Obsessive-Compulsive Disorder

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Obsessions are recurrent, intrusive thoughts, impulses, or images that are perceived as inappropriate, grotesque, or forbidden (DSM-IV). The obsessions, which elicit anxiety and marked distress, are termed “ego-alien” or “ego-dystonic” because their content is quite unlike the thoughts that the person usually has.

Obsessions are perceived as uncontrollable, and the sufferer often fears that he or she will lose control and act upon such thoughts or impulses. Common themes include contamination with germs or body fluids, doubts (i.e., the worry that something important has been overlooked or that the sufferer has unknowingly inflicted harm on someone), order or symmetry, or loss of control of violent or sexual impulses.

      Compulsions are repetitive behaviors or mental acts that reduce the anxiety that accompanies an obsession or “prevent” some dreaded event from happening (DSM-JV). Compulsions include both overt behaviors, such as hand washing or checking, and mental acts including counting or praying. Not uncommonly, compulsive rituals take up long periods of time, even hours, to complete. For example, repeated hand washing, intended to remedy anxiety about contamination, is a common cause of contact dermatitis.

      Although once thought to be rare, obsessive-compulsive disorder has now been documented to have a 1-year prevalence of 2.4 percent (Table 4-1).  Obsessive-compulsive disorder is equally common among men and women.     Obsessive-compulsive disorder typically begins in adolescence to young adult life (males) or in young adult life (females) (Burke et al., 1990; DSM-IV).  For most, the course is fluctuating and, like generalized anxiety disorder, symptom exacerbations are usually associated with life stress.

Common comorbidities include major depressive disorder and other anxiety disorders.  Approximately 20 to 30 percent of people in clinical samples with obsessive-compulsive disorder report a past history of tics, and about one-quarter of these people meet the full criteria for Tourette’ s disorder (DSM-JV). Conversely, up to 50 percent of people with Tourette’ s disorder develop obsessive-compulsive disorder (Pitman et al., 1987).

      Obsessive-compulsive disorder has a clear familial pattern and somewhat greater familial specificity than most other anxiety disorders. Furthermore, there is an increased risk of obsessive-compulsive disorder among first-degree relatives with Tourette’ s disorder. Other mental disorders that may fall within the spectrum of obsessive-compulsive disorder include trichotillomania (compulsive hair pulling), compulsive shoplifting, gambling, and sexual behavior disorders (Hollander, 1996). The latter conditions are somewhat discrepant because the compulsive behaviors are less ritualistic and yield some outcomes that are pleasurable or gratifying.

Body dysmorphic disorder is a more circumscribed condition in which the compulsive and obsessive behavior centers around a preoccupation with one’s appearance (i.e., the syndrome of imagined ugliness) (Phillips, 1991).