Obsessive-Compulsive Disorder (OCD) and Obsessive-Compulsive Spectrum Disorders (OCSDs)

Obsessive-Compulsive Disorder (OCD)

OCD consists of uncontrollable obsessions (repetitive thoughts), or uncontrollable compulsions (repetitive behaviors), that cause distress; are time consuming (an hour or more per day); or otherwise interfere with a person's functioning.

Obsessions are recurrent, intrusive thoughts, images, or impulses that cause distress; however, these thoughts are not about typical, everyday things such as with GAD. The content of the obsessions are not the kinds of thoughts the persons wishes to have, and are experienced as uncontrollable. Common obsessions are: 1) thoughts about contamination, 2) repeated and excessive doubts, such as wondering if a door was left unlocked, 3) a need to have things in a precise and particular order or arrangement (with intense distress if this order or arrangement is disturbed), 4) aggressive or horrific impulses, such as a desire to harm one's child, or 5) sexual imagery, such as intrusive pornographic imagery. While these are the most common types of obsessions, it does not necessarily mean that they are the only types of obsessions. Any distressing, repetitive, uncontrollable, and unwanted thought can form an obsession.

Individuals with OCD try to ignore or neutralize these intrusive thoughts, images, or impulses; i.e., they attempt to think about, or do something else to block the obsessions. Obsessions are not the same as hallucinations which are a hallmark symptom of several other, rather severe mental disorders. When someone is experiencing a hallucination, they are unaware that what they are experiencing is not real, and is being created in their own mind. In contrast, people who experience obsessions recognize that the obsessions are generated in their own mind.

One way people try to block or neutralize obsessions is through compulsive behaviors. Compulsions are recurring behaviors (such as repeatedly checking appliances or repeatedly washing hands) or repetitive mental acts (such as counting or praying) that an individual feels they must do in reaction to an obsession. Compulsions are used to avoid or reduce distress; or to prevent something terrible from happening. For example, a person may touch things only after they have all been bleached in order to avoid germs, or they may use items such as toothbrushes only once.

At some point, adults realize that the obsessions or compulsions are excessive, but this realization does not necessarily apply to children. Children's OCD presents similarly to adults, but they do not tend to ask for help so it becomes their parents' responsibility to identify these symptoms and seek treatment. Despite this lack of awareness, children may try to minimize their compulsions in front of others. OCD appears to be linked to a genetic vulnerability. Treatment for OCD is found in the Treatment Section.

Obsessive-Compulsive Spectrum Disorders (OCSDs)

Thus far, we have discussed the disorders that are currently categorized as anxiety disorders according to the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, 2000). However, there are a number of psychiatric disorders with symptoms that are largely obsessive and/or compulsive in nature; but, these disorders are not currently categorized as anxiety disorders (Yaryura-Tobias & Neziroglu, 1997). Because they share symptoms similar to OCD INSERT LINK p.36, they are often referred to as the Obsessive-Compulsive Spectrum Disorders (OCSDs). In the upcoming revision of the DSM (DSM-V), it is anticipated that several disorders may be re-classified and categorized into a new category called Obsessive-Compulsive Spectrum Disorders. We provide several examples of OCSDs that may likely be included in this newly proposed category: Body Dysmorphic Disorder, Trichotillomania, Hypochondriasis, Tourette's Disorder, and Hoarding. Treatment for these disorders is found in the Treatment Section.

1) Body Dysmorphic Disorder (BDD) In the current edition of the DSM (DSM-IV-R, 2000), this disorder is not included in the category of anxiety disorders; instead, it is included in the category called, "somatoform disorders." BDD is characterized by an excessive preoccupation with a slight or imagined bodily defect. Individuals with BDD are mostly concerned with skin imperfections (acne, scars, blemishes), hair (head or body hair, too little or too much), and facial features (overall shape, size, and symmetry of facial features). People with BDD engage in repetitive compulsive behaviors in order to check, camouflage, hide, or fix their perceived defect. Examples include excessive mirror checking, repetitive efforts to camouflage their perceived flaws, and avoiding usual activities, sometimes to the extent that they may become homebound at some point. Most individuals with BDD use some sort of body checking (such as examining themselves in a mirror or measuring body parts). They often find ways to avoid full exposure of their perceived defect such as wearing additional layers of clothing, or loosely-fitted clothing; and applying cosmetics. Other behaviors can include mirror avoidance, reassurance seeking, and comparing oneself to others. In addition, people with BDD worry about the malfunctioning of the "defective" body part (such as being unable to breath due to their "crooked" nose) and may seek out unnecessary treatment such as consulting with a dermatologist, or cosmetic surgeon. Another worry includes being concerned that other people may be taking special notice of their perceived flaw.

Now you may be thinking that some of these behaviors are things that everyone does, at least to some extent. So, what is the difference between BDD and taking a healthy interest in your personal appearance? The key to this distinction is the degree of interest and preoccupation, and the magnitude of concern; i.e., people with BDD have an excessive preoccupation with a slight or imagined defect. The concern over a minor defect is considered extreme, and the amount of time that is invested is significantly more than what other people ordinarily do with respect to their grooming and appearance. For instance, a woman might ordinarily take anywhere from ten minutes to one hour to get herself dressed and ready for the day. However, a woman with BDD may take four to six hours to accomplish the same thing, and she may subsequently cancel her plans if she feels her efforts were unsuccessful.

Here is an example: Gina, a sophomore in college, has developed minimal facial acne. As a result, she does not go out with friends unless she has spent hours meticulously putting on makeup. Sometimes, even after hours of getting ready, she finds that she did not do a good enough job and makes excuses not to go out. Gina spends several hours a day looking at her skin to see if it is changing; getting better or worse. There are times that she gets so stuck in this process that she does not attend classes and/or fails to complete her homework assignments, because she is so preoccupied with the condition of her skin. Whenever other people are around her, Gina makes sure that the lighting is low, or she will position herself so others cannot see her "horrible" skin. She has been to a dermatologist who told her that her acne was minimal, and provided her with a topical treatment. Gina was very frustrated that this dermatologist did not give her Accutane® so she makes appointments with several more dermatologists in the hopes of convincing them that her skin requires such a drastic treatment.

As demonstrated by this example, Gina's behavior goes above and beyond what ordinary people would do in a similar circumstance. Of course, it is perfectly normal to invest some time and money to achieve a pleasing and healthy physical appearance, but not to the extent that it interferes with the way one lives their life. Someone with symptoms of this severity would be unlikely to continue to function normally; indeed, Gina's functioning was certainly impaired on multiple levels. Treatment for BDD is found in the Treatment Section.

Authors Statement: Established in 1979, the Bio Behavioral Institute is a psychological and psychiatric clinic dedicated to the treatment and research of anxiety and mood disorders. Based in Long Island, NY, USA, the institute serves both a local and international clientele. Our staff have over 40 years of experience treating anxiety and mood disorders and have been at the forefront of scientifically supported treatments for anxiety disorders for many years. We offer a variety of programs provided by a multidisciplinary team of professionals. For more information, please visit us online at www.biobehavioralinstitute.com or view Bio Behavioral Institute and author biographical information on this website.