Cautionary Statement

This article is designed to increase the awareness of the psychiatric disorder Obsessive-Compulsive Disorder (OCD) in interested individuals and clinicians. Although the article outlines the essential features of OCD, it is important to note that diagnostic accuracy is typically higher when individuals consult with a mental health specialist. Equanimity Psychological Services (EPS) offer clinical consultations by trained professionals who are skilled in recognising the symptom profiles pathognomonic of the various psychological conditions.  

About OCD

The acronym “OCD” is now commonly used by professionals and non-professionals to describe a range of “normal” and “abnormal” (clinical) psychological phenomena. Yet for both clinician and non-professional alike, many remain unclear as to what constitutes a “normal” personal tendency to pickiness, cleanliness or orderliness and what constitutes a “clinical” condition. This article will tell you exactly what that difference is!  

So How Is OCD Detected? OCD is accurately identified when an individual satisfies full (all) diagnostic criteria of OCD stipulated in a recognised diagnostic manual. A subset of individuals who present with persistent or recurrent OCD symptoms which fall short of a full diagnosis can be described as harbouring “subthreshold OCD”. For identification purposes, this article will refer to the Diagnostic and Statistical Manual of Mental Disorders - 5th Edition (DSM-5)−published by the American Psychiatric Association (APA) in 2013. The DSM-5 lists four essential criteria (A-D) necessary for diagnosis (below).  

Criterion A

Criterion A specifies the presence of frequent obsessions, compulsions or both. In reality, the majority of OCD sufferers will experience both obsessions and compulsions and, close to 99% of people with obsessions, also have compulsions.  

So What Is An Obsession? In the context of mental health, obsessions have a very specific meaning. The DSM-5 defines an obsession as a repetitive thought, image or impulse. The content of obsessions often share a common theme. Thoughts of being contaminated, impulsively engaging in an aggressive act, doubting oneself, thoughts of engaging in highly inappropriate sexual behaviour, thoughts of impulsively blaspheming and needing to order objects in a particular way are common. To aid identification, obsessions posses the below five characteristics. Each characteristic will be apparent to a certain extent. Obsessions must not be confused with other repetitive distressing thoughts such as worries and depressive ruminations which do not possess the below characteristics.  

1) Intrusiveness: Individuals with OCD report that their obsessions occur spontaneously and involuntarily; that is, they just “pop” into the individual’s mind. Obsessions are often described as something different and stranger than worries. It is important to note that between 80%-90% of the world population experiences “unwanted intrusive thoughts”. However, of those 80%-90%, only 1-2% harbour clinical obsessions. The difference between a “normal” unwanted intrusive thought and a clinical obsession lies in the psychological evaluation (appraisal) of the intrusion by the individual (see the below other characteristics of obsessions). Non-clinical unwanted intrusive thoughts may lead to initial discomfort but are forgotten soon after and generate no lasting negative effect. Clinical obsessions, in contrast, are associated with a sense of individual shameful responsibility.  2) Unacceptability: By definition, obsessions produce psychological discomfort. The degree of discomfort varies in intensity which can range from mild irritability to intense fear.  3) Subjective resistance: When obsessions occur, individuals try to resist or dismiss their obsessions and may avoid specific situations or events that trigger their obsession. Some individuals try to distract their minds away from the obsession or seek reassurance when the obsession occurs.  4) Uncontrollability: Individuals with OCD report that they find it very hard to prevent their obsessions how ever hard they try.  5) Ego-dystonicity: This term refers to that fact that the content of an obsession opposes a person’s core values. Knowing if an individual’s intrusions are ego-dystonic are often intuitively evident and the assessing clinician typically does not need to engage in-depth questioning to determine this feature. For example, in the case of a distressed mother who reports thoughts of spreading lethal germs from the G.P. surgery to the family home, it is likely she will report intense distress associated with her thoughts and will probably describe a wish to keep her family happy and healthy. However, for others, this is not as evident. Recently, I came across a young man who reported frequent thoughts that “he might be gay”. He reported, “I know I’m not gay… but the thought keeps coming back that I might be”. On questioning, for him, “being gay is the worst thing you can be”. However, for those without this personal value, the obsession would not have manifested.  

For the clinician wanting to screen for obsessions, the Structured Clinical Interview for DSM (SCID) usefully asks: “… have you ever been bothered by thoughts that did not make any sense and kept coming back to you even when you tried not to have them?”  

So What Are Compulsions? Some of the easiest OCD symptoms to identify are compulsions (or rituals). These behavioural and cognitive phenomena typically occur in response to obsessions and serve to reduce (neutralise) the distress caused by an obsession or “ward off” perceived “dreaded events” associated with the obsession. For example, as in the case of frequent contamination obsessions, cleaning rituals are likely to develop. Affected individuals typically report a strong urge to undertake their compulsion and often describe a diminished sense of voluntary control over it. Following the performance of a compulsion, emotional distress usually reduces. Compulsions are different from other repetitive behaviours such as tics in the sense that they do not serve to alleviate anxiety. Compulsions occur as either covert (mental) acts or overt (behavioural) acts. Covert compulsions include repeating superstitious words, repeating phrases, praying and counting. Overt compulsions include repeated washing, checking and ordering (rearranging objects to restore balance or symmetry).  

For diagnostic purposes, the SCID usefully asks: “…was there anything you ever had to do over and over again and could not resist doing, such as washing your hands again and again, counting up to a certain number, or checking something several times to make sure you had done it right?”  

Criterion B: Clinical Significance

Criterion B specifies that the obsessions or compulsions are time consuming (e.g., take more than 1 hour per day), cause significant distress or markedly affect the individual’s everyday functioning.

Criterion C: The Symptoms Are Not Attributable to The Physiological Effects of a Substance or Medical Condition

Although rare, a handful of medical conditions listed below (and clozapine) can cause obsessions and compulsions.   

• Postencephalitis
• Postanoxic
• Postclosed head injury
• Sydenham’s chorea
• Huntington’s disease
• Simple partial seizures
• Infarction of the basal ganglia or right parietal lobe
• Fahr’s syndrome (idiopathic basal ganglia calcification)  

In cases whereby a direct link is made between the medical condition and obsessions and/or compulsions, a primary diagnosis of OCD should not be made. Rather the diagnosis of “Obsessive-Compulsive and Related Disorder Due to Another Medical Condition” or “Substance/Medication-Induced Obsessive-Compulsive and Related Disorder” should be made instead.    

Criterion D: The Symptoms Are Not better Accounted For By Another Mental Disorder   Various other psychiatric disorders can resemble OCD. In distinguishing OCD from other psychiatric disorders, it is important to note that the repetitive thoughts that bear the five hallmarks of obsessions (above) are very likely to be obsessions (e.g., they occur intrusively and are typically resisted by the individual). The clinching clue is that the obsessive individual will invariably begin to engage in rituals (compulsions) designed to relieve their distress. For example, as in the case of frequent doubting obsessions, repetitive checking is likely to be incorporated into the individual’s repertoire.  

Repetitive worry, which can be a feature of generalised anxiety disorder, is differentiated from obsessive thinking in that worries are typically consistent an individual’s values (are ego-syntonic rather than ego-dystonic) and, although often recognised as excessive, worries, unlike obsessions, are often perceived as a valid source of concern. Similarly, depressive ruminations which again are ego-syntonic are typically consistent with the mood state (e.g., depressive ruminations might focus on how cruel the world is). Worries and depressive ruminations are not associated with the emergence of neutralising rituals.  

Finally, one other psychiatric disorder which deserves attention is that of obsessive compulsive personality disorder (OCPD). Possibly, the largest proportion of individuals who describe themselves as “a bit OCD” are those diagnostic of OCPD. Despite the similar name, OCPD is different from OCD in the sense that OCPD is not characterised by obsessions and compulsions. Rather OCPD involves an enduring maladaptive pattern of orderliness, perfectionism and control.

By Thomas Brown MBPsS 

© 2017 Equanimity Psychological Services (EPS)  

All rights reserved

#HarleyStreet #London #Psychotherapy #Counselling #Anxiety #Depression #Equanimity #EPS