OCD: An Overview

Obsessive Compulsive Disorder (OCD) is often a source of humor and excuses by those who don’t have it, but it is a debilitating illness. This paper will define OCD, examine its symptoms, and probe treatments.

DEFINITION AND CAUSES: OCD is defined by its chronic symptoms, obsession and compulsion. Obsessions are thoughts, images, and urges that precipitate extreme anxiety (American Psychiatric Association [APA], 2013; National Institute of Mental Health [NIMH], 2016; Rachman and de Silva, 2009) Everyone has intrusive thoughts. Adam (2014) cites an experiment by Rachman and de Silva (1978) where people with OCD and unafflicted subjects were asked to list their weird thoughts over a two week period. When these were presented to a panel of experts, the experts could not distinguish the cards written by OCD sufferers from those written by the control group. What distinguishes the thoughts of OCD sufferers, this study suggests, is intensity, an inability to shut the thoughts down.

Compulsions are repetitive or ritualistic actions which an OCD sufferer performs repeatedly in response to some obsession or personal and rigid code of rules. (APA, 2013). Everyone checks or does things repetitively at some time during their day, but the person with OCD performs them so repetitively that she will spend an hour or more doing them each day or the thoughts and actions will disrupt their social, occupation, and other lives. (APA, 2013) The aim may be to relieve anxiety or to prevent some horrible catastrophe from happening. (APA, 2013, Rachman and de Silva, 2009)

Many theories attempt to identify the causes of OCD. This paper will briefly look at three: behaviorism, cognitive approaches, and biological theories.

Behaviorists hold that OCD is a learned behavior, an anxiety acquired through some trauma. They support this by the fact that OCD relieves anxiety. But they fail to explain why many patients cannot recall a triggering event. Nor can it explain the obsessions which appear to drive the ritualistic compulsions (Rachman and de Silva, 2009).

Cognitive modelers look to thought patterns. The Obsessive-Compulsive Working Group identifies six errors in thinking common to OCD patients who believe (1) the mind has the power or the responsibility to stop disasters and other negative outcomes; (2) bad thoughts can cause negative events or that thoughts are the moral equivalent of actually doing bad things; (3) it is possible to have total control over one’s thoughts; (4) Negativism; (5) Perfectionism; and (6) there is no uncertainty (Beyond OCD, 2017).

While the cognitive approach offers a thorough description of thought patterns, it does not explain what causes it. Biological researchers offer the explanation that an inadequate supply of serotonin causes symptoms. Critics argue that cognitive therapies are as effective as psychopharmaceutical treatment (Rachman and de Silva 2009). New research holds that an overactive signal pathway in the amygdala may be the culprit, offering new treatments (Ullrich, Weber, Post Poop, Grein, Gonzalez, Kreis, Üçeyler, Lesch, Schmidtt, Schuh, 2017).

WHAT OCD LOOKS LIKE: Adam (2014) cites the first case of OCD in the medical literature, “Madamoiselle F.” (Esquirol, 1845/1938). A French woman and accountant was obsessed with the thought that she was a thief. So she refused to wear aprons, removed the hems of her dresses, avoided handling money, rubbed her feet to remove any money that might have insinuated itself between her toes, shook her hand vigorously to do the same with her fingers, and checked and rechecked her books despite her reputation for honesty. Esquirol labeled her affliction as monomania, a partial insanity because she was aware of her madness as are most OCD sufferers.

The writer knows a few people with the disorder and many more who self diagnose. Self diagnosis and exaggeration of symptom was the subject of research for therapists and psychiatrists working at a clinic dedicated to OCD. Examining ten suspect cases, they found these clients tended to describe their symptoms using highly technical language harvested from the DSM which did not match the descriptions used by bona fide cases. Furthermore, the patients often manifested the nocebo effect where they developed unusual and undocumented side effects from the medications they were prescribed. Other mental disorders were frequently identified for this group. When they were questioned about their self diagnosis, many became angry and defensive. One man “pulled a knife from his waist, placed it on the table, and asked why the doctor did not believe that he had OCD” (Fontenelle, Lins-Martin, Natalia, Meica, Lima, de Menezes 2014). Clearly the popularization of the illness in best-selling books and television shows such as Monk has had its effect in creating a personality or other illness based obsession with having OCD.

The writer’s friends have genuine OCD diagnoses. One kept poking at the bridge of his nose until one day his finger slipped and he jabbed himself in the eye, detaching his retina. Another cannot go to bed without checking every door, window, lock, and appliance. This chore can take her more than an hour. She worries that her adoptive daughter mimics the behavior. Dematillomania, a disorder on the OCD spectrum, afflicts another friend of his. She picks at her face at the slightest sign of acne until she cannot go out. Others are concerned with germs and their appearance. (Sax 2017)

Obsession with contracting HIV bothers many OCD sufferers. Rapoport began noticing this trend in germophobia arising before the publication of her best-selling book in (1989). One of her patients lost his job after having a brawl over whether a co-worker should get an AIDS test. Adam (2014) says that he acts as if it is still 1988 at the height of the AIDS scare. He contrasts himself with Andy Warhol who would not eat food prepared by other gay men or wear clothes that had been washed and folded by gay men. Warhol, Adam argues, did not display OCD because he was acting on the best common knowledge of his time. Adam, on the other hand, obsessively calls HIV hotlines to check if he has been infected with HIV and should get an AIDS test – he is always told that he has nothing to worry about – but he is never convinced that he is not in danger. Louise was convinced that she was HIV positive, so she showered for hours, washed her hands and feet several times a day, and wouldn’t prepare or touch food for fear that she might contaminate it. Her ultimate catastrophe was infecting and killing her friends and family (Stuart 2017).

Shannon Shy’s illness took a different course. He rose to the rank of Lieutenant Colonel in the Marines despite his illness. Whenever he saw a car by the side of the road, he worried that there might be a dead body. Even though he tried to ignore the compulsion to stop, he often found himself turning around to check to be sure that everything was all right. He also obsessed over the covers of underground gas tank at filling stations: he would not step on them and otherwise avoided them. If he happened to drive over one, he would run to tell the attendant what he had done because he feared he might have caused an explosion or a fire. When he served as Officer of the Watch, he meticulously recorded every petty event that happened on his shift lest he leave out something that might be important. Other officers went out of their way to serve with him. He finally sought help when he heard the sound of a piece of lumber falling to the ground and imagined it was gunfire. There was no doubt that the lumber had caused the sound – he saw it fall. But he turned back and drove around until he found a pair of police officers who politely took his report (Shy 2009).

A Swedish study found that children with OCD experience more sleep disturbances than children with psychosis or school children of comparable age. This correlation awaits further research (Ivarsson and Larsson 2009). Another study, also out of Sweden, showed that people living with OCD have a higher suicide rate than those suffering from other psychiatric illnesses as well as the general population (Fernandez de la Cruz, Rydell, Runeson, D’Onofrio , Brander, Ruck, Lichtenstein, Larsson, Mataix-Cols 2016). OCD is not only a debilitating illness but a dangerous one.

TREATMENT: Psychiatrists prescribe SSRIs such Fluorhexidrine to control obsessions, compulsions, and accompanying anxiety. Anafranil – a tricyclic antidepressant has been used successfully since the late 1980s when Rapoport used it with her patients. The finding that overactivity of the receptor tyrosine kinase TrkB is at the root of OCD suggests that cancer drugs controlling the Ras/ERK-MAP kinase cascade may be of help (Ullrich, Weber, Post Poop, Grein, Gonzalez, Kreis, Üçeyler, Lesch, Schmidtt, Schuh, 2017).

Psychosurgeries – including brain surgery, Gamma knife, and Deep Brain Stimulation — have proved helpful in some severe cases.

SUMMARY: Obsessive-Compulsive Disorder is a debilitating illness with its origins in the amygdala. Sufferers can experience symptoms that cripple their ability to function. The intensity of the obsessions may lead some to attempt to escape their pain via the avenue of suicide. New research offers the hope of new treatments using already available cancer drugs. It is not something to be joked about.

Citations

Adam, David. (2014). The Man Who Couldn’t Stop: OCD and the True Story of a Life Lost in Thought. New York: Sarah Crichton Books, Farrar, Straus and Giroux.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Beyond OCD. (2017). What causes OCD? Retrieved April 30, 2017 from http://beyondocd.org/information-for-individuals/what-causes-ocd/.

Esquirol, J. (1845/1938). Mental Maladies: A Treatise on Insanity. Philadelphia: Lea and Blanchard. Cited in Adam (2014).

Fernandez de la Cruz L , Rydell M , Runeson B , D’Onofrio BM , Brander G , Ru?ck C , Lichtenstein P , Larsson H , Mataix-Cols D (2016). Suicide in obsessive-compulsive disorder: A population-based study of 36,788 Swedish patients. Molecular Psychiatry, 2016 Jul 19. doi:10.1038/mp.2016.115

Ivarsson, Tord and Larsson, Bo. 2009. Sleep problems as reported by parents in Swedish children and adolescents with obsessive-compulsive disorder (OCD), child psychiatric outpatients and school children. Nordic Journal of Psychiatry. 63:6. DOI: 10.3109/08039480903075200

National Institute of Mental Health (2016). Obsessive Compulsive Disorder. Retrieved April 30, 2017, from https://www.nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd/index.shtml.

Rachman, Stanley and de Silva, Padmal. (1978). Abnormal and Normal Obsessions. Behaviour Research and Therapy, 16, pp. 233-48.

Rachman, Stanley and de Silva, Padmal (2009). Facts : Obsessive-Compulsive Disorder : The Facts (4th edition). Oxford, England: Oxford University Press.

Rapoport, Judith L M.D. 1989. The Boy Who Couldn’t Stop Washing: The Experience and Treatment of Obsessive-Compulsive Disorder. Boston: E.P. Dutton.

Shy, Shannon. 2009. “It’ll be Okay.”: How I Kept Obsessive-Compulsive Disorder (OCD) from Ruining My Life. Bloomington, Indiana: Authorhouse.

Stuart, Ralph. (2017). The OCD Stories: Stories that educate and inspire those with OCD. Kindle edition downloaded March 28, 2017 from https://www.amazon.com/OCD-Stories-educate-inspire-those-ebook/dp/B06XVF7DNM.

Ullrich M, Weber M, Post A M, Popp S, Grein J, Zechner M, Guerrero González H, Kreis A, Schmitt A G, Üçeyler N, Lesch K-P, Schuh K. 2017. OCD-like behavior is caused by dysfunction of thalamo-amygdala circuits and upregulated TrkB/ERK-MAPK signaling as a result of SPRED2 deficiency. Molecular Psychiatry. DOI: 10.1038/mp.2016.232 cited in University of Würzburg. 2017. Cause of obsessive-compulsive disorder discovered. ScienceDaily. Retrieved May 8, 2017 from www.sciencedaily.com/releases/2017/03

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Joel is the founder of DBSA South Orange County. He received a degree in Anthropology from Pomona College, one of Forbes Magazine’s ten top undergraduate schools. His manic adventures include traveling to former Yugoslavia during the 1992 war, believing he was the Creator of a messed up Universe, road rages, and running up $40,000 in credit card bills. He lives with his wife, dog, and cat in Trabuco Canyon, California.