Instruct: Given a question, retrieve relevant documents that can help answer the question.
Query: What's a ritual in OCD?
Obsessive–compulsive disorder (OCD) is a mental disorder where people feel the need to check things repeatedly, perform certain routines repeatedly (called "rituals"), or have certain thoughts repeatedly (called "obsessions").[1] People are unable to control either the thoughts or the activities for more than a short period of time.[1] Common activities include hand washing, counting of things, and checking to see if a door is locked.[1] Some may have difficulty throwing things out.[1] These activities occur to such a degree that the person's daily life is negatively affected.[1] This often takes up more than an hour a day.[2] Most adults realize that the behaviors do not make sense.[1] The condition is associated with tics, anxiety disorder, and an increased risk of suicide.[2][3]
Additional initiatives the IOCDF has prioritized this year include revamping and updating the “OCD in the Classroom” program, launching a Pediatric OCD website, promoting awareness through OCD Awareness Week events, and building and developing international resources for individuals suffering with OCD around the world.
Obsessive–compulsive disorder (OCD) is not classified as an anxiety disorder by the DSM-5 but is by the ICD-10. It was previously classified as an anxiety disorder in the DSM-IV. It is a condition where the person has obsessions (distressing, persistent, and intrusive thoughts or images) and compulsions (urges to repeatedly perform specific acts or rituals), that are not caused by drugs or physical order, and which cause distress or social dysfunction. The compulsive rituals are personal rules followed to relieve the anxiety. OCD affects roughly 1-2% of adults (somewhat more women than men), and under 3% of children and adolescents.
Best estimates are that about 1 in 100 adults – or between 2 and 3 million adults in the United States – currently have obsessive–compulsive disorder or OCD. There are also at least 1 in 200 – or 500,000 – children and teenagers that have OCD. That means four or five children with OCD are likely to be enrolled in any average size elementary school. In a medium to large high school, there could be 20 students struggling with the challenges caused by OCD.
Some OCPD features are common in those afflicted with OCD. For example, perfectionism, hoarding, and preoccupation in details (which are three characteristics of OCPD) were found in people with OCD and not in people without OCD, showing a particular relationship between these OCPD traits with OCD.[13] The reverse is also true: certain OCD symptoms appear to have close parallels in OCPD ones. This is particularly the case for checking and ordering and symmetry symptoms. OCPD samples who have OCD are particularly likely to endorse obsessions and compulsions regarding symmetry and organization.[14] Washing symptoms, which are among the most common OCD symptoms, don't appear to have much of a link with OCPD, in contrast.
ERP is predicated on the idea that a therapeutic effect is achieved as subjects confront their fears, but refrain from engaging in the escape response or ritual that delays or eliminates distress. In the case of individuals with OCD or an anxiety disorder, there is a thought or situation that causes distress. Individuals usually combat this distress through specific behaviors that include avoidance or rituals. However, ERP involves purposefully evoking fear, anxiety, and or distress in the individual by exposing him/her to the feared stimulus. The response prevention then involves having the individual refrain from the ritualistic or otherwise compulsive behavior that functions to decrease distress. The patient is then taught to tolerate distress until it fades away on its own, thereby learning that rituals are not always necessary to decrease distress or anxiety. Over repeated practice of ERP, patients with OCD expect to find that they can have obsessive thoughts and images but not have the need to engage in compulsive rituals to decrease distress.
Therapeutic treatment may be effective in reducing ritual behaviors of OCD for children and adolescents.[93] Similar to the treatment of adults with OCD, CBT stands as an effective and validated first line of treatment of OCD in children.[94] Family involvement, in the form of behavioral observations and reports, is a key component to the success of such treatments.[95] 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.[94] After one or two years of therapy, in which a child learns the nature of his or her obsession and acquires strategies for coping, that child may acquire a larger circle of friends, exhibit less shyness, and become less self-critical.[96]
In a report on Scottish Folds, the Breed Standards Advisory Council (BSAC) for New Zealand Cat Fancy (NZCF) states that "Breeders may not have appreciated the strength of the evidence that heterozygous cats can and do develop [feline] OCD." While research shows that all heterozygous folds develop OCD, and anecdotal evidence shows that heterozygous folds can and do develop OCD, they do not show whether mildly affected parents are more likely to have mildly affected offspring. They also do not show what percentage of Folds are severely affected. The report states that there is not enough information to justify banning Scottish Fold matings but enough to justify a level of concern. Recommended guidelines includes:
Twin studies and family association studies have demonstrated that there are definite genetic factors underlying obsessive-compulsive disorder. The majority of family association studies demonstrated that at least some forms of OCD are familial. The rate of OCD among relatives of affected individuals was significantly higher than the estimated population prevalence of OCD and the rate among controls. Relatives of adults with OCD were approximately two times more likely to be affected than the controls, while relatives of children and adolescents with OCD were about ten times more likely to have OCD as well. However, that familial association could also have been caused by cultural or environmental factors. Currently, there have been very few studies investigating the environmental factors behind OCD. However, in a retrospective study of environmental risk factors, researchers found that prolonged labor and edema during pregnancy were correlated to OCD, suggesting that the environment plays some role in determining its manifestation.
A 2007 study found that 78% of a clinical sample of OCD patients had intrusive images. Most people who suffer from intrusive thoughts have not identified themselves as having OCD, because they may not have what they believe to be classic symptoms of OCD, such as handwashing. Yet, epidemiological studies suggest that intrusive thoughts are the most common kind of OCD worldwide; if people in the United States with intrusive thoughts gathered, they would form the fourth-largest city in the US, following New York City, Los Angeles, and Chicago.
Early onset OCD, manifesting in childhood or adolescence, is a subtype of OCD etiologically distinct from adult onset OCD. This early onset OCD is reported to be genetically related to tic disorders and Tourette’s syndrome, as one study has found that patients with early onset OCD have a higher rate of Tourette’s and other tic disorders. Family association studies have suggested that early onset OCD is correlated to increased familial and possibly genetic risk. The rate of OCD and subclinical OCD among relatives of probands whose OCD manifested in childhood or adolescence was at least twice as high as the rate among relatives of probands whose OCD manifested in adulthood. Other studies have also indicated that there is an inverse relationship between the age of onset of the proband and the risk of OCD in relatives. Consequently, it is possible that there are different genetic mechanisms behind the two types of OCD; therefore, it may be necessary to control for age of onset when examining candidate genes.
At one point doctors believed McIngvale's OCD was too severe to be treatable. Her rituals included having to repeat menial tasks 42 times, an obsession with religious symbolism, and washing her hands over 100 times a day. She engaged in exposure with response prevention (ERP) treatment for her OCD and now successfully manages her illness.
Obsessive-compulsive individuals have difficulty forgetting unwanted thoughts. When they encode this information into memory they encode it as a neutral or positive thought. This is inconsistent with what a person without OCD would think about this thought, leading the individual with OCD to continue displaying their specific "ritual" to help deal with their anxiety. When asked to forget information they have encoded, OCD patients have difficulty forgetting what they are told to forget only when the subject is negative. Individuals not affected by OCD do not show this tendency. Researchers have proposed a general deficit hypothesis for memory related problems in OCD. There are limited studies investigating this hypothesis. These studies propose that memory is enhanced for menacing events that have occurred during the individuals life. For example, a study demonstrated that individuals with OCD exhibit exceptional recall for previously encountered events, but only when the event promoted anxiety in the individual.
Typical obsessive themes center on contamination, illness, worries about disaster, and orderliness. However, people with OCD also obsess about violence, religious questions, and sexual experiences. Up to a quarter of people with OCD may experience sexual obsessions, and some OCD sexual obsessions have been linked to childhood sexual abuse of OCD sufferers. Repetitive sexual thoughts are seen in many disorders in addition to OCD, but these disorders bear no relation to OCD. For example, sexual thoughts unrelated to OCD are common to people with paraphilias, post-traumatic stress disorder, sexual dysfunction, or sexual addiction. The recurrent sexual thoughts and feelings in these situations are sometimes referred to as sexual obsessions. However, their content, form, and meaning vary depending on the disorder, with OCD sexual obsessions being not only involuntary but also unwanted, and causing great mental distress and suffering for the person with OCD.
Behavior therapy has proven to be an effective method for treating OCD. Patients are exposed to the theme that is typically avoided, while being restricted from performing their usual anxiety reducing rituals. Behavior therapy rarely eliminates OCD, but it helps to reduce the signs and symptoms. With medication, this reduction of the disorder is even more evident. Antidepressants are usually the first prescribed medication to a patient with OCD. Medications that treat OCD typically inhibit the reuptake of serotonin.
Some people with OCD exhibit what is known as overvalued ideas. In such cases, the person with OCD will truly be uncertain whether the fears that cause them to perform their compulsions are irrational or not. After some discussion, it is possible to convince the individual that their fears may be unfounded. It may be more difficult to do ERP therapy on such people because they may be unwilling to cooperate, at least initially. There are severe cases in which the person has an unshakeable belief in the context of OCD that is difficult to differentiate from psychotic disorders.[30]
Reduced dopamine D1 receptor (D1) and dopamine D2 receptor (D2) have been reported in the striatum in people with OCD, along with both increased and decreased reports of dopamine transporter (DAT) binding. While antipsychotics are sometimes used to treat refractory OCD, they frequently fail in treating or exacerbate OCD symptoms. Furthermore psychostimulants are sometimes used to treat OCD. Treatment with deep brain stimulation is effective in OCD, and response correlates with increased dopamine in the nucleus accumbens. Combined this evidence suggests that OCD may be associated with both increased and decreased dopamine signaling, or that a unidirectional model may not be adequate.
OCD frequently co-occurs with both bipolar disorder and major depressive disorder. Between 60–80% of those with OCD experience a major depressive episode in their lifetime. Comorbidity rates have been reported at between 19–90% due to methodological differences. Between 9–35% of those with bipolar disorder also have OCD, compared to the 1–2% in the general population. Around 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 as high as 51%.[107]
Kleptomania is frequently thought of as being a part of obsessive-compulsive disorder (OCD), since the irresistible and uncontrollable actions are similar to the frequently excessive, unnecessary, and unwanted rituals of OCD. Some individuals with kleptomania demonstrate hoarding symptoms that resemble those with OCD.
Prevalence rates between the two disorders do not demonstrate a strong relationship. Studies examining the comorbidity of OCD in subjects with kleptomania have inconsistent results, with some showing a relatively high co-occurrence (45%-60%) while others demonstrate low rates (0%-6.5%). Similarly, when rates of kleptomania have been examined in subjects with OCD, a relatively low co-occurrence was found (2.2%-5.9%).
Compulsions in male lab mice, such as those in obsessive-compulsive disorder (OCD), may be caused by low estrogen levels. When estrogen levels were raised through the increased activity of the enzyme aromatase in male lab mice, OCD rituals were dramatically decreased. Hypothalamic protein levels in the gene COMT are enhanced by increasing estrogen levels which are believed to return mice that displayed OCD rituals to normal activity. Aromatase deficiency is ultimately suspected which is involved in the synthesis of estrogen in humans and has therapeutic implications in humans having obsessive-compulsive disorder.
The Delayed-Maturation Theory of Obsessive Compulsive Disorder 
suggests that Obsessive Compulsive Disorder (OCD) can be caused by delayed maturation of the frontal striatal circuitry or parts of the brain that make up the frontal cortex, striatum, or integrating circuits. Some researchers suspect that variations in the volume of specific brain structures can be observed in children that have OCD (Lambert, K.G; Kinsley, C.H., 2011). It has not been determined if delayed-maturation of this frontal circuitry contributes to the development of OCD or if OCD is the ailment that inhibits normal growth of structures in the frontal striatal, frontal cortex, or striatum. However, the use of neuroimaging has equipped researchers with evidence of some brain structures that are consistently less adequate and less matured in patients diagnosed with OCD in comparison to brains without OCD. More specifically, structures such as the caudate nucleus, volumes of gray matter, white matter, and the cingulate have been identified as being less developed in people with OCD in comparison to individuals that do not have OCD (Lambert, K.G.; Kinsley,C.H.). However,the cortex volume of the operculum (brain) is larger and OCD patients are also reported to have larger temporal lobe volumes; which has been identified in some women patients with OCD (Jenike, M.; Breiter, H.; at el, 1996). Further research is needed to determine the effect of these structural size differences on the onset and degree of OCD and the maturation of specific brain structures.
In 1986, the International OCD Foundation – originally the Obsessive Compulsive Foundation – was created by a small, dedicated group of individuals who had OCD. They were all participating in research studies at the Connecticut Mental Health Center in New Haven, CT. The principal investigator on the studies was Wayne Goodman, M.D., a junior faculty psychiatrist who started the OCD program at Yale University School of Medicine during his residency training there. It was also Dr. Goodman's idea to bring the group together.
Originally the plan had been to just form a self-help group, but as soon as they got together they realized that there was a great deal of work to be done to defeat OCD. So in November 1986, they started the Foundation as a way to get the word out about OCD and its treatment. This was the first time for many of them to find some relief from OCD and to meet others who were also suffering from OCD. Being together inspired them to start working together to help others suffering from OCD.
It cannot be overemphasized that the sexual obsessions in OCD are the opposite of the usual sexual daydream or fantasy. The thoughts are not really part of the person's identity, but they are the sort of thoughts or impulses the person with OCD fears that he/she may have. The sexual ideation in OCD is unpleasant and distressing for the person with OCD. The individual with OCD does not want the thought to become real. The idea of acting out the obsession fills the OCD victim with dread. The sexual ideation in such situations is termed "ego-dystonic" or ego-alien, meaning that the behavior and/or attitudes are seen by the individual as inconsistent with his or her fundamental beliefs and personality. Therefore, OCD can decrease libido.
Primarily cognitive obsessive-compulsive disorder (also commonly called "primarily obsessional OCD", purely obsessional OCD, Pure-O, OCD without overt compulsions or with covert compulsions) is a lesser-known form or manifestation of OCD. For people with primarily obsessional OCD, there are fewer observable compulsions, compared to those commonly seen with the typical form of OCD (checking, counting, hand-washing, etc.). While ritualizing and neutralizing behaviors do take place, they are mostly cognitive in nature, involving mental avoidance and excessiverumination. Primarily obsessional OCD often takes the form of intrusive thoughts of a distressing or violent nature (e.g., impulsion phobia).
Checking rituals, such as checking several times to determine if all of the doors to a house are locked, are also common safety behaviors. People with OCD often believe that if they do not perform their checking rituals, others will be in danger. Consequentially, people with OCD often perceive themselves as more responsible for the wellbeing of others than people without the disorder. Therefore, people with OCD use safety behaviors when they believe that other people will be in danger if these behaviors are not used. Continuous checking reduces the certainty and vividness of memories related to checking. Exposure and response prevention therapy is effective in treating OCD.