Do you know that the presence of unwanted thoughts and repeated indescribable actions is a disease, called Obsessive-Compulsive Disorder? For example, the person's doubt about turned off iron is an obsession.
OCD is an anxiety disorder in which the mind is flooded with recurrent and persistent thoughts, images and impulses. These obsessions are perceived as involuntary, senseless, repugnant and difficult to dismiss. Obsessions are usually concerned with contamination, harming of one or others, excessive doubt or breaking social rules, such as swearing or making inappropriate sexual advances in public. Such thoughts are widespread with 90% of people reporting their occurrence yet few develop such exaggerated behavior that a single aspect of life becomes one's sole reason for being. The obsession usually produces a feeling of anxiety and the urge to neutralize the obsession by carrying out a particular behavior. The act is performed with a sense of subjective compulsion and a desire to resist the compulsion. Compulsions are stereotyped, repetitive behaviors, performed according to strict rules. The behavior is designed to prevent some future event and thus alleviate anxiety, e.g. a patient may repeatedly have the obsessive thought that objects are covered with cancer germs and so compulsively wash their hands. Other common compulsions include counting, checking, touching, and hoarding (DSM III-R, 1987).
The victim often realizes the action is futile and irrational, with 78% of patients viewing their compulsion as rather silly or absurd. Constant requests for reassurance are also common, e.g. repeatedly asking whether they show signs of disease. Verbal reassurance or medical examination merely reduces the anxiety for a few minutes or hours. These requests are like an addiction, reassurance merely reinforcing the probability that further requests will be made. These endless requests can be viewed as compulsive rituals. OCD affects 1-3% of the population often beginning in early adulthood following a stressful life event. It shows marked co morbidity with depression and alcohol abuse, panic attacks and phobias, and various personality disorders. Sufferers usually have severe interpersonal problems; people who require their spouse to have a four hour bath before sexual intercourse, or their children to wash their hands for half an hour before eating, may evoke feelings of resentment. This hostility can produce feelings of depression and generalized anxiety in the sufferer. Furthermore marital distress may exasperate the condition, as the patient substitutes their compulsive symptoms for overt marital conflict. The person was thus fixated at the anal stage, and the struggle between the id and the ego's defense mechanisms results in OCD. When the id dominates disturbing, unacceptable obsessions intrude. Compulsions reflect partial success of the defense mechanisms. For example, an individual fixated at the anal stage may, by reaction formation, resist the urge to soil and become compulsively neat and orderly. Treatment thus attempted to remove the repression, allowing the patient to confront the underlying fear that a particular impulse will be gratified. The symptoms themselves were not targeted since they are merely a defense against the repressed conflict.
Unfortunately psychoanalysis is ineffective at treating OCD. Indeed free association makes the problem worse by feeding the patient's mania. To illustrate how the theory is implemented in practice let us look at one of the most common OCD, excessive hand washing due to fear of contamination by dirt or germs. The main principles are to face up to what is feared, never to avoid discomfort, and to practice repeatedly doing what is feared until (Marks, 1981). Hospitalization may be required to start the treatment as the patient usually finds self-directed exposure difficult to initiate, but generalization to the home setting begins immediately. Firstly the rationale behind the treatment is explained. Patients often worry that the anxiety might not subside. The therapist should agree that this may be true, but question the patient about the longest period they have managed to resist the compulsion and the worst that could happen if the compulsion was resisted for, say, one hour. This can then lead into behavioral experiments with the patient investigating the effects of not washing. Secondly a treatment plan is formulated with the patient, by agreeing short-, medium- and long-term target plans, focusing on those symptoms that are interfering most with the patient's life, and that they are most motivated to tackle. The patient is then introduced to the exposure. This is the most difficult stage because the patient will express considerable distress. If the therapist remains firm yet understanding a trusting, task-orientated relationship should develop. The patient should not be reassured about the safety of the task, e.g. by denying that the patient can pick up germs from the object. Failure to establish a confident, structured approach at this stage is difficult to correct later. Cognitive therapy is used in conjunction with the above behavioral techniques forming a two-pronged attack on the problem. This is important as a patient may show reduced anxiety in the behavioral system (e.g. by approaching the feared stimulus) but show an increase in subjective anxiety and anxious thoughts. The cognitive model argues that patients are particularly vulnerable to interpreting intrusive thoughts as indicating that they may be in a position to prevent harm to them or others (i.e. over perceive their responsibility).
The patient believes that having influence over potential harm is identical to being responsible for it. These beliefs are activated by a critical incident, which involves an element of increased perceived responsibility, e.g. news item about the spread of AIDS. Such occurrences may trigger negative automatic thoughts that their actions (or inaction) may make them responsible for harm. These thoughts are plausible and believable so the individual becomes anxious and takes precautions to reduce the responsibility, e.g. washing to remove the HIV virus. Such neutralizing maintains the obsession by preventing the patient from disconfirming their fears of harm. It also increases the acceptance of worries about responsibility, and makes the obsession thought the subject of further cognitive processing. OCD is increasingly recognized to have a biochemical basis with particular interest focused on fluoxetine (Prozac), the serotonin reuptake blocker. However, because psychological treatments aim to bring about permanent changes they are generally better at preventing relapse as compared with medication. Combinations are well worth investigating, but problems may arise if the patient fails to make use of psychological methods because improvement is attributed to the drug. In conclusion OCD is perhaps the most intractable of the neuroses, though cognitive-behavior therapy has proved remarkably effective in its treatment. An advantage of this therapy is the way in which it can be adapted and improved, by adding or removing components. It seems likely that techniques will be refined further over the next decade, particularly by increasingly intertwining the cognitive and behavioral treatments.
