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Obsessive Compulsive Disorder

Guy Doron

The clinical phenomena associated with OCD, such as persistent unwanted aggressive, horrific or sexual thoughts accompanied by ritualistic behaviors have been known in the psychiatric literature for more than two centuries (Berrios, 1989; Himmelhoch, Levine, & Gershon, 2001). In 1837, Esquirol described the "folie du doute", the doubting madness, highlighting the role of doubt and indecisiveness in OCD. Others included developmental stages and subtypes in their conceptualizations of OCD (Berrios, 1989). Freud (1896/1909) suggested that OCD symptoms are the result of the unsuccessful functioning of defense mechanisms characteristic of the anal-sadistic psycholsexual developmental stage. In an attempt to resolve the conflict between unacceptable, unconscious sexual or aggressive impulses and the demands of conscience ego, individuals suffering from OCD use undoing (i.e., neutralizing unacceptable ideas by compulsive acts) and reaction formation (i.e., unconsciously developing attitudes and behaviors that are opposite of unacceptable repressed desires and impulses). Pierre Janet (1903) in his work Les Obsessions et la Psychasthenie (Obsessions and Psychasthenia), identified three stages of OCD. The first stage included the psychasthenic state or the obsessive personality. This was followed by a forced agitations stage comprising of tics and rituals. Finally, there is the deepest and final stage of psychasthenic illness in which the individual lacks sufficient psychological tension (a form of nervous energy) to complete higher level mental activities, leading to the activation of primitive psychological operations such as obsessions and compulsions.

The current definition of OCD according to the Statistical Manual of Mental Disorders (DSM IV; APA, 1994) includes obsessions and/or compulsions. A diagnosis of OCD is appropriate when either, or both, obsessions or compulsions are experienced at least at some stage as excessive, unreasonable and inappropriate, cause significant distress, and are very time consuming or interfere with daily functions. The most common obsessions include fear of contamination, feelings of doubt, a need to have things in a particular order, somatic concerns and repugnant (i.e., aggressive or horrific impulses) and sexual intrusions. The most common compulsions involve checking, hand washing and cleaning, counting, assurance seeking, symmetry and precision, repeating actions, hoarding, and ordering. Although a minority of OCD sufferers experience only obsessions or only compulsions, most experience both (Jenike, 1986; Rachman, 1993; Rasmussen & Eisen, 1992).

The wide range of themes and behavioral manifestations of OCD has led to attempts to identify homogeneous subgroups within the broad concept of OCD (e.g., Baer, 1994; Calamari et al., in press; Leckman, Grice, Boardman, & Zhang, 1997; Summerfeldt, Richter, Antony, & Swinson, 1999). Current research suggests that different subgroups of obsessive compulsive (OC) symptoms may have a different etiology, cognitive underpinning and require different interventions (e.g., Foa, Kozak, Salkovskis, Coles, & Amir, 1998; Leckman et al., 1997; McKay et al, 2004; Tolin et al., 2003). In fact, different explanations have been suggested for different OC symptoms such as checking (e.g., Rachman, 2002), contamination (e.g., Rachman, 2004) and obsessions (e.g., Rachman, 1997). Recent data examining OCD symptom dimensions also reported changes occurring within rather than between OCD symptoms dimensions (Mataix-Cols, Rauch, Baer, Eisen, Shira et al., 2002) and the strongest predictor of having a given symptom following a two year period was having reported having the same symptom previously (Mataix-Cols et al., 2002). These findings suggest meaningful differences in cognitive underpinnings between OCD symptoms subtypes or dimensions.

Checking is arguably the most common OCD symptom (Stein, Forde, Anderson, & Walker, 1997). Some studies suggest that a ratio of 4:3 or 6:3 between checking and the next most common compulsion, cleaning (e.g., Antony, Downie, & Swinson, 1997; Henderson & Pollard, 1988). Checking symptoms commonly manifest as stereotyped, repetitive and seemingly intentional checking of different objects (e.g., gas, taps, doors, stove, windows, homework assignments) to ensure safety to self/others or "adequate" completion of tasks. Some researchers linked checking with failure to arrive at feelings of certainty (Rachman, 2002), or the need to avoid "not just quite right" experiences (Coles, Frost, Heimberg, & Rheaume, 2003). Checkers can spend hours in repeated checking behaviors, experiencing extreme feelings of doubt and repeatedly seeking reassurance from others.

Contamination fears and washing compulsions are frequently seen among OCD sufferers. Individuals with contamination fears are usually preoccupied and/or disgusted by dirt or germs and compulsive cleaning is commonly driven by fears of contamination and its consequences (Jones & Menzies, 1997, 1998; Krochmalik, Jones, Menzies, & Kirkby, 2004; Rachman, 2004), although clearly can be motivated by the need for perfection (Guidano & Liotti, 1983, Tallis, 1996). More often though, the intense anxiety associated with contamination results in a strong need to engage in washing and cleaning behaviors. Repetitive washing and cleaning rituals may include the whole household or all one's possessions, or may be restricted to certain places and objects. The purpose of such actions is to reduce or remove the significant threat (e.g., to physical, mental or social well being) to self or others. Contamination fears may lead the individual to avoid leaving their home or allowing any visitors (including family and friends) inside the home (or particular areas of the home). Gloves, coats, or even masks may be used in order to prevent contamination from spreading or infecting places or people. In fact, cleaning and washing compulsions may be triggered by direct or indirect contact with the feared object or even individuals (Rachman, 2004).

Some OCD sufferers a show strong urge or need for symmetry and ordering. Such individuals report feelings of uneasiness unless they perform certain tasks in a symmetrical or balanced manner (Coles, Frost, Heimberg, & Rheaume, 2003). The need for symmetry and ordering may include objects or even body parts. For instance, an individual may feel anxiety or fear if the objects in their bedroom are not in a specific order or a specific location in the house. Others may feel a compulsion to move their leg or arm muscles in a specific way followed by the same muscle motion in the other leg or arm. The need for order or symmetry is sometimes associated with the concern of a feared event occurring unless the action is balanced.

Obsessions are defined as thoughts, images or impulses that are egodystonic and that intrude into consciousness. As seen above, compulsive behaviors such as washing and checking are frequently a response to the anxiety provoked by such thoughts or images (APA, 1994). The most frequent obsessions are feelings of extreme doubt, uncertainty and fears of being contaminated (Rachman & Hodgston, 1980; Rasmussen & Eisen, 1992). Obsessions may also include themes such as aggressive, sexual and/or blasphemous intrusions. Obsessions are often very distressing to the individual experiencing them. An individual may describe having fears of committing an immoral act or fears of having committed such an act in the past. Indeed, obsessions are frequently associated with reassurance seeking behaviors (e.g. confessions or checking). Thus, obsessions and compulsions are time consuming, distressing and can be debilitating.

OCD patients generally report lower quality of life than both the general population and patients with chronic illness (WHO, 1996). For instance, in one study comparing 60 OCD outpatients with diabetes patients and the general population, OCD patients reported higher ratings of problems with work functioning, daily functioning and social functioning due to emotional problems, than both control groups (Koran, Thienemann, & Davenport, 1996). OCD patients described problems with disruption of relationship functioning including lower likelihood of marrying (Emmelkamp, de Haan, & Hoogduin, 1990; Rasmussen & Eisen, 1992; Riggs, Hiss, & Foa, 1992) increased unemployment (Leon, Portera, & Weissman, 1995), and marital distress in comparison to the general population (Emmelkamp et al., 1990; Riggs et al., 1992). Family disharmony and anger about the continuous pressure to participate in the OC rituals were also reported by OCD suffers (Koran, 2000).

Recent data suggests six-month prevalence of OCD to be between 0.7% and 2.1% and life time prevalence between 1.9% and 3.5% (e.g., Angst et al., 2004; Bebbington, 1998; Canino, Bird, Shrout, Rubio-Stipec, & et al., 1987; Kolada, Bland, & Newman, 1994; Narrow, Rae, Robins, & Regier, 2002; Rasmussen & Eisen, 1992; Robins, Helzer, Weissman, & al., 1984)}. The Institute of Mental Health Epidemiologic Catchment Area (ECA) study (Regier & et al., 1984) was conducted from 1980-1985 with 20,861 participants on five sites in the USA. Revised prevalence estimates of the ECA data using a clinical significance criteria indicated one year prevalence rate of 2. 1% for OCD (Narrow et al., 2002). More recently, lifetime prevalence was assessed in a face-to-face household survey using the fully structured World Health Survey version of the Composite International Diagnostic Interview (Kessler, Berglund, Demler, Jin, & Walters, 2005) with findings suggesting a slightly lower life time prevalence of 1.6%.

OCD onset usually occurs before the age of 25 years. Some studies have reported that as many as 70%-80% of adults develop OCD before the age of 20 years (Angst et al., 2004; Pauls, Alsobrook, Goodman, Rasmussen, & et al., 1995). Other studies (e.g., Rasmussen & Eisen, 1992) have reported about one third of OCD patients develop major OCD symptoms before the age of 15, another third before the age of 25 years and less than 15% develop the disorder after the age of 35. Although the development of OCD is commonly gradual (Rasmussen & Eisen, 1992), acute onset following a distressing or significant life event such as childbirth has also been reported (e.g., Abramowitz, Moore, Carmin, Wiegartz & Purdon, 2001; Williams & Koran, 1997).

The reported average age of onset seems to differ between genders with men usually reporting slightly earlier onset of the disorder. For instance, Ramussen and Eisen (1992) reported an average age of onset of 21 years for men and 22 years for women. The Epidemiological Catchment Area Survey (ECA) found the average age of onset to be 22.4 for men and 23 years for women. However, some researchers reported average onset of symptoms as early as 9.6 years for males and 11 years for females (Swedo, Rapoport, Leonard, Lenane et al., 1989).

Research into sex ratio is somewhat equivocal with some sites reporting higher prevalence for females (e.g., Bebbington, 1998; Weissman, Bland, Canino, Greenwald, & et al., 1994) and others little or no differences between the genders (e.g., Kolada et al., 1994). The current accepted opinion is that both males and females are equally affected (Rasmussen et al.,1992; APA, 1994). However, studies in pediatric settings suggest a significantly higher male to female ratio (e.g., Swedo et al., 1989; Thomsen & Mikkelsen, 1991; Wever & Rey, 1997). OCD affects all ethnic groups (Rasmussen et al., 1992). Indeed, findings suggest that OCD is equally prevalent in developed and developing countries (Sasson et al., 1997).

Patients with OCD are at high risk of having comorbid major depression and other anxiety disorders. The most common lifetime diagnosis is major depression (67%), with concurrent unipolar depression seen in up to a third of individuals with OCD and a mood disorder secondary to OCD in up to 85% of patients (Angst et al., 2004; Karno, Golding, Sorenson., & Burnam, 1988; Rasmussen & Eisen, 1992). OCD also tends to occur with other anxiety disorders such as simple phobia (22%), social phobia (18%) and panic disorder (12%; Rasmussen & Eisen, 1992). Comorbid eating disorders also seem to be substantial such that 10% of female OCD patients have a history of anorexia (Kasvikis, Tsakiris, Marks, Basoglu, & et al., 1986) and bulimia 14% (Angst et al., 2004).

In summary, this part of chapter 1 described the phenomenology, epidemiology and course of OCD. It emphasized the variety in OC symptoms, their early development, their high rates of comorbidity, and the severity of disability associated with OCD.

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