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Obsessive Compulsive Disorders (OCDs) involve habitual, repetitive behaviours that can be bizarre, disruptive and eventually disabling. They can destroy lives and relationships and are one of the most common of the emotional disorders.
The last five years have seen substantive advances in the state of knowledge of all aspects of OCD and this volume brings together many of the recognised leaders in the field to provide a state-of-the-art account of theory, assessment and practice in treatment.
A comprehensive text for trainees and practitioners.
? Presents current theories as well as treatment, focusing mainly on Cognitive Therapy methods of treatment
? Covers the assessment, nature and treatment of a wide range of sub-types of OCD
? Written by an international team of experts
Part of the renowned Wiley Series in Clinical Psychology
Annette Krochmalik and Ross G. Menzies
This opening chapter will endeavour to provide an historical account of obsessive-compulsive disorder (OCD), and will also examine contemporary diagnostic and classificatory issues. The similarity of OCD to a number of other disorders, including the degree of co-morbidity with these, will also be addressed. Finally, a close examination of the epidemiology of the condition will be provided.
The symptoms of OCD have been identified, with some consistency, from as early as the seventeenth century. At this time, obsessions were considered to exist purely within a religious framework and sufferers were considered to be possessed by outside forces, such as the devil (Salzman & Thaler, 1981). Not surprisingly, the most popular treatment method was exorcism, which, by all reports, resulted in some cases of therapeutic success. While little is known about the type of compulsive behaviour that dominated clinical presentations in this period, it is noteworthy that washing/cleaning behaviours have been clearly described from the earliest literature. Perhaps the first fictional portrayal of OCD is Shakespeare's illustration of Lady Macbeth in the sixteenth century. As we all know, this character, in an attempt to rid herself of guilt, repeatedly engaged in hand washing, a behaviour which continues to dominate much of the contemporary literature on the condition.
By the early part of the nineteenth century, OCD had moved from the spiritual to the medical field of enquiry. The condition was considered to be a variant of 'insanity', a construct earlier introduced and defined by a number of French psychiatrists. Esquirol (1838) was the first to argue that, since his patients were aware that their obsessions were irresistible, they possessed a certain degree of insight. Thus, the emergence of 'neurosis' began during the early 1800s, a notion further developed when Morel described OCD as a 'disease of emotions'. He used the word 'delire' to allow for the unconventional reference to the presence of insight. Towards the end of the nineteenth century, Legrand du Saulle described OCD as an insanity with insight, but suggested that psychotic symptoms could be present (an issue that was later to become a contentious one in differential diagnosis). Of course, at this time, OCD, phobias, panic and other somatic symptoms were not well differentiated, further confusing the definition and description of OCD.
Across Europe, these early descriptions of OCD focused on differing aspects of the disorder, and were dependent largely on prevailing cultural issues in the homeland of the writer. While the English concentrated on the religious perspective of OCD and viewed the disorder as a melancholic illness, the French stressed the loss of will, or volition, and identified anxiety at the heart of the disorder. German writers, such as Westphal (1878), identified irrational thoughts as neurological events that had a cognitive representation.
These early European descriptions of OCD, especially the French and German perspectives, paved the way for the psychological perspective that was to emerge from the beginning of the twentieth century. Until this time, OCD was considered a medical condition, which warranted treatment within a medical framework (Rachman & Hodgson, 1980). It was only when clinical psychology emerged from the existing framework of clinical psychiatry that a non-pathological, non-religious view of OCD was clearly offered. Drawing on the research by Legrand du Saulle, Janet (1903) was the first to put forward the psychological view of obsessive-compulsive neurosis. He proposed that all obsessional patients possessed an 'abnormal' personality, with features such as anxiety, excessive worrying, lack of energy and doubting, and described successful treatment of compulsive rituals consistent with the later development of behaviour therapy (Jenike et al., 1998a; Rachman & Hodgson, 1980).
At around this time Freud (1896) proposed a revolutionary theory for the existence of obsessional thinking in which he defined obsessional ideas as 'transformed self-reproaches which have re-emerged from repression and which always relate to some sexual act that was performed with pleasure in childhood' (Freud, 1896, p. 169). This suggestion was formulated predominantly from his experience with patients at the turn of the nineteenth century. Although Freud saw a number of patients whom he considered to be suffering from obsessional neurosis, much of his thinking (and writing) on OCD was based on the now famous 'Rat Man', a case which will be briefly outlined below.
The patient, a youngish man of university education, told Freud that he had suffered from obsessions since early childhood. As a child, he had experienced an unnatural obsession about the death of his father (having believed that he had the power to control his father's general well-being). Without apparent questioning, the patient proceeded to discuss his infantile sexuality. From an early age, he expressed the wish to see girls naked and had a desire to touch them. Accompanying this desire was the feeling that if he did not prevent such thoughts, his father might die. The patient subsequently developed certain impulses that he believed would be effective in warding off the impending evil. These 'impulses' are now more commonly known as compulsions that serve to reduce the anxiety associated with his obsessive thinking.
Later in this patient's life, he came across a senior officer who conveyed a form of punishment that was extremely unnerving to him. This particularly horrendous method of torture involved the criminal being tied up and then having rats placed under a pot, which was turned upside down on the man's buttocks. The rats, having no means of escape, slowly bore their way into the man's buttocks (Freud, 1909). Although the patient expressed horror as he conveyed this story to Freud, Freud interpreted it as one of 'horror at pleasure of his own of which he himself was unaware' (p. 167). The precipitating cause of this man's obsessional thinking was never clearly identified by Freud or by the patient himself. Freud (1909) argued that the 'infantile preconditions of the neurosis may be overtaken by amnesia ... though the immediate occasions of the illness are ... retained in the memory' (pp. 195-6).
In a second illustrative example of OCD from the dynamic perspective, Freud (1909) described the symptoms of a patient who displayed an obsession with cleanliness. This particular individual was a government official who always presented crisp paper notes as payment. Freud remarked that that they were distinctive because they were always clean and smooth. The patient replied that he had ironed them at home for fear of contracting an illness from the bacteria on the notes. Because of Freud's suspicion of a link between the neuroses and infantile sexuality, he enquired about the patient's sexual life. The patient replied that he found it gratifying to masturbate a number of young women with his hands. To this Freud replied, 'but aren't you afraid of doing (them) some harm, fiddling about in (their) genitals with your dirty hand?' (p. 197). The patient was horrified and remarked that it had never done any of the girls harm. On the contrary, he claimed, they had enjoyed the activity. Freud believed that this patient was able to justify his inappropriate sexual behaviour by the displacement of his self-reproach and, in line with his theory, assumed that the patient's sexual gratification was 'probably impelled by some powerful infantile determinants' (p. 198).
Instead of a medical treatment regime typical of the late nineteenth century, Freud opted for psychoanalysis, an attempt to resolve past conflicts in the afflicted individual by appealing to the unconscious. However, this form of treatment did little to improve the outcome of OCD patients (Jenike et al., 1998a). An important distinction was also made. Freud believed that obsessive-compulsive neurosis existed as a syndrome separate from the 'anal-erotic' character. The latter syndrome, according to Freud, predisposed an individual to the development of OCD. It is this distinction, as discussed later in this chapter, that (in part) led to the present-day differentiation of OCD and obsessive-compulsive personality disorder (OCPD).
The most significant theoretical developments in the period since Freud are undoubtedly the emergence of the neurobiological and psychological/ cognitive perspectives. Since they, along with the treatments that stem from them, will be described in detail in various chapters that follow, they will not be dealt with here. Instead, attention will turn to the classification of the disorder, which, along with improvements in assessment, may be regarded as the other significant development in the area in the twentieth century.
CLASSIFICATION OF OCD
Contemporary attempts at the classification of OCD are now governed by two systems, the International Classification of Diseases, 10th Revision (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders, 4th edn (DSM-IV;APA, 1994). Although the ICD-10 (WHO,1992) is regarded as the official coding system in many countries, the DSM-IV (APA, 1994) is the more popular amongst mental health professionals (Andrews et al., 1999).
Current Classification According to DSM-IV
The DSM-IV (APA, 1994) describes OCD according to five diagnostic criteria. The principle features of the disorder are: (a) recurrent thoughts, or images (termed 'obsessions') that are considered intrusive and that cause significant distress; and (b) ritualistic behaviours (termed 'compulsions') typically engaged in to rid or neutralise obsessive thoughts. Although it may be difficult to ascertain the degree of distress, the DSM-IV maintains that an individual must experience a significant disturbance in normal functioning, or engage in obsessive-compulsive activity for at least 1 hour/day, to be given a diagnosis of OCD. Further, the individual must, at some point during the course of the disorder, recognise the irrationality of his/her thoughts and behaviour. A specification of poor insight may be added to the diagnosis of OCD when an individual does not currently recognise that the obsessions and compulsions are excessive or unreasonable.
Previously, a diagnosis of OCD implied that the individual could generally recognise that his/her fears were irrational or unreasonable throughout the life of his/her disorder (Enright & Beech, 1997). It was only in DSM-IV that a 'poor insight' specification was added in order to account for a number of individuals who appear to fail to accept the senselessness and futility of their obsessive and compulsive behaviours. The addition of this category in the diagnosis of OCD may be considered favourable from a treatment perspective, since it is well established that individuals with a strong conviction that their fears are realistic have poor outcomes in behavioural programs (Foa, 1979). However, a number of writers have argued that the added specification of 'poor insight' does not help to clarify the distinction between OCD and other disorders. In fact, it may further complicate classificatory difficulties as it introduces a new problem. OCD sufferers with poor insight, or overvalued ideas, must now be distinguished from individuals with delusional beliefs. DSM-IV dictates that OCD should be diagnosed when 'an individual whose extreme preoccupation ... although exaggerated, is less intense than in a Delusional Disorder' (APA, 1994, p. 422). But what is 'less intense' and how may it be defined?
In sum, the addition of 'poor insight' to the diagnosis of OCD brings about a number of difficulties that render the differential diagnosis of this disorder problematic. In order to establish a clear-cut definition of OCD, these concerns need to be considered. The following section will address: (a) the question of the classification of OCD as an anxiety disorder; and (b) the significant degree of overlap with a number of other disorders, e.g. the obsessive-compulsive spectrum disorders, the mood disorders, the personality disorders, and the schizophrenic disorders.
OCD AND THE ANXIETY DISORDERS
Ever since the introduction of the DSM-III, OCD has been classified amongst the anxiety disorders. However, the substantial overlapping features and high co-morbidity rate of OCD with other anxiety disorders complicates the diagnosis of OCD.
Distinctions between OCD and GAD
First and foremost, the greatest difficulty in the differential diagnosis of OCD and generalised anxiety disorder (GAD) lies in the distinction between worry and obsession. A number of researchers have attempted to clarify this distinction but there is little evidence to suggest that worry and obsessions do not simply reflect the same mental process (Turner 1992). The only distinguishing feature between these concerns offered by the DSM-IV (APA,1994) appears to rest on the consistency or duration of distress for sufferers of the two conditions. Worry appears to be a more drawn-out or consistent concern in GAD than does obsession in OCD, in that the former must 'occur more days than not for at least 6 months'. Descriptions of obsession imply a recurrence and persistence in thought but do not include any given time duration. In terms of the level of disturbance, there appears to be no distinction. Andrews et al. (1994) argue that the most important distinguishing feature is that the content of worry/obsession may be regarded as different in these two disorders. These authors argue that individuals suffering from GAD are primarily concerned with everyday issues (e.g. family, health or occupational issues that may be deemed 'appropriate'), whereas OCD sufferers frequently report unusual themes concerning dirt and contamination, aggression, hoarding and religion.
But is a distinction based simply on 'content' areas adequate? Is it possible (and clinically valid) to distinguish between everyday worries and other concerns? For example, if an individual expresses worries about the possible contamination of her child, is this concern different from a 'family or health concern' frequently reported by patients with GAD?
Important also is the notion of 'rumination' and its distinction from typical obsessional activity in OCD and worry amongst patients with GAD (see further discussion in Chapter 11). De Silva & Rachman (1992) have noted that the content of ruminatory thoughts tend to concern religious, philosophical or metaphysical subjects, which, once again, may tend to prove difficult to distinguish from obsessive thoughts or generalised worry.
Excerpted from Obsessive-Compulsive Disorder by Ross Menzies Copyright © 2003 by Ross Menzies. Excerpted by permission.
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|About the Editors|
|List of Contributors|
|Ch. 1||The Classification and Diagnosis of OCD||3|
|Ch. 2||The Phenomenology of OCD||21|
|Ch. 3||Neuropsychological Models of OCD||39|
|Ch. 4||Cognitive-behavioural Theory of OCD||59|
|Ch. 5||Repetitive and Iterative Thinking in Psychopathology: Anxiety-inducing Consequences and a Mood-As-Input Mechanism||79|
|Ch. 6||Personality and Individual Differences in OCD||101|
|Ch. 7||Obsessive-compulsive Washing||121|
|Ch. 8||Compulsive Checking||139|
|Ch. 9||Compulsive Hoarding||163|
|Ch. 10||Primary Obsessional Slowness||181|
|Ch. 11||Obsessions, Ruminations and Covert Compulsions||195|
|Ch. 12||Atypical Presentations||209|
|Ch. 13||The Obsessive-compulsive Spectrum and Body Dysmophic Disorder||221|
|Ch. 14||Assessment Procedures||239|
|Ch. 15||Exposure and Response Prevention for OCD||259|
|Ch. 16||Cognitive Therapy for OCD||275|
|Ch. 17||Pharmacological and Neurosurgical Treatment of OCD||291|
|Ch. 18||OCD in Children and Adolescents||311|
|Ch. 19||The Management of Treatment-resistant Cases and other Difficult Clients||321|
|Ch 20||Training, Resources and Service Provision||349|