Sleep and obsessive-compulsive disorder (OCD)

Summary

Obsessive-compulsive disorder (OCD) is a chronic mental illness that can have a debilitating effect on daily functioning. A body of research reveals altered sleep behaviour in OCD sufferers; however, findings are inconsistent and there is no consensus on the nature of this relationship. Understanding sleep disturbance in OCD is of critical importance given the known negative consequences of disturbed sleep for mood and emotional wellbeing. A systematic literature search was conducted of five databases for studies assessing sleep in adults diagnosed with OCD. Fourteen studies met inclusion criteria and qualitative data analysis methods were used to identify common themes. There was some evidence of reduced total sleep time and sleep efficiency in OCD patients. Many of the sleep disturbances noted were characteristic of depression. However, some OCD sufferers displayed delayed sleep onset and offset and an increased prevalence of delayed sleep phase disorder (DSPD). Severe OCD symptoms were consistently associated with greater sleep disturbance. While the sleep of OCD patients has not been a major focus to date, the existing literature suggests that addressing sleep disturbance in OCD patients may ensure a holistic approach to treatment, enhance treatment efficacy, mitigate relapse and protect against the onset of co-morbid psychiatric illnesses.

Introduction

Obsessive-compulsive disorder (OCD) is a common and often debilitating psychiatric condition with an estimated lifetime prevalence of 2–3%.¹ As the name implies, OCD is characterised by obsessions (distressing and recurrent thoughts, impulses or images of an inappropriate or intrusive nature) and compulsions (excessive action taken to relieve the anxiety caused by the obsessions and often ritualistic in nature).² OCD is typically a chronic illness, but symptoms may vary in severity over time.³ Severity of symptoms is usually assessed via the Yale-Brown obsessive compulsive scale (Y-BOCS).⁴ The Y-BOCS evaluates OCD symptoms according to the extent to which obsessions and compulsions interfere with a patient's time and daily functioning, cause distress, are actively resisted and whether or not they can be controlled. While sleep disturbance is not a part of the diagnostic criteria for OCD there is a body of research identifying sleep disturbances in individuals diagnosed with OCD. In particular, severe OCD symptoms appear to be associated with greater sleep disturbance.

Sleep disturbance has been shown to have profound negative consequences for multiple aspects of daily functioning, particularly mood and emotional well-being.5, 6 In turn, reduced mood and emotional well-being are associated with negative health outcomes, anti-social behaviour, impaired mental and physical performance and increased recall of negative memories.7, 8, 9, 10, 11, 12 Thus, adequate sleep is critical for the maintenance of positive mental health. Indeed, sleep disturbance has been associated with multiple psychiatric illnesses¹³ and demonstrated as a risk factor for late-life suicide,¹⁴ and the onset of major depression¹⁵ and schizophrenia.¹⁶ The potential role of sleep disturbance in the onset of mental illnesses is therefore well established. Further, sleep disturbance may also hinder treatment efficacy given that poor sleep has been associated with impairments in both insight and communication.⁶

The nature of sleep disturbance in OCD is of critical importance given the potential for disturbed sleep to negatively influence mood and emotional wellbeing, to precede the onset of pathological psychiatric symptoms and to potentially impede therapeutic progress. Further, understanding the nature of sleep disturbance in OCD may shed light on the etiology and symptomatology of this illness. In turn, this information could be used in the development of efficacious treatment programs or in the promotion of strategies that encourage positive mental health. The present review provides an important first step in understanding the role of sleep and sleep disturbance in OCD by providing a systematic review and analysis of current knowledge.