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Obsessive Compulsive Disorder (OCD): How Does It Work?

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Obsessive-compulsive disorder (OCD) is a condition that includes a pattern of obsessions that lead to repetitive behaviours or compulsions. Individuals diagnosed with OCD may experience a great deal of stress or frustrations in overcoming their anxieties.  

OCD by definition is ‘represented by a diverse group of symptoms that include intrusive thoughts, rituals, preoccupations, and compulsions’. These affect the individual’s life significantly, preventing them from feeling like they are in control.

Obsessions and compulsions are the key characteristics of OCD. Obsessions can be recurrent and intrusive thoughts, feelings, ideas, or sensations, whereas compulsions are conscious, standardised acts or behaviours that are in response to the obsession. However, unlike other addictions the individual is never satisfied. These acts are often viewed as absurd or irrational yet impossible to resist. Resisting such acts only leads to debilitating anxiety.

Aetiology and Epidemiology 

Neuro-imaging shows altered function between the orbitofrontal cortex, caudate, and thalamus in people with OCD. Serotonergic drugs are found to be effective in managing obsessions and compulsions, but it is not clear whether the neurotransmitter serotonin is associated with the disorder. 

Learning theorists believe that obsessions are conditioned stimuli while compulsions are developed when a person discovers that it relieves anxiety, eventually becoming a fixated pattern of behaviour. 

Risk factors of OCD include the following:

  • Environmental stressors like pregnancy, childbirth, and parental care of children.
  • Family history, the risk of developing OCD increases if other family members also have OCD
  • Stressful life events 

An individual should consult a doctor if they experience obsessions or compulsions that appear to affect their quality of life. The mean age of onset of OCD is 20 years for both males and females, although men can be diagnosed earlier (18-19 years old). A 2011 statistics data by Institute of Mental Health (IMH) concluded that one in 32 Singaporeans have OCD

Symptom Patterns 

The major symptom patterns are the following

  • Contamination is a most common obsession and the compulsions associated with it are usually hard to avoid such as peeing, defecating, microscopic germs and dust. It can range from a person repetitively washing hands after the slightest contact with an object that is viewed as dirty, to a person scrubbing their skin off or never leaving the house at all. 
  • Pathological doubt is when the person is consumed with doubt followed by compulsions of unreasonable checking to clear their doubt. The doubt usually relates to danger, like leaving the gas stove on or forgetting to lock doors, and the compulsion associated with it is to check numerous times. 
  • Intrusive thoughts are not associated with compulsions but such obsessive thoughts can cause great distress. These thoughts may be about death (or suicide ideation), violence (wanting to stab someone or push them off an edge of a building), or sexual in nature (preoccupation with sexual fantasies). 
  • Symmetry is when an individual obsesses about symmetry and precision, resulting in slowness and delays brought about by their compulsions. 

Other symptom patterns include religious obsessions and compulsions, compulsive hair pulling or trichotillomania, nail-biting, and even masturbation. 

Diagnosing OCD 

A psychiatrist should be consulted if an individual shows the above signs and symptoms. In some instances, individuals might first consult other specialists such as a dermatologist for eczema-like appearance of the skin or chapped hands, or a paediatrician for a child’s repetitive hand washing, or a dentist for gum lesions because of excessive teeth cleaning.

In OCD, the obsessions or compulsions are time-consuming (> 1 hour per day) and the individual experiences significant distress and impairment in functioning. 

Obsessive-Compulsive Disorder (OCD) and Obsessive-Compulsive Personality Disorder (OCPD) 

This is a difficult distinction to establish for most clinicians. OCPD is characterised by perfectionism and inflexibility. Hallmark traits include emotional constriction, orderliness, perseverance, stubbornness, and preoccupation with rules and regulations. Such individuals often have limited interpersonal skills. A diagnosis of OCPD is often reserved for those with extreme impairment in functioning and social effectiveness. 

Treatment of OCD 

Pharmacotherapy and behaviour therapy might be effective, and may have long-term benefits. The main principle of behaviour therapy is usually exposure and response prevention. Desensitisation, thought stopping, flooding, implosion therapy, and aversive conditioning are commonly used strategies. Cognitive Behavioural Therapy (CBT) presents the strongest evidence, specifically Exposure and Response Prevention (ERP). Family therapy is also suggested in building treatment alliances. In extreme cases, psychosurgery might be an option.

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