obsessive–compulsive disorder obsessive–compulsive disorder obsessive–compulsive disorder (ocd) is a mental and behavioral disorder in which an individual has intrusive thoughts (an obsession) and feels the need to perform certain routines (compulsions) repeatedly to relieve the distress caused by the obsession, to the extent where it impairs general function. "ocd" redirects here. not to be confused with obsessive–compulsive personality disorder. for other uses, see ocd (disambiguation). obsessive–compulsive disorderfrequent and excessive hand washing occurs in some people with ocd.specialtypsychiatrysymptomsfeel the need to check things repeatedly, perform certain routines repeatedly, have certain thoughts repeatedlycomplicationstics, anxiety disorder, suicideusual onsetbefore 35 yearsrisk factorschild abuse, stressdiagnostic methodbased on the symptomsdifferential diagnosisanxiety disorder, major depressive disorder, eating disorders, obsessive–compulsive personality disordertreatmentcounseling, selective serotonin reuptake inhibitors, clomipraminefrequency2.3% obsessions are persistent unwanted thoughts, mental images, or urges that generate feelings of anxiety, disgust, or discomfort. some common obsessions include fear of contamination, obsession with symmetry, the fear of acting blasphemously, the sufferer's sexual orientation, and the fear of possibly harming others or themselves. compulsions are repeated actions or routines that occur in response to obsessions to achieve a relief from anxiety. common compulsions include excessive hand washing, cleaning, counting, ordering, avoiding triggers, hoarding, neutralizing, seeking assurance, praying, and checking things. people with ocd may only perform mental compulsions, this is called primarily obsessional obsessive–compulsive disorder (pure o). many adults with ocd are aware that their compulsions do not make sense, but they perform them anyway to relieve the distress caused by obsessions. compulsions occur often, typically taking up at least one hour per day and impairing one's quality of life. compulsions cause relief in the moment, but cause obsessions to grow over time. more than three million americans suffer from ocd.according to mercy, approximately 1 in 40 u.s. adults and 1 in 100 u.s. children have ocd. the cause of ocd is unknown. there appear to be some genetic components, and it is more likely for both identical twins to be affected than both fraternal twins. risk factors include a history of child abuse or other stress-inducing events; some cases have occurred after streptococcal infections. diagnosis is based on presented symptoms and requires ruling out other drug-related or medical causes; rating scales such as the yale–brown obsessive compulsive scale (y-bocs) assess severity. other disorders with similar symptoms include generalized anxiety disorder, major depressive disorder, eating disorders, tic disorders, and obsessive–compulsive personality disorder. the condition is also associated with a general increase in suicidality. ocd is chronic and long-lasting with periods of severe symptoms followed by periods of improvement. treatment can improve ability to function and quality of life. treatment for ocd may involve psychotherapy such as cognitive behavioral therapy (cbt), pharmacotherapy such as antidepressants, or surgical procedures such as deep brain stimulation. cbt increases exposure to obsessions and prevents compulsions, while metacognitive therapy encourages ritual behaviors to alter the relationship to one's thoughts about them. selective serotonin reuptake inhibitors (ssris) are a common antidepressant used to treat ocd. ssris are more effective when used in excess of the recommended depression dosage; however, higher doses can increase side effect intensity. commonly used ssris include sertraline, fluoxetine, fluvoxamine, paroxetine, citalopram, and escitalopram. some patients fail to improve after taking the maximum tolerated dose of multiple ssris for at least two months; these cases qualify as treatment-resistant and can require second-line treatment such as clomipramine or atypical antipsychotic augmentation. surgery may be used as a final resort in the most severe or treatment-resistant cases, though most procedures are considered experimental due to the limited literature on their side effects. obsessive–compulsive disorder affects about 2.3% of people at some point in their lives, while rates during any given year are about 1.2%. it is unusual for symptoms to begin after age 35, and around 50% of patients experience detrimental effects to daily life before age 20. males and females are affected equally, and ocd occurs worldwide. the phrase obsessive–compulsive is sometimes used in an informal manner unrelated to ocd to describe someone as excessively meticulous, perfectionistic, absorbed, or otherwise fixated. however, the actual disorder is not characterized by that, and many individuals with ocd may be dirty, unclean, or uncaring about disease/symmetry. signs and symptoms ocd can present with a wide variety of symptoms. certain groups of symptoms usually occur together; these groups are sometimes viewed as dimensions, or clusters, which may reflect an underlying process. the standard assessment tool for ocd, the yale–brown obsessive compulsive scale (y-bocs), has 13 predefined categories of symptoms. these symptoms fit into three to five groupings. a meta-analytic review of symptom structures found a four-factor grouping structure to be most reliable: a symmetry factor, a forbidden thoughts factor, a cleaning factor, and a hoarding factor. the symmetry factor correlates highly with obsessions related to ordering, counting, and symmetry, as well as repeating compulsions. the forbidden thoughts factor correlates highly with intrusive thoughts of a violent, religious, or sexual nature. the cleaning factor correlates highly with obsessions about contamination and compulsions related to cleaning. the hoarding factor only involves hoarding-related obsessions and compulsions, and was identified as being distinct from other symptom groupings. when looking into the onset of ocd, one study suggests that there are differences in the age of onset between males and females. in children, a study found the average age of onset of ocd to be 9.6 for male children and 11.0 for female children. when looking at both adults and children a study found the average ages of onset to be 21 and 24 for males and females respectively. looking at women specifically, a different study suggested that 62% of participants found that their symptoms worsened at a premenstrual age. across the board, all demographics and studies showed a mean age of onset of less than 25. some ocd subtypes have been associated with improvement in performance on certain tasks, such as pattern recognition (washing subtype) and spatial working memory (obsessive thought subtype). subgroups have also been distinguished by neuroimaging findings and treatment response, though neuroimaging studies have not been comprehensive enough to draw conclusions. subtype-dependent treatment response has been studied, and the hoarding subtype has consistently been least responsive to treatment. while ocd is considered a homogeneous disorder from a neuropsychological perspective, many of the symptoms may be the result of comorbid disorders. for example, adults with ocd have exhibited more symptoms of attention–deficit/hyperactivity disorder (adhd) and autism spectrum disorder (asd) than adults without ocd. in regards to the cause of onset, researchers asked participants in one study what they felt was responsible for triggering the initial onset of their illness. 29% of patients answered that there was an environmental factor in their life that did so. specifically, the majority of participants who answered with that noted their environmental factor to be related to an increased responsibility. obsessions main article: intrusive thought people with ocd may face intrusive thoughts, such as thoughts about the devil (shown is a painted interpretation of hell). obsessions are stress-inducing thoughts that recur and persist, despite efforts to ignore or confront them. people with ocd frequently perform tasks, or compulsions, to seek relief from obsession-related anxiety. within and among individuals, initial obsessions vary in clarity and vividness. a relatively vague obsession could involve a general sense of disarray or tension, accompanied by a belief that life cannot proceed as normal while the imbalance remains. a more intense obsession could be a preoccupation with the thought or image of a close family member or friend dying, or intrusive thoughts related to relationship rightness. other obsessions concern the possibility that someone or something other than oneself—such as god, the devil, or disease—will harm either the patient or the people or things the patient cares about. others with ocd may experience the sensation of invisible protrusions emanating from their bodies, or feel that inanimate objects are ensouled. some people with ocd experience sexual obsessions that may involve intrusive thoughts or images of "kissing, touching, fondling, oral sex, anal sex, intercourse, incest, and rape" with "strangers, acquaintances, parents, children, family members, friends, coworkers, animals, and religious figures," and can include heterosexual or homosexual contact with people of any age. similar to other intrusive thoughts or images, some disquieting sexual thoughts are normal at times, but people with ocd may attach extraordinary significance to such thoughts. for example, obsessive fears about sexual orientation can appear to the affected individual, and even to those around them, as a crisis of sexual identity. furthermore, the doubt that accompanies ocd leads to uncertainty regarding whether one might act on the troubling thoughts, resulting in self-criticism or self-loathing. most people with ocd understand that their thoughts do not correspond with reality; however, they feel that they must act as though these ideas are correct or realistic. for example, someone who engages in compulsive hoarding might be inclined to treat inorganic matter as if it had the sentience or rights of living organisms, despite accepting that such behavior is irrational on an intellectual level. there is debate as to whether hoarding should be considered an independent syndrome from ocd. compulsions main article: compulsive behavior a person exhibiting skin-picking disorder some people with ocd perform compulsive rituals because they inexplicably feel that they must do so, while others act compulsively to mitigate the anxiety that stems from obsessive thoughts. the affected individual might feel that these actions will either prevent a dreaded event from occurring, or push the event from their thoughts. in any case, their reasoning is so idiosyncratic or distorted that it results in significant distress, either personally, or for those around the affected individual. excessive skin picking, hair pulling, nail biting, and other body-focused repetitive behavior disorders are all on the obsessive–compulsive spectrum. some individuals with ocd are aware that their behaviors are not rational, but they feel compelled to follow through with them to fend off feelings of panic or dread. furthermore, compulsions often stem from memory distrust, a symptom of ocd characterized by insecurity in one's skills in perception, attention, and memory, even in cases where there is no clear evidence of a deficit. common compulsions may include hand washing, cleaning, checking things (such as locks on doors), repeating actions (such as repeatedly turning on and off switches), ordering items in a certain way, and requesting reassurance. although some individuals perform actions repeatedly, they do not necessarily perform these actions compulsively; for example, morning or nighttime routines and religious practices are not usually compulsions. whether behaviors qualify as compulsions or mere habit depends on the context in which they are performed. for instance, arranging and ordering books for eight hours a day would be expected of someone who works in a library, but this routine would seem abnormal in other situations. in other words, habits tend to bring efficiency to one's life, while compulsions tend to disrupt it. furthermore, compulsions are different from tics (such as touching, tapping, rubbing, or blinking) and stereotyped movements (such as head banging, body rocking, or self-biting), which are usually not as complex and not precipitated by obsessions. it can sometimes be difficult to tell the difference between compulsions and complex tics, and about 10–40% of people with ocd also have a lifetime tic disorder. people with ocd rely on compulsions as an escape from their obsessive thoughts; however, they are aware that relief is only temporary, and that intrusive thoughts will return. some affected individuals use compulsions to avoid situations that may trigger obsessions. compulsions may be actions directly related to the obsession, such as someone obsessed with contamination compulsively washing their hands, but they can be unrelated as well. in addition to experiencing the anxiety and fear that typically accompanies ocd, affected individuals may spend hours performing compulsions every day. in such situations, it can become difficult for the person to fulfill their work, familial, or social roles. these behaviors can also cause adverse physical symptoms; for example, people who obsessively wash their hands with antibacterial soap and hot water can make their skin red and raw with dermatitis. individuals with ocd often use rationalizations to explain their behavior; however, these rationalizations do not apply to the behavioral pattern, but to each individual occurrence. for example, someone compulsively checking the front door may argue that the time and stress associated with one check is less than the time and stress associated with being robbed,