What is OCD and how to manage it

Obsessive-compulsive disorder (OCD) is characterized by two interrelated phenomena: obsessions and compulsions . Obsessions are intrusive, repetitive, and unwanted thoughts, impulses, or images that cause significant distress. Compulsions are behaviors, both physical (which may be observed by others) and mental (which the person performs internally and are not observable), that are usually repetitive and are carried out to reduce the distress caused by the obsessions or to prevent harm to oneself or others (often loved ones). Sometimes, people with OCD feel compelled to perform actions in a rigid and stereotyped manner, following self-imposed rules (doing things in a certain order or a specific number of times) until they feel they are "right."

It's important to understand that having OCD is not the same as being "manic." We can all have occasional intrusive thoughts, habits, or self-imposed rules, but these don't cause significant distress if we don't engage in them, they don't occupy more than an hour a day, and they aren't repeated daily. In contrast, in people with OCD, the thoughts, images, or impulses, and the associated rituals, are very frequent, take up a large amount of their time, are accompanied by intense negative emotions (fear, disgust, guilt, etc.), and make it difficult for them to adapt and function in various areas of their lives (studies, work, family, friends, etc.).

The term "obsessive" is sometimes misused to describe certain personality traits and confused with having OCD. People with obsessive-compulsive personality disorder have certain persistent character traits that make it difficult for them to adapt appropriately to their family, social, work, or academic environments. These traits are characterized by a tendency toward perfectionism, excessive demands in various areas, a tendency toward rigidity and rumination, and a general preoccupation with order and small details, even if this leads to reduced efficiency, disproportionate time spent on tasks, or difficulties in relationships in some cases.

A person with OCD may or may not have an obsessive-compulsive personality, since both conditions sometimes coexist, and in other cases, the person with OCD may have a perfectly well-adjusted personality or exhibit other types of dysfunctional personality traits (avoidant, dependent, borderline, etc.). Personality assessment should be carried out when the obsessions and rituals have improved as much as possible, and always by a specialist (when a person with OCD is experiencing a particularly severe episode, their personality may appear dysfunctional, but they may turn out to be a much more well-adjusted and functional person once their OCD improves).

We currently have very effective treatments, both psychological and pharmacological, for OCD, which can reduce symptoms and even eliminate them completely, allowing those affected to lead perfectly normal lives . This positive prognosis is especially clear in childhood-onset forms of OCD.

More than half of the children who are diagnosed with OCD in childhood will no longer exhibit obsessive symptoms when they reach adulthood.

These childhood forms of OCD, which have a particularly good prognosis, are often accompanied by other neurodevelopmental disorders such as tics or attention deficit hyperactivity disorder (ADHD).

A key aspect of maximizing the chances of a successful response to treatment for OCD is to start it as soon as possible; hence the importance of early diagnosis . This is often not easy because people tend to hide their symptoms out of shame, because they believe they should be able to control them on their own, or even because they are unaware that their symptoms constitute a disorder. Some studies describe that, in many cases, between 5 and 10 years pass from the onset of obsessions and rituals until an OCD diagnosis is made.

Performing rituals continuously for many years leads to the development of distorted ideas that worsen the disorder (the person believes, for example, that nothing bad has happened to their loved ones because they have carried out their rituals, or that they have not caught a disease because they have washed their hands repeatedly, when in reality in both cases, nothing terrible has happened because the obsessions do not represent real risks but imagined threats).

For this reason, it is important to begin cognitive-behavioral therapy as soon as possible when OCD appears. This approach helps the person, on the one hand, to interrupt the rituals (what we know as exposure and response prevention), thus avoiding the false confirmations of obsessive fears, and, on the other hand, to detect and modify the distorted beliefs that often accompany OCD. These include thought-action fusion (the belief that simply thinking about something increases the likelihood of it happening), overestimation of risk and intolerance of uncertainty (if I am not certain of safety, it means there is danger), and perfectionism (there is only one perfect and desirable way to do things).

Obsessive-compulsive disorder (OCD) is a disorder that typically begins in childhood, adolescence, or early adulthood . There is a first peak in childhood/adolescence (between 6 and 12 years old) and another in young adulthood (between 18 and 25 years old). Some people recall having obsessions or rituals practically since they can remember (5-6 years old), while others are able to pinpoint when their first obsession appeared (sometimes after a triggering event).

It's important to keep in mind that not all repetitions or rituals we see in a young child are obsessive symptoms. Rituals and repetitive behaviors are normal during the early years of a child's development . In fact, they are necessary and developmental, since children learn through patterns, imitation, and repetition, so they are very common in early childhood. Around age two, they begin to establish many routines, which provide them with structure. As they get older, they may collect or classify objects, repeat phrases, stories, or movies they like, or sometimes they may perform actions that resemble OCD rituals (repeatedly touching objects, placing them in a certain order, etc.). Unlike true rituals, these behaviors are not experienced as distressing; rather, they are usually performed according to the child's interests and are often easily redirected play that doesn't interfere with their daily life.

Studies show that in approximately 35% of people with OCD, the onset of symptoms is related to certain triggers. These triggers can be physical (such as certain infections, hormonal factors, or substance use) or life events that involve changes (both positive and negative for the individual).

Regarding physical factors , the clearest examples are what are known as PANDAS (Post-Streptococcal Neuropsychiatric Disorders), cases in which there is a sudden and rapid onset or worsening of obsessive symptoms or tics, usually in children who have suffered a respiratory infection caused by a bacterium of the streptococcus family. In these cases, the body generates antibodies to defend itself against the bacteria, which attack certain areas of the brain (the basal ganglia), causing the onset or worsening of obsessive symptoms.

We also know that hormonal changes can affect the onset and course of OCD. It is common for girls with obsessive symptoms to experience the onset of the disorder around the year of menarche, their first period. It is also relatively common for some women to begin experiencing obsessive symptoms during pregnancy or especially postpartum, or to experience a worsening of symptoms during different phases of the menstrual cycle (ovulation, menstruation). In these cases, if symptoms worsen significantly during menstruation, regulating the cycles with oral contraceptives can be attempted, and it will also be especially important to monitor the progression of OCD if the woman becomes pregnant.

Finally, some people describe the onset of obsessive-compulsive disorder after using certain drugs such as cannabis or cocaine . In these cases, it is essential to recommend complete abstinence from drugs.

Regarding changes in the environment , we know that OCD can sometimes appear after traumatic events and also in situations that represent a significant change for the individual, especially if they involve an increased sense of responsibility (starting new studies, a new job, moving out of the family home, beginning a romantic relationship, etc.). Those who associate the onset of their OCD with environmental stressors tend to be somewhat older and have less of a family history of OCD than those with a more "spontaneous" onset.

OCD affects both sexes equally , although as with many other mental disorders, women tend to seek help more than men, and in clinical samples there is sometimes a greater representation of women.

Regarding differences in symptoms, in the earliest onset forms of the disorder in childhood, it is more common in males, those with a history of tics or attention deficit hyperactivity disorder, and those with symptoms related to order/symmetry (need to place or touch objects, arrange them, etc.). In females, OCD tends to have a slightly later onset (sometimes around the time of menarche), and contamination obsessions and washing/cleaning rituals are more frequent. Symptoms of depression are often present alongside OCD.

In general, it is considered that at least one year should pass before a stable diagnosis of OCD can be established. This is because some people may experience occasional obsessive symptoms for a shorter and more limited period, which will not constitute a disorder and will resolve on their own over time. Furthermore, this minimum period of one year also helps avoid overdiagnosing young children with OCD, as they may occasionally exhibit symptoms that appear obsessive (repetition of certain gestures, games, behaviors, etc.) as part of the normal process of growth and learning (known as circular reactions).

The most recommended treatment for mild-to-moderate OCD is cognitive-behavioral therapy (CBT) , primarily through exposure and response prevention (ERP) combined with cognitive restructuring. For moderate to severe OCD , medication is recommended as a starting point, along with CBT . In cases with very significant and debilitating symptoms, it may be necessary to begin with medication alone and, once it has at least partially reduced the symptoms, then add behavioral therapy.

Exposure and response prevention involves asking the person to confront situations that trigger obsessions (exposure) without carrying out the rituals (response prevention). For example, touching "contaminated" objects and then not washing their hands; leaving the house without checking the door or appliances, etc. It is very important to motivate the person at the beginning of cognitive-behavioral therapy, working on their awareness of the disorder and empowering them to overcome the obsessions that limit their life. Individual and group therapy are often used, since interacting with others who are going through the same thing helps to understand what is happening and prepare for change. Furthermore, it is advisable to provide psychoeducation about the disorder, individually or in groups, to the family or loved ones who live with the person with OCD. In the case of children and adolescents, it is often necessary to involve schools in these psychoeducational aspects, especially when there is significant interference in the school environment.

Behavioral therapy is extraordinarily effective at all ages, but it is especially indicated in children and adolescents, constituting the treatment of choice in childhood and adolescent OCD.

Regarding anti-obsessive medications , there are several options. First-line medications are a group of drugs called selective serotonin reuptake inhibitors (SSRIs), which include fluoxetine, fluvoxamine, sertraline, citalopram, escitalopram, and paroxetine. These medications are used not only for OCD but also to treat depression and other anxiety disorders, but it's important to know that they have a specific anti-obsessive effect, regardless of whether the person is depressed or not. These medications must be taken at higher doses to treat OCD than those used for depression, and their effect takes between 8 and 12 weeks to appear, so it's normal not to notice significant changes in the first few days of treatment. If there is no adequate response to SSRIs, we can use another medication, also from the antidepressant family, that acts on serotonin: clomipramine (Anafranil).

Finally, if we have not achieved sufficient improvement with SSRIs or Anafranil, these can be combined with reduced doses of some drugs from the antipsychotic family (such as aripiprazole or risperidone), which have also been shown to be able to reduce the frequency of occurrence of obsessions or the discomfort that accompanies them.

It is difficult to establish a treatment response timeframe that applies to everyone. Generally, if we use medication to treat someone with OCD, it will be necessary to wait 12 to 16 weeks, once the person has reached the appropriate dose of the medication, to properly assess their response. In some treatment strategies (for example, when we add a reduced-dose antipsychotic to someone who has shown partial improvement with a serotonin-adrenergic drug), we should observe the response after 3–4 weeks.

In the case of drugs, it is especially important to respect two maxims: take the drugs at the correct anti-obsessive dose (higher than the dose used when only seeking their antidepressant effect) and do so for a sufficient time.

In the case of people receiving behavioral therapy, a minimum of 10-12 sessions are usually necessary to observe improvements in less severe cases, and a minimum of 20 sessions is recommended if the symptoms are more severe (usually the sessions are carried out weekly, but there are also some intensive cognitive-behavioral therapy programs, in which the sessions are daily, which allows for a faster improvement of the symptoms).

Each case must be individualized, as it depends on the severity of the OCD, the degree of resistance to compulsions, and the tolerance and effectiveness of the psychotropic medication. To prevent relapses , it is important to maintain antidepressant treatment (these are the drugs of choice, at anti-obsessive doses, which are significantly higher than antidepressant doses) for one to two years after achieving improvement and clinical stability. After this time, if discontinuing the medication is considered, the person must be informed about how to respond to potential relapses. This withdrawal should also be gradual and supervised by specialists. In the event of relapses, it may be necessary to maintain the medication for an extended or even indefinite period.

SSRI antidepressants (selective serotonin reuptake inhibitors) are the medication of choice for OCD and are generally well-tolerated, but close monitoring is necessary because the doses are higher than in cases of anxiety or depression. In addition, other types of psychotropic medications, such as low doses of atypical antipsychotics, may be used together because they enhance the anti-obsessive effect.

It is very important not to stop taking medication abruptly, as this could cause withdrawal symptoms, which are very unpleasant (sweating, anxiety, discomfort, nausea). It is necessary to consult your psychiatrist if you need to reduce or change your medication.

The treatment for OCD is psychological and does not always require medication . Furthermore, it involves a specific type of psychotherapy: cognitive behavioral therapy (CBT).

Other types of therapy , such as psychoanalysis, have not been shown to be effective in reducing rituals or improving OCD symptoms. Yoga, meditation, and other alternative tools have not shown evidence of effectiveness in managing and treating rituals; however, they can be helpful tools for channeling anxiety , as is exercise in general. Regarding meditation, it is not a type of therapy but rather the practice of mindfulness, which allows you to acquire healthy habits, which is beneficial for your physical and mental health when there is no disorder. When a mental disorder such as OCD is present, it is advisable to seek specialized mental health services for a professional evaluation.

There is a type of third-generation psychological therapy called Mindfulness -Based Cognitive Therapy, which includes elements of meditation, but also of cognitive therapy, and has been shown to be effective in helping to improve obsessive symptoms in people with a partial response to cognitive-behavioral therapy.

OCD itself is not dangerous for the person who has it. In fact, although the person may experience very disturbing or strange intrusive thoughts that are aggressive or sexual, these thoughts are in their mind, and the person rejects them and wants to neutralize them so they go away as quickly as possible. The person with OCD is afraid that something bad will happen, that things will happen to other people or to themselves; they feel responsible for the pain of others, so in general, they avoid harm or danger. The problem is that these thoughts and the constant need to neutralize them cause them a great deal of suffering. Therapy trains the individual to break this cycle of neutralization and cognitively addresses these intrusive thoughts, improving the person's quality of life.

It is estimated that around 15% of people with autism spectrum disorder (ASD) have comorbid obsessive-compulsive disorder (OCD ). It is sometimes difficult to differentiate between the two, as people with ASD often exhibit restricted and repetitive behaviors that could be mistaken for obsessive-compulsive symptoms. Sometimes, the rigidity and inflexibility associated with ASD contribute to the development of fixed routines and rituals centered around a specific theme. In essence, ASD symptoms such as difficulty adapting to change, a need for control, and a tendency to follow repetitive and stereotyped patterns can be factors that maintain OCD in a person with ASD.

However, a key factor in the differential diagnosis between OCD and ASD is that, unlike the repetitive behaviors of ASD, the compulsions of OCD:

• They are preceded by an obsession.
• They are performed in response to the anxiety produced by the obsession.
• They are not desired; they are rejected by the individual who wants to neutralize them.

Repetitive behaviors in ASD are core symptoms of the developmental disorder itself and include two or more of the following:

• Stereotyped movements (often self-stimulatory).
• Inflexibility in routines, ritualized patterns of behavior, intolerance to change, rigid thinking patterns.
• Restricted and fixed interests of high intensity and perseverance.
• Hypo- or hyperreactivity to sensory stimuli.

Rigid behavioral patterns in people with ASD often provide a sense of security; they also have a need for clear rules to follow and to create predictability in their daily lives (schedules, routines), otherwise they become confused and dysregulated; this gives them structure and stability.

Children with ASD and comorbid OCD should be assessed by a specialized, multidisciplinary unit capable of addressing both conditions. It is crucial to adopt an ASD-focused approach that addresses social communication difficulties, as well as the thought patterns characteristic of individuals with ASD, such as literal thinking, emotional and social cognition challenges, and cognitive inflexibility.

It's important to understand how aware a person is of their own ASD, both for self-knowledge and to begin any psychological therapy, whether for treating OCD or other symptoms. It's crucial to distinguish between the unwanted compulsions of OCD (which are very distressing and should be addressed gradually) and the stereotypical behaviors, routines, and need for predictability that individuals with ASD experience. These latter behaviors are inherent to the neurodevelopmental disorder itself and are not experienced as distressing; rather, they sometimes provide structure and serve as a form of self-regulation.

Cognitive-behavioral therapy can improve the quality of life for people with ASD and OCD , but it is crucial to individualize treatment and carefully prioritize which OCD symptoms should be addressed, their level of interference in daily life, and to distinguish between compulsions and repetitive ASD symptoms characteristic of the disorder. It is important to note that there are few studies on the clinical management of both comorbidities, so clinical trials of the same nature as those conducted with individuals with OCD without ASD are needed.

In childhood, we more frequently see OCD associated with ADHD in tic disorders, such as Tourette syndrome, a disorder that involves both vocal and motor tics for more than a year and is often associated with other psychiatric comorbidities in 60-80% of cases. The most specific and frequent comorbidity is ADHD, followed by OCD and ASD. Therefore, it is common to find children with tics, ADHD, and OCD in the context of a tic disorder like Tourette syndrome, especially around the age of 10-12 (the period of greatest tic exacerbation in chronic tic disorders or Tourette syndrome).

Regarding mood disorders, depression is the most common co-occurring condition with OCD (often as a consequence of the suffering caused by obsessions and the resulting impairment in daily functioning). Bipolar disorder can also occur, although less frequently than depression. In individuals with both OCD and bipolar disorder, proper management of medication is especially important, as the use of high doses of antidepressants (common in OCD) can increase the risk of manic decompensation in bipolar disorder (episodes of euphoria). It is essential to ensure adequate treatment with mood stabilizers (such as lithium or valproate) and to maximize the use of behavioral therapy to reduce the need for combining high doses of antidepressants.

If you suspect your son or daughter may have obsessive-compulsive disorder, there are some questions we as parents can observe and answer:

• Do you wash your hands or clean a lot?
• Do you check things a lot?
• Is there a thought that bothers you and that you can't get out of your head?
• Does he spend a lot of time on activities (slowly getting dressed, washing up, for example, to the point of being late for school)?
• Do you usually arrange things in a certain way and are you bothered by clutter?

These very basic questions can provide clues to rule out obsessive-compulsive disorder, but a proper diagnostic study should be carried out, and this requires a complete examination in consultation.

Sometimes children exhibit repetitive behaviors or even compulsions in response to stressful situations. It's important to consult a professional and explore possible triggers that might be behind the symptom. Not all repetitive behaviors are OCD; they could be other diagnoses such as anxiety, other obsessive-compulsive spectrum disorders, or an acute stress response. A thorough diagnosis in a consultation is necessary to begin treatment. In addition to establishing the diagnosis within mental health services, they will help you manage the compulsive behaviors your daughter is exhibiting. These behaviors typically don't resolve quickly; it's a process that requires assessment, addressing contributing factors, and developing a therapeutic plan.

It's common for many young people not to seek help or openly discuss their OCD symptoms because some of their intrusive thoughts are strange or absurd. They're usually embarrassed to share them, perform rituals "in secret," and may even subtly involve you, as parents, by asking you to do, for example, "what their OCD tells them to do": "Repeat that word," "Close that door," "Check that," "Place that object like this," etc.

It's important to communicate well with your daughter and, without invading her space, show her support and be there for her, so she knows she can trust you and that you're there if she needs to share something that's troubling her. It's also important to follow the therapists' advice and adhere to the proposed treatment plan without giving in to the demands of OCD.

Sometimes there may be some tolerance of the symptoms on the part of the family members , and some accommodation to the rituals, so it is very important to work with the parents and cohabitants, and that they do not become involved in the rituals of their children.

If these aspects are tolerated, OCD enters the home and ends up "dominating everyone," and this, to a certain extent, in moderate to severe cases, significantly interferes with family dynamics. If parents don't compromise, episodes of significant conflict can arise. Setting "limits to OCD" as parents is a key focus in therapy with adolescents. In adults, it's also beneficial to provide training to partners, parents, or cohabitants.

The content of obsessions can vary greatly among affected individuals, and often a single person may have several different obsessions simultaneously, or these may change throughout their life. So-called magical thinking (usually the fear that something bad will happen to oneself or a loved one, or sometimes to anyone in general) is a very common theme in people with OCD and is often accompanied by repetitive rituals (touching an object several times, repeating an action such as sitting down or getting up from a chair or bed, dressing and undressing, the need to repeat certain words or phrases, etc.), a need for order/symmetry (arranging objects in a certain way), and avoidance behaviors (not stepping on certain areas of the floor, not touching certain objects, etc.). These obsessions are usually experienced with intense anxiety, as the person feels guilty, believing that if they don't carry out their ritual, something terrible might happen to themselves or their loved ones.

Another distinct theme is religious (which affects around 20% of people with OCD) and may be related to moral issues (about doing or not doing certain actions that are considered morally incorrect) or to impulses/images of blasphemy or sacrilege (fear of having insulting or aggressive thoughts or impulses towards religious figures).

It is important to remember that, on the other hand, the most frequent obsessive symptoms are:

• Doubts or fear of making a mistake that could have a negative consequence , which are associated with checking rituals (present in 60% of people with OCD)
• Fears of contagion of diseases or contact with dirt , with washing/cleaning rituals (which are present in 40-50% of people with OCD).
• Aggressive or "repugnant" obsessions in the form of images or impulses in which the person fears losing control and causing harm to a loved one
• Obsessions with sexual content in which the person may be afraid of feeling sexual attraction to children, their own family members, etc.

In these cases, it is very important to reassure her, explain that these types of thoughts are obsessions, and help her recognize them without fear, with the certainty that they pose no risk to herself or to those close to her.

It would be important to observe whether concerns about order are associated with other temperamental traits such as perfectionism, self-criticism, or a need for control. With children, it's important to ask about any stressful or traumatic events in the past year, changes in their environment, their relationships with peers, their underlying temperament, and whether there have been any changes within the family. As parents, we could also observe whether, in addition to concerns about order, the child has a need for symmetry in everyday objects or situations; whether there are any repetitive behaviors (counting, handwashing, a need to repeat words, etc.). If these concerns cause distress, we recommend seeking help from mental health professionals to redirect or manage them so they don't interfere so much with their daily life.

Pathological jealousy, or morbid jealousy, can appear in the context of an altered emotional state or a more severe mental disorder. It is important to explore the content of the person's thoughts and examine any internal conflicts they may have, how they relate to others, and the bonds they form—whether more or less dependent—throughout their life. In this regard, a psychotherapeutic approach would be necessary.

Cognitive behavioral therapy (the preferred treatment for OCD) can be helpful for many types of disorders and symptoms, such as pathological jealousy, but it requires motivation and awareness of the problem on the part of the individual. Sometimes it's necessary to incorporate therapies from other schools of thought, such as dialectical behavior therapy, which can help with emotional regulation; or systemic family therapy, and a subtype of this, such as couples therapy. Each case is unique, and sometimes the symptom is just the tip of the iceberg. It's necessary to delve into the individual's possible internal conflicts so they can find explanations for certain behaviors and insecurities and be able to mentally prepare to initiate change.

In cases of jealousy, it's important to determine if the person suffers from morbid jealousy: a type of belief, sometimes almost delusional, that they are being cheated on by their partner. This type of disorder is especially common in men with a long history of alcohol dependence, and its treatment is complex. Antipsychotics are often tried at low doses, with limited success rates.

The goal of mental health diagnosis is not to label or excuse behaviors. In fact, our understanding of mental health is often influenced by stigma , and it's worthwhile to normalize mental health disorders, just as we do with other specialties.

It is important to make an accurate diagnosis not only to identify the problem but also to establish appropriate treatment, especially in childhood and adolescence, since children can sometimes engage in repetitive behaviors for various reasons. These behaviors are often more behavioral than cognitive, and children don't express their distress as much as adults. Some repetitions and rituals in young children can be normal; in other cases, they might stem from a need for control and a sense of security without reaching the level of OCD; in still other instances, they could be associated with a specific personality and thinking style (exaggerated responsibility, overestimation of threat, avoidance of harm); and in other cases, they might meet 100% of the criteria for OCD with clear obsessions and compulsions that interfere with their daily lives.

The treatment and approach in each of the specific situations mentioned is different. Making an accurate diagnosis is crucial, as OCD is often overdiagnosed, or people delay seeking help when it is indeed present. Diagnosis is very important so that both the family and the child or adolescent are aware of what is happening to them, always in accordance with their developmental age. Behaviors should not be excused by attributing them to disorders, because OCD treatment is highly proactive and requires the active involvement of both the family and the affected individual in the process.

It would be important for you to consult your psychiatrist and psychologist so they can conduct a complete psychopathological evaluation and categorize these symptoms: whether they are related to obsessive-compulsive disorder, intrusive thoughts, mental rituals, or are of another type. It is important that you contact your mental health team whenever new symptoms appear or worsen.

When a person is an adult, it can be more difficult for them to seek help voluntarily if they aren't fully aware of a mental health problem. For this reason, mental health awareness campaigns are conducted to increase visibility and encourage people to see a specialist. However, it's possible that, for now, they aren't aware of how OCD limits their life or that they've become too accustomed to the symptoms because they're afraid of making changes or confronting the rituals.

Sometimes it's necessary to allow a reasonable amount of time for the person to reflect on the role OCD plays in their life. It's important to offer support without being intrusive, and to try to discuss with them how much freedom they could experience if they address their OCD and how much their quality of life would improve if they sought professional help. Sometimes a close friend or partner can be crucial in helping them take the step to seek help.

If you notice that OCD is interfering with your relationships with loved ones, it may be time to resume therapy and try to confront the rituals, not only because they may "bother" your loved ones but also for yourself, since OCD is telling you to perform absurd actions that take up your time, do not calm your anxiety (since you need to ritualize again) or not enough.

Although you might think they give you a sense of relief and control, it's a false feeling induced by the disorder. On the one hand, I would recommend that you continue with therapy to keep improving. On the other hand, it would also be important for everyone around you to have a compassionate attitude , since OCD isn't attention-seeking behavior, nor are you doing it to annoy others. In therapy, we usually address the case as a family, especially if there are children and adolescents involved, but also with adults.

As we've discussed in previous questions, it's very common for families to be involved in rituals, sometimes to shorten their duration (in severe cases, the affected person can spend hours performing a ritual), so they ask their relatives to end it for them. Parents, wanting to spare their children suffering, may participate in these rituals. However, sometimes the transfer of these rituals to the family can be powerful, and when the family sets limits on the OCD, the affected person may not tolerate it, leading to conflicts that require mediation and negotiation in therapy.

Sometimes it is necessary to carry out interventions at home because, on the one hand, it can greatly help family members to set limits and assist in exposures and, on the other hand, it offers a very objective view to the clinical professional, allowing these rituals to be addressed in the person's natural environment, which is where they will perform them most (Sometimes, the person is able to inhibit the rituals in the consultation and then, at home, perform them intensely).

Sometimes it's very difficult to distinguish certain compulsions from tics, especially complex motor tics. People with chronic tic disorders (CTT) or Tourette syndrome may also present with both conditions simultaneously (tics and OCD), and sometimes it's difficult to differentiate between them in the same person. Most often, however, Tourette's and CTT present with obsessions and some compulsions without reaching the level of OCD, although in 30-40% of cases they can significantly interfere with daily life, meeting the diagnostic criteria for OCD.

It usually appears around age 12 and is more common in boys, as tic disorders are three times more frequent in boys than in girls. Tics are involuntary, repetitive, and cyclical movements. They can be motor (movements) or vocal (noises), and can be simple (e.g., blinking, neck tilting) or complex (e.g., jumping, moving forward and backward, bending forward, hitting, touching objects or people, hitting oneself or one's head, scratching one's nose, etc.). Repetition or checking compulsions, or even compulsions related to order/symmetry, can sometimes be confused with complex motor tics, but it is important to note that tics, unlike compulsions, are:

• Involuntary movements.
• They respond to so-called premonitory sensations (tension in the body, itching, etc.) not to an obsession or a self-imposed rule.
• They don't calm anxiety, but rather the premonitory feeling.
• They are sudden, repetitive, non-rhythmic movements (unlike the movements that appear in ASD, which are rhythmic).

The movements caused by tics are usually less complex than compulsions and lack a purpose; they are not intended to reduce or neutralize the anxiety produced by compulsions. Compulsions are more elaborate acts. We emphasize that it can sometimes be very difficult to distinguish a complex motor tic from a compulsion, and this confusion can increase when the person presents with both disorders comorbidly.