Obsessive-Compulsive Disorder (OCD)
Recent research shows that the symptoms of OCD follow a few broad themes; within these themes, obsessions can take a countless number of forms. Common examples include the following:
• Contamination (e.g., fears of germs, dirtiness, chemicals,
Like obsessions, compulsions can take many forms, which can include the following:
• Washing and Cleaning (e.g., excessive showering, hand washing,
Compulsions can take up considerable time, and often cause problems in day-to-day life in many ways. For example, people with contamination obsessions may wash so often and so long that their hands become inflamed. A person with doubting obsessions about whether she has performed routine activities may be chronically late for appointments, due to repeated checking of appliances or taps.
Other Behavioural Features of Obsessive-Compulsive
• Avoidance – Compulsions are performed in the attempt to reduce negative emotions, such as anxiety, that arise from obsessions. Another behavior that can also perform this function is avoidance. People with OCD often find that they avoid situations that provoke obsessions. Avoidance can take many forms – some of them quite subtle – and can have a profound impact on the individual’s day-to-day life. For example, a person with intrusive thoughts about harming his child may feel a need to avoid being alone with the child, bathing or dressing the child, or even looking at pictures of the child, all because these situations have the power to evoke distressing obsessions.
• Thought Suppression – Some obsessions, particularly those that are personally offensive or frightening, can prompt the person to spend a lot of energy deliberately trying to force obsessive thoughts out of awareness, or to suppress them. Although thought suppression is an understandable strategy, research has shown it to be problematic in OCD in several ways: a) deliberately trying not to think of a specific thing usually has the contrary effect of making the thought more likely to return, and b) unintentionally, it reinforces the notion that the obsession is a valid belief or fear, when in fact it is not; this can serve to strength the distress power of the obsession. Either way, the effect of thought suppression may be to increase obsessions.
Official Diagnostic Criteria for OCD
• The presence of obsessions or compulsions (as described above)
Causes of OCD
• Neurotransmitters – Neurotransmitters are chemical messengers that pass information from one nerve cell in the brain to the next. The neurotransmitter most clearly implicated in the development and maintenance of OCD is serotonin. The greatest evidence for this comes from the finding that medications that act to increase levels of serotonin at several sites in the brain – such as serotonin reuptake inhibitors – are effective in reducing obsessions and compulsions.
• Genetics – Evidence is quite strong that OCD runs in families. No specific genes for OCD have yet been identified, so vulnerability to OCD cannot be determined via genetic testing. However, research suggests that genes can play a role in the development of the disorder. Recent research suggests that when a parent has OCD, the risk that a child will develop OCD is increased slightly, but this may only be true for some forms of OCD. For example, factors implicated in familial include age of onset (e.g., childhood-onset OCD tends to run in families) and family history of tic-related disorders, like Tourette’s disorder.
• Personality Traits – Research has shown that several general personality traits may be linked to some forms of OCD. One of these is trait anxiety, or the predisposition to be made anxious more easily, or more frequently, or by a greater number of experiences, than other people. Another is anxiety sensitivity, or the tendency to feel uncomfortable with, and have catastrophic thoughts about, one’s anxiety (e.g., a racing heart may prompt thoughts that one might lose control or go crazy). Another trait sometimes associated with OCD is perfectionism, particularly when it entails excessively high or rigid standards for oneself that rarely, if ever, feel satisfied.
• Attention & Information Use – People with OCD tend to pay special attention to information that is in line with their concerns, and less attention to information that isn’t. For example, someone with contamination concerns related to contracting AIDS may focus in on a statement he once heard about the remote possibility that mosquitoes can transmit the disease. The anxiety prompted by this information has several problematic consequences: a) the desperate search to check this threatening fact with 100% certainty – rarely possible in the real world – results in other information that is neutral or contradictory being downplayed, and b) anxiety reducing compulsive behaviors like reassurance-seeking, prompted by this information, may be reinforced because they feel like rational information seeking.
• Life Experiences – Life stress puts people with OCD at risk for worsening of their symptoms. During stressful periods (e.g., a new baby, work stress, marital problems, exams at school), people with OCD often report increased obsessions and greater difficulty resisting compulsions. Other emotional problems, such as depression, may also interact with OCD vulnerability to worsen its symptoms.
Effective Treatments for OCD
The decision of whether to take medication for OCD, and which medication to take should be based on the individual’s past treatment history, the individual’s medical history, possible interactions between the medication and other drugs that person may be taking, potential side effects, and other factors.
In rare cases, individuals with OCD may benefit from combining more than one medication. For example, some people (particularly those who do not respond to an SSRI alone, or those have difficulty recognizing that their obsessions and compulsions are excessive or unreasonable), may benefit from the combination of an SSRI antidepressant and a medication such as risperidone (a medication that is also used to treat psychotic symptoms such as hallucinations and delusions).
In very rare cases, individuals with OCD may undergo cingulotomy, a type of brain surgery. This intervention is reserved for the most severe forms of OCD, after all other treatment options have failed. A significant percentage of individuals who undergo this procedure experience a reduction in OCD symptoms, despite not having responded to the usual treatments previously.
CBT is based upon the following understanding of OCD: Obsessions, with their power to elicit such distress, lead the individual to engage in behaviors (e.g., compulsions, avoidance), which may provide a temporary relief. However, these compulsive behaviors are problematic for several reasons:
So, CBT has two general aims: a) controlling compulsive rituals and avoidance, and b) reducing the anxiety associated with obsessions, and through this, reducing their intensity and frequency.
• Behavior Therapy - The building blocks of behavior therapy for OCD are exposure and ritual prevention (ERP). ERP involves a) confronting a distressing situation or experience repeatedly, until it no longer triggers distress, while b) resisting the drive to engage in problematic anxiety-reducing behaviors. In the case of OCD, it is the obsessions that prompt the distress. So, in ERP for OCD, exposure is to obsessions, accomplished through deliberately seeking out situations that have the power to provoke them. For example, an individual with contamination obsessions about germs could be encouraged to practice touching items that have been in public places, with no compulsive washing or avoidance -- something that would quickly prompt their obsessive thoughts -- until this no longer causes notable anxiety. A new situation could then be added, and practiced until it also loses its power to cause anxiety, and so on. Over time, exposure first weakens the distress caused by obsessions, then the frequency and intensity of the obsessions themselves. ERP works best when it occurs frequently (e.g., at least four or five times per week), and lasts long enough for the anxiety to decrease (up to two hours).
• Cognitive Therapy – Involves learning to identify one’s anxious beliefs about the meaning of obsessions and to replace them with more realistic thoughts. For example, if an individual is concerned that having an obsession about harming someone may make it more likely that that will actually happen, the individual might be taught to examine the evidence for the specific belief (e.g., I’ve had that thought hundreds of times and it has never happened) or for the more general belief that all thoughts that pop into one’s mind are always meaningful.
Did you know ...?
• OCD affects about one percent of the population, although estimates are somewhat inconsistent across studies.
• In adults, OCD is slightly more common in women than in men, but in children the pattern is reversed. More boys than girls have OCD, and OCD often has an earlier onset in boys than in girls.
• About 90% of people have occasional intrusive thoughts and repetitive behaviors that are very similar to those that occur in OCD. The main difference is that people with OCD experience obsessions and engage in compulsions much more frequently than the average person, and are much more distressed by their symptoms.
Readings for Consumers
2. Baer, L. (2000). Getting control: Overcoming your obsessions and compulsions, Revised Edition. New York, NY: Plume.
3. Baer, L. (2001). The imp of the mind. New York: Dutton.
4. Chansky, T. (2000). Freeing your child from obsessive-compulsive disorder. New York: Crown.
5. Ciarrochi, J. W. (1995). The doubting disease. Mahwah, New Jersey: Paulist Press.
6. de Silva, P. & Rachman, S. (1998). Obsessive-compulsive disorder: The facts (2nd ed.). New York, NY: Oxford University Press.
7. Foa, E.B., & Kozak, M.J. (1997). Mastery of your obsessive compulsive disorder, client workbook. Boulder, CO: Graywind Publications.
8. Foa, E.B. & Wilson, R. (2001). Stop obsessing! How to overcome your obsessions and compulsions, revised edition. New York: Bantam Books.
9. Hyman, B., & Pedrick, C. (1999) The OCD workbook. Oakland, CA: New Harbinger Publications, Inc.
10. Osborn, I. (1998). Tormenting thoughts and secret rituals: The hidden epidemic of OCD. New York: Pantheon Books.
11. Penzel, F. (2000). Obsessive-compulsive disorders: A complete guide to getting well and staying well. New York: Oxford University Press.
12. Rapoport, J. (1999). The boy who couldn't stop washing, Penguin Books, New York.
13. Schwartz, J.M. (1996). Brain lock: Free yourself from obsessive-compulsive behavior. New York: HarperCollins.
14. Steketee, G.S. (1999). Overcoming obsessive compulsive disorder (client manual). Oakland, CA: New Harbinger Publications.
15. Steketee, G., & White, K. (1990). When once is not enough. Oakland, CA: New Harbinger Publications.
Readings For Professionals
2. Frost, R.O., & Steketee, G. (Eds.) (2002). Cognitive approaches to obsessions and compulsions: Theory, assessment, and Treatment; Oxford, UK: Pergamon.
3. Goodman, W.K., Rudorfer, M.V., & Maser, J.D. (1999). Obsessive-compulsive disorder: Contemporary issues in treatment. Mahwah, NJ: Lawrence Erlbaum Associates, Inc.
4. Jenike, M.A., Baer, L., & Minichiello, W.E. (1998). Obsessive-compulsive disorders: Practical management. St. Louis, MO: Mosby.
5. Koran, L.M. (1999). Obsessive-compulsive and related disorders in adults: A comprehensive clinical guide. New York: Cambridge University Press.
6. Kozak, M.J., & Foa, E.B. (1997). Mastery of your obsessive compulsive disorder, Therapist guide. Boulder, CO: Graywind Publications.
7. March, J., & Muller, K. (1998). OCD in children and adolescents: A cognitive-behavioral treatment manual, New York: Guilford Press.
8. Steketee, G.S. (1993). Treatment of obsessive-compulsive disorder, New York: Guilford Press.
9. Steketee, G. S, (1998). Overcoming OCD: A behavioral and cognitive protocol for the treatment of OCD. New York, NY: New Harbinger.
10. Steketee, G., & Pigott, T. (1999). Obsessive compulsive disorder: The latest assessment and treatment strategies. Evanston, WY: Compact clinicals.
11. Swinson, R.P., Antony, M.M., Rachman, S., & Richter, M.A, (Eds.) (1998). Obsessive-compulsive disorder: Theory, research and treatment. New York: Guilford Press.
2. Obsessive Compulsive Foundation, & Grayson, J. (1997). G.O.A.L. (Giving Obsessive-compulsives another lifestyle (video tape). North Branford, CT: Obsessive-Compulsive Foundation.
3. Turner, S.M. (1996). Behavior therapy for obsessive-compulsive disorder (video tape). APA Psychotherapy Videotape Series. Washington, DC: American Psychological Association.
© 2002 Laura J. Summerfeldt, Ph.D. & Martin M. Antony, Ph.D.