Causes and Symptoms
Obsessive-compulsive disorder (OCD) is a disorder characterized by persistent
intrusive and uncontrollable thoughts and the subsequent need to perform specific
behaviors repeatedly. The presence of obsessions or compulsions must be
time-consuming, cause distress or impairment, and be recognized as excessive or
unreasonable by the person with OCD. The obsessions and compulsions must not be
caused by medication, drug abuse, or another medical condition.
Obsessive-compulsive behavior is highly distressing because it feels as if one’s
behavior or thoughts are no longer voluntarily controlled. The more frequently
these uncontrolled alien and perhaps unacceptable thoughts or actions are
performed, the more distress is induced. An individual with OCD may at various
times have either obsessions (which are thought-related) or compulsions (which are
action-related), or both.
OCD affects 1 to 2 percent of the population; most of those afflicted begin
suffering from the disorder in late adolescence or early adulthood, although some
cases of OCD present in childhood. Onset is often preceded by a stressful event
such as pregnancy, childbirth, or family conflict. It may be closely associated
with depression, with the disorder developing soon after a bout
of depression or the depression developing as a result of the disorder. OCD
affects men and women in roughly equal numbers.
Individuals with OCD generally recognized and are distressed by the irrational or
excessive nature of their obsessions and compulsions. Obsessions generally fall
into one of five recognized categories. Obsessive doubts are persistent doubts
that a task has been completed; the individual is unwilling to accept and believe
that the work is done satisfactorily. Obsessive thinking is an almost infinite
chain of thought, targeting future events. Obsessive impulses are very strong
urges to perform certain actions, whether they be trivial or serious, that would
likely be harmful to the affected person or someone else or that are socially
unacceptable. Obsessive fears are thoughts that the person has lost control and
will act in some way that will cause public embarrassment. Obsessive images are
continued visual pictures of either a real or an imagined event. Common obsessions
relate to contamination, safety, the fear of committing a socially unacceptable
behavior, the need for order, and sexual or aggressive thoughts.
Four factors are commonly associated with obsessive characteristics, not only in
people with OCD but in the general population as well. First, obsessive
individuals are unable to control their mental processes completely. Practically,
this means the loss of control over thinking processes, such as intrusive thoughts
of a loved one dying or worries about hurting someone unintentionally. Second,
there may be thoughts and worries over the potential loss of motor control,
perhaps causing impulses such as shouting obscenities in public or performing
inappropriate sexual acts. Third, many obsessive individuals may be afraid of
contamination and suffer irrational fear and worry over exposure to germs, dirt,
or diseases. The last factor is checking behavior, or backtracking previous
actions to ensure that the behavior was done properly, such as checking that doors
and windows are shut, faucets are turned off, and so on.
Compulsions may be either mild or severe and debilitating. Mild compulsions might
be superstitions, such as refusing to walk under a ladder or throwing salt over
one’s shoulder. Severe compulsions become fixed, unvaried ritualized behaviors; if
these compulsions are not practiced precisely in a particular manner or a
prescribed number of times, then intense anxiety may result. These strange
behaviors may be rooted in superstition; many of those suffering from the disorder
believe that performing the behavior may ward off danger. Compulsive acts are not
ends in themselves but are “necessary” to produce or prevent a future event from
occurring. Although the enactment of the ritual may assuage tension, the act does
not give the person with OCD pleasure.
Common compulsions include cleaning, checking, counting, arranging, touching
objects, hoarding, seeking reassurance, and making lists. For people with
repeating compulsions, they must do everything by numbers. Checking is another
compulsive act; a compulsive checker believes that it is necessary to check and
recheck that everything is in order. Cleaning is a behavior in which the person
believes he or she must engage; they may wash and scrub repeatedly, especially if
they think that they have touched something dirty. A fourth common compulsive
action is avoidance; for certain superstitious or magical reasons, certain objects
must be avoided. Some individuals with compulsions experience compelling urges for
perfection in even the most trivial of tasks; often the task is repeated to ensure
that it has been done correctly. Some determine that objects must be in a
particular arrangement; these individuals are considered “meticulous.” A few
people with OCD have hoarding compulsions; they are unable to throw away trash or
rubbish. Many individuals have a constant need for reassurance; for example, they
want to be told repeatedly that they have not been contaminated.
The direct cause of OCD is uncertain, and no single cause for OCD has been
isolated. Sigmund
Freud (1856–1939) first proposed that obsessive thoughts are
a replacement for more disturbing thoughts or actions that induce guilt or anxiety
in the sufferer. However, today it is believed that OCD is caused by a complex
interaction of genetic, behavioral, cognitive, cultural, and neurobiological
factors. OCD tends to run in families; however, genes appear to be only partly
responsible for causing OCD. Twin studies have suggested that genetic factors
influence 45 to 65 percent of cases of childhood-onset OCD and 27 to 47 percent of
adult-onset OCD. Other suspected influences include abnormalities with the
neurotransmitter serotonin in the brain.
Treatment and Therapy
Diagnostic techniques evaluating OCD usually involve psychological evaluation. It
is important to determine whether an individual is actually suffering from OCD or
other potential problems such as schizophrenia or a mood disorder.
Additionally, it is important to determine whether more than one disorder is
present. OCD may occur in conjunction with other disorders, such as substance use
disorders, eating
disorders, and mood disorders. When this occurs, treatment
must be adjusted. For example, when depression is also noted, both disorders must
be addressed in treatment. OCD is related to other disorders characterized by
repetitive behaviors and intrusive thoughts, including body dysmorphic
disorder, hoarding disorder, trichotillomania, and excoriation disorder.
In cases when differentiation is required between OCD and schizophrenia, the
concern is to understand the nature of the dysfunctional thoughts and behaviors.
For instance, a distinction can be made by determining the motive behind the
ritualized behavior. Stereotyped behaviors are symptomatic of both disorders. In
the person with schizophrenia, however, the behavior is triggered by delusions
rather than by compulsions. People suffering from delusions do not resist the
ideas inundating their minds, and ritualized behavior does not necessarily
decrease the feelings associated with the intrusive ideas. On the other hand,
people with OCD usually experience decreases in anxiety when they perform their
rituals and may be absolutely certain of the need to perform their rituals, though
other aspects of their thinking and logic are perfectly clear. They generally
resist the ideas that enter their minds and realize the absurdity or abnormality
of the thoughts to some extent. As thoughts and images intrude into the mind, the
person may sometimes appear to have symptoms that mimic schizophrenia.
Other problems having symptoms in common with OCD are Tourette
syndrome and stimulant use. What seems to separate the
symptoms of these disorders from those experienced with OCD is that the former are
organically induced. Thus, the actions of a sufferer from Tourette syndrome may be
mechanical since they are not purposely enacted. In the case of the stimulant
user, the acts may bring pleasure and are not resisted, but reinforced by the drug
effects.
Most people experience obsessive thoughts on occasion; in fact, the obsessions of
individuals without OCD are not significantly different from the obsessions of
those with OCD. The major difference is that those with the disorder have
longer-lasting, more intense, and less easily dismissed obsessive thoughts. The
importance of this overlap is that mere symptoms are not a reliable tool to
diagnose OCD, since some of the same symptoms are experienced by the general
population.
Assessment of OCD separates the obsessive from the compulsive components so that
each can be examined. Obsession assessment should determine the triggering fears
of the disorder, both internal and external, including thoughts of unpleasant
consequences. The amount of anxiety that these obsessions produce should be
monitored. The compulsive behaviors then should be examined in the same light.
The greatest chance for successful treatment occurs with individuals who
experience mild symptoms who seek help soon after the onset of symptoms and who
had few problems before the disorder began. While OCD can be challenging to treat,
many valuable and successful treatment strategies are available. Types of
treatment fall into four categories: psychotherapy, behavioral therapy, drug
therapy, and psychosurgery. The treatments of choice are behavioral and drug
therapies.
The most effective treatment for controlling OCD is the behavioral therapy.
Cognitive-behavioral therapy (CBT) involves the
identification of misperceptions and negative thoughts and repeated attempts to
challenge these beliefs and replace them with less distressing thoughts. CBT may
include psychoeducation, cognitive training, mapping OCD target symptoms, and
exposure and response prevention therapy. Exposure and response prevention therapy
(also called exposure and ritual prevention therapy) is a form of CBT specifically
designed to treat OCD symptoms. It involves gradual yet prolonged confrontation
with the anxiety-producing stimuli in the presence of a supportive therapy. This
exposure often begins with imagined stimuli and eventually progresses to real-life
exposure to the anxiety-provoking stimuli. The exposure continues until the
person's anxiety decreases, in a process called habituation. Exposure and response
prevention therapy also involves active abstinence from rituals and compulsive
behaviors, although this approach does not involve active blocking of the person's
compulsions. Exposure and response prevention therapy is highly effective in the
treatment of OCD, particularly when the client has less severe forms of OCD, does
not have a comorbid diagnosis of depression, adheres to exposure homework early in
the therapeutic process, has contamination fears or overt ritualistic behaviors,
and has undergone no previous treatment.
Therapeutic approaches to the treatment of OCD may be supplemented with
medications. Selective serotonin reuptake inhibitors (SSRIs) are
considered to be the first-line agents for the treatment of OCD and often have
remarkable effects on OCD, helping individuals to experience a change in their
thinking and behavior, as well as relief. SSRIs appear to improve OCD symptoms
compared with tricyclic antidepressants or monoamine oxidase inhibitors.
Approximately 40 to 60 percent of persons with OCD will respond to SSRIs.
Some psychiatrists may recommend psychosurgery to relieve a patient’s symptoms in
severe or intractable cases. Cingulotomy and deep brain
stimulation are reported to reduce symptom severity in
patients with treatment-refractory OCD. Electroconvulsive therapy has also been
reported to be effective in the treatment of OCD. Alternative treatments for OCD
that have demonstrated benefit include kundalini yoga meditation and progressive
muscle relaxation.
Perspective and Prospects
Descriptions of OCD-like behavior go back to medieval times; a young man who could
not control his urge to stick out his tongue or blurt out obscenities during
prayer was reported in the fifteenth century. Medical accounts of the disorder and
the term “obsessive-compulsive” originated in the mid-nineteenth century. At that
time, obsessions were believed to occur when mental energy ran low. Later, Freud
attributed the characteristics to a regression to early childhood, when there are
perhaps strong urges to be violent and/or to dirty and mess one’s surroundings. To
avoid acting on these tendencies, he theorized, an avoidance mechanism is
employed, and the symptoms of obsession and/or compulsion appear.
Although not totally disabling, OCD behaviors can be strongly incapacitating and
cause a significant amount of distress. Most parents will agree that children
commonly have rituals to which they must adhere or compulsive actions they carry
out. A particular bedtime story may be read every night for months on end, and
children’s games involve counting or checking rituals. It is also not atypical for
adults without psychiatric disorders to experience some mild obsessive thoughts or
compulsive actions, as seen in an overly tidy person or in group rituals performed
in some religious sects. Excessively stressful events may trigger obsessions as
well. Further research into the biopsychosocial causes of OCD will be important in
developing future treatment approaches.
Bibliography
American Psychiatric
Association. Diagnostic and Statistical Manual of Mental Disorders:
DSM-5. 5th ed. Arlington: American Psychiatric Assoc., 2013.
Print.
Barlow, David H.
Anxiety and Its Disorders. 2nd ed. New York: Guilford,
2004. Print.
Barlow, David H., ed.
Clinical Handbook of Psychological Disorders. 4th ed.
New York: Guilford, 2008. Print.
Crowe, Elijah M., and Aiden R. O'Dell,
eds. Obsessive-Compulsive Disorder: Symptoms, Prevalence, and
Psychological Treatments. New York: Nova, 2014.
Print.
Grant, Jon E., Samuel R. Chamberlain, and
Brian L. Odlaug. Clinical Guide to Obsessive Compulsive and Related
Disorders. Oxford: Oxford UP, 2014. Print.
Kring, Ann M., et al.
Abnormal Psychology. 12th ed. Hoboken: Wiley, 2012.
Print.
Menzies, Ross, and
Padmal de Silva, eds. Obsessive Compulsive Disorder: Theory,
Research, and Treatment. New York: Wiley, 2003.
Print.
Oltmanns, Thomas F.,
et al. Case Studies in Abnormal Psychology. 9th ed.
Hoboken: Wiley, 2012. Print.
No comments:
Post a Comment