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Obsessive-compulsive disorder (OCD) as defined by
the DSM-IV is defined by obsessions or compulsions severe enough
to be time-consuming. This is defined by more than one hour a day,
or they cause enough marked distress and impairment in an individual’s
life that it impedes them from functioning in a healthy matter.
So what are obsessions? According to the DSM-IV, obsessions are
persistent ideas, thoughts, impulses or images that are intrusive
and inappropriate. They do cause anxiety and subsequently, they
have been referred to as ego-dystonic, which refers to the fact
that these feelings, thoughts, are not in the individuals control,
and do elicit intense anxiety and stress. These individuals usually
recognize that these thoughts are of their own mind, and they are
problematic. Some common obsessions may be related to contamination
(fear of shaking hands), germs, dirt, and issues with cleanliness,
using hand towels to open up doors of bathrooms, or opening them
with their shoes. This author had a patient who would go to the
rest room, whether at home or when he was out, and he would use
a paper towel to hold onto his genitalia to urinate. This is an
extreme example, related to concerns over cleanliness and ego dystonic
anxiety and stress over an exaggerated concern of becoming ill.
More severe, aggressive impulses and thoughts may be related to
hurting one’s child. Sexual obsessions are also very common.
These could be recurrent pornographic thoughts or images.
Compulsions, according to the DSM-IV, are repetitive behaviors,
the goal being to reduce stress and anxiety, not to provide pleasure
or satisfaction. Individuals become very focused on performing these
compulsions, and become addicted, if you will, to performing them.
Some common compulsions seen are frequent hand washing, frequently
washing vehicles, locking or unlocking doors, repeating certain
actions over and over, counting, praying, and repeating words silently,
continuously organizing. These repeated actions give a sense of
control to their environment. It is not uncommon for these individuals
to be somewhat restricted emotionally, with histories of acting
out or explosive angry outbursts. Subsequently controlling their
environment becomes extremely important, keeping things very organized,
neat and clean. They most frequently will lack a cognitive awareness
of this behavior, and usually defend it tooth and nail. Some compulsions
can be grossly overwhelming, and can impede overall daily functioning.
Associated disorders that are fairly common are individuals displaying
symptoms of hypochondria, guilt, refusal to leave the house, bordering
on agoraphobia. You see a lot of compulsive behavior in children
with Tourette’s disorder.
There is no data that indicates that certain cultures have higher
rates of obsessive-compulsive disorders than others. It is important
to note that certain cultures and religions do perform rituals and
ceremonies that could be interpreted by the uninitiated as obsessive-compulsive
disorder.
It is EXTREMELY important to do a thorough, detailed history before
making a diagnosis. It is also important to do your due diligence
and research an individual’s particular ethnic and cultural
background before coming up with the diagnosis of obsessive-compulsive
disorder.
Causes of Obsessive Compulsive Disorder
Biological theory: Some experts strongly believe low levels of
serotonin in the brain cause OCD. It has been show with PET scans
that these individuals do burn up more energy than individuals without
OCD. The jury is still out, and the study has not confirmed any
of this. We do know that hereditarily there is a strong link between
twins.
In researching OCD causes, as well as many mental illness causes,
it is curious to this author the need for professionals to validate
some organic or physiological foundational cause. It is very difficult
to find research on environmental influences that cause OCD. The
nature vs. nurture has long been debated. This author is convinced
that there are clearly environmental influences in a child’s
life that contribute to the development of compulsions and obsessions.
Obsessive-compulsive disorders can clearly be an outgrowth of environment
stress and influence by dysfunctional parents, as well as past traumas
in one’s life. We see similar compulsive behaviors in post-traumatic
stress disorder. We also see compulsive behaviors in abuse situations.
One can speculate why there is not much research on environmental
influences of OCD. We will leave that topic for another time.
Treatment of Obsessive Compulsive Disorder
SSRI’s have been shown to be somewhat effective in OCD. The
jury is still out on the effectiveness of taking medication alone.
However a greater rate of success has been achieved combining SSRI’s
with one-on-one therapy two times per week for severe cases. Success
rate is reduced when therapy is limited to once per week.
The therapeutic process can be quite difficult, as these individuals
can be very defensive, and unwilling to look at or give up their
rituals. Since these rituals do serve in calming the individual
down and alleviating stress, they are very difficult to give up.
Minimal one-on-one therapy usually lasts 10 months to one year.
This is not a short-term treatment, comparing it to, for example,
treatment for a phobia, where you might see an individual less than
6 months.
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