Obsessive-compulsive disorder

Chances are you know someone who describes herself as "compulsive." She is likely to be the kind of person who pays bills long before they are due, has a home that is as neat as a pin, and is very attentive to detail. Her existence is extremely orderly.

Such self-described "compulsives" are not to be confused with people who have obsessive-compulsive disorder (OCD) and whose lives are often in disarray. The latter are in constant psychic pain and are tormented by recurrent, intrusive thoughts, such as fear of contamination or infection. They are irresistibly compelled to take certain "protective" measures -- such as washing their hands -- over and over again. Although they know that both their apprehensions and ritualistic responses are without basis, they have little control over either.

OCD is classified as an anxiety disorder in which the obsession -- the intrusive thought -- is a source of anxiety and the compulsion -- the ritualistic behavior -- is undertaken to alleviate anxiety. Children commonly adopt rituals and chants during certain stages of development, and most of us occasionally have intrusive thoughts or repeat certain actions as adults. However, to warrant the psychiatric diagnosis of OCD, such thoughts have to be persistent and disturbing and the rituals must be repeated, often for hours, until the person feels comfortable. The obsessions and compulsions must significantly disrupt the person's life.

OCD is considered to occupy an extreme end of the continuum that includes a compulsive personality style. It is generally thought to be a chronic condition, which, in women, begins in the teens or 20s and may wax and wane over a lifetime. It rarely disappears spontaneously. Many people who have OCD also suffer from depression, eating disorders, social phobias, panic attacks, or other anxiety disorders.

Obsessions
Not only thoughts, but images, ideas, beliefs, or impulses can constitute obsessions. These usually spring up unbidden and most with OCD try to resist them. They commonly fit one of three categories:

Fear of contamination by dirt, bacteria, or other sources.
Fear of being about to do or of having inflicted harm, such as murder, rape, hitting a pedestrian while driving, or starting a fire.
Doubting. A lack of trust in one's own perceptions, such as whether one's hands are clean, whether the door is locked, or whether the iron is unplugged.
Compulsions
Acting out certain rituals usually reduces the anxiety associated with the obsession. Many compulsions are directly, although not rationally, related to an obsession -- for example, washing one's hands excessively or checking a door repeatedly to make sure that it is locked.

Others may have no relation whatsoever to the obsession. For example, a woman with OCD might count backward from 100 by threes to quell the persistent fear that her child's school bus will explode.

Causes
There are several theories concerning the roots of OCD. As with most mental disorders, it is likely a product of both environmental influences and brain chemistry. Some psychiatrists believe that, in susceptible people, OCD stems from difficulties in emotional development due to losses, traumas, illness, family problems, or other factors. There is also evidence of an abnormality in serotonin -- a chemical that carries impulses between nerve cells -- in people with OCD. This may be either a cause or an effect of OCD. In women with OCD, fluctuations in estrogen, progesterone, and prolactin -- a hormone that triggers lactation -- are also associated with flares of the condition.

Treatment
Many women with OCD carry out their rituals in private and are ashamed to seek help. This is unfortunate, because OCD is a highly treatable disorder; an estimated 40-60% of patients who undergo a combination of psychotherapy and drug treatment show significant improvement, usually within 12 weeks.

The tricyclic antidepressant clomipramine (Anafranil), and the selective serotonin reuptake inhibitors (SSRIs) fluvoxamine (Luvox) and fluoxetine (Prozac) have reduced patients' anxiety sufficiently to allow them to undergo therapy. Two additional SSRIs, sertraline (Zoloft), and paroxetine (Paxil), are also used to treat OCD, but are not FDA-approved for that purpose.

Psychotherapy is directed at helping patients to understand and overcome personality traits, such as procrastination and self-doubt, that often accompany OCD. It should also help them cope with the damage to relationships and to self-esteem that the disorder has caused. Psychoanalysis, though long and expensive, has been effective in people with obsessional symptoms.

Cognitive-behavioral therapy, the most common approach, concentrates on facing the obsession head-on and avoiding the habitual compulsive response. For example, a patient may be directed to leave the house and wait for successively longer periods before checking the lock. Eventually, she will be able to leave the house without returning to check the door.

For further information:

The OCD Foundation, Inc., P.O. Box 70, Milford, CT 06460; (203) 878-5669 or 1-800-NEWS-4OCD (1-800-639-7462).

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