Psychological Disorders: Obsessive-Compulsive Disorder
American
Description
Either obsessions or compulsions:
Obsessions as defined by (1), (2), (3), and (4):
recurrent
and persistent thoughts, impulses, or images that are experienced,
at some time during the disturbance, as intrusive and inappropriate
and that cause marked anxiety or distress
the thoughts, impulses, or images are not simply excessive worries
about real-life problems
the person attempts to ignore or suppress such thoughts, impulses,
or images, or to neutralize them with some other thought or action
the person recognizes that the obsessional thoughts, impulses, or
images are a product of his or her own mind (not imposed from without
as in thought insertion)
Compulsions as defined by (1) and (2):
repetitive
behaviors (e.g., hand washing, ordering, checking) or mental acts
(e.g., praying, counting, repeating words silently) that the person
feels driven to perform in response to an obsession, or according
to rules that must be applied rigidly
the behaviors or mental acts are aimed at preventing or reducing distress
or preventing some dreaded event or situation; however, these behaviors
or mental acts either are not connected in a realistic way with what
they are designed to neutralize or prevent or are clearly excessive
At some point during the course of the disorder, the person has recognized
that the obsessions or compulsions are excessive or unreasonable.
Note: This does not apply to children.
The obsessions or compulsions cause marked distress, are time consuming
(take more than 1 hour a day), or significantly interfere with the
person's normal routine, occupational (or academic) functioning, or
usual social activities or relationships.
If another Axis I disorder is present, the content of the obsessions
or compulsions is not restricted to it (e.g., preoccupation with food
in the presence of an Eating Disorder; hair pulling in the presence
of Trichotillomania; concern with appearance in the presence of Body
Dysmorphic Disorder; preoccupation with drugs in the presence of a
Substance Use Disorder; preoccupation with having a serious illness
in the presence of Hypochondriasis; preoccupation with sexual urges
or fantasies in the presence of a Paraphilia; or guilty ruminations
in the presence of Major Depressive Disorder).
The disturbance is not due to the direct physiological effects of
a substance (e.g., a drug of abuse, a medication) or a general medical
condition.
Specify if:
With Poor Insight: if, for most of the time during the current episode
the person does not recognize that the obsessions and compulsions
are excessive or unreasonable
European
Description
The essential feature of this disorder is recurrent obsessional thoughts
or compulsive acts. (For brevity, "obsessional" will be
used subsequently in place of "obsessive-compulsive" when
referring to symptoms.) Obsessional thoughts are ideas, images or
impulses that enter the individual's mind again and again in a stereotyped
form. They are almost invariably distressing (because they are violent
or obscene, or simply because they are perceived as senseless) and
the sufferer often tries, unsuccessfully, to resist them. They are,
however, recognized as the individual's own thoughts, even though
they are involuntary and often repugnant. Compulsive acts or rituals
are stereotyped behaviours that are repeated again and again. They
are not inherently enjoyable, nor do they result in the completion
of inherently useful tasks. The individual often views them as preventing
some objectively unlikely event, often involving harm to or caused
by himself or herself. Usually, though not invariably, this behaviour
is recognized by the individual as pointless or ineffectual and repeated
attempts are made to resist it; in very long-standing cases, resistance
may be minimal. Autonomic anxiety symptoms are often present, but
distressing feelings of internal or psychic tension without obvious
autonomic arousal are also common. There is a close relationship between
obsessional symptoms, particularly obsessional thoughts, and depression.
Individuals with obsessive-compulsive disorder often have depressive
symptoms, and patients suffering from recurrent depressive disorder
may develop obsessional thoughts during their episodes of depression.
In either situation, increases or decreases in the severity of the
depressive symptoms are generally accompanied by parallel changes
in the severity of the obsessional symptoms.
Obsessive-compulsive
disorder is equally common in men and women, and there are often prominent
anankastic features in the underlying personality. Onset is usually
in childhood or early adult life. The course is variable and more
likely to be chronic in the absence of significant depressive symptoms.
Diagnostic
Guidelines
For a definite diagnosis, obsessional symptoms or compulsive acts,
or both, must be present on most days for at least 2 successive weeks
and be a source of distress or interference with activities. The obsessional
symptoms should have the following characteristics:
(a)
they must be recognized as the individual's own thoughts or impulses:
(b) there must be at least one thought or act that is still resisted
unsuccessfully, even though others may be present which the sufferer
no longer resists;
(c) the thought of carrying out the act must not in itself be pleasurable
(simple relief of tension or anxiety is not regarded as pleasure in
this sense);
(d) the thoughts, images, or impulses must be unpleasantly repetitive.
Includes:
* anankastic neurosis
* obsessional neurosis
* obsessive-compulsive neurosis
Differential
Diagnosis
Differentiating between obsessive-compulsive disorder and a depressive
disorder may be difficult because these two types of symptoms so frequently
occur together. In an acute episode of disorder, precedence should
be given to the symptoms that developed first; when both types are
present but neither predominates, it is usually best to regard the
depression as primary.
In
chronic disorders the symptoms that most frequently persist in the
absence of the other should be given priority.
Occasional
panic attacks or mild phobic symptoms are no bar to the diagnosis.
However, obsessional symptoms developing in the presence of schizophrenia,
Tourette's syndrome, or organic mental disorder should be regarded
as part of these conditions.
Although
obsessional thoughts and compulsive acts commonly coexist, it is useful
to be able to specify one set of symptoms as predominant in some individuals,
since they may respond to different treatments.
F42.0
Predominantly Obsessional Thoughts Or Ruminations
These may take the form of ideas, mental images, or impulses to act.
They are very variable in content but nearly always distressing to
the individual. A woman may be tormented, for example, by a fear that
she might eventually be unable to resist an impulse to kill the child
she loves, or by the obscene or blasphemous and ego-alien quality
of a recurrent mental image. Sometimes the ideas are merely futile,
involving an endless and quasi-philosophical consideration of imponderable
alternatives. This indecisive consideration of alternatives is an
important element in many other obsessional ruminations and is often
associated with an inability to make trivial but necessary decisions
in day-to-day living.
The
relationship between obsessional ruminations and depression is particularly
close: a diagnosis of obsessive-compulsive disorder should be preferred
only if ruminations arise or persist in the absence of a depressive
disorder.
F42.1
Predominantly Compulsive Acts (Obsessional Rituals)
The majority of compulsive acts are concerned with cleaning (particularly
hand-washing), repeated checking to ensure that a potentially dangerous
situation has not been allowed to develop, or orderliness and tidiness.
Underlying the overt behaviour is a fear, usually of danger either
to or caused by the patient, and the ritual act is an ineffectual
or symbolic attempt to avert that danger. Compulsive ritual acts may
occupy many hours every day and are sometimes associated with marked
indecisiveness and slowness. Overall, they are equally common in the
two sexes but hand-washing rituals are more common in women and slowness
without repetition is more common in men.
Compulsive
ritual acts are less closely associated with depression than obsessional
thoughts and are more readily amenable to behavioural therapies.