Fig. 12.1
The OCD cycle
12.2 Epidemiology
OCD is estimated to be the fourth most common psychiatric diagnosis, preceded by phobias, substance abuse, and major depressive disorder. The World Health Report 2001 estimates the burden of OCD to 2.5 % of the total global YLDs. Weissman et al. (1994) examined the prevalence of OCD in diverse cultures (Cross-National Collaborative Study) and reported lifetime prevalence of 1.9–2.5 %.
Onset of OCD is generally in late adolescence and adulthood, though in some cases symptoms may begin in childhood. When onset is in adolescence, boys are more likely to be affected than girls—about 60 % of patients are male possibly due to the earlier age at onset in males (Reddy et al. 2000). OCD typically appears to be a chronic disorder with a waxing and waning course. Demal et al. (1993) differentiated five courses of OCD: continuous and unchanging (27.4 %); continuous with deterioration (9.7 %); continuous with improvement (24.4 %); episodic with partial remission (24.2 %); and episodic with full remission (11.3 %).
OCD frequently co-occurs with other disorders. Most often, OCD is found to co-occur with major depression. Comorbidity with panic disorder, phobias, and eating disorders is also observed fairly commonly. Studies have also found a striking comorbidity between OCD and Tourette’s syndrome.
12.3 Clinical Features
Obsessions and compulsions are the primary features of OCD. Most people with OCD report both obsessions and compulsions, with some studies reporting figures as high as 90 % (Foa 1995). Another key feature is the distress that accompanies the obsessions—this distress may manifest itself in the form of anxiety, dread, disgust, or guilt among others. Compulsions serve as a means to reduce this distress and generally seem to the individual to be “beyond control.” Both obsessions and compulsions are viewed as irrational and excessive by most affected individuals, even when intense and vivid, and are known to be a product of his/her own mind. Though this is true for most cases, in some cases, OCD may be associated with poor insight.
Contamination fears may include intense anxiety or concern regarding germs or dirt, bodily fluids (saliva, urine, blood, etc.), contact with certain places, surfaces, people, or animals. They may fear coming in contact with germs or other contaminants for fear of contracting an illness and/or passing it on to others. In some cases, this fear of contracting an illness may be replaced by a generalized and overwhelming feeling of disgust or “being dirty.” What constitutes a “contaminant” may vary from individual to individual—while some may show fear of germs or dirt and some may extend this fear to other substances such as sticky substances such as glue, bodily fluid, and household items such as cleaning agents among others (Table 12.1).
Table 12.1
Common types of obsessions
Common types of obsessions | |
|---|---|
• Contamination fears | • Fears of harming self or others |
• Pathological doubt | • Sexual obsessions |
• Religious/moral obsessions | • Concerns about symmetry and order |
Fears of harming self or others may include intense anxiety or concern regarding harming other people without seriously intending to, being responsible for harm caused to others, not doing anything to prevent harm to self or others, and excessive concerns regarding certain unlucky numbers/dates.
Pathological doubt involves intense anxiety or concern that something terrible may happen because they have not completed an act thoroughly or completely.
Sexual obsessions may include intense anxiety or concern regarding perverse sexual ideas, repetitive forbidden sexual topics, perverse/unwanted sexual images, doubts regarding sexual orientation, and fear of committing sexual aggression (rape, etc.).
Religious and Moral Obsessions, or Blasphemous thoughts, involve repetitive blasphemous ideas—abuses/perverse imagery related to God, excessive concerns about morality or scrupulousness and ideas of right and wrong, excessive concerns about sin and punishment.
Excessive need for symmetry and order involves intense anxiety or concern regarding exactness/sameness, order and arrangement and excessive attention to, and concern regarding even or odd numbers (Table 12.2).
Table 12.2
Common types of compulsions
Common types of compulsions |
|---|
Checking—repeatedly checking locks, gas stoves, keys, money, etc. |
Counting—counting associated with routine activities, e.g., counting the number of stairs being descended, counting the number of times a switch is turned off, counting until ten before descending every step, etc. |
Ordering/arranging—fixing everything over and over again until it feels “just right,” such as fixing paintings on walls properly, and arranging and rearranging one’s own cupboard or table |
Cleaning—washing hands, taking excessively long time in the shower, repeatedly cleaning objects around the house such as clothes constantly cleaning the house |
Repeating—this may involve repeating routine activities, repeating what is being said by self or others, etc. |
Apart from these common types of compulsions, some people may experience a compulsion to perform routine activities extremely slowly, a phenomenon known as primary obsessional slowness. In other cases, an individual may be compelled to not throw away things that are not necessary or to collect things thrown away by others with the belief that they may belong to them, in what is known as hoarding.
In recent years, the concept of mental compulsions and rituals is also coming to light. For example, an individual may not perform an outward, overt act to neutralize his anxiety but may silently repeat prayers a fixed number of times to do the same. The prayer then comes to serve as a covert compulsion or mental ritual. Often, an individual may not engage in the compulsion directly but may insist on family members or significant others performing the act. For example, an individual who has been instructed to refrain from excessive cleaning may insist that his family members clean all items thoroughly before they are handed over to him, thereby reducing his anxiety while not engaging in the compulsion directly. This phenomenon of transferring responsibility for the compulsion, known as proxy compulsions, is especially important in therapy along with that of mental compulsions.
12.4 Cognitive Behavioural Conceptualization of OCD
Many cognitive behavioural theories now emphasize that the problem of OCD is not limited to thoughts, but is the result of a set of reactions to what would otherwise be considered normal intrusive thoughts. These reactions could range anywhere from anxiety to guilt and heightened responsibility and personal significance, with consequent efforts at suppression. The crucial difference between normal intrusive thoughts and obsessions lies in the meaning attached by the adolescent to these thoughts and their intrusive nature.
12.4.1 Cognitive Biases in OCD
Personal meaning/significance of thoughts: Many individuals with OCD believe that their intrusive thoughts hold personal significance to them or are reflective of their character. For example, blasphemous thoughts are especially intrusive to those who may believe themselves to be god loving/fearing people and may generate distressing thoughts about these beliefs such as “If I have such thoughts about God, it means I am a bad person,” “Having such thoughts about God reflects on my true character,” etc.
Thought–action fusion (Rachman 1993): This refers to the belief that having a thought about doing something is equal or equivalent to having performed that action and that thoughts of possible dreaded consequences/misfortunes increase the likelihood of their occurring. For example, a woman having thoughts about harming her child believes that it is as bad as actually harming the child and that such thoughts increase the likelihood that she will harm her child.
Inflated sense of responsibility (Salkovskis 1985): The idea that the probability of a disaster is higher if they are responsible, even if they have no control over the outcome. For example, an adolescent suffering from OCD may believe that harm may come to his family if he does not wash his hands repeatedly—this sense of inflated responsibility for his family’s well-being drives him to perform the compulsive acts.
Non–specific cognitive biases: Other biases may include:
Overestimation of the likelihood that harm will occur
Belief in being more vulnerable to danger
Intolerance of uncertainty, ambiguity, and change
The need for control
Excessively narrow focusing of attention to monitor for potential threats
Excessive attentional bias on monitoring intrusive thoughts, images, or urges
Reduced attention to real events.
12.4.2 Behavioral Perspectives
Put simply, the paradigm of operant condition can be used to explain compulsions. Following the anxiety produced by obsessive thoughts which is experienced as distressing, compulsions serve to neutralize the anxiety and this relief is experienced as reinforcing. Therefore, viewed classically, this negative reinforcement maintains the compulsive behavior.
Mowrer’s two process theory (1960) is a more elaborate account of acquisition and maintenance of compulsion and avoidance behaviors. According to this theory, classical conditioning explains how a neutral event acquires the capacity to induce arousal or anxiety by means of pairing with aversive event, thought, or impulse. As explained, compulsions act as negative reinforcers and are therefore maintained. The theory also accounts for avoidance, and since the triggers are actively avoided, the individual never gets the opportunity or required exposure to learn that anxiety relief may also be experienced without performing the compulsions; hence, extinction of the responses becomes difficult. Also, avoidance limits any opportunities for habituation of anxiety.
12.4.2.1 Case Vignette
A is a 13-year-old male belonging to middle socioeconomic strata and studying in class IX in a private school in urban setting. He was brought to the therapist with complaints of prolonged hours spent taking bath and repetitive washing of his hands and feet since past one and a half years. They also reported that he appears distressed and preoccupied at all times, yet does not share his troubles on being asked.
A was maintaining well until one and a half years back. Parents noticed a change in his behavior when he refused to attend the diwali puja held at his home and became agitated when his parents insisted on the same. They noticed that he did not take part in the festivities at all and remained aloof from family members. Gradually, he started interacting with family members as before but continued to appear distressed. They noticed that after some time, he started spending long hours in the shower which escalated to 3–4 h at the time of intake. He was also observed to continually wash his hands 7–8 times over a number of times per day. Sometimes they would see him mumbling something to himself. This is when they got worried and brought him for a referral.
On interview, A reported that he had experiences great distress during the puja before diwali. He felt “uncomfortable” looking at pictures and idols of God, and abusive words kept coming into his mind no matter how much he tried to block them or distract himself. He became very scared and refused to participate in the prayers the following week. He was too scared to tell his parents as he thought they would reprimand him for his bad thoughts. However, he was constantly troubled by the idea that he had those thoughts, and after a while, the bad words about God kept coming into his mind even without looking at pictures or participating in prayer. He felt that he had committed a terrible sin and thus felt that he needed to cleanse himself. He started spending long hours in the shower and would go wash his hands and feet every time an abusive word came to mind. He noted that the frequency and intensity of cleaning had increased over time, and the distress due to these words had also increased. He lived in constant fear that he would be punished and frequently apologized verbally to God and prayed for forgiveness—what his parents had observed as mumbling.
As a result of his troubles, he stopped participating in family prayers and going to temples, kept a close watch on himself to avoid meeting priests or accidentally viewing pictures of God, and kept a constant vigilance on his thoughts in an attempt to control them. He reported that all this left him exhausted and he was always tired and anxious, and that his school work was beginning to suffer.
12.4.3 Cognitive Behavioural Formulation
12.5 Assessment
Assessment in OCD involves a detailed procedure that goes beyond general intake and administration of clinical scales. Key components to be evaluated in the clinical interview include cognitive, behavioral, and emotional aspects.
Cognitive aspects include form and content of obsessions, cognitive neutralizing, and avoidance.
In the presented case, for example, the form and content of sexual imagery—whether thought, impulse, or action—is to be determined. Triggers for the obsessions such as visiting temples, seeing idols and pictures of God, attending prayers, etc. are explored. Cognitive neutralizing is seen in the form of repeating prayers and apologizing to God mentally.
Beliefs relating to the obsessions are explored. For example, in the present case, A’s beliefs about the obsession, and his idea about why he has them and why they persist is discussed. The personal meaning of his obsessions is explored, that is, what he thinks it means when he has these obsessions and what they reflect about him. The distress associated with his evaluations of these beliefs or his misinterpretations is explored.
Behavioral aspects include triggers for obsessions, avoidance, ritualizing, reassurance seeking, and proxy compulsions.
In the present case, these can be seen in the form of triggers such as going to the temple, avoidance of prayer and temples, and overt compulsions such as constant cleaning to “remove sin.” It is also essential to note if the adolescent is indulging in any proxy compulsions such as asking the family to pray/clean, etc.
Emotional aspects include mood changes associated with obsessions and temporal nature of the association.
In the present case, A reported that he experiences intense guilt along with the obsessions and therefore tried to suppress or forget them. When he failed to control his thoughts, he started feeling anxious and depressed and noted that whenever he felt intense anxiety or low mood, his obsessions would return. He reported that he almost always noted this “cycle” where his bad mood would cause him to dwell on obsessions, which would further increase his anxiety and low mood, making it difficult to focus on other things or carry out other activities.
Assessment of dysfunction due to illness is also essential. It is important to note what area of the adolescent’s life is directly or indirectly affected by the illness behavior. This may also provide important cues to identifying avoidance.
For example, A reported that he avoided all family functions since some form of prayer was always involved. Because of this, he reported that his cousins made fun of him and called him a loner. He felt that he was constantly bullied, and his family thought he was just being dramatic to get away from prayers because he thought they were boring. His studies were starting to get affected as he felt that he would not be able to do well in exams without praying, and because he was now a sinner, God would punish him by making him fail his examinations, so why should he study.
Some common clinical scales used for assessment, specifically in OCD, are enumerated below.
Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Goodman et al. (1989)Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
