Obsessive-Compulsive Disorder (OCD)

According to the Diagnostic and Statistical Manual of Mental Disorder-Fourth Edition (DSM-IV), the essential features of Obsessive-Compulsive Disorder (OCD) are recurrent obsessions or compulsions that are severe enough to be time consuming (e.g., they take more than one hour per day) or cause marked distress or significant impairment. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable.

Obsessions are persistent ideas, thoughts, impulses or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress. The most common obsessions are repeated thoughts about contamination (e.g., becoming contaminated by shaking hands), repeated doubts (e.g., wondering whether one has performed some act such as having hurt someone in a traffic accident, or having left a door unlocked), and a need to have things in a particular order (e.g., intense distress when objects are disordered or asymmetrical). The thoughts, impulses or images are not simply excessive worries about real-life problems (e.g., concerns about difficulties in life, such as financial, work, or school problems). The individual with obsessions usually attempts to ignore or suppress such thoughts or impulses, or to neutralize them with some other thought or action (e.g., a compulsion). For example, an individual plagued by doubts about having turned off the stove attempts to neutralize the doubts by repeatedly checking to ensure that it is off.

Compulsions are repetitive behaviours (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently), the goal of which is to prevent or reduce anxiety or distress, not to provide pleasure or gratification. In most cases, the person feels driven to perform the compulsion to reduce the distress that accompanies an obsession or to prevent some dreaded event or situation. For example, individuals with obsessions about being contaminated may reduce their mental distress by is washing their hands until their skin is raw; individuals distressed by obsessions about having left a door unlocked may be driven to check the lock every few minutes throughout an entire night. By definition, compulsions are either clearly excessive, or are not connected in a realistic way with what they are designed to neutralize or prevent. The most common compulsions involve washing and cleaning, counting, checking, requesting or demanding assurances, repeating actions, and ordering.

By definition, adults with OCD had at some point recognized that that obsessions or compulsions are excessive or unreasonable. This requirement does not apply to children because they may lack sufficient cognitive awareness to make this judgement. When attempting to resist a compulsion, the individual may have a sense of mounting anxiety or tension that is often relieved by yielding to the compulsion. In the course of the disorder, after repeated failure to resist the obsession or compulsion, the individual may give in to them, no longer experience a desire to resist them and may incorporate the compulsions into his or her daily routines.

The obsessions or compulsions must cause marked distress, be time consuming (take more than one hour per day), or significantly interfere with the individual’s normal routine, occupational functioning, or usual social activities or relationships with others. Obsessions or compulsions can displace useful and satisfying behaviour and can be highly disruptive to overall functioning. Because obsessive intrusions can be distracting, they frequently result in inefficient performance of cognitive tasks that require concentration, such as reading or computation. In addition, many individuals avoid objects or situations that provoke obsessions or compulsions. Such avoidance can become extensive and can severely restrict general functioning.

The two proven treatments for OCD are medication and a cognitive behavioural treatment called Exposure Plus Ritual Prevention. Aside from the serotonin reuptake inhibitors (Paxil, Zoloft, Luvox), the most effective medication for treatment of OCD is the tricyclic antidepressant, Clomipramine (Anafranil). The drugs have the clear benefit in that they are helpful for approximately 50% of people and they do not require much effort to take. The downside to medication treatments are unwanted side effects (e.g., dry mouth, sleep changes) and the fact that most people who withdraw from medication have a return of OCD symptoms.

Cognitive-behavioural therapy in the Form of Exposure Plus Ritual Prevention requires repeated, prolonged confrontation (from forty minutes to two hours) to situations or objects that evoke obsessional distress. In addition, the client must abstain from rituals, despite strong urges to ritualize. Exposure can be conducted in imagination or in reality. Exposure is generally gradual, with the client confronting situations that provoke moderate distress before confronting more upsetting ones. Advantages of this form of therapy are that 75% of individuals who complete cognitive-behavioural therapy do well immediately after treatment and in the long run. The drawbacks to this form of therapy are the substantial effort required and the degree of emotional challenges experienced by clients.