Psychiatric Database for Writers: Obsessive Compulsive Disorder (OCD)

Obsessive Compulsive Disorder (OCD) affects approximately one in every fifty persons. Individuals with this disorder have problems with certain kinds of thoughts (called obsessions) and behaviors (called compulsions).


What is an obsession? 

The term “obsession” refers to distressing thoughts or psychic images that are repetitive in nature and difficult to get rid of. The more the sufferer tries to avoid them, the worse they become. These thoughts are always unwanted. The patient recognizes his obsession as excessive but can’t stop the cycle.  You’ll find examples below.

Obsessions strike where one is most vulnerable.   

A priest experiences distressing, sacrilegious thoughts (for example, a repeated mantra like “I hate God”) and/or images (doing horrible things to a nun)

A mother can’t stop thinking, “I hope my son dies today.” She knows the thought isn’t true – she loves her son, would do anything for him — but can’t seem to turn it off.

Obsessions can be the “norm” taken to an extreme. 

A student thinks it’s a good idea to wash his hands before eating (normal).

Another student worries about contamination so much that he washes his hands every fifteen minutes, leaving them chapped and red.  He knows it’s a problem but can’t stop.


What are compulsions? 

If obsessions describe what a person thinks, compulsions describe what one does. A compulsion is a strong, usually irresistible impulse to perform an action or behavior, especially when that action is senseless or contrary to one’s will.  See below for examples.

Compulsions must be acted on to avoid anxiety 

A woman needs to drive around the block five times before parking in her garage.  She knows the compulsion is senseless, but she can’t go on with her day until she does it.

Every night, before going to bed, a man checks and rechecks all household windows and doors to make sure everything is locked – but finds he must check window and door FIFTEEN separate times before he feels comfortable enough to climbs into bed.

Compulsions can be experienced as a way to “undo” an obsession  

A child believes she needs to count to 100 every day after school, or else her mother will have an accident on the way to pick her up and never be seen again.

A man struggles with intense, persistent unwanted thoughts about killing his family, something he would never do.  The obsession is extremely distressing but is countered each day when he says the Our Father prayer twenty-five times in a row.


An aside…

An addict has a strong, irresistible impulse to use drugs.  Is that a compulsion?

It’s easy to confuse the two: both describe the irresistible impulse to perform a certain behavior, right?  Nope.  The difference lies in the type of impulse and type of end-point, or action.  An addict’s impulse to use is driven by a good feeling, anticipation, as they know there’s something pleasant up ahead if they give into the impulse.  Addicts use drugs because the action of using brings pleasure.  An individual with OCD isn’t driven by something pleasurable — the end-point has nothing to do with pleasure.  Quite the opposite: people with OCD perform compulsions to avoid suffering, and the end-point (the compulsion) is typically a senseless, time-consuming, embarrassing tasks that must be performed to avoid anxiety.  


What is the typical treatment for OCD?

Treatment typically includes medications and Cognitive Behavioral Therapy (CBT), usually a combination of both.  Brain surgery can be helpful for individuals with severe, treatment-refractory OCD. (There are also various self-help techniques available in bookstores and online, though I won’t go into this.)

Medications are key. 

Although we don’t understand the exact mechanism, some antidepressants  have been shown to be extremely helpful for individuals with OCD.  The most frequently prescribed medication for this particular disorder are Luvoxamine and Clomipramine.  Individuals usually require very high doses.  Sedatives like Klonopin or Xanax can be helpful with anxiety and panic, but are best used short-term.

Psychotherapy. 

Cognitive Behavioral Therapy (CBT) is the most popular type of talk-therapy, when it comes to OCD.   Rather than searching for some psychic reason for the condition, CBT is about the here-and-now. The cognitive aspect focuses on rewriting problem thoughts.  For example, fear of contamination might be challenged by reviewing the evidence: studies suggest that touching a doorknob in a public place is unlikely to trigger disease. The behavioral side of CBT is geared towards action.  Usually this involves delaying time between urge to complete a compulsion and actually doing it.

An aside…

The interesting thing here about therapy for OCD is that it focuses on pushing further INTO the pathology itself, especially obsessions. For example, an individual plagued with thoughts about killing his family should NOT avoid the thoughts.  Quite the opposite: he should pursue them purposefully, full-throttle, as often as possible – until the thoughts lose their power. Eventually one realizes that a thought is just a thought, no matter its content. 

Psycho-surgery.  Surgical options for OCD include placement of a Vagus Nerve or deep brain stimulator as well as psychosurgery that uses radio-frequency waves to disrupt the cortico-striatal circuit in the brain.  The cortico-striatal circuit has been implicated in OCD.  Long term outcome for these procedures appear to be somewhere between 25 and 70 percent in alleviating OCD symptoms.  


That’s a quick overview of OCD.  Thanks for reading.


Alex Natalian, Psychiatrist and Author

Alex Natalian is a penname for psychiatrist KRR.

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