Obsessive-Compulsive Disorder: Neurobiology and the Latest in Treatment

Derick E. Vergne, MD


May 17, 2017

In This Article

The Phenomenology of Obsessive-Compulsive Disorder

Patients with OCD cannot control their obsessions; they are never-ending, difficult to eradicate, and only partially ameliorated after the resulting compulsive act. Compulsions are almost as automatic as reflexes and, therefore, devoid of any rationality. The commonality between obsessions and compulsions is the lack of control felt by the sufferer, which is why suicide rates are high in this population. Kamath and colleagues found that 58% of patients with OCD have suicidal ideation, and about 28% attempt to commit suicide.[5]

The American Psychiatric Association criteria for the diagnosis of obsessive-compulsive disorder include[6]:

  1. Recurrent and persistent thoughts, urges, or impulses that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.

  2. An attempt to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action.

  3. The obsessions or compulsions are time-consuming.

In other words, there is no control over the beginning or end of a thought, its content, or its repetition. OCD is a cycle that has no end, and the patient will try to stop it to no avail. Stopping feels impossible because of the belief that "something very bad" will happen if the cycle ends. By performing an action or ritual, the person feels she or he is paying "dues," and will somehow be forgiven for the audacity of trying to stop the cycle of obsessions. The action, or compulsion, seeks to find a "solution" to the thought the patient originally had.

For example, an "impure" sexual thought repeats itself, and the patient therefore begins to believe that he or she is an impure person. Such a person will feel that this impurity will lead to a family member's failure to achieve some goal, such as an expected work promotion, as if the outcome can be somehow controlled from afar. This is magical thinking.

The patient will certainly conclude that this belief does not make sense, and understands that it is impossible to affect the outcome of a family member's career. Yet, because the patient can never be certain of that, he or she performs the ritualistic repetition, making ensure, for example, to walk symmetrically or to look up after every three steps to "bless" the family member.

The thought, or obsession, is an action that needs a reaction, which is the compulsive, repetitive act. The obsession needs its compulsion just as the itch needs the scratch. Obsessions and compulsions are interlinked, interminable, and exhausting.


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