Obsessive-compulsive disorders (OCD – TOC)
For me, speaking about the obsessive disorder is to speak about an old enemy I must defeat
I have faced it every day for over 34 years, usually present in one or many of my patients. This enemy hides easily among the symptoms exhibited by the patient, and shows the skill to distort them and lead to a treatment failure when it is not discovered timely and treated from the very beginning.
I consider it one of “the poor disorders” in mental health:
· The obsessional disorder isn’t even registered in the “Diccionario de la Real Academia Española de la Lengua”. The dictionary contains the word obsession, defined as “A mood impairment produced by a fixed idea, which attacks the mind with tenacious persistency.”
· In the Undergraduate School of Medicine this disorder is largely unmentioned. I don’t think its descriptions in the textbooks take more than a page.
· In the Primary Care consultations very few of these patients get a diagnosis and little is known about effective treatments.
· In Psychiatry until May 2013 it has been considered as a form of anxiety.
Hence my happiness when the DSM-5 acknowledges its significance
· In the DSM-IV (in use for 19 years, 1994-2013) the Obsessive Compulsive Disorder was listed as a form of anxiety.
· In the DSM-5 from May 2013 (Diagnostic and Statistical Manual of Mental Disorders-V) I was happy to see the Obsessive Compulsive Disorder listed as a group of disorders, like anxiety, depression, schizophrenia…And including many disorders (Table 1), previously distributed in other groups.
Key definitions for understanding the obsessive disorders:
When possible I will summarize and adapt to the readers the definitions and classifications achieved by the consensus of the American Psychiatric Association (DSM-5, 2014).
The obsessive-compulsive disorders are characterized by the presence of obsessions and/or compulsions.
What are the obsessions?
- They are thoughts, impulses or recurrent and persistent images.
- They are experienced at some point during the disorder as intrusive and unwanted.
- Intrusive: intruding where it is not welcome nor invited (Merriam-Webster)
- They cause anxiety or distress in most individuals.
- The individual try to ignore or suppress such thoughts, urges or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).
Doctor, you must help me, I cannot keep seeing these images of my husband and son with their necks broken in an accident, I see them bleeding out. They are truck drivers. I only stop seeing them if I mentally repeat even numbers. That is how I protect them, but I am exhausted, I cannot stop and if they work at night I do not sleep, I keep repeating even numbers…
What are the compulsions?
- They are repetitive behaviors or mental acts that an individual feels compelled to do in response to an obsession.
- Behaviors (e.g., hand washing, ordering, checking).
- Mental acts (e.g., praying, counting, repeating words silently).
- They are repetitive and the subject performs them in response to an obsession, or according to rules that must be applied rigidly.
- The goal of such behaviors or mental acts is to prevent or reduce the anxiety or distress, or to prevent a dreaded event or situation.
- However, these behaviors or mental acts are not connected realistically with what they are meant to neutralize or prevent, or are clearly excessive.
- O according to rules that must be applied rigidly.
Subjects enduring other obsessive-compulsive disorders and related disorders are also worried and display repetitive behaviors or mental actions as a consequence of these concerns.
The other obsessive-compulsive disorders (OCD) are characterized by repetitive behaviors focused on the body (e.g., pulling one’s hair, pinching one’s skin) and by attempts to reduce or stop such behaviors (DSM-5, 2014).
My day should be 48 hours long! Cleaning every door knob before touching them, cleaning the steering wheel of the car, putting on and removing so many times the gloves so as not to touch with my skin, washing my hands so many times, several showers…all of that just to be sure not to contaminate myself and infect the people I love.
What is the difference between OCD and an obsessive-compulsive personality disorder?
Even though the obsessive-compulsive personality disorder and the obsessive-compulsive disorder have similar names, their clinical manifestations are quite different.
The obsessive-compulsive personality disorder (OCPD):
- Is not characterized by intrusive thoughts, images, pulses or repetitive behaviors performed as a consequence of these intrusions.
- Rather, it implicates:
- A constant and general poor adaptation.
- Excessive perfectionism.
- Rigid control.
A person could recieve both diagnoses if he/she presents symptoms of both disorders
The obsessive-compulsive disorder and related disorders are nine:
1. Obsessive-compulsive disorder (OCD).
2. Body dysmorphic disorder (preoccupations with an unobservable defect in one’s own appearance).
3. Hoarding disorder (difficulty to discard one’s own possessions or to separate from them).
4. Trichotillomania (hair pulling disorder).
5. Excoriation disorder (skin picking).
6. OCD and related disorders induced by substances/drugs.
7. OCD and related disorders due to other medical conditions.
8. Other OCDs and specified related disorders.
9. Other OCDs and unspecified related disorders (e.g., repetitive behaviors focused on the body, obsessive jealousy) (DSM-5, 2014).
· The obsessive-compulsive disorder and related disorders differ from normal behavior in that concerns and rituals are more excessive or persistent than usual for that development stage.
· The distinction between subclinical symptoms and a clinical disorder need the assessment of several factors, including the individual distress level and functional impairment.
Few “dimensions” of OCD symptoms are common
Although the specific content of obsessions and compulsions varies among individuals:
· The cleaning symptoms (the contamination obsessions and cleaning compulsions).
· The symmetry (symmetry and repetition obsessions, counting and ordering compulsions).
· Taboo or forbidden thoughts (e.g., aggressive, sexual, and religious obsessions and compulsions).
· Harm thoughts (e.g., the fear of hurting oneself or others and related checking compulsions).
Body dysmorphic disorder
It is characterized by:
A preoccupation for one or several defects perceived in one’s own appearance that are unobservable or slightly appreciated and by:
a) Repetitive behaviors (e.g., checking oneself in the mirror, excessive grooming, skin picking or excessive search for reassurance information)
b) Or mental acts (e.g., comparing one’s own appearance with that of others) in response to these appearance concerns.
The diagnosis is not given when the concern is restricted to weight or body fat, similar to that observed in eating disorders.
Muscle dysmorphia is a form of body dysmorphic disorder characterized by the person’s belief that his/her body structure is too small or not muscular enough (DSM-5, 2014).
· It is characterized by a persistent difficulty to separate from one’s own possessions, regardless of their real value, as a consequence of a strong need of saving objects and avoiding the distress associated with the discarding.
· The hoarding disorder is different from normal collecting. For instance, the hoarding disorder’s symptoms lead to the accumulation of a large number of possessions that fill up and clutter active living areas to the extent that their intended use is no longer possible.
· The excessive acquisition that characterizes most, but not all, individuals with hoarding disorder is associated with excessive collecting, shopping or robbery of items that are unnecessary or for which there is no space available for storing
Trichotillomania (hair pulling disorder)
· It is characterized by recurrent hair pulls leading to hair loss and repetitive attempts to reduce or stop such hair pulls.
Excoriation disorder (skin-picking disorder)
· It is characterized by a recurrent skin picking leading to skin damage, and by repetitive attempts to reduce or stop such picking.
· The repetitive behaviors focused on the body that characterize both the trichotillomania and the excoriation disorder are not caused by obsessions or preoccupations.
· They can be preceded or accompanied by:
-Different emotional states –anxiety or boredom.
-A growing feeling of stress.
-Gratification, pleasure or relief when the hair is pulled out or the skin hurt.
· People with these disorders can have different degrees of conscious knowledge of their behavior, and while some individuals engage in this behavior showing a more focused attention in it (because of the stress that precedes it and the relief that follows it), others display a more automatic behavior (the behaviors apparently take place without full insight).
OCDs and related behaviors induced by substances/drugs
· They exhibit symptoms caused by intoxication or withdrawal of substances or drugs.
The OCD and related disorders due to other medical conditions
· They involve typical symptoms of OCD and related disorders as a direct physiopathological consequence of a medical disorder.
Other OCDs and specified related disorders, and OCDs and unspecified related disorders
· They display symptoms that don’t meet the OCD criteria due to their atypical presentation or uncertain etiology, and the available information is not enough to diagnose other OCD or related disorder.
· Unspecified related disorders are:
-The disorder of repetitive behaviors focused on the body.
-The obsessive jealousy.
· For the OCD and related disorders with a cognitive component, the insight of the condition is used as a specifier; in these disorders, the insight varies between:
-"Good or fair insight",
- "Poor insight"
-"Absent insight/delusional beliefs" regarding the beliefs associated with the disorder.
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DSM-5. (2014). Manual diagnóstico y estadísticode los trastornos mentales (DSM-5) (5ª ed.). Arlington, VA, USA: Asociación Americana de Psiquiatría.
(RAE. 2014). La 23ª edición del Diccionario de la RAE. Obtenido de http//www.rae.es/