13 Obsessive-Compulsive Disorder
Obsessive-Compulsive Disorder
Have you ever had a strange thought pop into your mind, such as picturing the stranger next to you naked? Or maybe you walked past a crooked picture on the wall and couldn’t resist straightening it. Most people have occasional strange thoughts and may even engage in some “compulsive” behaviors, especially when they are stressed (Boyer & Liénard, 2008; Fullana et al., 2009). But for most people, these thoughts are nothing more than a passing oddity, and the behaviors are done (or not done) without a second thought. For someone with obsessive-compulsive disorder (OCD), however, these thoughts and compulsive behaviors don’t just come and go. Instead, strange or unusual thoughts are taken to mean something much more important and real, maybe even something dangerous or frightening. The urge to engage in some behavior, such as straightening a picture, can become so intense that it is nearly impossible not to carry it out, or causes significant anxiety if it can’t be carried out. Further, someone with OCD might become preoccupied with the possibility that the behavior wasn’t carried out to completion and feel compelled to repeat the behavior again and again, maybe several times before they are “satisfied.”
People suffering from OCD may have an irrational fear of germs and “becoming contaminated”.
To receive a diagnosis of OCD, a person must experience obsessive thoughts and/or compulsions that seem irrational or nonsensical, but that keep coming into their mind. Some examples of obsessions include doubting thoughts (such as doubting a door is locked or an appliance is turned off), thoughts of contamination (such as thinking that touching almost anything might give you cancer), or aggressive thoughts or images that are unprovoked or nonsensical. Compulsions may be carried out in an attempt to neutralize some of these thoughts, providing temporary relief from the anxiety the obsessions cause, or they may be nonsensical in and of themselves. Either way, compulsions are distinct in that they must be repetitive or excessive, the person feels “driven” to carry out the behavior, and the person feels a great deal of distress if they can’t engage in the behavior. Some examples of compulsive behaviors are repetitive washing (often in response to contamination obsessions), repetitive checking (locks, door handles, appliances often in response to doubting obsessions), ordering and arranging things to ensure symmetry, or doing things according to a specific ritual or sequence (such as getting dressed or ready for bed in a specific order). To meet diagnostic criteria for OCD, engaging in obsessions and/or compulsions must take up a significant amount of the person’s time, at least an hour per day, and must cause significant distress or impairment in functioning.
About 1-3% of the population has met criteria for OCD over the course of a lifetime (Kessler, Berglund, et al., 2005). 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. Whereas OCD was previously categorized as an Anxiety Disorder, in the most recent version of the DSM (DSM-5; APA, 2013) it has been reclassified under the more specific category of Obsessive-Compulsive and Related Disorders. People with OCD often confuse having an intrusive thought with their potential for carrying out the thought. Whereas most people when they have a strange or frightening thought are able to let it go, a person with OCD may become “stuck” on the thought and be intensely afraid that they might somehow lose control and act on it. Or worse, they believe that having the thought is just as bad as doing it. This is called thought-action fusion. For example, one patient was plagued by thoughts that she would cause harm to her young daughter. She experienced intrusive images of throwing hot coffee in her daughter’s face or pushing her face underwater when she was giving her a bath. These images were so terrifying to the patient that she would no longer allow herself any physical contact with her daughter and would leave her daughter in the care of a babysitter if her husband or another family was not available to “supervise” her. In reality, the last thing she wanted to do was harm her daughter, and she had no intention or desire to act on the aggressive thoughts and images, nor does anybody with OCD act on these thoughts, but these thoughts were so horrifying to her that she made every attempt to prevent herself from the potential of carrying them out, even if it meant not being able to hold, cradle, or cuddle her daughter. These are the types of struggles people with OCD face every day.
The diagnosis is based on the symptoms and requires ruling out other drug-related or medical causes. Rating scales such as the Yale–Brown Obsessive Compulsive Scale (Y-BOCS) can be used to assess the severity. The 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 structure (grouping) to be most reliable. The observed groups included a “symmetry factor”, a “forbidden thoughts factor”, a “cleaning factor”, and a “hoarding factor”. The “symmetry factor” correlated highly with obsessions related to ordering, counting, and symmetry, as well as repeating compulsions. The “forbidden thoughts factor” correlated highly with intrusive and distressing thoughts of a violent, religious, or sexual nature. The “cleaning factor” correlated highly with obsessions about contamination and compulsions related to cleaning. The “hoarding factor” only involved hoarding-related obsessions and compulsions and was identified as being distinct from other symptom groupings.
Treatment of Obsessive-Compulsive Disorder
Treatment involves psychotherapy, such as cognitive behavioral therapy (CBT), and sometimes antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) or clomipramine, a tricyclic antidepressant (TCA). CBT for OCD involves increasing exposure to what causes the problems while not allowing the repetitive behavior to occur. While clomipramine appears to work as well as SSRIs, it has greater side effects and thus is typically reserved as a second-line treatment. Atypical antipsychotics may be useful when used in addition to an SSRI in treatment-resistant cases but are also associated with an increased risk of side effects. Without treatment, the condition often lasts decades. OCD frequently co-occurs with both bipolar disorder and major depressive disorder. Between 60–80% of those with OCD experience a major depressive episode in their lifetime. Comorbidity rates have been reported at between 19–90% due to methodological differences. Between 9–35% of those with bipolar disorder also have OCD, compared to the 1–2% in the general population. Around 50% of those with OCD experience cyclothymic traits or hypomanic episodes. OCD is also associated with anxiety disorders. Lifetime comorbidity for OCD has been reported at 22% for specific phobia, 18% for social anxiety disorder, 12% for panic disorder, and 30% for generalized anxiety disorder. The comorbidity rate for OCD and ADHD has been reported as high as 51%.
Therapy
One exposure and ritual prevention activity would be to check the lock only once, and then leave.
The specific technique used in CBT is called exposure and response prevention (ERP) which involves teaching the person to deliberately come into contact with the situations that trigger the obsessive thoughts and fears (“exposure”), without carrying out the usual compulsive acts associated with the obsession (“response prevention”), thus gradually learning to tolerate the discomfort and anxiety associated with not performing the ritualistic behavior. At first, for example, someone might touch something only very mildly “contaminated” (such as a tissue that has been touched by another tissue that has been touched by the end of a toothpick that has touched a book that came from a “contaminated” location, such as a school). That is the “exposure”. The “ritual prevention” is not washing. Another example might be leaving the house and checking the lock only once (exposure) without going back and checking again (ritual prevention). The person fairly quickly habituates to the anxiety-producing situation and discovers that their anxiety level drops considerably; they can then progress to touching something more “contaminated” or not checking the lock at all—again, without performing the ritual behavior of washing or checking.
ERP has a strong evidence base, and it is considered the most effective treatment for OCD. A 2007 Cochrane review also found that psychological interventions derived from CBT models were more effective than treatment as usual consisting of no treatment, waiting list or non-CBT interventions. It has generally been accepted that psychotherapy in combination with psychiatric medication is more effective than either option alone.
Key Takeaways
Exposure and response prevention (ERP)
Therapy that involves teaching the person to deliberately come into contact with the situations that trigger the obsessive thoughts and fears (“exposure”), without carrying out the usual compulsive acts associated with the obsession (“response prevention”), thus gradually learning to tolerate the discomfort and anxiety associated with not performing the ritualistic behavior.
Obsessive-compulsive disorder (OCD)
A disorder characterized by the desire to engage in certain behaviors excessively or compulsively in hopes of reducing anxiety. Behaviors include things such as cleaning, repeatedly opening and closing doors, hoarding, and obsessing over certain thoughts.
Thought-action fusion
The tendency to overestimate the relationship between a thought and an action, such that one mistakenly believes a “bad” thought is the equivalent of a “bad” action.
“Obsessive-Compulsive and Related Disorders” is adapted from Abnormal Psychology by Coursehero, used under CC BY-SA: Attribution-ShareAlike.
