Obsessive Compulsive Disorder (OCD) is an anxiety disorder, first and foremost. It is not a thought disorder. Although the thoughts associated with OCD are bizarre, they are not at all the focal point of the therapeutic objective. The essential features of OCD are recurrent obsessions (thoughts) that create an awareness of alarm or threat. (e.g., "I might get AIDS from the germs on that door knob;" "Since I had the thought of killing my baby, I might be capable of doing it;" "If I don't pick up that Band-Aid someone else might get sick from it, and I would hold myself culpable;" etc.). Persons typically engage in some avoidance or escape response in reaction to the obsessive threat (I typically refer to the obsessive threat as a "spike."). Obsessions take the form of either a perceived threat of physical harm to oneself or others or, in some cases, more of a metaphysical or spiritual threat to oneself, others, or perhaps a deity. I conceptualize the overall syndrome of OCD to consist of three primary branches. Within all three branches, in approximately 80% of all cases, persons performing these rituals are painfully aware that their behavior is unreasonable and irrational (see Speak of the Devil). However this insight provides no relief. Therefore attempting to help sufferers through reassurance has no long lasting positive effect.
It is not unusual for people to question whether they might qualify for a diagnosis of OCD given that most of the following examples are not unlike what most of us do to a limited degree on an everyday basis. Everyday examples of OCD like behavior include using one's foot to flush a toilet, knocking on wood three times to ward of a bad omen, throwing salt over one's shoulder for a positive future, or feeling inspired to say "God forbid!" after mentioning the potential death of a living person. Simplistic tests to determine whether these behaviors cross the line into the OCD realm include asking yourself how much money it would take for you not to perform the safe behavior. Persons operating in the non-OCD realm would most likely accept between $10 to $100 to do something that would make them feel uncomfortable. Persons with OCD typically would not accept upwards in the neighborhood of $100,000 to face their feared concern. Another criterion involves the degree to life's disruption. We all have quirks that take up small bits of the day. Very often, people wrestling with OCD invest hours of their day avoiding these concerns. All of us periodically hear a song (typically a noxious one) repeat itself like a broken record, playing over and over again in our mind. For the great majority of us the repetitiousness of this becomes mildly annoying, for persons with OCD the intolerance and rejection of this mental experience generates a tremendous amount of agitation and anxiety over losing control of one's mind!
The most common and well-studied branch of OCD involves the OC where the undoing response generally involves some overt behavior. The most commonly thought of form of OCD involves contamination. Here an awareness of germs, disease, or the mere presence of dirt evokes a sense of threat and an incredible inspiration to reduce the presence of these contaminants. Most commonly the escape ritual involves a cleaning response (e.g., hand washing, chronic cleaning). The next most common form of OCD involves checking. Typically checking involves door locks, light switches, faucets, stoves or items that left unchecked might pose a risk to either one's well-being or the well-being of others. It is not at all uncommon for persons with this manifestation to check items between 10 to 100 times. The overwhelming impulse to recheck remains until the person experiences a reduction in tension despite the realization that the item is secure.
Less common forms of OCD include hoarding, which is the excessive saving of typically worthless items such as junk mail, or excessive purchasing of certain items (e.g., owning hundreds of pairs of shoes). Other typically hoarded items include garbage, novelty items, or magazines and newspapers. A common rationale given to justify obsessive-compulsive hoarding behavior is an overriding fear that one day these items might come in handy or be of some value and therefore must not be thrown away. Another subgroup of hoarders involves persons who become emotionally attached to the items or feel that these items hold some emotional significance that reflects a particular moment in time. The person feels that relinquishing the item is in some way tantamount to releasing a past experience or association with a significant other.
Ordering is a subcategory where persons feel compelled to place items in a designated spot or order. This person fears a sense of being overwhelmed and impending anarchy if items are not placed exactly as they are arbitrarily determined. Persons with this condition typically line up items in parallel locations, but the focus is on the concept that each item belongs in a particular place. Another form of OCD is perfectionism, in which persons feel compelled to habitually check for potential mistakes or errors that might reveal their own faults or might jeopardize the person's stature at work.
The next branch discussed will be the purely obsessional OC (Pure-O, see Thinking the Unthinkable ). The objective in this classification involves the escape or avoidance (through excessive mental behavior) of noxious and unwanted thoughts. In its most generic form, persons might have upsetting words or phrases repeated in their head, not unlike what most experience when an unpleasant song is played over and over in our mind without our active choice in it being there. Persons with the Pure-O classification also can experience what seems to them to be threatening ideation involving the potential that they might do harm to others or that merely the idea of having the threatening thought suggests something evil or depraved about their identity, capability, or self worth. This classification periodically also involves persons who engage in a tremendous amount of problem solving (also referred to as ruminating), as a ritual. Endless attempts to answer questions related to one's own sexual orientation or even something as simplistic as the name of one's third grade teacher might occupy endless hours of problem solving.
This classification also involves persons with a heightened sense of superstitiousness, in which, for example, certain numbers might take on a great significance related to positive or negative outcomes. Typically, positive numbers or perhaps the number "seven" involve a greater likelihood for safety or permission to proceed with a given task. Other numbers forewarn of something ominous about to happen. These persons typically engage in elaborate touching or counting rituals to ensure that the safe or desirable number is the one upon which the task or thought is to be ended. Superstitiousness need not be limited to numbers. The old quirky childhood games of avoiding cracks or walking under ladders takes on a significance beyond most people's ability to comprehend.
The last branch involves a somewhat more complex and difficult to treat form of OCD. That is responsibility OC (hyperscrupulosity). Here, the person's concern is not for themself, but directed toward the well-being of others. Typically, significant others (although sometimes society at large) are thought of as the predominant focus on which to prevent harm from coming. The responsibility OC might take on a Pure-O form such as getting a noxious thought that some harm might come to someone else. And the person might feel compelled to pray in a way to stave off that harm coming to another. Also the responsibility OC might engage in elaborate cleansing rituals to prevent others from receiving germs or diseases which he or she may be carrying, yet feels no fear for his own well-being. Persons with this form of OC often engage in warning others about possible risks or cleansing their environment of possible risks to others at large. Persons with responsibility OC often engage in excesses for another's distress or danger, so as not to be held culpable. The reason this form is particularly difficult to treat is the combination of anxiety in association with the risk and guilt at being responsible for adversity happening to others.
More obscure forms of OCD involve body dysmorphia. Body dysmorphia is a condition wherein persons become excessively focused on some body part, which they perceive to be grossly malformed. Typically, the area that a person with body dysmorphia focuses upon would never be thought of as a defect to others in the person's peer group. Persons with body dysmorphia engage in elaborate checking rituals to try to gain reassurance or assess the severity of their deformity in the mirror or go for repeated plastic surgery or often engage others in the attempt to gain reassurance in the absence of the problem. Another obscure sub-classification of OCD involves an olfactory obsession in which persons are entrenched in the idea that some part of their body is emitting a noxious aroma. Typically, the areas that the person is convinced emits the noxious smell involve genitalia, breath, feet, or underarms.
The last form of OCD involves a preoccupation with the potential of having some physical malady, typically cancer or some life threatening disease. This condition continues to be referred to as hypochondriasis and exists in the DSM-IIIR as a separate disorder from OCD. However, like body dysmorphic disorder, the symptoms and endless search for reassurance fall completely under the diagnostic category of OCD.
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