanSwedo EmilyColas VicMeyer DanielA.Geller DavidShannahoff-Khalsa GaryRoyGeffken ChristopherPittenger PopularcultureLiteratureFictional MatchstickMen Plyushkin Xenocide Nonfiction EverythinginItsPlace JustChecking Media AsGoodasItGets TheAviator MatchstickMen AdrianMonk Pure "$pringfield" StraightUp Related Obsessive–compulsivepersonalitydisorder Obsessionaljealousy PANDAS PrimarilyObsessionalOCD Relationshipobsessive–compulsivedisorder Socialanxietydisorder Tourettesyndrome vteOCDpharmacotherapiesAntidepressants SSRIs(citalopram,escitalopram,fluoxetine,fluvoxamine,paroxetine,sertraline) SNRIs(venlafaxine) TCAs(clomipramine) Others Typicalantipsychotics(haloperidol) Atypicalantipsychotics(aripiprazole,olanzapine,quetiapine,risperidone) 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