Obsessive-Compulsive Disorder (OCD)

OBSESSIVE-COMPULSIVE DISORDER [OCD] - Information prepared by Clinical Psychologist Reinette Steyn [see www.lenseseyes.com ]

OCD is classified as one of the Anxiety Disorders. There are two components:

OBSESSIONS are recurrent and persistent thoughts [e.g. Red is a dirty colour], impulses [e.g. to say a swear word or utter a sound or make a movement], or images [e.g. pictures in the mind, for instance, about murdering someone] that are experienced at some time during the disturbance. They are experienced as intrusive [stopping the sufferer from continuing with planned activities] and inappropriate [such as washing hands that are not dirty] and cause marked anxiety or distress for the sufferer [they don't want to think, feel or imagine what they do but feel they can't stop it]. Obsessions are not simply excessive worries about real-life problems but seem illogical or irra-tional to observers. Attempts to ignore or suppress such thoughts or impulses or to neutralise them with some other thought or action are frequently made, with no or little result. These obsessional thoughts, impulses, or images are recognised to be a product of one's own mind and not imposed from without; i.e. they are not delusional beliefs or hallucinations: the sufferer knows they are emanating from him/herself. Common obsessions include repetitive thoughts of violence (e.g. killing one's child), contamination (e.g. becoming infected by shaking hands), doubt (wondering repeatedly whether one has performed some act, such as having hurt someone in a traffic accident, or left the stove on).

COMPULSIONS are repetitive behaviours that the person feels driven to perform in order to "neutralize" an ob-session, or according to self-appointed rules that must be rigidly applied [e.g. “I must touch all the lampposts when I walk; if I miss one, I must start the journey from scratch again.”. These behaviours or mental acts are aimed at pre-venting or reducing distress [usually anxiety] or preventing some dreaded event or situation [“I will die of a terrible infectious disease if I touch people’s hands in greeting them.”]. The behaviours or thoughts do not connect realisti-cally with what they were designed to neutralise or prevent, or they are clearly excessive. Typical compulsions in-clude hand-washing, ordering, or checking. Mental compulsions include praying, counting, and repeating words silently.

Obsessions or Compulsions may be part of another disorder and then not classified as OCD, for instance, constant thinking about food can be part of an eating disorder, or thinking repetitive guilty thoughts may be a symptom of major depressive disorder.

OCD can occur "with poor insight", which means the sufferer does not se that the thoughts or actions are irrational, excessive or ineffective. In such cases, prognosis [the chance of getting better] is poor. As with other psychiatric illnesses, persons with obsessive blasphemous or sexual thoughts, etc., were considered to be possessed by demons.

Exorcism [usually including torture] was the treatment of choice. Literature has many examples of obsessions and compulsions, such as Shakespeare's Lady Macbeth who had to keep washing the blood of people she’d murdered off her hands while sleep-walking (17th-century). In the 20th and 21st centuries, television and film characters have helped to make the disorder understandable to the general public, e.g. Mr Monk, the ex-detective who needs “wipes” on hand to clean his hands or to protect them when others want to shake hands with him – with him the disorder became apparent after his wife was murdered. Jack Nicholson’s character in the movie “As Good as it Gets”, even teaches a dog to copy his compulsive behaviours and to avoid stepping on the cracks between paving stones! In fact, stressful events such as pregnancy, sexual problems, death of relative, etc. are often found to be the cause, even though there can be a delay of up 5 – 10 years before symptoms start. But when they start, it tends to be sudden, and then they progress in severity.

Freud's writings on psychoanalysis of the Rat Man in the 20th century, suggested that OCD results from unconscious conflicts and from the isolation of thoughts and behaviours from their emotional causes. His treatment was an at-tempt to resolve the unconscious conflicts presumed to cause the behaviours. In the 1950s greater success was found in the use of exposure and response prevention techniques used in Cognitive-Behavioural Therapies [CBT]. There were decades of speculation about whether OCD was “genetic” or “learnt” behaviour. By the 1990s neuro-logical causes were found in dysfunction of basal ganglia and frontal lobe. OCD patients had significantly more grey brain matter and less white matter than normal controls, suggesting that OCD may be due to abnormal development of the brain.

2 - 3% of the population suffer from OCD, with onset almost always before age 40. About 20% of OCD patients exhibit tics, and some have Tourette's Syndrome.

TREATMENT: Treatment with antidepressant serotonin is partially helpful in OCD symptoms, although there seems to be no sero-tonin dysfunction in OCD patients.

Serotonin treatment alone is not successful. Cognitive-Behavioural Therapy [CBT] appears to work best and re-quires techniques like Interrupting compulsive sequences [.g. shouting "Stop!!!" very loudly when someone begins their obsessive or compulsive thoughts or rituals], desensitizing techniques [like progressive desensitization, flood-ing and endurance training], creating healthier alternative patterns of anxiety management, giving information about brain processes involved, creating Reward structures [e.g. by reinforcing non-OCD behaviours with positive atten-tion], and planning Reward-Distraction sequences. OCD patients believe they can influence stop bad things from happening by rituals, or cause them, by thinking: they need to be helped to change their beliefs about the world and their power [or lack of power] in it in a manner that makes it feel safe for them to change their behaviours. 60-70% of OCD patients are much improved after behavioural treatment, even after several years. Hypnosis is helpful to decrease symptoms and help to strengthen the ego and create a more stable personality. Psychoanalytic or psychodynamic therapy has not been found to be effective.

DIAGNOSIS: Patients usually present with specific and pronounced obsessions or compulsive rituals but often people hide the symptoms that they find embarrassing or disgusting, and appear completely normal to the casual observer. Patients who divulge the nature of the obsessions may appear bizarre or irrational, but they usually retain full insight, recognising that they thoughts and impulses are unreasonable and alien to their personality. OCD can appear with any type of personality and their demeanour may range from histrionic crying to obsessive fussiness and controlling. Often patients appear to have personality disorders, but those features usually subside as OCD symptoms improve. [Kaplan & Sadock].

There are many different subtypes of Obsessions and compulsions; usually the compulsions are what is noticed and the underlying obsessive thoughts or images are related on enquiry. Most common are cleaning and checking com-pulsions. Less common are: placing objects in a specific order, primary obsessional slowness which results in be-coming stuck for hours while performing everyday tasks like dressing or eating, fears of bowel movements or urina-tion in public [also common to Panic attacks], and face-picking, nail-picking and hair-pulling [Trichotilomania].

OCD requires correct intervention after diagnosis by a clinically qualified practitioner such as a Clinical Psycholo-gist or a Psychiatrist. It is unwise to diagnose oneself on, for instance, internet information, although such information could pave the way for seeking expert help, especially for CBT and if medication should be necessary. Please consult an appropriate practitioner if you think you or someone else may have OCD.