Obsessive Compulsive

Disorder (OCD)
An Introduction

Prepared by Turfa Ahmed, 2nd year M.Phil. Clinical Psychology trainee, CPCUC
An Overview

 John Moore (1691), Bishop of Norwich, England, described an individual obsessed

by
 “naughty, and sometimes blasphemous thoughts that start in their minds, while they are
exercised in the worship of God, despite all their endeavors to stifle and suppress them…
the more they struggle with them, the more they increase…”

 In The anatomy of melancholy, by Robert Burton (1883), an individual is described

 “who dared not go over a bridge, come near a pool, rock, steep hill, lie in a chamber
where cross beams were, for fear he may be tempted to hang, drawn or precipitate
himself…. he [was] afraid he shall speak aloud … something indecent, unfit to be said”
❑ Esquirol (1838) described OCD as a “monomania,”

“chained to actions that neither reason nor emotion have originated, that
conscience rejects, and will cannot suppress.”

❑ Morel (1860 & 1866) described OCD as a disease of the autonomic nervous system
and called it “délire émotif,” a neurosis.

❑ Pierre Janet (1903) described how obsessions and compulsions develop over three
phases: initially characterized by a “psychasthenic” state (indecisiveness, need for
perfectionism and orderliness, and restricted emotional expression); followed by a
stage of “forced agitations” (need for symmetry, repeating, and checking); and,
finally, manifestations of frank obsessions and compulsions (aggressive, religious
and sexual themes).

❑ Freud described the famous case of Rat Man and popularized psychoanalytic
explanations and therapy for OCD.
 The essential features of OCD are the repeated occurrence of
personally distressing or functionally impairing obsessions and/or
compulsions (APA, 2013).
 Obsessions are unwanted, unacceptable, and repetitive intrusive thoughts,
images, or urges that are resisted and generally produce distress even though
the person may recognize that the thoughts are excessive or senseless
(Rachman, 1985).
 Compulsions are repetitive behaviors or mental acts associated with a
subjective urgency whose aim is to prevent a dreaded outcome or reduce
distress normally caused by an obsession.
Most common
obsessions

Obsession Compulsion
 FEAR of CONTAMINATION . . . . . . . . . . ................................. . .Washing/cleaning
 FEAR of HARM, ILLNESS or DEATH . . . . . ................................. . .Checking
 FEAR of VIOLATING RELIGIOUS RULES (SCRUPULOSITY)............Praying
 NEED for SYMMETRY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Arranging or “evening up”
 NEED for PERFECTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .Seeking reassurance
 NEED to HAVE SOMETHING “JUST RIGHT”. . . . . . . . . . . . . . ...... .Repeating
 FEAR of DISCARDING SOMETHING IMPORTANT . . . . . . . . . .......Hoarding
 The Defining Features of Obsessions

Intrusiveness The thought, image, or impulse repeatedly enters consciousness in

an unintended, involuntary manner; that is, it occurs against one’s
will.
Unacceptability The extent that a repetitive intrusive thought is considered unwanted
or undesired or engenders disapproval.
Subjective resistance A strong urge to resist, suppress, dismiss, or prevent the obsession
through avoidance, mental control strategies, or compulsive rituals.
Perceived An evaluation of diminished control over the obsession that is
uncontrollability considered unacceptable and threatening.
Differences in compulsions
Compulsive cleaning
 stronger phobic component involving
escape.
Compulsive checking
 doubting and indecision with active
avoidance behavior.
 took longer to complete, had a slow
onset, evoked more internal resistance,
and were more often accompanied by
feelings of anger or tension.
 more difficulty obtaining the required
certainty or assurance that the possible
negative future event had been averted
Reference: Rachman and Hodgson (1980)
 Diagnostic classification differences
DSM 5
 the presence of either obsessions or compulsions
or both.
 required to be timeconsuming (e.g. taking more
than 1 hour daily)
 cause clinically significant distress and/ or
impairment in social or occupational function.
 not attributable to the effects of a substance or
another medical condition.
 the disturbance is not better explained by the
symptoms of another mental disorder.
 the degree of insight that a patient possesses,
ranging from ‘good or fair’ to ‘absent’ or
‘delusional’.
 Tic-related.
ICD 10
 OCD can present with obsessions or compulsions or
both.
 the obsessional symptoms or compulsive acts must
be present on most days for at least 2 successive
weeks
 be a source of distress and/ or interference with usual
activities.
 thoughts or impulses being recognized as the
person’s own, there must be at least one thought or
act that is resisted unsuccessfully.
 compulsive acts, while they may relieve tension, are
not in themselves intrinsically pleasurable.
 predominantly taking the form: obsessional thoughts
and ruminations, or compulsive acts, or mixed
obsessional thoughts and acts.
 Exclusion:

DSM 5
❑ Differentiates OCD from more Axis I
disorders, but allows OCD to be
diagnosed with depressive disorders,
schizophrenia, and Tourette syndrome.
Specifically, allows OCD to be diagnosed
even in the presence of delusional OCD
beliefs
ICD 10
❑ Specific rules aboutdiagnosing OCD with
depressive disorders; cannot diagnosis
OCD in those with schizophrenia or
Tourette syndrome
 Clinical Picture
Obsessional Obsessional Obsessional Obsessional Obsessional Obsessional
thoughts ruminations impulses rituals slowness phobias
Words, ideas, Internal Urges to Both mental Obsessional Obsessional
and beliefs debates in perform acts, activities thoughts thoughts and
that are which usually and repeated and rituals lead compulsive
recognized by arguments for of a violent or but senseless to slow rituals may
patients as their and against embarrassing behaviours. performance, a worsen in
own, and even the kind. few obsessional certain
that intrude simplest patients are situations. The
forcibly into the everyday afflicted by person may
mind. It is the actions are extreme avoid such
combination of reviewed slowness that is situations
an inner sense endlessly. out of because they
of compulsion proportion to cause distress,
and of efforts at other just as people
resistance. symptoms. with phobic
disorders avoid
specific
situations
 Thought–action Responsibility Non-specific Emotion
fusion cognitive biases
• Thoughts or images • The belief that one has • Intolerance of • anxiety
become fused with power that is pivotal to uncertainty, ambiguity • disgust
reality. bring about or prevent and change • shame
subjectively crucial • The need for control
• magical thinking’ • guilt
negative outcomes. • Excessively narrow
(Rachman, 1993) These outcomes may focusing of attention • embarrasment
• moral thought– be actual, that is to monitor for potential • frustration
action fusion having consequences threats • irritability
• thought–object in the real world, • Excessive attentional
fusion (Gwilliam et and/or at a moral bias on monitoring
al, 2004). level (Salkovskiset al, intrusive thoughts,
1995). images or urges
• An overestimation. • Reduced attention to
real events
• the belief that harm
might occur to the self,
a loved one or
another vulnerable
person through what
the individual might
do or fail to do.
 Safety-seeking
behaviours
• action taken in a feared
situation with the aim of
preventing catastrophe
and reducing harm
(Salkovskis, 1985).
• includes compulsions and
neutralising behaviours.
• Neutralising is any covert,
voluntary or effortful
mental action carried out
to prevent or minimise
harm and anxiety with the
goal to either
compensate or eliminate
the effects of the
obsession.
• paradoxical
enhancement of the
frequency of the thought
in a rebound manner.
Avoidance Excessive reassurance
seeking (ERS)
• effort or activity intended to • focuses on a perceived threat
avert a perceived internal and its associated distress.
or external trigger of the
obsession and its • reassurance seeking in OCD is
associated distress. often more stereotypic.
• Rachman (2002) described ERS
• most commonly seen in as a checking compulsion by
fears of contamination. proxy, in which the person
repeatedly seeks the same
• Avoidance can also occur reassurance from others, often
mentally: trying not to think looking for the same specific
or feel something upsetting. answer to obtain relief from
anxiety, discomfort, and a
heightened sense of
responsibility for harm
associated with the obsession.
References

 Clark, D. A. (2020). Cognitive-Behavioral Therapy for OCD and Its Subtypes. 2nd Edition.
The Guilford Press: NY.
 Harrison, P., Cowen, P., Burns, T., & Fazel, M. (2018). Shorter Oxford Textbook of Psychiatry.
Oxford University Press: UK.
 Veale, D. (2007). Cognitive–behavioural therapy for obsessive–compulsive disorder.
Advances in Psychiatric Treatment, 13, 438–446.
 Simpson, H. B., & Reddy, Y. C. J. (2014). Obsessive-Compulsive disorder for ICD-11:
proposed changes to diagnostic guidelines and specifiers. Rev Bras Psiquiatr, 36(1), 3-13.