Obsessive–compulsive disorder

The characteristic features of obsessive–compulsive disorder (OCD) are obsessions and compulsions which interfere with a person’s ability to cope with their daily life.

Obsessions, also known as obsessional ruminations, are unpleasant or distressing thoughts, impulses or images that come to mind over and over again, despite conscious efforts to stop them (Fig. 1). They dominate the person’s mind and the sufferer is unable to distract themselves, leading to impairment of social and occupational function. Common themes for obsessional thoughts include violence, sex, contamination and blasphemy. Obsessional images may be of violent or gory scenes that come vividly to mind again and again, and cannot be ignored or suppressed. An obsessional impulse might be a recurrent impulse to hurt someone, usually someone the sufferer would not consciously wish to hurt. Such impulses are distressing and it is uncommon for people to act on them. It is important to distinguish obsessional thoughts from thought insertion, a first rank symptom of schizophrenia, in which the patient believes they are experiencing thoughts that are not their own. In contrast, obsessional thoughts are always recognised as arising from the patient’s own mind.

Fig. 1 Obsessions – repeated and unpleasant thoughts, impulses or images.

Compulsions consist of a strong urge to perform an action or complex series of actions repeatedly, even though they are recognised as unnecessary. Compulsions can often be resisted for short periods, but this is usually associated with increasing levels of anxiety that can only be relieved by performing the compulsive act. Compulsions can take very many forms (Fig. 2), but the commonest are:

hand washing and other cleaning behaviours

counting, e.g. repeatedly counting objects in a room or avoiding particular numbers

checking, e.g. returning home again and again to check the oven has been turned off or the door is locked

touching, e.g. feeling compelled to touch each wall of every room entered

arranging objects in lines, patterns, numbers, etc.

Fig. 2 Compulsions.

Complex rituals incorporating many of these compulsive acts may be developed and can cause substantial functional impairment.

The clinical picture in OCD is very variable. Patients may have obsessions only, compulsions only, or a combination of both. There is a very close relationship with depressive disorder. About 70% of cases have at least one episode of depressive disorder at some time in their life, and the two disorders can coexist. Patients with depressive episodes can develop obsessional symptoms without having full-blown OCD and in these cases treatment of the depressive disorder is usually enough to resolve the obsessional symptoms completely without other more specific treatments.

Related posts:

Mood stabilisers and ECT Old age psychiatry I Diagnosis and classification of schizophrenia Anxiety disorders – clinical presentation and aetiology Old age psychiatry II Personality disorders – introduction and classification

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