Obsessive compulsive disorder (OCD): an overview

By Cristiano Antonino On Dec 6, 2022

Obsessive compulsive disorder is characterised by recurring thoughts, images or impulses. These trigger anxiety/disgust and ‘compel’ the person to carry out repetitive material or mental actions in order to calm down

Sometimes obsessions are also incorrectly called manias or fixations.

As the name implies, obsessive compulsive disorder involves the existence of symptoms such as obsessions and compulsions.

At least 80% of obsessive patients have obsessions and compulsions, less than 20% have only obsessions or only compulsions.

Spread of OCD

Obsessive-compulsive disorder (OCD) affects 2 to 3% of people over a lifetime, regardless of gender.

It may begin in childhood, adolescence or early adulthood. In many cases, the first symptoms appear very early, in most cases before the age of 25 (15% of subjects remember an onset around the age of 10).

If OCD is not adequately treated, first of all with specific cognitive behavioural psychotherapy, it tends to become chronic and worsen over time.

Obsessions and compulsions in OCD

Obsessions are intrusive and repetitive thoughts, images or impulses that are perceived as uncontrollable by the person experiencing them.

Such ideas are felt as disturbing and usually judged as unfounded or excessive.

Obsessions in OCD activate unpleasant and very intense emotions, especially anxiety, disgust and guilt.

Consequently, they feel the need to do everything possible to reassure themselves and manage their emotional distress.

Compulsions typical of obsessive compulsive disorder are also called ceremonial or rituals

They are repetitive behaviours (such as checking, washing/washing, ordering, etc.) or mental actions (praying, repeating formulas, counting) aimed at containing the emotional discomfort caused by the thoughts and impulses that characterise the obsessions described above.

Compulsions easily become rigid rules of behaviour and are definitely excessive, sometimes bizarre in the eyes of observers.

Types of Obsessive-Compulsive Disorder (OCD)

Those suffering from obsessive disorders may:

be exceedingly afraid of dirt, germs and/or disgusting substances;
be terrified of inadvertently causing harm to themselves or others (of whatever nature: health, economic, emotional, etc.) through mistakes, carelessness, carelessness, carelessness;
being afraid of losing control of one’s impulses by becoming aggressive, perverse, self-damaging, blasphemous, etc.; and
having persistent doubts about their feelings towards their partner or about their sexual orientation, even though they usually recognise that this is not justified;
feeling the need to perform actions and arrange objects always in the ‘right way’, complete, ‘well done’.

Symptoms of OCD

The symptoms of OCD are very heterogeneous, but in practice a few types are usually distinguished.

Some patients may have more than one type of disorder at the same time or at different times in their lives.

Contamination

The symptoms are obsessions and compulsions related to improbable (or unrealistic) infections or contaminations.

“Contaminant” substances often become not only objective dirt, but also urine, feces, blood and syringes, raw meat, sick people, genitals, sweat, and even soaps, solvents and detergents containing potentially “harmful” chemicals.

Sometimes the dirty feelings are triggered by even immoral thoughts or memories of traumatic events, without any contact with contaminants. In this case we speak of mental contamination.

If the person comes into contact with one of the “contaminating” agents, or in any case feels dirty, he implements a series of compulsions (rituals) of washing, cleaning, sterilization or disinfection.

This in order to neutralize the action of germs and to calm down with respect to the possibility of contagion or to get rid of the feeling of dirt and disgust.

Controlling OCD

The symptoms are obsessions and compulsions involving protracted and repeated checks without necessity, aimed at repairing or preventing serious misfortunes or accidents.

People who suffer from it tend to check and double check.

This is to make sure that everything possible has been done to prevent any possible catastrophe.

Sometimes to calm down about the obsessive doubt of having done something wrong and not remembering it.

Within this category there are symptoms such as checking that you have closed the doors and windows of the house, the car doors, the gas and water tap, the garage shutter or the medicine cabinet.

But also to have turned off electric stoves or other appliances, the lights in every room of the house or the headlights of the car.

Or that you didn’t lose personal things by dropping them or that you didn’t accidentally hit someone with your car.

Pure obsessions

Symptoms are thoughts or, more often, images relating to scenes in which the person engages in unwanted and unacceptable behaviors.

These are meaningless, dangerous or socially inappropriate (assaulting someone, having homosexual or paedophilic relationships, cheating on a partner, swearing, committing blasphemous acts, offending loved ones, etc.).

These people have neither mental rituals nor compulsions, just obsessive thoughts.

Nonetheless, they implement strategies to calm down.

For example, they mentally review the past to make sure they haven’t done certain things.

Or they constantly monitor the sensations they experience and strive to counter unwelcome thoughts and impulses.

Superstitious obsessions

This is superstitious thinking carried to excess.

The subject is dominated by rules according to which he must do or not do certain things, pronounce or not pronounce certain words, see or not see certain things (e.g. hearses, cemeteries, mortuary posters), certain numbers or certain colors, etc. counting or not counting objects a precise number of times, repeating or not repeating particular actions the “right” number of times.

All this because violating the rules could be decisive for the outcome of the events and cause negative things to happen to oneself or to others.

This effect can only be averted by repeating the act (e.g. deleting and rewriting the same word, thinking of positive things) or by doing some other “anti-jinx” ritual.

Order and symmetry

Those who suffer from it absolutely do not tolerate objects being placed in even the slightest disordered or asymmetrical way.

This gives him an unpleasant feeling of lack of harmony and logic.

Books, sheets, pens, towels, videotapes, CDs, clothes in the wardrobe, plates, pots, cups, must be perfectly aligned, symmetrical and ordered according to a logical sequence (e.g. size, colour, etc.).

When this doesn’t happen, these people spend hours of their time rearranging and aligning these objects, until they feel completely calm and satisfied.

Hoarding/hoarding

It is a rather rare type of obsession that characterizes those who tend to keep and accumulate (and sometimes even collect on the street) insignificant and useless objects (old magazines and newspapers, empty cigarette packs, empty bottles, used paper towels, of foodstuffs), due to the enormous difficulty they have in throwing them away.

Nowadays this problem is considered distinct from the real OCD and takes the name of hoarding disorder.

A particular form of obsession is that which concerns the excessive and irrational worry about having a defective or deformed part of one’s body (see dysmorphophobia).

Treatment of obsessive compulsive disorder

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Psychotherapy for OCD

Cognitive-behavioral psychotherapy is the psychotherapeutic treatment of choice for the treatment of obsessive-compulsive disorders.

It, as the name implies, consists of two types of psychotherapy that complement each other: behavioral psychotherapy and cognitive psychotherapy.

Behavioral interventions

The most widely used technique within the behavioral approach to treating OCD is exposure and response prevention. It has shown the highest levels of effectiveness.

Exposure to an anxiety-provoking stimulus is based on the fact that anxiety and disgust tend to decrease spontaneously after a long contact with the stimulus itself.

Thus, people obsessed with germs can be encouraged to stay in contact with objects “containing germs” (e.g., picking up money) until the anxiety subsides.

The repetition of the exposure, which must be carried out in an extremely gradual and tolerable way for the patient, allows the decrease of the anxiety up to its complete extinction.

For the exposure technique to be more effective for the treatment of obsessive compulsive disorder, it is necessary that it is accompanied by the response prevention technique.

The usual ritualistic behaviors that follow the onset of the obsession are suspended, or at least initially postponed.

Taking up the previous example, the person with obsessive symptoms related to germs is exposed to the anxiety-provoking stimulus and is asked to force himself not to carry out his washing ritual, waiting for the anxiety to spontaneously disappear.

In short, the principle “look fear in the face and it will cease to trouble you” is followed.

Cognitive interventions

Cognitive psychotherapy aims to cure OCD through the modification of some automatic and dysfunctional thought processes.

In particular, it acts on the excessive sense of responsibility, on the excessive importance attributed to thoughts, on the overestimation of the possibility of controlling one’s thoughts and on the overestimation of the dangerousness of anxiety, which constitute the main cognitive distortions of patients with OCD.

Drug therapy for OCD

The pharmacological treatment of obsessive compulsive disorder has historically been characterized by the use of the tricyclic antidepressant clomipramine (Anafranil).

Recently, the use of selective serotonin reuptake inhibitors (SSRIs) has become widespread, which, to a substantial therapeutic equivalence demonstrated by various studies, associate fewer side effects.

To have an effective anti-obsessive treatment of antidepressant molecules, the guidelines suggest the use of dosages close to the maximum allowed for each molecule.

It may take ten to twelve weeks before a positive clinical response is obtained.

A percentage of patients that can vary from 30 to 40% do not respond to pharmacological treatment for OCD.

Even for patients who respond significantly to pharmacological treatment, the extent of the response is usually incomplete, with few patients going on to be totally symptom free.

In order to achieve therapeutic efficacy, the combination of clomipramine and an SSRI drug may be indicated, intravenously administered clomipramine (which has been shown to be an effective therapy for the treatment of obsessive oral treatment) or latest generation neuroleptics, such as Risperidone (Risperdal, Belivon), Olanzapine (Zyprexa) and Quietapine (Seroquel).

In any case, pharmacological therapy, which can only be of help, must always be accompanied by cognitive behavioral therapy, a first choice intervention for the treatment of obsessive compulsive disorder.