an anxiety-producing situation, discovering a considerable drop in anxiety level. erp has a strong evidence base, and is considered the most effective treatment for ocd. however, this claim was doubted by some researchers in 2000, who criticized the quality of many studies. acceptance and commitment therapy (act), a newer therapy also used to treat anxiety and depression, has also been found to be effective in treatment of ocd. act uses acceptance and mindfulness strategies to teach patients not to overreact to or avoid unpleasant thoughts and feelings but rather "move toward valued behavior." a 2007 cochrane review found that psychological interventions derived from cbt models, such as erp and act, were more effective than non-cbt interventions. other forms of psychotherapy, such as psychodynamics and psychoanalysis, may help in managing some aspects of the disorder. however, in 2007, the american psychiatric association (apa) noted a lack of controlled studies showing their efficacy, "in dealing with the core symptoms of ocd." for body-focused repetitive behaviors (bfrb), behavioral interventions such as habit-reversal training and decoupling are recommended. psychotherapy in combination with psychiatric medication may be more effective than either option alone for individuals with severe ocd. erp coupled with weight restoration and serotonin reuptake inhibitors has proven the most effective when treating ocd and an eating disorder simultaneously. medication a blister pack of sertraline under the brand name zoloft the medications most frequently used to treat ocd are antidepressants, including selective serotonin reuptake inhibitors (ssris) and serotonin-norepinephrine reuptake inhibitors (snris). sertraline and fluoxetine are effective in treating ocd for children and adolescents. ssris help people with ocd by inhibiting the reabsorption of serotonin by the nerve cells after they carry messages from neurons to synapse; thus, more serotonin is available to pass further messages between nearby nerve cells. ssris are a second-line treatment of adult ocd with mild functional impairment, and as first-line treatment for those with moderate or severe impairment. in children, ssris can be considered as a second-line therapy in those with moderate to severe impairment, with close monitoring for psychiatric adverse effects. patients treated with ssris are about twice as likely to respond to treatment as are those treated with placebo, so this treatment is qualified as efficacious. efficacy has been demonstrated both in short-term (6–24 weeks) treatment trials, and in discontinuation trials with durations of 28–52 weeks. clomipramine, a medication belonging to the class of tricyclic antidepressants, appears to work as well as ssris, but has a higher rate of side effects. in 2006, the national institute for health and care excellence (nice) guidelines recommended augmentative second-generation (atypical) antipsychotics for treatment-resistant ocd. atypical antipsychotics are not useful when used alone, and no evidence supports the use of first-generation antipsychotics. for ocd treatment specifically, there is tentative evidence for risperidone, and insufficient evidence for olanzapine. quetiapine is no better than placebo with regard to primary outcomes, but small effects were found in terms of y-bocs score. the efficacy of quetiapine and olanzapine are limited by an insufficient number of studies. a 2014 review article found two studies that indicated that aripiprazole was "effective in the short-term", and found that "here was a small effect-size for risperidone or anti-psychotics in general in the short-term"; however, the study authors found "no evidence for the effectiveness of quetiapine or olanzapine in comparison to placebo." while quetiapine may be useful when used in addition to an ssri/snri in treatment-resistant ocd, these drugs are often poorly tolerated, and have metabolic side effects that limit their use. a guideline by the american psychological association suggested that dextroamphetamine may be considered by itself after more well-supported treatments have been attempted. procedures electroconvulsive therapy (ect) has been found to have effectiveness in some severe and refractory cases. transcranial magnetic stimulation has shown to provide therapeutic benefits in alleviating symptoms. surgery may be used as a last resort in people who do not improve with other treatments. in this procedure, a surgical lesion is made in an area of the brain (the cingulate cortex). in one study, 30% of participants benefitted significantly from this procedure. deep brain stimulation and vagus nerve stimulation are possible surgical options that do not require destruction of brain tissue. in the united states, the food and drug administration approved deep-brain stimulation for the treatment of ocd under a humanitarian device exemption, requiring that the procedure be performed only in a hospital with special qualifications to do so. in the united states, psychosurgery for ocd is a treatment of last resort, and will not be performed until the person has failed several attempts at medication (at the full dosage) with augmentation, and many months of intensive cognitive–behavioral therapy with exposure and ritual/response prevention. likewise, in the united kingdom, psychosurgery cannot be performed unless a course of treatment from a suitably qualified cognitive–behavioral therapist has been carried out. children therapeutic treatment may be effective in reducing ritual behaviors of ocd for children and adolescents. similar to the treatment of adults with ocd, cognitive behavioral therapy stands as an effective and validated first line of treatment of ocd in children. family involvement, in the form of behavioral observations and reports, is a key component to the success of such treatments. parental interventions also provide positive reinforcement for a child who exhibits appropriate behaviors as alternatives to compulsive responses. in a recent meta-analysis of evidenced-based treatment of ocd in children, family-focused individual cbt was labeled as "probably efficacious," establishing it as one of the leading psychosocial treatments for youth with ocd. after one or two years of therapy, in which a child learns the nature of their obsession and acquires strategies for coping, they may acquire a larger circle of friends, exhibit less shyness, and become less self-critical. although the known causes of ocd in younger age groups range from brain abnormalities to psychological preoccupations, life stress such as bullying and traumatic familial deaths may also contribute to childhood cases of ocd, and acknowledging these stressors can play a role in treating the disorder. epidemiology age-standardized disability-adjusted life year estimated rates for obsessive-compulsive disorder per 100,000 inhabitants in 2004 no data <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–compulsive disorder affects about 2.3% of people at some point in their life, with the yearly rate about 1.2%. ocd occurs worldwide. it is unusual for symptoms to begin after the age of 35 and half of people develop problems before 20. males and females are affected about equally. however there is an earlier age for onset for males than females. prognosis quality of life is reduced across all domains in ocd. while psychological or pharmacological treatment can lead to a reduction of ocd symptoms and an increase in reported quality of life, symptoms may persist at moderate levels even following adequate treatment courses, and completely symptom-free periods are uncommon. in pediatric ocd, around 40% still have the disorder in adulthood, and around 40% qualify for remission. history plutarch, an ancient greek philosopher and historian, describes an ancient roman man who possibly had scrupulosity, which could be a symptom of ocd or ocpd. this man is described as "turning pale under his crown of flowers," praying with a "faltering voice," and scattering "incense with trembling hands." in the 7th century ad, john climacus records an instance of a young monk plagued by constant and overwhelming "temptations to blasphemy" consulting an older monk, who told him: "my son, i take upon myself all the sins which these temptations have led you, or may lead you, to commit. all i require of you is that for the future you pay no attention to them whatsoever.": 212 the cloud of unknowing, a christian mystical text from the late 14th century, recommends dealing with recurring obsessions by attempting to ignore them, and, if that fails, to "cower under them like a poor wretch and a coward overcome in battle, and reckon it to be a waste of your time for you to strive any longer against them", a technique now known as emotional flooding.: 213 from the 14th to the 16th century in europe, it was believed that people who experienced blasphemous, sexual or other obsessive thoughts were possessed by the devil.: 213 based on this reasoning, treatment involved banishing the "evil" from the "possessed" person through exorcism. the vast majority of people who thought that they were possessed by the devil did not have hallucinations or other "spectacular symptoms" but "complained of anxiety, religious fears, and evil thoughts.": 213 in 1584, a woman from kent, england, named mrs. davie, described by a justice of the peace as "a good wife", was nearly burned at the stake after she confessed that she experienced constant, unwanted urges to murder her family.: 213 the english term obsessive–compulsive arose as a translation of german zwangsvorstellung (obsession) used in the first conceptions of ocd by karl westphal. westphal's description went on to influence pierre janet, who further documented features of ocd. in the early 1910s, sigmund freud attributed obsessive–compulsive behavior to unconscious conflicts that manifest as symptoms. freud describes the clinical history of a typical case of "touching phobia" as starting in early childhood, when the person has a strong desire to touch an item. in response, the person develops an "external prohibition" against this type of touching. however, this "prohibition does not succeed in abolishing" the desire to touch; all it can do is repress the desire and "force it into the unconscious." freudian psychoanalysis remained the dominant treatment for ocd until the mid-1980s, even though medicinal and therapeutic treatments were known and available, because it was widely thought that these treatments would be detrimental to the effectiveness of the psychotherapy.: 210–211 in the mid-1980s, this approach changed, and practitioners began treating ocd primarily with medicine and practical therapy rather than through psychoanalysis.: 210 notable cases john bunyan (1628–1688), the author of the pilgrim's progress, displayed symptoms of ocd (which had not yet been named). during the most severe period of his condition, he would mutter the same phrase over and over again to himself while rocking back and forth.: 53–54 he later described his obsessions in his autobiography grace abounding to the chief of sinners, stating, "these things may seem ridiculous to others, even as ridiculous as they were in themselves, but to me they were the most tormenting cogitations.": 53–54 he wrote two pamphlets advising those with similar anxieties.: 217–218 in one of them, he warns against indulging in compulsions: "have care of putting off your trouble of spirit in the wrong way: by promising to reform yourself and lead a new life, by your performances or duties".: 217–218 british poet, essayist and lexicographer samuel johnson (1709–1784) also had ocd. he had elaborate rituals for crossing the thresholds of doorways, and repeatedly walked up and down staircases counting the steps.: 54–55 he would touch every post on the street as he walked past, only step in the middles of paving stones, and repeatedly perform tasks as though they had not been done properly the first time.: 55 the american aviator and filmmaker howard hughes is known to have had ocd. friends of hughes have also mentioned his obsession with minor flaws in clothing. this was conveyed in the aviator (2004), a film biography of hughes. english singer-songwriter george ezra has openly spoken about his life-long struggle with ocd, particularly primarily obsessional obsessive–compulsive disorder (pure o). world renowned swedish climate activist greta thunberg is also known to have ocd, among other mental health conditions. american actor james spader is also known to have ocd. society and culture this ribbon represents trichotillomania and other body-focused repetitive behaviors. concept for the ribbon was started by jenne schrader. colors were voted on by a trichotillomania facebook community, and made official by the trichotillomania learning center in august 2013. art, entertainment and media movies and television shows may portray idealized or incomplete representations of disorders such as ocd. compassionate and accurate literary and on-screen depictions may help counteract the potential stigma associated with an ocd diagnosis, and lead to increased public awareness, understanding and sympathy for such disorders. in the film as good as it gets (1997), actor jack nicholson portrays a man with ocd who performs ritualistic behaviors that disrupt his life. the film matchstick men (2003) portrays a con man named