Obsessive-compulsive disorder (OCD) is a persistent mental illness characterised by intrusive thoughts that enter the mind involuntarily, rituals, mental preoccupation and compulsions. These recurring obsessions and compulsions cause considerable distress. Obsessions and compulsions significantly affect a person's daily life and routine activities and substantially interfere with their ability to work and maintain relationships.
An obsession is a thought, emotion, idea or feeling that repeatedly and involuntarily enters a person's mind. While obsessions involve a person's mental processes, compulsions are behaviours: conscious, fixed, repetitive actions such as counting, checking and avoidance. Every patient with OCD knows that their obsessions are irrational but says they ‘cannot stop them’.
Although a compulsive act is often a ritual performed to reduce the anxiety and distress associated with an intrusive obsession, it often does not work. While it may bring a brief sense of relief, in the long term it increases anxiety and causes the illness to progress.
How Common Is Obsessive-Compulsive Disorder?
Its prevalence in the general population is around 2-3%. In adults, there is no difference in prevalence between women and men. During adolescence, boys are affected more often than girls. The age of onset is generally around 20.
OCD can often be accompanied by other mental illnesses. The most common co-occurring mental illnesses are depression (67%) and social phobia. Other co-occurring diagnoses include alcohol use disorder, generalised anxiety disorder, panic disorder, specific phobias, obsessive-compulsive personality disorder characterised by traits such as preoccupation with detail and perfectionism, eating disorders and tic disorders.
What Causes Obsessive-Compulsive Disorder?
As with many mental illnesses, numerous factors are associated with the development of OCD. Research shows that biological factors, genetic predisposition, behavioural factors, personality traits and environmental factors are among the underlying causes.
Brain imaging studies have identified abnormal findings, particularly related to serotonin. Patients' relatively higher response rates to serotonergic medications support the presence of abnormalities in this system. The fact that OCD is more common in identical twins than in fraternal twins highlights the importance of its genetic basis. In addition, behavioural learning and cultural factors may also contribute to the familial nature of the illness.
Electrophysiological studies and EEG research show that OCD and depression share certain abnormal findings. This is important in explaining why these two illnesses so often occur together.
What Symptoms Do We See in OCD?
The combination of symptoms seen in OCD may differ from patient to patient, and the same patient may experience different obsessions and compulsions at different times. For example, a mother may have an obsession about harming her child and, feeling deeply distressed and anxious about this obsession, may develop a ritualised compulsion such as reciting a particular prayer a set number of times to neutralise the thought, or may try to relieve her distress by hiding all the knives in the house. Someone with a cleanliness obsession such as ‘My hands are dirty’ may wash their hands (a compulsion) until they believe their hands are clean
Similarly, a person with OCD may repeatedly check the stove because of an obsession involving uncertainty, such as ‘Did I turn the stove off or not?’ Although the checking compulsion gives the person a brief, temporary sense of relief, it causes the illness to progress in the long term.
Other obsessions seen in this illness include involuntary thoughts about sacred religious matters, contamination, doubt, symmetry and order, and sexual or other content that distresses the person. In general, people with OCD experience obsessions, which are thoughts that enter the mind involuntarily, and compulsions, which are actions performed to relieve the anxiety these thoughts cause.
How Is Obsessive-Compulsive Disorder Treated?
OCD is a persistent mental illness, and effective treatment requires a multifaceted approach. Research supporting the role of biological factors in the illness has made medication a treatment priority.
However, medication alone is often insufficient for OCD and does not adequately prevent future relapse. In this context, cognitive behavioural therapy and TMS treatment (transcranial magnetic stimulation), which is approved by the FDA for OCD, have emerged as new treatment options and are increasingly used worldwide.
The most appropriate approach to OCD includes one or more of the treatment options of medication, psychotherapy and TMS, along with psychoeducation for the family about the illness.
TMS treatment is the first choice for patients with OCD who have difficulty taking medication, cannot take medication for various reasons, have not responded adequately to medication, need the effects of medication to be enhanced, cannot complete the homework assigned in cognitive behavioural therapy, or are not suited to working with this form of therapy.
What Is the Course of Obsessive-Compulsive Disorder?
In this group of patients, symptoms more often begin suddenly. In around 50-70% of patients, symptoms begin after an event such as pregnancy, a stressful life event or a loss. Because patients often manage to conceal their symptoms, there is a delay of approximately 5-10 years before they seek medical help. The course of the illness fluctuates in some patients and remains steady in others.
Around 20-30% of patients experience a marked improvement in symptoms, while 40-50% experience moderate improvement. In the remaining 20-40%, the illness follows a persistent and unfavourable course.
At least 1/3 of patients with OCD experience depression. Suicide is a significant risk in this group of patients, who experience considerable distress.
Signs of an Unfavourable Course
- Accommodating compulsions rather than resisting them
- Onset in childhood
- Presence of bizarre compulsions
- Need for hospitalisation
- Co-occurring major depression
- Presence of delusional beliefs
- Episodes of psychosis (when obsessions and compulsions are perceived as ego-syntonic)
- Co-occurring personality disorder (particularly schizotypal personality disorder)
Findings Suggesting a Favourable Course
- Good social and occupational functioning
- An event that triggered the symptoms
- Episodic symptoms
- High adherence to treatment
- A high sociocultural level in the patient and family
- Good cooperation with the treatment team
There is no relationship between the content of a patient's obsessions and the course of the illness.
Publications on the role of TMS in OCD:
