Obsessive-compulsive disorder (OCD) is a mental illness that affects almost 3% of Americans. It does not discriminate; it is said that several celebrities have come out to talk about their struggles with OCD from soccer legend David Beckham to superstar Justin Timberlake.
Several treatments have been studied for OCD with positive effects. Continue reading to learn more about OCD and what you can do to help yourself or a loved one who suffers from it.
What Is OCD?
OCD is a common and often chronic mental disorder that affects up to 2 to 3% of adults and up to 1% of children .
The OCD Cycle: Obsessions (repetitive thoughts) and compulsions (repetitive actions) characterize OCD. The disorder begins with an obsession that leads to anxiety, which then leads to compulsions to relieve this anxiety .
This image represents this repetitive loop:
The obsessions and compulsions can be unique to each individual. Four to five symptom clusters are common, and each has its associated compulsions :
- Symmetry obsession
- Contamination and cleaning obsessions
- Aggressive, sexual, and religious obsessions
- Hoarding obsessions
Around 30 to 50% of individuals with OCD are often diagnosed before the age of 10. There may be a difference between childhood and adult-onset OCD. However, there is no definite explanation for this hypothesis [4, 5].
Causes of OCD – What Is Going On in the Brain of Someone with OCD?
OCD is the dysfunction of the cortico-striato-thalamo-cortical (CSTC) circuit, which is summarized in the following image :
Neurotransmission is more sensitive to environmental triggers in OCD patients because their genetics increases vulnerability. Imbalances in the CSTC transmission result in the physical production of OCD symptoms.
Patients with OCD have a disproportionately high blood cortisol level (stress hormone). The vulnerability of OCD patients to chronic stress causes significant changes in goal-directed behaviors, abilities to interact with the environment, and decision-making skills .
It is often necessary to try more than one therapy before finding an effective treatment.
Neurotransmitters, Inflammatory Biomarkers, and Hormones Involved in OCD
1) Glutamate and GABA
The SLC1A1 gene codes for transporters that clear glutamate from the synapse of neurons, which helps to make GABA. Without SLC1A1, mice had significantly less GABA and increased glutamate and exhibited OCD behaviors .
After injecting ketamine, a substance that blocks glutamate receptors, patients had a rapid reduction in OCD symptoms. There was also an increase in GABA which was positively correlated with the resolution of OCD symptoms .
Mice with high dopamine had more signs of OCD in one study .
Another study found that quinpirole, which increases dopamine release, led to significant increases in compulsive behavior in rats .
4) Sex Hormones
Progesterone is lower during the premenstrual period and menopause, which might be the cause in the flair of symptoms.
In rats, progesterone can also improve GABA function .
Fluctuations of these hormones (e.g., during reproductive events) cause changes in OCD symptoms. 101 women with OCD were surveyed about these changes. About half (49/101) reported an increase in symptoms during the premenstrual period and 9 during the menopause. During pregnancy, 17 reported worsening of symptoms and 11 reported improvement .
5) HPA Axis
The hyperactivity of the HPA axis, which is seen in OCD patients, causes an increase in the release of certain hormones. These include corticotropin-releasing hormone (CRH), adrenocorticotropic hormone (ACTH), and cortisol.
In a study, 23 children with OCD had higher early-morning cortisol values when compared with healthy people. Cortisol levels in the OCD group were reduced in response to a psychological stressor (exposure to a fire alarm), while an increase was found in healthy controls .
6) Inflammatory Biomarkers
Compared with healthy controls, 40 patients with OCD had significantly increased levels of inflammatory markers (CCL3, CXCL8, sTNFR1) in a study .
OCD Risk Factors
1) Infection During Childhood
A pediatric autoimmune neuropsychiatric disorder associated with Streptococcus (PANDAS) can lead to compulsions, tics, or other psychiatric symptoms. This occurs in children who develop rheumatic fever or Sydenham’s chorea (usually after a Streptococcus infection) .
Pediatric acute-onset neuropsychiatric syndrome (PANS) includes cases where Streptococcus is not involved and metabolic disorders or environmental factors are the triggers .
Individuals with PANDAS or PANS develop autoimmune antibodies to specific parts of their brain (basal ganglia). These antibodies cause inflammation of the basal ganglia neurons. This weakens the blood-brain barrier and other antibodies can leak into the brain, which leads to the symptoms of OCD .
2) Psychiatric Illnesses
Individuals with other psychiatric illnesses are at a higher risk for OCD .
Those who experienced abuse, either physical or sexual, or trauma in childhood are at an increased risk as well .
Tourette syndrome, which causes tics in individuals, is associated with OCD and ADHD .
Is OCD Genetic?
Research supports that OCD is often inherited and passed down within families .
Of 18 studies following families with adults with OCD, 16 determined that OCD was familial .
A meta-analysis including almost 25,000 identical and fraternal twin pairs found that both genetic and environmental factors are important in the development of OCD .
- If you have a family member with adult-onset OCD, you are two times more likely to develop OCD than the other people without a family member with OCD.
- If you have a family member with childhood-onset OCD, you are 10 times more likely to develop OCD than those not related to someone with OCD .
In childhood-onset OCD, 40 to 65% of symptoms are inherited. In adult-onset OCD, 27 to 47% are inherited .
Symptoms and Diagnosis of OCD
Diagnosing OCD can be difficult because individuals often feel shame and are secretive about their symptoms .
The staging of the disorder is:
Obsession → anxiety → compulsion → relief 
Various obsessions include:
- Inability to let go of thoughts
- Pathologic doubt
- Superstition and symmetry
These obsessions develop into compulsions .
- An individual who is obsessed with dirt/germs will have compulsive behaviors like washing or cleaning rituals
- A person who is obsessed with symmetry and exactness will have compulsive behaviors like ordering and arranging
- A person with sexual or self-control obsessions will avoid situations that trigger the thoughts. They have mental rituals employed to counteract these thoughts or isolate themselves 
- An individual who chronically has looping thoughts about particular subjects that they can’t get out of their mind.
Compulsions may not be as obvious as these examples. Most often, individuals have mental rituals, which they are reluctant to report due to stigma or embarrassment .
Standard of Care for OCD
The standard treatment of OCD includes psychotherapy and antidepressant medication. Follow the treatment plan prescribed by your doctor carefully. Never change or discontinue the treatment without consulting your doctor.
1) Cognitive Behavioral Therapy (CBT)
CBT has proven to be an effective method for treating OCD .
In a meta-analysis of 16 clinical trials and 756 people, CBT was proven to improve OCD symptoms .
2) Exposure and Response Prevention (ERP) Method
With ERP, a patient is first exposed to triggers and then should learn skills to stop the compulsions. The exposures can be images or descriptions that are read repeatedly to desensitize patients from their obsessions. By addressing both obsessions and compulsions, ERP has been proven to be more effective than addressing either one alone .
Approved Drug Treatments
1) Selective Serotonin Reuptake Inhibitors (SSRIs)
Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatments for OCD because they have fewer side effects .
One in five patients who take SSRIs for OCD has at least a 25% reduction in symptoms compared to placebo. Most people respond to SSRIs after six weeks. However, it is recommended to try the medication for at least eight to twelve weeks to have an effect. Evidence suggests that in order to avoid relapse, about six to twelve months of therapy is necessary .
Each SSRI works slightly different from the other, therefore therapy is individualized to each patient’s characteristics. For example, fluoxetine may be preferred in those who forget to take their medication daily since it lingers in the body for weeks .
Overweight patients may benefit from either fluoxetine or sertraline since they are both associated with the lowest weight gain .
Citalopram can increase the risk of heart abnormalities with daily doses of over 20 mg. A recent study disproved this elevated risk to the heart. However, if an individual is suffering from heart issues, it may be in his/her best interest to avoid citalopram and use a safer SSRI .
A recent meta-analysis associated high doses of SSRIs with greater efficacy than low or medium doses .
There are limitations to SSRIs. They often do not completely resolve all symptoms of OCD, and they have a two- to three-month lag time to achieve their full effect .
Of note, all antidepressants have an FDA issued black box warning for their potential to increase suicidal thoughts when starting antidepressants. It is important to contact a medical provider if this occurs .
There are also side effects associated with SSRIs that can be remembered as the 7 S’s:
- Stomach upset (nausea)
- Sleep disturbances
- Sexual dysfunction
- Stress (mostly agitation)
- Serotonin syndrome (caused by too much serotonin usually presents as an intense headache, flushing, muscle rigidity and diarrhea – rare)
- Size increase (weight gain)
- Suicidal thoughts
Similar symptoms may also occur during withdrawal when discontinuing SSRIs .
2) Tricyclic Antidepressants (TCA)
Clomipramine has fallen out of favor because there are more effective drugs with fewer side effects .
Some people may fail to respond to the antidepressants described above. The following drugs have been tested in people with OCD, normally as an add-on to conventional medication. You may only include these drugs in your treatment plan if prescribed by your doctor.
Memantine, a medication used for Alzheimer’s disease, blocks NMDA receptors, which reduces glutamate’s effects in the brain.
In a clinical trial on 38 patients, approximately 89% of those combining the SSRI fluvoxamine with memantine no longer had OCD symptoms after eight weeks compared with 32% combining it with a placebo .
Ketamine blocks glutamate receptors (NMDA). In a small trial on 15 untreated adults with OCD, infusion with ketamine significantly improved obsessive symptoms. Additionally, 50% still maintained this improvement one week later .
Ondansetron is helpful for nausea by blocking certain serotonin receptors. In an eight-week pilot study on 42 people, ondansetron combined with fluoxetine decreased OCD symptoms when compared to the placebo .
Mirtazapine is an atypical antidepressant that increases serotonin in the brain differently from SSRIs.
In a 12-week clinical trial of 30 people taking 60mg mirtazapine, mirtazapine outperformed placebo and decreased symptoms by about 20%. A bit over half of the people improved with the treatmentm.
5) Pregabalin and Gabapentin
Gabapentin and pregabalin are used for nerve pain and as anticonvulsants to prevent seizures. Because they are structurally similar to the neurotransmitter GABA, they are thought to enhance its effects [61, 62].
One study on 40 people showed that gabapentin enhanced the effectiveness of SSRIs at alleviating early OCD symptoms .
Similarly, pregabalin enhanced the effectiveness of conventional OCD therapy and reduced the symptoms by 26% in a case series of 12 patients. The only side effects reported were dizziness and fatigue .
6) Mood Stabilizers (Lamotrigine and Topiramate)
Lamotrigine and topiramate both inhibit the actions of glutamate and have been studied as adjunctive agents for OCD.
In a study, 41 OCD patients who failed their first trial of an SSRI were given topiramate or placebo with an SSRI. There was a 32% decrease in OCD symptoms in those taking topiramate group versus only 2.4% in the placebo group .
Although this seems promising, there is very little evidence supporting topiramate’s effectiveness, and it does have adverse effects in the brain such as paresthesias (abnormal burning or prickling sensation) .
Lamotrigine decreased symptoms of observable obsessions and compulsions when used along with an SSRI in a clinical trial on 51 people. The main adverse events included headaches and skin rash. Lamotrigine can cause a deadly hypersensitivity reaction in the form of a rash called Stevens-Johnsons Syndrome (SJS), so it is important to monitor closely [66, 67].
Stimulants may have a role in the treatment of OCD, especially with co-occurring ADHD. A single dose of d-amphetamine had short term benefits in resolving OCD symptoms in a small trial on 12 people .
Clonazepam, clonidine, and clomipramine (TCAs) were compared to the control diphenhydramine (Benadryl) in a trial on 28 people. Roughly 40% of the patients whose symptoms were not resolved with clomipramine responded to clonazepam .
Clonazepam may be helpful in relieving symptoms of anxiety, but, it should be used with caution in patients with previous benzodiazepine or other substance abuse histories .
Opioid drugs are often effective in various mental illnesses, including promising results in treatment-resistant OCD. However, given their addictive properties, they should be used with extreme caution [71, 72].
Naloxone, a blocker of opioid receptors, exacerbated symptoms of OCD, while tramadol, which activates them, relieved OCD symptoms .
Riluzole, which is used in ALS, decreases the neurotransmission of glutamate. Its combination with SSRIs improved the symptoms in patients with treatment-resistant OCD .
One study with 28 people used Benadryl (diphenhydramine) as the placebo because it was assumed to have no effect on OCD. However, Benadryl improved the symptoms .
More Invasive Treatments for OCD
The following treatments are being investigated for people with OCD who don’t respond to psychotherapy or medication. Because they may have serious risks and haven’t been thoroughly tested, make sure you understand all the pros and cons before undergoing these procedures.
1) Repetitive Transcranial Magnetic Stimulation (rTMS)
rTMS introduces a magnetic field pulse to the brain, which affects neuronal activity .
In a meta-analysis of 10 clinical trials and almost 300 people with OCD, rTMS decreased the symptoms in approximately 35% of the patients (versus 13% for the mock treatment) .
The short-term side effects were localized pain, burning, prickling sensation (paresthesia), hearing changes, altered levels of blood thyroid-stimulating hormone and lactate, and hypomania (a mild form of mania).
In rare instances, high-frequency rTMS can cause seizures .
2) Deep Brain Stimulation (DBS)
An invasive strategy in which electrodes are surgically implanted in the brain to send localized electric impulses has been tested for OCD in a few cases .
The average overall response rate to DBS was about 50%. The studies reported limited side effects and concluded that DBS was relatively safe .
However, the following adverse effects have been documented in a few cases :
- Bleeding in the brain (without symptoms)
- Superficial infection
- Worsening of depression or OCD
- Short-term sadness, anxiety, or euphoria
3) Ablative Neurosurgery
Two different surgical procedures that create lesions on specific parts of the brain to alter its circuitry were tested in 87 people with treatment-resistant OCD. They helped 30 to 60% of the patients [80, 81].
Natural and Alternative Approaches for OCD
You may try the complementary approaches listed below if you and your doctor determine that they could be appropriate for improving your OCD symptoms. Discuss the strategies listed here with your doctor. Remember that none of them should ever be done in place of what your doctor recommends or prescribes.
The purported benefits of the following supplements and lifestyle interventions are only backed by limited, low-quality clinical studies, most of which used them as an add-on to conventional therapies. There is insufficient evidence to support their use in people with OCD, but you may implement them if your doctor determines that they may help in your case. Never use these strategies as a replacement for approved medical therapies.
Inositol, a component of cell membranes, is involved in cell communication and also increases the sensitivity of serotonin receptors .
In a 6-week study of 10 OCD patients, 18 g of inositol improved anxiety and depression symptoms, and caused very few side effects (mostly digestive). In another trial, the same dose only enhanced the effects of SSRIs in 3 out of 10 patients with treatment-resistant OCD [83, 84].
At this dose, inositol was more effective than fluvoxamine in a clinical trial on 20 people with panic disorder. Because this drug is approved for OCD, further clinical trials comparing both treatments could shed some light on the effectiveness of inositol .
In a brain imaging study of 14 people with OCD, those who responded to inositol showed increased baseline activity in a brain region (left medial prefrontal region) but reduced activity after inositol treatment in other regions (left superior temporal gyrus, middle frontal gyrus and precuneus, and right paramedian post-central gyrus) when compared to non-responders .
2) N-Acetyl Cysteine (NAC)
In a 12-week study of 50 people with compulsive hair pulling (trichotillomania, which is on the OCD spectrum) NAC improved the symptoms “much or very much” in 56% of the patients (compared with only 16% of the placebo group) .
A systematic review of four pilot trials using NAC for 12-weeks (2,400–3,000 mg/day) concluded that NAC was promising at reducing the severity of OCD symptoms and caused minimal side effects .
However, a more recent 16-week trial on 44 people didn’t find NAC more effective than the placebo 
NAC added to the effects of SSRIs (citalopram) in improving resistance to compulsions in OCD a 10-week clinical trial on 34 children and adolescents .
In a 12-week study on 24 OCD patients given 60 grams of glycine as an add-on to conventional therapy, there was a minor decrease in OCD symptoms. Importantly, ten patients dropped out of the study due to the bad taste of glycine, which caused nausea in some cases .
Sarcosine is an inhibitor of glycine uptake, which increases the availability of this amino acid in the brain. In a clinical trial on 25 people with OCD, 8 improved their OCD symptoms after taking sarcosine .
In a five-week double-blind trial with 24 patients, 300 mg of caffeine was slightly more effective than 30 mg dextroamphetamine as an add-on therapy to improve OCD symptoms. All patients completed the study without adverse events .
The results of this study were recently replicated in a clinical trial on 62 people .
5) Milk Thistle
In an 8-week clinical trial on 35 OCD patients, 200 mg milk thistle decreased the symptoms. However, it was less effective than fluoxetine .
6) Borage Oil
Borage is a plant whose flower and oil are both used for OCD. It had anti-anxiety effects similar to benzodiazepines (ex. Valium) in mice models .
In a 6-week trial on 44 OCD patients, 500 mg of borage extract 1x/day decreased OCD symptoms and anxiety .
In an 8-week study on 23 OCD patients, zinc supplementation (as an add-on to fluoxetine) helped decrease obsessions and compulsions without causing adverse effects .
In a study on almost 100 people, blood iron levels were 41 – 44% lower in patients with mild and moderate OCD .
Low iron is also associated with higher tic severity in Tourette syndrome. Iron supplementation decreased the severity of tics over 6-12 months in a clinical trial on 57 children with Tourette. Since there is a relation between this syndrome and OCD, this suggests that iron supplementation may help for OCD as well .
In 5 pilot trials on over 150 people with OCD receiving behavioral or pharmacological therapy, a 12-week aerobic exercise intervention reduced OCD symptoms. The benefits remained for 6 months [109, 110, 111, 112, 113].
Mindfulness meditation is thought to help people with anxiety to mentally avoid their triggers. A pilot study with 17 participants showed a reduction in OCD symptoms in patients who partook in mindfulness meditation .
Reducing anxiety may be a beneficial approach to eliminating symptoms of OCD. Read our post on the Top 31 Natural Treatments for Anxiety for more information.
3) Music Therapy
Music therapy helped to alleviate symptoms of obsession and anxiety in one month in a small trial on 30 patients who were all already being treated for OCD .
In a pilot study on 19 people with OCD, acupuncture (as an add-on therapy) improved the symptoms. However, the study compared acupuncture with the absence of treatment instead of using a proper placebo control (i.e., needles randomly placed by someone without training in acupuncture) .