On the popular TV show "Monk," private detective Adrian Monk has problems. Lots of them. In addition to solving crimes, Monk spends his time dealing with uncontrollable habits, such as obsessively cleaning his apartment or using sanitized wipes after shaking someone's hand. He's also afraid of practically everything, but particularly heights, large groups, germs and all manner of potential dangers. Monk manages to overcome his obsessive habits -- sometimes even using them to his advantage -- and catch criminals. But Monk isn't just a quirky character. He has obsessive-compulsive disorder (OCD).
The actor behind Monk is Tony Shalhoub, and he's won three Emmy Awards for his work on the show. Shalhoub has said that he can identify with his character's obsessive traits, as can, perhaps, many viewers [source: WebMD]. To portray Monk, Shalhoub has said that he allows every normally checked impulse that a healthy person might have -- say, the desire to move an object that's out of place or take care of the lint on a stranger's shoulder -- to be acted out [source: New York Times]. Consequently, Adrian Monk is a whirlwind of uncontrollable habits and tics, such as skipping over cracks in the sidewalk. But unlike many OCD sufferers, Monk is relatively functional, routinely solving crimes and nabbing criminals.
OCD has also been immortalized on the silver screen, perhaps most famously by Jack Nicholson's character in the film "As Good as It Gets." But whereas Monk is kind, clever and funny, Nicholson's character, Melvin Udall, is rude and irritable. So it may be that Monk's lovable nature and the humor he brings to his foibles have contributed to the show's success and brought attention to a disorder that afflicts millions of people. One of the show's virtues is that it uses Monk's OCD in a light, humorous way and that his OCD-caused fastidiousness often helps him to solve crimes. (The show's tagline is "Obsessive. Compulsive. Detective.")
The USA network, home of "Monk," launched a public service campaign to boost awareness of OCD and its treatment. The show's Web site also presents information about OCD. However, the show's depiction of OCD may be misleading because for many patients, obsessive-compulsive disorder is debilitating, preventing them from living ordinary lives. In this article, we'll take a look at OCD, its symptoms, its possible causes, how it's diagnosed and how it may be treated. We'll also take a look at what distinguishes someone who happens to be perfectionistic or obsessive from someone who has full-blown OCD.
An estimated 5 to 7 million people in the United States have obsessive-compulsive disorder [source: New York Times]. The actual number may be even higher, representing 2 to 3 percent of the country's population [source: NIH]. No matter the number, OCD is a serious anxiety disorder, appearing equally as often in men and women (though it often appears earlier in men).
The components of OCD may be divided into two main categories: obsessions and compulsions. Obsessive thoughts produce a compulsive response in the form of frequently performed actions or rituals. People with OCD perform rituals, such as repeatedly washing their hands, as a way of suppressing or responding to these obsessive thoughts. Unfortunately, the obsessive thought -- in this case, that one's hands are dirty -- is nearly impossible to get rid of, despite being not being grounded in reality. Some rituals involve physical action while others only occur in the mind, such as counting stairs or the number of words a person says.
A person with OCD feels surrounded by disorder and the unknown, and rituals allow him or her to feel more in control. Many people with the disorder have a "magic number" that they apply to different actions, whether it's touching an object or chewing food a certain number of times. Besides repeated hand washing, common rituals include touching door knobs and other objects, counting, locking and unlocking doors, and arranging items in a symmetrical or orderly manner. Some people with OCD are obsessed with cleanliness and order, while others may be hoarders, unable to get rid of anything.
A common undercurrent of OCD is feeling plagued by doubt. Obsessive, doubting thoughts may lead someone with OCD to need constant reassurance that something is in its proper place or that an appliance is turned off. Whereas a normal person may wonder if his or her car is locked, then remember that it is and move on, someone with OCD would be so wracked with doubt that even a return to the car (or several) would not allay his or her fears. This lack of certainty, especially with regards to the safety of oneself and others, is a common feature of OCD [source: New York Times].
Many people perform OCD-type rituals every day. Who hasn't gone back home to make sure that an appliance is off or reassembled items sitting on a desk to make them look more symmetrical? But it's the obsessive, repeated and uncontrollable nature of these rituals that differentiates the OCD sufferer from a healthy person. These obsessive thoughts are also accompanied by extreme anxiety, which is then channeled into the ritual, itself seen as some sort of stress-management tool.
The obsessive thoughts of an OCD patient often go against personal, religious or societal ethics -- thoughts may be about harming others or engaging in other inappropriate actions. Some people with the disorder are obsessed with the idea that their actions (or lack of action) may harm others. The desire to tell some authority figure, such as a waiter at a restaurant, about the (usually remote) possibility of danger is called a reporting compulsion, and the consequences can be embarrassing. Restaurants, in fact, with the numerous possibilities for acquiring germs or an accident occurring, are a nightmare for many people with OCD.
Besides the pain of anxiety, OCD can be harmful because its rituals can consume a person's life, taking up hours of the day and affecting one's professional and social relationships. The simple prospect of going outside may seem impossible for someone who must bathe for hours just to feel clean. Tangible effects of OCD may include baldness from pulling at the hair or skin problems from excessive hand washing.
So what causes these compulsions?
OCD Causes and Diagnosis
OCD usually appears in early adulthood, although children can have it too. In such cases, the disorder usually appears around age 10 [source: Mayo Clinic]. The actual causes of the disease remain unknown, though it likely has a hereditary component [source: NIH]. Stress also seems to boost one's chances of developing OCD, while many OCD-related thoughts and rituals can themselves inflict enormous stress. Recent research indicates a relationship between the areas of the brain associated with decision-making, movement, and checking or stopping thoughts; overactivity in this mental circuit could contribute to the disorder [source: Men's Health].
OCD can only be definitively diagnosed through a clinical interview with a doctor. A doctor will ask a patient a variety of questions about his or her behavior and medical history in forming a diagnosis. But new research may offer doctors new tools in identifying the disorder, even in identifying a person's susceptibility to developing it. The new technique depends on fMRI scans, which allow doctors to look at areas of the brain known to be associated with OCD. (These areas of the brain are also associated with Parkinson's disease.) In the brain of someone with OCD, the area linked with making basic decisions becomes highly active as the patient struggles to make choices [source: CNN].
We've discussed some of the main symptoms of OCD, which include obsessive thoughts and compulsive rituals designed to control or suppress those thoughts. These obsessive thoughts can generally be broken down into four main types. First, there's the obsession over germs, commonly associated with OCD. Then there's the need for things to be in the right place, often in a manner producing acceptable symmetry. The third type is doubt, such as feeling like you might have hit a pedestrian or constantly needing to confirm that an appliance hasn't been left on. Finally, there are disturbing, pressing thoughts that don't go away -- uncomfortable sexual urges or the desire to commit a violent act.
Not every compulsion is evidence of OCD. For example, many people bite their nails as a regular habit. There can be a relaxing element in doing this (as in, biting nails lessens the compulsion to do so), but on its own, nail biting isn't evidence of a disorder. Remember: OCD provokes anxiety and produces unwanted images, thoughts, compulsions and a pathological level of doubting.
OCD symptoms can ebb with time or proper treatment, but in general, the condition is chronic, and many people must contend with it for their entire lives. Besides the hours consumed in rituals, the overwhelming pressure to perform these rituals and the public embarrassment that they can produce often cause people to shelter themselves inside, afraid to engage the world and encounter friends or family. This condition is often known as agoraphobia, a fear of crowded places. Besides agoraphobia, many OCD sufferers have additional anxiety disorders, depression or eating disorders. OCD is also associated with an increased rate of substance abuse.
On the next page, we'll take a look at the treatment options for OCD.
Many people with OCD are reluctant to seek treatment, often because they're ashamed or don't even realize they have a problem. Others may attribute their compulsive, perfectionist behavior to their success in life [source: Men's Health]. And for those who have OCD, the people around them may not take the disease seriously, making light of it and not realizing how devastating the condition can be. One person, who had to seek temporary hospitalization to battle the disorder, compared having OCD to the disorientation of "living in an Escher print" [source: Men's Health].
As with many mental disorders, antidepressants are often used in treating OCD. Some antidepressants are explicitly approved by the FDA for treatment of the disorder while others are used "off-label." When medication alone does not work, most turn to psychotherapy, specifically cognitive behavioral therapy (CBT).
The basic function of cognitive behavioral therapy is to change existing patterns of behavior and obsessive thoughts. A therapist will work with a patient to undermine negative beliefs that lead to self-destructive behavior. Together they analyze recurring thoughts, especially those that seem to arise automatically and continually, and figure out what causes them and how to deal with them. Sometimes the thoughts themselves can't be directly confronted, but the behaviors they produce can be changed instead. Besides producing changes in behavior and lessening anxiety, CBT has been proven to have actual biological effects by changing neurotransmitter activity [source: New York Times].
A common technique used in CBT is exposure and response prevention, in which a patient confronts an obsession and tries to avoid performing the required ritual. In this way patients can test their emotional and physical responses to certain thoughts in order to see that those thoughts or the reactions they produce aren't based in reality. Continual exposure to those thoughts may also make patients less reactive to them. This tactic doesn't work immediately on one's worst compulsions. Instead, a patient will rank his or her obsessions in order of how much anxiety they produce. He or she will first confront those that produce less anxiety. Ideally, the patient can eventually tackle all of his or her obsessions, while also producing a method for dealing with new compulsions that may arise.
For some people, a combination of medication and therapy isn't enough, and a more immersive treatment method is needed. They might choose temporary hospitalization at a facility dedicated to treating OCD, like the OCD Institute at McLean Hospital, a collaboration between Massachusetts General Hospital and McLean Hospital (affiliated with Harvard University).
For more information about OCD and other articles on mental health and neurological disorders, try the links on the next page.
More Great Links
- "Brain Scans Show Heightened Risk for Obsessive-Compulsive Disorder." HealthDay. NIH. July 17, 2008. http://www.nlm.nih.gov/medlineplus/news/fullstory_67086.html
- "Cognitive Behavioral Therapy." National Alliance on Mental Illness. June 2003. http://www.nami.org/Template.cfm?Section=About_Treatments_and_Supports&template=/ContentManagement/ContentDisplay.cfm&ContentID=7952
- "Disorder drives man to eat 23,000 Big Macs." Associated Press. MSNBC. Sept. 10, 2008. http://www.msnbc.msn.com/id/26623057/
- "Monk." IMDB. http://www.imdb.com/title/tt0312172/
- "Obsessive-Compulsive Disorder." NIH. June 26, 2008. http://www.nimh.nih.gov/health/publications/anxiety-disorders/obsessive-compulsive-disorder.shtml
- "Obsessive-compulsive disorder (OCD). Mayo Clinic. Dec. 21, 2006. http://www.mayoclinic.com/print/obsessive-compulsive-disorder/DS00189/METHOD=print&DSECTION=all
- "Obsessive-Compulsive Disorder (OCD)." Anxiety Disorders Association of America.http://www.adaa.org/GettingHelp/AnxietyDisorders/OCD.asp
- "Obsessive-compulsive personality disorder." NIH. Nov. 15, 2006. http://www.nlm.nih.gov/medlineplus/ency/article/000942.htm
- Bell, Jeff. "OCD: When anxiety is at the table." New York Times. Harvard University. Feb. 6, 2008. http://www.mclean.harvard.edu/pdf/news/mitn/nyt080206.pdf
- Cohen, Elizabeth. "When the brain doesn't know when to stop." CNN. Jan. 17, 2006. http://www.cnn.com/2006/HEALTH/conditions/01/16/btsc.cohen/index.html
- Crandell, Caitlin. "O Is For Obsessive Compulsive Disorder." Santa Barbara Independent. July 27, 2008. http://www.independent.com/news/2008/jul/27/o-obsessive-compulsive-disorder/
- Dolan, Andy. "The obsessive disorder that haunts my life." Daily Mail. April 3, 2006. http://www.dailymail.co.uk/tvshowbiz/article-381802/The-obsessive-disorder-haunts-life.html
- Katz, Jeremy. "Are You Crazy Enough to Succeed?" Men's Health. http://www.menshealth.com/cda/article.do?site=MensHealth&channel=health&category=other.diseases.ailments&conitem=530aeca61c3aa110VgnVCM10000013281eac____
- Pearlman, Eve. "Actor Tony Shalhoub Takes on Obsessive Compulsive Disorder." WebMD. May 28, 2008. http://www.webmd.com/mental-health/features/actor-tony-shalhoub-takes-on-obsessive-compulsive-disorder
- Ryan, Suzanne C. "Bring in 'da Monk." Pittsburgh Post-Gazette. Harvard University. June 25, 2004. http://www.mclean.harvard.edu/pdf/news/ppg062504.pdf