Obsessive-compulsive disorder

Obsessive Compulsive Disorder (OCD) is a psychiatric disorder characterized by the presence of both intrusive thoughts (called “obsessions”) and compulsive behaviors.

Obsessions

Obsessions are intrusive thoughts, images, or urges that cause anxiety, are experienced as disturbing and inappropriate, and are defined as “egodystonic,” i.e., distant from the self-concept.

To give an example, an obsession might affect a very religious person who experiences blasphemous thoughts or impulses and who recognizes such thoughts or impulses as distant from his or her self. They are not part of his personality or history.

In other cases, people with OCD may have an extreme fear of dirt or germs, a fear of infection, or a fear of not being able to control their impulses and harming themselves or others.

Compulsions

Compulsions often follow very specific rules of behavior and are performed in “response” to an obsession, in an attempt to control the negative emotions associated with the intrusive thought. These behaviors can vary greatly from person to person, but they tend to be characterized by repetitive rituals that the person feels compelled to perform.

For example, a person with an obsession about contamination might repeatedly wash his or her hands or clean excessively. Another obsessed with leaving the front door open may feel the need to check it repeatedly. These rituals are often performed in rigid patterns and can take up a lot of time, causing significant disruptions in daily life.

Although compulsions provide temporary relief from the anxiety caused by obsessions, they often prove counterproductive, increasing long-term anxiety and reinforcing the obsessive-compulsive cycle. In fact, OCD is one of the most disabling psychiatric disorders, greatly reducing the quality of life of those who suffer from it.

Prevalence and age of onset of OCD

OCD affects approximately 2-3% of the population over the course of a lifetime. Typically, 90% of people with OCD have both obsessions and compulsions. This percentage rises to 98% when counting and mental compulsions are considered true obsessions. However, it is possible to observe people who develop only obsessions and others who develop only compulsions.

OCD often begins in adolescence. However, in recent years there has been an increase in cases of OCD in children with adult-like symptoms. In general, the onset of OCD in children or adolescents is more common in males and is often associated with greater symptom severity.

In addition, people with OCD often suffer from other psychiatric disorders. In fact, OCD is often associated with disorders such as generalized anxiety disorder, panic disorder, or major depression.

Causes of Obsessive Compulsive Disorder

The causes that lead to the development of OCD are varied and not fully understood. In fact, as with many psychiatric disorders, it is not possible to attribute the development of OCD to a single factor.

Hypotheses about possible causes fall into two broad groups: psychological causes and biological and genetic causes. It is plausible that there are predisposing biological factors and psychological and environmental aspects that promote the onset of the disorder. In fact, recent developments in genetic biology indicate that environment and gene expression are interdependent factors and that it is not possible to point to a single cause.

Psychological causes of Obsessive Compulsive Disorder

There are two theories that postulate psychological causes in the development of OCD. The first, a behavioral one, refers to Pavlol’s concept of “classical conditioning,” while the second is more cognitive in nature.

According to the classical conditioning hypothesis, it is possible for an emotionally neutral stimulus (such as the touch of a doorknob) to become associated, even by chance, with the fear of becoming ill. Once this association is established, the individual may find that the fear resulting from touching the doorknob can be reduced by washing their hands. Continuation of these behaviors would lead to reinforcement of the association, resulting in the development of OCD.

Another theory, which is cognitive in nature, hypothesizes that the cause of obsessive thoughts is related to the way some people relate to their thoughts. Specifically, these individuals would have difficulty perceiving the difference between thinking about something and actually doing it.

They would then be subjects inclined to believe, for example, that thinking about hurting someone is as morally reprehensible as actually doing it. This cognitive error, called fusion-thinking-action (Berle & Starcevic, 2005), would be a major cause of OCD, according to this theory.

Biological Causes of OCD

In addition to psychological causes, there are several biological causes of OCD. Studies conducted on homozygotic and heterozygotic twins have shown that one of the causes of OCD is genetic predisposition.

This means that some people are more genetically predisposed to developing OCD than others. Studies of families of OCD patients have shown that family members have a 3 to 12 times higher risk of developing the disorder than the general population.

Extensive neurotransmitter studies have also clearly shown that one of the neurotransmitters most implicated in OCD is serotonin. In fact, antidepressants, including clomipramine and some SSRIs in particular, have been shown to be effective in treating OCD.

Symptoms of OCD

The main symptoms of OCD, as we have just seen, fall into two broad categories. Obsessions and compulsions.

Most common obsessions

  • Fear of dirt, with the thought that one’s body (often hands) or other objects are dirty despite numerous washes.
  • Contamination phobia, characterized by the fear that physical contact with another person (e.g., a handshake) may transmit disease.
  • Frequent doubts about habitual actions, such as whether the car is locked or the gas is turned off.
  • Order and symmetry, experiencing a sense of deep discomfort when a certain order is not maintained (e.g., when objects on a desk are out of place).
  • Fear of losing control and hurting oneself or others.
  • Blasphemous thoughts.

Most common compulsions

  • Frequent grooming, especially frequent showering or hand washing.
  • Checking to dispel obsessive doubts, such as repeatedly checking that one has locked one’s car or turned off the gas.
  • Ordering one’s belongings by following strict patterns, such as maintaining symmetry in the arrangement of objects on one’s desk.
  • Counting and recounting objects.
  • Mental compulsions, such as repeating a word, phrase, or prayer over and over in one’s mind without being able to stop.
  • In general, compulsive symptoms are repetitive rituals structured around rigid rules that cannot be broken. Even the slightest violation of one of these rules usually results in a crisis, forcing the person to repeat the compulsive ritual again.

OCD and DSM-5 diagnosis

How is OCD diagnosed? According to DSM-5, the Diagnostic and Statistical Manual of Mental Disorders, a person must meet the following criteria to be diagnosed with OCD:

A. Presence of obsessions, compulsions, or both:

Obsessions may be characterized by:

  • Recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted, causing anxiety or distress.
  • Attempts to ignore, repress, or neutralize these thoughts/impulses/images with another thought or action (e.g., a compulsion).

Compulsions are characterized by

  • Repetitive behaviors (e.g., washing hands, ordering, checking) or mental acts (e.g., praying, counting, mentally repeating words) that the person feels compelled to perform in response to an obsession or in order to follow rigid rules.
  • These behaviors or mental acts are intended to prevent or reduce anxiety or distress or to avoid a feared event, but are not realistically related to what they are intended to neutralize/prevent or are clearly excessive.

B. Obsessions or compulsions last a long time (e.g., more than one hour per day) or cause significant distress or impairment in important areas of functioning (social, occupational, etc.).

C. OCD symptoms are not due to the physiological effects of a substance (e.g., drug, medication) or medical condition.

D. The disorder is not best explained by the symptoms of another mental disorder.

Treatment of OCD

Psychological treatment

One of the most effective psychological interventions in the treatment of OCD is exposure with response prevention (E/RP). This approach involves exposing the patient to potentially anxiety-provoking stimuli.

Once exposed, the patient is prevented from engaging in the compulsive behaviors, allowing the anxiety to subside naturally. Although this type of treatment has shown excellent results, it is very stressful and has a high dropout rate.

These behavioral treatments have evolved into the so-called third generation of behavioral therapies, including Acceptance and Commitment Therapy, which, again based on behavioral principles, uses metacognitive modalities to manage emotions more functionally.

Classical cognitive-behavioral psychotherapeutic approaches have also proven effective in the treatment of OCD.

Pharmacological treatments

The pharmacological treatments of choice for OCD are those that act on the serotonergic system. In particular, many SSRIs have been shown to be effective in treating OCD by significantly reducing symptoms, improving mood, and reducing anxiety.

It is important to note, however, that medication therapy for these disorders can vary from person to person, both in the choice of medication and in dosage. For these reasons, it is always important to rely on one’s psychiatrist for appropriate medication treatment that takes into account individual variables.

In fact, the severity and intensity of the symptoms of the disorder may vary from person to person, suggesting a differentiated course of treatment.

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