Search This Blog

Friday, November 8, 2024

Christian perfection

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Christian_perfection
The mediaeval scala naturae as a staircase, implying the possibility of progress: Ramon Llull's Ladder of Ascent and Descent of the Mind, 1305

Within many denominations of Christianity, Christian perfection is the theological concept of the process or the event of achieving spiritual maturity or perfection. The ultimate goal of this process is union with God characterized by pure love of God and other people as well as personal holiness or sanctification. Other terms used for this or similar concepts include entire sanctification, holiness, perfect love, the baptism with the Holy Spirit, the indwelling of the Holy Spirit, baptism by fire, the second blessing, and the second work of grace.

Understandings of the doctrine of Christian Perfection vary widely between Christian traditions, though these denominational interpretations find basis in Jesus' words recorded in Matthew 5:48, "Be ye therefore perfect, even as your Father which is in heaven is perfect" (King James Version) but not Matthew 19:21, "Jesus said unto him, If thou wilt be perfect, go and sell that thou hast, and give to the poor, and thou shalt have treasure in heaven: and come and follow me."

The Roman Catholic Church teaches that Christian perfection is to be sought after by all of the just (righteous). Eastern Orthodoxy situates Christian perfection as a goal for all Christians. Traditional Quakerism uses the term perfection and teaches that it is the calling of a believer.

Perfection is a prominent doctrine within the Methodist tradition, in which it is referred to as Christian perfection, entire sanctification, holiness, baptism of the Holy Spirit, and the second work of grace. Holiness Pentecostalism inherited the same terminology from Methodism, with exception of the fact that Holiness Pentecostals take the term Baptism with the Holy Spirit to mean a separate third work of grace of empowerment evidenced by speaking in tongues, whereas Methodists use the term Baptism of the Holy Spirit to refer to the second work of grace, entire sanctification.

Other denominations, such as the Lutheran Churches and Reformed Churches, reject the possibility of Christian perfection in this life as contrary to the doctrine of salvation by faith alone, holding that deliverance from sin is begun at conversion but is only completed in glorification. Contrasting to all, Christian Science teaches that as man is made in God's image and likeness (Genesis 1:27), "The great spiritual fact must be brought out that man is, not shall be, perfect and immortal".

Terminology

The terms "perfect" and "perfection" are drawn from the Greek teleios and teleiōsis, respectively. The root word, telos, means an "end" or "goal". In recent translations, teleios and teleiōsis are often rendered as "mature" and "maturity", respectively, so as not to imply an absolute perfection of no defects. But the words "mature" and "maturity" do not capture the full meaning of "end" or "goal". (Even these recent translations use the word "perfect" when not referring to people, as in James 1:17.) In the Christian tradition, teleiōsis has also referred to personal wholeness or health, an unswerving commitment to the goal.

Church Fathers and Medieval Theologians

In the Farewell Discourse Jesus promised to send the Holy Spirit to his disciples after his departure, depiction from the Maesta by Duccio, 1308–1311.

The roots of the doctrine of Christian perfection lie in the writings of some early Roman Catholic theologians considered Church Fathers: Irenaeus, Clement of Alexandria, Origen and later Macarius of Egypt and Gregory of Nyssa.

Irenaeus wrote about the spiritual transformation that occurred in the believer as the Holy Spirit is to "fit us for God." In antiquity, baptism was commonly referred to as the perfecting of the Christian. This view was expressed by Clement of Alexandria in his work Paedagogus: "Being baptized, we are illuminated; illuminated we become children [lit. 'sons']; being made children, we are made perfect; being made perfect, we are immortal." In another work, the Stromata, Clement discussed three stages in Christian life that led to a more mature perfection. The first stage was marked by the change from heathenism to faith and initiation into the Christian religion. The second stage was marked by a deeper knowledge of God that resulted in continuing repentance from sin and mastery over the passions (apatheia). The third stage led to contemplation and agape love. Origen also proposed his own stages of spiritual ascent beginning with conversion and ending with perfect union with God in love.

Gregory of Nyssa defined human perfection as "constant growth in the good". For Gregory, this was brought about by the work of the Holy Spirit and the self-discipline of the Christian. Macarius of Egypt taught that all sin could be washed away and that a person could be made perfect in the "span of an hour" while stressing the fact that entire sanctification had a two-fold nature, as "an act and a process". Pseudo-Macarius taught that inner sin was rooted out of the pure in heart, but he also warned against the hidden potential for sin in everyone so that no one should ever say, "Because I am in grace, I am thoroughly freed from sin."

By the 4th century, the pursuit of the life of perfection was identified with asceticism, especially monasticism and withdrawal from the world. In the 12th century, Bernard of Clairvaux developed the idea of the ladder of love in his treatise, On the Love of God. This ladder had four rungs or degrees. The first and lowest degree was love of self for self. The second degree was love of God for what he gives. The third degree was love of God for his own sake; it would not be difficult, according to Bernard, for those who truly loved God to keep his commandments. The fourth degree was love of self only for God's sake; it was believed that this degree of perfection in love was only rarely achieved before death.

Thomas Aquinas wrote of three possible levels of perfection. The first, absolute perfection, is where God is loved as much as he can be loved; only God himself can be this perfect. The second level, where love for God fills a person constantly, is possible after death but not in life. The lowest level of perfection was thought to be possible to achieve while living. Theologian Thomas Noble described Aquinas' view of this level of perfection as follows:

All Christians have the grace of caritas infused into them at baptism and this love for God excludes all mortal sins. Such sins are not impossible, and, if committed, require the grace of penance, but Christians do not live committing flagrant acts of intentional sin contrary to their love for God. That is incompatible with the state of grace. But those who are no longer beginners, but making progress in the life of perfection, come to the point where everything contrary to being wholly in love with God is excluded: they love God with all their hearts.

According to the standard formulation of the process of Christian perfection, as formulated by Dionysius the Pseudo-Areopagite (late 5th to early 6th century), there are three stages:

  • Katharsis or purification;
  • Theoria or illumination, also called "natural" or "acquired contemplation;"
  • Union or Theosis; also called "infused" or "higher contemplation"; indwelling in God; vision of God; deification; union with God

Daniel L. Burnett, a professor at Wesley Biblical Seminary, writes that:

Views compatible with the Wesleyan understanding of entire sanctification were carried forward in later times by men like the medieval Catholic priest Thomas a Kempis, the Protestant Reformers Caspel Schwenkfeld and Thomas Munzer, the Dutch theologian Jacobus Arminius, the German Pietist Phillip Jacob Spener, the Quaker founder George Fox, the Anglican bishop Jeremy Taylor, and the English devotional writer William Law. Many of these influences fed into [John] Wesley's heritage and laid the foundation for the development of his thought. In fact, the concept of entire sanctification is so pervasive throughout church history that it can accurately be said that virtually all the major traditions—Orthodox, Catholic, Reformed, and Anglican—played some part in shaping Wesley's passion for holiness.

Roman Catholic teaching

According to the teaching of the Roman Catholic Church, something is perfect when nothing is lacking in its nature or purpose. The ultimate purpose of Man is union with God, also called divinization. This is accomplished on earth by grace and in heaven by the beatific vision. Perfect union with God while on earth is impossible; therefore, absolute perfection is reserved for heaven.

The Roman Catholic Church teaches that Christian perfection is a spiritual union with God that is attainable in this life. It is not absolute perfection as it exists alongside human misery, rebellious passions, and venial sin. Christian perfection consists of charity or love, since it is this virtue that unites the soul to God. It is not just the possession and preservation of sanctifying grace, since perfection is determined by one's action—the actual practicing of charity or the service of God.

The more charity a person possesses, the greater the perfection of the soul. A person who is perfect in so far as being free from mortal sin obtains salvation and can be called just, holy, and perfect. A person who is perfect insofar as also being free from venial sin and all affections which separate a person from God is in a state of active service and love of God. This is the perfect fulfillment of the law—loving God and loving other people.

The Roman Catholic Church teaches that Christian perfection is something all should pursue in light of Jesus' injunction in Matthew 5:48. There is also, however, what is called "religious perfection", which is pursued by those committed to living religious life, such as members of religious orders. All Roman Catholics are obliged to attain perfection by observing the commandments, but religious life imposes a more exacting obligation, requiring the religious to also observe the evangelical counsels (also known as "counsels of perfection") of poverty, chastity, and obedience. The evangelical counsels are believed to promote perfection in two ways. They remove the obstacles to perfection—lust of the eyes, lust of the flesh, and the pride of life. They also increase a person's love of God by freeing the affections from earthly ties.

El Camino de Perfección is a method for making progress in the contemplative life written by Saint Teresa of Ávila for the sisters of her reformed convent of the Discalced Carmelites. St. Teresa was a major figure of the Counter-Reformation in 16th century Spain. Christian Perfection is also the title of a book written by theologian Réginald Garrigou-Lagrange. Perfectae Caritatis, the Decree on the Adaptation and Renewal of Religious Life, is one of the shorter documents issued by the Second Vatican Council. Approved by vote of 2,321 to 4 of the bishops assembled at the council, the decree was promulgated by Pope Paul VI on October 28, 1965. As is customary for Church documents, the title is taken from the Latin incipit of the decree: "Of Perfect Charity".

Eastern Orthodox teaching

The Orthodox Church teaches that "perfection is possible for us as human beings as long as we understand it in its proper, dynamic sense" and that humans are "made for Theosis, for the deification ('divinizing') of the totality of our being, body, mind, heart, and soul". This is in accordance with the writings of Saint Paul that encourage Christians to seek after the righteousness of Jesus to be transformed from "one degree of glory to another".

Byzantine Orthodox hagiographer and hymnodist St Symeon the Metaphrast (10th c.) declared:

Those who deny the possibility of perfection inflict the greatest damage on the soul in three ways. First, they manifestly disbelieve the inspired Scriptures. Then, because they do not make the greatest and fullest goal of Christianity their own, and so do not aspire to attain it, they can have no longing and diligence, no hunger and thirst for righteousness (cf Matt. 5:6); on the contrary, content with outward show and behavior and with minor accomplishments of this kind, they abandon that blessed expectation together with the pursuit of perfection and of the total purification of the passions. Third, thinking they have reached the goal when they have acquired a few virtues, and not pressing on to the true goal, not only are they incapable of having any humility, poverty and contrition of heart but, justifying themselves on the grounds that they have already arrived, they make no efforts to progress and grow day by day. People who think it is impossible to attain through the Spirit the 'new creation' of the pure heart (cf 2 Cor. 5:17) are rightly and explicitly likened by the apostle to those who, because of their unbelief, were found unworthy of entering the promised land and whose bodies on that account 'were left lying in the desert' (Heb. 3:17).

Anabaptist teaching

Anabaptist Christians (inclusive of the Mennonite, Amish, Hutterite, Bruderhof, Schwarzenau Brethren, River Brethren and Apostolic Christian denominations) believe that "because they have voluntarily chosen to follow Christ as their only authority", they can be successful in their pursuit of Christian perfection. Professor of Religious Studies Ira Chernus explicates Anabaptist doctrine:

... Anabaptists put special stress on the power of faith to produce good works and a more moral life. ... they are guided by the concluding injunction of the Sermon on the Mount: "You shall be perfect, as your Heavenly Father is perfect." They strive for perfection; they view their church as the visible body of Christ, which must be, and can be, a "spotless congregation." As one of their greatest early leaders, Menno Simmons, said: "The reborn willfully here sin no more."

In particular, the Apostolic Christian Church is "distinguished by its emphasis on entire sanctification".

Wesleyan teaching

John Wesley

In traditional Calvinism and high church Anglicanism, perfection was viewed as a gift bestowed on righteous persons only after their death (see Glorification). John Wesley, the founder of Methodism, was responsible for reviving the idea of spiritual perfection in Protestantism. Wesley's views were elaborated in A Plain Account of Christian Perfection, published in 1777.

According to Noble, Wesley transformed Christian perfection as found in church tradition by interpreting it through a Protestant lens that understood sanctification in light of justification by grace through faith working by love. Wesley believed that regeneration (or the new birth), which occurred simultaneously with justification, was the beginning of sanctification. From his reading of Romans 6 and 1 John 3:9, Wesley concluded that a consequence of the new birth was power over sin. In a sermon titled "Christian Perfection", Wesley preached that "A Christian is so far perfect as not to commit sin."

"The term "sinless perfection" was one which Wesley never used because of its ambiguity." John William Fletcher, an early Methodist divine who John Wesley chose to lead the Methodist movement if he died, clarified the Wesleyan doctrine by stating "that the doctrine of an evangelically sinless perfection is truly Scriptural." And "I say evangelically sinless, because, without the word evangelically, the phrase "sinless perfection" gives an occasion of cavilling to those who seek it." Methodists are able to hold this doctrine based upon Wesley's definition of actual sin:

Nothing is sin, strictly speaking, but a voluntary transgression of a known law of God. Therefore, every voluntary breach of the law of love is sin; and nothing else, if we speak properly. To strain the matter farther is only to make way for Calvinism. There may be ten thousand wandering thoughts, and forgetful intervals, without any breach of love, though not without transgressing the Adamic law. But Calvinists would fain confound these together. Let love fill your heart, and it is enough!

Involuntary transgressions (such as those arising from ignorance, error, and evil tempers), according to Wesley, were not properly called sins. Therefore, regenerated Christians would continue to be guilty of involuntary transgressions and would need to practice regular confession. Furthermore, Christians continued to face temptation, and Wesley acknowledged that it was possible for a regenerated Christian to commit voluntary sin (if, in the words of Noble, the Christian ceased "actively trusting in God through Christ and living in the divine presence"), which would also necessitate confession of sin.

The power over sin received at regeneration was just the lowest stage of Christian perfection according to Wesley. Based on 1 John 2, Wesley proposed three stages in the Christian life: little children, young men, and finally fathers. Young men were defined as those who had experienced victory over temptation and evil thoughts. Fathers were defined as mature Christians who were filled with the love of God.

Wesley believed this last stage of Christian maturity was made possible by what he called entire sanctification (a phrase derived from First Thessalonians 5:23). In Wesley's theology, entire sanctification was a second work of grace received by faith that removed inbred or original sin, and this allowed the Christian to enter a state of perfect love—"Love excluding sin" as stated in the sermon "The Scripture Way of Salvation". Wesley described it as having "purity of intention", "dedicating all the life to God", "loving God with all our heart", and as being the "renewal of the heart in the whole image of God". A life of perfect love meant living in a way that was centered on loving God and one's neighbor. As such, Wesley taught that the manifestation of being entirely sanctified included engagement in works of piety and works of mercy. In his Sermon called "The Circumcision of the Heart" Wesley described it like this:

It is that habitual disposition of soul which, in the sacred writings, is termed holiness; and which directly implies, the being cleansed from sin, "from all filthiness both of flesh and spirit;" and, by consequence, the being endued with those virtues which were also in Christ Jesus; the being so "renewed in the spirit of our mind," as to be perfect as our Father in heaven is perfect."

Even this was not an absolute perfection. The entirely sanctified Christian was perfect in love, meaning that the heart is undivided in its love for God or that it loves nothing that conflicts with its love for God. Christians perfected in love were still subject to conditions of the Fall and liable to commit unintentional transgressions. In consequence, these Christians still had to depend on forgiveness through Christ's atonement. However, with Wesley's concept of sin, he did believe in freedom from sin. In fact, he described it like this: "Certainly sanctification (in the proper sense) is "an instantaneous deliverance from all sin;" and includes "an instantaneous power then given".

Wesley's concept of Christian perfection had both gradual and instantaneous elements. In his 1765 sermon "The Scripture Way of Salvation", Wesley emphasized the instantaneous side, stating, "Do you believe we are sanctified by faith? Be true, then, to your principle and look for this blessing just as you are, neither better nor worse; as a poor sinner that has still nothing to pay, nothing to plead but 'Christ died'. And if you look for it as you are, then expect it now."

In "Thoughts on Christian Perfection" (1759), Wesley stressed the gradual aspect of perfection, writing that it was to be received "in a zealous keeping of all the commandments; in watchfulness and painfulness; in denying ourselves and taking up our cross daily; as well as in earnest prayer and fasting and a close attendance on all the ordinances of God ...it is true we receive it by simple faith; but God does not, will not, give that faith unless we seek it with all diligence in the way which he hath ordained." In addition, Wesley also believed that Christian perfection, once received, might be forfeited. The systematic theologian of Methodism, John William Fletcher, termed the reception of entire sanctification as Baptism with the Holy Spirit. Fletcher emphasized that the experience of entire sanctification, through the indwelling of the Holy Spirit, cleanses the believer from original sin and empowers the believer for service to God.

John Wesley taught outward holiness as an expression of "inward transformation" and theologians in the Wesleyan Methodist tradition have noted that the observance of standards of dress and behaviour should follow the New Birth as an act of obedience to God.

Mainline Methodism

Methodists often seek the new birth and entire sanctification at the mourners' bench or chancel rails during services held in local churches, tent revivals and camp meetings (pictured are people praying at Mount Zion United Methodist Church in Pasadena, Maryland).

Calling it "the grand depositum" of the Methodist faith, Wesley specifically taught that the propagation of the doctrine of entire sanctification to the rest of Christendom was the main reason that God raised up the Methodists in the world. After Wesley's death, his teachings on Christian perfection remained important to the Methodist church, but, according to historian David Bebbington, "the tradition fell into decay." As later generations of Methodists sought greater respectability in the eyes of other Christian denominations, some turned to "a watered-down version" of the doctrine outlined by William Arthur (who served as Secretary of the Wesleyan Methodist Missionary Society) in his popular work The Tongue of Fire, published in 1856. While Arthur encouraged readers to pray for a greater experience of the Holy Spirit, he de-emphasized the instantaneous aspect of Christian perfection. According to Bebbington, this eliminated the distinctiveness of Wesleyan entire sanctification, and by the 1860s, the idea that Christian perfection was a decisive second blessing or stage in Christian sanctification had fallen out of favor among some Methodists, though not all Methodists, as academic institutions affiliated with mainline Methodism such as Asbury Theological Seminary, Methodist camp meetings, and other Holiness Methodist associations within the Church continued to be a beacon for the holiness movement.

In contemporary Methodist Churches, Christian perfection remains official doctrine and both its gradual and instantaneous aspects are recognized. A Catechism for the Use of the People Called Methodists teaches:

Through the Holy Spirit God has given us His love so that we may love Him in return with all our heart, soul, mind and strength, and our neighbour as ourselves. This is a gift offered to all Christians, and by responding we affirm that there is no limit to what the grace of God is able to do in a human life. By giving us the Holy Spirit, God assures us of His love for us and enables us to love as He, in Christ, loves us. When God's love is perfected in us, we so represent Christ to our neighbours that they see Him in us without hindrance from us. Perfect love, as Christian perfection is often called, is the result of, and can only be maintained by, complete dependence on Jesus Christ. It is given either gradually or at one moment...

Candidates for ordination are asked the following question, "Do you expect to be made perfect in love in this life?" In the Methodist Church of Great Britain, the distinctive Wesleyan teachings are summed up in the phrase "All need to be saved; all can be saved; all can know they are saved; all can be saved to the uttermost" (the word "uttermost" referring to Christian perfection).

The Confession of Faith, one of the Doctrinal Standards of the United Methodist Church, teaches that entire sanctification may be bestowed upon the believer gradually or instantaneously:

We believe sanctification is the work of God's grace through the Word and the Spirit, by which those who have been born again are cleansed from sin in their thoughts, words and acts, and are enabled to live in accordance with God's will, and to strive for holiness without which no one will see the Lord.

Entire sanctification is a state of perfect love, righteousness and true holiness which every regenerate believer may obtain by being delivered from the power of sin, by loving God with all the heart, soul, mind and strength, and by loving one's neighbor as one's self. Through faith in Jesus Christ this gracious gift may be received in this life both gradually and instantaneously, and should be sought earnestly by every child of God.

We believe this experience does not deliver us from the infirmities, ignorance, and mistakes common to man, nor from the possibilities of further sin. The Christian must continue on guard against spiritual pride and seek to gain victory over every temptation to sin. He must respond wholly to the will of God so that sin will lose its power over him; and the world, the flesh, and the devil are put under his feet. Thus he rules over these enemies with watchfulness through the power of the Holy Spirit.

James Heidinger II, former president of the Good News movement, an evangelical caucus within the United Methodist Church, has emphasized the significance of the doctrine of entire sanctification within Methodism: "There is no question about the importance of the doctrine of perfection in the history of Methodism. Wesley believed that this emphasis was a peculiar heritage given to the Methodists in trust for the whole Church." However, he has also noted that uncertainty, among some, exists within the denomination over the teaching: "Our discomfort with this doctrine today is seen in services of ordination when candidates are asked, 'Are you going on to perfection?' Our misunderstanding about this often brings uneasy chuckles and quick disclaimers that we certainly don't claim to be 'perfect' in our Christian life." Brian Beck, former President of the Methodist Conference in Britain, expressed his personal opinion in 2000 that "The doctrine [of sanctification] remains with us in Charles Wesley's hymns, but the formative framework, and even, I suspect, the spiritual intention, have largely gone." Writing on the need for improved spiritual formation within the British Methodist Church and the US-based United Methodist Church, Methodist theologian Randy L. Maddox commented that the terms "holiness of heart and life" and "Christian Perfection" were considered "prone to moralistic, static and unrealistic connotations, resulting in the growing uncomfortableness with and neglect of this aspect of our Wesleyan heritage." The Rev. Dr. Kevin M. Watson, a United Methodist clergyman and Assistant Professor of Historical Theology and Wesleyan Studies at Seattle Pacific University, implores fellow pastors: "Teaching and preaching the possibility of being made perfect in love for God and neighbor, and seeking to actually become entirely sanctified are the reasons Methodism was 'raised up.' May we remember who we are and why the Holy Spirit brought us to life."

The Global Methodist Church enshrines the doctrine of entire sanctification in its official catechism, teaching that "Entire sanctification is a state of perfect love, righteousness, and true holiness which every regenerate believer may obtain." It teaches that Christian perfection may be "received in this life either gradually or instantaneously" and that it should be "sought earnestly by every child of God." In order to maintain this state of holiness, the believer must "respond wholly to the will of God so that sin will lose its power over us; and the world, the flesh, and the devil are put under our feet."

For John Wesley, the preaching of Christian perfection was crucial to the spiritual health of a Methodist church: he taught that "Where Christian perfection is not strongly and explicitly preached, there is seldom any remarkable blessing from God; and consequently little addition to the society, and little life in the members of it." As such, he urged ministers: "Till you press the believers to expect full salvation [entire sanctification] now, you must not look for any revival."

Holiness movement

In the 19th century, there were Methodists who sought to revitalize the doctrine of Christian perfection or holiness, which had, in the words of religion scholar Randall Balmer, "faded into the background" as mainline Methodists gained respectability and became solidly middle class. While it originated as a revival movement within the Methodist Episcopal Church and many adherents of the holiness movement remained within mainline Methodism, the holiness movement grew to be interdenominational and gave rise to a number of Wesleyan-holiness denominations, including the Free Methodist Church, Church of the Nazarene, the Church of God (Anderson, Indiana), The Salvation Army, and the Wesleyan Methodist Church.

An early promoter of holiness was American Methodist Phoebe Palmer. Through her evangelism and writings, Palmer articulated an "altar theology" that outlined a "shorter way" to entire sanctification, achieved through placing oneself on a metaphorical altar by sacrificing worldly desires. As long as the Christian placed themselves on the altar and had faith that it was God's will to accomplish sanctification, the Christian could be assured that God would sanctify them. In the words of historian Jeffrey Williams, "Palmer made sanctification an instantaneous act accomplished through the exercise of faith." Many holiness denominations require pastors to profess that they have already experienced entire sanctification. This emphasis on the instantaneous nature of Christian perfection rather than its gradual side is a defining feature of the Wesleyan-holiness movement. The Discipline of the Bible Methodist Connection of Churches thus teaches that:

We believe that entire sanctification is that work of the Holy Spirit by which the child of God is cleansed from inherited depravity and empowered for more effective service through faith in Jesus Christ. It is subsequent to regeneration and is accomplished in a moment of time when the believer presents himself a living sacrifice, holy and acceptable unto God. The Spirit-filled believer is thus enabled to love God with an undivided heart.

A second defining emphasis of the Holiness movement is the complete destruction and eradication of the sinful nature. H. Orton Wiley, the premier Holiness systematic theologian, quotes R. T. Williams explaining:

It is folly to try to pass as a believer in holiness and at the same time question its doctrine of eradication. There cannot be such a thing as holiness in its final analysis without the eradication of sin. Holiness and suppression are incompatible terms. "The old man" and counteraction make a pale and sickly kind of holiness doctrine. It is holiness and eradication or holiness not at all.

Another key aspect of the Holiness movement is their close adherence to Wesley's definition of sin. Wesley stated in a letter:

Nothing is sin, strictly speaking, but a voluntary transgression of a known law of God. Therefore, every voluntary breach of the law of love is sin; and nothing else, if we speak properly. To strain the matter farther is only to make way for Calvinism. There may be ten thousand wandering thoughts, and forgetful intervals, without any breach of love, though not without transgressing the Adamic law. But Calvinists would fain confound these together. Let love fill your heart, and it is enough!

With this understanding of sin, clergy aligned with the holiness movement teach the possibility of complete freedom from all sin, both inward and outward, as expressed by John Fletcher's statement "He who is possessed of love, is free from all sin."

Holiness Pentecostalism

Holiness Pentecostal denominations, also known as Wesleyan Pentecostals or Methodistic Pentecostals are Pentecostals that believe in entire sanctification as a second work of grace. Inheriting Wesleyan–Arminian theology from the holiness movement within Methodism, Holiness Pentecostals are the original branch of Pentecostalism, and these denominations include the Apostolic Faith Church, the Calvary Holiness Association, the Congregational Holiness Church, the Free Gospel Church, the International Pentecostal Holiness Church, the Church of God (Cleveland), the Church of God in Christ and The (Original) Church of God; the Heritage Bible College is a Bible college that trains many Holiness Pentecostal clergy. In the United States, major Holiness Pentecostal camp meetings include the Portland AFC Camp Meeting (Portland, Oregon), Blanchard Holiness Camp Meeting (Blanchard, OK), Dripping Springs Holiness Camp Meeting (Glenwood, Arkansas) and Muldrow Holiness Camp Meeting (Muldrow, OK). For Holiness Pentecostals, entire sanctification is the second work of grace in a series of three distinct blessings that Christians experience. The first work of grace is conversion (the new birth) and the third work of grace is the baptism in the Holy Spirit (which is marked by speaking in tongues). Methodism (inclusive of the holiness movement) teaches two works of grace—the New Birth and Entire Sanctification, while Holiness Pentecostals add a third work of grace, Baptism in the Holy Spirit evidenced by speaking in tongues, to this sequence (in contrast, in Methodism, baptism with the Holy Spirit refers to entire sanctification). According to church historian and theologian Ted A. Campbell, this three-part pattern is often explained by stating "Holy Spirit cannot fill an unclean vessel", so the cleansing of the heart that takes place in entire sanctification is necessary before a person can be filled or baptized with the Holy Spirit. The testimony of those who attended the Azusa Street Revival was "I am saved, sanctified, and filled with the Holy Ghost" in reference to the three works of grace of Holiness Pentecostals, the oldest branch of Pentecostalism. In contrast, Finished Work Pentecostal denominations, such as the Assemblies of God, reject the doctrine of entire sanctification.

Quaker teaching

George Fox, the founder of Quakerism, taught Christian perfection, also known in the Friends tradition as "perfection", in which the Christian believer could be made free from sin. In his Some Principles of the Elect People of God Who in Scorn are called Quakers, for all the People throughout all Christendome to Read over, and thereby their own States to Consider, he writes in section "XVI. Concerning Perfection":

HE that hath brought Man into Imperfection is the Devil, and his work who led from God; for Man was Perfect before he fell, for all God's Works are Perfect; So Christ that destroyes the Devil and his works, makes man Perfect again, destroying him that made him Imperfect, which the Law could not do; so by his Blood doth he cleanse from all Sin; And by one offering, hath he Perfected for ever them that are Sanctified; And they that do not Believe in the Light which comes from Christ, by which they might see the Offering, and receive the Blood, are in the unbelief concerning this. And the Apostles that were in the Light, Christ Jesus, (which destroyes the Devil and his works) spoke Wisdom among them that were Perfect, though they could not among those that were Carnal; And their Work was for the perfecting of the Saints, for that cause had they their Ministry given to them until they all came to the Knowledge of the Son of God, which doth destroy the Devil and his works, And which ends the Prophets, first Covenant, Types, Figures, Shadowes; And until they all came to the Unity of the Faith which purified their hearts, which gave them Victory over that which separated [sic] from God, In which they had access to God, by which Faith they pleased him, by which they were Justified; And so until they came unto a Perfect Man, unto the Measure of the Stature of the fulness of Christ; and so the Apostle said, Christ in you we Preach the hope of Glory, warning every man, that we might present every Man Perfect in Christ Jesus.

The early Quakers, following Fox, taught that as a result of the New Birth through the power of the Holy Spirit, man could be free from actual sinning if he continued to rely on the inward light and "focus on the cross of Christ as the center of faith". George Fox emphasized "personal responsibility for faith and emancipation from sin" in his teaching on perfection. For the Christian, "perfectionism and freedom from sin were possible in this world".

This traditional Quaker teaching continues to be emphasized by Conservative Friends, such as the Ohio Yearly Meeting of the Religious Society of Friends and Holiness Friends, such as the Central Yearly Meeting of Friends.

Keswickian teaching

Keswickian theology teaches a second work of grace that occurs through "surrender and faith", in which God keeps an individual from sin. Keswickian denominations, such as the Christian and Missionary Alliance, differ from the Wesleyan-Holiness movement in that the Christian and Missionary Alliance does not see entire sanctification as cleansing one from original sin, whereas holiness denominations espousing the Wesleyan–Arminian theology affirm this belief.

Criticism

There are Protestant denominations that reject the possibility of Christian perfection. Lutherans, citing letters by Paul of Tarsus in Romans 7:14–25 and Philippians 3:12, believe that "although we will strive for Christian perfection, we will not attain it in this life." Modern apologists further note that:

Our salvation is complete and is simply received by faith. Good works are the fruit of that faith. Good works show that we are saved, but have no part in saving us. Becoming more and more God-like in this life is the result of being saved. If we are saved by becoming more and more God-like, our salvation is in doubt because our being God-like is never perfect in this life. The troubled conscience will find little comfort in an incomplete process of theosis, but will find much comfort in God's declaration of full and free forgiveness.

While Presbyterians believe that Christians do "grow in God's grace" or holiness as they become conformed to the image of Christ, they reject the notion that perfection is attainable. In their view, sin will continue to affect one's motives and actions. This means that perfection is only attainable in glorification after death.

Obsessive–compulsive disorder

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Obsessive%E2%80%93compulsive_disorder

Obsessive–compulsive disorder
Frequent and excessive hand washing occurs in some people with OCD.
SpecialtyPsychiatry
SymptomsFeel the need to check things repeatedly, perform certain routines repeatedly, have certain thoughts repeatedly
ComplicationsTics, anxiety disorder, suicide
Usual onsetBefore 35 years
Risk factorsGenetics, biology, temperament, childhood trauma
Diagnostic methodClinically based on symptoms; Y-BOCS is the gold standard tool to assess severity
Differential diagnosisAnxiety disorder, major depressive disorder, eating disorders, tic disorders, obsessive–compulsive personality disorder
TreatmentCounseling, selective serotonin reuptake inhibitors, clomipramine
Frequency2.3%

Obsessive–compulsive disorder (OCD) is a mental and behavioral disorder in which an individual has intrusive thoughts (an obsession) and feels the need to perform certain routines (compulsions) repeatedly to relieve the distress caused by the obsession, to the extent where it impairs general function.

Obsessions are persistent unwanted thoughts, mental images, or urges that generate feelings of anxiety, disgust, or discomfort. Some common obsessions include fear of contamination, obsession with symmetry, the fear of acting blasphemously, the sufferer's sexual orientation, and the fear of possibly harming others or themselves. Compulsions are repeated actions or routines that occur in response to obsessions to achieve a relief from anxiety. Common compulsions include excessive hand washing, cleaning, counting, ordering, repeating, avoiding triggers, hoarding, neutralizing, seeking assurance, praying, and checking things. People with OCD may only perform mental compulsions such as needing to know or remember things. While this is sometimes referred to as primarily obsessional obsessive–compulsive disorder (Pure O), it is also considered a misnomer due to associated mental compulsions and reassurance seeking behaviors that are consistent with OCD.

Compulsions occur often and typically take up at least one hour per day, impairing one's quality of life. Compulsions cause relief in the moment, but cause obsessions to grow over time due to the repeated reward-seeking behavior of completing the ritual for relief. Many adults with OCD are aware that their compulsions do not make sense, but they still perform them to relieve the distress caused by obsessions. For this reason, thoughts and behaviors in OCD are usually considered egodystonic. In contrast, thoughts and behaviors in obsessive–compulsive personality disorder (OCPD) are usually considered egosyntonic, helping differentiate between the two.

Although the exact cause of OCD is unknown, several regions of the brain have been implicated in its neuroanatomical model including the anterior cingulate cortex, orbitofrontal cortex, amygdala, and BNST. The presence of a genetic component is evidenced by the increased likelihood for both identical twins to be affected than both fraternal twins. Risk factors include a history of child abuse or other stress-inducing events such as during the postpartum period or after streptococcal infections. Diagnosis is based on clinical presentation and requires ruling out other drug-related or medical causes; rating scales such as the Yale–Brown Obsessive–Compulsive Scale (Y-BOCS) assess severity. Other disorders with similar symptoms include generalized anxiety disorder, major depressive disorder, eating disorders, tic disorders, body-focused repetitive behavior, and obsessive–compulsive personality disorder. Personality disorders are a common comorbidity, with schizotypal and OCPD having poor treatment response. The condition is also associated with a general increase in suicidality. The phrase obsessive–compulsive is sometimes used in an informal manner unrelated to OCD to describe someone as excessively meticulous, perfectionistic, absorbed, or otherwise fixated. However, the actual disorder can vary in presentation, and individuals with OCD may not be concerned with cleanliness or symmetry.

OCD is chronic and long-lasting with periods of severe symptoms followed by periods of improvement. Treatment can improve ability to function and quality of life, and is usually reflected by improved Y-BOCS scores. Treatment for OCD may involve psychotherapy, pharmacotherapy such as antidepressants, or surgical procedures such as deep brain stimulation or, in extreme cases, psychosurgery. Psychotherapies derived from cognitive behavioral therapy (CBT) models, such as exposure and response prevention, acceptance and commitment therapy, and inference based-therapy, are more effective than non-CBT interventions. Selective serotonin reuptake inhibitors (SSRIs) are more effective when used in excess of the recommended depression dosage; however, higher doses can increase side effect intensity. Commonly used SSRIs include sertraline, fluoxetine, fluvoxamine, paroxetine, citalopram, and escitalopram. Some patients fail to improve after taking the maximum tolerated dose of multiple SSRIs for at least two months; these cases qualify as treatment-resistant and can require second-line treatment such as clomipramine or atypical antipsychotic augmentation. While SSRIs continue to be first-line, recent data for treatment-resistant OCD supports adjunctive use of neuroleptic medications, deep brain stimulation, and neurosurgical ablation. There is growing evidence to support the use of deep brain stimulation and repetitive transcranial magnetic stimulation for treatment-resistant OCD.

Obsessive–compulsive disorder affects about 2.3% of people at some point in their lives, while rates during any given year are about 1.2%. More than three million Americans suffer from OCD. According to Mercy, approximately 1 in 40 U.S. adults and 1 in 100 U.S. children have OCD. Although possible at times with triggers such as pregnancy, onset rarely occurs after age 35, and about 50% of patients experience detrimental effects to daily life before age 20. While OCD occurs worldwide, a recent meta-analysis showed that women are 1.6 times more likely to experience OCD. Based on data from 34 studies, the worldwide prevalence rate is 1.5% in women and 1% in men.

Signs and symptoms

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 looking into 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 for male children and 11.0 for female children. 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 (Lack 2012). 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.

In regards to the cause of onset, researchers asked participants in one study what they felt was responsible for triggering the initial onset of their illness. 29% of patients answered that there was an environmental factor in their life that did so. Specifically, the majority of participants who answered with that noted their environmental factor to be related to an increased responsibility.

Obsessions

People with OCD may face intrusive thoughts, such as thoughts about the devil (shown is a painted interpretation of Hell).

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. 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 "kissing, touching, fondling, oral sex, anal sex, intercourse, incest, and rape" with "strangers, acquaintances, parents, children, family members, friends, coworkers, animals, and 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

A person exhibiting skin-picking disorder

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. Some individuals with OCD are aware that their behaviors are not rational, but they feel compelled to follow through with them to fend off feelings of panic or dread. 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. In addition to experiencing the anxiety and fear that typically accompanies OCD, affected individuals may spend hours performing compulsions every day. In such situations, it can become difficult for the person to fulfill their work, familial, or social roles. These behaviors can also cause adverse physical symptoms; for example, people who obsessively wash their hands with antibacterial soap and hot water can make their skin red and raw with dermatitis.

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.

In cognitive behavioral therapy (CBT), OCD patients are asked to overcome intrusive thoughts by not indulging in any compulsions. They are taught that rituals keep OCD strong, while not performing them causes OCD to become weaker. 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. For body-focused repetitive behaviors (BFRB) 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.

OCD sometimes manifests without overt compulsions, which may be termed "primarily obsessional OCD." 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, in the middle of the continuum, 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.

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. After some discussion, it is possible to convince the individual that their fears are unfounded. It may be more difficult to practice exposure and response prevention therapy (ERP) on such people, as they may be unwilling to cooperate, at least initially. 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. Furthermore, severe and frequent overvalued ideas are considered similar to idealized values, which are so rigidly held by, and so important to affected individuals, that they end up becoming a defining identity. 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. The Overvalued Ideas Scale (OVIS) has been developed as a reliable quantitative method of measuring levels of OVI in patients with OCD, and research has suggested that overvalued ideas are more stable for those with more extreme OVIS scores.

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.

Video game addiction

In April 2018, the International Journal of Environmental Research and Public Health published a systematic review of 24 studies researching associations between internet gaming disorder (IGD) and various psychopathologies that found a significant correlation between IGD and obsessive–compulsive disorder symptoms in 3 of 4 studies.

Pediatric OCD

Approximately 1–2% of children are affected by OCD. There is a lot of similarity between the clinical presentation of OCD in children and adults, and it is considered a highly familial disorder, with a phenotypic heritability of around 50%. Obsessive–compulsive disorder symptoms tend to develop more frequently in children 10–14 years of age, with males displaying symptoms at an earlier age, and at a more severe level than females. In children, symptoms can be grouped into at least four types, including sporadic and tic-related OCD.

The Children's Yale–Brown Obsessive–Compulsive Scale (CY-BOCS) is the gold standard measure for assessment of pediatric 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. The CY-BOCS Total Severity score is an important monitoring tool as it is responsive to pharmacotherapy and psychotherapy. 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).

CBT is the first line treatment for mild to moderate cases of OCD in children, while medication plus CBT is recommended for moderate to severe cases. Serotonin reuptake inhibitors (SRIs) are first-line medications for OCD in children with established AACAP guidelines for dosing.

Associated conditions

People with OCD may be diagnosed with other conditions as well, such as obsessive–compulsive personality disorder, major depressive disorder, bipolar disorder, generalized anxiety disorder, anorexia nervosa, social anxiety disorder, bulimia nervosa, Tourette syndrome, transformation obsession, ASD, ADHD, dermatillomania, body dysmorphic disorder, and trichotillomania. More than 50% of people with OCD experience suicidal tendencies, and 15% have attempted suicide. Depression, anxiety, and prior suicide attempts increase the risk of future suicide attempts.

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, while another found that fewer than 5% of males have OCD and 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. Moreover, severe OCD symptoms are consistently associated with greater sleep disturbance. Reduced total sleep time and sleep efficiency have been observed in people with OCD, with delayed sleep onset and offset.

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. Both environmental and genetic factors are believed to play a role. Risk factors include a history of adverse childhood experiences or other stress-inducing events.

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:

1) 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.

2) 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)

3) This disturbance does not only occur during delirium.

4) 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. Furthermore, individuals with OCD are more likely to have first-degree family members exhibiting the same disorders than matched controls. In cases in which OCD develops during childhood, there is a much stronger familial link in the disorder than with cases in which OCD develops later in adulthood. In general, genetic factors account for 45–65% of the variability in OCD symptoms in children diagnosed with the disorder. A 2007 study found evidence supporting the possibility of a heritable risk for OCD.

Research has found there to be a genetic correlation between anorexia nervosa and OCD, suggesting a strong etiology. First and second hand relatives of probands with OCD have a greater risk of developing anorexia nervosa as genetic relatedness increases.

A mutation has been found in the human serotonin transporter gene hSERT in unrelated families with OCD.

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. The PANDAS hypothesis is unconfirmed and unsupported by data, and two new categories have been proposed: PANS (pediatric acute-onset neuropsychiatric syndrome) and CANS (childhood acute neuropsychiatric syndrome). The CANS and PANS hypotheses include different possible mechanisms underlying acute-onset neuropsychiatric conditions, but do not exclude GABHS infections as a cause in a subset of individuals. PANDAS, PANS, and CANS are the focus of clinical and laboratory research, but remain unproven. 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

Some parts of the brain showing abnormal activity in OCD: Orbitofrontal cortex integrates rewards, emotions, and behaviors; anterior cingulate cortex is involved in error detection; amygdala is involved in emotional interpretation of reward

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. Decreased volumes of the dorsolateral prefrontal cortex related to executive function has also been observed in OCD.

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. Increased white matter volume and decreased fractional anisotropy in anterior midline tracts has been observed in OCD, possibly indicating increased fiber crossings.

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.

Neurobiological

From the observation of the efficacy of antidepressants in OCD, a serotonin hypothesis of OCD has been formulated. Studies of peripheral markers of serotonin, as well as challenges with proserotonergic compounds have yielded inconsistent results, including evidence pointing towards basal hyperactivity of serotonergic systems. 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.

A complex relationship between dopamine and OCD has been observed. Although antipsychotics, which act by antagonizing dopamine receptors, may improve some cases of OCD, they frequently exacerbate others. Antipsychotics, in the low doses used to treat OCD, may actually increase the release of dopamine in the prefrontal cortex, through inhibiting autoreceptors. Further complicating things is the efficacy of amphetamines, decreased dopamine transporter activity observed in OCD, and low levels of D2 binding in the striatum. Furthermore, 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, nor are there any medical exams that can predict if one will fall victim to such illnesses. To be diagnosed with OCD, a person must have obsessions, compulsions, or both, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM notes that there are multiple characteristics that can turn obsessions and compulsions from normalized behavior to "clinically significant." There has to be recurring and strong thoughts or impulsive that intrude on the day-to-day lives of the patients and cause noticeable levels of anxiousness.

These thoughts, impulses, or images are of a degree or type that lies outside the normal range of worries about conventional problems. 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. It is helpful to quantify the severity of symptoms and impairment before and during treatment for OCD. In addition to the person's estimate of the time spent each day harboring obsessive-compulsive thoughts or behaviors, concrete tools can be used to gauge the person's condition. This may be done with rating scales, such as the Yale–Brown Obsessive Compulsive Scale (Y-BOCS; expert rating) or the obsessive–compulsive inventory (OCI-R; self-rating). With measurements such as these, psychiatric consultation can be more appropriately determined, as it has been standardized.

In regards to diagnosing, the health professional also looks to make sure that the signs of obsessions and compulsions are not the results of any drugs, prescription or recreational, that the patient may be taking.

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. Within OCD, these specific categories are often diagnosed into their own type of OCD.

OCD is sometimes placed in a group of disorders called the obsessive–compulsive spectrum.

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. That being said, OCD does often go hand in hand with other mental disorders. For this reason, one may be diagnosed with multiple mental disorders at once.

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. Poor indicates that the patient believes their obsessional beliefs are probably true. Absent/delusional indicates that they fully believe their obsessional thoughts to be true. Approximately 4% or fewer individuals with OCD will be diagnosed as absent/delusional. Additionally, as many as 30% of those with OCD also have a lifetime tic disorder, meaning they have been diagnosed with a tic disorder at some point in their life.

There are several different types of tics that have been observed in individuals with OCD. These include but are not limited to, "grunting", "jerking" or "shrugging" body parts, sniffling, and excessive blinking.

There has been a significant amount of progress over the last few decades, and as of 2022 there is statically significant improvement in the diagnostic process for individuals with OCD. One study found that of two groups of individuals, one with participants under the age of 27.25 and one with participants over that age, those in the younger group experienced a significantly faster time between the onset of OCD tendencies and their formal diagnoses.

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.

Therapy

One exposure and ritual prevention activity would be to check the lock only once and then leave.

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) or serotonin–norepinephrine reuptake inhibitors (SNRIs) medication does not effectively treat OCD symptoms, or vice versa, for individuals who begin treatment with psychotherapy. This technique is considered superior to others due to the lack of medication used. However, up to 25% of patients will discontinue treatment due to the severity of their tics. CBT normally lasts anywhere from 12-16 sessions, with homework assigned to the patient in between meetings with a therapist. (Lack 2012). Modalities differ in ERP treatment but both virtual reality based as well as unguided computer assisted treatment programs have shown effective results in treatment programs.

For example, a patient might be asked to touch something very mildly contaminated (exposure), and wash their hands only once afterward (response prevention). Another example might entail asking the patient to leave the house and check the lock only once (exposure), without going back to check again (response prevention). After succeeding at one stage of treatment, the patient's level of discomfort in the exposure phase can be increased. When this therapy is successful, the patient will quickly habituate to an anxiety-producing situation, discovering a considerable drop in anxiety level.

ERP has a strong evidence base, and is considered the most effective treatment for OCD. However, this claim was doubted by some researchers in 2000, who criticized the quality of many studies. 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 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. Research on Inference-Based Cognitive-Behavior Therapy (I-CBT) suggests it can lead to improvements for those with OCD.

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 (BFRB), behavioral interventions such as habit-reversal training and decoupling are recommended.

Psychotherapy in combination with psychiatric medication may be more effective than either option alone for individuals with severe OCD. ERP coupled with weight restoration and serotonin reuptake inhibitors has proven the most effective when treating OCD and an eating disorder simultaneously.

Medication

A blister pack of sertraline under the brand name Zoloft

The medications most frequently used to treat OCD are antidepressants, including selective serotonin reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs). Sertraline and fluoxetine are effective in treating OCD for children and adolescents.

SSRIs help people with OCD by inhibiting the reabsorption of serotonin by the nerve cells after they carry messages from neurons to synapse; thus, more serotonin is available to pass further messages between nearby nerve cells.

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.

In 2006, the National Institute for Health and Care Excellence (NICE) guidelines recommended augmentative second-generation (atypical) antipsychotics for treatment-resistant OCD. Atypical antipsychotics are not useful when used alone, and no evidence supports the use of first-generation antipsychotics. For OCD treatment specifically, there is tentative evidence for risperidone, and insufficient evidence for olanzapine. Quetiapine is no better than placebo with regard to primary outcomes, but small effects were found in terms of Y-BOCS score. The efficacy of quetiapine and olanzapine are limited by an insufficient number of studies. A 2014 review article found two studies that indicated that aripiprazole was "effective in the short-term", and found that "[t]here was a small effect-size for risperidone or antipsychotics in general in the short-term"; however, the study authors found "no evidence for the effectiveness of quetiapine or olanzapine in comparison to placebo." While quetiapine may be useful when used in addition to an SSRI/SNRI in treatment-resistant OCD, these drugs are often poorly tolerated, and have metabolic side effects that limit their use. A guideline by the American Psychological Association suggested that dextroamphetamine may be considered by itself after more well-supported treatments have been attempted.

Procedures

Electroconvulsive therapy (ECT) has been found to have effectiveness in some severe and refractory cases. Transcranial magnetic stimulation has shown to provide therapeutic benefits in alleviating symptoms.

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 (FDA) 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 stands as an effective and validated first line of treatment of OCD in children. Family involvement, in the form of behavioral observations and reports, is a key component to the success of such treatments. 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. After one or two years of therapy, in which a child learns the nature of their obsession and acquires strategies for coping, they may acquire a larger circle of friends, exhibit less shyness, and become less self-critical. 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. 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

Age-standardized disability-adjusted life year estimated rates for obsessive-compulsive disorder per 100,000 inhabitants in 2004
  no data
  <45
  45–52.5
  52.5–60
  60–67.5
  67.5–75
  75–82.5
  82.5–90
  90–97.5
  97.5–105
  105–112.5
  112.5–120
  >120

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. It is unusual for symptoms to begin after the age of 35 and half of people develop problems before 20. Males and females are affected about equally. However, there is an earlier age for onset for males than females.

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.

Abu Zayd Al-Balkhi, the 9th century Islamic polymath, was likely the first to classify OCD into different types and pioneer cognitive behavioral therapy, in a fashion unique to his era and which was not popular in Greek medicine. In his medical treatise entitled Sustenance of the Body and Soul, Al-Balkhi describes 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 suggests treating obsessive thoughts with positive thoughts and mind-based therapy.

From the 14th to the 16th century in Europe, it was believed that people who experienced blasphemous, sexual or other obsessive thoughts were possessed by the devil. Based on this reasoning, treatment involved banishing the "evil" from the "possessed" person through exorcism. 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." In 1584, a woman from Kent, England, named Mrs. Davie, described by a justice of the peace as "a good wife", was nearly burned at the stake after she confessed that she experienced constant, unwanted urges to murder her family.

The English term obsessive–compulsive arose as a translation of German Zwangsvorstellung (obsession) used in the first conceptions of OCD by Karl Westphal. Westphal's description went on to influence Pierre Janet, who further documented features of OCD. In the early 1910s, Sigmund Freud attributed obsessive–compulsive behavior to unconscious conflicts that manifest as symptoms. Freud describes the clinical history of a typical case of "touching phobia" as starting in early childhood, when the person has a strong desire to touch an item. In response, the person develops an "external prohibition" against this type of touching. However, this "prohibition does not succeed in abolishing" the desire to touch; all it can do is repress the desire and "force it into the unconscious." 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. In the mid-1980s, this approach changed, and practitioners began treating OCD primarily with medicine and practical therapy rather than through psychoanalysis.

One of the first successful treatments of OCD, exposure and response prevention, emerged during the 1960s, when psychologist Vic Meyer exposed two hospitalized patients to anxiety-inducing situations while preventing them from performing any compulsions. Eventually, both patients' anxiety level dropped to manageable levels. Meyer devised this procedure from his analysis of fear extinguishment in animals via flooding. 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.

Obsessive–compulsive symptoms worsened during the early stages of the COVID-19 pandemic, particularly for individuals with contamination-related OCD.

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. He later described his obsessions in his autobiography Grace Abounding to the Chief of Sinners, stating, "These things may seem ridiculous to others, even as ridiculous as they were in themselves, but to me they were the most tormenting cogitations." He wrote two pamphlets advising those with similar anxieties. In one of them, he warns against indulging in compulsions: "Have care of putting off your trouble of spirit in the wrong way: by promising to reform yourself and lead a new life, by your performances or duties".

British poet, essayist and lexicographer Samuel Johnson (1709–1784) also had OCD. He had elaborate rituals for crossing the thresholds of doorways, and repeatedly walked up and down staircases counting the steps. He would touch every post on the street as he walked past, only step in the middle of paving stones, and repeatedly perform tasks as though they had not been done properly the first time.

The "Rat Man", real name Ernst Lanzer, a patient of Sigmund Freud, suffered from what was then called "obsessional neurosis". Lanzer's illness was characterised most famously by a pattern of distressing intrusive thoughts in which he feared that his father or a female friend would be subjected to a purported Chinese method of torture in which rats would be encouraged to gnaw their way out of a victim's body by a hot poker.

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 openly spoken about his life-long struggle with OCD, particularly primarily obsessional obsessive–compulsive disorder (Pure O).

Swedish climate activist Greta Thunberg is also known to have OCD, among other mental health conditions.

American actor James Spader has also 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, David Beckham shared details about his compelling cleaning rituals, need for symmetry in the fridge, and the impact of OCD on his life.

Society and culture

This ribbon represents trichotillomania and other body-focused repetitive behaviors.

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.
  • 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".
  • The British TV series Pure (2019) stars Charly Clive as a 24-year-old Marnie who is plagued by disturbing sexual thoughts, as a kind of primarily obsessional obsessive compulsive disorder.

Research

The naturally occurring sugar inositol has been suggested as a treatment for OCD.

μ-Opioid receptor agonists, such as hydrocodone and tramadol, may improve OCD symptoms. Administration of opioids may be contraindicated in individuals concurrently taking CYP2D6 inhibitors such as fluoxetine and paroxetine.

Much research is devoted to the therapeutic potential of the agents that affect the release of the neurotransmitter glutamate or the binding to its receptors. These include riluzole, memantine, gabapentin, N-acetylcysteine (NAC), topiramate, and lamotrigine. Research on the potential for other supplements, such as milk thistle, to help with OCD and various neurological disorders, is ongoing.

Other animals

Advocacy

Many organizations and charities around the world advocate for the wellbeing of people with OCD, stigma reduction, research, and awareness. The International OCD Foundation (IOCDF) is the largest 501(c)3 nonprofit organization dedicated to serving a broad community of individuals with OCD and related disorders, their family members and loved ones, and mental health professionals and researchers around the world. Since 1986, the IOCDF provides up-to-date education and resources, strengthens community engagement worldwide, delivers quality professional training to clinicians, and funds groundbreaking research.

Delayed-choice quantum eraser

From Wikipedia, the free encyclopedia https://en.wikipedia.org/wiki/Delayed-choice_quantum_eraser A delayed-cho...