We will now examine who can develop OCD and why this might happen. We will look at population data on OCD. The role of inheritance, genetics, and possible environmental factors will be discussed, as well as the idea of developing resilience. Next, we will explore OCD throughout the life cycle. OCD is a common disorder in childhood and seems to have some differences compared to adult-onset OCD. Following a discussion of OCD in childhood or early adult life, we will look at how the pattern changes throughout the years and into middle and old age.
This chapter will also examine how culture may have an effect on the presentation of OCD. For example, all religions involve ritual and symbolic behaviours which have some similarities to OCD but generally do not take over a person's life. When OCD features religious ideas, other members of the same religion can often distinguish that the person with OCD is taking this to an extreme.
Who Gets OCD?
In Chapter 1, we briefly discussed the role that inheritance may play in developing OCD and how some obsessive traits may be helpful in developing a successful life path. In the case of OCD, the obsessions and compulsions become overwhelming and interfere with the person's life objectives, aims, and ambitions. OCD can affect people of any gender and of any social class, race, nationality, or religion.
Many years ago, OCD was thought to be a rare condition. Large population studies performed in the 1980s showed that this was untrue and that 2 or 3 per cent of the population suffer from OCD during their lifetime Reference Karno, Golding, Sorenson and Burnam[1]. Of course, estimating the prevalence of OCD is not an easy task. Many people with OCD are ashamed and embarrassed by their condition and will go to great lengths to try to hide it rather than admit to problems. It has been found that some people with OCD may resist seeking help for decades. In addition, population studies may run the risk of including people with mild obsessions and compulsions which do not interfere with their lives, and this may falsely increase the numbers. Generally, it seems that the figure of 2 or 3 per cent of the population is accurate for most societies.
Population studies generally suggest that women with OCD outnumber men with OCD by a ratio of 1.5:1. The interesting twist in this fact is that with regard to hospital, clinic, and professional referrals, more men than women are referred for help. This may be because men tend to have more severe conditions compared to women. Alternatively, it might be that men's absences from work are more likely to be noticed than women's absences. Women more frequently have washing compulsions and avoidance, whereas men more frequently have checking compulsions or complex thought compulsions. Of course, these trends, based on large populations of people with OCD, do not mean that a woman cannot have the most profound OCD with thought compulsions or that a man cannot have washing rituals; they simply demonstrate overall trends in the population.
The average age of onset of OCD is approximately 20 years. However, there does appear to be a peak of development of OCD around or just before puberty and then a much larger peak of onset in early adult life. Men are more likely to report that their OCD started in their early teens, whereas women more commonly have an onset in their early 20s. These figures are averages, and OCD does occur at extremely young ages and also at older ages. It is quite rare for OCD to develop without any earlier symptoms after the age of 40 years, and in such cases, further tests are usually advisable to ensure there are no other complications.
Until recently, it was thought to be unusual for children to suffer from OCD. Now it is known that OCD is, in fact, one of the most common mental disorders in childhood and may affect up to 5 per cent of children and adolescents. The clinical presentation in childhood is similar to that seen in adults. Again, boys tend to develop the condition earlier than do girls. The prognosis for OCD in childhood is generally better than that for adults.
If Someone in My Family Has OCD, Does That Mean I Will Get It?
The issue of genetics and psychological problems and mental illness is a complex one. Most conditions are not caused by a single gene but, rather, are ‘multifactorial’. In other words, the characteristics may run in families, but not everyone in a family will suffer from the condition. The same is true for OCD. What also appears to be true is that even if an individual inherits a very strong chance of suffering from OCD, it is not guaranteed that he or she will develop the condition. Increasingly, research seems to show that the way in which genes express themselves can be modified by external events. Some people, even within the same family, appear more prone than others to developing problems. This resilience seems likely to be partly inherited and partly a result of upbringing and early life experience. In the past, parents often took responsibility for causing their offspring's psychological problems due to poor parenting. This is clearly unfair and not the case. Parents share some of their genes with their offspring, and so parenting styles are partly influenced by their own genetic makeup and personality. Second, although it appears likely that a warm, loving family environment may provide the offspring with somewhat greater resilience, this can never be absolute. People from the very best families who have received an abundance of warmth, love, and the best parenting can still develop psychological problems. The genes are still the main deciding factor.
Not even the happiest and most loving family experience can completely prevent OCD from occurring in some individuals. The pattern of age of onset for OCD reflects this idea. Most adult patients with OCD develop it in early adult life and often in association with a major negative life event. In these cases, it may be reasonable to assume that the individual had a high genetic susceptibility to OCD and that, due to the individual's resilience, it took a major life event for OCD to be manifest; that the individual had moderate genetic susceptibility to OCD and poor resilience; or that the individual had a low susceptibility to OCD, and an extremely traumatic life event coupled with low resilience resulted in OCD. Therefore, it can be seen that factors which may determine whether or not an individual develops OCD include their genetic makeup, resilience (which is likely to be due to both genetics and early life nurturing), and the scale and impact of the negative life event.
A smaller but still significant number of adults with OCD develop it before puberty. These individuals are slightly more likely to be male rather than female. It has also been noted that they may have some specific neurological signs which do not interfere with normal functioning but may suggest high genetic loading for OCD.
What Will Happen If You Do Develop OCD?
Many children who develop OCD go on to recover; OCD is one of the most common psychological problems seen in childhood. Most children will experience a phase of OCD-like behaviours which will resolve in time. Other children go on to develop OCD, but the prognosis is extremely good. Apart from the small group of individuals who go on to develop long-standing OCD into adulthood, most children who are treated for OCD respond well and recover completely. Treatment for childhood OCD is mostly psychological, but short-term drug use can also be helpful for some children.
The course that OCD takes when untreated is variable. Some people may have occasional, discrete episodes interspersed with periods during which they are symptom-free. These episodes are often precipitated by stress surrounding a major life event, such as bereavement, illness, pregnancy, or loss of a job. Some people with apparent very late-onset OCD may develop this after retirement, but careful examination of the life history can show that there may have been previous short-lived episodes of OCD or strong OCD tendencies which were controlled by the discipline of working. Other people develop OCD and it remains at a similar level for many years until successfully treated. Another group of people may have OCD which is consistently present but which waxes and wanes throughout the years; sometimes these variations are related to life circumstances at the time, and sometimes they are apparently unrelated. Finally, a small group develops OCD which becomes increasingly restrictive over the years. The content of the obsessions in all types of OCD may change throughout the years, or in some cases it will remain consistent.
Because many people with OCD often do not seek help for years or even decades, fewer of them are married or in cohabiting relationships than would be expected based on their age. Many people with OCD live alone, and a significant number live with their parents. OCD can be a huge burden on families because they feel the need to comply with the OCD ‘rules’ of their family member. The prime consideration must always be the well-being of any children. OCD in a parent can lead to a restricted life for any children present. Everyone involved with a person with OCD needs to ensure that children are free to have as happy and carefree lives as possible and are able to play normally inside and outside the home and interact with their peers. Some people with OCD live with aging parents, who are called on to perform functions to help their children at an age when they would normally be autonomous.
Fred is a 45-year-old man who has suffered from OCD with fear of contamination for 25 years. He lives with his 85-year-old parents. Due to his OCD, Fred believes he is unable to shower himself because he thinks he may not do it ‘sufficiently’. He insists that his parents shower him once a week. These showers must be performed according to Fred's strict OCD ‘rules’. When his parents refuse to comply with these ‘rules’, Fred becomes angry and threatening.
Fred's story shows how the family, as well as the sufferer, can become completely enveloped in OCD. It is never acceptable for an individual to be coerced into performing OCD compulsive rituals for another person. Violence and threats cannot be tolerated. The problem is often that parents of the person with OCD may feel guilty about their son's or daughter's plight, wrongly thinking it is their ‘fault’. Most parents do not like to see their offspring suffer and so will start to perform some of the compulsive rituals for them in the hope of easing the distress. Unfortunately, this help can escalate until the whole family is ‘imprisoned’ by the OCD. In addition, parents can unwittingly worsen the situation by delaying the time until people such as Fred seek help.
As well as fewer people with OCD being married or living with a partner, fewer are employed compared to the general population of the same age. Some people have OCD and work in jobs in which some minor OCD traits may appear to be an advantage. These traits can also frequently get out of control.
Jenny, a 20-year-old student nurse, has recently become extremely concerned that she may cause an infection to spread to a patient in her current placement on an elderly ward. The hospital has strict policy guidance about staff hand washing and the use of protective gowns and gloves when handling bodily fluids. However, Jenny fears these do not go far enough. She insists on wearing a new pair of gloves for every activity, which is beyond the hospital guidance on infection. If she has to prepare a sterile trolley for a doctor to perform a blood test, she will take up to an hour to ensure it is clean and sterile. Rather than just cleaning the surface once, she will repeatedly clean the trolley until she believes it is ‘just right’. Although at first the more senior staff believed Jenny would settle into the job and become less anxious, the charge nurse is now planning to fail her for this placement due to her slowness and overly meticulous behaviour.
George is a 30-year-old architect. He is studious and hard-working and is generally appreciated by his boss. For the past ten years, George has been overly concerned that he may make an error which would result in either a catastrophic problem with a building he has been working on or lead to him losing his job. George arrives at work at 7:00 a.m. every morning, which is two hours before he is due at work. He rarely leaves work before 7:00 p.m., and even then he tends to take home files and work on his computer at home, checking and rechecking his calculations repeatedly. On weekends, he generally works 15–18 hours a day checking and rechecking his work. Due to these excessive hours, he often fails to eat or drink sufficiently and has found that he feels permanently exhausted and cannot sleep well at night. Despite working the extra hours, George has not yet been noted to have any difficulty by his work colleagues, who are unaware of the number of hours he is working.
These examples demonstrate how OCD can impact the working environment. In Jenny's case, she is too slow and careful to perform her job usefully. George is performing well and the amount of time he works is currently unknown by his superiors, but his excessive working hours are impacting his general health and well-being.
Is OCD New and Caused by Modern Society? What about Religion and Culture?
OCD is not a modern-day disease of the Western world; rather, there is evidence of its existence in historical figures as well as across all cultures. John Bunyan, the author of Pilgrim's Progress, was born in 1628, and it has been suggested that he may have suffered from OCD. In his spiritual autobiography, Bunyan, a strict Christian, describes blasphemous thoughts repeatedly entering his mind. He found these thoughts deeply abhorrent and repeatedly tried to distract himself or to ‘put this right’ by saying he did not mean these thoughts. A more modern example is that of the famous film producer, aviator, aircraft manufacturer, successful businessman, and playboy, Howard Hughes. He suffered from obsessions concerning his health and fear of death. Despite being a multimillionaire, he became increasingly concerned about his health and developed an extreme lifestyle. Ultimately, he lived the life of a recluse, living in a bare room with no clothes and eating and drinking at starvation levels. This self-neglect may have led to a hastening of his death at the age of 71 years.
OCD has been found in very different cultures throughout the world. There have been reports of OCD with similar characteristics and a similar prevalence amongst the Han population in China and the ultra-Orthodox Jewish population in Israel, as well as similar reports from Iran, India, and Western countries. The detailed content of the obsessions may vary from culture to culture – for example, it has been noted that the ultra-Orthodox Jewish person with OCD tends to have obsessions related to religious teachings – but the forms these obsessions take are indistinguishable throughout the world.
In the past, it was often argued that certain religious upbringings may lead to OCD. There is no evidence that this is true. There does seem to be a tendency for people with OCD to be attracted to more dogmatic branches of religions, in which there is a firm stance on what is ‘right’ and what is ‘wrong’, rather than more philosophical beliefs, in which there is less certainty. OCD is not, however, related to any specific religion; it has been reported in Christians, Muslims, Jews, Hindus, Buddhists, Confucians, and Taoists, as well as atheists and agnostics. It was once thought that the religions themselves may precipitate OCD. This was first reported in Italy, where a higher proportion of people with OCD were found in religious orders than in the outside population. However, it seems more likely that people with OCD were more attracted to the certainty and security of religious life rather than the religion itself being a causal factor. All religions have ritualistic and symbolic aspects which may resemble OCD. Some people with OCD believe that their religion requires them to carry out their OCD behaviours. Overall, it seems that whereas some people with OCD-like tendencies or even real OCD may be attracted to the stricter forms of religion, there is no evidence that any religion causes OCD. Religions with a more rigid ‘black-and-white’ approach to life seem to be particularly attractive to some people with OCD compared to religions with a more philosophical approach. People who practice religions and adhere to various religious rituals can generally be distinguished from people who perform their OCD compulsions to excess within their religions.
Emma is a 45-year-old woman with a 30-year history of OCD. She worries that she may have harmed others and constantly checks to ensure this is not the case. In addition, she constantly asks for reassurance from family and friends that she has not committed the heinous act she is currently worrying about. If she reads about a terrible murder in the papers or sees a news bulletin describing such an event, she will check that she was not in the vicinity of the event and will then ask for repeated reassurance from her husband or others around her at the time that she did not commit the act. This is extremely difficult for her husband, who frequently is asked for reassurance for four or five hours at a time after he returns home from work. In the past, Emma frequently telephoned the police to ‘confess’ her guilt even though she based her confessions on only sketchy media reports about the crimes. She realises that she has no memory of the events but worries that she may have forgotten them. The police no longer pay any attention to her ‘confessions’, but on one occasion they took up the floorboards of her house because she was worried she may have murdered a man and hidden him there.
After many years of this behaviour, Emma resisted all offers of therapy but was befriended by a member of a local church. Emma began to attend the church, whose members believed in spiritual healing. Part of the spiritual healing involved not only other church members praying intensely for one to be healed but also public confession of one's sins. Emma became a regular attendee at these confession sessions, where she tended to dominate the proceedings with her current worries of crimes she may have committed. At first, the church was welcoming and tried to accommodate her. Soon, the members realised that she had a serious psychological problem. The minister approached her and suggested that she get referred for treatment. She was also told that although she was still most welcome to attend church, she was no longer welcome at the public confession sessions.
The story of Emma shows how a particular aspect of religion can become very attractive to someone with OCD. It also demonstrates that regular worshippers are able to identify a person who is taking the religion too far and needs help. People have been advised to seek help from a variety of religions when following religious rituals excessively. It may be useful for the therapist to work in conjunction with the local priest, mullah, minister, vicar, or rabbi with the consent of the person with OCD to ensure that treatment is truly in accordance with appropriate religious beliefs.
Although once thought to be a rare condition, OCD affects 2 or 3 per cent of the population and is therefore a very common disorder.
Both men and women can be affected by OCD, and overall the gender ratio is approximately equal.
Most people develop OCD in early adult life and often, but not always, following a negative life event.
A smaller but significant number of adults with OCD developed it in childhood, usually just before puberty.
OCD is also a very common childhood problem.
Children with OCD have a better prognosis than adults, and the vast majority respond extremely well to treatment.
OCD tends to run in families, but it is not a straightforward inheritance pattern. Both genes and life experiences may have a role in precipitating OCD symptoms.
OCD is not a new condition, and historical figures throughout the ages have been described with what seems to be OCD.
OCD can often appear similar to religious rituals. Members of a faith can generally distinguish when an individual is taking the religion ‘too far’. Strict religious orders of any faith may attract people with OCD, but there is no evidence that religion causes OCD.
It may be useful for therapists to work collaboratively with a prominent member of the person with OCD's religious group if he or she would like this to occur.
