Psychology (9990) | Obsessive-compulsive disorder (OCD)

🧠 Welcome to the Clinical Psychology Notes: Obsessive-Compulsive Disorder (OCD)

Hello future psychologists! This chapter focuses on Obsessive-Compulsive Disorder (OCD), a condition often misunderstood in popular culture. It's crucial for clinical psychology students to grasp not just the symptoms, but also the different theories that explain why this disorder happens and how we treat it.

Don't worry if the cycle of obsessions and compulsions seems tricky at first. Think of OCD as a brain stuck in a loop: a scary thought (obsession) triggers extreme anxiety, which is only temporarily relieved by an action (compulsion).

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1.5.1 Diagnostic Criteria for Obsessive-Compulsive Disorder

What is OCD?

OCD is characterised by two core components:

1. Obsessions: Recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted, causing marked anxiety or distress.
2. Compulsions: Repetitive behaviours (e.g., hand washing, checking) or mental acts (e.g., counting, praying) that the individual feels driven to perform in response to an obsession, or according to rules that must be strictly applied.

Did you know? The person knows their obsessions are often irrational or excessive, but they cannot stop them.

A. Diagnostic Criteria (ICD-11 Focus)

The International Classification of Diseases (ICD-11) is used globally for classifying health conditions. For OCD, the diagnosis focuses on:

• Obsessions and/or compulsions must be present on most days for a period of at least several weeks.
• They must cause significant distress or interfere with personal functioning (e.g., social life, work, education).

Types of Obsessions and Compulsions (The most common themes):

• Contamination: Fear of germs or dirt (Obsession) leading to excessive cleaning/washing (Compulsion).
• Checking: Fear that harm has come to oneself or others (Obsession) leading to checking doors, locks, or appliances repeatedly (Compulsion).
• Symmetry/Ordering: Need for things to be in perfect order (Obsession) leading to arranging items in a precise way (Compulsion).
• Harming/Aggressive Thoughts: Intrusive thoughts about hurting others (Obsession) leading to mental rituals or avoiding sharp objects (Compulsion).

Study Example: Rapoport (1989) – 'Charles'

Rapoport’s work, particularly the case study of a boy named Charles, illustrates the severe impact of OCD. Charles was obsessed with the idea of 'rightness' and symmetry. His compulsions included slow rituals to ensure everything felt 'just right', often taking hours to dress or eat, severely impacting his daily life and development.

This case highlights the idiographic nature of OCD—how symptoms manifest uniquely in one individual—despite the disorder being nomothetic (having general diagnostic criteria).

B. Measures of OCD

To accurately measure the severity of OCD symptoms, psychologists use standardized psychometric tools:

1. Maudsley Obsessive-Compulsive Inventory (MOCI):
A quick self-report questionnaire, typically comprising true/false questions. It assesses four main symptom areas: checking, washing, slowness, and doubting. It provides a simple quantitative score.

2. Yale-Brown Obsessive-Compulsive Scale (Y-BOCS):
This is often the 'gold standard' measure. It is a semi-structured interview (uses both open and closed questions) where a clinician rates the patient's obsessions and compulsions based on severity, distress, time spent, and interference. It provides a more detailed, objective (clinician-rated) quantitative score than the MOCI.

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1.5.2 Explanations of Obsessive-Compulsive Disorder

A. Biological Explanations (Reductionist View)

The biological approach suggests that OCD is caused by physical factors, often focusing on biochemistry and genetics, providing a highly reductionist explanation.

1. Biochemical Explanation

OCD is often linked to an imbalance of the neurotransmitter Serotonin. Serotonin regulates mood, sleep, and impulse control. If there is low activity of serotonin (perhaps due to the brain reabsorbing it too quickly), the brain struggles to inhibit repetitive thoughts and actions.

Memory Aid: Serotonin helps you stop. If it's low, you can't stop the O-C loop.

2. Genetic Explanation

Twin and family studies suggest OCD can be inherited. While no single "OCD gene" has been identified, specific genes may make an individual vulnerable to developing the disorder.

For example, research comparing identical (monozygotic) and non-identical (dizygotic) twins shows higher concordance rates (both twins having the disorder) for identical twins, suggesting a strong genetic component (Nature).

B. Psychological Explanations (Holistic View)

1. Cognitive Explanation (Thinking Error)

This perspective focuses on maladaptive thought patterns, suggesting that individuals with OCD misinterpret or inflate the importance of their intrusive thoughts.

• Inflated Responsibility: They believe they are personally responsible for preventing negative outcomes. (e.g., "If I don't check the oven 10 times, the house fire will be my fault.")
• Perfectionism/Intolerance of Uncertainty: They feel a need for absolute certainty and perfection, leading to constant checking or repeating rituals until they feel 'right'.

Analogy: If most people hear a car alarm (intrusive thought) and ignore it, an OCD sufferer treats it like a five-alarm fire requiring immediate, exhaustive action.

2. Behavioural Explanation (Operant Conditioning)

The behavioural approach suggests OCD is a learned behaviour that persists due to reinforcement (a learning theory assumption).

• Classical Conditioning (Acquisition): The obsession (e.g., touching a doorknob) becomes associated with fear/anxiety.
• Operant Conditioning (Maintenance): The individual performs a compulsion (e.g., washing hands) and the anxiety immediately decreases. This immediate reduction of anxiety is a powerful form of negative reinforcement, making them more likely to repeat the compulsion next time.

3. Psychodynamic Explanation

Freud suggested that OCD stems from unresolved conflicts during the anal stage of psychosexual development (age 1-3). If a child struggles with toilet training and control, they may develop extreme needs for neatness, order, and control later in life (unconscious conflict).

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1.5.3 Treatment and Management of Obsessive-Compulsive Disorder

A. Biological Treatments

The primary biological treatment is medication aimed at correcting the suspected biochemical imbalance (serotonin deficiency).

Selective Serotonin Reuptake Inhibitors (SSRIs):
SSRIs work by blocking the reabsorption (reuptake) of serotonin in the synapse, increasing the amount of serotonin available to transmit signals. This helps improve mood and reduce the anxiety and repetitive urges associated with OCD.

Note: SSRIs manage symptoms but do not cure the underlying cause. They are often most effective when combined with psychological therapy.

B. Psychological Therapies

1. Exposure and Response Prevention (ERP)

ERP is a behavioural therapy based on the principles of classical conditioning (extinction) and operant conditioning (breaking the negative reinforcement cycle).

Step-by-Step ERP Process:

1. Exposure: The patient is deliberately exposed to the object or situation that triggers their obsession and anxiety (e.g., touching a dirty floor).
2. Response Prevention: The patient is then strictly prevented from carrying out the compulsive ritual (e.g., they must not wash their hands).
3. Extinction: Over time, they learn that the anxiety naturally decreases on its own (a process called habituation) without the compulsion. This breaks the link between the obsession and the need for the ritual.

Study Example: Lehmkuhl et al. (2008)
This study applied ERP to children with OCD who also had co-morbid (co-occurring) Tourette Syndrome. They found that ERP was effective even when these additional tics and disorders were present, highlighting the robust nature of the behavioural technique.

2. Cognitive-Behavioural Therapy (CBT)

CBT combines the behavioural techniques of ERP with cognitive restructuring (challenging the thinking errors). This targets both the ritual (behaviour) and the belief system (cognition) driving the obsession.

• Cognitive Restructuring: Challenging the distorted beliefs, such as the idea of "inflated responsibility" or the belief that thoughts equal actions.
• Example: A therapist might challenge the thought: "If I don't check the lock, someone will break in." The therapist asks for evidence for and against this belief.

Key Study: Lovell et al. (2006) – Telephone-administered CBT

Context: Lovell et al. investigated a practical and accessible way to deliver CBT for OCD, moving beyond traditional face-to-face sessions.

Aim: To compare the effectiveness of face-to-face CBT versus CBT delivered over the telephone for patients with OCD.

Design/Procedure:

• Method: A Randomised Controlled Non-inferiority Trial (RCT). This design aims to show that a new treatment (telephone CBT) is just as good (non-inferior) as an established treatment (face-to-face CBT).
• Sample: Participants diagnosed with OCD were randomly assigned to one of two groups.
• Procedure: Both groups received 10 sessions of CBT over 8 weeks. One group received the sessions face-to-face, the other received them via telephone.
• Data Collection: Severity of OCD symptoms was measured using the Y-BOCS both before and after treatment, and at a follow-up stage.

Results/Conclusion:

• Both groups showed significant and comparable reductions in their Y-BOCS scores.
• The telephone-administered CBT was found to be non-inferior to face-to-face CBT.
• Conclusion: Telephone CBT is a highly effective, practical, and more accessible treatment for OCD.

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1.5.4 Key Issues, Debates, and Methodology Summary

When discussing OCD, you must be prepared to link the content to A-Level issues and research methods:

Relevant Issues and Debates:

• Nature versus Nurture: Biological explanations support the nature side (genetics, biochemical), while psychological explanations (Behavioural, Cognitive) support the nurture side (learning, environment).
• Reductionism versus Holism: Biological explanations (SSRIs, serotonin) are highly reductionist, breaking OCD down to a single chemical imbalance. ERP/CBT uses a more holistic approach, considering thoughts, feelings, and behaviours.
• Individual versus Situational Explanations: Explanations focusing on genetic vulnerability (individual) contrast with explanations focusing on how the environment reinforces compulsive behaviours (situational).
• Determinism versus Free-will: Biological explanations are determinist (behaviour is controlled by brain chemistry). Cognitive therapy allows for free-will as it assumes patients can consciously choose to challenge their thoughts.

Relevant Research Methods:

• Interviews/Case Studies: Essential for diagnosis (Y-BOCS) and for gathering detailed, idiographic information on symptom manifestation (e.g., Rapoport's Charles).
• Psychometrics: Used to measure symptom severity (MOCI, Y-BOCS), producing quantitative data which allows for reliability testing.
• Randomised Controlled Trials (RCTs): Used in treatment studies like Lovell et al. (2006) to ensure high validity when comparing treatment effectiveness.
• Reliability: High inter-rater reliability is crucial for diagnostic tools like the Y-BOCS to ensure different clinicians score the symptoms consistently.

Remember to always use a study example (like Lovell or Rapoport) to support your points on methodology and debates in your essays!