Obsessive compulsive disorder
(The psychiatry bible)
Obsessive compulsive disorder
- Either obsessions or compulsions:
Obsessions as defined by (1), (2), (3), and (4):
- recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
- the thoughts, impulses, or images are not simply excessive worries about real-life problems
- the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action
- the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)
Compulsions as defined by (1) and (2):
- repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
- the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive
- At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children.
- The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships.
- If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an Eating Disorders; hair pulling in the presence of Trichotillomania; concern with appearance in the presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence of a Substance Use Disorder; preoccupation with having a serious illness in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia ; or guilty ruminations in the presence of Major Depressive Disorder).
- The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
With Poor Insight: if, for most of the time during the current episode the person does not recognize that the obsessions and compulsions are excessive or unreasonable
Sensible Psychology Definition
Overwhelming preoccupation with irrational fears combined with compulsive attempts to reduce the fear through protective behaviours
Commonly known as OCD
OCD is a severe anxiety disorder of the imagination.
The sufferer is constantly assailed by intrusive thoughts presaging some terrible outcome. These thoughts induce very high levels of anxiety and distress which the sufferer (naturally) attempts to alleviate.
The sufferer ‘misuses’ their imagination to generate all kinds of ‘magical associations’ (such as that washing a certain number of times will avert some disaster).
The intrusive thoughts produce uneasiness, apprehension, fear, or worry. These thoughts sometimes (though not always) produce compulsive behaviours such as checking, hoarding, avoiding certain numbers, cleaning and washing or opening and closing a door a certain number of times.
The actions are meant to reduce tension and fear and often do so for a little while.
Sometimes the thoughts produce the fear that the sufferer will or might indulge in some criminal or sexual activity which would be awful if carried out. Sometimes the sufferer may worry they have done something terrible without remembering it.
OCD sufferers usually know that what they are doing is irrational but it doesn’t feel irrational – and that’s the problem.
Obsessive Compulsive Disorder: The eternal search for reassurance
I once worked with a man who told me that, when he went on a plane, he would worry about the safety of the plane as a kind of ‘insurance policy’. When I asked what on earth he meant, he said: “Well. if I didn’t worry, I would worry that by not worrying I would be tempting fate and the plane might crash!” He felt that his worrying in some way kept the plane airborne and could help avert disaster.
He was no fool. He knew this was a little unscientific, to say the least, but it worked for him. He’d never been in a plane crash, had he? It’s like the old joke – Why did the Frenchman sprinkle salt on the road? To keep the elephants away, of course. But there aren’t any elephants in France! See, it works!
This is the very heart of Obsessive Compulsions. What the sufferer fears is the consequences of not carrying out the OCD ritual or, in the case of the man in the plane, not thinking certain repetitive thoughts and worries.
Where do the weird rituals come from?
When wild animals are locked up in tiny spaces they become anxious and as a result may begin to engage in repetitive behaviours such as scratching, biting, and prowling up and down. (1) If these animals could count then they might well count repetitively, or say words over again. Stress makes us want to do something and if there is nothing obvious to be done (such as run away from a stress-inducing lion) then we will find stuff to do. And this might include repetitive actions.
Obsessive Compulsive Disorder: Am I crazy?
Those experiencing OCD will often worry that they are ‘going crazy’. But these people are not mad – just anxious. I’ll often explain to them that anxiety likes to have a focus. Just as water needs a channel to give it shape so that it can flow so too, when we feel anxious and there is no obvious cause for anxiety, our minds will busily concoct stuff to be anxious about – even if we have to ‘shape’ the anxiety through our imagination.
Magical thinking and Obsessive Compulsive Disorder
We all have deep in-built emotional needs to:
- feel safe and secure to a reasonable degree
- feel we have control – or at least a good level of influence – over our lives and environment.
When these emotional needs are not met adequately and appropriately, we may blindly try to meet them by developing predictable and reliable rituals as a substitute. This is, essentially, an attempt to make us feel safe through routine and the familiar – even if the ‘familiar’ is washing your hands a hundred times a day. The attempt to feel safe then becomes a habit in itself and, paradoxically, can make people feel even less in control.
Magical thinking is a common human response that can be seen in all cultures (and many religions). It makes a completely unwarranted but emotionally powerful causal connection between one thing and another. For example, although there is no possible connection between the number of times you check that the door is locked and the risk to your children of getting run over by a car, the OCD sufferer strongly feels and believes that carrying out this checking will directly avert this disaster (or whatever disaster it is that they are obsessed with).
The addictive nature of OCD
An important aspect of OCD not addressed in the DSM classification is how addictive it can be.
Just as with an addiction, the OCD sufferer may
- constantly think about or plan their next ‘fix’ of compulsive activity
- feel a build up of stress if they haven’t been able to get that fix by carrying out their compulsive behaviour
- become agitated if others try to stop them carrying out ritualistic behaviour
- experience habituation – that is, the more they do it, the more they feel they need to do it
- experience withdrawal – especially if the underlying anxiety hasn’t been appropriately dealt with
- use the compulsive behaviour as a way of escape from the problems of everyday life because of its trancelike effect
Treatment for Obsessive Compulsive Disorder
No clear cause has been established for OCD, although theories have been put forward that it may be genetic, and/or due to a faulty serotonergic system in the brain.
As with many anxiety conditions the following (I’m tempted to say ‘the usual’) drugs are often prescribed.
Common drug treatments
Block the stimulating effect of adrenaline and other stress hormones and so can reduce physical symptoms like trembling and sweating
No effect on emotional symptoms of anxiety.
Possible side effects
- poor sleep (2)
- sexual dysfunction
Most commonly prescribed: Paxil; Zoloft (SSRIs) Effexor (SNRI)
Alter the balance of serotonin (SSRI) and norepinephrine (SNRI) in the brain.
No more effective than placebo in treating depression or anxiety disorders.(3)
- sexual problems
- sleep disruption
- weight gain
- dry mouth
- gastrointestinal problems
- abdominal pain
(colloquially known as Benzos)
Increase the efficacy of a natural brain chemical (GABA) that reduces neuronal activity, inducing a calming effect.
Sedative and addictive.
- decreased alertness and concentration
- negative impact on driving skills (4) (5)
- long term use has been implicated in deterioration of mental and physical health (6)
The sensible psychology approach
To treat obsessive compulsive disorder successfully, we need to deal with the fear of not thinking or not doing something obsessively.
Just as we can fear the inclusion of something in our environment (such as a mugger!) so, too, we can fear the exclusion of something (such as a partner leaving us). In the case of OCD, the fear is focussed on what might happen if the ‘insurance policy’ isn’t paid, that’s to say, the compulsive activity isn’t carried out.
The hypnotic qualities of OCD
We regularly use hypnosis to help lift people out of problem states. From our point of view, it is noteworthy that OCD clients typically report ‘trancing out’ when they are engaging in their obsessive thoughts or compulsive acts.
The obsessively hoovering Sally was a case in point:
“When I am vacuuming I simply can’t think about anything else. I am totally zoned out. Only this cleaning is real and solid to me. Hours can pass without my noticing how long I’ve been doing it.”
Obsessive thoughts and compulsive actions narrow the focus of attention and are therefore ‘hypnotic’. Time seems to disappear and it’s hard to think of anything else.
This means that OCD sufferers are often (inadvertently) adept at developing trance states – but the wrong kind of trance state. One of our goals in treating OCD is to teach them how to develop positive trance states that prevent them from falling into the OCD trance.
So we will use hypnosis to
- help them relax deeply (OCD is emotionally and physically exhausting)
- teach them how to calm down emotional arousal and fears
- separate the OCD from their core identity, so it no longer feels like ‘part of who I am’ and is thus easier to detach from
- rehearse feeling relaxed about not engaging in the OCD behaviour or thought patterns
- rehearse comfortably engaging in other activities and pursuing their true goals
Obsessions and compulsions hold out an enticing but entirely false promise of peace of mind. The OCD sufferer who learns how to manage their own emotional states and successfully meet their own real human needs in ways that are satisfying to them can escape those compulsive shackles. For good.
- Behaviourists call these behaviours stereotypies; veterinarians prefer the term compulsive disorders. These are behaviours that an animal does over and over again, in an identical pattern. A familiar example is animals confined in a zoo who pace back and forth in their pens. Often, these enclosures are too small and the animals don’t have enough to do. See Mental health and well-being in animals by Franklin D. McMillan, 2005
- Stoschitzky K, Sakotnik A, Lercher P, et al. (1999). “Influence of beta-blockers on melatonin release“. Eur. J. Clin. Pharmacol. 55 (2): 111-5.
- See: The Emperor’s New Drugs: Exploding the Antidepressant Myth (2009) by Irving Kirsch.
- Rapoport MJ, Lanctôt KL, Streiner DL (2009). “Benzodiazepine use and driving: a meta-analysis”. J Clin Psychiatry 70
- Orriols L, Salmi LR, Philip P (2009). “The impact of medicinal drugs on traffic safety: a systematic review of epidemiological studies“. Pharmacoepidemiol Drug Saf 18 (8): 647-58.
- Longo LP, Johnson B (2000). “Addiction: part I. Benzodiazepines-side effects, abuse risk and alternatives“. Am Fam Physician 61 (7): 2121-8.
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