Obsessive Compulsive Disorder is defined by the occurrence of unwanted obsessive thoughts or distressing images, usually followed by compulsive behaviour designed to neutralize these obsessive thoughts and images or to prevent some dreaded event or situation.
Symptoms of OCD
1. Obsessions – Are unwanted and recurring thoughts and images that come unbidden to the mind and appear irrational and uncontrollable to the individual experiencing them. They may also take various forms like extreme doubting, procrastination and indecision which strongly interferes with one’s normal functioning. The most commonly seen obsessions are obsessional thoughts and images, obsessional ruminations and doubts, obsessional impulses, obsessional phobias and obsessional slownessoq.
Obsessional thoughts and images refers to words, ideas, images and beliefs recognized by the patients as his own, that intrude forcibly into his mind. They are usually unpleasant and attempts are made to exclude them. Obsessional thoughts may take the form of single words, phrases or rhymes; are usually unpleasant or shocking to the patient and may be obscene or blasphemous. Obsessional images are vividly imagined scenes, often violent or disgusting in nature, involving abnormal sexual practices. Obsessive thoughts may centre on a variety of topics.
Obsessional ruminations and doubts refer to internal debates in which arguments for and against even the simplest everyday actions are reviewed endlessly. Some obsessional doubts may concern actions that may not have been completed adequately (such as locking the door) or that might have harmed the other people or may be related to religious convictions.
Obsessional impulses refer to urges to perform acts usually of a violent or embarrassing kind, for example, jumping from a moving vehicle, shouting blasphemies in church etc.
Obsessional phobias refer to fear and avoidance of situations in which the possibility of acting on ones violent obsessional thoughts is high. For example, if an individual gets obsessional thoughts of harming another person, then he is likely to develop phobia for places like kitchen where knives are kept.
Obsessional slowness refers to an extreme slowness seen in some patients which is out of proportion to other symptoms.
2. Compulsions- Involve repetitive behavior (e.g. hand washing, checking etc.) or mental acts (e.g., praying, counting etc.) that the person feels driven to perform in response to an obsession to reduce distress or prevent a dreaded event or situation. A true compulsion is viewed by the person as somehow foreign to his or her personality.
Common compulsive rituals centre around checking, counting or cleaning activities. These rituals can be mental activities or repeated actions. Mental activities may take the form of counting repeatedly in a special way or repeating a certain form of a word. The repeated actions may take the form of repeated senseless behaviors such as washing the hands 20 or more times in a day after touching any object. The compulsive rituals may or may not be understandably related to obsessional thoughts. Some patients feel compelled to repeat such actions a certain number of times and if they are not able to do so, then they may start the whole sequence again. Patients are often aware that their rituals are illogical and usually try to hide them. Some individuals may show a high need for repeated reassurance.
3. An individual suffering from OCD may also show symptoms of prominent anxiety or depressive symptoms as a reaction to the obsessional symptoms or may complain of depersonalization (a state in which one’s feelings and thoughts seems unreal or not to belong to oneself). Anxiety is the affective symptom. Nearly all people afflicted with OCD fear that something terrible will happen to themselves or others for which they will be responsible. Compulsions usually reduce anxiety, at least in the short term, and the tendency to judge risks unrealistically seems to be a very important feature of OCD.
Causes of OCD
Various factors that seem to play a role in OCD are given below:
1. The Psychoanalytical Perspective: According to Freud, OCD patients have not been able to solve oedipal conflict and have either never advanced beyond this stage or have regressed to an earlier stage. They seem fixated at the anal stage. It is this anal stage where these children derive sensual pleasure from defecating– both as a physical release and as a creative act. This is also the time, when parents are trying to toilet train their children, which involves learning to control and delay these urges. If parents are too harsh and they make the child feel bad and dirty about soiling himself or herself and may instill rage in the child, as well as, guilt or shame about these drives.
2. The Behavioral Perspective: Behaviorist view obsessions and compulsions as learned behavior reinforced by their consequences. According to Mowrer’s two process theory of avoidance learning, neutral stimuli (shaking hands) become associated with aversive stimuli (scary idea of contamination) through a process of classical conditioning and come to elicit anxiety. When an action like washing hands reduces anxiety then the washing response gets reinforced making it more likely to occur again in the future when the anxiety about contamination was evoked in other situation. Once learned, such avoidance responses are extremely resistant to extinction.
3. The Cognitive Perspective: According to Carr (1974) OCD results from a negative cognitive set of unrealistically over estimating the risk involved in a situation. These people cannot shrug off negative thoughts which then reoccur persistently later leading to obsessions and compulsions (Clark and Purdon, 1993). According to Salkovskis et al (1997) and Rachman and Hodgson (1985), these people cannot turn over their thoughts, are depressed, generally anxious and have more rigid and moralistic thinking because of which feelings of guilt easily seep in which may further lead to compulsions.
4. The Biological Perspective: Serotonin levels seem to play a role in OCD as drigs like clomipramine and some antidepressants (Fluoxetine) which affect serotonin have been shown to be useful in the treatment of OCD. Also, both Dopamine and acetylcholine coupled with serotonin seem to play a role in OCD (Rauch and Jenika, 1993).
➢ Psycho-education: OCD runs a fluctuating course with long periods of remission. Treatment should begin with an explanation of the symptoms to both the patient and his family members who may also be involved in the patient’s rituals.
➢ Exposure and response prevention therapy (ERP): The therapy aims at exposing the individual to any environmental cues that increase the symptoms and then preventing the individual from engaging in the compulsive response. Exposure is likely to increase anxiety in the individual. To reduce anxiety, the individual is encouraged to engage in relaxation techniques.
➢ To deal effectively with obsessions, thought stopping has also been used.
➢ Cognitive therapy: seeks to reduce attempts to suppress and avoid obsessional thoughts, since these attempts have been shown to increase, rather than decrease, their frequency. These techniques may be combined with exposure to tape-recorded repetition of the thoughts, and by disputing any other cognitive distortions present in the patient.
➢ Drugs: like Clomipramine, specific serotonin re-uptake inhibitors (SSRIs), and anxiolytic drugs have also been found to be effective in the treatment of OCD.
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