1

Neurosis
Neurosis is a class of functional mental disorders involving distress but neither
delusions nor hallucinations, whereby behavior is not outside socially acceptable
norms.[1] It is also known as psychoneurosis or neurotic disorder, and thus those
suffering from it are said to be neurotic.

History
The term neurosis was coined by the Scottish doctor William Cullen in 1769 to
refer to "disorders of sense and motion" caused by a "general affection of the
nervous system". For him, it described various nervous disorders and symptoms
that could not be explained physiologically. It derives from the Greek word νεῦρον
(neuron, "nerve") with the suffix -ωσις -osis (diseased or abnormal condition). The
term was however most influentially defined by Carl Jung and Sigmund Freud
over a century later. It has continued to be used in contemporary theoretical writing
in psychology and philosophy.[2]

The American Diagnostic and Statistical Manual of Mental Disorders (DSM) has
eliminated the category of "neurosis", reflecting a decision by the editors to
provide descriptions of behavior as opposed to hidden psychological mechanisms
as diagnostic criteria,[3] and, according to The American Heritage Medical
Dictionary, it is "no longer used in psychiatric diagnosis".[4] These changes to the
DSM have been controversial.[5]

Signs and symptoms

There are many forms of neurosis: obsessive–compulsive disorder, anxiety
neurosis, hysteria (in which anxiety may be discharged through a physical
symptom), and a nearly endless variety of phobias as well as obsessions such as
pyromania. According to C. George Boeree, professor emeritus at Shippensburg
University, effects of neurosis can involve:

...anxiety, sadness or depression, anger, irritability, mental confusion, low sense of

self-worth, etc., behavioral symptoms such as phobic avoidance, vigilance,
impulsive and compulsive acts, lethargy, etc., cognitive problems such as
unpleasant or disturbing thoughts, repetition of thoughts and obsession, habitual
fantasizing, negativity and cynicism, etc. Interpersonally, neurosis involves
 2

dependency, aggressiveness, perfectionism, schizoid isolation, socio-culturally

inappropriate behaviors, etc.[6]

Cause
Psychoanalytical theory

As an illness, neurosis represents a variety of mental disorders in which emotional

distress or unconscious conflict is expressed through various physical,
physiological, and mental disturbances, which may include physical symptoms
(e.g. hysteria). The definitive symptom is anxieties. Neurotic tendencies are
common and may manifest themselves as depression, acute or chronic anxiety,
obsessive–compulsive tendencies, specific phobias, such as social phobia,
arachnophobia or any number of other phobias, and some personality disorders:
paranoid, schizotypal, borderline, histrionic, avoidant, dependent and obsessive–
compulsive. It has perhaps been most simply defined as a "poor ability to adapt to
one's environment, an inability to change one's life patterns, and the inability to
develop a richer, more complex, more satisfying personality." [6] Neurosis should
not be mistaken for psychosis, which refers to loss of touch with reality, or
neuroticism, a fundamental personality trait according to psychological theory.

According to psychoanalytic theory, neuroses may be rooted in ego defense

mechanisms, but the two concepts are not synonymous. Defense mechanisms are a
normal way of developing and maintaining a consistent sense of self (i.e., an ego),
while only those thoughts and behavior patterns that produce difficulties in living
should be termed "neuroses".

Jung's theory

Carl Jung found his approach particularly fitting for people who are successfully
adjusted by normal social standards, but who nevertheless have issues with the
meaning of their life.

I have frequently seen people become neurotic when they content themselves with
inadequate or wrong answers to the questions of life (Jung, [1961] 1989:140).

The majority of my patients consisted not of believers but of those who had lost
their faith (Jung, [1961] 1989:140).

[Contemporary man] is blind to the fact that, with all his rationality and efficiency,
he is possessed by "powers" that are beyond his control. His gods and demons have
 3

not disappeared at all; they have merely got new names. They keep him on the run
with restlessness, vague apprehensions, psychological complications, an insatiable
need for pills, alcohol, tobacco, food – and, above all, a large array of neuroses.
(Jung, 1964:82).

Jung found that the unconscious finds expression primarily through an individual's
inferior psychological function, whether it is thinking, feeling, sensing, or intuition.
The characteristic effects of a neurosis on the dominant and inferior functions are
discussed in Psychological Types.

Jung saw collective neuroses in politics: "Our world is, so to speak, dissociated
like a neurotic" (Jung, 1964:85).

Horney's theory

In her final book, Neurosis and Human Growth, Karen Horney laid out a complete
theory on the origin and dynamics of neurosis.[7]

In essence, neurosis is a distorted way of looking at the world and at oneself,

determined by compulsive needs rather than by a genuine interest in the world as it
is.

She proposes that it is transmitted to a child from his or her early environment, and
that there are a large number of ways this can happen, but:

When summarized, they all boil down to the fact that the people in the
environment are too wrapped up in their own neuroses to be able to love the child,
or even to conceive of him as the particular individual he is; their attitudes toward
him are determined by their own neurotic needs and responses.[8]

The child's initial reality is then distorted by his or her parents' needs and
pretenses. Growing up with neurotic caretakers, the child quickly becomes
insecure themselves, developing basic anxiety. To deal with this anxiety, the
growing child's own imagination goes to work, creating an idealized self-image:

Each person builds up his personal idealized image from the materials of his own
special experiences, his earlier fantasies, his particular needs, and also his given
faculties. If it were not for the personal character of the image, he would not attain
a feeling of identity and unity. He idealizes, to begin with, his particular "solution"
of his basic conflict: compliance becomes goodness, love, saintliness;
aggressiveness becomes strength, leadership, heroism, omnipotence; aloofness
 4

becomes wisdom, self-sufficiency, independence. What—according to his

particular solution—appear as shortcomings or flaws are always dimmed out or
retouched.[9]

Once one identifies with the idealized image, a number of effects follow. One will
make claims on others and on life based on the prestige one feels entitled to
because of the idealized image. One will impose a rigorous set of standards on
oneself in order to attempt to actually measure up to what the idealized image is.
One will cultivate pride, and with that will come the vulnerabilities associated with
pride that lacks a foundation of real esteem. Finally, one will hate and despise
oneself for all one's factual limitations, which keep getting in the way and
threatening to pop the bubble. Vicious circles operate to strengthen all of these
factors.

Eventually, as one grows to adulthood, one particular "solution" to all the inner
conflicts and vulnerabilities will solidify. One will be expansive and will display
symptoms of narcissism, perfectionism, or vindictiveness. Or one will be self-
effacing, and be compulsively compliant and display symptoms of neediness or
codependence. Or one will be resigned, and display schizoid tendencies.

In Horney's view, milder anxiety disorders and full-blown personality disorders all
fall under her basic scheme of neurosis as variances in the degree of severity and in
the individual dynamics.

The opposite of neurosis is a condition Horney calls self-realization, which is when

an individual responds to the world with the full depth of his or her spontaneous
feelings rather than just anxiety-driven compulsion, resulting in the person growing
to actualize his or her inborn potentialities, in a process Horney compares with an
acorn growing into a tree.

References
1. "neurosis" at Dorland's Medical Dictionary
2. Russon, John (2003). Human Experience: Philosophy, Neurosis, and the Elements of
Everyday Life. State University of New York Press. ISBN 0-7914-5754-0. See also
Kirsten Jacobson, (2006), "The Interpersonal Expression of Human Spatiality: A
Phenomenological Interpretation of Anorexia Nervosa," Chiasmi International 8, pp.
157–74.
3. Horwitz and Wakefield (2007). The Loss of Sadness. Oxford. ISBN 978-0-19-531304-8.
4. The American Heritage Medical Dictionary. Houghton Mifflin. 2007. ISBN 978-0-618-
82435-9.
 5

5. Wilson, Mitchell, (1993), "DSM-III and the Transformation of American Psychiatry: A

History". The American Journal of Psychiatry, 150,3, pp. 399–410.
6. Boeree, Dr. C. George (2002). "A Bio-Social Theory of Neurosis". Retrieved 2009-04-
21.
7. Horney, Karen (1950). Neurosis and Human Growth: The Struggle Toward Self-
Realization. W. W. Norton & Company, Inc. ISBN 978-0-393-30775-7
8. Horney p.18
9. Horney p.22

Further reading
 Angyal, Andras. (1965). Neurosis and treatment: a holistic theory. Edited by E.
Hanfmann and R. M. Jones
 Fenichel, Otto. (1945) The Psychoanalytic Theory of Neurosis. New York: Norton
Publishing Company.
 Freud, Sigmund. The Standard Edition of the Complete Psychological Works of Sigmund
Freud. Trans. James Strachey. 24 vols. London: Hogarth, 1953–74.
 Horney, Karen. Neurosis and Human Growth." Norton, 1950.
 Horney, Karen. Our Inner Conflicts." Norton, 1945.
 Horney, Karen. The Collected Works. (2 Vols.) Norton, 1937.
 Horwitz, A. V. and J. C. Wakefield. The Loss of Sadness: How Psychiatry Transformed
Normal Sorrow into Depressive Disorder. Oxford University Press, 2007. ISBN 978-0-
19-531304-8.
 Jung, C.G., et al. (1964). Man and his Symbols, New York, N.Y.: Anchor Books,
Doubleday. ISBN 0-385-05221-9.
 Jung, C.G. (1966). Two Essays on Analytical Psychology, Collected Works, Volume 7,
Princeton, N.J.: Princeton University Press. ISBN 0-691-01782-4.
 Jung, C.G. [1921] (1971). Psychological Types, Collected Works, Volume 6, Princeton,
N.J.: Princeton University Press. ISBN 0-691-01813-8.
 Jung, C.G. [1961] (1989). 'Memories, Dreams, Reflections, New York, N.Y.: Vantage
Books. ISBN 0-679-72395-1
 Russon, John. (2003). Human Experience: Philosophy, Neurosis, and the Elements of
Everyday Life. Albany: State University of New York Press. ISBN 0-7914-5754-0
 Nancy McWilliams (2011). Psychoanalytic Diagnosis, Second Edition: Understanding
Personality Structure in the Clinical Process. Guilford Press. ISBN 978-1-60918-494-0.
 Winokur, Jon. Encyclopedia Neurotica. 2005. ISBN 0-312-32501-0.
 LADELL RM, HARGREAVES TH (October 1947). "The Extent of Neurosis". Br Med J
2 (4526): 548–549. doi:10.1136/bmj.2.4526.548. PMC 2055884. PMID 20267012.

This page was last modified on 28 April 2014 at 10:11.

 6

Obsessive–compulsive disorder (OCD)

Repetitive hand-washing is a common OCD symptom

ICD-10 F42

ICD-9 300.3

DiseasesDB 33766

MedlinePlus 000929

MeSH D009771

Obsessive–compulsive disorder (OCD) is an anxiety disorder characterized by

intrusive thoughts that produce uneasiness, apprehension, fear, or worry; by
repetitive behaviors aimed at reducing the associated anxiety; or by a combination
of such obsessions and compulsions. Symptoms of the disorder include excessive
washing or cleaning; repeated checking; extreme hoarding; preoccupation with
sexual, violent or religious thoughts; relationship-related obsessions; aversion to
particular numbers; and nervous rituals, such as opening and closing a door a
certain number of times before entering or leaving a room. These symptoms can be
alienating and time-consuming, and often cause severe emotional and financial
distress. The acts of those who have OCD may appear paranoid and potentially
psychotic. However, OCD sufferers generally recognize their obsessions and
compulsions as irrational and may become further distressed by this realization.
 7

Obsessive–compulsive disorder affects children and adolescents, as well as adults.

Roughly one third to one half of adults with OCD report a childhood onset of the
disorder, suggesting the continuum of anxiety disorders across the lifespan.[1]

The phrase obsessive–compulsive has become part of the English lexicon, and is
often used in an informal or caricatured manner to describe someone who is
excessively meticulous, perfectionistic, absorbed, or otherwise fixated.[2] Although
these signs are present in OCD, a person who exhibits them does not necessarily
have OCD, but may instead have obsessive–compulsive personality disorder
(OCPD), an autism spectrum disorder, or disorders where perseveration
(hyperfocus) is a feature in ADHD, PTSD, bodily disorders, or just a habit
problem.[3]

Despite the irrational behaviour, OCD is sometimes associated with above-average

intelligence.[4][5] Its sufferers commonly share personality traits such as high
attention to detail, avoidance of risk, careful planning, exaggerated sense of
responsibility and a tendency to take time in making decisions.[6] Multiple
psychological and biological factors may be involved in causing obsessive–
compulsive syndromes. Standardized rating scales such as Yale–Brown Obsessive
Compulsive Scale can be used to assess the severity of OCD symptoms.[7]

Signs and symptoms

Obsessions

Obsessions are thoughts that recur and persist despite efforts to ignore or confront
them.[8] People with OCD frequently perform tasks, or compulsions, to seek relief
from obsession-related anxiety. Within and among individuals, the initial
obsessions, or intrusive thoughts, vary in their clarity and vividness. A relatively
vague obsession could involve a general sense of disarray or tension accompanied
by a belief that life cannot proceed as normal while the imbalance remains. A more
intense obsession could be a preoccupation with the thought or image of someone
close to them dying[9][10] or intrusions related to "relationship rightness."[11] Other
obsessions concern the possibility that someone or something other than oneself—
such as God, the Devil, or disease—will harm either the person with OCD or the
people or things that the person cares about. Other individuals with OCD may
experience the sensation of invisible protrusions emanating from their bodies, or
have the feeling that inanimate objects are ensouled.[12]
 8

Some people with OCD experience sexual obsessions that may involve intrusive
thoughts or images of "kissing, touching, fondling, oral sex, anal sex, intercourse,
incest and rape" with "strangers, acquaintances, parents, children, family members,
friends, coworkers, animals and religious figures", and can include "heterosexual
or homosexual content" with persons of any age.[13] As with other intrusive,
unpleasant thoughts or images, most "normal" people have some disquieting sexual
thoughts at times, but people with OCD may attach extraordinary significance to
the thoughts. For example, obsessive fears about sexual orientation can appear to
the person with OCD, and even to those around them, as a crisis of sexual
identity.[14][15] Furthermore, the doubt that accompanies OCD leads to uncertainty
regarding whether one might act on the troubling thoughts, resulting in self-
criticism or self-loathing.[13]

People with OCD understand that their notions do not correspond with reality;
however, they feel that they must act as though their notions are correct. For
example, an individual who engages in compulsive hoarding might be inclined to
treat inorganic matter as if it had the sentience or rights of living organisms, while
accepting that such behavior is irrational on a more intellectual level.

Primarily obsessional

OCD sometimes manifests without overt compulsions.[16] Nicknamed "Pure-O",[17]

or referred to as Primarily Obsessional OCD, OCD without overt compulsions
could, by one estimate, characterize as many as 50 percent to 60 percent of OCD
cases.[18] Primarily obsessional OCD has been called "one of the most distressing
and challenging forms of OCD."[19] People with this form of OCD have
"distressing and unwanted thoughts pop into [their] head frequently", and the
thoughts "typically center on a fear that you may do something totally
uncharacteristic of yourself, something ...potentially fatal...to yourself or
others."[19] The thoughts "quite likely, are of an aggressive or sexual nature."[19]

Rather than engaging in observable compulsions, the person with this subtype
might perform more covert, mental rituals, or might feel driven to avoid the
situations in which particular thoughts seem likely to intrude. [17] As a result of this
avoidance, people can struggle to fulfill both public and private roles, even if they
place great value on these roles and even if they had fulfilled the roles successfully
in the past.[17] Moreover, the individual's avoidance can confuse others who do not
know its origin or intended purpose, as it did in the case of a man whose wife
began to wonder why he would not hold their infant child.[17] The covert mental
rituals can take up a great deal of a person's time during the day.
 9

Compulsions

Dermatillomania

Some people with OCD perform compulsive rituals because they inexplicably feel
they have to, others act compulsively so as to mitigate the anxiety that stems from
particular obsessive thoughts. The person might feel that these actions somehow
either will prevent a dreaded event from occurring, or will push the event from
their thoughts. In any case, the individual's reasoning is so idiosyncratic or
distorted that it results in significant distress for the individual with OCD or for
those around them. Excessive skin picking (i.e., dermatillomania) or hair plucking
(i.e., trichotillomania) and nail biting (i.e., onychophagia) are all on the Obsessive-
Compulsive Spectrum. Individuals with OCD are aware that their thoughts and
behavior are not rational,[20] but they feel bound to comply with them to fend off
feelings of panic or dread.

Some common compulsions include counting specific things (such as footsteps) or

in specific ways (for instance, by intervals of two), and doing other repetitive
actions, often with atypical sensitivity to numbers or patterns. People might
repeatedly wash their hands[21] or clear their throats, make sure certain items are in
a straight line, repeatedly check that their parked cars have been locked before
leaving them, constantly organize in a certain way, turn lights on and off, keep
doors closed at all times, touch objects a certain number of times before exiting a
room, walk in a certain routine way like only stepping on a certain color of tile, or
have a routine for using stairs, such as always finishing a flight on the same foot.

The compulsions of OCD must be distinguished from tics; movements of other

movement disorders such as chorea, dystonia, myoclonus; movements exhibited in
stereotypic movement disorder or some people with autism; and the movements of
seizure activity.[22] There may exist a notable rate of comorbidity between OCD
and tic-related disorders.[22]
 10

People rely on compulsions as an escape from their obsessive thoughts; however,

they are aware that the relief is only temporary, that the intrusive thoughts will
soon return. Some people use compulsions to avoid situations that may trigger their
obsessions. Although some people do certain things over and over again, they do
not necessarily perform these actions compulsively. For example, bedtime
routines, learning a new skill, and religious practices are not compulsions. Whether
or not behaviors are compulsions or mere habit depends on the context in which
the behaviors are performed. For example, arranging and ordering DVDs for eight
hours a day would be expected of one who works in a video store, but would seem
abnormal in other situations. In other words, habits tend to bring efficiency to one's
life, while compulsions tend to disrupt it.[23]

In addition to the anxiety and fear that typically accompanies OCD, sufferers may
spend hours performing such compulsions every day. In such situations, it can be
hard for the person to fulfill their work, family, or social roles. In some cases, these
behaviors can also cause adverse physical symptoms. For example, people who
obsessively wash their hands with antibacterial soap and hot water can make their
skin red and raw with dermatitis.[24]

People with OCD can use rationalizations to explain their behavior; however, these
rationalizations do not apply to the overall behavior but to each instance
individually. For example, a person compulsively checking the front door may
argue that the time taken and stress caused by one more check of the front door is
much less than the time and stress associated with being robbed, and thus checking
is the better option. In practice, after that check, the person is still not sure and
deems it is still better to perform one more check, and this reasoning can continue
as long as necessary.

Overvalued ideas

Some OCD sufferers exhibit what is known as overvalued ideas. In such cases, the
person with OCD will truly be uncertain whether the fears that cause them to
perform their compulsions are irrational or not. After some discussion, it is
possible to convince the individual that their fears may be unfounded. It may be
more difficult to do ERP therapy on such patients because they may be unwilling
to cooperate, at least initially. There are severe cases in which the sufferer has an
unshakeable belief in the context of OCD that is difficult to differentiate from
psychosis.[25]
 11

Cognitive performance

A 2009 study that conducted "a battery of neuropsychological tasks to assess nine
cognitive domains with a special focus on executive functions concluded that 'few
neuropsychological differences emerged between the OCD and healthy
participants when concomitant factors were controlled.'"[26][clarify][non-primary source needed]

A 2013 meta-analysis confirmed OCD patients to have mild but wide-ranging

cognitive deficits; significantly regarding spatial memory, to a lesser extent with
verbal memory, fluency, executive function and processing speed, while auditory
attention was not significantly effected.[27] Where spatial memory had been
evaluated by results from Corsi block-tapping test, Rey-Osterrieth Complex Figure
Test-immediate recall and Spatial Working Memory between search errors. Verbal
memory by Verbal Learning Test-delayed recall and Logical Memory II. Verbal
fluency by Category fluency and Letter fluency. Auditory attention by Digit Span
Test.Processing speed by Trail Making Test part A. [27]

Indeed OCD patients show impairment in formulating organizational strategy for

coding information, set-shifting, motor and cognitive inhibition.[28]

Associated conditions
People with OCD may be diagnosed with other conditions, as well or instead of
OCD, such as the aforementioned obsessive–compulsive personality disorder,
major depressive disorder, bipolar disorder,[29] generalized anxiety disorder,
anorexia nervosa, social anxiety disorder, bulimia nervosa, Tourette syndrome,
Asperger syndrome, attention deficit hyperactivity disorder, dermatillomania
(compulsive skin picking), body dysmorphic disorder, and trichotillomania (hair
pulling). In 2009 it was reported that depression among those with OCD is
particularly alarming because their risk of suicide is high; more than 50 percent of
patients experience suicidal tendencies, and 15 percent have attempted suicide. [30]
Individuals with OCD have also been found to be affected by delayed sleep phase
syndrome at a substantially higher rate than the general public.[31] Moreover severe
OCD symptoms are consistently associated with greater sleep disturbance.
Reduced total sleep time and sleep efficiency have been observed in OCD patients,
with delayed sleep onset and offset and an increased prevalence of delayed sleep
phase disorder.[32]

Behaviorally, there is some research demonstrating a link between drug addiction

and the disorder as well. For example, there is a higher risk of drug addiction
 12

among those with any anxiety disorder (possibly as a way of coping with the
heightened levels of anxiety), but drug addiction among OCD patients may serve
as a type of compulsive behavior and not just as a coping mechanism. Depression
is also extremely prevalent among sufferers of OCD. One explanation for the high
depression rate among OCD populations was posited by Mineka, Watson, and
Clark (1998), who explained that people with OCD (or any other anxiety disorder)
may feel depressed because of an "out of control" type of feeling.[22]

Someone exhibiting OCD signs does not necessarily have OCD. Behaviors that
present as (or seem to be) obsessive or compulsive can also be found in a number
of other conditions as well, including obsessive–compulsive personality disorder
(OCPD), autism spectrum disorders, disorders where perseveration is a possible
feature (ADHD, PTSD, bodily disorders or habit problems),[3] or sub-clinically.

Some with OCD present with features typically associated with Tourette's
syndrome, such as compulsions that may appear to resemble motor tics; this has
been termed "tic-related OCD" or "Tourettic OCD".[33][34]

Causes
Scholars generally agree that both psychological and biological factors play a role
in causing the disorder, although they differ in their degree of emphasis upon either
type of factor.

Psychological

An evolutionary psychology view is that moderate versions of compulsive

behavior may have had evolutionary advantages. Examples would be moderate
constant checking of hygiene, the hearth, or the environment for enemies.
Similarly, hoarding may have had evolutionary advantages. In this view OCD may
be the extreme statistical "tail" of such behaviors possibly due to a high amount of
predisposing genes.[35]

Biological

OCD has been linked to abnormalities with the neurotransmitter serotonin,

although it could be either a cause or an effect of these abnormalities. Serotonin is
thought to have a role in regulating anxiety. To send chemical messages from one
neuron to another, serotonin must bind to the receptor sites located on the
neighboring nerve cell. It is hypothesized that the serotonin receptors of OCD
sufferers may be relatively understimulated. This suggestion is consistent with the
 13

observation that many OCD patients benefit from the use of selective serotonin
reuptake inhibitors (SSRIs), a class of antidepressant medications that allow for
more serotonin to be readily available to other nerve cells.[36]

A possible genetic mutation may contribute to OCD. A mutation has been found in
the human serotonin transporter gene, hSERT, in unrelated families with OCD.[37]
Moreover, data from identical twins supports the existence of a "heritable factor for
neurotic anxiety".[38] Further, individuals with OCD are more likely to have first-
degree family members exhibiting the same disorders than do matched controls. In
cases where OCD develops during childhood, there is a much stronger familial link
in the disorder than cases in which OCD develops later in adulthood. In general,
genetic factors account for 45–65% of OCD symptoms in children diagnosed with
the disorder.[39] Environmental factors also play a role in how these anxiety
symptoms are expressed; various studies on this topic are in progress and the
presence of a genetic link is not yet definitely established.

People with OCD evince increased grey matter volumes in bilateral lenticular
nuclei, extending to the caudate nuclei, while decreased grey matter volumes in
bilateral dorsal medial frontal/anterior cingulate gyri.[40][41] These findings contrast
with those in people with other anxiety disorders, who evince decreased (rather
than increased) grey matter volumes in bilateral lenticular / caudate nuclei, while
also decreased grey matter volumes in bilateral dorsal medial frontal/anterior
cingulate gyri.[41] Orbitofrontal cortex overactivity is attenuated in patients who
have successfully responded to SSRI medication, a result believed to be caused by
increased stimulation of serotonin receptors 5-HT2A and 5-HT2C.[42] The striatum,
linked to planning and the initiation of appropriate actions, has also been
implicated; mice genetically engineered with a striatal abnormality exhibit OCD-
like behavior, grooming themselves three times as frequently as ordinary mice. [43]
Recent evidence supports the possibility of a heritable predisposition for
neurological development favoring OCD.[44]

Rapid onset of OCD in children and adolescents may be caused by a syndrome

conntected to Group A streptococcal infections (PANDAS)[45][46] or caused by
immunologic reactions to other pathogens (PANS).[47]

Neurotransmitters

Researchers have yet to pinpoint the exact cause of OCD, but brain differences,
genetic influences, and environmental factors are being studied. Brain scans of
 14

people with OCD have shown that they have different patterns of brain activity
than people without OCD and that different functioning of circuitry within a
certain part of the brain, the striatum, may cause the disorder. Differences in other
parts of the brain and neurotransmitter dysregulation, especially serotonin and
dopamine, may also contribute to OCD.[48] Independent studies have consistently
found unusual dopamine and serotonin activity in various regions of the brain in
individuals with OCD. These can be defined as dopaminergic hyperfunction in the
prefrontal cortex and serotonergic hypofunction in the basal ganglia.[49][50][51]
Glutamate dysregulation has also been the subject of recent research,[52][53]
although its role in the disorder's etiology is not yet clear.

Diagnosis
Formal diagnosis may be performed by a psychologist, psychiatrist, clinical social
worker, or other licensed mental health professional. To be diagnosed with OCD, a
person must have obsessions, compulsions, or both, according to the Diagnostic
and Statistical Manual of Mental Disorders (DSM). The Quick Reference to the
2000 edition of the DSM states that several features characterize clinically
significant obsessions and compulsions. Such obsessions, the DSM says, are
recurrent and persistent thoughts, impulses, or images that are experienced as
intrusive and that cause marked anxiety or distress. These thoughts, impulses, or
images are of a degree or type that lies outside the normal range of worries about
conventional problems.[54] A person may attempt to ignore or suppress such
obsessions, or to neutralize them with some other thought or action, and will tend
to recognize the obsessions as idiosyncratic or irrational.

Compulsions become clinically significant when a person feels driven to perform

them in response to an obsession, or according to rules that must be applied rigidly,
and when the person consequently feels or causes significant distress. Therefore,
while many people who do not suffer from OCD may perform actions often
associated with OCD (such as ordering items in a pantry by height), the distinction
with clinically significant OCD lies in the fact that the person who suffers from
OCD must perform these actions, otherwise they will experience significant
psychological distress. These behaviors or mental acts are aimed at preventing or
reducing distress or preventing some dreaded event or situation; however, these
activities are not logically or practically connected to the issue, or they are
excessive. In addition, at some point during the course of the disorder, the
individual must realize that their obsessions or compulsions are unreasonable or
excessive.
 15

Moreover, the obsessions or compulsions must be time-consuming (taking up more

than one hour per day) or cause impairment in social, occupational, or scholastic
functioning.[54] It is helpful to quantify the severity of symptoms and impairment
before and during treatment for OCD. In addition to the patient’s estimate of the
time spent each day harboring obsessive-compulsive thoughts or behaviors, Fenske
and Schwenk in their article "Obsessive-Compulsive Disorder: Diagnosis and
Management," argue that more concrete tools should be used to gauge the patient’s
condition (2009). This may be done with rating scales, such as the most trusted
Yale–Brown Obsessive Compulsive Scale (Y-BOCS). With measurements like
these, psychiatric consultation can be more appropriately determined because it has
been standardized.[30]

Versus obsessive–compulsive personality disorder

OCD is often confused with the separate condition obsessive–compulsive

personality disorder (OCPD). OCD is egodystonic, meaning that the disorder is
incompatible with the sufferer's self-concept.[55][56] Because ego dystonic disorders
go against a person's self-concept, they tend to cause much distress. OCPD, on the
other hand, is egosyntonic — marked by the person's acceptance that the
characteristics and behaviours displayed as a result are compatible with his or her
self-image, or are otherwise appropriate, correct or reasonable.

As a result, people with OCD are often aware that their behavior is not rational, are
unhappy about their obsessions but nevertheless feel compelled by them, and may
be riddled with anxiety.[57] By contrast people with OCPD are not aware of
anything abnormal; they will readily explain why their actions are rational, it is
usually impossible to convince them otherwise, and they tend to derive pleasure
from their obsessions or compulsions.[57]

Versus other conditions

OCD is different from behaviors such as gambling addiction and overeating.

People with these disorders typically experience at least some pleasure from their
activity; OCD sufferers do not actively want to perform their compulsive tasks and
experience no pleasure from doing so.

Management
Behavioral therapy (BT), cognitive behavioral therapy (CBT), and medications are
first-line treatments for OCD.[58] Psychodynamic psychotherapy may help in
 16

managing some aspects of the disorder. The American Psychiatric Association

notes a lack of controlled demonstrations that psychoanalysis or dynamic
psychotherapy is effective "in dealing with the core symptoms of OCD."[59] The
fact that many individuals do not seek treatment may be due in part to stigma
associated with OCD.

Behavioral therapy

The specific technique used in BT/CBT is called exposure and ritual prevention
(also known as "exposure and response prevention") or ERP; this involves
gradually learning to tolerate the anxiety associated with not performing the ritual
behavior. At first, for example, someone might touch something only very mildly
"contaminated" (such as a tissue that has been touched by another tissue that has
been touched by the end of a toothpick that has touched a book that came from a
"contaminated" location, such as a school.) That is the "exposure". The "ritual
prevention" is not washing. Another example might be leaving the house and
checking the lock only once (exposure) without going back and checking again
(ritual prevention). The person fairly quickly habituates to the anxiety-producing
situation and discovers that their anxiety level has dropped considerably; they can
then progress to touching something more "contaminated" or not checking the lock
at all—again, without performing the ritual behavior of washing or checking.[60]

Exposure ritual/response prevention (ERP) has a strong evidence base. It is

considered the most effective treatment for OCD.[60] However, this claim has been
doubted by some researchers criticizing the quality of many studies.[61]

It has generally been accepted that psychotherapy, in combination with psychiatric

medication, is more effective than either option alone. However, more recent
studies have shown no difference in outcomes for those treated with the
combination of medicine and CBT versus CBT alone.[62]

Medication

Medications as treatment include selective serotonin reuptake inhibitors (SSRIs)

and the tricyclic antidepressants, in particular clomipramine.

Treatment of OCD is an area needing significant improvement in prescribing

regimens.[63] Benzodiazepines are sometimes used, although they are generally
believed to be ineffective for treating OCD; however, effectiveness was found in
one small study.[64] In most cases antidepressant therapy alone provides only a
partial reduction in symptoms, even in cases that are not deemed treatment
 17

resistant. Much current research is devoted to the therapeutic potential of the

agents that affect the release of the neurotransmitter glutamate or the binding to its
receptors. These include riluzole,[53] memantine, gabapentin, N-acetylcysteine, and
lamotrigine.

The atypical antipsychotics such as quetiapine have also been found to be useful as
adjuncts to an SSRI in treatment-resistant OCD. However, these drugs are often
poorly tolerated, and have metabolic side effects that limit their use. None of the
atypical antipsychotics appear to be useful when used alone.[65]

Electroconvulsive therapy

Electroconvulsive therapy (ECT) has been found to have effectiveness in some

severe and refractory cases.[66]

Psychosurgery

For some, medication, support groups and psychological treatments fail to alleviate
obsessive–compulsive symptoms. These patients may choose to undergo
psychosurgery as a last resort. In this procedure, a surgical lesion is made in an
area of the brain (the cingulate cortex). In one study, 30% of participants benefited
significantly from this procedure.[67] Deep-brain stimulation and vagus nerve
stimulation are possible surgical options that do not require destruction of brain
tissue. In the US, the Food and Drug Administration approved deep-brain
stimulation for the treatment of OCD under a humanitarian device exemption
requiring that the procedure be performed only in a hospital with specialist
qualifications to do so.[68]

In the US, psychosurgery for OCD is a treatment of last resort and will not be
performed until the patient has failed several attempts at medication (at the full
dosage) with augmentation, and many months of intensive cognitive–behavioral
therapy with exposure and ritual/response prevention.[69] Likewise, in the United
Kingdom, psychosurgery cannot be performed unless a course of treatment from a
suitably qualified cognitive–behavioral therapist has been carried out.

Children

Therapeutic treatment may be effective in reducing ritual behaviors of OCD for

children and adolescents.[70] Family involvement, in the form of behavioral
observations and reports, is a key component to the success of such treatments. [71]
Parental intervention also provides positive reinforcement for a child who exhibits
 18

appropriate behaviors as alternatives to compulsive responses. After one or two

years of therapy, in which a child learns the nature of his or her obsession and
acquires strategies for coping, that child may acquire a larger circle of friends,
exhibit less shyness, and become less self-critical.[72]

Although the causes of OCD in younger age groups range from brain abnormalities
to psychological preoccupations, life stress such as bullying and traumatic familial
deaths may also contribute to childhood cases of OCD, and acknowledging these
stressors can play a role in treating the disorder.[73]

Epidemiology

Age-standardized disability-adjusted life year rates for obsessive-compulsive

disorder per 100,000 inhabitants in 2004.
no data

<45

45–52.5

52.5–60

60–67.5

67.5–75

75–82.5

82.5–90

90–97.5

97.5–105

105–112.5

112.5–120

>120
 19

OCD occurs in between 1 to 3% of children and adults.[74] It occurs equally in both

sexes. In 80% of cases, symptoms present before the age of 18.[better source needed][75] A
2000 study by the World Health Organization found some variety in prevalence
and incidence of OCD around the world, with figures in Latin America, Africa,
and Europe at two to three times those in Asia and Oceania.[76]

One Canadian study found that prevalence of OCD had little correlation with race.
However, respondents who marked Judaism as their religion were overrepresented
among OCD patients.[77]

Prognosis
Psychological interventions such as behavioral and cognitive-behavioral therapy as
well as pharmacological treatment can lead to substantial reduction of OCD
symptoms for the average patient. However, OCD symptoms persist at moderate
levels even following adequate treatment course and a completely symptom-free
period is uncommon.[78]

History
From the 14th to the 16th century in Europe, it was believed that people who
experienced blasphemous, sexual, or other obsessive thoughts were possessed by
the Devil.[55] Based on this reasoning, treatment involved banishing the "evil" from
the "possessed" person through exorcism.[79][80] In the early 1910s, Sigmund Freud
attributed obsessive–compulsive behavior to unconscious conflicts that manifest as
symptoms.[79] Freud describes the clinical history of a typical case of "touching
phobia" as starting in early childhood, when the person has a strong desire to touch
an item. In response, the person develops an "external prohibition" against this type
of touching. However, this "prohibition does not succeed in abolishing" the desire
to touch; all it can do is repress the desire and "force it into the unconscious".[81]

Society and culture

This ribbon represents Trichotillomania and other body focused repetitive behaviors. Concept for the ribbon was started by
Jenne Schrader. Colors were voted on by the Trichotillomania Facebook community, and made official by Trichotillomania
Learning Center in August of 2013
 20

Movies and television often portray idealized representations of disorders such as

OCD. These depictions may lead to increased public awareness, understanding,
and sympathy for such disorders.[82]

 British poet, essayist, and lexicographer Samuel Johnson is an example of a

historical figure with a retrospective diagnosis of OCD. He had elaborate
rituals for crossing the thresholds of doorways, and repeatedly walked up
and down staircases counting the steps.[83]
 American aviator and filmmaker Howard Hughes is known to have suffered
from OCD. Friends of Hughes have mentioned his obsession with minor
flaws in clothing and he is reported to have had a great fear of germs,
common among OCD patients.[84]
 English footballer David Beckham has been outspoken regarding his
struggle with OCD. He said that he has to count all of his clothes, and his
magazines have to lie in a straight line.[85]
 Canadian comedian, actor, television host, and voice actor Howie Mandel,
best known for hosting the game show Deal or No Deal, wrote an
autobiography, Here's the Deal: Don't Touch Me, describing how OCD and
mysophobia (fear of germs) affect his life.[86]
 American game show host Marc Summers wrote Everything in Its Place: My
Trials and Triumphs with Obsessive Compulsive Disorder, describing the
effect of OCD on his life.[87]

Research
The naturally occurring sugar inositol has been suggested as a treatment for
OCD.[88]

Nutrition deficiencies may also contribute to OCD and other mental disorders.
Vitamin and mineral supplements may aid in such disorders and provide nutrients
necessary for proper mental functioning.[89]

μ-Opioids, such as hydrocodone and tramadol, may improve OCD symptoms.[90]

Administration of opiate treatment may be contraindicated in individuals
concurrently taking CYP2D6 inhibitors such as fluoxetine and paroxetine.[91]
 21

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obsessive-compulsive disorder". Expert Opinion on Investigational Drugs 12 (6): 993–1001.
doi:10.1517/13543784.12.6.993. PMID 12783603.
91. Koran, Lorrin M. (2007). "Obsessive-Compulsive Disorder: An Update for the Clinician". Focus
(5): 3.

Further reading

 Abramowitz, Jonathan, S. (2009). Getting over OCD: A 10 step workbook for taking back your life.
New York: Guilford Press. ISBN 0-06-098711-1.
 Schwartz, Jeffrey M.; Beverly Beyette (1997). Brain lock: free yourself from obsessive–compulsive
behavior: a four-step self-treatment method to change your brain chemistry. New York:
ReganBooks. ISBN 0-06-098711-1.
 26

 Lee, PhD. Baer (2002). The Imp of the Mind: Exploring the Silent Epidemic of Obsessive Bad
Thoughts. New York: Plume Books. ISBN 0-452-28307-8.
 Osborn, Ian (1999). Tormenting Thoughts and Secret Rituals : The Hidden Epidemic of Obsessive–
Compulsive Disorder. New York: Dell. ISBN 0-440-50847-9.
 Wilson, Rob; David Veale (2005). Overcoming Obsessive–Compulsive Disorder. Constable &
Robinson Ltd. ISBN 1-84119-936-2.
 Davis, Lennard J. (2008). Obsession: A History. University of Chicago Press. ISBN 978-0-226-
13782-7.
 Emily, Colas (1998). Just Checking: Scenes from the Life of an Obsessive-compulsive. New York:
Pocket Books. p. 165. ISBN 067102437X.

Mental and behavioral disorders (F 290–319)

Anxiety disorder: Obsessive–compulsive disorder (F42, 300.3)

This page was last modified on 14 May 2014 at 03:17.

Intrusive thoughts
Intrusive thoughts are unwelcome involuntary thoughts, images, or unpleasant
ideas that may become obsessions, are upsetting or distressing, and can be difficult
to manage or eliminate.[1] When they are associated with obsessive-compulsive
disorder (OCD), depression, body dysmorphic disorder (BDD), and sometimes
attention-deficit hyperactivity disorder (ADHD), the thoughts may become
paralyzing, anxiety-provoking, or persistent. Intrusive thoughts may also be
associated with episodic memory, unwanted worries or memories from OCD,[2]
posttraumatic stress disorder, other anxiety disorders, eating disorders, or
psychosis.[3] Intrusive thoughts, urges, and images are of inappropriate things at
inappropriate times, and they can be divided into three categories: "inappropriate
aggressive thoughts, inappropriate sexual thoughts, or blasphemous religious
thoughts".[4]

Description
Many people experience the type of bad or unwanted thoughts that people with
more troubling intrusive thoughts have, but most people can dismiss these
thoughts.[1] For most people, intrusive thoughts are a "fleeting annoyance."[5]
Psychologist Stanley Rachman presented a questionnaire to healthy college
students and found that virtually all said they had these thoughts from time to time,
 27

including thoughts of sexual violence, sexual punishment, "unnatural" sex acts,

painful sexual practices, blasphemous or obscene images, thoughts of harming
elderly people or someone close to them, violence against animals or towards
children, and impulsive or abusive outbursts or utterances.[6] Such bad thoughts are
universal among humans, and have "almost certainly always been a part of the
human condition".[7]

When intrusive thoughts occur with obsessive-compulsive disorder (OCD),

patients are less able to ignore the unpleasant thoughts and may pay undue
attention to them, causing the thoughts to become more frequent and distressing. [1]
The thoughts may become obsessions which are paralyzing, severe, and constantly
present, and can range from thoughts of violence or sex to religious blasphemy. [5]
Distinguishing them from normal intrusive thoughts experienced by many people,
the intrusive thoughts associated with OCD may be anxiety provoking,
irrepressible, and persistent.[8]

How people react to intrusive thoughts may determine whether these thoughts will
become severe, turn into obsessions, or require treatment. Intrusive thoughts can
occur with or without compulsions. Carrying out the compulsion reduces the
anxiety, but makes the urge to perform the compulsion stronger each time it recurs,
reinforcing the intrusive thoughts.[1] According to Baer, suppressing the thoughts
only makes them stronger, and recognizing that bad thoughts do not signify that
one is truly evil is one of the steps to overcoming them. [9] There is evidence of the
benefit of acceptance as an alternative to suppression of intrusive thoughts. A study
showed that those instructed to suppress intrusive thoughts experienced more
distress after suppression, while patients instructed to accept the bad thoughts
experienced decreased discomfort.[10] These results may be related to underlying
cognitive processes involved in OCD.[11] However accepting the thoughts can be
more difficult for persons with OCD. In the 19th century, OCD was known as "the
doubting sickness";[12] the "pathological doubt" that accompanies OCD can make it
harder for a person with OCD to distinguish "normal" intrusive thoughts as
experienced by most people, causing them to "suffer in silence, feeling too
embarrassed or worried that they will be thought crazy".[13]

The possibility that most patients suffering from intrusive thoughts will ever act on
those thoughts is low. Patients who are experiencing intense guilt, anxiety, shame,
and upset over these thoughts are different from those who actually act on them.
The history of violent crime is dominated by those who feel no guilt or remorse;
the very fact that someone is tormented by intrusive thoughts and has never acted
on them before is an excellent predictor that they will not act upon the thoughts.
 28

Patients who are not troubled or shamed by their thoughts, do not find them
distasteful, or who have actually taken action, might need to have more serious
conditions such as psychosis or potentially criminal behaviors ruled out.[14]
According to Baer, a patient should be concerned that intrusive thoughts are
dangerous if the person does not feel upset by the thoughts, or rather finds them
pleasurable; has ever acted on violent or sexual thoughts or urges; hears voices or
sees things that others do not see; or feels uncontrollable irresistible anger.[15]

Inappropriate aggressive thoughts

Intrusive thoughts may involve violent obsessions about hurting others or

themselves.[16] They can include such thoughts as harming an innocent child;
jumping from a bridge, mountain, or the top of a tall building; urges to jump in
front of a train or automobile; and urges to push another in front of a train or
automobile.[4] Rachman's survey of healthy college students found that virtually all
of them had intrusive thoughts from time to time, including:[6]

 causing harm to elderly people

 imagining or wishing harm upon someone close to oneself
 impulses to violently attack, hit, harm or kill a person, small child, or animal
 impulses to shout at or abuse someone, or attack and violently punish
someone, or say something rude, inappropriate, nasty, or violent to someone.

These thoughts are part of being human, and need not ruin quality of life. [17]
Treatment is available when the thoughts are associated with OCD and become
persistent, severe, or distressing.

Inappropriate sexual thoughts

Sexual obsessions involve intrusive thoughts or images of "kissing, touching,

fondling, oral sex, anal sex, intercourse, and rape" with "strangers, acquaintances,
parents, children, family members, friends, coworkers, animals and religious
figures", involving "heterosexual or homosexual content" with persons of any
age.[18]

Like other unwanted intrusive thoughts or images, everyone has some

inappropriate sexual thoughts at times, but people with OCD may attach
significance to the unwanted sexual thoughts, generating anxiety and distress. The
doubt that accompanies OCD leads to uncertainty regarding whether one might act
on the intrusive thoughts, resulting in self-criticism or loathing.[18]
 29

One of the more common sexual intrusive thoughts occurs when an obsessive
person doubts his or her sexual identity. As in the case of most sexual obsessions,
sufferers may feel shame and live in isolation, finding it hard to discuss their fears,
doubts, and concerns about their sexual identity.[12]

A person experiencing sexual intrusive thoughts may feel shame, "embarrassment,

guilt, distress, torment, fear of acting on the thought or perceived impulse, and
doubt about whether they have already acted in such a way." Depression may be a
result of the self-loathing that can occur, depending on how much the OCD
interferes with daily functioning or causes distress.[18] Their concern over these
thoughts may cause them to scrutinize their bodies to determine if the thoughts
result in feelings of arousal. However, focusing attention of any part of the body
can result in feelings in that part of the body, hence doing so may decrease
confidence and increase fear about acting on the urges. Part of treatment of sexual
intrusive thoughts involves therapy to help sufferers accept intrusive thoughts and
stop trying to reassure themselves by checking their bodies.[19]

Blasphemous religious thoughts

Blasphemous thoughts are a common component of OCD, documented throughout

history; notable religious figures such as Martin Luther and St. Ignatius were
known to be tormented by intrusive, blasphemous or religious thoughts and
urges.[20] Martin Luther had urges to curse God and Jesus, and was obsessed with
images of "the Devil's behind".[20][21] St. Ignatius had numerous obsessions,
including the fear of stepping on pieces of straw forming a cross, fearing that it
showed disrespect to Christ.[20][22] A study of 50 patients with a primary diagnosis
of obsessive-compulsive disorder found that 40% had religious and blasphemous
thoughts and doubts—a higher, but not statistically significantly different number
than the 38% who had the obsessional thoughts related to dirt and contamination
more commonly associated with OCD.[23] One study suggests that content of
intrusive thoughts may vary depending on culture, and that blasphemous thoughts
may be more common in men than in women.[24]

According to Fred Penzel, a New York psychologist, some common religious

obsessions and intrusive thoughts are:[13]

 sexual thoughts about God, saints, and religious figures

 bad thoughts or images during prayer or meditation
 thoughts of being possessed
 fears of sinning or breaking a religious law or performing a ritual incorrectly
 30

 fears of omitting prayers or reciting them incorrectly

 repetitive and intrusive blasphemous thoughts
 urges or impulses to say blasphemous words or commit blasphemous acts
during religious services.

Suffering can be greater and treatment complicated when intrusive thoughts

involve religious implications;[20] patients may believe the thoughts are inspired by
Satan,[25] and may fear punishment from God or have magnified shame because
they perceive themselves as sinful.[26] Symptoms can be more distressing for
sufferers with strong religious convictions or beliefs.[13]

Baer believes that blasphemous thoughts are more common in Catholics and
evangelical Protestants than in other religions, whereas Jews or Muslims tend to
have obsessions related more to complying with the laws and rituals of their faith,
and performing the rituals perfectly.[27] He hypothesizes that this is because what is
considered inappropriate varies among cultures and religions, and intrusive
thoughts torment their sufferers with whatever is considered most inappropriate in
the surrounding culture.[28]

Associated conditions
Intrusive thoughts are associated with OCD or obsessive-compulsive personality
disorder,[29] but may also occur with other conditions[3] such as post-traumatic
stress disorder,[30] clinical depression,[31] postpartum depression,[8] and
anxiety.[32][33] One of these conditions[34] is almost always present in people whose
intrusive thoughts reach a clinical level of severity.[35] A large study published in
2005 found that aggressive, sexual, and religious obsessions were broadly
associated with comorbid anxiety disorders and depression.[36] The intrusive
thoughts that occur in a schizophrenic episode differ from the obsessional thoughts
that occur with OCD or depression in that the intrusive thoughts of schizophrenics
are false or delusional beliefs (i.e. held by the schizophrenic individual to be real
and not doubted, as is typically the case with intrusive thoughts) .[37]

Post-traumatic stress disorder

The key difference between OCD and post-traumatic stress disorder (PTSD) is that
the intrusive thoughts of PTSD sufferers are of traumatic events that actually
happened to them, whereas OCD sufferers have thoughts of imagined catastrophes.
PTSD patients with intrusive thoughts have to sort out violent, sexual, or
blasphemous thoughts from memories of traumatic experiences.[38] When patients
 31

with intrusive thoughts do not respond to treatment, physicians may suspect past
physical, emotional, or sexual abuse.[39]

Depression

People who are clinically depressed may experience intrusive thoughts more
intensely, and view them as evidence that they are worthless or sinful people. The
suicidal thoughts that are common in depression must be distinguished from
intrusive thoughts, because suicidal thoughts—unlike harmless sexual, aggressive,
or religious thoughts—can be dangerous.[40]

Postpartum depression

Unwanted thoughts by mothers about harming their newborn infants are common
in postpartum depression.[41] A 1999 study of 65 women with postpartum major
depression by Katherine Wisner et al. found the most frequent aggressive thought
for women with postpartum depression was causing harm to their newborn
infants.[42] A study of 85 new parents found that 89% experienced intrusive images,
for example, of the baby suffocating, having an accident, being harmed, or being
kidnapped.[8][43]

Some women may develop symptoms of OCD during pregnancy or the postpartum
period.[8][44] Postpartum OCD occurs mainly in women who may already have
OCD, perhaps in a mild or undiagnosed form. Postpartum depression and OCD
may be comorbid (often occurring together). And though physicians may focus
more on the depressive symptoms, one study found that obsessive thoughts did
accompany postpartum depression in 57% of new mothers.[8]

Wisner found common obsessions about harming babies in mothers experiencing

postpartum depression include images of the baby lying dead in a casket or being
eaten by sharks; stabbing the baby; throwing the baby down the stairs; or drowning
or burning the baby (as by submerging it in the bathtub in the former case or
throwing it in the fire or putting it in the microwave in the latter). [42][45] Baer
estimates that up to 200,000 new mothers with postpartum depression each year
may develop these obsessional thoughts about their babies;[46] and because they
may be reluctant to share these thoughts with a physician or family member, or
suffer in silence and fear they are "crazy", their depression can worsen.[47]

Intrusive fears of harming immediate children can last longer than the postpartum
period. A study of 100 clinically depressed women found that 41% had obsessive
fears that they might harm their child, and some were afraid to care for their
 32

children. Among non-depressed mothers, the study found 7% had thoughts of

harming their child[48]—a rate that yields an additional 280,000 non-depressed
mothers in the United States with intrusive thoughts about harming their
children.[49]

Frequency
According to Baer, most people who suffer bad or unacceptable thoughts have not
identified themselves as having OCD, because they may not have what they
believe to be classic symptoms of OCD, such as handwashing. Yet, he says,
epidemiological studies suggest that intrusive thoughts are the most common kind
of OCD worldwide; if people in the United States with intrusive thoughts gathered,
they would form the fourth-largest city in the US, following New York City and
Chicago.[50] A 2007 study found that 78% of a clinical sample of OCD patients had
intrusive images.[3]

The prevalence of OCD in every culture studied is at least 2% of the population,

and the majority of those have obsessions, or bad thoughts, only; this results in a
conservative estimate of more than 2 million sufferers in the United States alone
(as of 2000).[51] One author estimates that one in 50 adults has OCD and about 10–
20% of these have sexual obsessions.[18] A recent study found that 25% of 293
patients with a primary diagnosis of OCD had a history of sexual obsessions.[52]

Treatment
Treatment for intrusive thoughts is similar to treatment for OCD. Exposure and
response prevention therapy—also referred to as habituation or desensitization—is
useful in treating intrusive thoughts.[18] Mild cases can also be treated with
cognitive behavioral therapy, which helps patients identify and manage the
unwanted thoughts.[8]

Exposure therapy

Exposure therapy is the treatment of choice for intrusive thoughts.[53] According to

Deborah Osgood-Hynes, Psy.D. Director of Psychological Services and Training at
the MGH/McLean OCD Institute, "In order to reduce a fear, you have to face a
fear. This is true of all types of anxiety and fear reactions, not just OCD."[18]

Because it is uncomfortable to experience bad thoughts and urges, shame, doubt or

fear, the initial reaction is usually to do something to make the feelings diminish.
 33

By engaging in a ritual or compulsion to diminish the anxiety or bad feeling, the

action is strengthened via a process called negative reinforcement—the mind
learns that the way to avoid the bad feeling is by engaging in a ritual or
compulsions. When OCD becomes severe, this leads to more interference in life
and continues the frequency and severity of the thoughts the person sought to
avoid.[18]

Exposure therapy (or exposure and response prevention) is the practice of staying
in an anxiety-provoking or feared situation until the distress or anxiety diminishes.
The goal is to reduce the fear reaction, learning to not react to the bad thoughts.
This is the most effective way to reduce the frequency and severity of the intrusive
thoughts.[18] The goal is to be able to "expose yourself to the thing that most
triggers your fear or discomfort for one to two hours at a time, without leaving the
situation, or doing anything else to distract or comfort you."[54] Exposure therapy
will not completely eliminate intrusive thoughts—everyone has bad thoughts—but
most patients find that it can decrease their thoughts sufficiently that intrusive
thoughts no longer interfere with their lives.[55]

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is a newer therapy than exposure therapy,

available for those unable or unwilling to undergo exposure therapy. [53] Cognitive
therapy has been shown to be useful in reducing intrusive thoughts,[56][57] but
developing a conceptualization of the obsessions and compulsions with the patient
is important.[58]

Pharmaceutical

Antidepressants or antipsychotic medications may be used for more severe cases if

intrusive thoughts do not respond to cognitive behavioral or exposure therapy
alone.[8][59] Whether the cause of intrusive thoughts is OCD, depression, or post-
traumatic stress disorder, the selective serotonin reuptake inhibitor (SSRI) drugs (a
class of antidepressants) are the most commonly prescribed.[59] Intrusive thoughts
may occur in persons with Tourette syndrome (TS) who also have OCD; the
obsessions in TS-related OCD are thought to respond to SSRI drugs as well.[60]

Antidepressants which have been shown to be effective in treating OCD include

fluvoxamine (trade name[61] Luvox), fluoxetine (Prozac), sertraline (Zoloft),
paroxetine (Paxil), citalopram (Celexa), and clomipramine (Anafranil).[62]
Although SSRIs are known to be effective for OCD in general, there have been
fewer studies on their effectiveness for intrusive thoughts.[63] A retrospective chart
 34

review of patients with sexual symptoms treated with SSRIs showed the greatest
improvement was in those with intrusive sexual obsessions typical of OCD.[64] A
study of ten patients with religious or blasphemous obsessions found that most
patients responded to treatment with fluoxetine or clomipramine.[65] Women with
postpartum depression often have anxiety as well, and may need lower starting
doses of SSRIs; they may not respond fully to the medication, and may benefit
from adding cognitive behavioral or response prevention therapy.[66]

Patients with intense intrusive thoughts that do not respond to SSRIs or other
antidepressants may be prescribed typical and atypical neuroleptics including
risperidone (trade name Risperdal), ziprasidone (Geodon), haloperidol (Haldol),
and pimozide (Orap).[67]

Studies suggest that therapeutic doses of inositol may be useful in the treatment of
obsessive thoughts.[68][69]

Notes
1. "Intrusive thoughts". OCD Action. Archived from the original on September 28, 2007.
Retrieved December 27, 2010.
2. Baer (2001), pp. 58–60
3. Brewin CR, Gregory JD, Lipton M, Burgess N (January 2010). "Intrusive images in
psychological disorders: characteristics, neural mechanisms, and treatment implications".
Psychol Rev 117 (1): 210–32. doi:10.1037/a0018113. PMC 2834572. PMID 20063969.
4. Baer (2001), p. xiv.
5. Baer (2001), p. 5
6. As reported in Baer (2001), p. 7: Rachman S, de Silva P (1978). "Abnormal and normal
obsessions". Behav Res Ther 16 (4): 233–48. doi:10.1016/0005-7967(78)90022-0.
PMID 718588.
7. Baer (2001), p. 8
8. Colino, Stacey. "Scary Thoughts: It's Normal for New Parents to Worry Their Baby May
Face Harm. For Some Women, Though, Such Fears Become Overwhelming". The
Washington Post (March 7, 2006). Retrieved on December 30, 2006.
9. Baer (2001), p. 17
10. Marcks BA, Woods DW (April 2005). "A comparison of thought suppression to an
acceptance-based technique in the management of personal intrusive thoughts: a
controlled evaluation". Behav Res Ther 43 (4): 433–45. doi:10.1016/j.brat.2004.03.005.
PMID 15701355.
11. Tolin DF, Abramowitz JS, Przeworski A, Foa EB (November 2002). "Thought
suppression in obsessive-compulsive disorder". Behav Res Ther 40 (11): 1255–74.
doi:10.1016/S0005-7967(01)00095-X. PMID 12384322.
12. Penzel, Fred. "How Do I Know I'm Not Really Gay?" Retrieved on January 1, 2007
13. Penzel, Fred. "Let He Who Is Without Sin": OCD and Religion. Retrieved on January 1,
2007
 35

14. Baer (2001), pp. 37–38

15. Baer (2001), pp. 43–44
16. Baer (2001), pp. 33, 78
17. Baer (2001), p. xv
18. Osgood-Hynes, Deborah. "Thinking Bad Thoughts" (PDF). MGH/McLean OCD
Institute, Belmont, MA. OCD Foundation, Milford, CT. Archived from the original on
June 25, 2008. Retrieved December 27, 2010.
19. Baer (2001), p. 35
20. Baer (2001), p.106
21. Erickson, Erik H. Young Man Luther: A Study in Psychoanalysis and History. New York:
W.W. Norton, 1962
22. Ciarrocchi, Joseph W. "Religion, Scrupulosity, and Obsessive-Compulsive Disorder," in
Michael A. Jenike, Lee Baer, and William A. MInichiello, eds., Obsessive-Compulsive
Disorders: Practical Management, 3rd ed. St. Louis: Mosby, 1998
23. Shooka A, al-Haddad MK, Raees A (1998). "OCD in Bahrain: a phenomenological
profile". Int J Soc Psychiatry 44 (2): 147–54. doi:10.1177/002076409804400207.
PMID 9675634.
24. Ghassemzadeh H, Mojtabai R, Khamseh A, Ebrahimkhani N, Issazadegan AA, Saif-
Nobakht Z (March 2002). "Symptoms of obsessive-compulsive disorder in a sample of
Iranian patients". Int J Soc Psychiatry 48 (1): 20–8. doi:10.1177/002076402128783055.
PMID 12008904.
25. Baer (2001), p. 108
26. Baer (2001), p. 109
27. Baer (2001), pp. 111–112
28. Baer (2001), p. 112
29. Baer (2001), p. 40, 57
30. Michael T, Halligan SL, Clark DM, Ehlers A (2007). "Rumination in posttraumatic stress
disorder". Depress Anxiety 24 (5): 307–17. doi:10.1002/da.20228. PMID 17041914.
31. Christopher G, MacDonald J (November 2005). "The impact of clinical depression on
working memory". Cogn Neuropsychiatry 10 (5): 379–99.
doi:10.1080/13546800444000128. PMID 16571468.
32. Antoni MH, Wimberly SR, Lechner SC, et al. (October 2006). "Reduction of cancer-
specific thought intrusions and anxiety symptoms with a stress management intervention
among women undergoing treatment for breast cancer". Am J Psychiatry 163 (10): 1791–
7. doi:10.1176/appi.ajp.163.10.1791. PMID 17012691.
33. Compas BE, Beckjord E, Agocha B, et al. (December 2006). "Measurement of coping
and stress responses in women with breast cancer". Psychooncology 15 (12): 1038–54.
doi:10.1002/pon.999. PMID 17009343.
34. Baer also mentions Tourette syndrome (TS), but notes that it is the combination of
comorbid OCD—when present—and tics that accounts for the intrusive, obsessive
thoughts. People with tic-related OCD (OCD plus tics) are more likely to have violent or
sexual obsessions. Leckman JF, Grice DE, Barr LC, et al. (1994). "Tic-related vs. non-
tic-related obsessive compulsive disorder". Anxiety 1 (5): 208–15. PMID 9160576.
35. Baer (2001), p. 51
 36

36. Hasler G, LaSalle-Ricci VH, Ronquillo JG, et al. (June 2005). "Obsessive-compulsive
disorder symptom dimensions show specific relationships to psychiatric comorbidity".
Psychiatry Res 135 (2): 121–32. doi:10.1016/j.psychres.2005.03.003. PMID 15893825.
37. Waters FA, Badcock JC, Michie PT, Maybery MT (January 2006). "Auditory
hallucinations in schizophrenia: intrusive thoughts and forgotten memories". Cogn
Neuropsychiatry 11 (1): 65–83. doi:10.1080/13546800444000191. PMID 16537234.
38. Baer (2001), pp. 62–64
39. Baer (2001), p. 67
40. Baer (2001), pp. 51–53
41. Baer (2001), p. 20
42. As reported in Baer (2001), pp. 20–23, 139–40: Wisner KL, Peindl KS, Gigliotti T,
Hanusa BH (March 1999). "Obsessions and compulsions in women with postpartum
depression". J Clin Psychiatry 60 (3): 176–80. doi:10.4088/JCP.v60n0305.
PMID 10192593.
43. Abramowitz JS, Khandker M, Nelson CA, Deacon BJ, Rygwall R (September 2006).
"The role of cognitive factors in the pathogenesis of obsessive-compulsive symptoms: a
prospective study". Behav Res Ther 44 (9): 1361–74. doi:10.1016/j.brat.2005.09.011.
PMID 16352291.
44. Arnold LM (August 1999). "A Case Series of Women With Postpartum-Onset
Obsessive-Compulsive Disorder". Prim Care Companion J Clin Psychiatry 1 (4): 103–
108. doi:10.4088/PCC.v01n0402. PMC 181073. PMID 15014682.
45. Baer (2001), p. 21
46. Baer (2001), p. 22
47. Baer (2001), p. 23
48. As reported in Baer (2001), p. 51: Jennings KD, Ross S, Popper S, Elmore M (July
1999). "Thoughts of harming infants in depressed and nondepressed mothers". J Affect
Disord 54 (1–2): 21–8. doi:10.1016/S0165-0327(98)00185-2. PMID 10403143.
49. Baer (2001), p. 24
50. Baer (2001), p. xvii
51. Baer (2001), pp. 36–37
52. Grant JE, Pinto A, Gunnip M, Mancebo MC, Eisen JL, Rasmussen SA (2006). "Sexual
obsessions and clinical correlates in adults with obsessive-compulsive disorder". Compr
Psychiatry 47 (5): 325–9. doi:10.1016/j.comppsych.2006.01.007. PMID 16905392.
53. Baer (2001), p. 91
54. Baer (2001), p. 73
55. Baer (2001), p. 86
56. Deblinger E, Stauffer LB, Steer RA (November 2001). "Comparative efficacies of
supportive and cognitive behavioral group therapies for young children who have been
sexually abused and their nonoffending mothers". Child Maltreat 6 (4): 332–43.
doi:10.1177/1077559501006004006. PMID 11675816.
57. Sousa MB, Isolan LR, Oliveira RR, Manfro GG, Cordioli AV (July 2006). "A
randomized clinical trial of cognitive-behavioral group therapy and sertraline in the
treatment of obsessive-compulsive disorder". J Clin Psychiatry 67 (7): 1133–9.
doi:10.4088/JCP.v67n0717. PMID 16889458.
58. Purdon C (November 2004). "Cognitive-behavioral treatment of repugnant obsessions". J
Clin Psychol 60 (11): 1169–80. doi:10.1002/jclp.20081. PMID 15389619.
 37

59. Baer (2001), pp. 113–114

60. Baer (2001), p. 144
61. Medication trade names may differ between countries. In general, this article uses North
American trade names.
62. Baer (2001), p. 116
63. Baer (2001), p. 115
64. As reported in Baer (2001), p. 115: Stein DJ, Hollander E, Anthony DT, et al. (August
1992). "Serotonergic medications for sexual obsessions, sexual addictions, and
paraphilias". J Clin Psychiatry 53 (8): 267–71. PMID 1386848.
65. As reported in Baer (2001), p. 115: Fallon BA, Liebowitz MR, Hollander E, et al.
(December 1990). "The pharmacotherapy of moral or religious scrupulosity". J Clin
Psychiatry 51 (12): 517–21. PMID 2258366.
66. Baer (2001), p. 120
67. Baer (2001), p. 119
68. Albert U, Bergesio C, Pessina E, Maina G, Bogetto F (June 2002). "Management of
treatment resistant obsessive-compulsive disorder. Algorithms for pharmacotherapy".
Panminerva Med 44 (2): 83–91. PMID 12032425.
69. Palatnik A, Frolov K, Fux M, Benjamin J (June 2001). "Double-blind, controlled,
crossover trial of inositol versus fluvoxamine for the treatment of panic disorder". J Clin
Psychopharmacol 21 (3): 335–9. doi:10.1097/00004714-200106000-00014.
PMID 11386498.
* Levine J (May 1997). "Controlled trials of inositol in psychiatry". Eur
Neuropsychopharmacol 7 (2): 147–55. doi:10.1016/S0924-977X(97)00409-4.
PMID 9169302.

References
 Baer, Lee. The Imp of the Mind: Exploring the Silent Epidemic of Obsessive Bad
Thoughts. New York, Dutton, 2001. ISBN 0-525-94562-8

Further reading
 Abramowitz JS, Schwartz SA, Moore KM, Luenzmann KR (2003). "Obsessive-
compulsive symptoms in pregnancy and the puerperium: a review of the literature". J
Anxiety Disord 17 (4): 461–78. doi:10.1016/s0887-6185(02)00206-2. PMID 12826092.
 Julien D, O'Connor KP, Aardema F (April 2007). "Intrusive thoughts, obsessions, and
appraisals in obsessive-compulsive disorder: a critical review". Clin Psychol Rev 27 (3):
366–83. doi:10.1016/j.cpr.2006.12.004. PMID 17240502.
 Marsh R, Maia TV, Peterson BS (June 2009). "Functional disturbances within
frontostriatal circuits across multiple childhood psychopathologies". Am J Psychiatry 166
(6): 664–74. doi:10.1176/appi.ajp.2009.08091354. PMC 2734479. PMID 19448188.
 Rachman S (December 2007). "Unwanted intrusive images in obsessive compulsive
disorders". J Behav Ther Exp Psychiatry 38 (4): 402–10.
doi:10.1016/j.jbtep.2007.10.008. PMID 18054779.
 38

 Yorulmaz O, Gençöz T, Woody S (April 2009). "OCD cognitions and symptoms in

different religious contexts". J Anxiety Disord 23 (3): 401–6.
doi:10.1016/j.janxdis.2008.11.001. PMID 19108983.

Anxiety disorder: Obsessive–compulsive disorder (F42, 300.3)

 Yale–Brown Obsessive Compulsive Scale

History

 Basal ganglia (striatum)

 Orbitofrontal cortex
Neuroanatomy  Cingulate cortex
 Brain-derived neurotrophic factor

 5-HT1Dβ
 5-HT2A
Biology  5-HT2C
 μ Opioid
 H2
Receptors
 NK1
 M4
 NMDA
 non-NMDA

 Obsessions (associative
 diagnostic
 injurious
 scrupulous
 pathogenic
 sexual)
Symptoms
 Compulsions (impulses, rituals
 tics)
 Thought suppression (avoidance)
 Hoarding (animals, books
 possessions)

 Escitalopram
 Fluoxetine
Selective  Fluvoxamin
serotonin  Paroxetine
Treatment Serotonergics reuptake  Sertraline
inhibitors  Citalopram
 Nefazodone

Serotonin-  Venlafaxine
 39

norepinephrine  Desvenlafaxine
reuptake  Duloxetine
inhibitors
Monoamine  Phenelzine
oxidase  Tranylcypromine
inhibitors
Tricyclic  Clomipramine
antidepressants
 Lysergic acid diethylamide
Serotonergic
 Psilocin
psychedelics

 Inositol
Nootropics

 Hydrocodone
 Morphine
Mu opioidergics
 Tramadol

 Diphenhydramine
Anticholinergics

NMDA  Riluzole
glutamatergics
NK-1  Aprepitant
tachykininergics
 Nicotine
 Memantine
Other
 Tautomycin

 Cognitive behavioral therapy (Exposure and response

Behavioral prevention)

 OCD Action
Organizations

 Edna B. Foa
 Stanley Rachman
 Adam S. Radomsky
Notable
 Jeffrey M. Schwartz
people
 Susan Swedo
 Emily Colas

 Matchstick Men
Popular
Literature/Comics Fictional  O.C. & Dee
culture
 Plyushkin
 40

 Xenocide

 Everything in Its Place

Nonfiction  Just Checking

 As Good as It Gets
 The Aviator
 Matchstick Men
Media
 Adrian Monk
 Sheldon Cooper

 Obsessive–compulsive personality disorder

 Obsessional jealousy
 Primarily Obsessional OCD
Related  Relationship obsessive–compulsive disorder
 Social anxiety disorder
 Tourette syndrome

This page was last modified on 22 May 2014 at 12:14.

Primarily Obsessional OCD

Primarily Obsessional Obsessive-Compulsive Disorder (also commonly called
Purely Obsessional OCD, Pure-O, OCD without overt compulsions or with
covert compulsions)[1] is a lesser-known form or manifestation of OCD. For
people with primarily obsessional OCD, there are fewer observable compulsions,
compared to those commonly seen with the typical form of OCD (checking,
counting, hand-washing etc.). While ritualizing and neutralizing behaviors do take
place, they are mostly cognitive in nature, involving mental avoidance and
excessive rumination.[2] Primarily obsessional OCD often takes the form of horrific
intrusive thoughts of a distressing or violent nature.

Common themes
Primarily obsessional OCD has been called "one of the most distressing and
challenging forms of OCD."[3] People with this form of OCD have "distressing and
unwanted thoughts pop into [their] head frequently", and the thoughts "typically
center on a fear that you may do something totally uncharacteristic of yourself,
 41

something ...potentially fatal...to yourself or others."[4] The thoughts "quite likely,

are of an aggressive or sexual nature."[5]

The nature and type of primarily obsessional OCD varies greatly, but the central
theme for all sufferers is the emergence of a disturbing intrusive thought or
question, an unwanted/inappropriate mental image, or a frightening impulse that
causes the person extreme anxiety because it is antithetical to closely held religious
beliefs, morals, or societal mores.[6] The fears associated with primarily
obsessional OCD tend to be far more personal and terrifying for the sufferer than
what the fears of someone with traditional OCD may be. Pure-O fears usually
focus on self-devastating scenarios that the sufferer feels would ruin their life or
the lives of those around them. An example of this difference could be that
someone with traditional OCD is overly concerned or worried about security or
cleanliness. While this is still distressing, it is not to the same level as someone
with Pure-O, who may be terrified that they have undergone a radical change in
their sexuality (i.e.: might be or might have changed into a pedophile), that they
might be a murderer or that they might cause any form of harm to a loved one or
an innocent person, or to themselves, or that they will go insane.

They will understand that these fears are unlikely or even impossible but the
anxiety felt will make the obsession seem real and meaningful. While those
without primarily obsessional OCD might instinctively respond to bizarre intrusive
thoughts or impulses as insignificant and part of a normal variance in the human
mind, someone with Pure-O will respond with profound alarm followed by an
intense attempt to neutralize the thought or avoid having the thought again. The
person begins to ask themselves constantly "Am I really capable of something like
that?" or "Could that really happen?" or "Is that really me?" (even though they
usually realize that their fear is irrational, which causes them further distress)[7] and
puts tremendous effort into escaping or resolving the unwanted thought. They then
end up in a vicious cycle of mentally searching for reassurance and trying to get a
definitive answer.[2][8]

Common intrusive thoughts/obsessions include themes of:

 Responsibility: with an excessive concern over someone's well-being

marked specifically by guilt over believing they have harmed or might harm
someone, either on purpose or inadvertently.[9]
 Sexuality: including recurrent doubt over one's sexual orientation (also
called HOCD or "homosexual OCD"). People with this theme display a very
different set of symptoms than those actually experiencing an actual crisis in
 42

sexuality. One major difference is that people who have HOCD report being
attracted sexually towards the opposite sex prior to the onset of HOCD,
while homosexual people whether in the closet or repressed have always had
such same sex attractions for lifelong.[10] The question "Am I gay" takes on a
pathological form. Many people with this type of obsession are in healthy
and fulfilling romantic relationships, either with members of the opposite
sex, or the same sex (in which case their fear would be "Am I
straight?").[6][11][12]
 Violence: which involves a constant fear of violently harming oneself or
loved ones or persistent worry that one is a pedophile and might harm a
child.[11][13] Subjects who are fearful they might be pedophiles often
incorrectly refer to themselves with the term "POCD" to mean "pedophile-
OCD."
 Religiosity: manifesting as intrusive thoughts or impulses revolving around
blasphemous and sacrilegious themes.[13][14]
 Health: including consistent fears of having or contracting a disease
(different from hypochondriasis) through seemingly impossible means (for
example, touching an object that has just been touched by someone with a
disease) or mistrust of a diagnostic test.[13][14]
 Relationship obsessions (ROCD): in which someone in a romantic
relationship endlessly tried to ascertain the justification for being or
remaining in that relationship. It includes obsessive thoughts to the tune of
"How do I know this is real love?" "How do I know he/she is the one?" "Am
I attracted enough to this person?" or "Am I in love with this person, or is it
just love?" "Does he/she really love me?" and/or obsessive preoccupation
with the perceived flaws of the intimate partner. [15][16] The agony of
attempting to arrive at certainty leads to an intense and endless cycle of
anxiety because it is impossible to arrive at a definite answer.[17]

Diagnosis and treatment

Those suffering from primarily obsessional OCD might appear normal and high-
functioning, yet spend a great deal of time ruminating, trying to solve or answer
any of the questions that cause them distress.[2][6]

For example, an intrusive thought "I could just kill Bill with this steak knife" is
followed by a catastrophic misinterpretation of the thought, i.e. "How could I have
such a thought? Deep down, I must be a psychopath."[18] This might lead a person
to continually surf the web, reading numerous articles on defining psychopathy.
This reassurance-seeking ritual will, ironically, provide no further clarification and
 43

could exacerbate the intensity of the search for the answer. There are numerous
corresponding cognitive biases present, including thought-action fusion, over-
importance of thoughts, and need for control over thoughts.[18]

Despite how real and imposing the intrusive thoughts may be to an individual, the
sufferer will probably never carry out actions related to these thoughts, even if one
believes themselves capable of doing so. One of the reasons for this is because the
person in question will go to extreme lengths to avoid circumstances which could
trigger their intrusive thoughts.

The disorder is particularly easy to miss by many well-trained clinicians, as it

closely resembles markers of generalized anxiety disorder and does not include
observable, compulsive behaviors. Clinical "success" is reached when the Pure-O
sufferer becomes indifferent to the need to answer the question. While many
clinicians will mistakenly offer reassurance and try to help their patient achieve a
definitive answer (an unfortunate consequence of therapists treating primarily
obsessional OCD as generalized anxiety disorder), this method only contributes to
the intensity or length of the patient's rumination, as the neuropathways of the
OCD brain will predictably come up with creative ways to "trick" the person out of
reassurance, negating any temporary relief and perpetuating the cycle of obsessing.

The most effective treatment for primarily obsessional OCD appears to be

Cognitive-Behavioral Therapy.[19] More specifically exposure and response
prevention (ERP) as well as Cognitive Therapy (CT)[19][20] which may or may not
be combined with the use of medication, such as SSRIs.[2][21][22] People suffering
from OCD without overt compulsions are considered by some [23] researchers[24]
more refractory towards ERP compared to other OCD sufferers[24] and therefore
ERP can prove less successful than CT.[23]

Exposure and response prevention (ERP) of Pure-O is theoretically based on the

principles of classical conditioning and extinction. The spike often presents itself
as a paramount question or disastrous scenario. A response that answers the spike
in a way that leaves ambiguity is sometimes warranted. "If I don't remember what I
had for breakfast yesterday my mother will die of cancer!" Using the antidote
procedure, a cognitive response would be one in which the subject accepts this
possibility and is willing to take the risk of his mother dying of cancer or the
question recurring for eternity. No effort is expended in directly answering the
question in an effort to find resolution. In another example, the spike would be,
"Maybe I said something offensive to my boss yesterday." A recommended
response would be, "Maybe I did. I'll live with the possibility and take the risk he'll
 44

fire me tomorrow." Using this procedure, it is imperative that the distinction be

made between the therapeutic response and rumination. The therapeutic response
does not seek to answer the question but to accept the uncertainty of the unsolved
dilemma.[25]

Acceptance and commitment therapy (ACT) is a newer approach that also is used
to treat POCD as well as other mental disorders (anxiety, depression etc.)

Notes and references

1. Hyman, Bruce and Troy DeFrene. Coping with OCD. 2008. New Harbinger Publications.
Page 64.
2. Obsessive compulsive disorder By Frederick M. Toates, Olga Coschug-Toates, 2nd
Edition 2000, Pages 111-128
3. Hyman, Bruce and Troy DeFrene. Coping with OCD. 2008. New Harbinger Publications.
4. Hyman, Bruce and Troy DeFrene. Coping with OCD. 2008. New Harbinger Publications.
5. Hyman, Bruce and Troy DeFrene. Coping with OCD. 2008. New Harbinger Publications.
6. The OCD workbook By Bruce M. Hyman, Cherry Pedrick, Pages 16-23
7. Obsessive compulsive disorder By Frederick M. Toates, Olga Coschug-Toates, 2nd
Edition 2000, Pages 94-96
8. The American Psychiatric Publishing textbook of psychiatry, By Robert E. Hales, Stuart
C. Yudofsky, Glen O. Gabbard, American Psychiatric Publishing, includes Purely
Obsessional OCD in its definition of O.C.D.
9. http://www.ocdonline.com/articlephillipson2.php
10. http://www.neuroticplanet.com/hocd.php
11. Obsessive-compulsive related disorders By Eric Hollander, pages 140-146
12. Homosexuality Anxiety: A Misunderstood Form of OCD
http://www.brainphysics.com/research/HOCD_Williams2008.pdf
13. Akhtar, S., Wig, NA, Verma, VK, Pershad, D., & Verma, SK A phenomenological
analysis of symptoms in obsessive-compulsive neurosis. 1975
14. Use of factor analysis to detect potential phenotypes in obsessive-compulsive disorder,
Psychiatry Research, Volume 128, Issue 3, Pages 273-280 D.Denys, F.de Geus, H.van
Megen, H.Westenberg
15. Doron, Guy; Derby, D., Szepsenwol. O., & Talmor. D. (2012). "Flaws and All: Exploring
Partner-Focused Obsessive-Compulsive Symptoms". Journal of Obsessive-Compulsive
and Related Disorders 1 (1): 234–243. doi:10.1016/j.jocrd.2012.05.004.
16. Doron, Guy; Derby, D., Szepsenwol. O., & Talmor. D. (2012). "Tainted Love: exploring
relationship-centered obsessive compulsive symptoms in two non-clinical cohorts".
Journal of Obsessive-Compulsive and Related Disorders 1 (1): 16–24.
doi:10.1016/j.jocrd.2011.11.002.
17. How Relationship Substantiation can Jeopardize your Romantic Life
http://www.obsessivecompulsions.com/rocd
18. The Treatment of Obsessions by Stanley Rachman. Oxford University Press, New York,
N.Y., 2003 Reviewed by Dean McKay, Ph.D., A.B.P.P. Fordham University, Bronx,
New York
 45

19. Concepts and Controversies in Obsessive-Compulsive Disorder Source: Springer

Science, Business Media Author(s): Abramowitz, Jonathan S.; Houts, Arthur C.
20. G.S. Steketee, R.O. Frost, J. Rhéaume and S. Wilhelm, Cognitive theory and treatment of
obsessive-compulsive disorder. In: MA Jenike, L Baer and WE Minichiello (Eds.),
Obsessive-Compulsive Disorder: Theory and Management. (3rd ed., pp 368-399)
Chicago: Mosby.
21. http://www.ocdonline.com/definecbt.php
22. Understanding and Treating Obsessive-Compulsive Disorder: A Cognitive Behavioral
Approach, Lawrence Erlbaum Associates, Inc.; 1 edition (September 2, 2005)
23. Purdon, C.A. & Clark, D.A. (2005). Overcoming Obsessive Thoughts: How to gain
control of your OCD. Oakland, CA: New Harbinger.
24. Obsessive Compulsive Disorder Research, By B. E. Ling, 2005. Nova Science Pub Inc.
Page 128
25. http://www.ocdonline.com/articlephillipson1.php/

Books
 The Imp of the Mind: Exploring the Silent Epidemic of Obsessive Bad Thoughts by Lee
Baer, Ph.D.
 The Treatment of Obsessions (Medicine) by Stanley Rachman. Oxford University Press,
2003
 Brain lock: Free yourself from obsessive-compulsive behavior: A four-step self-treatment
method to change your brain chemistry by Jeffrey Schwartz and Beverly Beyette. New
York: Regan Books, 1997. ISBN 0-06-098711-1.
 The OCD Workbook by Bruce Hyman and Cherry Pedrick.

Anxiety disorder: Obsessive–compulsive disorder (F42, 300.3)

 Yale–Brown Obsessive Compulsive Scale

History

 Basal ganglia (striatum)

 Orbitofrontal cortex
Neuroanatomy  Cingulate cortex
 Brain-derived neurotrophic factor

 5-HT1Dβ
Biology  5-HT2A
 5-HT2C
 μ Opioid
Receptors
 H2
 NK1
 M4
 NMDA
 46

 non-NMDA

 Obsessions (associative
 diagnostic
 injurious
 scrupulous
 pathogenic
 sexual)
Symptoms
 Compulsions (impulses, rituals
 tics)
 Thought suppression (avoidance)
 Hoarding (animals, books
 possessions)

 Escitalopram
 Fluoxetine
Selective  Fluvoxamin
serotonin  Paroxetine
reuptake  Sertraline
inhibitors  Citalopram
 Nefazodone

Serotonin-  Venlafaxine
norepinephrine  Desvenlafaxine
reuptake  Duloxetine
Serotonergics inhibitors
Monoamine  Phenelzine
oxidase  Tranylcypromine
Treatment inhibitors
Tricyclic  Clomipramine
antidepressants
 Lysergic acid diethylamide
Serotonergic
 Psilocin
psychedelics

 Inositol
Nootropics

 Hydrocodone
 Morphine
Mu opioidergics
 Tramadol

 Diphenhydramine
Anticholinergics
 47

NMDA  Riluzole
glutamatergics
NK-1  Aprepitant
tachykininergics
 Nicotine
 Memantine
Other
 Tautomycin

 Cognitive behavioral therapy (Exposure and response

Behavioral prevention)

 OCD Action
Organizations

 Edna B. Foa
 Stanley Rachman
 Adam S. Radomsky
Notable
 Jeffrey M. Schwartz
people
 Susan Swedo
 Emily Colas

 Matchstick Men
 O.C. & Dee
Fictional  Plyushkin
 Xenocide
Literature/Comics
 Everything in Its Place
Popular Nonfiction  Just Checking
culture
 As Good as It Gets
 The Aviator
 Matchstick Men
Media
 Adrian Monk
 Sheldon Cooper

 Obsessive–compulsive personality disorder

 Obsessional jealousy
 Primarily Obsessional OCD
Related  Relationship obsessive–compulsive disorder
 Social anxiety disorder
 Tourette syndrome

This page was last modified on 15 May 2014 at 20:56.

 48

Compulsive behavior

Dermatophagia - extreme nail biting / biting of skin to point of an obsessive

compulsive disorder (OCD) or other condition leading to self mutilating behaviour
such as autistic spectrum disorders (as is the case in this example) or Lesch-Nyhan
Syndrome.

Compulsive behavior is defined as performing an act persistently and repetitively

without it leading to an actual reward or pleasure.[1] Compulsive behaviors could
be an attempt to make obsessions go away.[2] The act is usually a small, restricted
and repetitive behavior, yet not disturbing in a pathological way. [1] Compulsive
behaviors are a need to reduce apprehension caused by internal feelings a person
wants to abstain or control.[3] A major cause of the compulsive behaviors is said to
be obsessive–compulsive disorder (OCD).[2] The main idea of compulsive behavior
is that the likely excessive activity is not connected to the purpose it appears to be
directed to.[1] Also, as well as being associated with obsessive–compulsive
disorder,[4] Furthermore, there are many different types of compulsive behaviors
including, shopping, hoarding, eating, gambling, trichotillomania and picking skin,
checking, counting, washing, sex, and more. Also, there are cultural examples of
compulsive behavior.

Disorders it is seen in
The most well-known disorder that is associated with compulsive behavior is
obsessive–compulsive disorder. It is defined as both a brain and behavior disorder,
characterized by having obsessions and compulsions. These cause extreme anxiety
in most cases.[5] The most common compulsions for people suffering from OCD
are washing, and checking.[4]

Another type of compulsive behavior disorder is compulsive sexual behavior; also

known as hypersexuality or nymphomania in females, and satyriasis in males.[6]
 49

For people with this, sex becomes an obsession, and sometimes involves fantasies
or different sexual experiences that are outside accepted norms.[7] These sexual
behaviors are known as paraphilias.[8]

Types
Shopping

Compulsive shopping is characterized by excessive shopping that causes

impairment in a person’s life such as financial issues or not being able to commit
to a family. The prevalence rate for this compulsive behavior is 5.8% worldwide,
and a majority of the people that suffer from this type of behavior are women
(approximately 80%). There is no proven treatment for this type of compulsive
behavior.[9]

Hoarding

Compulsive hoarding

Hoarding is characterized by excessive saving of possessions and having problems

when throwing these belongings away. Major features of hoarding include not
being able to use living quarters in the capacity of which it is meant, having
difficulty moving throughout the home due to the massive amount of possessions,
as well as having blocked exits that can pose a danger to the hoarder and their
family and guests. Items that are typically saved by hoarders include clothes,
newspapers, containers, junk mail, books, and craft items. Hoarders believe these
items will be useful in the future or they are too sentimental to throw away. Other
reasons include fear of losing important documents and information and object
characteristics.[10]
 50

Eating

Compulsive overeating has the characteristics of eating without being able to

control intake and due to this gaining weight becomes problematic. This overeating
is usually a coping mechanism to deal with issues in the individual’s life such as
stress. Most compulsive over-eaters know that what they are doing is an issue. This
compulsive behavior usually develops in early childhood. People that struggle with
compulsive eating usually do not have proper coping skills to deal with the issues
that are causing them to indulge in food to this extent. These binges usually are
accompanied by feelings of guilt and shame of handling the situation by
overindulgence in food. This is a compulsive behavior that can have deadly side
effects. Side effects include, but are not limited to, binge eating; depression;
withdrawal from activities due to weight; and spontaneous dieting. Though this is a
very serious compulsive behavior, getting treatment and a proper diet plan can help
individuals overcome these behaviors.[11]

Gambling

Compulsive gambling is characterized by having the desire to gamble and not

being able to resist said desires. The gambling leads to serious personal and social
issues in the individual’s life. This compulsive behavior usually begins in early
adolescence for men and between the ages of 20-40 for women. People that have
issues controlling compulsions to gamble usually have an even harder time
resisting when they are having a stressful time in life. People that gamble
compulsively tend to run into issues with family members, the law, and the places
and people they gamble with. The majority of the issues with this compulsive
behavior are due to lack of money to continue gambling or pay off debt from
previous gambling. Compulsive gambling can be helped with various forms of
treatment such as Cognitive Behavioral Therapy, Self-help or Twelve-step
programs, and potentially medication.[12]

Trichotillomania and skin picking

Trichotillomania is classified as compulsive picking of hair of the body. It can be

from any place on the body that has hair. This picking results in bald spots. Most
people that have mild Trichotillomania can overcome it via concentration and more
self-awareness.[13]

Those that suffer from compulsive skin picking have issues with picking, rubbing,
digging, or scratching the skin. These activities are usually to get rid of unwanted
blemishes or marks on the skin. These compulsions also tend to leave abrasions
 51

and irritation on the skin. This can lead to infection or other issues in healing.
These acts tend to be prevalent in times of anxiety, boredom, or stress.[14]

Checking, counting, repeating, and washing

Compulsive checking can include compulsively checking items such as locks,

switches, and appliances. This type of compulsion usually deals with checking
whether harm to oneself or others is possible. Usually, most checking behaviors
occur due to wanting to keep others and the individual safe.[15]

People that suffer from compulsive counting tend to have a specific number that is
of importance in the situation they are in. When a number is considered significant,
the individual has a desire to do the behavior such as wiping ones face off the
number of times that is significant. Compulsive counting can include instances of
counting things such as steps, items, behaviors, and mental counting.[16]

Compulsive repeating is characterized by doing the same activity multiple times

over. These activities can include re-reading a part of a book multiple times, re-
writing something multiple times, repeating routine activities, or saying the same
phrase over and over.[17]

Compulsive washing is usually found in individuals that have a fear of

contamination. People that have compulsive hand washing behaviors wash their
hands repeatedly throughout the day. These hand washings can be ritualized and
follow a pattern. People that have problems with compulsive hand washing tend to
have problems with chapped or red hands due to the excessive amount of washing
done each day.[18]

Sexual behavior

This type of compulsive behavior is characterized by feelings, thoughts, and

behaviors about anything related to sex. These thoughts have to be pervasive and
cause problems in health, occupation, socialization, or other parts of life. These
feelings, thoughts, and behaviors can include normal sexual behaviors or behaviors
that are considered illegal and/or morally and culturally unacceptable. This
disorder is also known as hypersexuality, hypersexual disorder, nymphomania or
sexual addiction.[7]
 52

Talking

Compulsive talking goes beyond the bounds of what is considered to be a socially

acceptable amount of talking.[19] The two main factors in determining if someone is
a compulsive talker are talking in a continuous manner, only stopping when the
other person starts talking, and others perceiving their talking as a problem.
Personality traits that have been positively linked to this compulsion include
assertiveness, willingness to communicate, self-perceived communication
competence, and neuroticism.[20] Studies have shown that most people who are
talkaholics are aware of the amount of talking they do, are unable to stop, and do
not see it as a problem.[21]

Cultural examples
 Lady Macbeth was obliged by her guilt feelings to repetitively wash her hands.[22]
 Samuel Johnson was compelled to obsessively count steps and stairs.[23]
 Len Deighton in his brainwashing thriller The IPCRESS File noted the relative immunity
to it of compulsive checkers: "people who go back twice to make sure the door is locked,
who walk down the street avoiding the joins in the paving, then become sure they've left
the kettle on. They are difficult to hypnotize and difficult to brain-wash".[24]

References
1. http://www.definitions.net/definition/compulsive behavior
2. "Obsessive-Compulsive Disorder (OCD): Symptoms, Behavior, and Treatment".
Helpguide.org. Retrieved 2013-11-29.
3. "Addictive Behaviors, Compulsions and Habits". Umass.edu. Retrieved 2013-11-29.
4. (1996). Obsessive Compulsive Disorder: Decade of the Brain. National Institutes of
Health.
5. "International OCD (Obsessive Compulsive Disorder) Foundation - What Is OCD?".
Ocfoundation.org. Retrieved 2013-11-29.
6. "What Is Sexual Addiction (Compulsive Sexual Behavior)? What Causes Sexual
Addiction?". Medical News Today. Retrieved 2013-11-29.
7. "Compulsive sexual behavior". MayoClinic.com. 2011-09-15. Retrieved 2013-11-29.
8. Lia Stannard. "Compulsive Behavior Signs & Symptoms". Livestrong.Com. Retrieved
2013-11-29.
9. USA (2013-08-12). "A review of compulsive buying disorder". Ncbi.nlm.nih.gov.
Retrieved 2013-11-29.
10. "International OCD Foundation (IOCDF) - Hoarding Center". Ocfoundation.org.
Retrieved 2013-11-29.
11. "Compulsive Eating". Mirror-mirror.org. 2013-01-24. Retrieved 2013-11-29.
12. USA. "Pathological gambling - National Library of Medicine - PubMed Health".
Ncbi.nlm.nih.gov. Retrieved 2013-11-29.
 53

13. "What Is Hair Pulling? | About Hair Pulling & Skin Picking | Trichotillomania Learning
Center". Trich.org. Retrieved 2013-11-29.
14. "What Is Skin Picking? | About Hair Pulling & Skin Picking | Trichotillomania Learning
Center". Trich.org. Retrieved 2013-11-29.
15. "Compulsive Checking in OCD". OCD Types. Retrieved 2013-11-29.
16. "Counting Compulsions". OCD Types. Retrieved 2013-11-29.
17. "Repeating". OCD Types. Retrieved 2013-11-29.
18. "Washing and Cleaning Compulsions". OCD Types. Retrieved 2013-11-29.
19. Bostrom, Robert N.; Grant Harrington, Nancy (1999). "An Exploratory Investigation Of
Characteristics Of Compulsive Talkers". Communication Education 48.1: 73–80.
20. McCroskey, James C.; Richmond, Virginia P. (1993). "Identifying Compulsive
Communicators: The Talkaholic Scale". Communication Research Reports 10.2: 107–
114.
21. Walther, Joseph B. (Aug 1999). "Communication Addiction Disorder: Concern over
Media, Behavior and Effects". Psych Central. Retrieved 21 Oct 2012.
22. S. K. Mangal, Abnormal Psychology (2008) p. 127
23. Juan, p. 160-1
24. Len Deighton, The IPCRESS File (1976) p. 211

Further reading
 Sandor Ferenczi, 'The Compulsion to Symmetrical Touching', Further Contributions to
the Theory and Technique of Psychoanalysis (1926)
 A. J. Lewis, 'Obsessional Illnes', in Inquiries in Psychiatry (1967)
 Rob Long, Obsessive Compulsive Disorder (2005)
 Lennard J. Davis, Obsession; A History (2008)

Anxiety disorder: Obsessive–compulsive disorder (F42, 300.3)

 Yale–Brown Obsessive Compulsive Scale

History

 Basal ganglia (striatum)

 Orbitofrontal cortex
Neuroanatomy  Cingulate cortex
 Brain-derived neurotrophic factor

Biology  5-HT1Dβ
 5-HT2A
 5-HT2C
Receptors  μ Opioid
 H2
 NK1
 M4
 54

 NMDA
 non-NMDA

 Obsessions (associative
 diagnostic
 injurious
 scrupulous
 pathogenic
 sexual)
Symptoms
 Compulsions (impulses, rituals
 tics)
 Thought suppression (avoidance)
 Hoarding (animals, books
 possessions)

 Escitalopram
 Fluoxetine
Selective  Fluvoxamin
serotonin  Paroxetine
reuptake  Sertraline
inhibitors  Citalopram
 Nefazodone

Serotonin-  Venlafaxine
norepinephrine  Desvenlafaxine
reuptake  Duloxetine
Serotonergics inhibitors
Monoamine  Phenelzine
oxidase  Tranylcypromine
Treatment inhibitors
Tricyclic  Clomipramine
antidepressants
 Lysergic acid diethylamide
Serotonergic
 Psilocin
psychedelics

 Inositol
Nootropics

 Hydrocodone
 Morphine
Mu opioidergics
 Tramadol

 Diphenhydramine
Anticholinergics
 55

NMDA  Riluzole
glutamatergics
NK-1  Aprepitant
tachykininergics
 Nicotine
 Memantine
Other
 Tautomycin

 Cognitive behavioral therapy (Exposure and response

Behavioral prevention)

 OCD Action
Organizations

 Edna B. Foa
 Stanley Rachman
 Adam S. Radomsky
Notable
 Jeffrey M. Schwartz
people
 Susan Swedo
 Emily Colas

 Matchstick Men
 O.C. & Dee
Fictional  Plyushkin
 Xenocide
Literature/Comics
 Everything in Its Place
Popular Nonfiction  Just Checking
culture
 As Good as It Gets
 The Aviator
 Matchstick Men
Media
 Adrian Monk
 Sheldon Cooper

 Obsessive–compulsive personality disorder

 Obsessional jealousy
 Primarily Obsessional OCD
Related  Relationship obsessive–compulsive disorder
 Social anxiety disorder
 Tourette syndrome

This page was last modified on 1 May 2014 at 00:46.

 56

Cause of obsessive-compulsive disorder

The cause of obsessive-compulsive disorder is concerned with identifying the
biological risk factors involved in the expression of obsessive-compulsive disorder
(OCD) symptomology. The leading hypotheses propose the involvement of the
orbitofrontal cortex, basal ganglia, and/or the limbic system, with discoveries being
made in the fields of neuroanatomy, neurochemistry, neuroimmunology,
neurogenetics, and neuroethology.

Neuroanatomy
Although there has been substantial debate regarding the assessment of OCD,
current research has gravitated toward structural and functional neuroimaging.
These technological innovations have provided a better understanding of the
neuroanatomical risk factors of OCD. These studies can be divided into four basic
categories: (1) resting studies that compare brain activity at rest in patients with
OCD to controls, (2) symptom provocation studies that compare brain activity
before and after incitement of symptoms, (3) treatment studies that compare brain
activity before and after treatment with pharmacotherapy, and (4) cognitive
activation studies that compare brain activity while performing a task in patients
with OCD to controls.[1]

Data obtained from this research suggests that three brain areas are involved with
OCD: the orbitofrontal cortex (OFC), the anterior cingulate cortex (ACC), and the
head of the caudate nucleus.[2] Several studies have found that in patients with
OCD, these areas: (1) are hyperactive at rest relative to healthy control; (2) become
increasingly active with symptom provocation; and (3) no longer exhibit
hyperactivity following successful treatment with SRI pharmacotherapy or
cognitive-based therapy.[3] This understanding is frequently cited as evidence that
abnormality in these neuroanatomical regions may cause OCD.

The OFC and ACC are intricately connected to the basal ganglia via the cortico—
basal ganglia—thalamocortical (CBGTC) loops.[4] Current theories suggests that
OCD may be the result of an imbalance between the “direct” and “indirect”
pathways through the basal ganglia. The direct pathways are described as running
from the cortex to the striatum, then to the globus pallidus internal segment (GPi)
and substantia nigra pars reticulate (SNr), then to the thalamus, and finally back to
the cortex. The indirect pathways are described as running from the cortex to the
striatum, then to the globus pallidus external segment (GPe), the subthalamic
 57

nucleus (STN), the GPi and SNr, then thalamus, and finally back to the cortex.[5]
While the net effect of the direct pathway is excitatory, the net effect of the indirect
pathway is inhibitory. Thus, it has been hypothesized that excessive relative
activity in the direct pathway in OFC/ACC CBGTC loops may result in a positive
feedback loop whereby obsessive thoughts are trapped.[6] Although structural and
functional neuroimaging studies have provided a strong basis for this supposition,
it is still unclear why patients with OCD develop specific obsessions instead of a
generalized obsessive behavior towards everything. While researchers have
suggested that a response bias exists toward particular stimuli, such as
contamination, the underlying cause is still unclear.[7]

Neurochemistry
While there seems to be a ubiquitous understanding that neurochemical
functioning is responsible for mediating the symptoms of OCD, recent
psychopharmacologic studies have found that the serotonin (5-HT)
neurotransmitter system plays a particularly critical role.[8] In comparison to
healthy controls, the long-term administration of selective serotonin reuptake
inhibitors (SSRIs) have been found to be more effective than noradrenergic
reuptake inhibitors in the treatment of OCD.[9] For example, Rapoport et al.
demonstrated that clomipramine was more effective than desipramine in
decreasing several types of repetitive behavior.[10] Research has also shown that the
administration of 5-HT antagonists often exacerbates symptoms of OCD.[11] While
these findings do not provide an explicit cause, they do set the stage for the notion
that psychiatric conditions can be dissected pharmacologically. Thus, the efficacy
in controlling obsessions and compulsions with SSRIs suggests that OCD has an
underlying neurochemical etiology.

Neuroimmunology
Henrietta Leonard and Susan Swedo provide evidence for neuroimmunological
risk factors in their article, “Paediatric autoimmune neuropsychiatric disorders
associated with streptococcal infection (PANDAS).[12]” The researchers suggest
that post-streptococcal autoimmunity may be a potential environmental cause of
childhood onset OCD. In the 1980s, a large cohort of children with OCD was
being evaluated prospectively. Following a streptococcal infection, a subgroup of
children expressed OCD symptom exacerbations that were characterized as
“coming on overnight.[13]” The primary hypothesis derived from this study is that
that in some cases, OCD may develop as a consequence of an autoimmune reaction
 58

in which antibodies to streptococcal infections attack and damage the basal

ganglia.

Obsessions and compulsions are also very common in several other medical
conditions, including: Tourette syndrome, Parkinson disease, epilepsy,
schizophrenia, Huntington disease, encephalitis lethargica, Sydenham chorea, and
damage to specific brain regions.[14] Similar to OCD, these disorders also exhibit
abnormalities in the basal ganglia. This portion of the brain is responsible for
mediating cognition, emotion, and movement. Disruption of the basal ganglia
results in a host of symptoms that are characterized by compulsivity (behavioral
patterns that are released repeatedly) and impulsivity (behavioral patterns that are
released suddenly by various stimuli).[15] This suggests that in patients with OCD,
the disorder may be the result of abnormal functioning of the basal ganglia.

Neurogenetics
Psychologists have suspected the influence of genetic factors for OCD since the
beginning of the twentieth century. Research studies have reported that nearly 37%
of parents and 21% of siblings of patients with OCD exhibit obsessive-compulsive
symptoms.[16] The Hopkins family study found that the prevalence of OCD in first-
degree relatives was approximately 11.7%, while the occurrence in relatives of
controls was around 2.7%.[17] Additional family studies have reported prevalence
rates of OCD in first-degree relatives of adolescent probrands between 7% and
15%. Furthermore, twin studies have reported a concordance of 80% among
monozygotic (identical) twins and 50% among dizygotic twins. [18] While there are
always many different environmental and biological risk factors that place an
individual at a greater diathesis for expressing a disorder, current neurogenetic
research provides strong support for the speculation that OCD is a genetically
based condition.

Neuroethology
The vast monolith of psychiatric research has placed an emphasis on proximate
mechanisms as the cause for illness. In contrast, evolutionary theory has
engendered questions regarding how distal mechanisms may be implicated with
pathogenesis. OCD involves several behavioral schemata that may have been
preserved over evolutionary history. Numerous species have inherited cognitive
patterns that lend to checking for danger, avoiding contamination, and hoarding
food.[19] Theorists have hypothesized that a dysfunction in any of these strategies
could lead to the expression of OCD. This conjecture is further supported by
 59

evidence that such inherited, species-specific strategies are stored in the basal
ganglia.[20]

Lick granuloma from excessive licking

When considering the expression of OCD in non-human species, researchers have

studied acral lick dermatitis (also known as lick granuloma) in large canines. This
disorder is characterized by excessive licking or scratching that leads to alopecia
(hair loss) and subsequent granulomatous lesions (vascular tissue on the surface of
a wound).[21] Rapoport et al. found that this obsessive-compulsive behavior was
alleviated in afflicted canines after administering clomipramine.[22] Thus, it is
conceivable that evolutionary selected traits could become maladaptive proceeding
neurological dysfunction.

References
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compulsive disorder in children and adults. Development and Psychopathology, 1251-
1283.
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compulsive disorder in children and adults. Development and Psychopathology, 1251-
1283.
3. Whiteside, S.P., Port, J.D., & Abramowitz, J.S. (2004). A meta-analysis of functional
neuroimaging in obsessive-compuslive disorder. Psychiatry Research, 132, 69-79.
4. Alexander, G.E., DeLong, M. R., & Strick, P. L. (1986). Parallel organization of
functionally segregated circuits linking basal ganglia and cortex. Annual review of
Neuroscience, 9, 357-381.
 60

5. Saxena, S., & Rauch, S. L. (2000). Functional neuroimaging and the neuroanatomy of
obsessive-compulsive disorder. Psychiatric Clinics of North America, 23, 563-586.
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obsessive-compulsive disorder. Psychiatric Clinics of North America, 23, 563-586.
7. Sasson, Y., Zohar, J., Chopra, M., Lustig, M., Iancu, I., & Hendler, T. (1997).
Epidemiology of obsessive-compulsive disorder. Seminars in Clinical Neuropsychiatry,
6, 82-101
8. Zohar, J. (1987). Obsessive-compulsive disorder: psychobiological approaches to
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animal model of obsessive-compulsive disorder. Archive of General Psychiatry, 49, 517-
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Neuropsychopharmacology (4), 191-198
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animal model of obsessive-compulsive disorder. Archive of General Psychiatry, 49, 517-
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22. Rapoport, J. L., Ryland, D. H., Kriete, M. (1992). Drug treatment of canine acral lick: an
animal model of obsessive-compulsive disorder. Archive of General Psychiatry, 49, 517-
521.

This page was last modified on 20 May 2014 at 22:06.