Obsessive Compulsive Disorder, Some Quick Facts
I was reading about Howie Mandel and it reminded me of this very brief article I wrote on OCD. I thought some might enjoy this.
Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by recurrent obsessive ideas, thoughts, impulses, or images that induce extreme anxiety in the individual and lead to the performance of compulsive behaviors that can be either physical (e.g., repetitive hand washing) or mental (e.g., ritualistic praying) in order to reduce the anxiety brought on by the obsessions. The obsessive thoughts are intrusive and persistent such that the individual is unable to ignore them. The functional link between the two aspects of this disorder is important to consider: obsessions represent recurrent thoughts or images that cause severe and intense anxiety in the individual, whereas the compulsions represent either overt or covert behaviors utilized to reduce the distress brought on by these obsessions (APA, 2000). The estimated lifetime prevalence for OCD is 1%–2% (Robins, Helzer, Weissman, & Orvaschel, 1984). Given OCD’s relatively high prevalence, the typical long gap that occurs between onset of the disorder and treatment in most individuals, and the associated severe dysfunction this disorder produces it is important to develop effective diagnostic and treatment regimes.
According to the text revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; APA, 2000) the diagnosis of OCD can be made when the individualhas either obsessions or compulsions, the person realizes at some point that their obsessions and/or compulsions are excessive or unreasonable (this not applicable to children), and these obsessions and compulsions significantly interfere with the person’s daily routine. With respect to the last aspect of the diagnosis, the DSM-IV diagnostic criteria state that there is a significant disruption in the person’s routine such that the complications of dealing with OCD takes up more than an hour a day (APA, 2000).
In addition to the three general the DSM-IV-TR also specifies general components of obsessions and compulsions that are useful for diagnostic purposes. Obsessions must be recurrent, intrusive, and lead to significant distress in the individual. The obsessions in OCD then are not just excessive worries about real life problems. This also means at some point the person realizes that the obsessions are irrational (except for children) and tries to ignore or suppress them but cannot. The compulsions are repetitive acts that the individual feels driven to perform in order to reduce the distress caused by the unrealistic obsessions (APA, 2000). Not engaging in the obsession leads to even more distress in the individual. Finally, if the person has another co-occurring psychiatric disorder such as depression the obsessions and/or compulsive behaviors cannot be better explained by that disorder and of course these behaviors cannot be better explained by substance use/abuse.
OCD shares some common features with other psychiatric disorders and it is very important to differentiate OCD from other disorders. First, it is common for the obsessions in OCD to be quite bizarre and they may be similar to schizophrenic delusions, so it is important to distinguish between the two (while it is rare, there are cases of a comorbid OCD disorder and schizophrenia diagnosed). The main difference between the delusions of schizophrenia and obsessions of OCD is that the majority of people with OCD will recognize their obsessions as being irrational. Only about 5% will have OCD “with poor insight” meaning that they are convinced in the rationality of their obsessions (APA, 2000). People with schizophrenia will be thoroughly convinced that their delusions represent reality. Another helpful distinction between OCD, schizophrenia, and delusional disorders that can be used for a differential is the presence of compulsions in OCD that are specifically performed to relieve the distress associated with the obsessions. It is important to understand that pure obsessional OCD only occurs in about 2% of OCD cases, so the presence of compulsions is a useful differentiation from other disorders (APA, 2000).
A common challenge for the clinician is to be able to differentiate the obsessions in OCD from depressive ruminations. Depressive ruminations are most often pessimistic thoughts about the world or the self, tend to shift in their focus, and often there are no attempts are overtly made to suppress them. Obsessions do not shift, are repetitive, and often are not pessimistic thoughts of the self. Depression often co-occurs with OCD, so it is important to treat depressive ruminations on and OCD obsessions separately.
OCD often co-occurs with other anxiety disorders but the presence of ritualistic compulsions will distinguish OCD as separate from other disorders such as Generalized Anxiety Disorder (Foa et al. 1995). Phobias are often easy to distinguish from OCD because people with phobias generally are able to avoid the phobic object and can forget about it, whereas people with OCD ruminate over their fears are unable to avoid or suppress them. Finally, the functional relationship between obsessions and compulsions will differentiate OCD from tic disorders.
When considering treating someone with OCD it is best to follow empirically validated procedures. Empirically validated psychotherapeutic interventions for OCD are typically cognitive or cognitive-behavioral (CBT) in nature. The cognitive component of therapy for obsessive-compulsive disorder will most often focus on the catastrophic nature of the obsessions and the responsibility that OCD suffers feel if they do not engage in their compulsions. There are typically four steps for dealing with the cognitive component of OCD (Schwartz, 1997):
1.) Re-labeling the obsessions and recognizing that the obsessive urges are the result of OCD.
2.) Re-attributing the intensity and intrusiveness of the urges to a biochemical imbalance in the brain as opposed to any control they have over the individual. By re-labeling and re-attributing the obsessions in OCD the person can be begin to assume control over them.
3.) Refocusing OCD thoughts by focusing on something else for a few minutes or doing something else in order to gain control.
4.) Revaluing the meaning of the obsessions and understanding that they are not significant themselves.
In addition to the purely cognitive component of OCD treatment it has long been recognized that CBT can combine changing thoughts with actual behavioral interventions to increase the efficacy of therapeutic techniques for anxiety disorders and depression. Specific CBT techniques empirically demonstrated to be effective for OCD include exposure and response preventiontechniques. Exposure therapies are often used in the treatment of anxiety disorders and involve repeated exposure to the source of the anxiety-provoking stimulus. In the case of OCD patient this would be the obsession(s). Following exposure to the obsession the patient is then refrained from engaging in the compulsive behavior (response prevention). Initially this produces severe anxiety, but this quickly dissipates and the person’s sense of urgency is extinguished. For instance, in the case of a “compulsive hand washer” the therapist may have the patient get his/her hands exposed to dirt or germs and then is prevented from washing them. The compulsion to wash will gradually wane and the person eventually learns to gain control over their OCD. The combined program of cognitive restructuring with exposure and response prevention has been found to be more effective than any of the components used alone, all though all three are effective if used separately (Foa, Steketee, Grayson, Turner, and Latimer, 1984). The effects of the exposure and response prevention technique have also been demonstrated to change the brain functioning in OCD patients in a manner similar to how psychiatric medications affect the brain (Schwartz, 1998).
In addition to psychotherapeutic techniques there are some medications that can assist in the treatment of OCD such as SSRIs or the tri-cyclic antidepressant Clomipramine, but these are best used in conjunction with psychotherapy such as exposure and response prevention (Foa et al., 2007). Medications alone do not appear to be as effective as psychotherapy. However, many find that the addition of a psychiatrist to the treatment assists these patients in their recovery.
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th Ed.). Arlington, VA: Author.
Foa, E.B., Kozak, M.J., Goodman, W.K., Hollander, E., Jenike, M.A., & Rasmussen, S.A. DSM-IV field trial: obsessive-compulsive disorder. American Journal of Psychiatry, 152 (1), 90-96.
Foa, E.B., Liebowitz, M.R., Kozak, M.J., Davies, S., Campeas, R., Franklin, M.E., Huppert, J.D., Kjernisted, K., Rowan, V., Schmidt, A.B., Simpson, H.B., & Tu, X. (2005). Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder. American Journal of Psychiatry, 162(1), 151-161.
Foa, E.B., Steketee, G., Grayson, J.B., Turner, R.M., and Latimer, (1984). Deliberate exposure and blocking of obsessive-compulsive rituals: Immediate and long-term effects. Behavior Therapy, 15 (5), 450-472.
Robins, L.N., Helzer, J.E., Weissman, M.M., & Orvaschel, H. (1984). Lifetime prevalence of specific psychiatric disorders in three sites. Archives of General Psychiatry, 41, 949– 958.
Schwartz, J.M. (1997). Brain lock: Free yourself from obsessive-compulsive behavior. New York: Harper Collins.
Schwartz, J.M. (1998). Neurobehavioral of cognitive behavioral response in obsessive compulsive disorder: An evolving perspective on brain and behavior. The British Journal of Psychiatry, Supplement, 35, 38-44.