Obsessive–compulsive disorder

OCD can present with a wide variety of symptoms. Certain groups of symptoms usually occur together 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: symmetry factor, forbidden thoughts factor, cleaning factor and 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 examining the onset of OCD, one study suggests that there are differences in the age of onset between males and females, with the average age of onset of OCD being 9.6 years for boys and 11.0 years for girls. Children with OCD often have other mental disorders, such as ADHD, depression, anxiety, and disruptive behavior disorder. Continually, children are more likely to struggle in school and experience difficulties in social situations. 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. While some studies have shown that OCD with earlier onset is associated with greater severity, other studies have not been able to validate this finding. 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. Obsessions OCD may face intrusive thoughts such as worrying about death. 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. Another common obsession is scrupulosity, the pathological guilt/anxiety about moral or religious issues. In scrupulosity, a person's obsessions focus on moral or religious fears, such as the fear of being an evil person or the fear of divine retribution for sin, for example going to Hell. Mysophobia, a pathological fear of contamination and germs, is another common obsession theme. Some people with OCD experience sexual obsessions that may involve intrusive thoughts or images of various sexual acts with strangers, acquaintances, relatives, animals, or 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 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. 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. 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, and checking is consequently the better option. This reasoning often occurs in a cyclical manner and can continue for as long as the affected person needs it to in order to feel safe. OCD sometimes manifests in mental instead of overt compulsions. This manifestation may be termed "primarily obsessional OCD" and typically involves mental compulsions, such as mental avoidance or excessive rumination. OCD without overt compulsions could, by one estimate, characterize as many as 50–60% of OCD cases. Insight and overvalued ideation The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) identifies a continuum for the level of insight in OCD, ranging from good insight (the least severe) to no insight (the most severe). Good or fair insight is characterized by the acknowledgment that obsessive–compulsive beliefs are not or may not be true, while poor insight is characterized by the belief that obsessive–compulsive beliefs are probably true. The absence of insight altogether, in which the individual is completely convinced that their beliefs are true, is also identified as a delusional thought pattern and occurs in about 4% of people with OCD. When cases of OCD with no insight become severe, affected individuals have an unshakable belief in the reality of their delusions, which can make their cases difficult to differentiate from psychotic disorders. Additionally, good insight can include cases where the individual has no insight during the experience but demonstrates insight later, when they are in a calmer state of mind. Some people with OCD exhibit what is known as overvalued ideas, ideas that are abnormal compared to affected individuals' respective cultures, and more treatment-resistant than most negative thoughts and obsessions. Similar to how insight is identified on a continuum, obsessive–compulsive beliefs are characterized on a spectrum, ranging from obsessive doubt to delusional conviction. In the United States, overvalued ideation (OVI) is considered most akin to poor insight—especially when considering belief strength as one of an idea's key identifiers. In adolescent OCD patients, OVI is considered a severe symptom. Historically, OVI has been thought to be linked to poorer treatment outcome in patients with OCD, but it is currently considered a poor indicator of prognosis. Cognitive performance Though OCD was once believed to be associated with above-average intelligence, this does not appear to necessarily be the case. A 2013 review reported that people with OCD may sometimes have mild but wide-ranging cognitive deficits, most significantly those affecting spatial memory and to a lesser extent with verbal memory, fluency, executive function and processing speed, while auditory attention was not significantly affected. People with OCD show impairment in formulating an organizational strategy for coding information, set-shifting, and motor and cognitive inhibition. Specific subtypes of symptom dimensions in OCD have been associated with specific cognitive deficits. For example, the results of one meta-analysis comparing washing and checking symptoms reported that washers outperformed checkers on eight out of ten cognitive tests. The symptom dimension of contamination and cleaning may be associated with higher scores on tests of inhibition and verbal memory. Pediatric OCD Approximately 1–2% of children are affected by OCD. An international study showed that OCD most often develops during childhood or adolescence, with 21% of subjects having developed symptoms during childhood (age 12 and under) and another 36% having developed symptoms during adolescence (ages 13-17). OCD diagnosis in children occurs at similar rates across different ethnic groups and races, but African American children are less likely to receive treatment. In children, symptoms can be grouped into at least four types, including sporadic and tic-related OCD. It follows the Y-BOCS format, but with a Symptom Checklist that is adapted for developmental appropriateness. Insight, avoidance, indecisiveness, responsibility, pervasive slowness and doubting are not included in a rating of overall severity. The CY-BOCS has demonstrated good convergent validity with clinician-rated OCD severity and good to fair discriminant validity from measures of closely related anxiety, depression and tic severity. Positive treatment response is characterized by 25% reduction in CY-BOCS total score and diagnostic remission is associated with a 45%-50% reduction in Total Severity score (or a score <15). Selective serotonin reuptake inhibitors (SSRIs) are first-line medications for OCD in children with established AACAP guidelines for dosing. Medication in addition to a CBT intervention like exposure and response prevention (ERP) is more beneficial than only using medication in the treatment of OCD in children. More than 50% of people with OCD experience suicidal tendencies and 15% have attempted suicide. It has been found that between 18 and 34% of females currently experiencing OCD scored positively on an inventory measuring disordered eating. Another study found that 7% are likely to have an eating disorder, Individuals with OCD have also been found to be affected by delayed sleep phase disorder at a substantially higher rate than the general public. Some research has demonstrated a link between drug addiction and OCD. For example, there is a higher risk of drug addiction among those with any anxiety disorder, likely as a way of coping with the heightened levels of anxiety. However, drug addiction among people with OCD may be a compulsive behavior. Depression is also extremely prevalent among people with OCD. One explanation for the high depression rate among OCD populations was posited by Mineka, Watson and Clark (1998), who explained that people with OCD, or any other anxiety disorder, may feel "out of control". Someone exhibiting OCD signs does not necessarily have OCD. Behaviors that present as obsessive–compulsive can also be found in a number of other conditions, including obsessive–compulsive personality disorder (OCPD), autism spectrum disorder (ASD) or disorders in which perseveration is a possible feature (ADHD, PTSD, bodily disorders or stereotyped behaviors). Some cases of OCD present symptoms typically associated with Tourette syndrome, such as compulsions that may appear to resemble motor tics; this has been termed tic-related OCD or Tourettic OCD. OCD frequently occurs comorbidly with both bipolar disorder and major depressive disorder. Between 60 and 80% of those with OCD experience a major depressive episode in their lifetime. Comorbidity rates have been reported at between 19 and 90%, as a result of methodological differences. Between 9–35% of those with bipolar disorder also have OCD, compared to 1–2% in the general population. About 50% of those with OCD experience cyclothymic traits or hypomanic episodes. OCD is also associated with anxiety disorders. Lifetime comorbidity for OCD has been reported at 22% for specific phobia, 18% for social anxiety disorder, 12% for panic disorder and 30% for generalized anxiety disorder. The comorbidity rate for OCD and ADHD has been reported to be as high as 51%. == Causes ==

The cause of OCD is unknown. Drug-induced OCD Some medications, toxin exposures and drugs, such as methamphetamine or cocaine, can induce obsessive–compulsive symptoms in people without a history of OCD. Atypical antipsychotics such as olanzapine and clozapine can induce OCD in some people, particularly individuals with schizophrenia. The diagnostic criteria include: • General OCD symptoms (obsessions, compulsions, skin picking, hair pulling, etc.) that developed soon after exposure to the substance or medication which can produce such symptoms. • The onset of symptoms cannot be explained by an obsessive–compulsive and related disorder that is not substance/medication-induced and should last for a substantial period of time (about 1 month) • This disturbance does not only occur during delirium. • Clinically induces distress or impairment in social, occupational or other important areas of functioning. Genetics There appear to be some genetic components of OCD causation, with identical twins more often affected than fraternal twins. OCD is believed to be a heterogeneous disorder. Genetic risk is linked to excitatory neurons in the hippocampus and cerebral cortex, D1 and D2 medium spiny neurons, and overlaps with anxiety, depression, anorexia nervosa, and Tourette syndrome. First and second hand relatives of probands with OCD have a greater risk of developing anorexia nervosa as genetic relatedness increases. A systematic review found that while neither allele was associated with OCD overall, in Caucasians, the L allele was associated with OCD. Another meta-analysis observed an increased risk in those with the homozygous S allele, but found the LS genotype to be inversely associated with OCD. A genome-wide association study found OCD to be linked with single-nucleotide polymorphisms (SNPs) near BTBD3 and two SNPs in DLGAP1 in a trio-based analysis, but no SNP reached significance when analyzed with case-control data. One meta-analysis found a small but significant association between a polymorphism in SLC1A1 and OCD. The relationship between OCD and Catechol-O-methyltransferase (COMT) has been inconsistent, with one meta-analysis reporting a significant association, albeit only in men, and another meta analysis reporting no association. It has been postulated by evolutionary psychologists that moderate versions of compulsive behavior may have had evolutionary advantages. Examples would be moderate constant checking of hygiene, the hearth or the environment for enemies. Similarly, hoarding may have had evolutionary advantages. In this view, OCD may be the extreme statistical tail of such behaviors, possibly the result of a high number of predisposing genes. Brain structure and functioning Imaging studies have shown differences in the frontal cortex and subcortical structures of the brain in patients with OCD. There appears to be a connection between the OCD symptoms and abnormalities in certain areas of the brain, but such a connection is not clear. Some people with OCD have areas of unusually high activity in their brain or low levels of the chemical serotonin, which is a neurotransmitter that some nerve cells use to communicate with each other, and is thought to be involved in regulating many functions, influencing emotions, mood, memory and sleep. Autoimmune A controversial hypothesis is that some cases of rapid onset of OCD in children and adolescents may be caused by a syndrome connected to Group A streptococcal infections (GABHS), known as pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). OCD and tic disorders are hypothesized to arise in a subset of children as a result of a post-streptococcal autoimmune process. Whether PANDAS is a distinct entity differing from other cases of tic disorders or OCD is debated. A review of studies examining anti-basal ganglia antibodies in OCD found an increased risk of having anti-basal ganglia antibodies in those with OCD versus the general population. Environment OCD may be more common in people who have been bullied, abused or neglected, and it sometimes starts after a significant life event, such as childbirth or bereavement. It has been reported in some studies that there is a connection between childhood trauma and obsessive-compulsive symptoms. More research is needed to understand this relationship better. == Mechanisms ==

Neuroimaging Functional neuroimaging during symptom provocation has observed abnormal activity in the orbitofrontal cortex (OFC), left dorsolateral prefrontal cortex (dlPFC), right premotor cortex, left superior temporal gyrus, globus pallidus externus, hippocampus and right uncus. Weaker foci of abnormal activity were found in the left caudate, posterior cingulate cortex and superior parietal lobule. However, an older meta-analysis of functional neuroimaging in OCD reported that the only consistent functional neuroimaging finding was increased activity in the orbital gyrus and head of the caudate nucleus, while anterior cingulate cortex (ACC) activation abnormalities were too inconsistent. A meta-analysis comparing affective and nonaffective tasks observed differences with controls in regions implicated in salience, habit, goal-directed behavior, self-referential thinking and cognitive control. For nonaffective tasks, hyperactivity was observed in the insula, ACC and head of the caudate/putamen, while hypoactivity was observed in the medial prefrontal cortex (mPFC) and posterior caudate. Affective tasks were observed to relate to increased activation in the precuneus and posterior cingulate cortex, while decreased activation was found in the pallidum, ventral anterior thalamus and posterior caudate. The involvement of the cortico-striato-thalamo-cortical loop in OCD, as well as the high rates of comorbidity between OCD and ADHD, have led some to draw a link in their mechanism. Observed similarities include dysfunction of the anterior cingulate cortex and prefrontal cortex, as well as shared deficits in executive functions. The involvement of the orbitofrontal cortex and dorsolateral prefrontal cortex in OCD is shared with bipolar disorder and may explain the high degree of comorbidity. People with OCD evince increased grey matter volumes in bilateral lenticular nuclei, extending to the caudate nuclei, with decreased grey matter volumes in bilateral dorsal medial frontal/anterior cingulate gyri. These findings contrast with those in people with other anxiety disorders, who evince decreased (rather than increased) grey matter volumes in bilateral lenticular/caudate nuclei, as well as decreased grey matter volumes in bilateral dorsal medial frontal/anterior cingulate gyri. Cognitive models Generally, two categories of models for OCD have been postulated. The first category involves deficits in executive dysfunction and is based on the observed structural and functional abnormalities in the dlPFC, striatum and thalamus. The second category involves dysfunctional modulatory control and primarily relies on observed functional and structural differences in the ACC, mPFC and OFC. One proposed model suggests that dysfunction in the orbitalfrontal cortex (OFC) leads to improper valuation of behaviors and decreased behavioral control, while the observed alterations in amygdala activations leads to exaggerated fears and representations of negative stimuli. Due to the heterogeneity of OCD symptoms, studies differentiating various symptoms have been performed. Symptom-specific neuroimaging abnormalities include the hyperactivity of caudate and ACC in checking rituals, while finding increased activity of cortical and cerebellar regions in contamination-related symptoms. Neuroimaging differentiating content of intrusive thoughts has found differences between aggressive as opposed to taboo thoughts, finding increased connectivity of the amygdala, ventral striatum and ventromedial prefrontal cortex in aggressive symptoms, while observing increased connectivity between the ventral striatum and insula in sexual or religious intrusive thoughts. Another model proposes that affective dysregulation links excessive reliance on habit-based action selection with compulsions. This is supported by the observation that those with OCD demonstrate decreased activation of the ventral striatum when anticipating monetary reward, as well as increased functional connectivity between the VS and the OFC. Furthermore, those with OCD demonstrate reduced performance in Pavlovian fear-extinction tasks, hyperresponsiveness in the amygdala to fearful stimuli and hyporesponsiveness in the amygdala when exposed to positively valanced stimuli. Stimulation of the nucleus accumbens has also been observed to effectively alleviate both obsessions and compulsions, supporting the role of affective dysregulation in generating both. Serotonin receptor and transporter binding studies have yielded conflicting results, including higher and lower serotonin receptor 5-HT2A and serotonin transporter binding potentials that were normalized by treatment with SSRIs. Despite inconsistencies in the types of abnormalities found, evidence points towards dysfunction of serotonergic systems in OCD. Orbitofrontal cortex overactivity is attenuated in people who have successfully responded to SSRI medication, a result believed to be caused by increased stimulation of serotonin receptors 5-HT2A and 5-HT2C. Dopaminergic dysfunction in cortico-striato-thalamo-cortical circuits has been implicated in cognitive rigidity, emotional dysregulation, and compulsive behaviors in OCD. A 2020 review found striatal D2 receptors are decreased in OCD, dopamine transporters are unchanged in OCD, and evidence for other dopaminergic changes is limited. Increased dopamine release in the nucleus accumbens after deep brain stimulation correlates with improvement in symptoms, pointing to reduced dopamine release in the striatum playing a role in generating symptoms. Abnormalities in glutamatergic neurotransmission have been implicated in OCD. Findings such as increased cerebrospinal glutamate, less consistent abnormalities observed in neuroimaging studies, and the efficacy of some glutamatergic drugs (such as the glutamate-inhibiting riluzole) have implicated glutamate in OCD. OCD has been associated with reduced N-Acetylaspartic acid in the mPFC, which is thought to reflect neuron density or functionality, although the exact interpretation has not been established. == Diagnosis ==

Formal diagnosis may be performed by a psychologist, psychiatrist, clinical social worker or other licensed mental health professional. OCD, like other mental and behavioral health disorders, cannot be diagnosed by a medical exam, A person may attempt to ignore or suppress such obsessions, neutralize them with another thought or action, or try to rationalize their anxiety away. People with OCD tend to recognize their obsessions as irrational. Compulsions become clinically significant when a person feels driven to perform them in response to an obsession or according to rules that must be applied rigidly and when the person consequently feels or causes significant distress. Therefore, while many people who do not have OCD may perform actions often associated with OCD (such as ordering items in a pantry by height), the distinction with clinically significant OCD lies in the fact that the person with OCD must perform these actions to avoid significant psychological distress. These behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these activities are not logically or practically connected to the issue or they are excessive. Moreover, the obsessions or compulsions must be time-consuming, often taking up more than one hour per day or cause impairment in social, occupational or scholastic functioning. or the obsessive–compulsive inventory (OCI-R; self-rating). A 2025 systematic review found that the 8-question Child Behavior Checklist–Obsessive-Compulsive Subscale (CBCL-OCD/OCS) demonstrates moderate accuracy in identifying children likely to have OCD and may help guide referrals for specialist evaluation. With measurements such as these, psychiatric consultation can be more appropriately determined, as it has been standardized. There are several types of obsessive thoughts that are found commonly in those with OCD. Some of these include fear of germs, hurting loved ones, embarrassment, neatness, societally unacceptable sexual thoughts etc. Another criterion in the DSM is that a person's mental illness does not fit one of the other categories of a mental disorder better. That is to say, if the obsessions and compulsions of a patient could be better described by trichotillomania, it would not be diagnosed as OCD. A different aspect of the diagnoses is the degree of insight had by the individual in regards to the truth of the obsessions. There are three levels, good/fair, poor and absent/delusional. Good/fair indicated that the patient is aware that the obsessions they have are not true or probably not true. Differential diagnosis OCD is often confused with the separate condition obsessive–compulsive personality disorder (OCPD). OCD is egodystonic, meaning that the disorder is incompatible with the individual's self-concept. As egodystonic disorders go against a person's self-concept, they tend to cause much distress. OCPD, on the other hand, is egosyntonic, marked by the person's acceptance that the characteristics and behaviors displayed as a result are compatible with their self-image, or are otherwise appropriate, correct or reasonable. As a result, people with OCD are often aware that their behavior is not rational and are unhappy about their obsessions, but nevertheless feel compelled by them. By contrast, people with OCPD are not aware of anything abnormal; they will readily explain why their actions are rational. It is usually impossible to convince them otherwise and they tend to derive pleasure from their obsessions or compulsions. == Management ==

Cognitive behavioral therapy (CBT) and psychotropic medications are the first-line treatments for OCD. This position is supported by the pattern of memory distrust; the more often compulsions are repeated, the more weakened memory trust becomes and this cycle continues as memory distrust increases compulsion frequency. One specific CBT technique used is called exposure and response prevention (ERP), which involves teaching the person to deliberately come into contact with situations that trigger obsessive thoughts and fears (exposure), without carrying out the usual compulsive acts associated with the obsession (response prevention). This technique causes patients to gradually learn to tolerate the discomfort and anxiety associated with not performing their compulsions. For many patients, ERP is the add-on treatment of choice when selective serotonin reuptake inhibitors (SSRIs) medication does not effectively treat OCD symptoms, or vice versa, for individuals who begin treatment with psychotherapy. A 2024 systematic review concluded, with high strength of evidence, that CBT with ERP provided via telehealth is equally as effective for reducing symptoms, in children and adolescents, as in-person treatment. ERP has a strong evidence base and is considered the most effective treatment for OCD. While ERP can lead a majority of clients to improvements, many do not reach remission or become asymptomatic; some therapists are also hesitant to use this approach. The recent development of remotely technology-delivered CBT is increasing access to therapy options for those living with OCD and remote versions appear to be equally as effective as in-person therapy options. The development of smartphone interventions for OCD that utilize CBT techniques are another alternative that is expanding access to therapy while allowing therapies to be personalized for each patient. 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". Inference-based therapy (IBT) is a form of cognitive therapy specifically developed for treating OCD. The therapy posits that individuals with OCD put a greater emphasis on an imagined possibility than on what can be perceived with the senses, and confuse the imagined possibility with reality, in a process called inferential confusion. According to inference-based therapy, obsessional thinking occurs when the person replaces reality and real probabilities with imagined possibilities. The goal of inference-based therapy is to reorient clients towards trusting the senses and relating to reality in a normal, non-effortful way. Differences between normal and obsessional doubts are presented and clients are encouraged to use their senses and reasoning as they do in non-obsessive–compulsive disorder situations. For body-focused repetitive behaviors such as trichotillomania (hair pulling), skin picking and onychophagia (nail biting), behavioral interventions such as habit reversal training and decoupling are recommended for the treatment of compulsive behaviors. A 2007 Cochrane review found that psychological interventions derived from CBT models, such as ERP, ACT and IBT, 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, behavioral interventions such as habit-reversal training and decoupling are recommended. Medication The medications most frequently used to treat OCD are antidepressants, including selective serotonin reuptake inhibitors (SSRIs). However, ERP alone may be as effective as ERP combined with an SSRI for OCD symptoms. 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. For OCD treatment, there is tentative short-term evidence supporting risperidone and aripiprazole, insufficient evidence for olanzapine, and quetiapine shows no significant benefit versus placebo, with overall conclusions limited by a small number of studies. Existing evidence suggests that repetitive TMS (rTMS), particularly targeting the dorsolateral prefrontal cortex and supplementary motor area, effectively reduces obsessive–compulsive disorder symptoms. The evidence is insufficient to conclude that electroconvulsive therapy is an effective treatment for OCD. Evidence is limited to low-quality case reports/series that suggest possible benefit in some severe, treatment-resistant cases; however, no randomized trials have been performed, leaving its efficacy unproven. 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. However, because deep brain stimulation results in such an instant and intense change, individuals may experience identity challenges afterward. 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, along with exposure and response prevention (ERP) therapy, stands as an effective and validated first line of treatment of OCD in children. 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. Trials have shown that children and adolescents with OCD should begin treatment with the combination of CBT with a selective serotonin reuptake inhibitor or CBT alone, rather than only an SSRI. 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. == Prognosis ==

Quality of life is reduced across all domains in OCD, which is vastly chronic. 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. The risk of having at least one comorbid personality disorder in OCD is 52%, which is the highest among anxiety disorders and greatly impacts its management and prognosis. == Epidemiology ==

estimated rates for obsessive-compulsive disorder per 100,000 inhabitants in 2004 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. == 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." 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. In his medical treatise entitled Sustenance of the Body and Soul, al-Balkhi described obsessions particular to the disorder as "Annoying thoughts that are not real. These intrusive thoughts prevent enjoying life, and performing daily activities. They affect concentration and interfere with ability to carry out different tasks." As treatment, al-Balkhi suggested treating obsessive thoughts with positive thoughts and mind-based therapy. 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". 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. The success of ERP clinically and scientifically has been summarized as "spectacular" by prominent OCD researcher Stanley Rachman decades following Meyer's creation of the method. In 1967, psychiatrist Juan José López-Ibor reported that the drug clomipramine was effective in treating OCD. Many reports of its success in treatment followed and several studies had confirmed its effectiveness by the 1980s. However, clomipramine was subsequently displaced by new SSRIs developed in the 1970s, such as fluoxetine and sertraline, which were shown to have fewer side effects. 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. American aviator and filmmaker Howard Hughes is known to have had OCD, primarily an obsessive fear of germs and contamination. 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 spoken about his life-long struggle with OCD, particularly primarily obsessional obsessive–compulsive disorder. Swedish climate activist Greta Thunberg is also known to have OCD, among other mental health conditions. Passing for Normal: A Memoir of Compulsion (2000) is a memoir by Amy Wilensky about her experience of OCD and Tourette syndrome. American actor James Spader has spoken about his OCD. In 2014, when interviewed for Rolling Stone he said: "I'm obsessive-compulsive. I have very, very strong obsessive-compulsive issues. I'm very particular. ... It's very hard for me, you know? It makes you very addictive in behavior, because routine and ritual become entrenched. But in work, it manifests itself in obsessive attention to detail and fixation. It serves my work very well: Things don't slip by. But I'm not very easygoing." In 2022 the president of Chile Gabriel Boric stated that he had OCD, saying: "I have an obsessive–compulsive disorder that's completely under control. Thank God I've been able to undergo treatment and it doesn't make me unable to carry out my responsibilities as the President of the Republic." In a documentary released in 2023, the footballer David Beckham discussed his compelling cleaning rituals, need for symmetry in the fridge and the impact of OCD on his life. In 2018, American rapper NF was diagnosed with obsessive–compulsive disorder. He addresses his experience with mental illness and therapy frequently in his music, particularly in the 2023 album Hope. In 2025, actress Jenna Ortega revealed that she struggles with it noting: "(I have) pretty intense OCD. Repetitive thoughts and counting everything multiple times and having to do the same action over and over... Sometimes my nights consist of just being really exhausted and going up and down the stairs six times because that's what I think I need to do to make sure no one breaks into my home." == Society and culture ==

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. • The play and film adaptations of The Odd Couple based around the character of Felix, who shows some of the common symptoms of OCD. • 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 Roy (Nicolas Cage) with OCD who opens and closes doors three times while counting aloud before he can walk through them. • Martin Scorsese's biographical drama film The Aviator (2004) portrays the life of Howard Hughes from 1927 to 1947, when he became a successful film producer and an aviation magnate while simultaneously growing more unstable due to severe obsessive–compulsive disorder (OCD). • In the television series Monk (2002–2009), the titular character Adrian Monk fears both human contact and dirt. • The one-man show The Life and Slimes of Marc Summers (2016), a stage adaptation of Marc Summers' 1999 memoir which recounts how OCD affected his entertainment career. • In the novel Turtles All the Way Down (2017) by John Green, teenage main character Aza Holmes struggles with OCD that manifests as a fear of the human microbiome. Throughout the story, Aza repeatedly opens an unhealed callus on her finger to drain out what she believes are pathogens. The novel is based on Green's own experiences with OCD. He explained that Turtles All the Way Down is intended to show how "most people with chronic mental illnesses also live long, fulfilling lives." • In the film The House That Jack Built (2018), the titular character, a serial killer, compulsively cleans a crime scene after obsessing over leaving evidence. • The British TV series Pure (2019) stars Charly Clive as 24-year-old Marnie, who is plagued by disturbing sexual thoughts, as a kind of primarily obsessional obsessive compulsive disorder. == Research ==

Cortical thickness differences in adults with OCD are linked to a network of brain-specific, developmentally expressed genes. OCD patients have thicker precentral and paracentral brain regions compared to controls and those with thinner precentral areas showed greater improvement with transcranial direct-current stimulation treatment, suggesting these structural differences may serve as neural biomarkers for predicting treatment response. Glutamatergic medications, such as N-acetylcysteine (NAC) and memantine, may improve symptoms of OCD, though high heterogeneity and potential publication bias warrant cautious interpretation. Augmenting SSRIs with NAC may modestly reduce OCD symptoms without increasing adverse events, though it may have limited efficacy. Ketamine, an N-methyl-D-aspartate (NMDA) glutamate receptor antagonist, has shown potential for rapid and tolerable symptom relief in OCD, but evidence is limited and inconsistent. Psychedelics have been investigated for their potential use in treating OCD; psilocybin is generally well-tolerated in OCD, with symptom reduction for some patients, but repeated dosing may be needed to maintain effects. == See also ==