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Obsessive-compulsive disorder (OCD)
OCD stands for obsessive-compulsive disorder. Obsessions are persistent thoughts that a person cannot make go away. Compulsions are irresistible impulses.
In obsessive-compulsive disorder, a person (who might otherwise seem perfectly normal) feels compelled to think about certain things or perform certain actions. Those thoughts and actions commonly do not make any sense to other people, and OCD sufferers may know this perfectly well, yet they are helpless to stop.
About 20% of people with OCD suffer only obsessions, or only compulsions. Most (80%) experience both.
One of the big changes in DSM-5 and ICD-11 was the creation of a new category for OCD, hoarding, hair-pulling (trichotillomania), and skin-picking. This meant removing OCD and the other syndromes from the category of anxiety disorders.
The re-shufflng of categories reflected the opinion of researchers that these disorders were related. In each case (OCD, trichotillomania, skin-picking, and hoarding) a person has irresistible impulses, even though the behavior is ultimately harmful. In each case, preventing the behavior (for example, cleaning out the home of a hoarder) produces great anxiety.
What do the disorders grouped together with OCD have in common?
One common manifestation of obsessive-compulsive disorder is excessive hand washing. This obsession centers on fears of contamination.
Why is fear of contamination such a common obsession? Probably this urge has deep biological roots.
Normally the urge to avoid disgusting and dirty things helps people avoid infection and disease. However, when fear of contamination results in washing hands 30-50 times a day, 10-15 minutes at a time, until the skin is raw and bleeding...then something is wrong.
Judith L. Rapoport wrote a book titled The Boy Who Couldn't Stop Washing, which featured many fascinating case histories of OCD. Rapoport points out that often an OCD sufferer is a sane person with an isolated problem. She wrote:
...One girl would get up at six every Sunday morning to spend three hours washing the walls of her room. She certainly knew that this was odd, but she just felt that she "had to do it" but didn't really know why. She said the washing had started quite suddenly about a year before.
'I just woke up one morning last summer,' she told me, 'and I had to do this.' ...This girl was close to her family, and a good student. She had close friends and a boyfriend. Her grades were good, and she took part in extracurricular activities at school and held a part-time job. (Rapoport, 1988, p.15)
What are common manifestations of OCD?
OCD is a spectrum disorder, so it is common to find mild cases that do not result in psychiatric treatment. One student wrote that she "never thought there was anything wrong with washing your hands thirty times, or not wanting to touch anything in the house" until she saw an Oprah Winfrey show featuring people with OCD. She wrote:
Some of their strange habits seemed very close to some of the things I did. But that program wasn't strong enough to make me think I had OCD. Later on, my mother noticed that I had another strange habit that may have been OCD. I can't help but to wipe my mouth after every bit of food I take.
Not only that but I had to have a new napkin every time because I thought that if I used the old napkin that I would get something on my face from the napkin. It was crazy because there was nothing even on my face, plus I was using about 100 napkins at one sitting. Well, it started to bother my boyfriend so I talked to a psychologist.
I don't have OCD, but from growing up in a strict and proper house it has had other effects and makes me a little obsessive over little things. I'm okay, but I still wipe my mouth after each bit; now I just rip the napkin up before I use it so that I don't use so many. [Author's files]
The student denies she has OCD, but it might be more accurate to say she has sub-threshold OCD (in other words, she is still functioning in day to day life). Her behavior is actually quite typical of OCD.
She has a compulsion (she feels compelled to wipe her mouth after each bite). She knows that what she is doing is "crazy" but cannot stop. Evidently the psychologist decided not to press the diagnosis of OCD upon her and simply provided her with a simple way to avoid consuming hundreds of napkins.
What is "checking" in OCD?
The act of checking something over and over is characteristic of OCD. Many people experience a mild form of this. For example, you may set your alarm clock, then lie in bed and ask yourself, "Did I set it?"
You might turn on the light, check your alarm clock, and verify that–sure enough–the alarm was set. That would indicate you are normal, because everybody does this occasionally. However, if you are still checking the alarm clock ten minutes later, that would resemble obsessive-compulsive disorder.
How does OCD often manifest itself, during childhood?
OCD runs in families and often shows up in childhood. OCD is sometimes manifested in children as a counting obsession. One student recalled that, as a young child, he could not climb stairs unless he counted them first.
Another student developed a counting compulsion at college. She wrote:
Recently I have been having this problem. I am having these strange feelings that if I don't do certain things, something bad may happen to me or someone I care about.
For instance, every day when I am walking into Psychology I feel like I have to kick four pine cones before I walk into the building. After class is over, and I am walking out to my car, I feel like I have to kick four more, and after this, I feel like I can get into my car and go on my way.
It's really weird, because also on Fridays before I go into the lecture hall to take my test, I feel like I have to take four drinks of water from the fountain or I will fail my test. I really don't understand why I do this.
It's strange to me that both of these weird things have to do with the number four. I don't know why I do these crazy things, I guess I just feel that if I don't do them, something bad will happen.
It's not only at school that I do these strange things, it's also when I'm at home. We live in a two-story home, and every time I go up or down the stairs, I feel like I have to touch every one of them, and if I don't, I have to go back to either the top or bottom and start over again.
It's sort of like there's a little voice inside of me telling me to do these things or something bad may happen. I don't know what it is that I think will happen, and I guess that part of me is really scared to see. [Author's files]
This student's report sheds a light on why OCD was previously classified as an anxiety disorder. The motivating force behind OCD symptoms is a feeling that "something bad" will happen if hands are not washed or a ritual such as counting stairs is not performed.
Why was OCD categorized as an "anxiety disorder"?
Such behaviors resemble avoidance behaviors, which are behaviors reinforced by the elimination of anxiety. Avoidance behaviors tend to persist because they are self-reinforcing. Even if the fear is groundless, the relief produced by an act of avoidance is real and acts to reinforce the behavior.
Administering a medication that raises serotonin levels, such as Anafranil or Prozac, eliminates OCD in about 60% of cases. However, medication by itself sometimes does not eliminate all the symptoms, and many people with OCD combine talking therapy or behavior therapy with medication. Some people seem to outgrow childhood symptoms of OCD without treatment.
What is body dysmorphic disorder?
Body dysmorphic disorder, historically known as "dysmorphobia," was classified as a somatoform disorder in older versions of DSM. With DSM-5 the category of somatoform disorders was eliminated, replaced by somatic symptom disorders. Body dysmorphic disorder (BDD) was re-classified as a variation of OCD.
BDD occurs when a person is preoccupied with a defect in appearance. It may be entirely imaginary or based on some minor problem that other people hardly notice.
DSM-5 further specifies that BDD involves repetitive behaviors (such as mirror checking or excessive grooming), and clinical significance (impairment in important areas of functioning). If focused on excessive fat or weight, the person must actually be normal in weight.
Schrof (1991) described one case:
Every day is a nightmare for David X. Rather than going to work or to school, the 30-year-old gets only as far as his bedroom mirror, where he finds a hideously distorted face: a crooked, swollen nose covered with scars, a bulging eye.
After four cosmetic surgeries, the defects remain. David quit college and moved home to his parents 10 years ago when he first began to see a repulsive image in the mirror. Since then, he has rarely left his room, afraid to let anyone catch sight of him.
Schrof adds, "David's story is doubly tragic because the flaws he sees exist not on his face, but in his mind." Remarkably, he was able to convince plastic surgeons to operate on his defects. Probably they thought he was exaggerating his problems and only wanted minor improvements in an otherwise normal face.
To David, however, the "hideous, distorted face" was real and did not change after the surgeries. Body dysmorphic disorder (BDD) often responds to anti-depressive drugs such as SSRIs that raise levels of serotonin.
Rapoport, J. L. (1989). The Boy Who Couldn't Stop Washing. New York: Dutton.
Schrof, J. M. (1991, November). Reflections of torment. U.S. News and World Report, 111, p.65.
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