Anxiety Disorders: Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a form of anxiety disorder that involves obsessions, compulsions or both. Obsessions are persistent, non-sensical and distressing thoughts, ideas, images or impulses that intrude into the person's consciousness and which the person recognises as unwanted. Compulsions are repetitive, purposeless actions or mental actions that a person feels compelled to perform in order to reduce anxiety. Minor obsessions and compulsions can play a useful role in everyday life. A student taping her finger on the desk in an exam might find it releases some tension and so helps her perform better. Checking that the gas is off and the doors are locked before going to bed, even two or three times, is prudent and probably not that uncommon. However, in order to be diagnosed as having an OCD the person must recognise that the obsession/compulsion is excessive or unreasonable, there should be marked distress and interference with normal routine, occupation or functioning. Obsessions Obsessions are thoughts that feel intrusive ("ego dystonic") and foreign ("ego alien"). They cannot be ignored and, even though the person acknowledges that they are the product of their own mind (unlike a schizophrenic's experience of thought insertion), they are still experienced as repugnant. There are three hallmarks that distinguish a clinical obsession from a more harmless recurring thought: obsessions are distressing and unwelcome, they arise from within and they are very difficult to control (Rosenhan et al. 1995). There are various forms of obsession: thoughts of contamination (55% of obsessives, according to Jenike et al. 1986) aggressive impulses (50%) orderliness (37%) concerns with physical health (35%) sexual content (32%) non-aggressive impulses, such as wanting to jump into the path of a train images, such as severed heads doubts, such as 'Did I do the right thing?', 'Does he really like me?', 'Will I make it?'

Similarly, a 1975 content analysis of the obsessions of 82 people with OCD by Akhtar et al. suggests five broad categories, in order of frequency: dirt and contamination, violence and aggression, orderliness of inanimate objects, sex, religion. There are cultural differences in the kinds of obsession most frequently diagnosed. Rachman and Hodgson (1980) found that in contrast to Western obsessions with contamination, people in New Delhi,

India, were more likely to be obsessed with aggression, orderliness or sexual matters. The same researchers found also that the content of obsessions changes as society changes over time. Compulsions Compulsions are the responses to obsessive thoughts (Rosenhan et al. 1995). They are repetitive rituals that can be covert mental acts (such as repeating a phrase or persistent counting) or overt purposeful acts (such as handwashing or checking). The rituals are performed in response to the anxiety that arises from obsessive thoughts, following the same rigid pattern each time and so are said to be stereotyped anxietyreducing rituals (Perrotto et al. 1993). Only rarely are people with OCD unable to identify the thought process (obsession) that leads them to compulsive acts. More usually, they can give an account of the link between a compulsive act, say, eating in a particular stylised manner, and their fear/obsession, say being possessed by the devil if they didn't eat in this way. However, the connection between the two aspects is not formed in any realistic or logical way. Hissing grotesquely, coughing and violently tossing your head whilst eating, I'm sure you'll agree, is not a guaranteed way of preventing possession by the devil! Taking extremely small steps as you leave the house to go to work will not guarantee that your family will not be swallowed by an earthquake. Nevertheless, the compulsion is meaningful to the person at some level and has some significant effect, albeit temporary, something a psychoanalytic psychologist would want to explore. One of the most striking cases of OCD was Howard Hughes, one of the world's richest people. He was obsessed with contamination and lived as a recluse for much of his life, employing staff to look after him and communicating with them through elaborate memos. He planned in detail how his servants should perform everyday operations to prevent germ infestation, such as opening doors (with their feet!) and preparing food (removing labels and scrubbing cans with a sterile brush before opening them). For a vivid account of this case, see Rosenhan et al. (1995) p.268. Frequency and Vulnerability At some time in their lives, between 2 and 3% of people will experience OCD, 2.6% prevalence according to Karno and Golding (1991). Robins et al. (1984) found that women are more vulnerable than men, Rasmussen et al. (1986) found that 55% of patients were female and Karno et al. (1991) found 60% female. There is a higher concordance rate between identical compared with fraternal twins (Carey and Gottesman 1981), suggesting a heritability factor. Average age of onset ranges from adolescence to midtwenties, with males peaking earliest (Rasmussen and Eisen 1990). Some people with other disorders are more likely than normal to experience OCD and are then said to be comorbid. Studies have shown a link between depression and OCD, with between 10 and 35% of depressed people having obsessions (Glittleson 1966, Sakai 1967). Such statistics should be treated with some caution, however, given that OCD is like other anxiety disorders in that it is towards one end of a continuum that has 'normal' anxiety at the other end. Frost et al. (1986) found that in a sample of 'normal' college students, 10-15% had checking rituals sufficient to put this behaviour into the same category as the checking behaviours of patients with OCD. To suggest a figure of 2.6% (or whatever) is to run the risk of nominalism, the process of making something appear separate and distinct by attaching a label to it (Remember from Ps2 that nominal level of measurement is grouping data into categories?). Nominalism is arbitrary and so subject to social and cultural factors. See your notes on defining normal/abnormal. The point is that most of us, sitting in our psychology

classroom, will have some pretty bizarre compulsive, aggressive, sexual or 'tidying' thoughts at times but the point at which it merits the label OCD reflects social and cultural contextual factors. Theories on the Causes of Obsessive-Compulsive Disorder (aetiology) There are three major theories that attempt to account for OCD; psychodynamic, cognitive-behavioural and biomedical. For a change, the theories seem to complement each other with the psychodynamic account being useful in explaining the occurrence of OCD, the cognitive-behavioural account suggesting how it continues and the biological account describing the underlying and necessary brain events associated with OCD. The following table represents a summary of the views, each of which is described in further detail below.

Views of Obsessive-Compulsive Disorder Theoretical view Psychodynamic Who develops OCD? People with specific unconscious conflicts (e.g. thoughts of injuring parent or child) People who cannot distract themselves easily from troubling thoughts, often combined with depression People with over-active cortical-striatalthalamic circuit What happens? Obsessive thought begins as a defence against a more unacceptable thought How is it sustained? The obsessions and compulsions successfully defend against the underlying anxiety The ritual temporarily relieves anxiety, which is then reinforced through repetition and operant conditioning Evolution has prepared us to see certain objects and situations as threatening and obsessions and compulsions are directed towards these How is it cured? By recognising and working through the unconscious conflict

Cognitivebehavioural

Obsessive thoughts become frequent and persistent, while depression simultaneously weakens ability to distract oneself

Biomedical

Spontaneous repetition of behaviour (perseveration) may be poorly inhibited, anxiety may be inadequately dampened, filtering of irrelevant information may be inadequate

Preventing the response whilst being exposed to the anxiety leads to extinction of the link, extinguishing the obsession Drugs (e.g. clomipramine) reduce activity of corticalstriatalthalamic circuit

adapted from Rosenhan and Seligman (1995) p272

Psychodynamic account An obsessive thought (such as 'I must not look at any fiery colours, red, orange, pink and so on') is viewed as a defence against some other more frightening thought, an underlying thought that the person can not admit to consciousness. This unconscious thought is threatening to awareness because it is significant so the person can not just bury and ignore it. The unconscious is not a waste bin. Defence mechanisms are used to express the dynamic tension caused by this disturbing thought continuing in the unconscious, remembering that defence mechanisms are unconscious distortions. Perhaps the person has an unconscious fear that her 'mother will die of a fever' and when this thought threatens to break through into consciousness the person experiences anxiety. Rather than acknowledging the original object of the anxiety (mother's dying), the person displaces the anxiety onto a less threatening object (fiery colours). Fiery colours are a substitution for the terrifying thought and have a curious internal logic rather than being arbitrary, in this case perhaps symbolizing the fever from which the person's mother might die. Thus, the particular content of the obsessions is seen as symbolic of the underlying conflict (based on a study by Rachman and Hodgson 1980). The Rat Man's (Freud 1909) obsessive thought 'Kill yourself!' was explained by his realization (i.e. acceptance in consciousness) that during a distressing separation from his girlfriend due to her grandmother's ill-health, he had been plagued by another obsession 'If you were commanded to cut your throat with a razor, what then?' This thought was a substitution of the guilt-provoking desire to kill the grandmother since she was depriving him of his girlfriend. This razor obsession led to the compulsive thought 'Kill yourself!' as an appropriate punishment for feeling such unreasonable and intolerant passion for his girlfriend. Cognitive-behavioural account Rachman and Hodgson (1980) start from the assumption that we all experience obsessional thoughts occasionally. We are able, however, to distract ourselves from such thoughts and to attend to matters at hand. We are also able to dismiss occasional abhorrent thoughts that might go through our minds. People with OCD are unable to distract themselves from such thoughts or dismiss them. It is particularly difficult to ignore or dismiss extremely anxiety provoking thoughts. Horowitz (1975) found that if an individual was particularly upset during a distressing film, then the subsequent thoughts about the film would be particularly intrusive and repetitive. Two assumptions underlie the cognitive-behavioural account: a) we all have unwanted and repetitive thoughts b) the more stressed we are, the more frequent and intense are these thoughts If the person is already depressed (see comments on comorbidity above), then the obsessive thoughts will be even more difficult to dismiss. The voluntary action of ignoring the thoughts is inhibited by depression (Seligman's 1975 notion of learned helplessness). The obsessive-compulsive's inability to ignore and dismiss the thought will lead to further anxiety and in turn to greater susceptibility, in a downward spiral. Compulsions arising from the obsessions are explained by this account on the grounds that the ritual is negatively reinforced by the removal of an aversive stimulus, namely the reduction of anxiety associated with the obsession. Checking the front door is locked at night may be followed by a reduction in anxiety

and therefore whenever the anxiety is experienced the door checking behaviour follows. The door checking provides a temporary relief and as the anxiety rekindles, a ritual develops. Biomedical account True to the medical model of mental disorders, this account assumes that OCD is a brain disease, on the grounds of four strands of evidence: neurological signs; brain scans; primitive content of obsessions and compulsions; the effectiveness of drug treatment. I Neurological signs Some psychomotor behaviours that are consistent with underlying neurological disorder, such as poor fine motor co-ordination, involuntary jerks and poor visual-motor performance, occur in many people with OCD. Hollander et al (1990) found that the more pronounced these so-called 'soft signs', the more severe the obsessions. OCD is comorbid with several neurological conditions such as epilepsy and Tourette's Syndrome (George et al 1993). II Brain scan abnormalities Caudate Brain areas implicated in OCD include the caudate nucleus nucleus, the frontal cortex and the cingulate cortex which Cingulate together form the hypothesised brain circuit known as the cortex cortical-striatal-thalamic circuit. These areas seem to be Frontal linked in functions concerning the filtering out of irrelevant cortex information. Researchers have found no structural irregularities here but an increased amount of activity in the Cortical-striatal-thalamic circuit 'circuit', though there seem to be conflicting findings from different researchers. PET scans have shown lower than usual concentrations of the neurotransmitter serotonin in this circuit. Damage to this area of the brain that causes interruptions to the serotonin circuit seems to impair the ability to ignore information so leading to excessive activity. However, we must remember that such findings are often from studies on non-human subjects or exceptional human case studies, the genralizability of which is questionable. Also, brain image studies are often inconsistent, partly because the structure of people's brains differs slightly and so the location of activity has a degree of speculation involved. Finally, it is possible that this pattern of brain activity is the result rather than the cause of obsessive-compulsive behaviour. III Primitive content The content of obsessions and compulsions seems to have some kind of pattern. We must ask why it is that so many people with OCDs are concerned with contamination, for instance. Why be obsessed with checking and washing? Evolutionary theorists point out that such concerns are of particular significance to the survival of an individual and so to the survival of the species. Marks and Tobena (1990) suggest that rituals and recurrent thoughts in OCD may be deep vestiges of primate instincts gone awry. IV Drugs Clomipramine alleviates symptoms of OCD in many patients, suggesting a biological basis to the disorder.

Treatments for Obsessive-Compulsive Disorder Many treatments have been tried, including ECT, antidepressants and lobotomies but with poor shortterm and worse long-term effects. Corresponding to the three accounts above, we'll look at how psychoanalysis, behaviour therapy and drugs are being used at present in attempts to treat OCD. Psychoanalytic therapy Here the main focus is on the person accepting the underlying conflict in their unconscious. Such acceptance comes about through the gradual analysis of the significance of defences through suggested interpretations, repression analysis, transference and resistance analysis and can take several years (Laughlin 1967). As ever, since it is not possible to carry out controlled studies of psychoanalytic technique it is difficult to assess its effectiveness. Behaviour therapies Three techniques which have been studied in controlled conditions are response prevention, flooding and modelling (Marks and Rachman 1978). These have resulted in noticeable reductions in symptoms. However, removing symptoms does not amount to a cure. Modelling might involve the therapist 'contaminating' himself with 'dirt' and with no ill effects. The client might then be encouraged to cover himself with dirt in the same way (flooding) and not be allowed to wash it off (response prevention). Thoughts of contamination and ritualistic washing could be expected to diminish after a relatively brief period of several weeks of such treatment. Several studies involving Marks and Rachman between 1971 and 1978 indicate a marked improvement in about two thirds of patients, maintained in all but 10% of such patients by a follow-up study six years later. Even though the specific effects of the reduction in obsessions, compulsions and anxiety are impressive, very few patients lose all symptoms or are functioning well in all areas of life (Beech et al 1979). Flooding and response prevention seem reliably to extinguish learned behaviours. (Note that these techniques should not work at all if the Primitive Content biological explanation outlined above were valid.) A rat that has learned to be helpless in the presence of an aversive stimulus (e.g. a signal followed by a shock) will sit still during the signal even when the barrier preventing escape has been removed. In other words the association between the UCS (shock) and the CS (signal) has been broken by response prevention such that the CS no longer produces the CR (running away). Applied to OCD, this means that when the client is exposed to the threatening situation and survives it, Pavlovian extinction occurs. Being exposed to dirt (CS) is no longer associated with illness (UCS) or taking leaps and bounds away from the house on the way to work in the morning is not associated with the house falling into a crevasse. According to Rosenhan and Seligman (1995) "flooding and response prevention may work for two reasons: (1) by showing the patient that the dreaded event does not occur in the feared situation (Pavlovian extinction), and (2) by showing the patient that no dreaded event occurs even thought the compulsive ritual is not performed (instrumental extinction of the compulsion)." (p.279) Drug treatment Clomipramine (trade named Anafranil) is an antidepressant drug which inhibits the re-uptake of serotonin. Leonard et al (1993) and others have found that with the use of this drug obsessions wane and compulsions can be more easily resisted than if a placebo is taken. Nearly half the group do not get better, however, and there are undesirable side effects including drowsiness and constipation. In the others, symptoms may be dampened but there is rarely a removal of all symptoms and the temptation to ritualize is still felt. Relapse upon ceasing to take the drug is wide spread, indicating clearly the distinction between treatment and cure.

Summary of treatments for OCD Neither behavioural nor drug therapies can be considered a cure but both relieve the symptoms in over half the cases and for a relatively long period of time. Considering the gains at the end of therapy and the extent of relapse after therapy, behavioural therapies seem to be slightly more effective. Foa and Kozak (1993) reviewed 16 studies involving over 300 patients and found that 83% of those treated behaviourally had improved by the end of therapy compared with 50-60% involved in drug treatment. In terms of relapse, those for whom clomipramine was an effective treatment all relapsed when no longer taking the drug (Thoren et al 1980) whereas those treated with behavioural measures showed much less relapse.