The modern age of society has facilitated a removal of taboo around many topics such as homosexuality and recreational marijuana use, but none of them are as important as the surging mental health movement. For years, people with undiagnosed mental health disorders were told to “man up” or “just be happy”, and those affected felt ashamed over something they had no control of. Now, with continued scientific research on brain chemistry and the effects of mental disorders, those affected are encouraged to speak out and find treatment from one of the thousands of therapists and doctors around the world. One such mental disorder is OCD. Short for Obsessive-Compulsive Disorder, OCD is one of the world’s most debilitating diseases, yet its portrayal in media has led to misconceptions about its severity and symptoms. Many people believe it's simply liking things to be clean, or flipping the light switch three times because they are comfortable with the number three. While these examples are sometimes symptoms, it is far more serious and complicated than most assume. OCD is characterized by obsessive thoughts that uncontrollably run through a person’s brain that result in a compulsive behavior by the individual in order to alleviate themself from the obsessions. There are multiple biological theories for a cause of OCD, and they are accompanied by certain treatments that target either passively or consciously altering brain chemistry. Finally, an examination of the significance of genetic and environmental factors is necessary to fully understand the development of OCD in an individual.
OCD is a complicated mental health disorder that causes those affected to be stuck in a constant circle of obsessions and compulsions. At some point in almost everyone’s life, they may struggle with compulsive behavior or obsessive thoughts, but that does not mean they are affected by OCD. OCD’s dramaticized and over exaggerated portrayal in the media has led to common misconceptions about the disorder and to it being used casually as an adjective of someone who likes something done right. In fact, it is far more serious. For a person to be diagnosed with OCD, the circle of obsession and compulsive behavior must consume an extraordinary amount of time per day (usually at least an hour) and interfere with activities that the subject finds important (Clark and Radomsky 2014). In order to understand this, one must look deeper into both the obsessions and the compulsive behavior of someone who has OCD.
Obsessions consist of unwanted thoughts, images, or impulses that occur continuously and uncontrollably inside the mind of an affected person. These thoughts usually are troubling or even revolting, and often lack any logical sense. Unfortunately, the verb “to obsess” is used often in everyday life, but what distinguishes the obsessions of someone with OCD from normal obsessions is the time consuming aspect of OCD. Someone without OCD may have temporarily disturbing thoughts or fears that occupy their mind, but they will soon move on as something else comes along to take their attention away. An individual with OCD will often be controlled by their obsessions, resulting in an inability to function normally, and an interference with activities and hobbies that are important to them (Clark and Radomsky 2014). Some of the common obsessions that have been identified by therapists and physicians are contamination by germs or body fluids, fear of losing control and acting on impulses to harm oneself or others, fear of harming others or being responsible for harm due to incompetence, perfectionism and a fear of losing things or forgetting information, and finally unwanted sexual thoughts involving homosexuality, incest, children, and sexual assault. The obsessions are only half of the disorder however, in order for a person to be diagnosed with OCD, they must have compulsions to act on these obsessions.
Compulsions are decisions or behaviors that a person makes in order to ease the obsessive thoughts that they struggle with. Many people with OCD acknowledge that these behaviors are only a temporary solution, but since they lack a better way to deal with the obsessions, they have no choice. Once again, there are many repetitive behaviors that may be ritualistic but lack the compulsive OCD element. Almost everyone has some sort of nighttime and morning routine that is usually followed similarly each morning, but these are healthy routines that encourage efficiency in a person’s daily life (Clark and Radomsky 2014). People with OCD are stuck with ritualistic and repetitive behaviors and would much prefer to not have to do their time consuming and agonizing routines in order to temporarily free themselves from obsessions. Keep in mind that for an impulse to be categorized as a compulsive behavior due to OCD, it must be a result of an obsession. For example, people constantly washing their hands, showering, do so to counteract the obsession of cleaning. Similarly, individuals with OCD will constantly reread/rewrite information to make sure they did so correctly, or perform a task a certain number of times because they feel that number is “safe” (Clark and Radomsky 2014). These impulsive behaviors can end up robbing hours of an individual’s day that could have otherwise been spent on productive activities.
A 1992, two physicians Rasmussen and Elsen conducted a study on the correlation of certain obsessions and compulsions among 560 individuals affected by OCD. They discovered that most patients have more than one or two symptoms due to the presence of both obsession and compulsions, and that “obsessions and compulsions present as infinitely personalized variations on a small number of themes: aggression, harm avoidance, contamination, distasteful or excessive sexual ideation, religious concerns, collecting, need for symmetry or order, need to know, and fear of illness” (Rasmussen and Elsen 1992). Based on their study, Rasmussen and Elsen were able to identify three clustered groups of symptoms that had strong correlation among the patients. The first, ordering compulsions along with repeating and hoarding rituals were strongly correlated with symmetry and exactness obsessions. Those who needed items to be arranged perfectly and tasks to be performed flawlessly had a strong tendency to repeat tasks and behaviors to make sure everything was right. Secondly, those obsessed with contamination also had strong compulsions to clean, which is to be expected. However, they were surprised to find that compulsive checkers also had obsessive fears of contamination. Finally, the researchers discovered a correlation that sexual and religious obsessions tended to be clustered with aggressive obsessions. The unwanted sexual thoughts that penetrate the mind of an OCD patient are often aggressive, immoral, and against the moral compass of the individual, resulting in a compulsive checking behavior to make sure they have not harmed others in any way (Leckman 1997). Understanding OCD on an external level is only half the battle, in order to effectively treat and eventually cure this disease, scientists must understand it on a biological level as well.
Originally, OCD was believed to be a mental condition, as scientists could not discover what caused it. However, recent studies have shown that OCD is caused by damage to the part of the brain known as the basal ganglia; which means OCD can be classified as a biological disorder instead of a mental problem. This theory was further cemented after researchers linked the development of OCD to several events such as hypoxia, bacterial infections, and neurotoxic agents. One thing these three things have in common is they all damage the basal ganglia. From these findings scientists believe they have enough evidence to support their claim that physical damage can result in a neuropsychological condition such as OCD (Gorbis 2018).
After scientists discovered the correlation between the basal ganglia and OCD, they began to study its structure to further understand the parts involved. After numerous radiological studies, scientists uncovered that there are two structures that interact with the basal ganglia that are more active in patients with OCD; the orbitofrontal cortex (OFC) and the anterior cingulate gyrus (ACG) (Gorbis 2018). The OFC and ACG both act to detect errors in brain circuits, and they are constantly interacting and exchanging information with the basal ganglia. There were two theories that were initially proposed to explain this phenomena. The first theory claimed that when either the OFC or ACG were damaged, their ability to detect errors was impaired, resulting in an increased repetition and frequency of messages and the onset of OCD. However, this did not explain why patients feel dread and anxiety that something is constantly wrong. The second theory stated that the onset of OCD is due to the overstimulation of the OFC and ACG. When the OFC and ACG are stimulated, their error detecting abilities are enhanced, however if they are hyper excited, they lose their ability to accurately detect errors and end up firing at inappropriate times. This results in excessive and unnecessary error messages to the basal ganglia that there is a problem, leading to the sense of dread and certainty that something is wrong (Gorbis 2018). The state of the brain when the ACG and OFC are in a hyper-excited state is known as brain lock. This describes the four areas of the brain that are overstimulated in the mind of an individual with OCD. The four areas become locked together, and in order to release it, patients are prescribed medications like Zoloft or Prozac, cognitive behavior therapy (CBT), or a combination of both.
Whether through medicine or cognitive behavioral therapy, treatment of OCD involves changing the chemistry of the brain to reduce OCD symptoms. CBT is a technique that allows individuals to comprehend the illogical nature of many of their fears and obsessions, and develop alternative coping methods instead of turning to compulsive behaviors. For example, a patient that has obsessive contamination fears would never want to be surrounded by dirt, therefore a therapist would place the patient in a dirty or messy room for a small period of time and not allow the patient to clean or move anything. Once the patient is able to tolerate that first small period of time in a dirty room, the therapist will gradually increase the time spent in the dirty room until the patient is able to fully tolerate the room without feeling the impulse to clean. Patients that undergo CBT actively alter their brain chemistry by training their responses to obsessive thoughts (Gorbis). While this process is difficult and time consuming, training the mind to help resist the compulsive behavior has been proven to be possible, and is a field that should continue to be pursued vigorously. On the pharmaceutical side, scientists and researchers have focused on the serotonin function as a key factor of OCD. They often prescribe selective serotonin reuptake inhibitors (SSRIs) such as Citalopram, Fluoxetine, Fluvoxamine, Sertraline, and Paroxetine. Their hypothesis is that low levels of serotonin in the brain is one of the main causes for OCD-like symptoms. The drugs stated above inhibit the reuptake of serotonin by the presynaptic neuron, which in turn leaves more available for the postsynaptic receptors. (Stanford Medicine 2018). Increased serotonin levels can lead to increased anti-obsessive thoughts, allowing the individual to further resist compulsive behavior (Baumgarten and Grozdanovic 1998). To further understand OCD, scientists are now attempting to determine the relative significance of hereditary and environmental factors in the development of OCD.
There is a multitude of evidence to suggest that OCD does have a hereditary element to its development. In 2014, a study led by Dr. Gerald Nestadt, a Johns Hopkins Professor of psychiatry, tested and analyzed the genomes of 1406 people with OCD, as well as close relatives of those with the conditions, and individuals form the general public, bringing the total to 5,061 genomes that were analyzed. His findings, published in the journal Molecular Psychiatry, show a “significant association” on chromosome 9 near a gene called protein tyrosine phosphokinase. Researchers believe this to be the first genetic marker to be discovered relating to OCD; an important note is that in animal studies, this gene is related to comprehension and memory sections that are affected by OCD in humans. Throughout the past 25 years, there have been over 15 family studies of OCD, and almost all support genetic transmission of the disorder. DW Black’s study in 1992 found that the risk of OCD-like obsession and compulsion symptoms were far greater in parents of OCD children than those of the controls (16% to 3%), while DL Pauls’ study in 1995 showed that the risk of OCD in first degree relatives of OCD subjects was higher than the control subjects (10% to 1.9%) (Nestadt et al. 2010). The rest of the family studies show prevalence rates of 7%-15% in first degree relatives of a child with OCD, which is much higher than the national prevalence rate of 2-3%. Additionally, other studies have shown that OCD that develops in children has a greater prevalence in first degree relatives than first degree relatives of someone with adult-onset OCD. In simpler terms, individuals who develop OCD at a young age most likely were influenced by a genetic factor from their parents, while individuals who develop OCD post-youth were likely affected by an environmental factor. (Browne et al. 2014).
Environmental factors are much more difficult to analyze than genetic factors for multiple reasons. First, each person’s ability to handle the trials and tribulations of their environment is unique. Secondly, the severity of the trials and tribulations themselves are also unique to each person. For example, the death of a parent may have a large effect on one individual’s mental health, or it may have absolutely zero effect on another’s. To counteract this, researchers study monozygotic twins. These twins have identical genomes, and are born and raised in the same family at the same time, creating as similar an environment as possible. Therefore, when something happens to one twin and not the other, it is easier to distinguish the effect it has on the subject. A study led by Danielle C. Cath and a group of four other researchers used data of adult twins that have been followed from 1991-2002, and had information collected on them every 2-3 years. The researchers attempted to discover differences between a pair of twins themselves and the differences in Obsessive/compulsive levels of one set of twins to another set. The comparisons within a set of twins were used to study unique environmental factors related to OCD symptoms. Even though the twins had the exact same genetic makeup, their scores on levels of OC symptoms often differed substantially over time. The clearest unique environmental factor that led to a difference in OC scores was sexual assault. Twins that reported sexual assault scored higher in OC symptoms than their twin in all but two cases. Comparing the scores of the twins in one pair to twins in another pair allowed researchers to evaluate the effect of common environmental factors, such as education, religious upbringing, and economic status. However, there was no association of OC symptoms with parental smoking or alcoholic behavior, nor was there any association with education level or religious upbringing. (Cath et al. 2008). The difference in OC symptom scores among monozygotic twins shows that there are environmental factors that encourage the development of OCD, but scientists are still struggling to determine exactly which factors play a role and how significant their role is.