Running Head: OBSESSIVE-COMPULSIVE DISORDER
The General Characteristics of Obsessive-Compulsive Disorder with Therapeutical Connections
Selin Yalçın
Abant İzzet Baysal University
Clinical Psychology M.S.
Abstract
The General Characteristics of Obsessive-Compulsive Disorder with Therapeutical Connections
Obsessive-Compulsive Disorder (OCD) is one of the frequently encountered disorders in clinical area which has been raising awareness in terms of the disturbances it creates in variety of settings from family dysfunction to the general standards of living of a client (Martis et al., 2004). This being the case, understanding the complex and comprehensive structure of this disorder in multiple aspects come into prominence. In this paper, it is aimed to give a brief overview about OCD on the basis of the aspects such as diagnostic features, epidemiology, etiology and treatment-related directions.
Basic Definitions
Providing the definitions of the basic components of OCD such as obsessions and compulsions is a convenient point to start describing the disorder.
Obsessions are simply defined as thoughts or images that are recurrent, intrusive disruptive and usually provoke distress and anxiety in the client (Soomro, 2012). These thoughts or images are often found to be difficult to have a control on, as well as self-generated and senseless by the most of the clients (Clark, 2007; Soomro, 2012).
Compulsions, on the other hand, are the behaviors which are triggered by obsessive thoughts or images, which have the motivation to prevent a certain kind of hazardous situations which are thought to be caused by the obsessions (Soomro, 2012). Fulfillment of the compulsions generally reduces the anxiety derived from the obsessions so that the client has an irresistible urge to perform these ritualistic and stereotyped behaviors or mental acts (Clark, 2007; Soomro, 2012).
In obsessive-compulsive disorder both obsessions and compulsions can be present together at the same time in a client, with the neutralizing function of the compulsions over the obsessions, however, there are cases in which only either of them is encountered (Butcher et al., 2013). The symptomatic features of OCD in diagnostic criteria may help us contour our knowledge on this disorder in a more concrete way.
Diagnosis
In DSM-5, which is the latest version of Diagnostic and Statistical Manual of Mental Disorders published in 2013, OCD appears under the category of “obsessive-compulsive and related disorders” which is different from DMS-IV in which the disorder was under the section of anxiety disorders (Thomsen, 2013). In the diagnostic criteria, the definitions of obsessions and compulsions are provided in the frame of the basic features which is mentioned above with a further emphasis on the compulsions being unrealistically linked with what they are intended to neutralize or prevent (APA, 2013). Moreover, the necessary duration of the obsessions or compulsions are stated as 1 hour or more in a day without mentioning of the duration in a weekly or monthly basis, with stressing the malfunctioning in various life contexts (APA, 2013). Furthermore, when giving an OCD diagnose, it is obliged to rule out possible substance or medication-related conditions that lead to obsessions and compulsions and also considering other disorders which may explain the symptoms in a client better than OCD (APA, 2013). Additionally, specifications criteria about the level of insight are identified in DSM-5 as “with good or fair insight”, “with poor insight” and “with absent insight/delusional beliefs” in addition to the specification whether there is a “tic-related” condition in the client (APA, 2013).
The changes between DSM-5 and DSM-IV are seemed to be mostly occurred due to the debate on whether OCD is an anxiety disorder or not, thus the section of OCD in DSM-IV is changed from anxiety disorders to obsessive-compulsive and related disorders in DSM-5 as it is mentioned previously (Thomsen, 2013). The other changes are generally in the frame of insight specifications such as excluding some criteria or differences in the word selections, with an extra caution for the children which identifies that the children cannot be expected to express the aims of their compulsions (APA, 1994; APA, 2013).
In ICD-10 criteria, OCD is under the section of “neurotic, stress related and somatoform disorders” (Thomsen, 2013). In these criteria the duration of the obsessions or compulsions specified as at least 2 weeks and the most important exclusion criteria is about the condition that obsessions and compulsions should not be related to any schizophrenia-related and affective disorders (WHO, 1993).
Looking at the diagnostic criteria, OCD is a disorder that possibly has some overlapping symptomatic features with other disorders. Therefore, to reach the most appropriate diagnosis in a client, it is crucial to differentiate OCD with other disorders having OCD-like symptoms but departs from it with some critical characteristics.
Differential Diagnosis
DSM-5 specifies the differential diagnosis between some other disorders and OCD as follows:
In generalized anxiety disorder (GAD) it is claimed that the thoughts which are intrusive and repetitive are mostly close to the real life issues; however in OCD, these thoughts occur mostly in a way they are irrational to current situations and also in some kind of a magical theme, and also there are compulsions linked to these intrusive thoughts (APA, 2013).
In specific phobia, the anxiety and fear response is due to a particular object as in the OCD, however in specific phobia the object that provokes fear usually has more specific characteristics and the behaviors carried on in response to the anxiety are not in a ritualistic way (APA, 2013).
In social anxiety disorder, the feared situation is specific to the social contexts and the possible behaviors that are displayed is only to reduce social anxiety which is different from OCD that is not only specific to social interactions (APA, 2013).
In major depressive disorder the ruminations resembles the obsessions in OCD; nevertheless in major depression the thoughts are generally connected to the mood and not necessarily perceived as distressing or intrusive and they are not related with the compulsions as in the OCD (APA, 2013).
In eating disorders the obsessions and compulsions are expected to be only related with food and gaining weight which is not specified in the OCD (APA, 2013).
Other related disorders which are under the same category with OCD have also some different characteristics discriminating them from OCD. For instance, in body dysmorphic disorder, most of the time the clients have obsessions and compulsions that are related to their physical appearance; in trichotillomania, hair-pulling disorder, there is only hair-pulling compulsions without the presence of any obsession; and in hoarding disorder the behaviors and emotions concentrate particularly on getting rid of items and feeling distress about it (APA, 2013). However, there is an important point to consider in hoarding disorder which is in the case of the presence of obsessions, such as the worry about incompleteness, that cause the hoarding behavior like collecting items to provoke a sense of completeness, giving the OCD diagnosis might be more appropriate than the hoarding disorder diagnosis (APA, 2013).
Tics which are repetitive and sudden movements that are not rhythmic; and some other stereotyped movements which are recurrent and do not have any function have also distinct characteristics from OCD because they do not aim neutralizing the obsessive thoughts, do not related to obsessions, and they are driven from sensory stimulations from outside which is not the case for OCD (APA, 2013).
For psychotic disorders, in DSM-5 it is suggested that some clients with OCD has poor insight and delusional beliefs, however, in psychotic disorders clients do not display the specific characteristics of obsessions and compulsions with emphasizing that OCD does not have some specific symptoms of schizophrenia-related disorders such as hallucinations (APA, 2013).
There are also some other behaviors that resembles compulsions such as in gambling disorder, sexual behaviors in paraphilias and substance abuse, but the point which differentiates them form OCD is that the client generally have pleasure from these behaviors rather only reduction of the anxiety as happens in OCD (APA, 2013).
The last condition which has differences from OCD is obsessive-compulsive personality disorder (OCPD). OCPD simply does not consist of recurrent ideas, images and behaviors but rather it is persistent disorder that is characterized by strict control and excessive perfectionism (APA, 2013). However, it should not be forgotten that there are cases that exhibits symptoms of both disorders and in that case both diagnosis can be given to the client (APA, 2013).
When the distinct points between OCD and other disorders are clarified, it is better to look into specific obsessions and compulsions which are frequently encountered in the clinical setting in depth.
Some Obsessions and Compulsions
Fear of Contamination
This is one of the most common fears among the clients with OCD which is seen in between 55% and 58% of the cases (Abramowitz et al., 2008). It is characterized by avoiding situations, such using public restrooms, which has the possibility to get microbes and viruses, and also by compulsions like hand washing and cleaning (Leckman et al., 2010).
Controlling Compulsions
Recurrently switching the electric lights, locking and unlocking the doors again and again to control whether they are actually turned off or locked without being sure of it in most of the time are the typical rituals which can generally be called as controlling compulsions (Abramowitz et al., 2008). Here, the clients’ motivation usually is to prevent future dreadful, catastrophic events whereas there is no actual harm or hazardous signals in the environment (Abramowitz et al., 2008). While in some cases these ritualistic behaviors become so time consuming that mostly the client ends up with a physical, emotional and economical breaking down; they are found to be related to some traits such as pathological suspicion, indecision, perfectionism and intolerance to uncertainty (Abramowitz et al., 2008).
Sorting, Insufficency, Organizing Compulsions
These compulsions are related to symmetry obsessions, counting and repeating behaviors which can be show up in various ways such as images or objects, sounds, tactile or properioceptive ways (Abramowitz et al., 2008). The clients usually tries to organize their environment including arranging their items in a symmetrical way and their anxiety level increases in the case of disorganization and dissymmetry but this feeling of anxiety turns into sense of insufficiency and the thought of “there are some things not going in a right way” (Abramowitz et al., 2008).
Other Obsessions and Compulsions
The other frequently encountered problematic thinking styles can be harming impulsions in which the individual thoughts or has images as he or she harms a close one; sexual obsessions occurs in which thoughts or images of harassing someone sexually; the obsessions against religious beliefs like thoughts of swearing in a sacred place (Abramowitz et al., 2008).
Epidemiology
Prevalence
According to the DSM-5, in the United States, it was found that the 12-month prevalence of OCD is 1.2% which is not very different from the international prevalence that is in between 1.1% and 1.8% (APA, 2013). In addition, more than 90% of the OCD cases were found to be have both obsessions and compulsions together (Butcher et al., 2013). The onset of OCD usually occurs about late adolescence and early adulthood (Butcher et al., 2013). Moreover, while females are seemed to be more affected form OCD in adulthood, conversely, males are more commonly affected from the disorder in their childhood (APA, 2013).
Comorbidity
According to the DSM-5 statistics, 76% of the cases with OCD have also other anxiety disorders such as panic disorder, social anxiety disorder, specific phobia and generalized anxiety disorder (APA, 2013). On the other hand, the comorbidity between affective disorders and OCD seems also high, which is 63% for any depressive or bipolar disorder and 41% for only depressive disorders (APA, 2013). There is an essential point to mention about depressive disorders and anxiety disorders with OCD that is while mostly OCD follows anxiety disorders, depressive disorders may occur after OCD (APA, 2013). Furthermore, it was found that while 23% and 32% of the OCD cases can have obsessive-compulsive personality disorder, 30% of them have tic disorder in lifetime period which is most common in males with the onset in childhood (APA, 2013; Thomsen, 2013). In children there is a frequently seen triad which is the occurance of tic disorder, ADHD and OCD together (APA, 2013). Additionally, there is also comorbidity between OCD and other related disorders like body dysmorphic disorder, hair-pulling disorder, skin-picking disorder and the oppositional defiant disorder because of the component of impulsivity in this disorder (APA, 2013). Lastly, it was found that the 12% of OCD cases can also be diagnosed with schizophrenia and schizoaffective disorder (APA, 2013).
Identification of possible causes and risk factors of OCD also has a crucial role to understand more about the prognosis, prevention and treatment of the disorder. In the next section of this paper, the risk factors are examined in a biopsychosocial cultural perspectives with some cognitive vulnerabilities specific to OCD.
Etiology
Biological Factors
Genetics
In most of the studies which were conducted with twins and families results demonstrate the great importance of the genetic factors on OCD. In twin studies, it was found that in identical twins, OCD is seen more frequently than the fraternal twins; and in family studies, among first degree relatives, OCD is seen 3 or 12 times more than normal prevalence (Butcher et al., 2013). In addition, findings show that in early onset of OCD genetics has more effect on the occurrence of the disorder than in later onset of OCD (Butcher et al., 2013).
Brain Functions
The studies which investigated the role of brain functions in OCD led to the similar results. It was demonstrated with brain imaging methods that the individuals with OCD generally have some abnormalities in subcortical structures such as basal ganglia which is a part of the limbic system, and excessive activation in orbitofrontal cortex and singulate frontal cortex which is again a part of the limbic system (Butcher et al., 2013). As a matter of fact, these structures of brain are mostly responsible from some primitive behaviors such as sexuality, aggression and cleaning (Butcher et al., 2013).
Neurotransmitter Abnormalities
The abnormalities in the serotonergic system is identified to be related to OCD which refers mostly to the increased level of serotonin or the because of some brain structures that are highly sensitive to serotonin (Butcher et al., 2013). Besides serotonergic system, recently the other systems have been also found to be have a role on OCD such as dysregulation of glutamate and dopaminergic system (Pittenger, Bloch, & Williams, 2011; Butcher et al., 2013).
Psychosocial Factors
Early life experiences, attachment and parenting style, stressful life events, familial and personality factors seem to have a precipitating impact on the onset of OCD according to the recent studies:
In a study conducted by Benedetti and his colleagues (2014), it is found that adults who experienced negative experiences in their childhood such as being exposed to both physical and emotional abuse and also neglect, are associated with treatment seeking behavior or early application to the consultant, especially in females, which is also suggests a gender difference.
In another study conducted by Doron and his colleagues (2012), it is found that insecure attachment in adulthood is found higher among people with OCD, even depression is controlled. Insecure attachment style in childhood is also seemed to have a connection to the OCD as it is proved in a study conducted by Rezvan and her colleagues (2012) which indicates the insecure attachment style in childhood and poor communication between parents and children contributes to the childhood onset of the OCD. Related with parenting, another study conducted by Timpano and her colleagues (2010) supports the protective factor of positive and warm relationships between parents and child by suggesting that authoritarian parenting style is significantly related with OCD symptoms in the adulthood. In addition, Clark and Beck (2010) in their book, drew attention to the other stressful life events specifying the important changes in a life course such as pregnancy, childbirth or traumatic events as possible triggers on the onset of the OCD, however they also mentioned that many cases also do not report any particular triggering event.
Another study conducted by Mataix-Cols and his colleagues (2013) offers the importance of environmental factors like family environment on OCD with suggesting that there is a high risk of OCD also for relatives with no biological connections such as spouses. Besides a study conducted by Murphy and Flessner supports the point about the impact of family environment on OCD suggesting a powerful relationship between childhood onset OCD and negative family functioning such as depression and anxiety symptoms seen in parents, feelings of guilt in parents and family accommodation.
Looking at the 5-factor personality traits which can be possibly related to OCD symptoms, only conscientiousness is found to reveal the most significant relationship with OCD (Inchausti et al., 2015).
Cognitive Factors
As in the famous example in which “not thinking about the white bear” is requested but individuals generally end up thinking of it more, suppressing the obsessive thoughts also makes them stronger and increases their frequency of occurrence as it is usually the case for the individuals with OCD, since they generally find their obsessions unacceptable and suppress them consequently (Butcher et al., 2013).
Another cognitive related phenomenon in OCD is evaluating one’s responsibility in his or her obsessive thoughts in an exaggerated way as if assuming that even the thought of engaging in an action is morally equals to actually doing it or thought of committing a negative action increases the possibility of committing it actually (Butcher et al., 2013). This phenomenon also called as “thought-action fusion” that triggers compulsive behaviors which are carried on to prevent “harmful” events (Butcher et al., 2013).
Cultural Factors
Looking at the literature, it can be concluded that OCD symptoms show some differences across different cultures. For instance, contamination and dirt obsessions seem to be more frequently seen than the obsessions about sex and religion in the sample comprising of Indians (Clark, 2007). Furthermore, religious obsessions might be more common in cultures that employs strict religious rules (Clark, 2007). According to another study conducted by Yorulmaz and Işık (2011) with Turkish and Western sample, it was found that thought-action fusion in the field of morality is more related with OCD symptoms in Turkish participants than Western participants.
The topics that are covered so far help to understand the main characteristics of OCD in a greater extent. However, undoubtedly, it is crucial to review the methods of assessing the OCD symptoms to reach the valid conclusions on diagnosis and treatment.
Assessment
One of the most frequently used measurement in the assessment of OCD is Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) (Aydemir & Köroğlu, 2014). Y-BOCS is a semi-structured inventory which is filled by the clinician in 19 items on 5 point Likert type scale (Aydemir & Köroğlu, 2014). Y-BOCS mainly assesses types and severity of OCD symptoms given with a symptom control checklist (Aydemir & Köroğlu, 2014).
Another frequently applied measurement to identify OCD symptoms is Maudsley Obsessional Compulsive Inventory (MOCI) which is a self-report questionnaire differently form Y-BOCS, and has 30 true-false items assessing various types of obsessive and compulsive symptoms such as “checking, washing, slowness/repetition, and doubting/conscientiousness” (Clark, 2007).
Other inventories which are preferred by clinicians to assess OCD are “Clark-Beck Obsessive-Compulsive Inventory (CBOCI)” , “Compulsive Activity Checklist (CAC)”, “Padua Inventor” which assesses the degree of the distress, “Obsessive-Compulsive Inventory (OCI)”, “Self-Monitoring Diaries” and “Behavioral Avoidance Tests (BATs)” (Clark, 2007).
Theories and Models
Behavioral Learning Theory
Behavioral learning theory is simply based on classical conditioning principles (Butcher et al., 2013). Related with how obsessions and compulsions nourish each other, this theory claims that individuals connect neutral stimuli from outside with their early fearful thoughts or experiences, therefore being exposed to that neutral stimuli leads to anxiety in the individual as time progresses (Butcher et al., 2013). When the compulsions, which function in the reduction of the anxiety, are involved in the equation, it becomes a cycle as follows: When the individual somehow associates hand shaking behavior (a neutral stimulus at first) with contamination (thinking to get germs from someone’s hand), inevitably he or she engages in the hand washing behavior which reduces fear or anxiety of being contaminated (Butcher et al., 2013). The reduction of the anxiety consequently reinforces the hand washing behavior and this reinforcement increases the possibility of recurrence of this behavior in the future too, which is very resistant cycle to be modified to be weaker or disappear (Butcher et al., 2013).
Cognitive Model of OCD
The cognitive model mainly focuses on the schemas that are dysfunctional and the faulty appraisals (Clark & Beck, 2010). According to Clark and Beck (2010), if the individual consider that his or her thoughts are irrational and not hazardous, the person ignores them and continue to daily life without any disturbance, however if the individual evaluates the thoughts as a threat or as a possible reason of a negative result that he or she can prevent, this situations causes distress and the individual has a sudden urge to carry out behaviors to neutralize the adverse effect of thoughts. This becomes a “vicious cycle” and in the short-term it reduces anxiety but in the long run it makes the obsessions more frequent and severe (Clark & Beck, 2010).
Another cognitive model was suggested by Salkowskis and Warwicks which is similar to Clark’s and Beck’s model but more elaborated with giving more information from the formulation and activation process of faulty appraisals through early life experiences to the neutralization of obsessive thoughts (Scott et al., 1989). Besides, the model specifies the behavioral, physiological, cognitive and affective symptoms of OCD (Scott et al., 1989).
Metacognitive Model
Metacognition is a phenomenon which refers to the complex structures of cognitions that organize and evaluate other more simple cognitions, in another words, metacognitive beliefs of an individual are simply about “what does the person think about his/her own thoughts” (Yörük & Tosun, 2015). In the context of OCD, metacognitve model claim that the metacognitive thoughts are more important than the thoughts themselves (Yörük & Tosun, 2015). According to the study of Şenormancı and his colleagues (2012), there are 3 types of metacognitve thoughts which are “thought-action fusion”, “metacognitive beliefs on performing the rituals” and “metacognitive beliefs on the signal to terminate these ritualistic behaviors”, and they also claim that studying on these metacognitve beliefs in the first place will also have a significant benefit to the therapy process.
Lastly, some types of treatment methods and procedures is considered in the frame of medications, brain stimulations, and mostly on the basis of cognitive behavioral therapy techniques.
Treatment
Medication
Especially in severe cases, the medications such as Klomipramin and Fluoksetin which affects on the neurotransmitter of serotonin and it is claimed that these medications reduces the 30% and 50% of the cases (Butcher et al., 2013). There are also evidences that implies the ineffectiveness of the medications, though in the cases in which serotonin-related medications do not help, clinicians refer to some psychotic medications, and when the medications are stopped to be taken, the relapse rate of the OCD symptoms are very high (Butcher et al., 2013). Additionally, it is important to note that application of both medications and behavioral therapy provides more benefits in children and adolescents than the adults (Butcher et al., 2013).
Deep Brain Stimulation (DBS)
Deep Brain Stimulation is a neurosurgical method in which some electrodes are implemented on the nucleus accumbens which is the structure related with pleasure, motivation, attention, reward and reinforcement (Milad & Rauch, 2012; Mantione et al., 2015).
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