What you think (obsessions)

Thoughts - single words, short phrases or rhymes that are unpleasant, shocking or blasphemous.
You try not to think about them, but they won't go away. You worry that you might be contaminated (by
germs, dirt, HIV or cancer), or that someone might be harmed because you hae been careless
Pictures in your mind - showing your !amily dead, or seeing yoursel! doing something iolent or
se"ual which is completely out o! character - stabbing or abusing someone, or being un!aith!ul. #e
know that people with obsessions do not become iolent, or act on these thoughts.
Doubts - you wonder !or hours whether you might hae caused an accident or mis!ortune to
someone. You may worry that you hae knocked someone oer in your car, or that you hae le!t your
doors and windows unlocked
Ruminations - you endlessly argue with yoursel! about whether to do one thing or another so you
can't make the simplest decision.
Perfectionism - you are bothered, in a way that other people are not, i! things are not in the e"actly
the right order, not balanced or not in the right place. $or e"ample, i! books are not lined up precisely
on a bookshe
Obsessivecompulsive disorder (OD) is an an"iety disorder characteri%ed by intrusie
thoughts that produce uneasiness, apprehension, !ear, or worry& by repetitie behaiors
aimed at reducing the associated an"iety& or by a combination o! such obsessions
and compulsions. 'ymptoms o! the disorder include e"cessie washing or cleaning&
repeated checking& e"treme hoarding& preoccupation with se"ual, iolent or religious
thoughts& relationship-related obsessions& aersion to particular numbers& and
nerous rituals, such as opening and closing a door a certain number o! times be!ore
entering or leaing a room. (hese symptoms can be alienating and time-consuming, and
o!ten cause seere emotional and !inancial distress. (he acts o! those who hae )*+ may
appear paranoid and potentiallypsychotic. Howeer, )*+ su!!erers generally recogni%e their
obsessions and compulsions as irrational and may become !urther distressed by this
reali%ation.
)bsessie,compulsie disorder a!!ects children and adolescents, as well as adults. -oughly
one third to one hal! o! adults with )*+ report a childhood onset o! the disorder, suggesting
the continuum o! an"iety disorders across the li!espan.
./0
(he phrase obsessivecompulsive has become part o! the 1nglish le"icon, and is o!ten used
in an in!ormal or caricatured manner to describe someone who is e"cessiely
meticulous, per!ectionistic, absorbed, or otherwise !i"ated.
.20
3lthough these signs are
present in )*+, a person who e"hibits them does not necessarily hae )*+, but may
instead hae obsessie,compulsie personality disorder ()*4+), an autism spectrum
disorder, disorders whereperseeration is a possible !eature (3+H+, 4('+, bodily disorders
or habit problems),
.50
or no clinical condition.
+espite the irrational behaiour, )*+ is sometimes associated with aboe-aerage
intelligence.
.60.70
Its su!!erers commonly share personality traits such as high attention to
detail, aoidance o! risk, care!ul planning, e"aggerated sense o! responsibility and a
tendency to take time in making decisions.
.80
9ultiple psychological and biological !actors
may be inoled in causing obsessie,compulsie syndromes. 'tandardi%ed rating scales
such as Yale,:rown )bsessie *ompulsie 'cale can be used to assess the seerity o!
)*+ symptoms.
.;
igns and symptoms
Obsessions
Main article: Intrusive thoughts
)bsessions are thoughts that recur and persist despite e!!orts to ignore or con!ront them.
.<0
4eople with )*+ !re=uently per!orm tasks, or compulsions, to seek relie! !rom obsession-
related an"iety. #ithin and among indiiduals, the initial obsessions, or intrusie thoughts,
ary in their clarity and iidness. 3 relatiely ague obsession could inole a general sense
o! disarray or tension accompanied by a belie! that li!e cannot proceed as normal while the
imbalance remains. 3 more intense obsession could be a preoccupation with the thought or
image o! someone close to them dying
.>0./?0
or intrusions related to @relationship
rightness.@
.//0
)ther obsessions concern the possibility that someone or something other than
onesel!Asuch as Bod, the +eil, or diseaseAwill harm either the person with )*+ or the
people or things that the person cares about. )ther indiiduals with )*+ may e"perience
the sensation o! inisible protrusions emanating !rom their bodies, or hae the !eeling that
inanimate obCects are ensouled.
./20
'ome people with )*+ e"perience se"ual obsessions that may inole intrusie thoughts or
images o! @kissing, touching, !ondling, oral se", anal se", intercourse, incest and rape@ with
@strangers, ac=uaintances, parents, children, !amily members, !riends, coworkers, animals
and religious !igures@, and can include @heterose"ual or homose"ual content@ with persons o!
any age.
./50
3s with other intrusie, unpleasant thoughts or images, most @normal@ people
hae some dis=uieting se"ual thoughts at times, but people with )*+ may attach
e"traordinary signi!icance to the thoughts. $or e"ample, obsessie !ears about se"ual
orientation can appear to the person with )*+, and een to those around them, as a crisis
o! se"ual identity.
./60./70
$urthermore, the doubt that accompanies )*+ leads to uncertainty
regarding whether one might act on the troubling thoughts, resulting in sel!-criticism or sel!-
loathing.
./50
4eople with )*+ understand that their notions do not correspond with reality& howeer, they
!eel that they must act as though their notions are correct. $or e"ample, an indiidual who
engages in compulsie hoarding might be inclined to treat inorganic matter as i! it had the
sentience or rights o! liing organisms, while accepting that such behaior is irrational on a
more intellectual leel.
Primarily obsessional
Main article: Primarily Obsessional OCD
)*+ sometimes mani!ests without oert compulsions.
./80
Dicknamed @4ure-)@,
./;0
or re!erred
to as 4rimarily )bsessional )*+, )*+ without oert compulsions could, by one estimate,
characteri%e as many as 7? percent to 8? percent o! )*+ cases.
./<0
4rimarily obsessional
)*+ has been called @one o! the most distressing and challenging !orms o! )*+.@
./>0
4eople
with this !orm o! )*+ hae @distressing and unwanted thoughts pop into .their0 head
!re=uently@, and the thoughts @typically center on a !ear that you may do something totally
uncharacteristic o! yoursel!, something ...potentially !atal...to yoursel! or others.@
./>0
(he
thoughts @=uite likely, are o! an aggressie or se"ual nature.@
./>0
-ather than engaging in obserable compulsions, the person with this subtype might per!orm
more coert, mental rituals, or might !eel drien to aoid the situations in which particular
thoughts seem likely to intrude.
./;0
3s a result o! this aoidance, people can struggle to !ul!ill
both public and priate roles, een i! they place great alue on these roles and een i! they
had !ul!illed the roles success!ully in the past.
./;0
9oreoer, the indiidual's aoidance can
con!use others who do not know its origin or intended purpose, as it did in the case o! a man
whose wi!e began to wonder why he would not hold their in!ant child.
./;0
(he coert mental
rituals can take up a great deal o! a person's time during the day.
ompulsions
+ermatillomania
Main article: Compulsive behavior
'ome people with )*+ per!orm compulsie rituals because they ine"plicably !eel they hae
to, others act compulsiely so as to mitigate the an"iety that stems !rom particular obsessie
thoughts. (he person might !eel that these actions somehow either will preent a dreaded
eent !rom occurring, or will push the eent !rom their thoughts. In any case, the indiidual's
reasoning is so idiosyncratic or distorted that it results in signi!icant distress !or the indiidual
with )*+ or !or those around them. 1"cessie skin picking (i.e., dermatillomania) or hair
plucking (i.e., trichotillomania) and nail biting (i.e., onychophagia) are all on the )bsessie-
*ompulsie 'pectrum. Indiiduals with )*+ are aware that their thoughts and behaior are
not rational,
.2?0
but they !eel bound to comply with them to !end o!! !eelings o! panic or dread.
'ome common compulsions include counting speci!ic things (such as !ootsteps) or in
speci!ic ways (!or instance, by interals o! two), and doing other repetitie actions, o!ten with
atypical sensitiity to numbers or patterns. 4eople might repeatedly wash their hands
.2/0
or
clear their throats, make sure certain items are in a straight line, repeatedly check that their
parked cars hae been locked be!ore leaing them, constantly organi%e in a certain way, turn
lights on and o!!, keep doors closed at all times, touch obCects a certain number o! times
be!ore e"iting a room, walk in a certain routine way like only stepping on a certain color o!
tile, or hae a routine !or using stairs, such as always !inishing a !light on the same !oot.
(he compulsions o! )*+ must be distinguished !rom tics& moements o! other moement
disorders such as chorea, dystonia, myoclonus& moements e"hibited instereotypic
moement disorder or some people with autism& and the moements o! sei%ure actiity.
.220
(here may e"ist a notable rate o! comorbidity between )*+ and tic-related disorders.
.220
4eople rely on compulsions as an escape !rom their obsessie thoughts& howeer, they are
aware that the relie! is only temporary, that the intrusie thoughts will soon return. 'ome
people use compulsions to aoid situations that may trigger their obsessions. 3lthough some
people do certain things oer and oer again, they do not necessarily per!orm these actions
compulsiely. $or e"ample, bedtime routines, learning a new skill, and religious practices are
not compulsions. #hether or not behaiors are compulsions or mere habit depends on the
conte"t in which the behaiors are per!ormed. $or e"ample, arranging and ordering +V+s !or
eight hours a day would be e"pected o! one who works in a ideo store, but would seem
abnormal in other situations. In other words, habits tend to bring e!!iciency to one's li!e, while
compulsions tend to disrupt it.
.250
In addition to the an"iety and !ear that typically accompanies )*+, su!!erers may spend
hours per!orming such compulsions eery day. In such situations, it can be hard !or the
person to !ul!ill their work, !amily, or social roles. In some cases, these behaiors can also
cause aderse physical symptoms. $or e"ample, people who obsessiely wash their hands
with antibacterial soap and hot water can make their skin red and raw with dermatitis.
.260
4eople with )*+ can use rationali%ations to e"plain their behaior& howeer, these
rationali%ations do not apply to the oerall behaior but to each instance indiidually. $or
e"ample, a person compulsiely checking the !ront door may argue that the time taken and
stress caused by one more check o! the !ront door is much less than the time and stress
associated with being robbed, and thus checking is the better option. In practice, a!ter that
check, the person is still not sure and deems it is still better to per!orm one more check, and
this reasoning can continue as long as necessary.
Overvalued ideas
'ome )*+ su!!erers e"hibit what is known as overvalued ideas. In such cases, the person
with )*+ will truly be uncertain whether the !ears that cause them to per!orm their
compulsions are irrational or not. 3!ter some discussion, it is possible to conince the
indiidual that their !ears may be un!ounded. It may be more di!!icult to do 1-4 therapy on
such patients because they may be unwilling to cooperate, at least initially. (here are seere
cases in which the su!!erer has an unshakeable belie! in the conte"t o! )*+ that is di!!icult to
di!!erentiate !rom psychosis.
.270
ognitive performance
3 2??> study that conducted @a battery o! neuropsychological tasks to assess nine cognitie
domains with a special !ocus on e"ecutie !unctions concluded that '!ew neuropsychological
di!!erences emerged between the )*+ and healthy participants when concomitant !actors
were controlled.'@
.280.clarify0.non-primary source needed0
3 2?/5 meta-analysis con!irmed )*+ patients to hae mild but wide-ranging cognitie
de!icits& signi!icantly regarding spatial memory, to a lesser e"tent with erbal
memory, !luency, e"ecutie !unction and processing speed, while auditory attention was not
signi!icantly e!!ected.
.2;0
#here spatial memory had been ealuated by results !rom *orsi
block-tapping test, -ey-)sterrieth *omple" $igure (est-immediate recall and 'patial
#orking 9emory between search errors. Verbal memory byVerbal Eearning (est-delayed
recall and Eogical 9emory II. Verbal !luency by *ategory !luency and Eetter !luency. 3uditory
attention by +igit 'pan (est.4rocessing speed by (rail 9aking (est part 3.
.2;0
Indeed )*+ patients show impairment in !ormulating organi%ational strategy !or coding
in!ormation, set-shi!ting, motor and cognitie inhibition.
.2<0
!ssociated conditions
4eople with )*+ may be diagnosed with other conditions, as well or instead o! )*+, such
as the a!orementioned obsessie,compulsie personality disorder, maCor depressie
disorder, bipolar disorder,
.2>0
generali%ed an"iety disorder, anore"ia nerosa, social an"iety
disorder, bulimia nerosa, (ourette syndrome, 3sperger syndrome, attention de!icit
hyperactiity disorder, dermatillomania (compulsie skin picking), body dysmorphic disorder,
and trichotillomania (hair pulling). In 2??> it was reported that depression among those with
)*+ is particularly alarming because their risk o! suicide is high& more than 7? percent o!
patients e"perience suicidal tendencies, and /7 percent hae attempted suicide.
.5?0
Indiiduals with )*+ hae also been !ound to be a!!ected by delayed sleep phase
syndrome at a substantially higher rate than the general public.
.5/0
9oreoer seere )*+
symptoms are consistently associated with greater sleep disturbance. -educed total sleep
time and sleep e!!iciency hae been obsered in )*+ patients, with delayed sleep onset and
o!!set and an increased prealence o! delayed sleep phase disorder.
.520
:ehaiorally, there is some research demonstrating a link between drug addiction and the
disorder as well. $or e"ample, there is a higher risk o! drug addiction among those with any
an"iety disorder (possibly as a way o! coping with the heightened leels o! an"iety), but drug
addiction among )*+ patients may sere as a type o! compulsie behaior and not Cust as a
coping mechanism. +epression is also e"tremely prealent among su!!erers o! )*+. )ne
e"planation !or the high depression rate among )*+ populations was posited by 9ineka,
#atson, and *lark (/>><), who e"plained that people with )*+ (or any other an"iety
disorder) may !eel depressed because o! an @out o! control@ type o! !eeling.
.220
'omeone e"hibiting )*+ signs does not necessarily hae )*+. :ehaiors that present as
(or seem to be) obsessie or compulsie can also be !ound in a number o! other conditions
as well, including obsessie,compulsie personality disorder ()*4+), autism spectrum
disorders, disorders where perseeration is a possible !eature (3+H+, 4('+, bodily
disorders or habit problems),
.50
or sub-clinically.
'ome with )*+ present with !eatures typically associated with (ourette's syndrome, such as
compulsions that may appear to resemble motor tics& this has been termed @tic-related )*+@
or @(ourettic )*+@.
.550.560
Causes
Main article: Cause of obsessive-compulsive disorder
'cholars generally agree that both psychological and biological !actors play a role in causing
the disorder, although they di!!er in their degree o! emphasis upon either type o! !actor.
Psychological
3n eolutionary psychology iew is that moderate ersions o! compulsie behaior may hae
had eolutionary adantages. 1"amples would be moderate constant checking o! hygiene,
the hearth, or the enironment !or enemies. 'imilarly, hoarding may hae had eolutionary
adantages. In this iew )*+ may be the e"treme statistical @tail@ o! such behaiors possibly
due to a high amount o! predisposing genes.
.570
"iological
Main article: Biology of obsessivecompulsive disorder
)*+ has been linked to abnormalities with the neurotransmitter serotonin, although it could
be either a cause or an e!!ect o! these abnormalities. 'erotonin is thought to hae a role in
regulating an"iety. (o send chemical messages !rom one neuron to another, serotonin must
bind to the receptor sites located on the neighboring nere cell. It is hypothesi%ed that the
serotonin receptors o! )*+ su!!erers may be relatiely understimulated. (his suggestion is
consistent with the obseration that many )*+ patients bene!it !rom the use o! selectie
serotonin reuptake inhibitors (''-Is), a class o! antidepressant medications that allow !or
more serotonin to be readily aailable to other nere cells.
.580
3 possible genetic mutation may contribute to )*+. 3 mutation has been !ound in the
human serotonin transporter gene, h'1-(, in unrelated !amilies with )*+.
.5;0
9oreoer, data
!rom identical twins supports the e"istence o! a @heritable !actor !or neurotic an"iety@.
.5<0
$urther, indiiduals with )*+ are more likely to hae !irst-degree !amily members
e"hibiting the same disorders than do matched controls. In cases where )*+ deelops
during childhood, there is a much stronger !amilial link in the disorder than cases in which
)*+ deelops later in adulthood. In general, genetic !actors account !or 67,87F o! )*+
symptoms in children diagnosed with the disorder.
.5>0
1nironmental !actors also play a role
in how these an"iety symptoms are e"pressed& arious studies on this topic are in progress
and the presence o! a genetic link is not yet de!initely established.
4eople with )*+ eince increased grey matter olumes in bilateral lenticular nuclei,
e"tending to the caudate nuclei, while decreased grey matter olumes in bilateral
dorsal medial !rontalGanterior cingulate gyri.
.6?0.6/0
(hese !indings contrast with those in people
with other an"iety disorders, who eince decreased (rather than increased) grey
matter olumes in bilateral lenticular G caudate nuclei, while also decreased grey matter
olumes in bilateral dorsal medial !rontalGanterior cingulategyri.
.6/0
)rbito!rontal
corte" oeractiity is attenuated in patients who hae success!ully responded
to ''-I medication, a result belieed to be caused by increased stimulation
o! serotonin receptors 7-H(23 and 7-H(2*.
.620
(he striatum, linked to planning and the
initiation o! appropriate actions, has also been implicated& mice genetically engineered with a
striatal abnormality e"hibit )*+-like behaior, grooming themseles three times as
!re=uently as ordinary mice.
.650
-ecent eidence supports the possibility o! a heritable
predisposition !or neurological deelopment !aoring )*+.
.660
-apid onset o! )*+ in children and adolescents may be caused by a syndrome conntected
to Broup 3 streptococcal in!ections (43D+3')
.670.680
or caused byimmunologic reactions to
other pathogens (43D').
.6;0
#eurotransmitters
-esearchers hae yet to pinpoint the e"act cause o! )*+, but brain di!!erences, genetic
in!luences, and enironmental !actors are being studied. :rain scans o! people with )*+
hae shown that they hae di!!erent patterns o! brain actiity than people without )*+ and
that di!!erent !unctioning o! circuitry within a certain part o! the brain, the striatum, may cause
the disorder. +i!!erences in other parts o! the brain and neurotransmitter dysregulation,
especially serotonin and dopamine, may also contribute to )*+.
.6<0
Independent studies
hae consistently !ound unusual dopamine and serotonin actiity in arious regions o! the
brain in indiiduals with )*+. (hese can be de!ined as dopaminergic hyper!unction in
the pre!rontal corte" and serotonergic hypo!unction in the basal ganglia.
.6>0.7?0
.7/0
Blutamatedysregulation has also been the subCect o! recent research,
.720.750
although its
role in the disorder's etiology is not yet clear.
Diagnosis
$ormal diagnosis may be per!ormed by a psychologist, psychiatrist, clinical social worker, or
other licensed mental health pro!essional. (o be diagnosed with )*+, a person must hae
obsessions, compulsions, or both, according to the +iagnostic and 'tatistical 9anual o!
9ental +isorders (+'9). (he Huick -e!erence to the 2??? edition o! the +'9 states that
seeral !eatures characteri%e clinically signi!icant obsessions and compulsions. 'uch
obsessions, the +'9 says, are recurrent and persistent thoughts, impulses, or images that
are e"perienced as intrusie and that cause marked an"iety or distress. (hese thoughts,
impulses, or images are o! a degree or type that lies outside the normal range o! worries
about conentional problems.
.760
3 person may attempt to ignore or suppress such
obsessions, or to neutrali%e them with some other thought or action, and will tend to
recogni%e the obsessions as idiosyncratic or irrational.
*ompulsions become clinically signi!icant when a person !eels drien to per!orm them in
response to an obsession, or according to rules that must be applied rigidly, and when the
person conse=uently !eels or causes signi!icant distress. (here!ore, while many people who
do not su!!er !rom )*+ may per!orm actions o!ten associated with )*+ (such as ordering
items in a pantry by height), the distinction with clinically signi!icant )*+ lies in the !act that
the person who su!!ers !rom )*+must per!orm these actions, otherwise they will e"perience
signi!icant psychological distress. (hese behaiors or mental acts are aimed at preenting or
reducing distress or preenting some dreaded eent or situation& howeer, these actiities
are not logically or practically connected to the issue, or they are e"cessie. In addition, at
some point during the course o! the disorder, the indiidual must reali%e that their obsessions
or compulsions are unreasonable or e"cessie.
9oreoer, the obsessions or compulsions must be time-consuming (taking up more than one
hour per day) or cause impairment in social, occupational, or scholastic !unctioning.
.760
It is
help!ul to =uanti!y the seerity o! symptoms and impairment be!ore and during treatment !or
)*+. In addition to the patientIs estimate o! the time spent each day harboring obsessie-
compulsie thoughts or behaiors, $enske and 'chwenk in their article @)bsessie-
*ompulsie +isorderJ +iagnosis and 9anagement,@ argue that more concrete tools should
be used to gauge the patientIs condition (2??>). (his may be done with rating scales, such
as the most trustedYale,:rown )bsessie *ompulsie 'cale (Y-:)*'). #ith
measurements like these, psychiatric consultation can be more appropriately determined
because it has been standardi%ed.
.5?0
$ersus obsessivecompulsive personality disorder
)*+ is o!ten con!used with the separate condition obsessie,compulsie personality
disorder ()*4+). )*+ is egodystonic, meaning that the disorder is incompatible with the
su!!erer's sel!-concept.
.770.780
:ecause ego dystonic disorders go against a person's sel!-
concept, they tend to cause much distress. )*4+, on the other hand, is egosyntonic A
marked by the person's acceptance that the characteristics and behaiours displayed as a
result are compatible with his or hersel!-image, or are otherwise appropriate, correct or
reasonable.
3s a result, people with )*+ are o!ten aware that their behaior is not rational, are unhappy
about their obsessions but neertheless !eel compelled by them, and may be riddled
with an"iety.
.7;0
:y contrast people with )*4+ are not aware o! anything abnormal& they will
readily e"plain why their actions are rational, it is usually impossible to conince them
otherwise, and they tend to derie pleasure !rom their obsessions or compulsions.
.7;0
$ersus other conditions
)*+ is di!!erent !rom behaiors such as gambling addiction and oereating. 4eople with
these disorders typically e"perience at least some pleasure !rom their actiity& )*+ su!!erers
do not actiely want to per!orm their compulsie tasks and e"perience no pleasure !rom
doing so.
Management
:ehaioral therapy (:(), cognitie behaioral therapy (*:(), and medications are !irst-line
treatments !or )*+.
.7<0
4sychodynamic psychotherapy may help in managing some aspects
o! the disorder. (he 3merican 4sychiatric 3ssociation notes a lack
o! controlled demonstrations that psychoanalysis or dynamic psychotherapy is e!!ectie @in
dealing with the core symptoms o! )*+.@
.7>0
(he !act that many indiiduals do not seek
treatment may be due in part to stigmaassociated with )*+.
"ehavioral therapy
(he speci!ic techni=ue used in :(G*:( is called e"posure and ritual preention (also known
as @e"posure and response preention@) or 1-4& this inoles gradually learning to tolerate
the an"iety associated with not per!orming the ritual behaior. 3t !irst, !or e"ample, someone
might touch something only ery mildly @contaminated@ (such as a tissue that has been
touched by another tissue that has been touched by the end o! a toothpick that has touched
a book that came !rom a @contaminated@ location, such as a school.) (hat is the @e"posure@.
(he @ritual preention@ is not washing. 3nother e"ample might be leaing the house and
checking the lock only once (e"posure) without going back and checking again (ritual
preention). (he person !airly =uickly habituates to the an"iety-producing situation and
discoers that their an"iety leel has dropped considerably& they can then progress to
touching something more @contaminated@ or not checking the lock at allAagain, without
per!orming the ritual behaior o! washing or checking.
.8?0
1"posure ritualGresponse preention (1-4) has a strong eidence base. It is considered the
most e!!ectie treatment !or )*+.
.8?0
Howeer, this claim has been doubted by some
researchers critici%ing the =uality o! many studies.
.8/0
It has generally been accepted that psychotherapy, in combination with psychiatric
medication, is more e!!ectie than either option alone. Howeer, more recent studies hae
shown no di!!erence in outcomes !or those treated with the combination o! medicine and
*:( ersus *:( alone.
.820
%edication
9edications as treatment include selectie serotonin reuptake inhibitors (''-Is) and
the tricyclic antidepressants, in particular clomipramine.
(reatment o! )*+ is an area needing signi!icant improement in prescribing regimens.
.850
:en%odia%epines are sometimes used, although they are generally belieed to be
ine!!ectie !or treating )*+& howeer, e!!ectieness was !ound in one small study.
.860
In most
cases antidepressant therapy alone proides only a partial reduction in symptoms, een in
cases that are not deemed treatment resistant. 9uch current research is deoted to the
therapeutic potential o! the agents that a!!ect the release o! the
neurotransmitter glutamate or the binding to its receptors. (hese include rilu%ole,
.750
memantine, gabapentin, D-3cetylcysteine, andlamotrigine.
(he atypical antipsychotics such as =uetiapine hae also been !ound to be use!ul as
adCuncts to an ''-I in treatment-resistant )*+. Howeer, these drugs are o!ten poorly
tolerated, and hae metabolic side e!!ects that limit their use. Done o! the atypical
antipsychotics appear to be use!ul when used alone.
.870
&lectroconvulsive therapy
1lectroconulsie therapy (1*() has been !ound to hae e!!ectieness in some seere and
re!ractory cases.
.880
Psychosurgery
$or some, medication, support groups and psychological treatments !ail to alleiate
obsessie,compulsie symptoms. (hese patients may choose to undergopsychosurgery as
a last resort. In this procedure, a surgical lesion is made in an area o! the brain (the cingulate
corte"). In one study, 5?F o! participants bene!ited signi!icantly !rom this procedure.
.8;0
+eep-
brain stimulation and agus nere stimulation are possible surgical options that do not
re=uire destruction o! brain tissue. In the K', the $ood and +rug 3dministration approed
deep-brain stimulation !or the treatment o! )*+ under a humanitarian deice e"emption
re=uiring that the procedure be per!ormed only in a hospital with specialist =uali!ications to
do so.
.8<0
In the K', psychosurgery !or )*+ is a treatment o! last resort and will not be per!ormed until
the patient has !ailed seeral attempts at medication (at the !ull dosage) with augmentation,
and many months o! intensie cognitie,behaioral therapy with e"posure and
ritualGresponse preention.
.8>0
Eikewise, in the Knited Lingdom, psychosurgery cannot be
per!ormed unless a course o! treatment !rom a suitably =uali!ied cognitie,behaioral
therapist has been carried out.
hildren
(herapeutic treatment may be e!!ectie in reducing ritual behaiors o! )*+ !or children and
adolescents.
.;?0
$amily inolement, in the !orm o! behaioral obserations and reports, is a
key component to the success o! such treatments.
.;/0
4arental interention also proides
positie rein!orcement !or a child who e"hibits appropriate behaiors as alternaties to
compulsie responses. 3!ter one or two years o! therapy, in which a child learns the nature
o! his or her obsession and ac=uires strategies !or coping, that child may ac=uire a larger
circle o! !riends, e"hibit less shyness, and become less sel!-critical.
.;20
3lthough the causes o! )*+ in younger age groups range !rom brain abnormalities to
psychological preoccupations, li!e stress such as bullying and traumatic !amilial deaths may
also contribute to childhood cases o! )*+, and acknowledging these stressors can play a
role in treating the disorder.
.;50
Epidemiology
3ge-standardi%ed disability-adCusted li!e year rates !or obsessie-compulsie disorder per
/??,??? inhabitants in 2??6.
no data
M67
67,72.7
72.7,8?
8?,8;.7
8;.7,;7
;7,<2.7
<2.7,>?
>?,>;.7
>;.7,/?7
/?7,//2.7
//2.7,/2?
N/2?
)*+ occurs in between / to 5F o! children and adults.
.;60
It occurs e=ually in both se"es. In
<?F o! cases, symptoms present be!ore the age o! /<.
.better source needed0.;70
3 2??? study by
the #orld Health )rgani%ation !ound some ariety in prealence and incidence o! )*+
around the world, with !igures in Eatin 3merica, 3!rica, and 1urope at two to three times
those in 3sia and )ceania.
.;80
)ne *anadian study !ound that prealence o! )*+ had little correlation with race. Howeer,
respondents who markedOudaism as their religion were oerrepresented among )*+
patients.
.;;0
Prognosis
4sychological interentions such as behaioral and cognitie-behaioral therapy as well as
pharmacological treatment can lead to substantial reduction o! )*+ symptoms !or the
aerage patient. Howeer, )*+ symptoms persist at moderate leels een !ollowing
ade=uate treatment course and a completely symptom-!ree period is uncommon.
.;<0
History
$rom the /6th to the /8th century in 1urope, it was belieed that people who e"perienced
blasphemous, se"ual, or other obsessie thoughts were possessed by the +eil.
.770
:ased on
this reasoning, treatment inoled banishing the @eil@ !rom the @possessed@ person
through e"orcism.
.;>0.<?0
In the early />/?s, 'igmund $reud attributed obsessie,compulsie
behaior to unconscious con!licts that mani!est as symptoms.
.;>0
$reud describes the clinical
history o! a typical case o! @touching phobia@ as starting in early childhood, when the person
has a strong desire to touch an item. In response, the person deelops an @e"ternal
prohibition@ against this type o! touching. Howeer, this @prohibition does not succeed in
abolishing@ the desire to touch& all it can do is repress the desire and @!orce it into the
unconscious@.
.</0
Society and culture
(his ribbon represents(richotillomania and other body !ocused repetitie behaiors. *oncept !or the ribbon
was started by Oenne 'chrader. *olors were oted on by the (richotillomania $acebook community, and
made o!!icial by (richotillomania Eearning *enter in 3ugust o! 2?/5
9oies and teleision o!ten portray ideali%ed representations o! disorders such as )*+.
(hese depictions may lead to increased public awareness, understanding, and sympathy !or
such disorders.
.<20
:ritish poet, essayist, and le"icographer 'amuel Oohnson is an e"ample o! a
historical !igure with a retrospectie diagnosis o! )*+. He had elaborate rituals !or
crossing the thresholds o! doorways, and repeatedly walked up and down staircases
counting the steps.
.<50
3merican aiator and !ilmmaker Howard Hughes is known to hae su!!ered !rom
)*+. $riends o! Hughes hae mentioned his obsession with minor !laws in clothing and
he is reported to hae had a great !ear o! germs, common among )*+ patients.
.<60
1nglish !ootballer +aid :eckham has been outspoken regarding his struggle with
)*+. He said that he has to count all o! his clothes, and his maga%ines hae to lie in a
straight line.
.<70
*anadian comedian, actor, teleision host, and oice actor Howie 9andel, best
known !or hosting the game show +eal or Do +eal, wrote an autobiography, ere!s the
Deal: Don!t "ouch Me, describing how )*+ and mysophobia (!ear o! germs) a!!ect his
li!e.
.<80
3merican game show host 9arc 'ummers wrote #verything in Its Place: My "rials
and "riumphs $ith Obsessive Compulsive Disorder, describing the e!!ect o! )*+ on his
li!e.
.<;0
Research
(he naturally occurring sugar inositol has been suggested as a treatment !or )*+.
.<<0
Dutrition de!iciencies may also contribute to )*+ and other mental disorders. Vitamin and
mineral supplements may aid in such disorders and proide nutrients necessary !or proper
mental !unctioning.
.<>0
P-)pioids, such as hydrocodone and tramadol, may improe )*+ symptoms.
.>?0
3dministration o! opiate treatment may be contraindicated in indiiduals concurrently
taking *Y42+8 inhibitors such as !luo"etine and paro"etine.
.>/0
Other animals
%ee also: &nimal psychopathology'Obsessive compulsive disorder (OCD)
References
#otes
/. 'ump up ( 'tewart et al. 2??;. 4rincipal *omponents 3nalysis o! )bsessie
*ompulsie +isorder 'ymptoms in *hildren and 3dolescents. :iological 4sychiatry. 8/.
pp2<7-2>/
2. 'ump up ( :errios B 1 (/><7) )bsessional +isordersJ 3 *onceptual History.
(erminological and *lassi!icatory Issues. In :ynum # $ et al. (eds) (he 3natomy o!
9adness Vol I , Eondon, (aistock, pp /88,/<;
3. Q Oump up toJ
a

b
4ediatric )bsessie-*ompulsie +isorder +i!!erential
+iagnoses , 2?/2
6. 'ump up ( Yaryura-(obias, OosR& De%iroglu, $ugen 3. (/>>;). Obsessive-
compulsive disorder spectrum: pathogenesis* diagnosis* and treatment. 3merican
4sychiatric 4ublishing. pp. />,2?. I':D >;<-?-<<?6<-;?;-<.
7. 'ump up ( 4eterson, :.'.& +.'. 4ine, 4. *ohen, O.'. :rook (2??/). @4rospectie,
longitudinal study o! tic, obsessie-compulsie, and attention-de!icitGhyperactiity
disorders in an epidemiological sample@. + &m &cad Child &dolesc Psychiatry )*(8)J
8<7,8>7. doiJ/?./?>;G????67<5-2??/?8???-???/6. 49I+ //5>256;.
8. 'ump up ( @::* 'cience, Human :ody S 9ind, 9ental disorders@. :bc.co.uk.
2??2-/?-?/. -etrieed 2?//-/2-/?.
;. 'ump up ( Boodman #.L, 4rice E.H, -asmussen '.3 et al, (/><>). @(he Yale,
:rown )bsessie,*ompulsie 'cale. I. +eelopment, use, and reliability@. &rch -en
Psychiatry )+ (//)J /??8,
/?//. doiJ/?./??/Garchpsyc./><>.?/</?//??6<??;.49I+ 28<6?<6.
<. 'ump up ( 9arkarian Y, Earson 9O, 3ldea 93 et al. ($ebruary 2?/?). @9ultiple
pathways to !unctional impairment in obsessie-compulsie disorder@. Clin Psychol
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>. 'ump up ( :aer (2??/), p. 55, ;<
/?. 'ump up ( :aer (2??/), p. "i.
//. 'ump up ( +oron, Buy& '%epsenwol. )., Larp, 1., S Bal. D. (2?/5). @)bsessing
3bout Intimate--elationshipsJ (esting the +ouble -elationship-Vulnerability
Hypothesis@.+ournal of Behavior "herapy and #/perimental Psychiatry )) (6)J 655,
66?.doiJ/?./?/8GC.Cbtep.2?/5.?7.??5. 49I+ 25;>2;72.
/2. 'ump up ( 9ash, 1. O., S #ol!e, +. 3. (2??7). &bnormal child psychology (5rd
ed.).:elmont, *3J (homson #adsworth, p. />;.
13. Q Oump up toJ
a

b
)sgood-Hynes, +eborah. (hinking :ad (houghts
(4+$). 9BHG9cEean )*+ Institute, :elmont, 93, published by the OCD 0oundation,
9il!ord, *(. -etrieed on +ecember 5?, 2??8.
/6. 'ump up ( 'teen 4hillipson I (hink It 9oed *enter !or *ognitie-:ehaioral
4sychotherapy, )*+)nline.com. -etrieed on 9ay /6, 2??>.
/7. 'ump up ( 9ark-3meen Oohnson, I'm Bay and You're Dot J Knderstanding
Homose"uality $ears brainphysics.com. -etrieed on 9ay /6, 2??>.
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obsessie thoughtsT :ehaiour -esearch and (herapy, 57, 557,56<.
17. Q Oump up toJ
a

b

c

d
Hyman, :. 9., S 4edrick, *. (2??7). "he OCD $or1boo1:
2our guide to brea1ing free from obsessivecompulsive disorder (2nd
ed.). )akland, *3JDew Harbinger, pp. /27,/28.
/<. 'ump up ( #eisman 9.9., :land -.*., *anino B.O., Breenwald '., Hwu H.B.,
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disorder@.+ournal of Clinical Psychiatry --J 7,/?.
19. Q Oump up toJ
a

b

c
Hyman, :ruce and (roy +e$rene. Coping $ith OCD. 2??<.
Dew Harbinger 4ublications.
2?. 'ump up ( 1lkin, B. +aid (/>>>). Introduction to Clinical Psychiatry. 9cBraw,
Hill 4ro!essional. I':D ?-<5<7-6555-2.
2/. 'ump up ( :oyd, 9ary 3nn (2??;). Psychiatric 3ursing. Eippincott #illiams S
#ilkins. p. 6/<. I':D ?-5>;-77/;<->.
iagnosis.edit/
0ymptoms.edit/
(he main symptoms o! )*4+ are preoccupation with remembering and paying attention to
minute details and !acts, !ollowing rules and regulations, compulsion to make lists and
schedules, as well as rigidityGin!le"ibility o! belie!s or showing per!ectionism that inter!eres
with task-completion. 'ymptoms may cause e"treme distress and inter!ere with a person's
occupational and social !unctioning.
.50
9ost people spend their early li!e aoiding symptoms
and deeloping techni=ues to aoid dealing with these strenuous issues.
.citation needed0
Obsessions.edit/
'ome, but not all, people with )*4+ show an obsessie need !or cleanliness. (his, and an
obsessie preoccupation with tidiness, may instead make daily liing di!!icult. (hough this
kind o! obsessie behaior may contribute to a sense o! controlling personal an"iety, tension
may continue. In the case o! a compulsie hoarder, attention to clean the home e!!ectiely
may be hindered by the amount o! clutter that the hoarder resoles to organi%e later.
.60
4erception o! own and others' actions and belie!s tend to be polarised (i.e., @right@ or
@wrong@, with little or no margin between the two) !or people with this disorder. 3s might be
e"pected, such rigidity places strain on interpersonal relationships, with !rustration
sometimes turning into anger and een iolence. (his is known asdisinhibition.
.70
4eople with
)*4+ o!ten tend to general pessimism andGor underlying !orm(s) o! depression.
.80.;0.<0
(his
can at times become so serious that suicide is a risk.
.>0
Indeed, one study suggests that
personality disorders are a signi!icant substrate to psychiatric morbidity. (hey may cause
more problems in !unctioning than a maCor depressie episode.
./?0
D0%.edit/
(he Diagnostic and %tatistical Manual of Mental Disorders !ourth edition, (+'9 IV-(- U
5?/.6), a widely used manual !or diagnosing mental disorders, de!ines obsessie,
compulsie personality disorder (in 3"is II *luster *) asJ
.//0
3 perasie pattern o! preoccupation with orderliness, per!ectionism, and mental and
interpersonal control, at the e"pense o! !le"ibility, openness, and e!!iciency, beginning by
early adulthood and present in a ariety o! conte"ts, as indicated by !our (or more) o! the
!ollowingJ
/. is preoccupied with details, rules, lists, order, organi%ation, or schedules to
the e"tent that the maCor point o! the actiity is lost
2. shows per!ectionism that inter!eres with task completion (e.g., is unable to
complete a proCect because his or her own oerly strict standards are not
met)
5. is e"cessiely deoted to work and productiity to the e"clusion o! leisure
actiities and !riendships (not accounted !or by obious economic necessity)
6. is oerconscientious, scrupulous, and in!le"ible about matters o! morality,
ethics, or alues (not accounted !or by cultural or religious identi!ication)
7. is unable to discard worn-out or worthless obCects een when they hae no
sentimental alue
8. is reluctant to delegate tasks or to work with others unless they submit to
e"actly his or her way o! doing things
;. adopts a miserly spending style toward both sel! and others& money is
iewed as something to be hoarded !or !uture catastrophes
<. shows rigidity and stubbornness
riticism.edit/
'ince +'9 IV-(- was published in 2???, some studies hae !ound !ault with its )*4+
coerage. 3 2??6 study challenged the use!ulness o! all but three o! the criteriaJ
per!ectionism, rigidity and stubbornness, and miserliness.
./20
3 study in 2??;
./50
!ound that
)*4+ is etiologically distinct !rom aoidant and dependent personality disorders,
suggesting it is incorrectly categori%ed as a *luster * disorder.
W1O.edit/
(he #orld Health )rgani%ation's I*+-/? uses the term ($ 8?.7 ) !nankastic personality
disorder.
./60
It is characteri%ed by at least three o! the !ollowingJ
/. !eelings o! e"cessie doubt and caution&
2. preoccupation with details, rules, lists, order, organi%ation or schedule&
5. per!ectionism that inter!eres with task completion&
6. e"cessie conscientiousness, scrupulousness, and undue preoccupation
with productiity to the e"clusion o! pleasure and interpersonal relationships&
7. e"cessie pedantry and adherence to social conentions&
8. rigidity and stubbornness&
;. unreasonable insistence by the indiidual that others submit e"actly to his or
her way o! doing things, or unreasonable reluctance to allow others to do
things&
<. intrusion o! insistent and unwelcome thoughts or impulses.
IncludesJ
compulsie and obsessional personality (disorder)
obsessie-compulsie personality disorder
1"cludesJ
obsessie-compulsie disorder
It is a re=uirement o! I*+-/? that a diagnosis o! any speci!ic personality
disorder also satis!ies a set o! general personality disorder criteria.
22. Q Oump up toJ
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b

c
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6>. 'ump up ( @1nhanced +opamine (ransporter +ensity in 4sychotropic-Daie
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#u, L.& Hanna, B. E.& -osenberg, +. -.& 3rnold, 4. +.
(2?/2). @(he role o! glutamate signaling in the pathogenesis and treatment o! obsessie,
compulsie disorder@. Pharmacology Biochemistry and Behavior 4** (6)J ;28,
;57.doiJ/?./?/8GC.pbb.2?//./?.??;. 49* 565;22?. 49I+ 22?26/7>. edit
54. Q Oump up toJ
a

b
;uic1 .eference to the Diagnostic Criteria from D%M-I<-"..
3rlington, V3J 3merican 4sychiatric 3ssociation, 2???.
55. Q Oump up toJ
a

b
3ardema, $. S )'*onnor. (2??;). (he menace withinJ
obsessions and the sel!. International Oournal o! *ognitie (herapy, 2/, /<2,/>;.
78. 'ump up ( 3ardema, $. S )'*onnor. (2??5). 'eeing white bears that are not
thereJ In!erence processes in obsessions. Oournal o! *ognitie 4sychotherapy, /;, 25,
5;.
57. Q Oump up toJ
a

b
*arter, L. @)bsessie,compulsie personality disorder.@ 4'Y*
2/? lectureJ )"!ord *ollege o! 1mory Kniersity. )"!ord, B3. 3pril //, 2??8.
7<. 'ump up ( +octor's Buide. (2??;). 3e$ guidelines to set standards for best
treatment of OCD. +octor's Buide 4ublishing, Etd.
7>. 'ump up ( Loran, E9& Hanna, BE& Hollander, 1& Destadt, B& 'impson, H:&
3merican 4sychiatric, 3ssociation (2??; Oul). @4ractice guideline !or the treatment o!
patients with obsessie-compulsie disorder.@. "he &merican 5ournal of psychiatry4+) (;
'uppl)J 7,75. 49I+ /;<6>;;8.
60. Q Oump up toJ
a

b
Huppert S -othJ (2??5) (reating )bsessie-*ompulsie
+isorder with 1"posure and -esponse 4reention. "he Behavior &nalyst "oday* =
(>)* 88 , ;?:3)
8/. 'ump up ( +onald $. LleinJ $lawed 9eta-3nalysis *omparing 4sychotherapy
#ith 4harmacotherapy. 3m O 4sychiatry /7;J<& 3ugust 2???.
82. 'ump up ( $oa 1:, Eiebowit% 9-, Lo%ak 9O, +aies ', *ampeas -, $ranklin
91, Huppert O+, LCernisted L, -owan V et al, (2??7). @-andomi%ed, placebo-controlled
trial o! e"posure and ritual preention, clomipramine, and their combination in the
treatment o! obsessie,compulsie disorder@. &m + Psychiatry4+3 (/)J /7/,
8/. doiJ/?.//;8Gappi.aCp./82././7/. 49I+ /78272/6.
85. 'ump up ( :lanco, *.& )l!son, 9.& 'tein, +O.& 'impson, H:.& Bamero!!, 9O.&
Darrow, #H. (Oun 2??8). @(reatment o! obsessie-compulsie disorder by K.'.
psychiatrists@. + Clin Psychiatry +5 (8)J >68,
7/. doiJ/?.6?<<GO*4.8;n?8//. 49I+ /8<6<876.
86. 'ump up ( $., 3lan& 'chat%berg, 9+& Demero!!, *harles :.& :allon, Oacob (5/
Ouly 2??>)."he &merican Psychiatric Publishing "e/tboo1 of Psychopharmacology
(%chat9berg* &merican Psychiatric Publishing "e/tboo1 of Psychopharmacology) (6 ed.).
3merican 4sychiatric 4ublishing, Inc. p. 6;?.I':D >;<-/-7<782-5?>->.
87. 'ump up ( +ecloedt 1H, 'tein +O (2?/?). @*urrent trends in drug treatment o!
obsessie-compulsie disorder@. 3europsychiatr Dis "reat +J 255,
62.doiJ/?.2/6;GD+(.'5/6>. 49* 2<;;8?7. 49I+ 2?72?;<;.
88. 'ump up ( 1a 9 *ybulska ($eb.2??8). @)bsessie *ompulsie disorder, the
brain and electroconulsie therapy@. British +ournal of ospital Medicine.+5(2)J;;,<2.
8;. 'ump up ( :arlow, +. H. and V. 9. +urand. #ssentials of &bnormal Psychology.
*ali!orniaJ (homson #adsworth, 2??8.
8<. 'ump up ( :arlas ' (3pril <, 2??>). @$+3 3pproes 4ioneering (reatment !or
)bsessie- *ompulsie +isorder@. Psychiatric "imes 3+ (6).
8>. 'ump up ( 'urgical 4rocedures !or )bsessie,*ompulsie +isorder, by 9. Oahn
and 9. #illiams, 4h.+,. :rain4hysics )*+ -esource, 3ccessed Ouly 8, 2??<.
;?. 'ump up ( #illiam )'+onohue and Lyle 1. $erguson (2??8)J 1idence-:ased
4ractice in 4sychology and :ehaior 3nalysis. (he :ehaior 3nalyst (oday, ;(5) 557,
56;.:3)
;/. 'ump up ( -apoport, O. 1. (/><>). )bsessie-compulsie +isorder In *hildren S
3dolescents. #ashingtonJ 3merican 4sychiatric 4ress.
;2. 'ump up ( 3dams, 4. E. (/>;5). )bsessie *hildrenJ 3 'ociopsychiatric 'tudy.
4hiladelphiaJ :runner G 9a%el.
;5. 'ump up ( +'3lessandro, (. (2??>). $actors In!luencing the )nset o! *hildhood
)bsessie *ompulsie +isorder. 4ediatric Dursing, 57(/), 65,8. (+ocument I+J
/8>2<?><2/).
;6. 'ump up ( 'aret, : (2?/5 Oan). @*hildhood obsessie-compulsie
disorder.@. Pediatrics in revie$ ? &merican &cademy of Pediatrics ,) (/)J />,2;& =ui%
2<.49I+ 252</57>.
;7. 'ump up (
.better source needed0
LenR%loi, 1.& Demoda, Z. (2?/?). @Benetic !actors in
obsessie-compulsie disorderJ summary o! genetic studies@. Psychiatria ungarica : &
Magyar Ps9ichiatriai "arsasag tudomanyos folyoirata 3- (7)J 5;<,
5>5. 49I+ 2//78>>/. edit
;8. 'ump up ( 3yuso-9ateos, Oose Euis. @Blobal burden o! obsessie-compulsie
disorder in the year 2???@. #orld Health )rgani%ation. -etrieed $ebruary 2;, 2?/5.
;;. 'ump up ( 'winson, -ichard 4. et al. (/>><). Obsessive-Compulsive Disorder:
"heory* .esearch* and "reatment. pp. /;,/<.
;<. 'ump up ( 1ddy L(, +utra E. :radley - #esten +. 3 multidimensional meta-
analysis o! psychotherapy and pharmacotherapy !or obsessie-compulsie disorder. *lin
4sychol -e. 2??6 +ec&26(<)J/?//,5?.
79. Q Oump up toJ
a

b
9. 3. Oenike& :aer, E.& S #. 1. 9inichiello. Obsessive
Compulsive Disorders: "heory and Management. Eittleton, 93J 4'B 4ublishing, /><8.
<?. 'ump up ( :errios B 1 (/><>) )bsessie *ompulsie +isorderJ Its conceptual
history in $rance during the />th *entury. Comprehensive Psychiatry 5?J <5,>7
</. 'ump up ( $reud, 'igmund (/>7?). "otem and "aboo:%ome Points of
&greement bet$een the Mental 8ives of %avages and 3eurotics. trans. 'trachey. Dew
YorkJ #. #. Dorton S *ompany. I':D ?-5>5-??/65-/. p. 2>.
<2. 'ump up ( Boldberg $- (2??;). @(urn bo" o!!ice moies into mental health
opportunitiesJ 3 literature reiew and resource guide !or clinicians and educators@, p.
<.Beneficial 0ilm -uides* Inc, -etrieed /; $ebruary 2?/?.
<5. 'ump up ( @'39K1E O)HD')D (/;?>,/;<6)J 3 4atron 'aint o! )*+T by $red
4en%el, 4h.+. !rom the 'cienti!ic 3disory :oard o! the International )*+ $oundation@.
#estsu!!olkpsych.homestead.com. -etrieed 2?/5-//-2>.
<6. 'ump up ( 9. +ittmanni (OulyG3ugust 2??7). @Hughes's germ phobia reealed in
psychological autopsy@. &P& Online: Monitor on Psychology ,+ (;).
<7. 'ump up ( @(he obsessie disorder that haunts my li!e@. Daily Mail (Eondon).
2??8-?6-?5.
<8. 'ump up ( @1^*1-4(J 'Here's the +ealJ +on't (ouch 9e' by Howie 9andel ,
3:* Dews@. 3bcnews.go.com. -etrieed 2?/?-?8-2?.
<;. 'ump up ( @(he )!!icial 9arc 'ummers #eb 'ite@. Viryours.com. -etrieed
2?//-/2-/?.
<<. 'ump up ( *am!ield, +3& 'arris, O& :erk, 9 (Oun /, 2?//). @Dutraceuticals in the
treatment o! obsessie compulsie disorder ()*+)J a reiew o! mechanistic and clinical
eidence.@. Progress in neuro-psychopharmacology : biological psychiatry ,- (6)J <<;,
>7. 49I+ 2/572<<5.
<>. 'ump up ( Eakhan '1, Vieira L$ (2??<). @Dutritional therapies !or mental
disorders@.3utr + 5J 2. doiJ/?.//<8G/6;7-2<>/-;-2. 49* 226<2?/. 49I+ /<2?<7><.
>?. 'ump up ( +aidson_, Ooyce& (hrostur :Corginsson_ (Oune 2??5). @*urrent and
potential pharmacological treatments !or obsessie-compulsie disorder@. #/pert Opinion
on Investigational Drugs 43 (8)J >>5,
/??/. doiJ/?./7/;G/5765;<6./2.8.>>5.49I+ /2;<58?5.
91. 'ump up ( Loran, Eorrin 9. (2??;). @)bsessie-*ompulsie +isorderJ 3n Kpdate
!or the *linician@. 0ocus (7)J 5.
!n7iety disorders are a group o! mental disorders characteri%ed by e"cessie !eelings
o! an"iety and !ear,
./0
where an"iety is worry about !uture eents and !ear is a reaction to
current eents.
./0
(hese !eelings may cause physical symptoms such as a racing heart and
shakiness.
./0
(here are arious !orms o! an"iety disorders, including generali%ed an"iety
disorder, phobic disorder, and panic disorder. #hile each has its own characteristics and
symptoms, they all include symptoms o! an"iety.
.20
3n"iety disorders are partly genetic but may also be due to drug use including alcohol
and ca!!eine. (hey o!ten occur with other mental disorders, particularly maCor depressie
disorder, bipolar disorder, certain personality disorders, andeating disorders. (he
term an"iety coers !our aspects o! e"periences that an indiidual may haeJ mental
apprehension, physical tension, physical symptoms and dissociatie an"iety.
.50
(he emotions
present in an"iety disorders range !rom simple nerousness to bouts o! terror.
.60
(here are
other psychiatric and medical problems that may mimic the symptoms o! an an"iety disorder,
such as hyperthyroidism.
*ommon treatment options include li!estyle changes, therapy, and medications. 9edications
are typically recommended only i! other measures are not e!!ectie.
.70
3n"iety disorders occur
about twice as o!ten in !emales as males, and generally begin during childhood.
./0
3s many
as /<F o! 3mericans and /6F o! 1uropeans may be a!!ected by one or more an"iety
disorders.
.80
ntrusive thoughts are unwelcome inoluntary thoughts, images, or unpleasant ideas that
may become obsessions, are upsetting or distressing, and can be di!!icult to manage or
eliminate.
./0
#hen they are associated with obsessie-compulsie
disorder ()*+), depression, body dysmorphic disorder (:++), and sometimes attention-
de!icit hyperactiity disorder (3+H+), the thoughts may become paraly%ing, an"iety-
prooking, or persistent. Intrusie thoughts may also be associated with episodic memory,
unwanted worries or memories !rom )*+,
.20
posttraumatic stress disorder, other an"iety
disorders, eating disorders, orpsychosis.
.50
Intrusie thoughts, urges, and images are o!
inappropriate things at inappropriate times, and they can be diided into three categoriesJ
@inappropriateaggressie thoughts, inappropriate se"ual thoughts, or blasphemous religious
thoughts@.
.60
ompulsive behavior is de!ined as per!orming an act persistently and repetitiely without it
leading to an actual reward or pleasure.
./0
*ompulsie behaiors could be an attempt to
make obsessions go away.
.20
(he act is usually a small, restricted and repetitie behaior,
yet not disturbing in a pathological way.
./0
*ompulsie behaiors are a need to reduce
apprehension caused by internal !eelings a person wants to abstain or control.
.50
3 maCor
cause o! the compulsie behaiors is said to beobsessie,compulsie disorder ()*+).
.20
(he
main idea o! compulsie behaior is that the likely e"cessie actiity is not connected to the
purpose it appears to be directed to.
./0
3lso, as well as being associated with obsessie,
compulsie disorder,
.60
$urthermore, there are many di!!erent types o! compulsie behaiors
including, shopping, hoarding, eating,gambling, trichotillomania and picking
skin, checking, counting, washing, se", and more. 3lso, there are cultural e"amples o!
compulsie behae
'amuel Oohnson
"orn /< 'eptember /;?>
().'. ; 'eptember)
Eich!ield, 'ta!!ordshire, Breat :ritain
Died /5 +ecember /;<6 (aged ;7)
Eondon, Breat :ritain
Occupation 1ssayist, le"icographer, biographer, poet
8anguage 1nglish
#ationality :ritish
0pouse(s) 1li%abeth Oeris 4orter
The 1istory of OD
The incidence of Obsessive-Compulsive Disode !OCD"# o Obsessive Compulsive $euosis %s i&
'%s once (no'n# is % el%&ivel) common disode %nd c%n be &%ced his&oic%ll)# coss-cul&u%ll) %nd
%coss % bo%d soci%l spec&um %nd does no& %ppe% &o es&ic& i&self &o %n) specific *oup of
individu%ls. On &he con&%)# ince%sed %v%il%bili&) of infom%&ion sho's numeous e+%mples of OCD#
%nd i&s occuence in &he lives of v%ious 'ell-(no'n fi*ues &hou*hou& &he %*es.
Martin Luther !14,3-1546"# &he fis& %nd mos& impo&%n& le%de of &he -o&es&%n& .efom%&ion in
/uope suffeed fom OCD. 0u&he1s po&2*2# -hilip 3el%nch&hon 'o&e &h%& of&en 'hen
con&empl%&in* &he '%&h of 4od he 'ould epe%&edl) min*le 'i&h his p%)es %nd 'en& on &o
cl%im. That these terrors he experienced either for the first time, or in the most acute manner, during
the year in which he was deprived of a favourite friend, who lost his life by some accident of which I
am ignorant.
3%&in 0u&he !14,3-1546"# pemimpin pe&%m% d%n )%n* p%lin* pen&in* d%l%m .efom%si -o&es&%n di
/op%h men*%l%mi OCD. 5n%( didi(n)% )%n* 0u&he# -hilip 3el%nch&hon menulis b%h%'% (e%p
%p%bil% menimb%n* (emu(%%n 5ll%h di% beul%n* (%li %(%n be*%ul den*%n sol%& d%n pe*i un&u(
menun&u&. 67&u c%% (e&%(u&%n ini di% men*%l%mi s%m% %d% un&u( (%li pe&%m%# %&%u den*%n c%% )%n*
p%lin* &eu(# p%d% &%hun ini di m%n% beli%u &el%h din%fi(%n %(%n (e*em%%n# )%n* (ehil%n*%n
hidupn)% oleh bebe%p% (em%l%n*%n di m%n% s%)% 8%hil
John Bunyan !162,-16,," is %lso believed &o h%ve suffeed 'i&h OCD. The 'i&e %nd pe%che#
f%mous fo 'i&in* Pilgrim's Progress, suffeed un'%n&ed in&usive &hou*h&s of % bl%sphemous n%&ue.
9e *%ve % vivid %ccoun& of &hese in his %u&obio*%phic%l boo( :race abounding to the chief of
sinners! published in 1666. One of his *e%& fe%s '%s &h%& ins&e%d of 'ods of p%ise# he mi*h& be&%)
4od %nd u&&e &eible %nd bl%sphemous %ccus%&ions %*%ins& him.
Dr. Samuel Johnson !1709-17,4"# %ccedi&ed 'i&h compilin* &he fis& dic&ion%) of &he /n*lish
l%n*u%*e# suffeed fom % compulsion of :odd movemen&s; %s descibed b) % fiend# 'i&in* some 225
)e%s %*o. <ohnson 'ould pefom hi*hl) i&u%lised movemen&s %nd %n&ics 'hen p%ssin* ove &he
&heshold of % doo. <us& befoe cossin* &he &heshold# he 'ould 'hil# &'is&# m%(e hi*hl) i&u%lised
h%nd mo&ions %nd &hen 8ump ove &he &heshold in % lon* le%p. 9e 'ould neve s&ep on c%c(s
be&'een p%vin* s&ones. =hen he 'en& fo % '%l(# he &ouched eve) pos& he p%ssed. 7f he missed one#
he 'en& b%c( &o &ouch i&. 7n % p%)e %ccedi&ed &o D <ohnson fom 1766 he 'o&e 1O 4od# *%n& me
epen&%nce# *%n& me efom%&ion. 4%n& &h%& 7 m%) be no lon*e dis&ubed 'i&h doub&s %nd h%%ssed
'i&h v%in &eos.1
/minen& evolu&ionis& Charles Darwin !1,09-1,,2" is no' %lso 'idel) %ccep&ed &o h%ve suffeed fom
OCD. D%'in 'o&e %bou& v%ious obsession%l &hou*h&s %nd ho' he could no& *e& %'%) fom &hem. 7n
% le&&e &o % fiend he 'o&e 17 could no& sleep %nd 'h%&eve 7 did in &he d%) h%un&ed me %& ni*h& 'i&h
vivid %nd mos& 'e%in* epe&i&ion1. The &hou*h&s# %s he himself pu& i&# 'ee of 1hoid spec&%cle1
includin* &hou*h&s &h%& his childen 'ould inhei& his (ind of illness %nd &o s&op &hem he 'ould &)
1closin* his e)es fiml)1 bu& &he) 'ould no& *o %'%). The b%d &hou*h&s duin* &he ni*h& 'ee moe
pesis&en& &h%n &hose in &he d%)# bec%use %& ni*h& he '%s no& dis&%c&ed fom &hem b) %c&ivi&). D%'in
%lso c%ved e%ssu%nce fom o&hes %nd '%s self ci&ic%l %nd %lso fel& himself &o be u*l) %nd 'ould
epe%& himself hundeds of &imes &he m%n&% 17 h%ve 'o(ed %s h%d %s 7 could# %nd no m%n c%n do
moe &h%n &his1.
-eh%ps &he mos& f%mous peson (no'n &o h%ve suffeed 'i&h OCD in moe ecen& &imes '%s &he
&'en&ie&h cen&u) 5meic%n %vi%&o# en*inee# indus&i%lis&# film poduce# film diec&o#
phil%n&hopis&# %nd one of &he 'e%l&hies& people in &he 'old# Howard Hughes !1905 -1976" 'hose
s&o) '%s &old in &he 2004 film# :The "viator!# diec&ed b) 3%&in >cosese %nd s&%in* 0eon%do
DiC%pio. 7n spi&e of his imme%su%ble fin%nci%l 'e%l&h# he spen& his fin%l d%)s bo&h men&%ll) %nd
ph)sic%ll) inc%ce%&ed b) his o'n con&%min%&ion &eos %nd el%bo%&e cle%nin* i&u%ls.
5l&hou*h &hee is no e%l evidence &o su**es& &h%& one of 9u*hes le%din* l%dies# Katherine
Hepburn, h%d OCD# 9o'%d 9u*hes '%s once epo&ed &o h%ve s%id ?&h%&# fo % 'om%n 'ho &%(es 1,
sho'es % d%)# she '%s in no posi&ion &o idicule his obsessions@A.
Thee %e of couse m%n) 'ell (no'n livin* celebi&ies &h%& h%ve in ecen& )e%s been epo&ed &o be
suffein* fom &he illness# o &%(en up &he *o'in* &end of cl%imin* &o be % :bi& OCD;. 3%n) of &hese
cl%ims c%n no& be veified 'i&h %n) de*ee of %ccu%c) %s &o % di%*nosis. =hils& 'e c%n no& see 'h%&
*oes on behind closed doos# o in % peson;s mind# i& is f%i &o s%) &h%& &hee is % hu*e diffeence
be&'een obsessive Bui(s# &h%& %el) c%use dis&ess o %n+ie&) %nd 'hich do no& '%%n& % di%*nosis of
OCD# comp%ed &o &he dis&essin* %nd un'%n&ed e+peience of obsessions %nd compulsions &h%&
imp%c& si*nific%n&l) upon % peson;s eve)d%) func&ionin*# %nd c%n le%ve % peson &o&%ll) debili&%&ed
fo hous %& % &ime - e%l OCD.
9nderstanding Obsessive:ompulsive Disorder
(OD)
ObsessiveCCompulsive Disode !OCD" is % seious %n+ie&)-el%&ed condi&ion 'hee % peson
e+peiences feBuen& in&usive %nd un'elcome obsession%l &hou*h&s# of&en follo'ed b) epe&i&ive
compulsions# impulses o u*es.
The illness %ffec&s %s m%n) %s 12 in eve) 1000 people !1.2D of &he popul%&ion" fom )oun* childen
&o %dul&s# e*%dless of *ende o soci%l o cul&u%l b%c(*ound. 7n f%c&# i& c%n be so debili&%&in* %nd
dis%blin* &h%& &he =old 9e%l&h O*%nis%&ion !=9O" h%s %c&u%ll) %n(ed OCD in &he &op &en of &he
mos& dis%blin* illnesses of %n) (ind# in &ems of los& e%nin*s %nd diminished Bu%li&) of life.
E%sed on cuen& es&im%&es fo &he FG popul%&ion# &hee %e po&en&i%ll) %ound 741#504 people livin*
'i&h OCD %& %n) one &ime. Eu& i& is 'o&h no&in* &h%& % dispopo&ion%&el) hi*h numbe# 50D of %ll
&hese c%ses# 'ill f%ll in&o &he sevee c%&e*o)# 'i&h less &h%n % Bu%&e bein* cl%ssed %s mild c%ses.
OCD pesen&s i&self in m%n) *uises# %nd ce&%inl) *oes f% be)ond &he common pecep&ion &h%& OCD
is meel) h%nd '%shin* o chec(in* li*h& s'i&ches. 7n *ene%l# OCD suffees e+peience obsessions
'hich &%(e &he fom of pesis&en& %nd uncon&oll%ble &hou*h&s# im%*es# impulses# 'oies# fe%s o
doub&s. The) %e of&en in&usive# un'%n&ed# dis&ubin*# si*nific%n&l) in&efee 'i&h &he %bili&) &o
func&ion on % d%)-&o-d%) b%sis %s &he) %e incedibl) difficul& &o i*noe. -eople 'i&h OCD of&en e%lise
&h%& &hei obsession%l &hou*h&s %e i%&ion%l# bu& &he) believe &he onl) '%) &o elieve &he %n+ie&)
c%used b) &hem is &o pefom compulsive beh%vious# of&en &o peven& peceived h%m h%ppenin* &o
&hemselves o# moe of&en &h%n no&# &o % loved one.
Compulsions %e epe&i&ive ph)sic%l beh%vious %nd %c&ions o men&%l &hou*h& i&u%ls &h%& %e
pefomed ove %nd ove %*%in in %n %&&emp& &o elieve &he %n+ie&) c%used b) &he obsession%l &hou*h&s.
5void%nce of pl%ces o si&u%&ions &o peven& &i**ein* &hese obsessive &hou*h&s is %lso consideed &o
be % compulsion. Eu& unfo&un%&el)# %n) elief &h%& &he compulsive beh%vious povide is onl)
&empo%) %nd sho& lived# %nd of&en einfoces &he oi*in%l obsession# ce%&in* % *%du%l 'osenin*
c)cle of &he OCD.
7& h%s &%di&ion%ll) been consideed &h%& &hee %e fou m%in c%&e*oies of OCD. 5l&hou*h &hee %e
numeous foms of &he illness 'i&hin e%ch c%&e*o)# &)pic%ll) % peson;s OCD 'ill f%ll in&o one of &he
fou m%in c%&e*oiesH
Chec(in*
Con&%min%&ion I 3en&%l Con&%min%&ion
9o%din*
.umin%&ions I 7n&usive Thou*h&s
Jo m%n) people 'i&h OCD &hee is of&en %n oveinfl%&ed sense of esponsibili&) &o peven& h%m %nd
%n ove-es&im%&ion %bou& &he peceived &he%& &h%& %n in&usive &hou*h& si*nifies. 7& is &hese f%c&os &h%&
help dive &he compulsive beh%vious# bec%use &he peson 'i&h OCD of&en feels ul&im%&el) esponsible
fo &)in* &o peven& b%d &hin*s h%ppenin*.
To some de*ee OCD-&)pe s)mp&oms %e pob%bl) e+peienced# %& one &ime o %no&he# b) mos&
people# especi%ll) in &imes of s&ess 'hee &he) h%ve succumbed &o &he seemin*l) nonsensic%l need &o
pefom %n odd %nd of&en unel%&ed beh%viou p%&&en. 9o'eve# OCD i&self c%n h%ve % &o&%ll)
dev%s&%&in* imp%c& on % peson;s en&ie life# fom educ%&ion# 'o( %nd c%ee enh%ncemen&&o soci%l
life %nd peson%l el%&ionships.
The (e) diffeence &h%& se*e*%&es li&&le Bui(s# of&en efeed &o b) people %s bein* :% bi& OCD;# fom
&he %c&u%l disode is 'hen &he dis&essin* %nd un'%n&ed e+peience of obsessions %nd compulsions
imp%c&s &o % si*nific%n& level upon % peson;s eve)d%) func&ionin* C &his epesen&s % pincip%l
componen& in &he clinic%l di%*nosis ofObsessie!Compulsie Disorder.
OCD is di%*nosed 'hen &he obsessions %nd compulsionsH
Consume e+cessive %moun&s of &ime !%ppo+im%&el) %n hou o moe"
C%use si*nific%n& dis&ess %nd %n*uish
7n&efee 'i&h d%il) func&ionin* %& home# school o 'o(# includin* soci%l %c&ivi&ies %nd
f%mil) life %nd el%&ionships.
OCD %ffec&s m%les %nd fem%les eBu%ll)# %nd on %ve%*e be*ins &o %ffec& people duin* l%&e
%dolescence fo men %nd duin* &hei e%l) &'en&ies fo 'omen.
>uffees of&en *o undi%*nosed fo m%n) )e%s# p%&l) bec%use of % l%c( of undes&%ndin* of &he
condi&ion b) &he individu%l &hemself %nd %mon*s& he%l&h pofession%ls# %nd p%&l) bec%use of &he
in&ense feelin*s of emb%%ssmen&# *uil& %nd some&imes even sh%me %ssoci%&ed 'i&h 'h%& is of&en
c%lled &he :sece& illness;. This of&en le%ds &o del%)s in di%*nosis of &he illness %nd del%)s in &e%&men&#
'i&h % peson of&en '%i&in* %n %ve%*e of 10C15 )e%s be&'een s)mp&oms developin* %nd see(in*
&e%&men&.
To suffees %nd non-suffees %li(e# &he &hou*h&s %nd fe%s el%&ed &o OCD c%n of&en seem pofoundl)
shoc(in*. 7& mus& be s&essed# ho'eve# &h%& &he) %e 8us& &hou*h&s C no& f%n&%sies o impulses 'hich
'ill be %c&ed upon.
Jo someone 'i&h OCD# &hei lo*ic%l mind %l'%)s em%ins func&ionin*# even if &hei OCD mind is
spi%llin* ou& of con&ol. 3os& people 'i&h OCD (no' &h%& &hei &hou*h&s %nd beh%viou %e i%&ion%l
%nd senseless# bu& feel comple&el) inc%p%ble of s&oppin* &hem# of&en fom fe% &h%& no& comple&in* %
p%&icul% beh%viou 'ill c%use h%m &o % loved one. $o m%&&e ho' sm%ll &he is(# &he peson 'i&h
OCD 'ill %l'%)s feel esponsible fo peven&in* &h%& b%d even& fom h%ppenin*.
OCD c%n %lso be % ch%meleon. Jo some people &he OCD s)mp&oms 'ill em%in unch%n*ed# bu& fo
o&hes i& is no& unusu%l &h%& ove &ime &hee m%) be ch%n*es &o &he &)pe of OCD &h%& becomes
bo&hesome. /Bu%ll)# i& is no& unusu%l fo s)mp&oms &o '%+ %nd '%ne ove &ime if un&e%&ed %nd
become % li&&le li(e % olleco%s&e# 'i&h &he sevei&) ince%sin* duin* &imes of s&ess# peh%ps %& 'o(#
univesi&) o 'i&hin el%&ionships# fo e+%mple.
Doub& is %no&he ch%%c&eis&ic of &he OCD suffee C &he Jench once c%lled OCD :l% folie de dou&e;
'hich &%nsl%&es &o :&he doub&in* dise%se;. Doub& is one of &he emo&ions &h%& feeds mos& obsessive %nd
compulsive beh%viou %nd i& is &his in%bili&) &o live 'i&h doub& %nd unce&%in&) &h%& dives OCD.
-eople 'i&h OCD pefe bl%c( o 'hi&e %ns'es fo &hei OCD# %&he &h%n bein* %ble &o %ccep& sh%des
of *e).
0ef& unchec(ed %nd un&e%&ed# OCD 'ill mushoom %nd feed upon i&self %nd c%n h%ve &he po'e &o
consume if lef& unch%llen*ed.
.eceivin* %ppopi%&e &e%&men&# &he hi*hes& Bu%li&) s&%nd%ds of c%e %nd suppo& %nd s&ic(in* &o &he
&e%&men& pl%n is &he (e) &o lon* &em ecove).
OCD is indeed % chonic# bu& %lso % ve) &e%&%ble medic%l condi&ion. 3os& people c%n le%n &o s&op
pefomin* &hei compulsive i&u%ls %nd &o dece%se &he in&ensi&) of &hei obsession%l &hou*h&s &hou*h
Co*ni&ive Eeh%viou%l The%p) !CET". CET is % fom of &%l(in* &he%p) &h%& focuses on &he poblems
% peson h%s in &he hee %nd no' %nd helps &hem e+ploe %nd undes&%nd %l&en%&ive '%)s of &hin(in*
!&he co*ni&ive %ppo%ch" %nd &o ch%llen*e &hei beliefs &hou*h beh%viou%l e+ecises.
7n m%n) c%ses# CET %lone is hi*hl) effec&ive in &e%&in* OCD# bu& fo some people % combin%&ion of
CET %nd medic%&ion c%n be effec&ive. 3edic%&ion m%) educe &he %n+ie&) enou*h fo % peson &o s&%&#
%nd even&u%ll) succeed in &he%p).
<us& %s % peson 'i&h some &)pes of di%be&es c%n le%n &o m%n%*e &he dise%se b) ch%n*in* &hei die&
%nd e+ecise h%bi&s# % peson 'i&h OCD c%n le%n &o m%n%*e s)mp&oms so &h%& &he) 'on;& in&efee
'i&h d%il) func&ionin*. This %llo's &hem &o e*%in % much impoved Bu%li&) of life# bu& i& is %lso
possible# 'i&h &he i*h& suppo& %nd &e%&men& &o %chieve % comple&e ecove) fom OCD.
Jo&un%&el)# &he medic%l pofession is slo'l) s&%&in* &o undes&%nd %nd iden&if) OCD s)mp&oms
much moe effec&ivel)# esul&in* in %n impovemen& in &e%&men&K ho'eve# i& does s&ill depend on
'hich p%& of &he coun&) )ou m%) live in. Eu&# in *ene%l# &hou*h ch%i&ies li(e OCD-FG 'hich help
&o %ise %'%eness %nd lobb) fo impovemen&s in impoved %ccess &o &e%&men&# &he po*nosis fo
people 'ho suffe 'i&h OCD is much moe hopeful &h%n eve befoe.
=e h%ve poduced &his *uide &o help )ou undes&%nd OCD be&&e %nd# moe impo&%n&l)# ho' &o &e%&
i&# %nd &o offe belief %nd hope &h%& ecove) fom ObsessiveCCompulsive Disode is possible.
T'o fi*ues domin%&ed &he e%l) 20&h-cen&u) his&o) of Os %nd CsH &he
Jench ps)chi%&is& -iee <%ne& %nd &he 5us&i%n ps)chi%&is& >i*mund Jeud.
=hile <%ne& e+p%nded on e+is&in* medic%l ide%s#
1
Jeud epesen&ed %
si*nific%n& be%( fom &he p%s&# % p%%di*m shif&.
Jeud in&epe&ed Os %nd
Cs symbolically. This c%n be seen in his
in&epe&%&ion of % )oun* 'om%n1s
compulsive bed&ime i&u%l. The 19-)e%-
old could no& *o &o sleep un&il she m%de
sue &he cloc(s %nd '%&ches in he oom
'ould no& '%(e he up# %%n*ed he bed
covein* %nd pillo's in e+%c&l) &he i*h&
'%)# %nd &oo( % doLen o&he s&eps %s p%&
of % one- &o &'o-hou ni*h&l) i&u%l. Jeud
in&epe&ed &he fluff) beddin* %s % s)mbol
of pe*n%nc) %nd &he cloc(s %s se+u%l
s)mbols# %s he e+pl%insH 6Cloc(s %nd
'%&chesM&hou*h else'hee 'e h%ve
found o&he s)mbolic in&epe&%&ions fo
&hemMh%ve %ived %& % *eni&%l ole o'in*
&o &hei el%&ion &o peiodic pocesses %nd eBu%l in&ev%ls of &ime#6 'o&e Jeud#
e+pl%inin* 'h) &he p%&ien& emoved &he cloc(s fom he oom. 6Ou p%&ien&
*%du%ll) c%me &o le%n &h%& i& '%s %s s)mbols of &he fem%le *eni&%ls &h%& cloc(s
'ee b%nished fom he eBuipmen& fo &he ni*h&.6
2
Jeud1s &heoies %bou& such m%&&es *%ined influence %nd con&inued &o be
f%il) 'ell-%ccep&ed up &o &he 1970s#
3
%l&hou*h# of couse# o&he ide%s %nd
%ppo%ches %lso e+is&ed.
4
Jo &he cle*)# Jeud1s ide%s %bou& Os %nd Cs mus& h%ve been Bui&e
difficul& &o endue. The cle*) esumed &hei o'n 'i&in* on &he sub8ec& %nd
offeed useful %dvice %bou& 6scuples6 !% &em fo Os %nd Cs" in boo(s b)
-%&ic( 4e%on !1921"# Demo& C%se) !194," %nd o&hes.
5
Jeud c%lled &he illness #wangsneurose. 7n /n*l%nd &his &em '%s
&%nsl%&ed %s 6obsession6 %nd in 5meic% i& bec%me 6compulsion.6 The &em
6obsessive-compulsive disode6 '%s even&u%ll) %dop&ed %s % compomise.
6
>i*mund Jeud %ound %*e 35
SIGMUND FREUD
Sigmund "reud #$%&'($)*)+ wrote a
tremendous amount about obsessional
neurosis. ,he e-.erpt below, a rather long
one, is /rom a le.ture he gae in $)$'($)$0
in whi.h he o//ered a symboli.
interpretation o/ a young woman1s
.ompulsie bedtime ritual.
[L]et us turn to my second example,
which is of quite a different kinda
sample of a very common species, a
sleep-ceremonial.
A nineteen-year-old girl, well
developed and gifted, was the only child
of parents to whom she was superior in
education and intellectual liveliness. As a
child she had been wild and high-spirited, and in the course of the last
few years had changed, without any visible cause, into a neurotic.... We
will not concern ourselves much with her complicated illness, which
called for at least two diagnosesagoraphobia and obsessional
neurosisbut will dwell only on the fact that she also developed a
sleep-ceremonial, with which she tormented her parents.... Our present
patient put forward as a pretext for her nightly precautions that she
needed quiet in order to sleep and must exclude every source of noise.
With that end in view she did two kinds of things. The big clock in her
room was stopped, all the other clocks or watches in the room were
removed, and her tiny wrist-watch was not allowed even to be inside her
bedside table. Flower-pots and vases were collected on the writing-table
so that they might not fall over in the night and break, and disturb her in
her sleep. She was aware that these measures could find only
an ostensible justification in the rule in favour of quiet: the ticking of the
little watch would not have been audible even if it had been left lying on
the top of the bedside table, and we have all had experience of the fact
that the regular ticking of a pendulum-clock never disturbs sleep but
acts, rather, as a soporific. She admitted too that her fear that flower-
pots and vases, if they were left in their places, might fall over and break
of the own accord lacked all plausibility. In the case of other stipulations
made by the ceremonial the need for quiet was dropped as a basis.
Indeed, the requirement that the door between her room and her
parents' bedroom should stay half-openthe fulfilment of which she
ensured by placing various objects in the open doorwayseemed on
the contrary to act as a source of disturbing noises. But the most
important stipulations related to the bed itself. The pillow at the top end
of the bed must not touch the wooden back of the bedstead. The small
top-pillow must lie on this large pillow in one specific way onlynamely,
so as to form a diamond shape. Her head had then to lie exactly along
the long diameter of the diamond. The eiderdown (or 'Duchent' as we
call it in Austria) [also called a duvet] had to be shaken before being laid
on the bed so that its bottom end became very thick; afterwards,
however, she never failed to even out this accumulation of feathers by
pressing them apart.
With your leave I will pass over the remaining, often very trivial,
details of the ceremonial; they would teach us nothing new, and would
lead us too far afield from our aims. But you must not overlook the fact
that all this was not carried out smoothly. There was always an
apprehension that things might not have been done properly. Everything
must be checked and repeated, doubts assailed first one and then
another of the safety measures, and the result was that one or two
hours were spent, during which the girl herself could not sleep and
would not allow her intimidated parents to sleep either.
The analysis of these torments did not proceed so simply.... I was
obliged to give the girl hints and propose interpretations, which were
always rejected with a decided 'no' or accepted with contemptuous
doubt. But after this first reaction of rejection there followed a time
during which she occupied herself with the possibilities put before her,
collected associations to them, produced recollections and made
connections, until by her own work she had accepted all the
interpretations. In proportion as this happened, she relaxed the
performance of her obsessional measures, and even before the end of
the treatment she had given up the whole ceremonial....
Our patient gradually came to learn that it was as symbols of the
female genitals that clocks were banished from her equipment for the
night. Clocks and watchesthough elsewhere we have found other
symbolic interpretations for themhave arrived at a genital role owing
to their relation to periodic processes and equal intervals of time. A
woman may boast that her menstruation behaves with the regularity of
clockwork. Our patient's anxiety, however, was directed in particular
against being disturbed in her sleep by the ticking of a clock. The ticking
of a clock may be compared with the knocking or throbbing in the clitoris
during sexual excitement. She had in fact been repeatedly woken from
her sleep by this sensation, which had now become distressing to her;
and she gave expression to this fear of an erection in the rule that all
clocks and watches that were going should be removed from her
neighbourhood at night. Flower-pots and vases, like all vessels, are also
female symbols. Taking precautions against their falling and being
broken at night was thus not without its good sense. We know the
widespread custom of breaking a vessel or plate at betrothal
ceremonies. Each man present gets hold of a fragment, and we may
regard this as a sign of his resigning the claims he had upon the bride in
virtue of a marriage-regulation dating from before the establishment of
monogamy. In connection with this part of her ceremonial the girl
produced a recollection and several associations. Once when she was a
child she had fallen down while she was carrying a glass or china vase
and had cut her finger and bled profusely. When she grew up and came
to know the facts about sexual intercourse she formed an anxious idea
that on her wedding-night she would not bleed and would thus fail to
show that she was a virgin. Her precautions against vases being broken
thus meant a repudiation of the whole complex concerned with virginity
and bleeding at the first intercoursea repudiation equally of the fear of
bleeding and of the contrary fear of not bleeding. These precautions,
which she subsumed under her avoidance of noise, had only a remote
connection with it.
She found out the central meaning of her ceremonial one day when
she suddenly understood the meaning of the rule that the pillow must
not touch the back of the bedstead. The pillow, she said, had always
been a woman to her and the upright wooden back a man. Thus she
wantedby magic, we must interpolateto keep the man and woman
apartthat is, to separate her parents from each other, not to allow
them to have sexual intercourse....
If a pillow was a woman, then the shaking of the eiderdown till all
the feathers were at the bottom and caused a swelling there had a
sense as well. It meant making a woman pregnant; but she never failed
to smooth away the pregnancy again, for she had for years been afraid
that her parents' intercourse would result in another child and so present
her with a competitor. On the other hand, if the big pillow was a woman,
the mother, then the small top-pillow could only stand for the daughter.
Why did this pillow have to be placed diamond-wise and her head
precisely along its centre line? It was easy to recall to her that this
diamond shape is the inscription scribbled on every wall to represent the
open female genitals. If so, she herself was playing the man and
replacing the male organ by her head....
Wild thoughts, you will say, to be running through an unmarried
girl's head. I admit that is so. But you must not forget that I did not make
these things but only interpreted them....
PIERRE JANET
2ierre Janet #$%&)($)30+, a "ren.h
psy.hiatrist, published a boo4
.on.erning obsessions and .ompulsions
in $)5*. His 0&5(page tome has neer
been translated into 6nglish. Howeer, a
detailed 6nglish(language synopsis is
aailable, /rom whi.h this e-.erpt is
ta4en.
In interviews [Janet wrote], obsessive patients usually experience
great difficulty and reluctance in divulging the content of their
obsessions and compulsions, which often involve forbidden thoughts
and acts of a sacrilegious, violent, or sexual nature. Their reporting is
universally accompanied by remorse, as if the imagined acts had
actually been committed. Some patients feel remorse about every
action they perform. Obsessions of shame of the self and the body are
common. There is often a sense of doing things wrongly and
imperfectly.
<%ne& &i&led his boo(
$bsessions and Psychasthenia
If the sufferer can admit to having done a good deed, he will impugn
the motive behind it. Everything is doubted....
Obsessives tend not to worry about things outside their control but
rather about things within their (imagined) control.... These actions are
generally bad, the opposite of what the patient wishes to do. One
patient, asked why she thought of killing her daughter and not her
husband, responded, "Oh, my husband, I don't love him enough to think
of killing him." Thus obsessions and compulsions often involve the
thought or action that is most objectionable to the patient and causes
him the most horror; this has been referred to as "association by
contrast."
... One property of obsessions is their easy evocability, even by
peripherally connected ideas. For example, the patient Jean avoided
wearing a certain pair of shoes because they made him think of a
woman with whom he was obsessed. The connection was that the
shoes had the number "49" on them, and the woman had been age 49
when his obsession with her had begun. Obsessional ideas may spread
like an oil slick to include more and more peripherally related ideas.
[Another class of symptoms] demonstrate a need for precision or
perfection in perceptions and actions. They include manias of order and
symmetry. If Jean on arising, chances to view a red object on his right,
he needs to find one on his left. Arithmetic manias arise because
numbers are seen as precise. Symbolism plays a large role in the
malady and the mania of symbolism is also related to the need for
precision, to express with sharpness feelings and ideas about which the
patient is uncertain. For Lod . . . pivoting on the heels symbolizes
religion "because one turns sideways to bow before the altar when one
passes in front of it."... The mania of slowness arises from the fear that
an action done quickly won't be done precisely, and the mania of
repetition arises from the feeling of discontent with the way an action
was previously performed; as does the mania of going back
(checking)....
These patients are characteristically thin, pale, and drawn and
frequently have dry skin and bad breath, all of which tend to improve
when their psychological troubles do....
[Their personality] is generally one of timidity. They often have a
horror of physical exercise, are awkward, and don't know what to do
with their hands. If there's anything they find more painful than a
decision, it's a fight, and they will sacrifice their own interests to avoid
one. They think in terms of perfectly honest and ideal worlds and
wouldn't dream of injuring anyone. Their dispositions are usually
melancholic....
Somatic treatment. When a psychasthenic [a broader term that
encompassed OCD sufferers] does come to the attention of a physician,
because he is likely to consider himself unique and not amenable to
treatment, the physician should not express surprise at the symptoms
but rather demonstrate familiarity with them.... Proper nutrition, sleeping
habits, fresh air, and avoidance of fatigue should be emphasized, and
any underlying medical conditions treated. Bromides in high doses may
be useful for agitation. The author has infrequently prescribed opium for
those suffering from great anxiety, though the danger of addiction
usually outweighs the potential benefits. Because the patient's excitation
is secondary and a manifestation of a diminution of central nervous
activity, tonic medications and cold hydrotherapy may be helpful. (pp.
293-5, 302, 309, 312)