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OCD and Related Issues

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Obsessive-Compulsive Disorder

What is it?

Obsessive-Compulsive Disorder (OCD) is categorised as an impulse-related disorder that also has an anxiety component. It is characterised by unwanted, intrusive thoughts (obsessions) and behaviours (compulsions) that cause significant distress and impact on daily functioning.

What are Obsessions?

Obsessions are thoughts, urges or images which come into the person’s mind, making them feel anxious and distressed because the thoughts are “strange and do not make sense”. These thoughts are upsetting, which can make a person feel anxious and sometimes make them doubt what is real versus imaginary. Sometimes there will be a link between the obsessive thought and the person’s life (e.g. obsessive thoughts about harm coming to a family member if they have had health issues). However often there is no logical pairing and these thoughts may come from “left field” which is often very disconcerting.

Why do these thoughts occur?

OCD is like a “missile effect” in that it targets what is most important to you and then twists it, so that something cherished becomes a nightmare. It is important for you to know that you are not “deviant or bad” – OCD is a disorder of thoughts and doubt. As people with OCD often repeat these thoughts over and over they can start to believe the thoughts. As a result the person falls into “black holes” or OCD mind traps and starts believing the following:

  • Because I am having these thoughts I must really want to have them
  • Because I am having these thoughts it makes it more likely to happen
  • Because I am having these thoughts I must be a “weird, deviant” person
  • I must not tell anyone else about these thoughts as it will change the way they think about me

What are Compulsions?

Compulsions are behaviours or acts designed to remove/neutralize the anxiety caused by the obsessive thoughts. They can be overt “outside” behaviours, like checking or seeking reassurance, or they can be covert “inside” behaviours, like counting or repeating. For example, a person may feel the need to continue checking a door handle until they ‘feel’ like it is locked. Conversely, while some compulsions are performed until the person feels “just right” other compulsions are carried out in “sets”. The reason people engage in compulsions is because they think it helps them reduce their anxiety – but, this is a trap… compulsions make it worse as they keep the OCD cycle going.

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Treatment

The most effective treatment for OCD is Cognitive Behavioural Therapy (CBT) – an important part of CBT for OCD is Exposure and Response Prevention (ERP). The exposure part of ERP aims to help the individual expose themselves to the thoughts, images, objects and situations that cause anxiety, distress or discomfort. The response prevention part of ERP aims to help the individual resist their compulsive behaviour once the obsessions, anxiety, or discomfort have been triggered.

The idea of purposefully being exposed to things that are difficult and anxiety-provoking may sound off-putting to most people with OCD; however, during ERP the individual is making a  choice to confront anxiety and stop doing the compulsions – over time this actually causes a reduction in the anxiety and distress, as well as the intensity and frequency of obsessive thoughts.

OCD in Adolescents

Adolescence is a very important period and there are many stresses (schoolwork and home life), and additional challenges (friendships). Consequently many teenagers are reluctant to disclose that they are experiencing “weird thoughts” because they want to “fit in” and are scared of what will happen. Fearing ridicule, teenagers may hide their compulsions when in front of friends at school or at home and become mentally exhausted from the strain. This may result in being too tired to play with friends, concentrate in school and cause family conflict.

Common Obsessions

  • Contamination from contact with certain people, or everyday items such as clothing, shoes, or schoolbooks
  • Obsessive doubt about locking doors, windows, lights…
  • Marked over-concern with the appearance of homework assignments
  • Excessive worry about the arrangement of everyday objects such as shoelaces, school books, clothes, or food
  • Doubt over whether you have performed an action (written something on MySpace/twitter or said something to a friend you did not).
  • Fears of accidentally harming a parent, sibling or friend
  • Superstitious fears that something bad will happen if a seemingly unconnected behaviour is done (or not done)

Common Compulsions

  • Compulsive washing, bathing, or showering
  • Ritualized/repeated touching of body parts or perform bodily movements in a specific order or symmetrical fashion
  • Specific, repeated bedtime rituals that interfere with normal sleep
  • Compulsive repeating of certain words or prayers to ensure that bad things don’t occur
  • Compulsive reassurance-seeking from parents or teachers about not having caused harm
  • Avoidance of situations in which they think “something bad” might occur

How Does Adolescent OCD Differ from Adult OCD?

The emotional and cognitive skills are still developing in the adolescent brain and as such teenagers with OCD may find it hard to understand their obsessions and compulsions. They may think that their fears are normal and fail to recognise that the behaviours are excessive. Adolescents with OCD may be resistant to discussing these problems because they feel frightened of the consequence. There may be a tendency to exhibit “magical thinking” or “Thought-Action Fusion” where they believe that their fears will come true if they talk about them with a therapist (or anyone). Others may deny symptoms, or want to avoid dealing with them in the hope that their OCD will just go away by itself

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OCD in Adults

As with adolescent OCD, the obsessions exeprienced by adults are also abhorrent and completely inconsistent with their true values and desires. This is very important to understand for some of the obsessions on the list below. Because the obsessions are so opposing to the person’s true self (yet the individual may not know their thoughts are occurring due to OCD), people often feel high levels of shame and embarrassment in addition to anxiety and fear.

Common Obsessions

  • Symmetry and arranging obsessions
  • Pathological doubts (doubts that a shadow or a pothole on the road might have been a person, or that twigs, cracks or shadows on the ground might be syringes/potentially dangerous objects).
  • Violent (violent images involving family or doubts that you may be responsible for hurting strangers as you pass them by)
  • Contamination fears (AIDS, HIV, etc.)
  • Sexual obsessions (fears of deviant behaviours, paedophilia, being unfaithful or suitability of one’s partner, sexuality). Most people with this type of OCD respond to their thoughts by reminding themselves that they would never do such a thing, and by trying to avoid situations where the thoughts are likely to occur)
  • Religious/moral questions (thoughts combining religion and sex.)
  • Relationship obsessions: pathological doubt about loving the other person, looking for signs that suggest it’s not love; obsessive fear that one has cheated on their partner when they have not, etc.

Common Compulsions

  • Avoidance: for example a person with sexual obsessions may avoid certain situations or people. Unfortunately the social isolation only feeds the anxiety.
  • Counting specific things (such as footsteps) or in specific ways (for instance, by intervals of two) and doing other repetitive actions
  • Washing compulsions, including specific order of washing oneself in the shower, or needing to wash repetitively
  • Reassurance seeking from others around you
  • Ordering and arranging: making sure certain items are in a straight line, repeatedly checking that their parked cars have been locked before leaving them, constantly organizing in a certain way
  • Checking: turn lights on and off, keep doors closed at all times,
  • Touching and tapping: touching objects a certain number of times before exiting a room; tapping an appliance for reassurance it is off.
  • Compulsive cleaning, even when things are objectively clean
  • Obsessive rumination or mental rehearsing “pure O’s”

Theories of Causes of OCD

There are plenty of theories surrounding the potential causes of OCD, involving one of the following or a combination; neurobiological, genetic, learned behaviours, pregnancy, environmental factors or specific events that trigger the disorder in a specific individual at a particular point in time.

1. Neurological/
Biological Factors

Research has suggested that OCD is linked to a genetic or biological cause, and that specific brain regions are involved based on brain scans. However, despite the recognition that certain parts of the brain are different in OCD sufferers, when compared with non-sufferers, it is still not known how these differences relate to the precise mechanisms of OCD.

It has been consistently demonstrated by brain imaging studies that blood flow patterns of individuals with OCD differ compared with controls. These studies have shown that the cortical and basal ganglia regions are most strongly implicated. However, analyses of multiple studies found that differences between people with OCD and healthy controls were found consistently only in the orbital gyrus and the head of the caudate nucleus.

These areas of the brain become relevant and ‘switched on’ in particular environments where the person is worrying. It is therefore not surprising that there are brain activation differences between people with OCD and those without; this does not mean that OCD is a biological disease

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2. PANDAS

PANDAS stands for Paediatric Autoimmune Neuropsychiatric Disorders associated with Streptococcal Infection (PANDAS).

Streptococcal infections trigger an immune response, which in some individuals generates antibodies that cross-react with the basal ganglia, which studies have shown is a key region in OCD. The explanation was that some children begin to exhibit OCD symptoms after a severe strep throat infection that worsen with recurring infections. It is thought that the body’s natural response to infection, the production of certain antibodies, when directed to parts of the brain might be linked in some way to PANDAS.

However, other studies have found no link between subsequent infections and exacerbation of symptoms. What is known for sure is that if OCD results from a strep throat infection the symptoms will start quickly, probably within one or two weeks. So it could be that rather than PANDAS causing OCD, it triggers symptoms in children who are already predisposed to the disorder (e.g. through genetics or other causal explanations).

3. Chemical Imbalance

Another theory is that OCD is based on a chemical imbalance. Such theories have focused on one particular neurotransmitter, serotonin, which is the chemical in the brain that sends messages between brain cells. It is has been supported that serotonin is involved in regulating everything (e.g. anxiety, memory, sleep).

Initially, it was suggested that there was a deficit in serotonin in OCD sufferers; however, this was not actually identified. Researchers then argued that the most robust evidence for the serotonin hypothesis is the specificity of serotonin reuptake inhibitors (SRI) and selective serotonin reuptake inhibitor (SSRI) medication. However, given that this effect was the observation that generated the hypothesis, it cannot reasonably be considered as evidence for it.
 

Of note is that relapse is frequently associated with the withdrawal of SSRI medications in OCD, more so than in other conditions (especially where no behavioural therapy is in place) – this is yet to be fully understood. This may suggest that if serotonin is not a specific cause of OCD, then it is likely an  important neurotransmitter involved in the maintenance of OCD.

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4. Genetic Factors

Some research points to the likelihood that those with OCD will have a family member with OCD or with one of the other disorders in the OCD ‘spectrum’. An analysis of multiple studies reported that a person with OCD is four times more likely to have another family member with OCD than a person who does not have the disorder.

This and other studies have raised the possibility of familial prevalence of OCD and led to a search to identify specific genetic factors that may be involved. Although recent studies have reported associations between OCD and specific genes, further research is required.

It also needs to be remembered that many sufferers do not identify OCD anywhere else in their family, or even other anxiety problems. What this suggests is that genetics may not be the only cause of OCD, and  that family prevalence of OCD could be learned behaviours in some cases.

5. Behavioural Theory

Successful use of behaviour treatment for two cases of chronic obsessional neurosis (the forerunner to OCD) during the 50s and 60s, followed by a series of successful case reports, paved the way for application of psychological models to obsessions. It was later proposed that ritualistic behaviours were a form of learned avoidance.

In the early 70s, exposure became the main component of behavioural treatment methods. These and other approaches were eventually incorporated into highly effective behavioural treatment programmes which included the principles of Exposure and Response Prevention (a main component used in treatment today).

Support for use of ERP was shown that when a ritual was triggered,  if the individual did not engage in the ritual (or compulsion), then both the discomfort and urge to do the ritual subsided.

These researchers specified that behavioural treatment of OCD was based on the hypothesis that obsessional thoughts became associated with anxiety through conditioning, and that the anxiety had failed to extinguish. 

6. Cognitive Theory

The cognitive model of OCD states that all people experience intrusive thoughts, but those people who have OCD often misinterpret the intrusive thoughts as being extremely important, having significant meaning, and possibly having catastrophic consequences.  

As a result, these thoughts develop into obsessions that are so distressing that the individual engages in compulsive behaviour to try to resist, block, or neutralise the obsessive thoughts.

In the cognitive theory the difference between normal intrusive thoughts and obsessional intrusive thoughts is based on the interpretation of the occurrence or content of these intrusions, rather than simply the occurrence of it.  

According to cognitive models, the interpretation of an intrusive thought results in a number of voluntary and involuntary reactions. Each of these reactions can impact and increase the belief in the initial interpretation; hence, negative interpretations can both cause and maintain (or even worsen) OCD.