Task 5. Thought suppression & Obsessive compulsive disorder
Learning goals
What is OCD and what are the subtypes?
Clark, D. A. and González, A. d. P. (2014). Obsessive-Compulsive Disorder, in The Wiley
Handbook of Anxiety Disorders
Obsessive-compulsive disorder (OCD) is moved from the classification within the anxiety
disorders to its own classification “Obsessive-Compulsive and Related Disorders”.
Definition and symptom features
Obsessions are persistent, unwanted, and intrusive thoughts, images, or impulses (urges)
that are normally distressing and difficult to control despite the individual’s attempt to
prevent their occurrence or to neutralize their adverse effects. The most common
obsessions deal with themes of dirt/contamination and pathological doubt over one’s
actions (e.g., locking the door/turning off the stove or water taps), followed to a lesser
extent by somatic concerns and order/symmetry, as well as repugnant thoughts of sex,
immorality, religion, harm or aggression to self or others. Obsessions usually cause
considerable anxiety, although the severity of the anxiety or distress can vary significantly.
Guilt is often associated with obsessions, especially when the obsessions are repugnant.
Obsessions and compulsions are usually functionally related. For example, obsessional fears
of dirt or contamination are often associated with cleaning and washing compulsions, and
doubting obsessions are accompanied by repeating and checking rituals. Occasionally, the
functional relation between an obsession and a compulsion is rather weak.
Compulsions are repetitive, stereotypic, intentional behaviors or mental acts that the person
feels driven to perform in order to neutralize anxiety associated with an obsession or
prevent some imagined dreaded outcome. Compulsions are intended to counteract or
neutralize the obsession by removing, preventing, or weakening the obsessive thought or its
associated distress. Although the individual may attempt to subjectively resist the
compulsion, the drive to perform the ritual becomes so great the individual finally gives into
the compulsive urge.
Although the majority of individuals with OCD have overt compulsive rituals, other forms of
neutralization may be even more prominent. Individuals with OCD may use other cognitive
strategies like reassurance seeking, rationalization, distraction, thought stopping, and
thought suppression even more than compulsive rituals to neutralize the obsession. In most
cases the compulsion serves multiple functions such as reduction of disgust feelings, to
correct or undo an obsession, or it can occur automatically without thinking.
Obsessions, worry, intrusive thoughts, and depressive rumination
Depressive rumination, pathological worry, trauma-related intrusions, and postevent
rumination (social anxiety) also forms of unconstructive repetitive thought that may be
associated with a sense of uncontrollability. An investigation is focused on the differentiation
of obsessions from worry. Although both worry and obsessions are excessive emotionally
valued cognitions, they are distinguished by their content. Obsessions tend to focus on fears
and concerns that are unrealistic, even irrational or imaginary, and so have been described
,as ego-dystonic. Worry focuses on more ego-syntonic, everyday negative outcomes
involving finances, work, family, health etc. Obsessions are also more likely to lead to overt
compulsions and to be judged as entirely unacceptable, even horrendous, by the individual.
Studies indicate that thought-action fusion (TAF) bias and, to a lesser extent, dysfunctional
beliefs about importance/control of thoughts may be specific to obsessions, whereas deficits
in attentional control are more characteristic of perseverative worry. A study showed, that
meta-worry (worry about worry) was related to both obsessions and worry, whereas
cognitive self-consciousness was distinct from obsessional thoughts and thought suppression
was more evident in worry. Repetitive behaviors or compulsions have also been reported in
GAD, although the checking associated with obsessions is more object focused and more
highly associated with TAF than the checking associated with worry. Together these findings
indicate that worry and obsessions are distinct repetitive cognitive phenomena, although
they do share many similar features. In the end differences in focus, underlying beliefs, and
associated response strategies might be the best approach for differentiating these
phenomena.
The study of Rachman and de Silva “Abnormal and Normal Obsessions” became a
foundation for the cognitive behavioural model of OCD. They found that 84% of nonclinical
individuals reported unwanted intrusive thoughts, images, or impulses that had a similar
theme or content to clinical obsessions. It would appear that the differences between
“normal” and “abnormal” can be distinguished more by their intensity or severity rather
than any distinct characteristic. Most studies have found that clinical obsessions are more
frequent, distressing, unacceptable, subjectively uncontrollable, resisted, and ego-dystonic
than the intrusions in nonclinical samples. Moreover, there is evidence that individuals with
OCD are more likely to use compulsions and other maladaptive control strategies in
response to their obsessions, avoid perceived triggers, and exhibit thought-action fusion and
overimportance of thought control appraisals.
The evidence that clinical obsessions may be qualitatively more extreme or bizarre than
nonclinical intrusions, is been discussed. It is argued that appraisals may play a more
important role in the intrusions of nonclinical individuals, whereas the occurrence of
obsessions in contexts that are inappropriate may distinguish clinical from nonclinical
obsession. However, there has been practically no experimental research to disentangle the
phenomenological features of clinical and nonclinical obsessions.
Rumination can be defined as conscious, recurrent thought about personal concerns that
recur without immediate environmental demands. In the context of depression, rumination
is repetitive and passive thinking about the possible causes and consequences of one’s
depressive symptoms. It is also suggested that rumination focusses on current distress or the
causes and consequences of stressful life events. In OCD, obsessional rumination is used
when there are obsessions without overt compulsive behaviour. However, it is argued that
the term should be reserved for cases in which a mental compulsion occurs in response to
an obsessional thought. Like depressive rumination, obsessional rumination has a more
intentional element than is evident in obsessions.
There has been little empirical research on depressive rumination in OCD. Observational
studies suggest that individuals with OCD often ruminate about the negative impact and
uncontrollability of their disorder.
,In sum, there are a number of qualities that distinguish obsessions from normal intrusive
thoughts. There is still much debate over whether content will be helpful, but certainly
clinical obsessions are much more frequent, intense, and uncontrollable than nonclinical
intrusive thoughts. Where to draw the diagnostic boundary in distinguishing pathological
and nonpathological obsessions is difficult. The degree of interference in daily living and
whether the obsessions are cued in an inappropriate context will be helpful in this regard.
The case for distinguishing rumination in OCD is more difficult given the lack of empirical
evidence. At this point, the practitioner must rely on clinical experience to guide a
sophisticated differentiation between ruminations and obsessions, especially when the
intrusions may be ego-syntonic such as in somatic obsessions.
Intrusions are part of obsessions, but they are not that severe because you apprise them
differently.
Diagnostic status
DSM-V considers OCD the prototypic disorder belonging to the category of “Obsessive-
Compulsive and Related Disorders” in which the individual must have either obsessions and/
or compulsions that cause significant distress, are time consuming, or interfere in normal
daily functioning. Obsessions are characterized as recurrent and persistent thoughts, images,
or impulses that cause high anxiety or distress, were at least at some time during the
disturbance experienced as intrusive and unwanted, and are suppressed or neutralized.
DSM-V describes compulsions as repetitive behaviors or mental acts that a person feels
driven to perform, and that are aimed at reducing anxiety (or distress) or preventing some
dreaded outcome. The rituals may not be connected in a realistic way with the target of
their neutralization efforts.
The new category “Obsessive-Compulsive and Related Disorders” includes OCD, hoarding
disorder, trichotillomania and skin-picking disorder, as well as several OCD residual
categories. The reclassification could have a significant impact on how we understand and
treat the disorder. Current cognitive and cognitive-behavioral perspectives have continued
to consider OCD an anxiety disorder.
A study concluded that OCD compared to other anxiety disorders has more symptom
heterogeneity, its neurocircuitry exhibits greater fronto-striatal hyperactivity, there is some
distinct impairment of inhibitory executive function, and it shows poorer response to
anxiolytic medications. At the same time, OCD is comorbid with other anxiety disorders and
OC spectrum disorders.
From the genetics type of view, OCD is both related to the obsessive compulsive and related
disorders kind of view and the anxiety kind of view
Epidemiology
Populations estimates
The lifetime prevalence of OCD in the general population varies between 1-3%. In the US, a
12-month and lifetime prevalence rate of 1,6% and 2,3% was reported. However, the
lifetime prevalence of OCD varies between countries. In most countries 1 of 100 individuals
experiences OCD, making it one of the least common of the anxiety disorders.
, Age and gender
The prevalence of OCD for children, adolescents and adults are similar. Adulthood age
differences have been reported, with OCD more prevalent among 20- to 44-year-olds (2,3%)
and least prevalent among adults over 65 years (0,7%). The ratio of women to men suffering
from OCD varies with the age group. During childhood and adolescence there is no
difference, but with adulthood prevalence is higher in women. Among older adults, the ratio
may be reversed with men reporting a higher prevalence of OCD than women.
Cultural differences
The core features of the disorder remain consistent across countries. However, cultural
differences may influence the frequency of different OCD symptom domains, the content of
obsessions, and degree of impairment. The most frequent obsessions and compulsions dealt
with contamination, germs, and cleaning. Aggressive obsessions were also very frequent,
especially in Brazil. The prevalence of different OCD subtypes differs considerably between
countries. The most frequent obsessions among those with OCD in Europe were accidentally
causing harm and compulsive mental checking (59%), followed by somatic concerns (32%)
and order/symmetry (27%).
Thus, cultural differences are apparent in the prevalence of OCD subtypes as well as the
content of obsessions and compulsions. Even though contamination and doubt obsessions,
and washing and checking compulsions are the most prevalent symptoms in most countries,
social and cultural factors can influence the function and consequences of OC symptoms. For
example, individuals might develop contamination and washing symptoms related to their
Islamic or Judaic religious beliefs about the sinfulness of being unclean, whereas individuals
in other societies that value cleanliness for health reasons might develop washing
compulsions because they fear physical disease. As well, cultural tolerance for certain
subclinical OC symptoms may vary, thereby providing a social sign for escalation into a
clinical disorder for vulnerable individuals. For example, could cultures that value mental
discipline or consciousness and exactness provide a social context for the development of
repugnant obsessions or pathological doubt, respectively?
Natural history
Onset
Often OC symptoms develop gradually so it is difficult to determine the age of onset. Early
onset (EO) is most often between 9 and 14 years and late onset (LO) in early adulthood. In a
study ¾ belonged in the EO group. Another study found that 96% of the participant had an
onset before 40. So, late childhood to adolescence is the most common age of onset for
OCD. Men with OCD have an earlier onset than women.
Course
OCD tends to take a chronic course with symptoms differing in response to stress and life
circumstances. Three outcomes to OCD were identified: chronic, episodic, or intermittent.
The most common course patterns were chronic (44%) and intermittent (56%). However,
40% who were initially intermittent switched to a chronic categorization in later
assessments. So, without treatment the modal course for OCD is a persistence of the
disorder over several years, if not decades.
