The many sides of Obsessive Compulsive Disorder

How can you tell whether you have Obsessive Compulsive Disorder (OCD)? The straight answer is that if your life is governed by obsessions and/or compulsions that are having a debilitating effect on your ability to function on a daily basis then you might have OCD. While the actual content of obsessions and compulsions can vary a great deal, they normally fall in one of these 5 dimensions:

  1. Cleaning, which can be expressed in contamination obsessions and cleaning compulsions: for example, the obsessive thought that one might be contaminated by germs can lead to washing one’s hands repeatedly until they bleed.
  1. Symmetry, which cab be expressed in obsessions with ordering things symmetrically or according to a certain criterion or colour, obsessions with repeating rituals in order to decrease anxiety, and counting compulsions. For example, the famous footballer David Beckham has admitted to the compulsion of having to arrange canned drinks in his fridge so that they are always in even number.
  1. Forbidden or taboo thoughts, which can be aggressive, religious or sexual in nature. For example, the compulsion to swear in a church or the obsessive thought of having sex with a priest.
  1. Harm, to oneself and/or others which can result in checking rituals, in seeking reassurance from others and in the performance of rituals in order to avoid arm.
  1. Difficulty discarding, which results in accumulating (hoarding) objects, is also a common manifestation of obsessions and compulsions. For example, the fear that one might run out of something or be in need in the future, might lead people to hoard specific items.

In 30% of the cases, the individuals who are diagnosed with OCD have a tic disorder. These are mainly males whose OCD is diagnosed in childhood. In many diagnosed case of OCD the individual has dysfunctional beliefs such as the tendency to overestimate threat, perfectionism, an inflated sense of responsibility just to mention a few. This can be related to irrational thinking which has been covered at length in another article.

The diagnostic criteria for OCD

The Diagnostic and statistical manual of Mental Disorders 5th Edition (DSM – V) classifies OCD as an anxiety disorder. According to the DSM – V, for an individual to be diagnosed with OCD he must meet the criteria listed below.

1. The individual has obsessions and/or compulsions.

Obsessions are defined as repetitive and persistent thoughts (e.g. of contamination) urges (e.g. to harm someone), or images (e.g. of sexual scenes) experienced as unwanted or intrusive and therefore causing anxiety or distress to the individual who tries wither to suppress or neutralize them with another thought or action, e.g. a compulsion.

Compulsions are either repetitive mental acts (e.g. counting) or behaviours (.e. g. ordering, checking) which the individual performs due to an obsession or to the application of some rigid rules. The aim of performing these mental acts and behaviours is to reduce anxiety or to prevent a feared event even though there is no connection between these and the feared event. The individual doesn’t experience pleasure but relief when performing a compulsion, namely repeating the thought or behaviour until it feels “just right”.

An example of the first diagnostic criterion is the obsession that one might become contaminated by germs which might lead to compulsive hand washing in the attempt to neutralize the contamination.

2. The obsessions and compulsions experienced are time-consuming, e.g. they take up more than 1 hour per day, or cause significant distress or impairment in one or more life domains (e.g. social, psychological, occupational, school, family, relationships, etc…). For example, if a child is obsessed with symmetry they might not be able to complete schoolwork and therefore fail at school. This might results in developmental difficulties. Obsessions and compulsions can cause impairment because of the time they take up which can affect work and school performance, or because they lead to avoiding certain situations and/or certain people thus limiting functioning. The severity of the symptoms can vary from mild to moderate, whereby the obsessions and compulsions take up between 1 and 3 hours a day, to severe, whereby the obsessions and compulsions are nearly constant, can take between 3 and 8 hours per day and are therefore incapacitating. If the symptoms are experienced for longer than 8 hours a day then the severity is extreme.

3. The obsessions and compulsions are not due to the effects of a substance, whether drug or medication, or to another medical condition.

4. Other mental disorders cannot better explain the symptoms experienced.

People with OCD vary with respect to the insight that they have into the accuracy of their beliefs. These are the different degrees of insight that people can have:

  • good or fair insight à meaning that the individual thinks that his beliefs are probably not true;
  • poor insight à meaning that the individual thinks that his beliefs are probably true;
  • absent insight/delusional belief à meaning that the individual is convinced that his beliefs are true. Those who fall in the last category correspond to about 4% of the diagnosed cases. The degree of insight can vary during the course of the illness.

What causes OCD?

The causes of OCD are largely unknown. However, different explanations have been put forward.

Biological explanations posit that there are differences in brain structure that distinguish people with OCD from non-sufferers. In particular, information is relayed to the striatum and the thalamus, which are deep-seated in the brain, from more cortical areas of the brain, requiring processing and further action. It is believed that people with OCD are unable to switch off the impulses relayed to these area of the brain once they have been dealt with, leading to the compulsive side of OCD. OCD has also been associated with abnormal levels of the neurotransmitter serotonin which regulates anxiety. This is indicated by the fact that medication that blocks the reuptake (absorption) of serotonin at the synapse and therefore makes more serotonin available, is effective in reducing the symptoms of anxiety experienced by some people with OCD.

According to the genetic explanation, people who develop OCD have a genetic predisposition. In support of this claim, research ahs shown that OCD runs in families. Therefore, there might be a genetic component to this disorder.

Behavioural explanations of OCD posit that the compulsions might be a behaviour learnt in childhood and which has strengthened over time.

Cognitive explanations attribute OCD to faulty beliefs and irrational thoughts and posit that since people with OCD have an inflated sense of responsibility, when they experience an intrusive thought this cannot be easily discarded and is therefore taken too seriously. This repeated misinterpretation leads to the development of obsessions which in turn lead to the development of a compulsion in order to reduce the anxiety associate with the obsessions.

Environmental factors, especially stress and traumatic life events, play a major role and might act as a trigger in the development of OCD. Therefore, a number of factors often interact int he development of OCD.

Treatment for OCD

The first step in treatment for OCD is becoming aware of the obsessions and compulsions. But how can you test whether these match the criteria for diagnosis or not? You can try and refrain from the compulsions for a given period of time and replace them with another activity such as meditating or writing a journal. If you are unsuccessful in doing so, then you should seek the help of a doctor.

The two types of treatment available for OCD are medication and psychotherapy. A combination of the two is more effective than either method used on its own.

As mentioned above, selective serotonin re-uptake inhibitors (SSRIs), which are an antidepressant, have been shown to be effective in reducing anxiety symptoms in some patients with OCD. There are more antidepressants available for the treatment of OCD but your therapist will be able to advise you on which might be more suitable to you depending on side effects and interaction with other medication.

The most effective type of psychotherapy has been proven to be exposure and response prevention (ERP) which involves gradually exposing the affected individual to his obsessions and fears whilst teaching him healthy ways to deal with his anxiety. Whilst this type of therapy requires effort and time, it produces good results and enables the individual to be able to cope with his fear and obsessions better in the future thus increasing life quality.

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