Obsessive Compulsive Disorder

Description
Sometimes called the doubting disease, Obsessive Compulsive Disorder (OCD) is characterized by
obsessions (uncontrollable and persistent thoughts and urges) and compulsions (repetitive excessive
behaviors or mental acts that a person performs to either reduce the anxiety caused by obsessive
thoughts or ward off calamity.) In order to receive a diagnosis of OCD, the obsessions and compulsions
must cause marked distress, are time consuming (more than one hour a day), or otherwise impair the
person's life. (American Psychiatric Association, 2000)
OCD is not to be confused with Obsessive Compulsive Personality Disorder; an inflexible trait
characterized by perfectionism. It is a disorder that involves thoughts or behaviors that people experience
often times as silly or excessive, but nearly impossible to stop.
Common obsessions include fear of sexual or aggressive impulses and contamination. To relieve many
of these obsessions, people will perform compulsions that are seen as magically protective (i.e.
counting, touching body parts, saying special words and phrases or by pursuing cleanliness through
elaborate rituals.) Another common compulsion involves repeatedly checking to ensure that certain acts
are carried out (i.e. checking for the tenth time to see that the door is locked and the oven or coffee pot is
off) (Kring, A.M., Davison, G.C., Neale, J.M., Johnson, S.L., 2007).

According to the National Institute of Mental Health (NIMH), OCD affects approximately 2.2 million
American adults (age eighteen and older) a year. In other words, about 1.0% of people in this age group
in a given year have OCD (The Numbers Count, 2007). According to Kid's Health, an estimated 2 percent
of children in America (usually diagnosed between seven and twelve) are diagnosed with OCD (Kid's
Health, 2007).

Etiology
No one knows for certain what causes OCD, but we do know that there are several factors that contribute
including neurobiological, behavior and cognitive factors.

Biological Factors
First, brain imaging studies have shown that the orbitofrontal cortex, the caudate nucleus and the anterior
cingulate are overactive in the brains of people with OCD. As to whether or not this overactivity drives the
OCD symptoms, or the symptoms drive the overactivity is unclear (Kring et al., 2007).
The apparent interplay between these parts of the brain is best described by Hyman and Pedrick (2005)
where they explain the following scenario:

Shows
like the
popular
"Monk"
bring
OCD to
light


Imagine all these parts of your brain screaming at you when your OCD symptoms are at their worst:
The thalamus sends messages from other parts of the body , making you hyperaware of everything going
on around your.
The caudate nucleus opens the gate and lets in unwanted intrusive thoughts.
The orbital cortex mixes thoughts with emotions, then tells you, Something is wrong here! Take cover!
The cingulate gyrus tells you to perform compulsions to relieve the anxiety the rest of your brain has
heaped on you.
Meanwhile, your synaptic clefts are screaming, Send in some more serotonin! Were running short here!
( p. 26, Hyman, B.M., Pedrick, C., 2005)

In addition to biological factors, there are behavioral and cognitive factors also at work. Some behavioral
models show that compulsions are reinforced because they reduce anxiety (Meyer& Chesser, 1970 as
cited in Kring et al., 2007)) For example, by checking to make sure that the iron is off, I would alleviate my
fear that the house will burn down if the iron were left on. Due to the temporary relief it provides, the
behavior is then continued.

Cognitive Factors
Cognitive explanation suggests that certain aspects of the disorder, repeated checking compulsions in
particular, can be due to the lack of confidence in the memory. "A meta-analysis of 794 people who had
taken part in twenty two studies suggested that people with OCD are unduly concerned about gaps in
their memory" ( p. 149 Kring et al., 2007 ).

Another cognitive factor lies in thought suppression. Researchers have discovered that:
1. People with OCD tend to believe that thinking about something can make it more likely to occur
(Rachman, 1997 as cited in Kring et al., 2007).
2. People with OCD are also likely to describe especially deep feelings of responsibility for what occurs
(Ladoceur et al., 2000, as cited in Kring et al, 2007).

Therefore, people with OCD are more likely to suppress thoughts. As a result, thought suppression can
actually have a paradoxical effect as research demonstrates. In other words, rather than extinguishing a
thought when trying to suppress it, your preoccupation with it actually becomes stronger! (Wegner et al.,
1987 as cited in Kring et al. 2007). Thought suppression contributes to the maintenance of OCD as well,
because the people with OCD are those that are more likely to give reasons for why they should suppress
thoughts (Kring et al., 2007).

Treatment
The scientific and clinical advances of the last thirty years have brought new hope for treatment of
OCD. Studies have shown that Exposure and Response Prevention (ERP) along with Cognitive Behavior
Therapy (CBT), and certain medications like serotonin reuptake inhibitors (SRIs), are proven effective in
the treatment of OCD.
Thus far, the most effective and widely used treatment for this disorder is ERP. The purpose of this
treatment is to eventually stop the rituals. In other words, if rituals (i.e. compulsions) are maintained
largely because they reduce the anxiety of the obsession, then the goal of ERP is to get the person to
expose themselves to a compulsion producing situation and then refrain from doing the compulsion. For
example, the contamination fearing person that touches the dirty laundry abstains from washing their
hands. One of the principles at work is called habituation. Habituation occurs when our nervous system
gets used to stimuli through repeated contact. For example, one of the most common treatments for
people who are plagued with intrusive thoughts (i.e. of a sexual or aggressive nature), is to have them
speak these thoughts into a tape recorder that has a loop tape and play it back to themselves. Through
habituation, the thoughts lose their shock value and diminish. Another example is of real-life or in
vivo exposure where the person is exposed to a real-life fear situation. For example, the same person
that feared touching the laundry in our earlier example, actually touches the laundry and abstains from
washing their hands. When they are not hurt or contaminated from this act, the fear decreases. This
treatment may sound simple enough, but to those suffering from OCD, it can seem like a terrifying
impossibility. ERP is best done in stages, where it can be introduced at a gradual pace. (Hyman, B.M.,
Pedrick, C., 2005)

The more CBT natured approaches to treatment, involve challenging the persons thoughts about what
will happen if they are to cease their compulsions. This includes engaging faulty beliefs that people with
OCD often hold. Some examples are magical thinking (i.e. if I think something bad, it will happen), What If
thinking (What if I die in the plane down to Fresno?) and Hypermortality (I will go to hell if I make a
mistake). Merely thinking about the faulty thoughts without an action (like ERP) to back it up is often not
enough, however CBT can enhance the treatment when coupled with an action like ERP.

Finally, serotonin reuptake inhibitors and some other antidepressants can be helpful in treating OCD. In
one study an SRI called clomipramine led to a 50 percent reduction in symptoms (Mundo, Maina, &
Uslenghi, 2000 as cited in Kring et al, 2007). Though this was an improvement, the test subjects still had
ongoing symptoms after treatment. It has also been shown that people are likely to relapse after stopping
the medications (Koran et al., 2002 as cited in Kring et al. 2007). According to Kozak, Liebowitz, & Foa,
adding clomipramine to ERP is no more effective then ERP alone (p 151 cited in Kring et al.). Yet,
medications can act quickly on symptoms of depression and anxiety which seem to accompany OCD. It is
reasonable to assume then that if these symptoms are debilitating, then medication should be taken in
conjunction with the ERP to ensure the treatments efficacy