Abnormal Psychology: Obsessive-Compulsive Disorder

An Overview

Obsessive-compulsive disorder (OCD) is a long-lasting mental and behavioural disorder featuring patterns of intrusive thoughts and fears known as obsessions. Obsessions are persistent unwanted thoughts, mental images, or urges that cause feelings of anxiety, disgust or discomfort. Such obsessions may lead one to do repetitive behaviours, known as compulsions, that get in the way of daily activities, cause a lot of distress and reduce quality of life. Many feel the need to perform certain routines repeatedly to relieve the discomfort caused by the obsession. Not performing the behaviours commonly causes great , usually attached to a specific fear of dire consequences if the behaviours are not completed. Many people with OCD know that their fears are irrational, though others think they could be true. Either way, people with OCD have difficulty disengaging from their obsessive thoughts and acting upon the compulsive actions.

Common obsessions include the fear of contamination, obsession with symmetry, the fear of harming others or themselves, fear of losing or misplacing something and needing things to be orderly and balanced. Common compulsions include arranging things in a specific order, excessive handwashing, hoarding items of no particular value, repeatedly checking things and rituals related to numbers (counting, doing a task a specific amount of times, or avoiding certain numbers).

The History of OCD

The name OCD did not come into fruition until the 20th century, however, evidence shows numerous examples of OCD-type symptoms in the lives of people throughout the ages. Such historical descriptions exist, with some even dating back to the 14th century. Much of these earlier historical records, from the 14th to 18th century, of OCD descriptions are found primarily in religious literature, rather than medical literature. Around this time, obsessional fears around religion were quite common. So, a new word for obsessions and compulsions came into usage, namely scrupulosity. (In the 17th century, such obsessions and compulsions were also described as symptoms of melancholy.) Scrupulosity, in a contemporary context, is a word which echoes the traditional use of the term "scruples" in religious contexts to describe the obsessive concern with one's own sins and compulsive performance of religious devotion. However, back then, it was a term that encompassed all types of obsessions and compulsions. The word itself derives from the Latin "scrupulum", meaning a sharp stone, implying a stabbing pain on the conscience. This term dates back centuries as several important historical and religious figures have records of suffering from compulsivity and obsessive thoughts.

“After I have trodden a cross formed by two straws, or after I have thought, said, or done some other thing, there comes to me from ‘without’ a thought that I have sinned, and on the other hand it seems to me that I have not sinned; nevertheless I feel some uneasiness on the subject, in as much as I doubt and do not doubt. That is a real scruple and temptation which the enemy sets.” – Saint Ignatius of Loyola (1491–1556) 

Towards the 1700s and 1800s, fewer religious obsessions were reported than in earlier centuries. Physicians described more types of behaviours such as washing, checking and obsessive fear of syphilis. However, the modern concepts of OCD really began to take form in the nineteenth century. This advent coincides with the rising popularity of faculty psychology, phrenology and mesmerism as well as the interest in neuropathological conditions. During this time, many physicians were struggling to understand mental illnesses, resorting to philosophy, physiology and political thought to help categorise and identify different types of abnormal psychological conditions.

Jean Etienne Dominique Esquiorial, a famous French psychiatrist, described OCD as a form of monomania. Monomania is an umbrella term for psychiatric conditions where patients have a single psychological obsession in an otherwise sound mind. In other words, monomanic patients can function normally in other areas except the affected part. This theory came with a few problems; Esquirol was conflicted about whether or not obsession was a thinking disorder or a disorder of the volitional faculty. (Volitional faculty is the inability to resist instinctive activity). As a result of this confusion, the concept of monomania was eventually abandoned by psychiatrists in the 1850s. They attempted to understand obsessions and compulsions within various broad categories we now identify as conditions such as phobias, panic disorder, agoraphobia, hypochondriasis, manic behaviour and even some forms of epilepsy.

Another significant figure worth mentioning, is Sigmund Freud, the Austrian founder of psychoanalysis. Influenced by ideas of mental structure and defence mechanisms, he gradually evolved a conceptualisation of OCD throughout the early 20th century. From his perspective, obsessive-compulsive behaviour is linked to unconscious conflicts manifested in symptoms of the illness. Said conflicts develop between the desires and subsequent actions of the conscious and unconscious minds. This line of thought led psychiatrists to conclude that OCD patients, frequently "compelled" to carry out actions for short, temporary relief from anxiety, know that their compulsions are irrational. In 1895, he coined the term obsessive neurosis "zwangsneurose", used by psychiatrists well into the 1990s. It was from this term that the name OCD originated. In the UK, Zwang, which would usually be translated as "forced" was instead translated as "obsession" while in the United States, it was translated as "compulsion". So, in the mid-century, Obsessive-Compulsive Disorder emerged as a compromise between the two.

How is OCD Diagnosed?

Researchers are still unsure what factors are behind OCD, however, they have several theories, including:

• Childhood Trauma
  • Forms of childhood trauma such as abuse or neglect are correlated to the development of OCD. People are more likely to experience obsession when they are exposed to stressful situations.
• Genetics
  • Studies have shown that those who are at higher risk for developing OCD usually have a first-degree relative with the condition. This risk increases if the relative developed OCD in their developmental years.
• Brain Changes
  • Some studies have shown that there are differences in the frontal cortex and subcortical structures of the brain in people who have OCD.

There is no universal procedure for diagnosing OCD. However, usually a healthcare provider reaches a diagnosis by asking you about your symptoms as well as medical and mental health history. Criteria explained in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V) are typically used to diagnose OCD. The criteria include: having obsessions or compulsions, with those obsessions or compulsions taking up a lot of time (more than an hour per day). The obsessions or compulsions also cause distress or affect participation in different activities and life events. Most importantly, the symptoms are not causes by other factors such as substance abuse, medications or another medical or psychological condition.

How is OCD Treated?

The most common form of treatment for OCD involves psychotherapy and medication. Medication usually includes antidepressants, or more specifically, serotonin reuptake inhibitors (SSRIs) which are used to help keep serotonin active in the brain for a longer period of time. They do this by limiting the reabsorption of serotonin back into the original neuron it came from, therefore prolonging the "happy" effects of the neurotransmitter. (Common SSRIs include citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline.)

Psychotherapy is beneficial as it aims to help patients identify and change unhealthy thoughts and behaviours together with a health professional. There are different variants of psychotherapy including Cognitive Behavioral Therapy (CBT), Exposure and Response Prevention (ERP) and Acceptance and Commitment Therapy (ACT).

• Cognitive Behavioural Therapy
  • During CBT sessions, a therapist helps the patient examine and understand their thoughts and emotions, helping them find ways to cope with harmful thoughts and stop negative habits while replacing them with healthier ways of coping.
• Exposure and Response Prevention
  • ERP is a specific type of CBT. It usually involves some form of exposure to a featured situation or image where the patient must resist their urge to perform a compulsion. One example could be a patient with an intense fear of or obsession with throwing themselves off a train platform. They may be shown a picture of a train station or even asked to take the train to work/school every now and then, making sure to resist their urge to perform compulsions when doing so. This is a very specific example, however, ERP sessions are almost always adapted to a patient's needs. This is done with a therapist, however, ERP sessions themselves can be self-administered on a daily basis. It could be as simple as not washing your hands for five minutes after touching a "dirty" object or resisting the urge to check if the front door is locked.
• Acceptance and Commitment Therapy
  • ACT sessions aim to help patients realise that their "obsessions" are just thoughts and have no real power at the end of the day. Taking the power away from these thoughts will help patients learn to live a meaningful and fulfilling life despite their OCD symptoms.

Interestingly enough, in some historical writings, there is a discussion about how doctors used bloodletting, or phlebotomy, to treat bad thoughts, what we now call OCD. This technique involved draining blood from the patient in an attempt to adjust the bodily "humors". To provide context, ancient origins believed that certain human moods, emotions and behaviours were caused by a lack or excess of body fluids known as humors. These included blood, so-called yellow bile, black bile and phlegm.

Concluding Note

Around 70 million people worldwide, 1 percent of the global population, deal with OCD. It is a chronic condition, meaning that one could get the symptoms under control and recover but, at present, there is no permanent cure. It can be very demanding and difficult for a person to live with OCD to the extent where it also affects those around them, causing significant distress and disruption in their lives. The constant need to perform rituals or manage intrusive thoughts can be time-consuming and exhausting, impacting relationships, work, and daily functioning. Loved ones may struggle to understand the behaviors or may become involved in the compulsions. Despite these challenges, various treatments such as the aforementioned cognitive-behavioral therapy (CBT), particularly exposure and response prevention (ERP), and medication can help manage symptoms. With proper support and treatment, individuals with OCD can lead fulfilling lives, though the journey often requires ongoing effort and understanding from both the person affected and those around them.