Obsessive-Compulsive Disorder (OCD) is a serious psychological disorder that has the potential to disrupt the daily functionings of the person afflicted by it. It is an anxiety disorder and most people have both the obsessive thoughts and the compulsive behaviour.
OCD affects about 2-3% of the population and is more likely to affect females than males. The onset of this disorder is usually late teens or early twenties and sufferers are normally aware that their thoughts and behaviours are irrational but they feel powerless to overcome them.
OCD comprises of Obsessions and Compulsions – obsessive thoughts and compulsive behaviours. Obsessions are persistent, recurrent thoughts, images and beliefs and are usually ugly in nature. These thoughts invade the mind of the sufferer and are uncontrollable. The compulsions are the behaviours that follow the obsessions, usually as a means of reducing them. The flow between obsessions and compulsions can interfere with the daily functioning of the sufferer.
Obsessions are usually identified as irrational by the individual experiencing them. The most common obsessions are related to fear of contamination, expressing sexual or aggressive impulse, or bodily dysfunctions.
Symptoms of OCD
Obsessional cleanliness: obsession with contamination leading to compulsive behaviour such as repeatedly washing hands to a point where hands can be scrubbed raw. Constantly scrubbing or bleaching of home, especially areas such as sinks, toilets, doorknobs.
Obsessional rituals: having a specifically ordered way of doing things. E.g. counting to three every time before eating a mouthful of food.
Obsessional doubts: doubting that an action has been carried out, e.g. doubting whether the door has been locked before leaving the house, or doubting that the iron was turned off.
Compulsive checking: this usually follows the doubting. Checking to see if the action was carried out. So if the individual doubts that the door was locked, he/she would check again and again to be sure. Sometimes the checking can be so severe that it could take a considerable amount of time out of their day doing this.
Obsessional ruminations: continuous review of arguments for and against even the simplest things. These are usually internal dialogue the individual has with themselves.
Obsessional impulses: strong urges to do things that would cause embarrassment, danger or even acts of violence.
The obsessions (OCD intrusive thoughts) usually create stress or anxiety in the individual and they attempt to relieve this with the compulsions that follow. However sometimes the compulsions can be dysfunctional, having a negative impact on their life. For example, someone with intrusive thoughts resulting in obsessional doubts may attempt to alleviate the doubts by checking, so much so that they endlessly check to be sure, however by the nature of the obsessional doubts they are rarely ever sure.
Causes of OCD
There really is no single identified cause for OCD, but it is thought to be a combination of neurological factors, genetic factors, cognitive factors, and behavioural factors.
There is evidence to suggest that there is a genetic link with OCD. It has been found that people with OCD have family members who either have OCD or other types of anxiety disorders. Whilst there is a genetic link this does not necessarily mean that an individual will develop OCD if their family members have the disorder. What it does mean is that they have an increased likelihood of developing the disorder.
Research suggests that low levels of serotonin (a neurotransmitter in the brain) are related to symptoms of OCD. Particularly low levels of serotonin in areas of the brain that control impulses about cleanliness, sex and violence (these incidentally are the focus areas for obsessions). PET scans have also shown increased activation in the frontal lobes of patients with OCD compared with patients without OCD.
Another structure in the brain that might explain OCD is a circuit that involves three anatomical brain regions: the orbital-frontal cortex (OFC), the caudate nucleus, and the thalamus. The OFC’s role is to become aware when something is wrong. When the OFC registers that something is wrong it sends a signal down to the thalamus. The thalamus becomes hyperactive and then sends a signal back to the OFC (this action forms the loop in the circuit). The caudate nucleus is situated between the thalamus and the OFC and it’s role is to regulate signals sent between them. Normally the caudate nucleus suppresses the original ‘worry’ signal sent from the OFC preventing the thalamus from getting excited or hyperactive. However in people with OCD it is thought that the caudate nucleus is damaged, so the thalamus becomes hyperactive, sending strong signals back to the OFC. The OFC then responds by increasing compulsive behaviour and the anxiety that accompanies it. Drug research supports this view as findings show that SSRI (selective serotonin reuptake inhibitor) medication increases the stimulation of serotonin receptors in the OFC and so inhibits its overactivity.
Cognitive and behavioural factors:
People with OCD are not able to turn off intrusive thoughts. It is suggested that because OCD sufferers tend to be rigid and moralistic in their thinking, they tend to judge their negative thoughts as being unacceptable therefore resulting in them feeling high levels of anxiety and guilt. A way to reduce these feelings of anxiety is to engage in compulsive behaviours. The compulsions are supposed to reduce feelings of anxiety but rarely do so, rather they tend to exacerbate the situation, leaving the individual repeating a cycle of actions.
Rachman (1997) suggested that obsessions are caused when the person catastrophically misinterprets the importance of the intrusive thoughts. When this happens it leads the person to a state of anxiety and distress, the person then tries to suppress these feelings with the compulsive behaviour. For example, intrusive thoughts about having dirty hands may lead a person with OCD to believe that they are going to die. This can cause distress and one way of relieving these feelings is to wash hands repeatedly in order to avoid that fate. The problem though is that compulsive behaviours tend to make the obsessive thoughts worse.
Whilst the onset of OCD is adolescence or young adulthood, some children may present with some symptoms of OCD. It is important to note that other disorders could present symptoms that mimick OCD so the child should be thoroughly checked by a mental health professional before a diagnosis is made. Children may go through phases where they obsess over things and may behave in compulsive ways, but they usually grow out of them. Download this free resource if you have a child with OCD. This resource will guide you through the things you can do to help your child manage the disorder.
All children worry and have doubts but when children have OCD they cannot stop worrying. Their thoughts are constantly on things being harmful, dangerous, dirty, or wrong. They may also worry about things going wrong or bad things happening. The child’s mind may be invaded by scary thoughts that they cannot control. They may obsess about things and wanting things to be just right all the time and may worry when that doesn’t happen or when things change. Children with OCD may also have the urge to do things repeatedly or may feel compelled to count things repeatedly. These are the ritualistic behaviour patterns of OCD – the compulsions. These compulsions are an attempt to get rid of the scary thoughts and children usually are unable to explain why it is they have to do these things. Usually though, they do have these compulsive behaviours to make sure that something bad doesn’t happen and is a way of controlling their world. The anxiety they feel leads them to dwell on thoughts repeatedly and to do things that help relieve the scary thoughts, this becomes a problem when it begins to interfere with their daily functions and their day to day activities. The child with OCD usually realises that they don’t need to repeat the actions over and over again, but feels like they have to as doing so does in the short-term relieve the anxiety felt with the obsessions. In the long-term though this is not the case as the obsessions are likely to intensify. OCD is not something the child has control over, nor is it something the child has caused themselves. As parents it is also important to understand that OCD is not something you could have caused. OCD is a disorder and is as real as any other psychological and/or physical disorder.
OCD in children is usually diagnosed between the ages of seven and twelve. This is the phase where they become increasingly concerned about their social environment and how they fit in. It is a time when they are increasingly worried about friendships and fitting in. Children with OCD may also have low self esteem or feel shame or embarrassed about their thoughts and behaviours.
Common obsessions in children:
- Fear of contamination or germs
- A need for order and symmetry
- Lucky or unlucky numbers
- Fear of themselves or their family being harmed or put in danger
- Intrusive sounds
- Intrusive words
Common compulsions in children:
- Constant hand washing
- Checking rituals including repeatedly checking homweork, checking that appliances are turned off
- Counting rituals: repeatedly counting objects, or counting number of times they swallow when having a drink, counting the number of times they chew they food
- Ordering or arranging objects
- Hoarding and collecting things. Random things or specific objects
OCD can have a negative effect on the family. The behaviour of the individual with OCD can cause annoyance, or possibly resentment in family members. This can increase the level of anxiety felt by the person suffering from OCD, and can be destructive for family relationships. It is important for family members to be patient and understand that OCD is not something that the person can control. A strong supportive environment is required to minimise the levels of anxiety experienced by the individual.
Cognitive Therapy as a Treatment for OCD
Cognitive-behavioural explanations for OCD lie in the understanding that the disorder is a result of irrational thinking patterns that are followed by maladaptive behaviours. OCD is a difficult disorder to understand and treat effectively. The ultimate goal for treatment would be to encourage the individual to learn to develop a tolerance for and an understanding of the reality that uncertainty and anxiety comes with everyday life and everyone experiences these at one point or another.
Cognitive therapy will involve challenging the irrational thoughts and exposing the sufferer to the things they fear. Repeated exposure to the source of the obsessions will reduce the responses. When exposed to the source of their obsessions, the individual will be prevented from doing the compulsive behaviour that usually follows. What then happens is that whilst they resist the compulsions, their anxiety levels would naturally drop showing them that they have control over their compulsions. The person with OCD is then taught other more healthy ways to respond to irrational obsessive thoughts.
Family therapy is also a good treatment method as OCD usually has a negative effect on family life. Through therapy family members learn tools and techniques to become better able to cope. Family members also learn not to blame the individual for their disorder and learn ways to be more supportive.