Obsessive-Compulsive Disorder

Understanding Obsessive-Compulsive Disorder

In the silent theater of the mind, where thoughts both benign and intrusive play out their endless drama, the specter of obsessive-compulsive disorder (OCD) takes center stage. It is a realm where the ordinary becomes the obsessive, the casual becomes the compulsory, and the mind’s own creations become its captor. Here, rituals and routines are not mere acts of habit, but lifelines thrown into the churning seas of anxiety, each repetition a desperate incantation for control and certainty. As we pull back the curtain on this psychological odyssey, we find individuals locked in a battle against invisible forces, seeking liberation from the relentless grip of compulsion and the haunting echo of obsession.

Obsessive-Compulsive Disorder (OCD) is a mental health condition characterized by intrusive, distressing thoughts (obsessions) and repetitive behaviors or mental acts (compulsions). This disorder can significantly impact a person’s daily life, affecting their work, relationships, and overall well-being.

Defining Obsessive-Compulsive Disorder

Jeffrey M. Schwartz, an American psychiatrist and researcher in the field of neuroplasticity and its application to obsessive-compulsive disorder wrote that “obsessive-compulsive disorder is a neuropsychiatric disease marked by distressing, intrusive, unwanted thoughts ( the obsession part ) that trigger intense urges to perform ritualistic behaviors ( the compulsion part ). Together, obsessions and compulsions can quickly become all-consuming.” He adds “one of the most striking aspects of OCD urges is that, except in the most severe cases, they are what is called ego – dystonic: they seem apart from, and at odds with, one’s intrinsic sense of self. They seem to arise from a part of the mind that is not you, as if a hijacker were taking over your brain’s controls, or an impostor filling the rooms of your mind” (Schwartz, 2003, p. 56).

History of Obsessive-Compulsive Disorder

The history of obsessive-compulsive disorder (OCD) is a journey through time and evolving understanding. In the 17th century, symptoms that we would now recognize as OCD were often described as manifestations of religious melancholy. Robert Burton, an Oxford scholar, documented a case in his work “The Anatomy of Melancholy” in 1621, where he described an individual’s fear of speaking something indecent or unfit during a silent sermon.

The term “scrupulosity,” which referred to obsessive concern with one’s own sins and compulsive religious devotion, was used in earlier centuries to describe what we would now call OCD. This term has its roots in religious texts rather than medical literature, with cases dating back to the 14th century.

It wasn’t until the 19th century that OCD began to be recognized as a distinct disorder. The modern concepts of OCD started to evolve in France and Germany, influenced by popular theories of the time such as Faculty Psychology, phrenology, and Mesmerism. The term “neurosis” at that time implied a neuropathological condition, and obsessions, where insight was preserved, were gradually distinguished from delusions, where it was not.

The term “obsessive-compulsive disorder” is a 20th-century medical term. Before this, people with OCD symptoms were thought to suffer from “scrupulosity.” As our understanding of mental health has advanced, so too has our grasp of OCD, leading to more effective treatments and a more compassionate view of those who live with this condition.

Symptoms and Diagnosis

Diagnosis typically involves a comprehensive evaluation of symptoms, medical history, and may include psychological assessments. According to the latest edition of the DSM-V, the elements of Obsessive-Compulsive Disorder (OCD) include:

Obsessions:

These are unwanted, persistent, and intrusive thoughts, urges, or images that cause significant anxiety or distress. The individual attempts to ignore or suppress these obsessions with some other thought or action. Bruce M. Hyman explains that “obsessions are persistent impulses, ideas, images, or thoughts that intrude into a person’s mind, causing intense anxiety and distress. The person knows the obsessive thoughts are inappropriate and make little sense, but they are so persistent that they are difficult to ignore” (Hyman, 2003).

Compulsions:

These are repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession. Carol Mathews, MD. explains them this way, “compulsions are repetitive ritualized behaviors that the person recognizes as unreasonable, unrealistic, or excessive but feels driven to perform to reduce anxiety, usually (although not always) in response to an obsession” (Mathews, 2021). The individual performs the behaviors or mental acts to prevent or reduce anxiety or distress. They may also perform these behaviors and mental acts to prevent some dreaded event or situation. However, these compulsions are not connected in a realistic way with what they are designed to neutralize or prevent. The behaviors are also clearly excessive.

Insight Specifiers:

The DSM-V includes specifiers related to the level of insight the individual has regarding the obsessive-compulsive beliefs. This ranges from good or fair insight to poor insight, to absent insight/delusional beliefs.

Tic Specifiers:

The DSM-V also includes a specifier indicating if there is a current or past history of a tic disorder.

The DSM-V emphasizes that the obsessions and compulsions must be time-consuming (e.g., take more than one hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Obsessive-Compulsive Disorder is a Disease

Too often we treat the symptoms of mental disorders as a choice. We judge the sufferer as a bad actor rather than a person with an illness. Schwartz wrote, “In the last two decades, further brain studies have validated the finding that putting these troubling feelings in proper context, calling them what they are—symptoms of a disease” (Schwartz, 2016).

Difference Between OCD and Obsessive-Compulsive Personality Disorder

Obsessive-Compulsive Disorder (OCD) and Obsessive-Compulsive Personality Disorder (OCPD) are distinct conditions, despite their similar names. Here are the key differences:

• Classification: OCD is classified under “obsessive-compulsive and related disorders,” while OCPD is listed as a personality disorder in the DSM-5.
• Symptoms:
  • OCD is characterized by unwanted, persistent thoughts (obsessions) and repetitive behaviors (compulsions) that the person feels urged to perform, usually as a way to make the obsessions go away.
  • OCPD involves a preoccupation with perfectionism, order, and control over one’s environment, without the presence of obsessions or compulsions. It’s marked by rigid thinking patterns and an inflexible adherence to rules.
• Insight: Individuals with OCD often have insight into their condition and recognize that their obsessions and compulsions are unreasonable. Gabor Maté, a Canadian physician with a background in family practice and a special interest in childhood development, explains, “the obsessive-compulsive person is intellectually aware that his impulse, say, to wash his hands for the hundredth time lacks reason, but he cannot stop himself (Maté. 2010. Kindle location: 5,123). In contrast, those with OCPD may lack self-awareness regarding their behavior and often believe that their way of thinking and acting is the only correct one.
• Impact on Life: While both conditions can cause distress, OCD symptoms are typically more distressing and can interfere with daily functioning. OCPD traits, on the other hand, can be ego-syntonic, meaning the individual sees them as valuable and beneficial.
• Treatment: Both conditions are treatable with psychotherapy, but the approaches may differ. OCD is often treated with a specific type of Cognitive Behavioral Therapy called Exposure and Response Prevention, while treatment for OCPD focuses on helping the individual understand the benefits of flexibility and the costs of perfectionism.

Causes and Risk Factors

The causes of Obsessive-Compulsive Disorder (OCD) are not fully understood, but a combination of genetic, neurological, behavioral, cognitive, and environmental factors are believed to play a role.

Potential Causes

Here’s a summary of the potential causes and risk factors:

• Genetic Factors: A family history of OCD may increase the risk, suggesting a possible genetic component.
• Brain Structure and Functioning: Changes in the body’s natural chemistry or brain functions may be involved. Abnormalities in certain areas of the brain, like the orbitofrontal cortex and basal ganglia, have been linked to OCD. A meta review of research reveals existence of “impairments spanning sensory integration, affective arousal, cognitive control, and motor action selection” ()
• Environmental Factors: Stressful life events or environmental stressors can trigger OCD in people with a predisposition to the disorder. Certain infections, such as streptococcal infections, have been associated with the onset of OCD symptoms, particularly in children (a condition known as PANDAS).
• Behavioral Factors: Learned behaviors can also play a role. For example, if a person finds that performing certain rituals reduces their anxiety, they may begin to perform that ritual more frequently.
• Cognitive Factors: People with OCD may have a tendency to have more rigid thought patterns or to interpret situations as more dangerous than they are, which can contribute to the development of the disorder.
• Other Mental Health Disorders: Having other mental health conditions such as depression or anxiety disorders can increase the risk of developing OCD.
• Personality Traits: Certain personality traits, such as perfectionism or a strong sense of responsibility, may make individuals more susceptible to OCD.

It’s important to note that having one or more of these risk factors does not mean a person will definitely develop OCD. It’s usually a combination of factors that contributes to the onset of the disorder. Effective treatments are available, and understanding these factors can help in managing the condition.

Treatment and Management

Medical professionals typically treat obsessive-compulsive disorder (OCD) through a combination of psychotherapy and medication, with the goal of reducing symptoms and improving quality of life.

• Psychotherapy: The most effective form of psychotherapy for OCD is Cognitive Behavioral Therapy (CBT), particularly a type known as Exposure and Response Prevention (ERP). ERP involves gradually exposing the patient to the source of their anxiety and teaching them to resist the urge to perform compulsive behaviors.
• Medication: Medical professionals commonly prescribe certain medications, particularly those known as Selective Serotonin Reuptake Inhibitors (SSRIs), to help control the obsessions and compulsions of OCD. Examples include clomipramine, fluoxetine, and sertraline.
• Self-Care: Alongside professional treatment, self-care strategies can also be beneficial. These include maintaining a healthy diet, regular exercise, adequate rest, and stress management techniques.
• Specialists: Mental health professionals such as psychiatrists and psychologists, who specialize in diagnosing and treating mental illnesses and behavioral problems.

Effective treatment for OCD often involves a combination of therapy and medication. It’s important for individuals with OCD to work closely with their healthcare providers to find the most effective treatment plan for their specific needs.

Self-Directed Neuroplasticity

Schwartz guides clients through a four step process in therapy that he suggests helps to create new brain connections that help clients manage the symptoms of obsessive-compulsive disorder. The four step process is relabeling, reattributing, refocusing, and revaluing.

Relabeling

Relabel answers the question, “What are these bothersome, intrusive thoughts?” Schwartz emphasizes the need to relabel unwanted thoughts, urges, and behaviors, calling them what they really are: They are obsessions and compulsions. He explains, “you must make a conscious effort to keep firmly grounded in reality. You must strive to avoid being tricked into thinking that the feeling that you need to check or to count or to wash, for example, is a real need. It is not” (Schwartz, 2016). The brain is sending false messages that the individual experiences as urges and bothersome thoughts.

Reattributing

Schwartz explains that the obsessive-compulsive symptoms persist because they are “a condition that has been scientifically demonstrated to be related to a biochemical imbalance in the brain that causes your brain to misfire.” He explains that if you persist in relabeling and re-attributing the symptoms to the brain eventually new connections evolve.

Schwartz adds that “in Reattribute, you learn to place a lot of the blame squarely on your brain: This is my brain sending me a false message. I have a medical condition in which my brain does not adequately filter my thoughts and experiences, and I react inappropriately to things that I know make no sense. But if I change the way I react to the false message, I can make my brain work better, which will improve the bad thoughts and feelings” (Schwartz, 2016).

Refocusing

In refocusing the goal is to connect the impulse to a new behavior. Schwartz explains, “the goal of this step is not to banish or obliterate the thought, but rather to initiate an adaptive behavior unrelated to the disturbing feeling even while the feeling is very much present. Refocusing on such a behavior, and thus resisting the false message to carry out the OCD compulsion, requires significant willpower, for the feeling that something must be washed or checked is still very much a part of the inner experience” (Schwartz, 2003, p. 83).

Basically, refocusing creates an acceptable work around to the compulsive behavior. The key of this step is to do another behavior as a replacement for the old behavior.

Revaluing

In revaluing, the individual with OCD internalizes the message that the “obsessive thoughts and compulsive urges are not important,” and they can deal with them.

Living with OCD

Living with OCD can be challenging, but with the right support and treatment, individuals can lead fulfilling lives. Building a strong support network, practicing self-care, and adhering to treatment plans can significantly improve the quality of life for those with OCD. Maté compares the impulsive nature of OCD with addiction. He wrote, “both the obsessive-compulsive and the addict experience overwhelming tension until they succumb to their compulsive drive. When they finally do, they gain an immense, if momentary, sense of relief” (Maté, 2010. Kindle location: 5,180).

OCD and Relationships

Obsessive-compulsive disorder (OCD) can significantly impact romantic relationships in various ways. The presence of intrusive thoughts and compulsive behaviors can create stress and strain for both partners.

The individual with OCD:

• Intrusive Thoughts: They may experience persistent doubts about the relationship, questioning their love or their partner’s love, which can lead to constant need for reassurance.
• Compulsions: Engaging in rituals can be time-consuming and interfere with shared activities, reducing the quality time spent together.
• Emotional Intimacy: The fear and doubt cast by OCD can create barriers to vulnerability and connection, making it difficult to form deeper emotional bonds.

The partner to the individual with OCD:

• Stress: The partner may feel overwhelmed by the OCD symptoms, leading to frustration or burnout from providing constant reassurance or dealing with the rituals.
• Communication: It may become challenging to communicate effectively if the individual with OCD requires frequent reassurance or if their compulsions dominate conversations.
• Intimacy: Sexual and emotional intimacy can be affected by the individual’s obsessions and compulsions, potentially leading to dissatisfaction or distance in the relationship.

The relationship with one partner with OCD:

• Conflict: Misunderstandings and tensions can arise due to the symptoms of OCD.
• Support: The relationship may become one-sided if one partner is constantly providing support without their own needs being met.

Despite these challenges, with proper treatment and mutual understanding, individuals with OCD and their partners can foster healthy and fulfilling relationships. Therapy, medication, and support groups can help manage symptoms. In addition, open communication and education about OCD can help partners support each other effectively.

An Example of a Day in Life with Obsessive-Compulsive Disorder

Sophie’s day begins before dawn, but not by choice. Her mind wakes her with a whisper that crescendos into a shout, reminding her of the rituals she must complete to keep her anxiety at bay. She rises, and the dance begins. She starts the day by taping the light switch three times to ward off darkness. Next, she then checks the stove four times to prevent a fire. And finally, she ends the rituals by washing her hands until they’re raw to cleanse away unseen germs.

At work, emails are triple-checked for mistakes that could spell disaster, and her desk is a geometric display of precision. Lunch is a silent countdown of bites chewed and swallowed, a ritual to ensure safety for her loved ones. Her colleagues see her as meticulous. But they don’t feel the iron grip of fear that clenches her stomach with each compulsion left unfulfilled.

Home again, and the sun sets on a day measured out in repetitions and checks. Sophie’s mind races through the inventory of tasks as she prepares for bed, each one a link in the chain that she hopes will hold back the tide of dread. Sleep will come, eventually, but only after the whispers quieten, satisfied with the day’s offerings to the relentless altar of OCD.

A Few Words by Psychology Fanatic

As we conclude our exploration of obsessive-compulsive disorder (OCD), we recognize it as a complex and often misunderstood condition that touches the lives of many. It is a disorder characterized not just by the visible rituals and compulsions, but also by the internal struggle with intrusive thoughts and relentless doubt. The journey of understanding OCD has evolved significantly. The early misconceptions have transformed to broader recognition of OCD as a treatable neurological and psychological disorder.

Treatment strategies like cognitive-behavioral therapy, particularly exposure and response prevention, along with pharmacological interventions, have opened doors to relief and recovery for those affected. The courage of individuals living with OCD, paired with ongoing research and compassionate clinical practice, continues to break down barriers. New discoveries offer hope and a path to reclaiming control and tranquility. As awareness grows and stigma fades, the future for individuals with OCD looks ever brighter, promising a life defined not by compulsion, but by the richness of possibility and the pursuit of well-being.

Last Update: April 20, 2024

References:

Hyman, Bruce M. (2003). Obsessive-Compulsive Disorder.

Maté, Gabor (2010). In the Realm of Hungry Ghosts: Close Encounters with Addiction. North Atlantic Books; Illustrated edition.

Mathews, Carol (2021). Obsessive-Compulsive Disorders. CONTINUUM: Lifelong Learning in Neurology,27(6), 1764-1784. DOI: 10.1212/con.0000000000001011

Perkes, I., Kassem, M., Hazell, P., Paxinos, G., Mitchell, P., Eapen, V., & Balleine, B. (2022). The anatomy of obsessive-compulsive disorder. medRxiv. DOI: 10.1101/2022.10.06.22280808

Schwartz, Jeffrey M. (2016). Brain Lock: Free Yourself from Obsessive-Compulsive Behavior. Harper Perennial; Illustrated edition.

Schwartz, Jeffrey M. (2003). The Mind and the Brain: Neuroplasticity and the Power of Mental Force. Harper Perennial.

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