What is Obsessive Compulsive Disorder?
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.
What are the 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.
What is (PANDAS) Pediatric-autoimmune neuropsychiatric disorder associated with streptococcal infection?
There is some evidence that children who have a severe strep infection have a sudden onset of symptoms such as tics, and OCD behavior. These children have been observed hoarding toys, putting toys in a certain order, becoming upset at a disruption of routine. The exact mechanism is not well understood, however the clinician should ask of any previous strep infections prior to the behavior occurring.
What is the 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.