Obsessive-Compulsive Disorder

Obsessive-Compulsive Disorder (OCD) is symptomatically characterized by recurrent and persistent thoughts, mental acts, or behaviors that people feel driven to enact. Individuals with OCD typically attempt to fight general anxiety by focusing on repeated thoughts and acts that can then be addressed and controlled.

Clinical Presentation

Obsessions are unwanted, repeated, persistent thoughts, images, or urges that the individual cannot ignore and that produce some level of anxiety or distress.

More often than not, obsessive thoughts are linked to compulsive mental processes or behaviors that the person feels he or she must do. Much of the time, compulsions are related to body functions or body experiences.

A person with obsessive thoughts about dirt or germs may feel driven to wash him or herself multiple times an hour. Because there is preciseness to both the thoughts and the actions, compulsionsOpens in new window tend to occur on a relatively regular schedule. The individual may wash his/her hands and arms every 15 minutes or a person may re-set a room every time upon entering.

DSM-5 Characterization

Individuals diagnosed with Obsessive-Compulsive Disorder must experience either obsessionsOpens in new window or compulsionsOpens in new window or both. In addition, the individual must be making an attempt to ignore the obsessions and/or reduce the anxietyOpens in new window, often by enacting the compulsion. The compulsion, however, is not realistically designed to handle or prevent the distress or the compulsive behaviors are clearly excessive.

The diagnosis requires the obsessionsOpens in new window and compulsionsOpens in new window to be time consuming, taking up more than an hour per day, and they must cause significant distress or impairment in social, occupational, or other forms of functioning. Approximately 30% of males who develop the disorder in childhood will also meet the criteria for Tic DisorderOpens in new window. About half of those diagnosed with Obsessive-Compulsive Disorder (OCD) will entertain suicidal thoughtsOpens in new window at some time during the course of the disorder.

Case Example: Jack N.

Jack was a 45-year-old male who had attented Columbia University and majored in Journalism. He had worked at several newspapers before joining a city broadcast-news organization, where for several years he was both a weekend anchor and the male host of a morning news and entertainment program.

Jack was a handsome man with a great television presence that made both guests and the audience feel at ease. It was during a morning interview with a psychiatrist who had recently written a book on Obsessive-Compulsive Disorder that Jack began to believe that he might have the disorder. He actually said so on the air, which led the station management to suggest that he take a camera team to his home to demonstrate what he believe may be his compulsive behaviors.

Jack was married, and he and his wife had two teenage daughters. They lived in a rather lavish two-story apartment in the city, that had large picture windows and beautiful wood floors. Twenty-two oriental rugs of varying sizes covered the floors, and all of these rugs had woven fringe on each end.

The minute that Jack entered the apartment, he felt compelled to make sure that each strand of fringe was perfectly straight. He had a flipping process for the smaller rugs that lined up some of the fringe, but in all cases, he would use one of seven combs he had purchased or made to comb out the fringe on each side of each rug.

While moving from rug to rug, he would also straighten out figurines on his mantel, move chairs and table back into place, or put papers and the mail in neat piles. The process took over two hours every time he came home. He knew it was unreasonable for him to expect such order, especially with two teenage daughters, but his anxiety would be overwhelming if he did not engage in his “rituals.”

The camera crew caught a glimpse of his daughters’ rooms, and, as might be guessed, both rooms were a mess—or as Jack described them, “a disaster.” He would occasionally sneak into “the girls’ rooms” when they were gone and clean every inch, putting everything in its correct place. The cleaning did not usually last all day, and his daughters never commented on it. No one bothered Jack anymore when he was straightening the house. His wife would occasionally greet him, but even that seemed to be ignored while he went about the process of straightening up.

Jack was considered one of the most engaging personalities on television in New York City, but at home, he hardly interacted with his spouse or his daughters, who long ago had given up on getting Dad to participate in the real life of the family.

What becomes clear is that Jack is in retreat from family life. His obsession with orderliness and his compulsion to straighten everything when he comes home occupies and fills his time so that he does not have to be a responsible spouse or a parent. He elevates his compulsion over connection with family and the activities of others. if the family were to simply remove all the rugs, Jack would slip into an anxiety attack that would incapacitate him even more. It is the back-up plan if what Adler (1932/1970) called “the compulsion neurosis” does not work out.

Biopsychosocial – Adlerian Conceptualization

People with OCD were more than twice as likely to have an immediate adult family member with OCD than not, with genetics affecting perhaps some of the familial tie. Sexual or physical abuse or trauma in early childhood increases the risk of the development of OCD.

Psychologically, obsessionsOpens in new window and compulsionsOpens in new window always reflect negativity and a need for order. The issue of control is paramount in the person’s life. The practice of obsessive-compulsive processes is a distraction from relationships and tasks in which others enage on a daily basis.

Males are more likely to have early (childhood/adolescence) onset of the disorder, more likely to have a comorbid Tic Disorder, and more likely to entertain inappropriate thoughts or seek symmetry in everything. Females tend to be more focused on body images or cleaning processes.

People with Obsessive-Compulsive Disorder use anxietyOpens in new window in one of two ways: It can be an excuse for avoiding or derailing their participation in necessary tasks in life — especially related to work or intimacy and family relationships; and it can be the assumption of a priviledged or powerful position in social and family relationships that serve to assert the necessity of perfection and the individual’s need to pursue it.

It is this development of an obsession or compulsion that diverts the insecure person from the more important life tasks of friendship, family, and work. By engaging in these more manageable processes, the individual retreats from more cooperative and life-sustaining efforts to keep busy with less meaningful tasks.

Those with OCD invest these obsessions and compulsions with such significance and importance that they must be performed in a ritualistic and often perfect manner. Further, they are the only people who can perform the tasks adequately, thereby elevating themselves and their efforts above the everyday activities and needs of others.

Treatment Considerations

The first considerations in treatment is whether the obsessions and/or compulsions are disturbing to anyone, to the client, or to those with whom the client must interact. In rare cases, no one is particularly disturbed by the thoughts or behaviors, and there is nothing that really needs to be done. In such cases, usually a compulsion is effective at controlling the anxiety.

When compulsive acts do not control the anxiety, or the thoughts and behaviors actually disturb the client or those with whom the client is involved, then treatment is warranted and generally proceeds with desensitization to anxiety-provoking stimuli followed by addressing those tasks of life that the OCD allows the client to avoid. In severe cases of anxiety associated with obsessions or compulsions, selective serotonin reuptake inhibitors, sometimes at fairly high dosages, have been used.

Behavioral therapists call the first step in treatment “Exposure and Ritual Prevention” therapy: It involves exposure to low-level anxiety stimuli without engaging in the compulsive response. Let us say that a person feels infected by the presence of germs and has developed a hand-washing response.

Therapy might start with a relative low level of exposure (a doorknob or a book handled by someone else) coupled with support for avoiding hand washing until the person feels calm again. In the case of Jack (below), it might involve support for entering his house and greeting his wife and children without checking to see what part of his home is out of place.

In the end, all obsessive-compulsive rituals are designed to be a retreat from the social, work, or intimacy tasks that Adler believed were central to all of life. Again, this process of discovery is gratly aided by a life-style assessment and the interpretation and understanding of early recollections (Powers & Griffith, 2012).