DEFINITION
Obsessive-compulsive disorders (OCD) are mental disorder characterized by unwanted obsessions and/or compulsions. Obsessions can and repeated thoughts, feelings, ideas, sensations, and compulsions might list behaviors that drive them to perform something repeatedly. Often the person uses the behaviors to get temporarily free themselves from of the obsessive thoughts.
CHARACTERISTICS
A person suffering from OCD will have occurring, anxiety producing obsessive thoughts and excessive, repetitive compulsive behaviors as a way of reducing the anxiety. The behaviors, even if temporarily relieving anxiety will not realistically be helpful or useful but time-consuming and energy demanding, they can even restrict the person in their day to day life.
SYMPTOMS
DSM-5 criteria for OCD diagnosis include the presence of obsessions and/or compulsions as well and the intent to suppress the unwanted obsessive thoughts by performing certain behaviors.
TYPES
Hoarding is a type of OCD characterized by excessive collection and possession of things and trouble of getting rid of them. Hoarders collect their possessions regardless of their material value, which can result in a cluttered home and health risks.
Body Dysmorphia disorder (BDD) is a type of OCD in which the individual has persistent negative thoughts about their appearance often involving some kind of fault or defect around the face and head. Compulsions for BDD may include repetitive mirror-checking behaviors, necessary grooming and persistent comparison with others.
Others:
Obsessions – fear of deliberate self-harm, fear of falling ill or getting an infection, fear about harming or killing others, fear of accidental injury both for self or others, concern about symmetry.
Compulsions – excessive washing, ordering things, repetitive checking, repetitive talking or counting.
CASE STUDIES
Rapoport (1989) conducted a case study on a 14 y.o. boy named Charles. He spent lengthy amounts of time engaged in repetitive washing behaviors and rituals due to to the obsessive belief of experiencing persistent stickiness on his skin.
Before the appearance of his compulsions, Charles was a good student with a passionate interest in academics however his OCD forced him to drop school because of him being unable to attend classes. He also lost of his friendship and only had one friend.
After taking a course of clomipramine (an antidepressant), Charles experienced a decline in his symptoms and was even able to pour honey on his skin. However, he developed a tolerance and relapsed back to his compulsions
MEASURES
MOCI – Maudsley Obsessive-Compulsive Inventory
A tool for assessing symptoms of OCD such as checking, washing, slowness and doubting. Not used for diagnostic. It consists of 30 items with the answer options ‘true’ or ‘false’, one point awarded for each answer. It is quick, the duration of taking it is about 5 minutes.
Some items from Hodgson and Rachman (1977)
– I frequently have to check things (gas, water taps) several times (checking OCD)
– I am not unduly concerned about germs and diseases ( washing OCD)
– I do not take a long time to dress in the morning (slowness OCD)
– Even when I do something very carefully, I often feel that is not quite right (doubting OCD)
Y-BOCS – Yale-Brown Obsessive Compulsive Scale
A test developed by Goodman et al (1989) for evaluating a person’s nature and intensity of OCD symptoms. It addresses obsessions such as contamination, sexual, aggressive, hoarding, religious, symmetry, body focus, and compulsions, for example, cleaning, washing, checking, repeating, counting, arranging, hoarding.
It is composed of a semi-structured interview lasting approximately 30 minutes, as well as a checklist with various obsessions and compulsions listed. Patients need to rate each item on a 10 level intensity scale based on the symptom’s time consuming, resistance difficulty and distress caused. The checklist may be used individually as an aid for planning the treatment or observing the progress of it. Overall scores can vary between 0 and 40; individuals with a score of 16 or over are considered within the clinical range of OCD.
EXPLANATIONS
1. Biomedical
The biological explanation for obsessive-compulsive and related disorders has three subcategories – genetic, biochemical and neurological.
– genetic: OCD is believed to occur due to faulty inherited genes that affect the synapses in the brain. The study by Mattheisen et al (2015) conducted on 1406 participants with and without various types of OCD found the genes PTPRD and SLITRK3 involved in the presence of OCD. Another study, Taj et al (2013) found an additional gene – DRD4 which interferes with the uptake of dopamine.
– biochemical: this explanation states that an imbalance in the oxytocin hormone may be the cause of OCD. Based on the cerebral spinal fluid analysis, Leckman et al (1994) found some forms of OCD related to the dysfunction of oxytocin, suggesting that certain behaviors consider as OCD symptoms can be due to the disproportion of this hormone.
– neurological: it suggests that defects in the brain structure may cause OCD. Studies found that flaws in the basal ganglia cause obsessive thinking symptomatic, so the person receives warning signals due to the improper function of the checking ‘loop’ controlled by the associated regions (orbitofrontal context and anterior cingulate gyrus).
2. Cognitive – behavioral
Rachman (1977) states that obsessive thinking is due to faulty reasoning because of wrong beliefs and that the compulsive behaviors are an outcome of this, where the person attempting to ease their obsession by engaging in relieving behaviors. The behaviors then become learned as an effect of operant conditioning, where the person is negatively reinforced for relieving a worrisome thought and positively reinforced with rewarded of knowing that temporarily everything is under control.
3. Psychodynamic
Freud suggests that OCD develops as a way of coping with childhood trauma during the anal stage and that obsessive thoughts originate from the conflict of the id and ego. During the anal stage of psychosexual development, disagreement can arise between the children learning how to go to the toilet and their parents asserting too much control over the process. The children may soil themselves or encounter other unpleasant experiences as they fear their parents’ reaction; they may develop ‘fixations’ as a result, which may reappear later in life in form of obsessions and compulsions.
TREATMENTS
1. Biomedical – SSRIs
SSRI are drugs that work selectively on the serotonin neurotransmitter. They work by minimizing the anxiety related to the disorder and therefore resulting in milder symptoms of OCD.
Soomro et al (2008) conducted a meta-analysis to compare the effectiveness of SSRIs with placebo. 3097 participants took part in the 17 studies, completing the Y-BOCS 3-6 weeks post-treatment. Improvements were seen in both individuals with depression and without; higher dosage was found to be more effective (Pampaloni et al., 2009)
2. Psychological – CBT and ERP
The Lovell et al (2006) study aimed to compare the effectiveness of face-to-face CBT and over the phone in individuals with OCD. 72 participants were selected from two hospital departments and were randomly assigned to their group. They underwent one session per week for 10 weeks in either face-to-face or telephone form of CBT. Three tools were used to assess the symptom improvements in participants: Y-BOCS, Beck depression inventory as well as a satisfaction questionnaire. The scores showed to be significantly lower in both conditions, showing the equal effectiveness of both CBT delivery methods. Participants reported high satisfaction with both, suggesting equal benefit from face-to-face and telephone CBT.
In the Lehmkuhl et al (2008) study, Jason, a 12-year-old boy with OCD was investigated for treatments with ERP – exposure and response prevention therapy. He was also suffering from ASD and was diagnosed with high functioning autism. Jason suffered from contamination OCD, was excessively washing his hands as well as counting and checking. His compulsions took a lot of his time on a daily basis and he experienced anxiety when they couldn’t be completed.
The ERP procedure involves 3 main steps – collecting information about the already present symptoms, ERP sessions initiated by the therapist and generalization and relapse training.
Jason learned coping statements for using when in anxiety-inducing situations, for example ‘I know that nothing bad will happen’. He was however not required to do visualization exercises as he couldn’t imagine hypothetical situations – his ERP techniques were altered and customized according to his needs.
After, the boy was exposed to his triggering stimuli, for example, asked to repeatedly touch contaminated objects like elevator buttons or door handles until he became habituated to them – got used to them until his anxiety level dropped. He practiced exposure to stimuli in between sessions in his daily life by handing papers in the classroom or touching contaminated objects at home.
The therapy resulted in Jason’s Y-BOCS score dropping from the initial 18 to a normal range of 3, remains the same at the 3 months follow up. Both Jason’s and his parents’ feedback stated a significant overall improvement in his OCD symptoms and social interactions in school.
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