Obsessive-Compulsive and Related Disorders
Obsessive-compulsive and related disorders are a group of disorders that tend to involve intrusive, distressing thoughts and repetitive behaviors or mental rituals.
Many people have occasional unwanted thoughts (for example, craving a double cheeseburger while dieting) or habits (like pacing when nervous). The key difference is severity and impairment: in obsessive-compulsive and related disorders, the thoughts and rituals are so frequent or intense that they disrupt daily life. This category includes obsessive-compulsive disorder (OCD), body dysmorphic disorder, and hoarding disorder.
obsessive-compulsive disorder (OCD)
Obsessive-compulsive disorder (OCD) is characterized by obsessions (intrusive, unwanted thoughts, urges, or images) and/or compulsions (repetitive behaviors or mental acts) that are experienced as distressing and difficult to control. The obsessions and compulsions are time-consuming or cause significant distress or impairment in daily functioning.
Common compulsive behaviors include repeated hand washing, checking (such as locks or appliances), ordering, or mental rituals like counting or repeating phrases. These behaviors are not performed for pleasure and are often not logically connected to the feared outcome they are intended to prevent.
Obsessions
Obsessions are persistent, intrusive, and unwanted thoughts, urges, or images that cause marked anxiety or distress (APA, 2013). Typical obsession themes include contamination, doubt, order and symmetry, and intrusive aggressive or sexual thoughts. Although these thoughts are generally recognized as irrational or excessive, attempts to suppress or ignore them are often unsuccessful.
Compulsions
Compulsions are repetitive behaviors or mental acts that are driven by the urge to reduce distress or prevent a feared event (APA, 2013). Examples include excessive cleaning, repeated checking, arranging items in specific ways, and mental rituals such as counting or praying. Compulsions usually provide only temporary relief, which reinforces the cycle of obsessive thoughts and ritualized behavior.
Lifetime prevalence estimates suggest that approximately 2–3% of U.S. adults will meet criteria for OCD. Without treatment, OCD often follows a chronic course and can significantly interfere with relationships, education, and employment.
Causes of OCD
Research suggests that OCD has a moderate genetic component. The disorder occurs more frequently among first-degree relatives of individuals with OCD, and twin studies show substantially higher concordance rates among identical twins than fraternal twins.
Neuroimaging studies consistently implicate dysfunction in fronto-striatal brain circuits, particularly the orbitofrontal cortex, which is involved in evaluating threat, decision-making, and behavioral control.
For example, in people with OCD, the orbitofrontal cortex becomes especially hyperactive when they are provoked with tasks in which, for example, they are asked to look at a photo of a toilet or of pictures hanging crookedly on a wall (Simon, Kaufmann, Müsch, Kischkel, & Kathmann, 2010). The orbitofrontal cortex is part of a series of brain regions that, collectively, is called the OCD circuit; this circuit consists of several interconnected regions that influence the perceived emotional value of stimuli and the selection of both behavioral and cognitive responses (Graybiel & Rauch, 2000).
As with the orbitofrontal cortex, other regions of the OCD circuit show heightened activity during symptom provocation (Rotge et al., 2008), which suggests that abnormalities in these regions may produce the symptoms of OCD (Saxena, Bota, & Brody, 2001). Consistent with this explanation, people with OCD show a substantially higher degree of connectivity of the orbitofrontal cortex and other regions of the OCD circuit than do those without OCD (Beucke et al., 2013).
Because these findings are correlational, they cannot establish whether brain differences cause OCD or result from long-term symptoms.
OCD and Classical Conditioning
The symptoms of OCD have been theorized to be learned responses, acquired and sustained as the result of a combination of two forms of learning: classical conditioning and operant conditioning (Mowrer, 1960; Steinmetz, Tracy, & Green, 2001). Specifically, the acquisition of OCD may occur first as the result of classical conditioning, whereby a neutral stimulus becomes associated with an unconditioned stimulus that provokes anxiety or distress.
When an individual has acquired this association, subsequent encounters with the neutral stimulus trigger anxiety, including obsessive thoughts; the anxiety and obsessive thoughts (which are now a conditioned response) may persist until they identify some strategy to relieve it. Relief may take the form of a ritualistic behavior or mental activity that, when enacted repeatedly, reduces the anxiety. Such efforts to relieve anxiety constitute an example of negative reinforcement (a form of operant conditioning).
Recall from the module on learning that negative reinforcement involves the strengthening of behavior through its ability to remove something unpleasant or aversive. Hence, compulsive acts observed in OCD may be sustained because they are negatively reinforcing, in the sense that they reduce anxiety triggered by a conditioned stimulus.
Suppose an individual with OCD experiences obsessive thoughts about germs, contamination, and disease whenever they encounter a doorknob. What might have constituted a viable unconditioned stimulus? Also, what would constitute the conditioned stimulus, unconditioned response, and conditioned response? What kinds of compulsive behaviors might we expect, and how do they reinforce themselves? What is decreased? Additionally, and from the standpoint of learning theory, how might the symptoms of OCD be treated successfully?
Related Disorders
body dysmorphic disorder
Body dysmorphic disorder is characterized by a persistent preoccupation with one or more perceived flaws in physical appearance that are either nonexistent or appear minimal to others (APA, 2013). These perceived defects can lead to intense beliefs that one is unattractive, ugly, deformed, or flawed.
The preoccupation may focus on any body area, but most commonly involves the skin, face, or hair. This excessive concern is accompanied by repetitive behaviors or mental acts, such as frequent mirror checking, attempts to conceal the perceived flaw, comparing one’s appearance to others, reassurance seeking, and, in some cases, repeated cosmetic procedures (Phillips, 2005). These behaviors are time-consuming and cause significant distress or impairment in daily functioning.
hoarding disorder
Hoarding disorder is characterized by persistent difficulty discarding or parting with possessions, regardless of their actual value (APA, 2013). Although hoarding was historically considered a subtype or symptom of obsessive-compulsive disorder, substantial evidence now supports its classification as a distinct disorder (Mataix-Cols et al., 2010).
The inability to discard items leads to the accumulation of possessions that clutter living areas and compromise their functionality—for example, kitchens that cannot be used for cooking or bedrooms that cannot be used for sleeping. Difficulty discarding items is often driven by beliefs that possessions may be useful in the future or by strong emotional or sentimental attachment to them.
A diagnosis of hoarding disorder is made only when the behavior is not attributable to another medical condition and is not better explained by another mental disorder, such as schizophrenia or major depressive disorder (APA, 2013).