What is OCD (Obsessive Compulsive Disorder)?
by Steven Phillipson, PhD
Obsessive Compulsive Disorder (OCD) is an anxiety disorder, first and foremost. It is not a thought disorder. Although the thoughts associated with OCD are bizarre, they are not at all the focal point of the therapeutic objective. The essential features of OCD are recurrent obsessions (thoughts) that create an awareness of alarm or threat. (e.g., "I might get AIDS from the germs on that door knob;" "Since I had the thought of killing my baby, I might be capable of doing it;" "If I don't pick up that Band-Aid someone else might get sick from it, and I would hold myself culpable;" etc.). One may typically engage in some avoidance or escape response in reaction to the obsessive threat (I typically refer to the obsessive threat as a "spike."). Obsessions take the form of either a perceived threat of physical harm to oneself, or to others; or in some cases more of a metaphysical or spiritual threat to oneself, to others, or to perhaps a deity. I conceptualize the overall syndrome of OCD to consist of three primary branches; within all three branches, in approximately 80% of all cases, one performing the above rituals are painfully aware that his or her behavior is unreasonable and irrational (see my article, "Speak of the Devil"). This insight alone, however, provides no relief, and attempting to help sufferers through reassurance has no long lasting positive effect.
It is not unusual for one to question whether he or she may qualify for a diagnosis of OCD, given that most of the following examples are not unlike what most do, albeit to a limited degree, on an everyday basis. Everyday examples of OCD-like behavior include using one's foot to flush a toilet, knocking on wood three times to ward off a bad omen, throwing salt over one's shoulder for a positive future, or feeling inspired to say "God forbid!" after mentioning the potential death of a living person. Simplistic tests to determine whether these behaviors cross the line into the OCD realm include, for example, asking one's self, "how much money it would take for me not to perform this 'safe' behavior". One operating in the non-OCD realm would most likely accept between $10 to $100 to do something that would make them feel uncomfortable. One with OCD typically would not accept upwards in the neighborhood of $100,000 to face his or her feared concern. Another criterion involves the degree to which anxiety-driven behavior disrupts the life of the concerned person. We all have quirks that take up small bits of the day. Very often, one wrestling with OCD invests hours of his or her day avoiding these concerns. All of us periodically hear a song repeat itself over and over again in our mind. For the great majority of us, the repetition becomes mildly annoying; for one with OCD, the intolerance and rejection of this mental experience generates a tremendous amount of agitation and anxiety over losing control of one's mind!
The most common and well-studied branch of OCD involves the OC where the undoing response generally involves some overt behavior. The most commonly conceived form of OCD involves contamination. Here, an awareness of germs, disease, or the mere presence of dirt evokes a sense of threat and an incredible inspiration to reduce the presence of these contaminants. Most commonly, the escape ritual involves a cleaning response (e.g., hand washing, chronic cleaning). The next most common form of OCD involves "checking". Typically checking involves door locks, light switches, faucets, stoves or items that, if left unchecked, might pose a risk to either one's own well-being or the well-being of others. It is not at all uncommon for a person with this manifestation to check items between 10 to 100 times before he or she is able to carry on with his or her day. The overwhelming impulse to recheck remains despite the fact that the items in question were secure from the beginning.
Less common forms of OCD include hoarding, which is the excessive saving of typically worthless items such as junk mail, or excessive purchasing of certain items (e.g., owning hundreds of tubes of toothpaste). Typically hoarded items include garbage, novelty items, or magazines and newspapers. A common rationale given to justify obsessive-compulsive hoarding behavior is an overriding fear that one day these items might "come in handy," or be of some value and therefore must not be thrown away. Another subgroup of hoarders involves persons who become emotionally attached to his or her items, or feel that these items hold some emotional significance that reflects a particular moment in time. The person feels that relinquishing the item is in some way tantamount to releasing a past experience or association with a significant other.
Ordering is a subcategory of OCD where one feels compelled to place items in a designated spot or order. Such a person fears a sense of being overwhelmed and a sense of an impending anarchy if items are not placed exactly as they arbitrarily "should" be. One with this condition typically lines up items in parallel locations, but the focus of such a person's obsession is on the concept that each item belongs in a particular place.
Another form of OCD is perfectionism, in which one feels compelled to habitually check for potential mistakes or errors that might reveal his or her own faults or might jeopardize the his or her stature, for example, at work.
Furthermore, there exists the Purely Obsessional compulsion (Pure-O; see the article, "Thinking the Unthinkable"). The objective in this classification involves the escape or avoidance (through excessive mental behavior) of noxious and unwanted thoughts. In its most generic form, Pure-O manifests through the repetition or a word or phrase in one's head, not unlike what one may experience when a song is involutarily "stuck in his or her head". One with the Pure-O classification also can experience apparently threatening ideation involving the potential to cause harm to others, or may experience that having the threatening thought at all suggests something evil or depraved about his or her identity, capability, or self worth. This classification also may involve engaging in a tremendous amount of ritualistic problem solving (rumination); endless attempts to answer questions related to one's own sexual orientation or even something as simplistic as the name of one's third grade teacher might occupy endless hours of problem solving.
This classification also involves a heightened sense of superstitiousness--for example, certain numbers might take on a great significance related to positive or negative outcomes. Typically, positive numbers or perhaps the number "seven" involve a greater likelihood for safety or permission to proceed with a given task. Other numbers forewarn of something ominous about to happen. One may typically engage in elaborate touching or counting rituals to ensure that the safe or desirable number is the one upon which the task or thought is to be ended. Superstitiousness need not be limited to numbers; the old quirky childhood games of avoiding cracks or walking under ladders takes on a significance beyond most people's ability to comprehend.
The last branch of OCD involves a somewhat more complex classification. That is Responsibility-OC (hyperscrupulosity). Here, one's concern is not for his or her self; instead, such concern is directed toward the well-being of others. Typically, significant others (or sometimes society at large) are thought of as the predominant focus for whom to prevent harm from coming. The Responsibility OC might take on a Pure-O form, such as the occurance of a thought that some harm might come to someone else. One with this diagnosis may feel compelled to pray to stave off harm to another. The Responsibility OC person might engage in elaborate cleansing rituals to prevent others from incurring germs or diseases which he or she may be carrying, yet for which he or she feels no fear for his or her own well-being. One with this form of OC often engages in warning others about possible risks or cleansing his or her environment of possible risks to others at large. One with Responsibility OC often engages in excesses for another's distress or danger, so as not to be held culpable. The reason that this form is particularly difficult to treat is due to the combination of anxiety in association with the perceived risk, and guilt from being responsible for adversity happening to others.
More obscure forms of OCD involve body dysmorphia. Body dysmorphia is a condition wherein one becomes excessively focused on some body part, which he or she perceives to be grossly malformed. Typically, the area on which a person with body dysmorphia focuses would never be thought of as a defect from the another's perspective. One with body dysmorphia engages in elaborate checking rituals to try to gain reassurance, assess the severity of his or her deformity in the mirror, undergoes repeated plastic surgery, or often engages others in the attempt to gain reassurance in the absence of the problem. Another obscure sub-classification of OCD involves an olfactory obsession, in which one is entrenched in the idea that some part of his or her body is emitting a noxious odor. Typically, the areas of concern are the genitalia, breath, feet, or underarms.
The last form of OCD involves a preoccupation with the potential of having some physical malady, typically cancer or some life threatening disease. This condition continues to be referred to as hypochondriasis and exists in the DSM-IIIR as a separate disorder from OCD. However, like body dysmorphic disorder, the symptoms and endless search for reassurance fall completely under the diagnostic category of OCD.