by Joye C. Anestis
Have you ever had an intrusive thought, a thought you just can't can't out of your head? And have you ever done anything to try to neutralize or get rid of it? If so, you're not alone! It has been estimated that 90% of the general population show signs of intrusive thoughts, images, impulses, and compulsions (Ladouceur et al., 2000). But for a small percentage of the population, intrusive thoughts and compulsions become so extreme that they characterize obsessive-compulsive disorder (OCD), a debilitating anxiety disorder. Although once thought to be rare, it is now estimated that 2-3% of the population suffers from this illness (e.g., Karno et al., 1988).
According to the DSM-IV-TR (APA, 2000), OCD consists of 2 main symptoms:
- Obsessions: persistent thoughts, images, or impulses that occur repeatedly and are experienced as intrusive, inappropriate, and distressing.
- Compulsions: repetitive behaviors or mental acts aimed at decreasing the discomfort caused by obsessive thoughts.
Common obsessions and corresponding compulsions are:
- dirt/contamination --> washing
- thoughts of injury/death --> mental ritual to counteract (e.g., counting to certain numbers in your head)
- some dangerous hazard to the home --> checking household items (e.g., the iron)
- symmetry --> straightening
- losing or needing something important --> hoarding.
This list is by no means inclusive - there are many many other obsessive-compulsive themes that people experience. Most commonly, individuals with OCD endorse experiencing a number of 
different types of obsessions and engaging in many different compulsions. The vast majority of individuals with OCD have both obsessions and compulsions, but a small subgroup (i.e., 2%) experience only obsessions (Foa et al., 1995).
To be diagnosed with OCD, the obsessions and compulsions have to be time-consuming and interfere with daily functioning. At some point in the course of the disorder, the individual has to recognize that the obsessions and compulsions are excessive and unreasonable (although there is a "poor insight" subtype that is appropriate if, for most of the time during the current episode, the individual does not recognize the excessive and unreasonable nature of the symptoms). The person also has to recognize that the obsessive thoughts are a product of his or her own mind (not imposed from without, as in thought insertion in schizophrenia).
In adults, OCD occurs at a slightly higher rate in females, whereas a higher prevalence rate in males has been observed in pediatric samples (e.g., Hanna, 1995). Age of onset ranges from early adolescence to young adulthood, with males generally having an earlier onset. The course of OCD without treatment is chronic, with some waxing and waning of episodes over time. 60-80% of individuals with OCD have at least one other co-occurring mental illness. Common comorbid disorders are other anxiety disorders, mood disorders (e.g., depression), Tourette's syndrome, and trichotillomania. OCD is the most debilitating of the anxiety disorders, associated with many impairments in general functioning, such as employment problems and interpersonal relationship difficulties (Emmelkamp et al., 1990; Leon et al., 1995; Riggs et al., 1992). Moreso than a lot of other mental illness, having OCD is a very aversive experience that leads to alot of social isolation. Folks with this illness know that their behaviors are perceived by others as odd but feel that they don't have any power to change it.
So how is OCD treated? The front-line treatment for OCD is a behavior therapy called exposure plus response prevention (also known as exposure plus ritual prevention, EX/RP) and/or a serotonin reuptake inhibitor (SRI, particularly clomipramine; Dougherty, Rauch, & Jenike, 2002). A recent randomized controlled trial compared EX/RP alone, clomipramine alone, and a combination of the two (Foa et al., 2005). EX/RP and EX/RP plus clomipramine had the greatest results, and there was no significant difference between the outcomes of participants in these 2 groups. Thus, it appears that receiving the psychotherapy alone was just as effective as combining it with medication.
EX/RP features 2 main components: 1) provoking obsessions via exposure in order to habituate to the subsequent anxiety and 2) at the same time, refraining from engaging in obsessive rituals to neutralize the anxiety. Exposures are usually conducted in a hierarchical manner, starting with less feared stimuli and gradually working up to the most feared situations. And exposure can be performed in vivo (in person) or imaginally. Cognitive restructuring is generally a key part of EX/RP. Treatment typically lasts 12-16 sessions, and can be administered weekly or more frequently. Look for a future PBB article to explain EX/RP in detail, discussing the treatment components as well as strategies for getting clients to engage in this treatment...but in the meantime, the following are excellent resources for information on EX/RP:
- Handbook of Psychological Disorders, Fourth Edition: A Step-by-Step Treatment Manual
- Stop Obsessing!: How to Overcome Your Obsessions and Compulsions (Revised Edition)
Cognitive therapy has also received considerable research support for its utility with OCD. From a cognitive therapy perspective, OCD symptoms are related to an exaggerated sense of personal responsibility. The person with OCD has an inflated sense of their influence on the safety of themselves and others and of their duty to maintain said safety. Cognitive therapy, thus, works to challenge and modify these dysfunctional ideas via cognitive restructuring. For further information on cognitive therapy for OCD, check out the following:
- Cognitive-Behavioral Therapy for OCD
- Cognitive Therapy for Obsessive-Compulsive Disorder: A Guide for Professionals
Anxiety Disorders and Phobias: A Cognitive Perspective
In sum, OCD is a devastating mental illness, but one for which there are several effective treatments. Below, I have listed training opportunities for therapists who wish to learn how to administer both of these treatments. If you think you or a loved one is suffering from OCD, please visit our list of EST clinics to find a clinic near you.
Training Opportunities
- Center for the Treatment and Study of Anxiety at the University of Pennsylvania
- The American Institue for Cognitive Therapy
- The Beck Institute for Cognitive Therapy and Research
Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.
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