Defining Obsessions and Compulsions

Obsessive-compulsive disorder (OCD) is a mental disorder characterized by intrusive thoughts (obsessions) that produce uneasiness, apprehension, fear, or worry, and by repetitive behaviors or rituals (compulsions) aimed at reducing the associated anxiety. People with OCD may have just the obsessions or a combination of obsessions and compulsions. 

Obsessions are characterized as persistent, unintentional, and unwanted thoughts and urges that are highly intrusive, unpleasant, and distressing (APA, 2013). Common obsessions include concerns about germs and contamination, doubts (“Did I turn the water off?”), order and symmetry (“I need all the spoons in the tray to be arranged a certain way”), and urges that are aggressive or lustful. Usually, the person knows that such thoughts and urges are irrational and thus tries to suppress or ignore them, but has an extremely difficult time doing so. 

Compulsions are ritualistic behaviors that an individual performs in order to mitigate the anxiety that stems from obsessive thoughts. They often include such behaviors as repeated and extensive hand washing, cleaning, checking (e.g., making sure the oven is off), counting things, hoarding, or ordering (e.g., lining up all the pencils in a particular way). They may also include such mental acts as counting, praying, or reciting something to oneself, as well as nervous rituals like rouching a doorknob or opening and closing a door a certain number of times before leaving a room. These compulsions can be alienating and time-consuming, often causing severe emotional, interpersonal, and even financial distress. The ability to relieve their stress is often temporary, and individuals may have a hard time switching from one task to another. 

Compulsion

Excessive hand-washing is a common compulsion found in individuals with OCD.

The acts of those who have OCD may appear paranoid and potentially psychotic, or disconnected from reality; however, OCD sufferers generally recognize their obsessions and compulsions as irrational. Roughly one-third to one-half of adults with OCD report a childhood onset of the disorder.

Colloquial Use of OCD

The phrase obsessive-compulsive is often used colloquially to indicate someone who is excessively meticulous, perfectionistic, or otherwise fixated. Although these signs are present in OCD, a person who exhibits them does not necessarily have OCD; they may instead have an autism spectrum disorder, obsessive-compulsive personality disorder (OCPD), or no clinical condition at all. The main difference between OCD and OCPD is that OCD is egodystonic, meaning that the disorder goes against the patient's self-concept. Their idea of their "ideal self" would not include the symptoms of OCD, and therefore the disorder causes a lot of distress. OCPD, on the other hand, is egosyntonic, meaning the patient sees the behaviors as appropriate, reasonable, or compatible with their self-image. 

DSM-5 Diagnostic Criteria

To be diagnosed with OCD, a person must experience obsessions, compulsions, or both. Such obsessions must be to a degree that lies outside the normal range of worries about conventional problems. A person will tend to recognize the obsessions as idiosyncratic or irrational, but still must perform them. Additionally, the degree of obsessions and compulsions must impair some aspect of the individual's social, occupational, or daily life functioning.

Etiology

Scholars generally agree that both psychological and biological factors play a role in causing the disorder, although there is disagreement about which plays a greater role. Evolutionary psychology indicates that some obsessions/compulsions may have at one point been advantageous, such as compulsive hygiene, checking the fire in the hearth, hoarding supplies, or monitoring the environment for enemies.

The results of family and twin studies suggest that OCD has a moderate genetic component. The disorder is five times more frequent in the first-degree relatives of people with OCD than in people without the disorder (Nestadt et al., 2000). Additionally, the concordance rate of OCD among identical twins is around 57%; however, the concordance rate for fraternal twins is 22% (Bolton, Rijsdijk, O’Connor, Perrin, & Eley, 2007). Studies have implicated about two dozen potential genes that may be involved in OCD; these genes regulate the function of three neurotransmitters: serotonin, dopamine, and glutamate (Pauls, 2010).

OCD has been linked to abnormalities with the neurotransmitter serotonin, although this could be either a cause or an effect of OCD. Serotonin is thought to have a role in regulating anxiety. The serotonin receptors of OCD sufferers may be under-stimulated, which is consistent with the observation that many OCD patients benefit from the use of selective serotonin reuptake inhibitors (SSRIs), a class of medications that allows more serotonin to be readily available. Additionally, a brain region that is believed to play a critical role in OCD is the orbitofrontal cortex (Kopell & Greenberg, 2008), an area of the frontal lobe involved in learning and decision-making.

Treatment

Behavioral therapy, cognitive behavioral therapy, and medications (such as SSRIs) are regarded as first-line treatments for OCD. A specific technique often used is exposure and ritual prevention, which involves gradually learning to tolerate the anxiety associated with not performing a compulsion or ritual. An example might be leaving the house and checking the lock only once (exposure) without going back and checking again (ritual prevention). The person habituates to the anxiety-producing situation and discovers that their anxiety level has dropped considerably; they can then progress to not checking the lock at all.