Introduction
Life becomes difficult for people with obsessive-compulsive disorder (OCD) as they tend to have persistent, upsetting thoughts (obsessions). In order to control the anxiety these thoughts produce they use rituals (compulsions). In other words OCD is a psychiatric anxiety disorder most commonly characterized by a subject’s obsessive, distressing, intrusive thoughts and related compulsions which try to neutralize the obsessions. In most of the cases of OCD it is the rituals that end up controlling them. For instance, if a person is obsessed with germs or dirt, they may develop a compulsion to wash their hands over and over again.
There are cases when some keep checking if they have locked the door properly since they develop an obsession with intruders. Though performing such rituals is not pleasurable, it produces temporary relief from the anxiety created by obsessive thoughts. Even though most adults with OCD are aware of the fact that what they are doing is absurd, some adults and most children may not realize that their behaviour is out of the ordinary (NIMH, 2008).
Obsessions can be defined as unwanted ideas, images, or impulses that repetitively enter a person’s mind. Although recognized as being self generated, they are experienced as “egodystonic” (out of character, unwanted, and distressing). Compulsions can be defined as repetitive stereotyped behaviours or mental acts determined by rules that must be applied rigidly. In general, they are intended to neutralise anxiety provoked by the obsessions (Heyman, 2006).
It is estimated that approximately 2.3% of people between the ages of 18 and 54 in the world suffer from OCD (ocd-world.org.uk, N.D). This problem can be accompanied by eating disorders (Wonderlich and Mitchell,1997), other anxiety disorders, or depression (Regier et al., 1998). Studies have found that there is not much difference in the number between males and females and usually appears in childhood, adolescence, or early adulthood (Robins and Regier 1991). One-third of adults with OCD develop symptoms as children, and research indicates that OCD might be genetic in nature (NIMH, 1998).
At some point of time the sufferer must realize that his/her obsessions or compulsions are unreasonable or excessive. Furthermore, the obsessions or compulsions must be time-consuming probable taking up more than one hour per day, cause distress, or cause harm in social, occupational, or school functioning (American Psychiatric Association, 2000). OCD often causes feelings similar to those of depression. This paper basically intends to review the presentation and assessment of OCD and discusses the current best treatment options.
Causes and related disorders
In the recent research the scientific community studying obsessive-compulsive disorder is split into two groups contradicting over the cause of OCD. One group believes that obsessive-compulsive behaviour is a psychological disorder; where as others thinks it has a neurological origin. A majority of researchers now believe in this neurological hypothesis. According to the studies conducted by Stanford University School of Medicine “although the causes of the disorder still elude us, the recent identification of children with OCD caused by an autoimmune response to Group A streptococcal infection promises to bring increased understanding of the disorder’s pathogenesis.” (Stanford University School of Medicine, 2008).
Symptoms
The first step of treatment plan is to identify the symptoms in a systematic way. There are several different ways OCD can present itself. However, the scientific community has identified the most common obsessions/compulsions types as follows:
- Checkers : These are people who believe that great harm will be brought to someone, either themselves or others, if they do not carry out their obsessions. Examples of these would be making sure all the plugs are switched off, or all the doors are locked properly so that no intrudes may enter. These people generally develop a complex routine of what they check and in what order.
- Hoarders: They tend to collect things that others would consider of little value. In general these people tend not to be able to throw any items out. As a result their houses may be considered ‘cluttered’ due to their collections.
- Obsessionals: They turn to repetitive actions and thoughts such as counting, repeating words or phrases in order to divert themselves from any sort of negative or unwanted thoughts of violence and harming others.
- Orderers: These people like everything in its place, everything must be ‘just right’, they are perfectionists. They can waste long hours arranging things until they are exactly right. These people get wild if any thing is moved from its original position which they have decided for that object.
- Washers and cleaners: These are people who fear dirt or germs, either for themselves or for others. For instance touching the taps may cause infection or disease. Or using a common toilet is harmful for their health. They will obsessively wash, sometimes to the point of causing damage to their skin (ocd-world.org.uk, N.D).
There are many other symptoms in addition to the once mentioned above. It is very important to diagnose the condition correctly by a mental health professional.
Cognitive Formulation
Professor Paul Salkovskis has been working on obsessional disorder related conditions since the late 1970’s. Cognitive models of obsessive-compulsive disorder found liability to be elevated in OC checkers, but not in non-checking OCD patients, relative to non-anxious controls. In a study, the liability measure included checking scenarios, thus leaving the possibility that these findings may have been due to criterion contamination (Cougle et al. 2007).
In another study to link between self-esteem and obsessional problems, patients with OCD were compared with people suffering from other anxiety disorders and non-anxious controls. The study was conducted using questionnaire which allowed the reliable coding of open ended responses focussed on issues surrounding self-worth; standardized measures of self-esteem and clinical symptomatology were also administered.
Results obtained from this study indicate that both clinical groups differed considerably from non-clinical controls on generalized self-esteem assessments. There was some evidence of OCD specific effects; obsessionals were more likely than anxious controls to link their self-worth to other people and their relationships. They also regarded the possibility of causing harm as likely to result in other people making extreme negative and critical judgements of them; the other groups expected the responses of others towards them to be more lenient (Ehntholt et. al 1999).
Behavioural Formulation
While there is enough data that medication can reduce symptoms, behavioural therapy and cognitive-behavioural therapy are time and again proposed as widely acceptable alternative treatments. These therapies have various components, but commonly include assisting the child or the adult to assist tolerate the anxiety provoking situations and thoughts, and overcoming the temptation to use the compulsive behaviour to manage their anxiety. Additionally the treatment also include psycho-education about anxiety and OCD, cognitive training involving learning to identify and challenge unhelpful ways of thinking, and parental involvement (Kearney et al. 2006).
Prior to the late 1960s, OCD was in general considered unresponsive to a range of conventional therapies. It was only in 1970’s a very successful behavioural treatment for OCD was developed by Drs. Rachman, Marks and Foa. This was called the exposure and response prevention (ERP). Initially this treatment regime was introduced by Victor Meyer in 1966. ERP basically involves the methodical, graded exposure to sequentially more fearful situations that bring out the obsession and at the same time preventing the person from performing the compulsive ritual. For instance, a person with a washing compulsion, might be first asked to handle books or any other stationeries that other people handled which will be moderately distressing.
Later, wash clothes in a public laundromat which the person may find it even more distressing, and finally use a public toilet which will be highly distressing. The person with OCD who is engaged in a series of exposure sessions that last for 1-2 hours at each fear level and at the same time being stopped from washing by the therapist is bound to show some improvement over a few attempts. Once the fear has subsided at one level, the person then proceeds to the next fear level.
The general principle applied here is that fear or distress tends to extinguish if a person remains in the fear situation for a long period of time. Therefore, repeated exposure with prevention of a compulsive ritual will eventually lead to significant reduction in the obsession and its associated distress. Individuals with OCD will recognize considerable progress with ERP after just 15 – 20 sessions. Studies have found that approximately 80% of individuals with OCD will experience significant symptom improvement with exposure/response prevention treatment.
In recent years new treatment protocols for obsessions have been developed that incorporate cognitive interventions together with exposure and response prevention in order to modify the faulty appraisals that perpetuate obsessional thinking. This new cognitive-behavioural therapy for OCD consists of educating the person with OCD about the cognitive nature of their obsessional problems, and how to identify their automatic faulty interpretations of the obsession and their counter-productive neutralization strategies (Clark, 1999).
Conclusion
If I had to plan a treatment regime for an OCD patient, I would follow the standard methodology of treatment using the latest developments in both cognitive as well as the behavioural therapies. For some behaviour therapy may not be suitable where as for others cognitive therapy would not be suited. Today, we have a good understanding of obsessive compulsive disorder. Obsessive compulsive disorder is a treatable problem and it is estimated that about 75% of people who complete exposure/response prevention treatment get well. New treatment protocols also have been developed for people who do not benefit from traditional exposure/response prevention therapy. Besides, it is much better to opt for cognitive-behavioural therapy with minimum or no administration of drugs with side effects.
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