Obsessive –Compulsive Disorder: Rachman & Silva

Obsessive –Compulsive Disorder: Rachman & Silva

Contents

1 Obsessive-compulsive disorder: what is it?. 2

What is an obsession?. 2

Thought action fusion. 3

What are compulsions?. 3

Compulsive cleaning. 3

Checking compulsion. 4

Covert compulsions. 4

The active nature of compulsions. 4

Resistance. 4

Compulsions and habits. 4

Putting matters right. 4

The relationship between obsessions and compulsions. 5

Avoidance. 5

Disruption. 5

Ritual and Rumination. 5

2. Relationship to other disorders. 5

Depression. 6

Morbid Preoccupation. 6

Schizophrenia. 6

Phobias. 6

Eating disorders. 6

Anorexia. 6

PTSD.. 6

Tourettes. 6

Body dysmorphia. 6

Brain damage. 6

Obsessional Personality. 7

Obessive compulsive personality disorder. 7

Excessive hoarding. 7

Morbid jealousy. 7

3.      Obsessive-compulsive patients. 7

Washer Cleaners. 7

Mental Contamination. 8

Checkers. 8

Other types of observable compulsion. 8

Those with obsessions withouth any observable compulsion. 8

Primary obsessional slowness. 8

Some general comments. 8

4.      Effects on family, work and social life. 9

How the family is affected. 9

Work. 9

5.      Prevalence and related factors. 9

6 Theories and explanations. 9

Psychological perspectives. 9

The learning view.. 9

The cognitive behavioural view.. 10

Psychoanalysis. 10

Biological causation. 10

Conclusion. 10

7 Treatment. 10

1 Obsessive-compulsive disorder: what is it?

Obsessions are recurrent, unwanted, intrusive, unacceptable, persistent thoughts or impulses that cause anxiety or distress.

Compulsions are repetitive behaviour that aim to reduce anxiety or tension

What is an obsession?

With obsessions there is a recognition that the thoughts are the clients own as opposed to some mental illnesses where the thoughts are seen to come from outside. The client then tries to resist these thoughts and their compulsions are a big part of this.  The sufferer feels besieged by these thoughts and indeed obsession is derived from the Latin to besiege. They are also intrusive, interrupting an ordinary or pleasurable activity. Most obsessions clash with a person’s values, thus are ego dystonic.  This leads to self-doubt that the intrusive thoughts might be acted upon or might come true against the person’s value system.

There are three types of obsessions, thought, image or impulse. The client attempts to block it, which works for a short time but then returns. For some it feels that the obsession is always there lurking.  Obsessions tend to flourish in unoccupied times and don’t do so well during times of activity or conversation. The clinical use of obsession is different from common use of it. The clinical use is that the thought is persistent and unwelcome, whereas everyday usage means highly passionate about something that can produce a positive outcome. Likewise the clinical sense the client always tries to block it, in the colloquial usage then this isn’t the case, quite the opposite.

The content of obsessions in descending order of frequency are aggression, sexual and blasphemous thoughts.  Obsessions are produce a fear of losing control and doing the feared thought.  This in turn leads to avoidance of the feared object.

It is probable that obsessions develop when a patient attaches personal significance to a thought that we all have from time to time. If someone is highly sensitive or has very stringent standards then they can attach importance to this event. 

These obsessional thoughts are usually kept secret by the client through fear he would be seen as mad or bad.  The internal resistance against obsession are blocking, disputing, trying to neutralise through prayer.

Thought action fusion

Sometimes the thought is seen as psychologically equivalent to the action.

What are compulsions?

Compulsions are repetitive, highly rule driven actions that are taken with the view of reducing harm to oneself or others.  They are driven by a powerful urge.  There is no pleasure derived from doing it, and the behaviour is seen to be irrational and excessive but yet there is a strong urge to do it.

Most common compulsions:

1.       Hand washing to drive out contamination

2.       Checking door handles gas etc.

3.       Checking that you have got something right, egg in business

Compulsive cleaning

This is to deal with the fear of contamination. This contamination can be due to contact with contaminating objects egg dirt, faeces etc., or contaminating mental objects, egg association with people who have or could harm the client. Hmm I don’t understand this. Contamination is the intense feeling of being infected. It is associated with feelings of fear, disgust, shame and repugnance. So there is a moral dimension to this too.  Thus there is the sense that to get rid of the repugnant feelings there is an attempt to remove these physically. I touch something I feel infected, so I try to do the opposite of touching the dirty, i.e. touching the clean to get rid of the very strong feeling but here’s the rub, it’s the feeling that needs to be influenced not the cause of it.  There is a feeling that catastrophe will ensue unless the compulsion is carried out

Checking compulsion

Checking seeks to prevent a feared outcome, the house blowing up due to a gas leak, the company going broke due to a mistaken calculation. This is due to a heightened sense of responsibility to protect oneself and others from harm, and indeed that you can completely.  There is a combination of grossly inflated responsibility for the feared outcome, and a grossly inflated seriousness of that outcome.  There is also the actual checking, then the mental checking, it is physically draining.

Covert compulsions

For instance having to say safety words every time you read about a disaster so that this prevents it happening again.

The active nature of compulsions

Compulsions are purposeful, they are performed reluctantly. There is some control that the patient can exert over them, postponing them, reshaping them, shortening them, or sometimes getting someone else to perform them.  Repetitive behaviour can be mistaken for compulsion but compulsions are not automatic, they are deliberate.

Resistance

There has at some time of a person’s OCD been some resistance to it, but after many failed attempts to control it then the resistance might have been given up, but then I suppose there is active resistance and conceptual resistance, the action is still ego dystonic.

Compulsions and habits

The clinical sense of compulsion is a purposive behaviour that is repetitively and reluctantly performed, which is different to the habits of nail biting which isn’t purposive and isn’t reluctantly done.

Putting matters right

This can be ordering things, CDs books etc., or one’s own appearance.  This can well take several hours and it needs to be done before fresh task scan be performed

To have a diagnosis of OCD, you can have obsession, compulsion or both. But it is not the mere presence of the obsession or compulsion but the seriousness of it, and how it impacts upon the person’s life.  Most people have some form of obsession or compulsion but they are less frequent than the OCD patient and less distressing.

Superstitions are similar to compulsions in that they can be used to ward off bad events are seen as irrational however superstitions are often used to create positive outcomes which compulsions are never used as.

To diagnose someone as OCD then there obsession or compulsion must cause significant distress and interfere with the functioning of their life.  OCD can be spread to those around the patient, where they start insisting that others around them perform the same rituals.

The relationship between obsessions and compulsions

Clients can have obsessions or compulsions or they can have both and be related. So a person might think they will go blind every time they see a black object then must engage in visualising objects of different colour.  Although it does make me think can they ever not be related, if someone has obsessional thoughts they can avoid, or try mental suppression, which could be a cover compulsion. Sometimes there is a compulsion with no obsession, so every time you touch an object with your left hand you need to touch it with your right.

The standard process for OCD although not always is

Trigger=>Discomfort=>Compulsive Urge=>Compulsive behaviour=>Reduction of discomfort

There is some debate about the reduction of comfort as some do not feel it, and some are left with feelings of despair and anxiety, so the discomfort before has been relieved but changed into a different form of discomfort.

Excessive checking often goes with inflated responsibility.  OCD clients often think that there is a greater likelihood of disaster occurring when they are solely responsible as opposed to someone else.

Many OCD clients seek reassurance , that they aren’t going insane, that they did do it properly.  When the reassurance question comes in, it is factual, although the client generally knows the answer and does want facts although that’s what they ask for but rather want their anxiety reduced and they ask indirectly.

Avoidance

This isn’t part of the OCD schema but rather is a consequence of it.

Disruption

If a compulsive ritual is interrupted it is invalidated and needs to be restarted. Thus most compulsions are carried out in private or at night, or both!!

Ritual and Rumination

A Ritual is a compulsion that is carried out in a rigid, set pattern and a sequence of steps with a clear beginning and end.  A rumination is a train of thought about a question that is undirected, unproductive and prolonged. Rituals and ruminations are common occurrences in OCD clients.

2. Relationship to other disorders

Close relationship with depression, comorbid with social phobia, PTSD goes with OCD, there is an overlap between eating disorders, body dismorphia and OCD. Morbid jealousy also goes with OCD.

Depression

3 out of 4 people with OCD are depressed or have been clinically depressed. Sometimes OCD develops after depression and is secondary.  As patients who are severely depressed do not respond well to psychological treatments this should be addressed first.

Morbid Preoccupation

Depressed patients are prone to develop morbid preoccupations. However a morbid preoccupation centre on realistic worries, and lack the repugnant or irrational qualities of obsessions.

Schizophrenia

Whilst there may be a development of OCD in the early stages of schizophrenia, there is no major relation with OCD. Schizophrenic patients think thoughts have been inserted in them where OC D sufferers take ownership of them.

Phobias

The difference with phobias, is if a phobic avoids their object they feel safe. With OCD this is not the case as the intrusion are widespread and can become more abstract and grow.  So phobias can be contained in a way OCD cannot.

Eating disorders

Anorexia

Anorexia is a different disorder, although it does co-exist frequently with OCD.

PTSD

Some of the responses to re-experiencing the trauma via unwanted images are compulsive behaviours, I didn’t do it, for instance, it wasn’t my fault.  OCD can develop as a safety ritual to protect after an assault that can cause PTSD. OCD clients do not have a history of trauma, and PTSD clients do not develop full OCD so can be considered as separate disorders.

Tourette’s

This condition has multiple tics, verbal and physical, they are different to OCD as they are not meaningful, nor can they be delayed or reshaped.

Body dysmorphia

This is excessive concern about imagined defects with the body. Common complaints are about the face or head. Asymmetry or lack of proportion can also be a concern. Reassurance seeking is very common. What marks it out as different from OCD is the delusional self-image which is not present in OCD.

Brain damage

Brain damage can result in repetitive behaviours but again differ from compulsions in that they lack intellectual content and intentionality.

Obsessional Personality

The obsessional “personality” is riven with meticulousness, orderliness and perfectionism, but is unrelated to OCD, indeed if you want to find a “personality” type that is the precursor to OCD then introversion and cautious people are the ones that can end up with OCD, so be ware and be a party animal!!

Obsessive compulsive personality disorder

This personality disorder’s traits are excessive rigidity and perfectionism, undue preoccupation with details, indecisiveness and people tend not be able to express warm and tender emotions. This is a personality disorder and has little to do with OCD, why the name then bob uh?

Excessive hoarding

The person who hoards, takes great care to protect their hoard. The five components of excessive hoarding are:

1.       The excessive acquisition of a very large number of unnecessary objects

2.       Apparently irrational emotional attachment to the objects

3.       Vigilant protection of the collection

4.       Cluttered living conditions

5.       An emotional and behavioural inability to discard the objects

This doesn’t surface as a problem until later life, as the hoard doesn’t get that big. OCD sufferers tend to happen in late adolescence and early adulthood. Indecisiveness is a common aspect for hoarders and they fret over whether to expand their collection, needing backups of certain objects. If they try to reduce their collection they end up churning the objects into smaller piles of the objects without removing any. If they do remove any of the objects they experience an emotional reaction which justifies their reason for keeping them.  There is a sense of safety of being with their collection and it therefore needs to be kept in view.  The common belief that hoarding is the result of childhood deprivation is not bourne out by scientific research.  CBT isn’t that effective with hoarding and there is no known best approach, just supportive therapy.

Morbid jealousy

This happens where the partner engages in a form of compulsive behaviour to ensure that their partner is faithful, trustworthy. Seeing their fear is irrational doesn’t shift it, if they shift partners, their jealousy follows them and they forget about their old person, they don’t get envious about status, goods etc., just jealous.

3.     Obsessive-compulsive patients

The most common forms of OCD are checking and washing.

Washer Cleaners

They are afraid of contamination from

1.       Bodily fluids

2.       Viruses, egg aids

3.       Chemicals

The object that can contaminate can be a person, place or object, usually you would guess the latter.  Compulsive cleaning aims to protect oneself against contamination, and what it does is aim to reduce the feeling of anxiety about being contaminated. Contamination usually is understood to occur at the hands and this is what is cleaned. Clients also seek to avoid the contaminating people, places and objects.

Mental Contamination

This occurs where there has been psychological pain, distress, shame, disgust, embarrassment, humiliation etc. It is difficult to locate where the contact object comes from as the feelings arise internally, but the rituals to decontaminate are the same.  Thus there’s is a feeling of contamination arising from psychological distress and a desire to cleanse this contamination.  The contact that provokes mental contamination can be anything that associates back to the original event, so it can be memories or objects.

Checkers

Checking   creates checking, the more checking that is done the more uncertainty is raised and then the greater the distress and the greater the need to check.    The checker loses confidence in their memory due to the number of times they check and the uncertainty that has been promoted.  The fear is for checkers that disaster will fall to them or others if they do not check sufficiently. The problems with checking behaviour is a grossly inflated sense of responsibility for a disaster happening, a grossly inflated sense of the probability of that disaster happening and a grossly inflated sense of the seriousness of that disaster should that happen. The common bias is that it will happen because I am responsible.

Checkers both have a high personal standards and an inflated sense of responsibility.

Other types of observable compulsion

There are people who have certain words that cause distress, or have to do certain things in certain orders, or symmetrically.  Likewise list making when carried to extremes can be detrimental.

Those with obsessions without any observable compulsion

The intrusive thought content here is sexual, blasphemous or violent. The client fears that they are mad, bad, or dangerous and provoke feelings of anxiety, self-doubt and guilt.  The compulsions that can accompany these will then be mental rituals, repeating prayers, or saying neutralising words.  The rituals that are repeated have to be done in an exact order or they have to be repeated, likewise if there is an interruption or distraction, or contamination of the ritual it has to be repeated.

Primary obsessional slowness

This is where a range of self-care tasks are ritualised and take an incredibly long time, four hours to brush your teeth. Here the primary problem is the slowness and meticulousness of the task.

Some general comments

Indecisiveness is a key element in OCD and the need to take a decision can spawn compulsions. Avoidance can also be a key factor in some OCD with the need to avoid a certain number. Likewise compulsions can sometimes be needed to perform a certain number of times and this number may have a symbolic significance. Perfectionism is also a key component as people with OCD tend to strive to doing things perfectly. Some people with OCD have a scrupulosity to tell the truth, to go through in minute detail the circumstances of an event even when the listener shows no interest, or indeed antipathy.  People with scrupulosity have an over inflated sense of conscience.

4.     Effects on family, work and social life

How the family is affected

The family can be effected directly by their compulsions and also indirectly by reassurance seeking.  Sometimes they are asked to carry out compulsive rituals themselves.  The patient can dominate the household with their demands and rituals.

Work

People with inflated sense of responsibility avoid promotion at work, as it will increase their stress.

5.     Prevalence and related factors

OCD does not develop late in life. Can be exacerbated by depression.  OCD is very much influenced by the society in which the person lives, which dictates what a troubling thought is and how you would neutralise it.

1% of people get OCD, 12% depression, 16% social phobia. The onset of the distress is generally gradual although there are rare occurrences of sudden manifestation due to trauma.  The more general picture is a background of emotional distress accompany thing the development of OCD. OCD doesn’t appear to be affected by your parents, so if your parent has OCD then you might show some similar characteristics but not get full blown OCD. Genetically there appears to be a contributory component but that this does not make someone vulnerable to OCD but rather to the range of anxiety disorders.

6. Theories and explanations

Psychological perspectives

The learning view

This sees that OCD is the result of maladaptive learning. So there is an anxious event and this anxiety gets reduced by certain behaviour so the behaviour is strengthened.  So in stressful\highly stressful situations rigid tried and tested anxiety reducing behaviour is resorted to, even if it isn’t the most effective in the long term. However learning theory struggles as an explanation as most OCD sufferers don’t have an initial traumatic event to start this. Likewise learning theory struggles to explain why only certain substances acquire frightening qualities and what the nature of obsessions, primary slowness and compulsive hoarding are, which are cognitive in nature. Learning theory would state there has been an initial event that is distressing that is managed by certain behaviour, but when it is a cognition that starts it with obsession, then how would it explain it, well it would say that the first cognition is distressing, then there is cognitive behaviour that seeks to reduce stress, so it seems ok, hmm may need to think more about this

The cognitive behavioural view

This sees the client as having an inflated sense of personal responsibility and an exaggerated sense of risk and danger. Many clients drop out of CBT treatment and treatment for mental contamination is at the development stage.

Psychoanalysis

Compulsions are seen as the mechanisms that suppress the real anxiety which holds in place a hidden unconscious desire\conflict.  Psychoanalysis is not recommended by NICE.

Biological causation

It is thought that OCD clients have insufficient serotonin, based on the fact that clomipramine, an anti-depressive drug can have therapeutic effect on clients.  However you can’t increase the drug and increase the effect, you can get similar effects using psychological methods rather than drugs. Biological explanations can’t deal with the very specific differences in OCD, i.e. why one washes and the other hoards. Again you can’t work from cure to cause, aspirins don’t tell us why headaches are caused.

Conclusion

There is no comprehensive explanation for OCD

7.     Treatment

Rationale

An OCD sufferer has a trigger situation that creates a cognitive fear. Their ritual is then used to reduce this fear and is associated with it so that they believe that the ritual decreases their fear, but what the evidence shows is that this fear would diminish on its own naturally, and doing this would show there was nothing to be afraid of, using the ritual shows there is something to be afraid of.  Early in treatment then the spontaneous decline can take up to 2 hours, later in treatment 2 minutes.

Modelling

The therapist demonstrates the exposure to the client then gets the client to copy it.  The patient is then asked to report on their strength of desire to carry out their compulsion.

Imaginal Exposure

This can be used for hard to create situations or as a build-up to actual exposure

Therapy in Practice

Create a fear hierarchy. Take a task, model it. Get the client to do it, when getting them to avoid their compulsive behaviour then some level of distraction could be useful. You must wait during the session until the fear has reduced to a manageable level so you could need 2 hours for the session during the early stages. One central aspect of therapy is information about OCD how it maintains. Second is getting the patient to feel control over their obsession as this is one of the damaging aspects of it, as they feel out of control.  A severely depressed patient with OCD is unlikely to respond well to treatment so best to treat the depression first.  There is no evidence that drugs make OCD any better, they can reduce the depression or anxiety but don’t touch the OCD.

Obsessions

Here the treatment looks to work with the interpretation of the thought that is had. Also what is looked at is that a thought can lead to a catastrophic consequence. People with obsessive thoughts try to control them which exaggerates their importance through the enhancement and rebound effect.  It is explained that everyone has unwanted, unpleasant thoughts from time to time, but attaches no significance to them.  People who suffer from obsessive thoughts are people of high standards and very sensitive such as Martin Luther and John Bunyan.

Obsessional Images

If someone has obsessional images, then the image can be manipulated. So if they see vomit, then they can shrink it to a dot, or if they see a violent scene they can focus on a neutral part of the scene to make it less distressing for them.

8.     Assessment, diagnosis and evaluation

Nothing of interest to report here

9.     OCD in children

Low prevalence of OCD in children, the areas are checking and cleaning and the need for symmetry in seen more in children than in adults. The difference between superstitions and OCD is OCD the ritual is always carried out to fend off the negative never, to encourage the positive. Superstitions are common practices whereas OCD is unique.

Obsessive thoughts that are repugnant are seldom seen in children. Most children grow out of their OCD behaviour. However those that don’t grow out of it, can develop severe and chronic problems.

How you see OCD in children is behavioural, where there is a rigid and repetitive behavioural pattern, where the child gets upset at interruptions to it.  They often say of their behaviour that they must do it right, perfectionism being a factor in 30% of cases. Children rarely complain of obsessions.

10.                         Some Practical advice

Everyone has some aspect of OCD, unwanted thoughts, compulsive behaviour, but it only becomes a problem through the severity of it, and the adverse impact on your life.