Obsessive-compulsive disorder (OCD) is a chronic and potentially disabling disease with significant negative social and economic consequences. According to modern classifications of diseases (ICD-10, DSM-IV), OCD is an independent category that combines psychopathological formations of the circle of obsessions (Taylor & Jang, 2011). Its main clinical manifestations are obsessions (repetitive, unwanted thoughts, images, emotional experiences, and urges) and compulsions (stereotyped, often ritualized actions or mental acts), which patients subjectively regard as “protective” (Cromer et al., 2007). However, the nature of the course, prognosis, dependence on situational factors, response to biological and psychological therapy of patients in this category vary significantly (Taylor & Jang, 2011). Therefore, the issues of clinical typology and the related tasks of differentiated prognostic and therapeutic assessment of OCD acquire great practical importance.
The approaches to clinical and psychopathological differentiation of OCD are currently insufficiently developed. Traditionally, researchers use approaches related to the assessment of the diseases’ etiological factors in order to overcome the poverty of the frameworks that rely on just description of the symptoms (Wheaton et al., 2010). At the same time, along with this, the research focusing on additional clinical signs and relationships among variables has proven fruitful. These include the nature of key experiences identified in psychopathological studies of obsessions and compulsions (Cromer et al., 2007), OCD symptoms dimensions as opposed to types of obsessions and compulsions (Wheaton et al., 2010), and types of dysfunctional beliefs systems (Taylor & Yang, 2010), the causal relationships between dysfunctional cognitive beliefs and metacognition (Hansmeier et al., 2016), and the functions of compulsions (Starcevic et al., 2011).
Given the complexity of the issue of clinical differentiation of obsessive-compulsive disorder, many modern researchers began to consider OCD as a group of conditions that are different in etiological and dynamic terms, united only by some common phenomenological manifestations, behind which are hidden close, but far from identical mechanisms of pathogenesis (Wheaton et al., 2010; Hansmeier et al., 2016). Therefore, the authors suggest that the task of modern OCD researchers is to develop and identify clinically significant subtypes that require particular, and therefore more effective, therapeutic strategies.
In addition, the development takes place in a theoretical direction. For example, the reciprocal diathesis-stress framework and predisposition approach, Cromer et al. (2007) suggest using a pathoplastic model substantiating modern views on the relationship between affective (depressive spectrum disorders are more often discussed) and personality disorders. Their study aims to examine relationships between TLEs (SLEs) and OCD more fully with the help of the pathoplastic model combined with a predisposition approach. In doing so, they are able to study not only the causation of the OCD by stressful events but also its symptoms ‘modification due to SLEs / TLEs. Moreover, the majority of studies agree on the definition of OCD as a dimension disorder. Wheaton et al. (2010) conducted an empirical analysis of the extent to which previously identified symptoms dimensions adequately represent current theoretical approaches to OCD.
In turn, popular science, documentary, and fiction films and video production aim at increasing the awareness of OCD and disorders among the general public. For example, The Touching Tree (Callner, 2012) tells the story of a boy with OCD symptoms, which he tries to hide from the teacher, but the latter notices the manifestation of the disease, and together they go on a journey towards acceptance in the course of the disease. Obsessive thoughts in OCD create intense stress, anxiety, tension and interfere with daily life. Obsessions can be very different: they can be very frightening, for example, a child may think that a loved one wants to kill him, or, conversely, he can kill a loved one, or that he has become dirty internally or externally from contact with some objects; but some obsessions are not frightening, but very disturbing, for example, when a child needs to recount something or repeat a certain number of times. It is necessary to understand that obsessions are different from childhood fantasies. The latter are usually pleasing to the child: he creates imaginary worlds, which does not cause him stress. With OCD, the child experiences tremendous stress. Moreover, repetitive actions are not enjoyable, and they are intended to reduce anxiety.
Stress, Trauma, and OCD
In any research, controlling socio-demographic characteristics (gender, age, etc.), comorbidities, and a disease onset-age is necessary. At the same time, Cromer et al.’s (2007) study demonstrates that Traumatic life events tend to be the common cause of OCD, and the severity of symptoms correlates with the number of TLEs. Besides, traumatic life events have been proven to trigger specifically obsessions/checking and symmetry/ordering symptoms. Furthermore, obsessions often develop in the context of depression. This looks like a psychologically understandable response to obsessive-compulsive symptoms in some patients, but recurrent episodes of depressive mood occur independently in others. Cromer et al. (2007) controlled the depression variable, and the relationship between TLEs and OCD still remains significant. Thus, traumas and stresses play a vital role in the genesis of OCD and the severity of its symptoms.
Cognitive Models, Systems of Beliefs, and Metacognition
In the context of the importance of comparing and isolating OCD from other diseases, especially disorders of the anxiety spectrum, as indicated above, cognitive models of OCD are being created, focusing on identifying pathological mechanisms in the form of a system of erroneous beliefs, which were considered a critical moment in the development and maintenance of this disorder. The literature also notes a theoretical search to explain the relationship between OCD and its various dimensions. For example, Wheaton et al. (2010) suggest that OCD symptoms dimensions can be predicted by identifying a spectrum of obsessive beliefs due to their causal relationship consistent with cognitive-behavioral conceptual models.
Thus, obsessions will lead to discomfort only if they cause these negative automatic thoughts through interaction with the individual’s fundamental belief system, the motivational-value sphere. Along with this, compulsions and cognitive rituals aim to reduce distress in the form of a decrease in the intensity of a sense of responsibility and self-blame and act as a decompensatory means of coping with discomfort due to obsessive mental components and stressful situations. According to Weaton et al. (2010), it is the peculiar form of organization and integration of experiences, the peculiarities of the inference scheme, that is the leading mechanism for the development of OCD. For example, responsibility/threat estimation beliefs are directly related to contamination symptoms, while perfection/certainty beliefs cause a range of symmetry symptoms. In turn, a set of beliefs such as importance/control of thoughts is associated with unacceptable thoughts, whereas being responsible for harm can be predicted by the presence of a responsibility/threat system.
Taylor and Jang (2011) note that obsessions arise from unwanted obsessive thoughts or images, accompanied by an assessment of these thoughts as significant, unacceptable, or pose a threat, for which the person is responsible, and emphasize the importance of dysfunctional beliefs in the development and maintenance of OCD symptoms. Existing models of obsessive symptoms are based on the fact that obsessions arise from a distorted interpretation of natural intrusions as particularly significant. In other words, the critical point in the pathogenesis of obsessions is the misinterpretation of common obsessive thoughts in the context of overestimating their importance and unacceptability.
Researchers of this psychological direction are attempting to comprehend those metacognitive patterns that may underlie the described dysfunctional beliefs and assessments. Thus, Hansmeier et al. (2016) show that metacognitive information processing acts as a supportive mechanism for OCD and contributes to increased symptoms. Based on a theoretical model proposed by Wells and Matthews (1994) and Wells (1997, 2000), the authors empirically show that negative metacognitive beliefs arise from the assessment of intrusive thoughts and cause or contribute to the development of OCD symptoms (as cited in Hansmeier et al., 2016). Metacognition not only relates to beliefs about the “necessary” behavior for a patient but also unites various beliefs and thoughts. Belief in “fusion of thoughts” occurs when a person believes that thinking about something increases the likelihood that it will happen. The need to control one’s thoughts is central to the metacognitive model, as it is triggered by anxiety and reflections associated with OCD symptoms.
Function of Compulsions
Compulsions (obsessive actions, rituals) are repetitive stereotyped behaviors that do not provide inner pleasure and do not lead to the performance of useful tasks; the meaning of compulsions is to prevent any objectively unlikely events, their essential effect is also to reduce the level of anxiety and internal discomfort (Cromer et al., 2007). Thus, compulsions as a type of manifestation of OCD symptoms affect the behavioral aspect of a person’s functioning. The psychological meaning of compulsion is to provide a protective function. It is this meaning that underlies the obsessive actions in the ritual activity of the patient. The ritual in social life is protective and therefore adaptive.
Starcevic et al. (2011) outline at least six functions of compulsions: “decreasing distress or anxiety,” “something bad or unpleasant would happen if the person did not perform the compulsion,” “getting rid or ‘undoing’ the obsessions,” “correcting things so that they look “just right” or perfect, “alleviating the feeling of disgust, “performed automatically without thinking why” (p. 453). Obsessions can manifest themselves in relatively light phenomena; in fact, the content of obsessions is not as dramatic as it might seem. It can be washing hands, the intrusive sound of melodies, counting various objects, numbers, and the clock strikes. This also includes obsessive rituals when eating, smoking, going to bed, and falling asleep – fixed habits that are not perceived painfully and which, by rejection or external influences, can stop without causing fear (Hansmeier et al., 2016). However, as Starcevic et al. (2011) suggest, there are different reasons for all the variety of compulsions, and the majority of the latter are performed for more than one reason. This leads to the realization that compulsions have more than one underlying function. Similarly, the researchers have established the correlation between the number of functions of compulsions and the severity of OCD. The results prove that functions of compulsions should be addressed in the course of treatment, especially among patients with a severe form of disorder.
References
Callner, J. (2012). The Touching Tree [Video] YouTube.
Cromer, K. R., Schmidt, N. B., & Murphy, D. L. (2007). An investigation of traumatic life events and obsessive-compulsive disorder. Behaviour Research and Therapy, 45(7), 1683-1691.
Hansmeier, J., Exner, C., Rief, W., & Glombiewski, J. A. (2016). A test of the metacognitive model of obsessive-compulsive disorder. Journal of Obsessive-Compulsive and Related Disorders, 10, 42-48.
Starcevic, V., Berle, D., Brakoulias, V., Sammut, P., Moses, K., Milicevic, D., & Hannan, A. (2011). Functions of compulsions in obsessive-compulsive disorder. Australian & New Zealand Journal of Psychiatry, 45(6), 449-457.
Taylor, S., & Jang, K. L. (2011). Biopsychosocial etiology of obsessions and compulsions: An integrated behavioral–genetic and cognitive-behavioral analysis. Journal of Abnormal Psychology, 120(1), 174-186.
Wheaton, M. G., Abramowitz, J. S., Berman, N. C., Riemann, B. C., & Hale, L. R. (2010). The relationship between obsessive beliefs and symptom dimensions in obsessive-compulsive disorder. Behaviour Research and Therapy, 48(10), 949-954.