Obsessive-Compulsive and Related Disorders

6.7 Describe the clinical features of obsessive- compulsive disorder and how it is treated.
Obsessive-compulsive and related disorders used to be classified in the DSM as anxiety
disorders; however, as of DSM-5 they have been classified separately as their own type of
disorder (see the box on Thinking Critically about
DSM-5). This new category includes not only OCD but also body dysmorphic disorder,
hoarding disorder, excoriation (skin-picking) disorder, and trichotillomania (compulsive hair
pulling).
Obsessive-Compulsive Disorder
Obsessive-compulsive disorder is defined by the occur- rence of both obsessive thoughts
and compulsive behav- iors performed in an attempt to neutralize such thoughts (see the
DSM-5 box for diagnostic criteria). Obsessions are persistent and recurrent intrusive
thoughts, images, or impulses that are experienced as disturbing, inappro- priate, and
uncontrollable. People who have such obses- sions actively try to resist or suppress them or
to neutralize them with some other thought or action. Compulsions involve overt repetitive
behaviors that are performed as lengthy rituals (such as hand washing, checking, putting
things in order over and over again). Compulsions may also involve more covert mental
rituals (such as counting, praying, or saying certain words silently over and over again). A
person with OCD usually feels driven to per- form this compulsive, ritualistic behavior in
response to an obsession, and there are often very rigid rules regard- ing exactly how the
compulsive behavior should be per- formed. The compulsive behaviors are performed with
the goal of preventing or reducing distress or preventing some dreaded event or situation.
OCD is often one of the most disabling mental disorders in that it leads to a lower quality of
life and a great deal of functional impairment (Stein et al., 2009).
Panic, Anxiety, Obsessions, and Their Disorders 227
DSM-5 Thinking Critically about DSM-5 Why Is OCD No Longer Considered to Be an
Anxiety Disorder?
In DSM-5, obsessive-compulsive disorder was removed from the anxiety disorders category
and placed into a new category called “obsessive-compulsive and related disorders.” (As
you already know from Chapter 5, PTSD was also removed and put into a new category
called “trauma and stressor-related disorders.”)
One reason for moving OCD into the new category was that anxiety is not generally used as
an indicator of OCD severity. Indeed, for people with certain forms of OCD such as
symmetry- related obsessions and compulsions, anxiety is not even a prom- inent symptom.
It was also noted that anxiety occurs in a wide range of disorders, so the presence of some
anxiety is not a valid reason to regard OCD as an anxiety disorder. Indeed D. J. Stein et al.
(2010) wrote that “the highly stereotyped, driven, repetitive, and nonfunctional quality of
compulsive behaviors differentiate OCD from normal acts and from the types of avoidance
that occur in other anxiety disorders” (p. 497).
Yet another reason is that the neurobiological underpinnings of OCD appear to be rather
different from those of other anxiety disorders, focusing on frontal-striatal neural circuitry
including the orbitofrontal cortex, anterior cingulate cortex, and striatum (espe- cially the
caudate nucleus). Studies examining the “OCD-related disorders” such as body dysmorphic
disorder (obsessing about perceived or imagined flaws in physical appearance) and trichotil-
lomania (chronic hair pulling) also suggest shared involvement of frontal-striatal neural
circuitry. Finally, other anxiety disorders respond to a wider range of medication treatments
than does OCD, which seems to respond selectively to SSRIs.
How compelling do these reasons sound to you? What kinds of research findings might
further support the grouping of OCD with related disorders such as hoarding or
trichotillomania? On the contrary, what research findings might incline you to think that it was
wrong to remove OCD from the anxiety disorders category?

228 Chapter 6
In addition, the person must recognize that the obses- sion is the product of his or her own
mind rather than being imposed from without (as might occur in schizophrenia). However,
there is a continuum of “insight” among persons with OCD about exactly how senseless and
excessive their obsessions and compulsions are (Ruscio et al., 2010). In a minority of cases,
this insight is absent most of the time. Most of us have experienced minor obsessive
thoughts, such as whether we remem- bered to lock the door or turn the stove off. In
addition, most of us occasionally engage in repetitive or stereotyped behavior, such as
checking the stove or the lock on the door or stepping over cracks on a sidewalk. One recent
study found that more than 25 percent of people in the United States report experiencing
obsessions or compul- sions at some time in their lives (Ruscio et al., 2010). With OCD,
however, the thoughts are excessive and much more persistent and distressing, and the
associated compulsive acts interfere with everyday activities. Diagnosis requires that
obsessions and compulsions take at least 1 hour per day, and in severe cases they may
take most of the per- son’s waking hours. It is important to note that normal and abnormal
obsessions and compulsive behaviors exist on a continuum, differing in the frequency and
intensity of the obsessions and in the degrees to which the obsessions and compulsions are
resisted and are troubling (Steketee & Barlow, 2002).
Many obsessive thoughts involve contamination fears, fears of harming oneself or others,
and pathological doubt. Other fairly common themes are concerns about or need for
symmetry (e.g., having magazines on a table arranged in a way that is “exactly right”),
sexual obsessions, and obsessions concerning religion or aggression. These themes are
quite consistent cross-culturally and across the life span (Steketee & Barlow, 2002).
Obsessive thoughts involving themes of violence or aggression might include a wife being
obsessed with the idea that she might poison her husband or child, or a daughter constantly
imagining pushing her mother down a flight of stairs. Even though such obsessive thoughts
are very rarely acted on, they remain a source of often excruciating torment to a person
plagued with them. The following case of Mark is fairly typical of severe OCD.
Obsessions about Confessing and Compulsive Checking
Mark was a 28-year-old single male who, at the time he entered treatment, suffered from
severe obsessive thoughts and images
about causing harm to others such as running over pedestri- ans while he was driving. He
also had severe obsessions that he would commit a crime such as robbing a store of a large
amount of money or poisoning family members or friends. These obsessions were
accompanied by lengthy and excessive checking rituals. For example, one day when he
drove, he began obsessing that he had caused an accident and hit a pedestrian at an
intersection, and he felt compelled to spend several hours driving and walking around all
parts of that intersection to find evidence of the accident.
At the time Mark went to an anxiety disorder clinic, he was no longer able to live by himself
after having lived alone for several years since college. He was a very bright young man with
considerable artistic talent. He had finished college at a prestigious school for the arts and
had launched a successful career as a young artist when the obsessions began in his early
20s. At first, they were focused on the possibility that he would be implicated in some crime
that he had not committed; later, they evolved to the point where he was afraid that he might
actually commit a crime and confess to it. The checking rituals and avoidance of all places
where such confessions might occur eventually led to his having to give up his career and
his own apartment and move back in with his family.
At the time he presented for treatment, Mark’s obsessions about harming others and
confessing to crimes (whether or not he had committed them) were so severe that he had
virtually confined himself to his room at his parents’ house. Indeed, he could leave his room
only if he had a tape recorder with him so that he would have a record of any crimes he
confessed to out loud because he did not trust his own memory. The clinic was several
hours’ drive from his home; his mother usually had to drive because of his obsessions about
causing accidents with pedestrians or moving vehicles and because the associated checking
rituals could punctuate any trip with several very long stops. He also could not speak at all
on the phone for fear of confessing some crime that he had (or had not) committed, and he
could not mail a letter for the same reason. He also could not go into a store alone or into
public bathrooms, where he feared he might write a confession on the wall and be caught
and punished.
As we have noted, people with OCD feel compelled to perform acts repeatedly that often
seem pointless and absurd even to them and that they in some sense do not want to
perform. There are five primary types of compul- sive rituals: cleaning (hand washing and
showering), checking, repeating, ordering or arranging, and counting (Antony et al., 1998;
Mathews, 2009), and many people exhibit multiple kinds of rituals. For a smaller number of
people, the compulsions are to perform various everyday acts (such as eating or dressing)
extremely slowly (primary obsessional slowness), and for others the compulsions are to
have things exactly symmetrical or “evened up” (Mathews, 2009; Steketee & Barlow, 2002).

Panic, Anxiety, Obsessions, and Their Disorders 229

DSM-5 Criteria for. . .
Obsessive-Compulsive Disorder
A. Presence of obsessions, compulsions, or both: Obsessions are defined by (1) and (2):
1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time
during the disturbance, as intrusive and unwanted, and that in most individuals cause
marked anxiety or distress.
2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to
neutralize them with some other thought or action (i.e., by performing a compulsion).
Compulsions are defined by (1) and (2):
1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g.,
praying, counting, repeat- ing words silently) that the individual feels driven to per- form in
response to an obsession or according to rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or
preventing some dread- ed event or situation; however, these behaviors or men- tal acts are
not connected in a realistic way with what they are designed to neutralize or prevent, or are
clearly excessive.
Note: Young children may not be able to articulate the aims of these behaviors or mental
acts.
B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day)
or cause clinically significant
People who suffer from OCD often exhibit repetitive behaviors that are structured around
rigid rules for performance. For example, this person turns the key in the lock a set number
of times every time she leaves the house.
distress or impairment in social, occupational, or other impor- tant areas of functioning.
C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical condition.
D. The disturbance is not better explained by the symptoms of another mental disorder (e.g.,
excessive worries, as in generalized anxiety disorder; preoccupation with appear- ance, as
in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding
disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in
excoriation [skin-picking] disorder; stereoty- pies, as in stereotypic movement disorder;
ritualized eating behavior, as in eating disorders; preoccupation with sub- stances or
gambling, as in substance-related and addictive disorders; preoccupation with having an
illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders;
impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in
major depres- sive disorder; thought insertion or delusional preoccupa- tions, as in
schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as
in autism spectrum disorder).
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (Copyright 2013). American Psychiatric Association.
Washing or cleaning rituals vary from relatively mild ritual-like behavior such as spending 15
to 20 minutes washing one’s hands after going to the bathroom, to more extreme behavior
such as washing one’s hands with disin- fectants for hours every day to the point where the
hands bleed. Checking rituals also vary in severity from rela- tively mild (such as checking all
the lights, appliances, and locks two or three times before leaving the house) to very
extreme (such as going back to an intersection where one thinks one may have run over a
pedestrian and spending hours checking for any sign of the imagined accident, much as
Mark does in the case study). Both cleaning and checking rituals are often performed a
specific number of times and thus also involve repetitive counting. The per- formance of the
compulsive act or the ritualized series of acts usually brings a feeling of reduced tension and
satis- faction, as well as a sense of control, although this anxiety relief is typically fleeting.
This is why the same rituals need to be repeated over and over (Purdon, 2009; Steketee &
Barlow, 2002).

230 Chapter 6
Prevalence, Age of Onset,
and Gender Differences
Approximately 2 to 3 percent of people meet criteria for OCD at some point in their lifetime,
and approximately 1 percent meet criteria in a given year (Ruscio et al., 2010). Over 90
percent of treatment-seeking people with OCD experience both obsessions and compulsions
(Foa & Kozak, 1995; Franklin & Foa, 2007). When mental rituals and compulsions such as
counting are included as compul- sive behaviors, this figure jumps to 98 percent.
Howard Stern, a famous radio personality and author, as with other people who have
suffered from OCD, found relief in a compulsive act or ritualized series of acts to bring about
a feeling of reduced tension and a sense of control. In his book Miss America, Stern
describes behaviors such as turning pages in magazines only with his pinky finger, walking
through doors with the right side of his body leading, and flipping through television stations
in a particular order before turning the set off.
Divorced (or separated) and unemployed people are somewhat overrepresented among
people with OCD (Torres et al., 2006), which is not surprising given the great difficulties this
disorder creates for interpersonal and occupational functioning. Some studies showed little
or no gender difference in adults, which would make OCD quite different from most of the
rest of the anxiety disor- ders. However, one British epidemiological study found a gender
ratio of 1.4 to 1 (women to men; Torres et al., 2006). OCD typically begins in late
adolescence or early adult- hood, but also can occur in children, where its symptoms are
strikingly similar to those of adults (Poulton et al., 2009; Torres et al., 2006). Childhood or
early adolescent onset is more common in boys than in girls and is often associated with
greater severity (Lomax et al., 2009) and greater heritability (Grisham et al., 2008). In most
cases the
disorder has a gradual onset, and once it becomes a seri- ous condition, it tends to be
chronic, although the severity of symptoms sometimes waxes and wanes over time
(Mataix-Cols et al., 2002).
Many of us show some compulsive behavior, but people with OCD feel compelled to perform
repeatedly some action in response to an obsession, in order to reduce the anxiety or
discomfort created by the obsession. Although the person may realize that the behavior is
excessive or unreasonable, he or she does not feel able to control the urge.
Obsessive-compulsive hand washers may spend hours a day washing and may even use
abrasive cleansers to the point that their hands bleed.
Comorbidity with Other Disorders
OCD frequently co-occurs with other anxiety disorders, most commonly social phobia, panic
disorder, GAD, and PTSD (Kessler, Chiu, Demler, et al., 2005; Mathews, 2009). Moreover,
approximately 25 to 50 percent of peo- ple with OCD experience major depression at some
time in their lives and as many as 80 percent experience sig- nificant depressive symptoms
(Steketee & Barlow, 2002; Torres et al., 2006), often at least partly in response to having
OCD.
Psychological Causal Factors
The following psychological factors may cause obsessive- compulsive disorder.
OCD AS LEARNED BEHAVIOR The dominant behav- ioral or learning view of
obsessive-compulsive disorder is derived from Mowrer’s two-process theory of avoidance
learning (1947). According to this theory, neutral stimuli become associated with frightening
thoughts or experi- ences through classical conditioning and come to elicit anx- iety. For
example, touching a doorknob or shaking hands might become associated with the “scary”
idea of contami- nation. Once having made this association, the person may discover that
the anxiety produced by shaking hands or touching a doorknob can be reduced by hand
washing.

Washing his or her hands extensively reduces the anxiety, and so the washing response is
reinforced, which makes it more likely to occur again in the future when other situa- tions
evoke anxiety about contamination (Rachman & Shafran, 1998). Once learned, such
avoidance responses are extremely resistant to extinction (Mineka & Zinbarg, 2006).
Moreover, any stressors that raise anxiety levels can lead to a heightened frequency of
avoidance responses in animals or compulsive rituals in humans (Cromer et al., 2007).
Several classic experiments conducted by Rachman and Hodgson (1980) supported this
theory. They found that for most people with OCD, exposure to a situation that provoked
their obsession (e.g., a doorknob or toilet seat for someone with obsessions about
contamination) did indeed produce distress, which would continue for a moderate amount of
time and then gradually dissipate. If the person was allowed to engage in the compulsive
ritual immedi- ately after the provocation, however, her or his anxiety would generally
decrease rapidly (although only tempo- rarily) and therefore reinforce the compulsive ritual.
This model predicts, then, that exposure to feared objects or situations should be useful in
treating OCD if the exposure is followed by prevention of the ritual, enabling the person to
see that the anxiety will subside naturally in time without the ritual (see also Rachman &
Shafran, 1998). This is indeed the core of the most effective form of behav- ior therapy for
OCD, as discussed later. Thus, the early behavioral model has been very useful in helping
us understand what factors maintain obsessive-compulsive behavior, and it has also
generated an effective form of treatment. However, it has not been so helpful in explain- ing
why people with OCD develop obsessions in the first place and why some people never
develop compulsive behaviors.
OCD AND PREPAREDNESS The preparedness concept described earlier that considers
the evolutionarily adaptive nature of fear and anxiety for our early ancestors also can help us
to understand the occurrence and persistence of OCD (De Silva, Rachman, & Seligman,
1977; Rapoport, 1989). The fact that many people with OCD have obses- sions and
compulsions focused on dirt, contamination, and other potentially dangerous situations has
led many researchers to conclude that these features of the disorder likely have deep
evolutionary roots (Mineka & Zinbarg, 1996, 2006). In addition, some theorists have argued
that the displacement activities that many species of animals engage in under situations of
conflict or high arousal resemble the compulsive rituals seen in obsessive- compulsive
disorder (Craske, 1999; Mineka & Zinbarg, 1996; Rapoport, 1989; Winslow & Insel, 1991).
Displace- ment activities often involve grooming (such as a bird preening its feathers) or
nesting under conditions of high conflict or frustration. They may therefore be related to the
distress-induced grooming (such as washing) or tidying rituals seen in people with OCD,
which are often provoked by obsessive thoughts that elicit anxiety.
COGNITIVE CAUSAL FACTORS
The Effects of Attempting to Suppress Obsessive Thoughts Quick, don’t think about a white
bear! Gotcha. When most people attempt to suppress unwanted thoughts they sometimes
experience a paradoxical increase in those thoughts later (Wegner, 1994). As already noted,
people with normal and abnormal obsessions differ primarily in the degree to which they
resist their own thoughts and find them unacceptable. Thus, one factor contributing to the
frequency of obsessive thoughts, and the negative moods with which they are often
associated, may be these attempts to suppress them (similar to what was discussed earlier
about the effects of attempts to control worry in people with GAD). For example, when
people with OCD are asked to record intrusive thoughts in a diary, both on days when they
were told to try to suppress those thoughts and on days without instructions to suppress,
they reported approximately twice as many intrusive thoughts on the days when they were
attempting to suppress them (Salkovskis & Kirk, 1997). In addition, thought suppression
leads to a more general increase in obsessive-compulsive symptoms beyond just the
frequency of obsessions (Purdon, 2004). Finally, naturalistic diary studies of people with
OCD reveal that they engage in frequent, strenuous, and time-consuming attempts to control
the intrusive thoughts, although they are generally not effective in doing so (Purdon et al.,
2007).
Quick, don’t think about a white bear!
Panic, Anxiety, Obsessions, and Their Disorders 231
Appraisals of Responsibility for Intrusive Thoughts
Salkovskis (e.g., 1989), Rachman (1997), and other cognitive theorists have distinguished
between obsessive or intrusive thoughts

232 Chapter 6
per se and the negative automatic thoughts and cata- strophic appraisals that people have
about experiencing such thoughts. For example, people with OCD often seem to have an
inflated sense of responsibility. In turn, in some vulnerable people, this inflated sense of
responsibility can be associated with beliefs that simply having a thought about doing
something (e.g., a mother’s thought about harming her infant) is morally equivalent to
actually hav- ing done it, or that thinking about the behavior increases the chances of
actually doing so. This is known as thought– action fusion (Berle & Starcevic, 2005;
Rachman et al., 2006). This inflated sense of responsibility for the harm they may cause can
motivate compulsive behaviors to try to reduce the likelihood of anything harmful happening
(Rachman et al., 2006). Thus, part of what differentiates normal people who have
obsessions and can ordinarily dismiss them from people with OCD is this sense of
responsibility that makes the thought so concerning to them.
Cognitive Biases and Distortions Cognitive factors have also been implicated in OCD. More
specifically, people with OCD have an attentional bias toward disturbing material relevant to
their obsessive concerns, much as occurs in the other anxiety disorders (McNally, 2000;
Mineka et al., 2003). They also have difficulty blocking out negative, irrelevant input or
distracting information, so they may attempt to suppress negative thoughts stimulated by this
information (McNally, 2000). As we have noted, trying to suppress neg- ative thoughts may
paradoxically increase their frequency. Moreover, those with OCD have low confidence in
their memory ability (especially for situations they feel responsi- ble for), which may
contribute to their repeating their ritu- alistic behaviors over and over again (Cougle et al.,
2007; Dar et al., 2000). An additional factor contributing to their repetitive behavior is that
people with OCD have deficits in their ability to inhibit both motor responses (Morein-Zamir
et al., 2010) and irrelevant information (Bannon et al., 2008).
Biological Causal Factors
In recent years there has been an increase in research on the possible biological basis for
OCD, ranging from studies about its genetic basis to studies of abnormalities in brain
function and neurotransmitter abnormalities. The evidence accumulating from all three kinds
of studies suggests that biological causal factors may play a stronger causal role for OCD
relative to the other disorders discussed in this chapter.
GENETIC FACTORS Evidence from twin studies reveals a moderately high concordance
rate for OCD for monozy- gotic twins and a lower rate for dizygotic twins. One review of 14
published studies included 80 monozygotic pairs of twins, of whom 54 were concordant for
the diagno- sis of OCD, and 29 pairs of dizygotic twins, of whom 9 were concordant. This is
consistent with a moderate genetic
heritability, although it may be at least partially a nonspe- cific “neurotic” predisposition
(Hanna, 2000; van Grootheest et al., 2007). Consistent with twin studies, most family studies
have found 3 to 12 times higher rates of OCD in first-degree relatives of OCD clients than
would be expected from current estimates of the prevalence of OCD (Grabe et al., 2006;
Hettema, Prescott, & Kendler, 2001). Finally, evidence also shows that early-onset OCD has
a higher genetic loading than later-onset OCD (Grisham et al., 2008; Mundo et al., 2006).
Further compelling evidence of a genetic contribution to some forms of OCD concerns a type
of OCD that often starts in childhood and is characterized by chronic motor tics (Lochner &
Stein, 2003). This form of tic-related OCD is linked to Tourette’s syndrome, a disorder
characterized by severe chronic motor and vocal tics that is known to have a substantial
genetic basis (see Chapter 15). For example, one study found that 23 percent of first-degree
relatives of peo- ple with Tourette’s syndrome had diagnosable OCD even though Tourette’s
syndrome itself is very rare (Pauls et al., 1986, 1991, 1995).
Finally, in recent years a number of molecular genetic studies have begun to examine the
association of OCD with specific genetic polymorphisms (naturally occurring variations of
genes; Grisham et al., 2008; Mundo et al., 2006; Stewart et al., 2007). Preliminary findings
indicate that different genetic polymorphisms are implicated in OCD with Tourette’s
syndrome and in OCD without Tourette’s syndrome, suggesting that these two forms of OCD
are at least partially distinguishable at a genetic level (Stewart et al., 2007).
The search for brain abnormalities in OCD has been intense in the past 30 years as
advances have been made in brain-imaging techniques. This research has revealed that
abnormalities occur primarily in certain cortical and subcortical structures such as the basal
ganglia. The basal ganglia are in turn linked at the amygdala to the limbic sys- tem, which
controls emotional behaviors. Findings from a good number of studies using PET scans
have shown that people with OCD have abnormally high levels of activity in two parts of the
frontal cortex (the orbital frontal cortex and the cingulate cortex/gyrus), which are also linked
to the lim- bic area. People with OCD also have abnormally high levels of activity in the
subcortical caudate nucleus, which is part of the basal ganglia (see the three-dimensional
depiction of the relevant brain parts in Figure 6.3). These primitive brain cir- cuits are
involved in executing primitive patterns of behavior such as those involved in sex,
aggression, and hygiene con- cerns. Indeed, activity in some of these areas is further
increased when symptoms are provoked by relevant stimuli that activate obsessive thoughts
(e.g., dirt; Evans, Lewis, & Iobst, 2004; Rauch & Savage, 2000). Studies have also shown
partial normalization of at least some of these abnormalities
OCD AND THE BRAIN

Panic, Anxiety, Obsessions, and Their Disorders 233 Figure 6.3 Neurophysiological
Mechanisms for Obsessive-Compulsive Disorder
This three-dimensional view illustrates parts of the brain implicated in OCD. The overlying
cerebral cortex has been made transparent so that the underlying areas can be seen. The
orbital frontal cortex, cingulate gyrus/cortex, and basal ganglia (especially the caudate
nucleus) are the brain structures most often implicated in OCD. Increased meta- bolic
activity has been found in each of these three areas in people with OCD.
Basal ganglia
Putamen and Globus pallidus
Caudate Cerebral nucleus cortex
Cingulate Frontal gyrus/cortex cortex
Cerebellum Thalamus
Orbital frontal cortex
Corpus callosum
with successful treatment through either medication or behavior therapy (Baxter et al., 2000;
Saxena et al., 2002, 2009). The orbital frontal cortex seems to be where primitive urges
regarding sex, aggression, hygiene, and danger come from (the “stuff of obsessions”; Baxter
et al., 1991, p. 116). These urges are ordinarily filtered by the caudate nucleus as they travel
through the cortico–basal–ganglionic– thalamic circuit, allowing only the strongest to pass on
to the thalamus. The caudate nucleus or corpus striatum (part of the set of structures called
the basal ganglia, which are involved in the execution of voluntary, goal-directed move-
ments) is part of an important neural circuit linking the orbital frontal cortex to the thalamus.
The basal ganglia also include two other structures—the globus pallidus and the substantia
nigra—that are also involved in this cortico– basal–ganglionic–thalamic circuit. The thalamus
is an important relay station that receives nearly all sensory
input and passes it back to the cerebral cortex.
This cortico–basal–ganglionic–thalamic circuit is nor- mally involved in the preparation of
complex sets of interre- lated behavioral responses used in specific situations such as those
involved in territorial or social concerns. Several theo- ries have been proposed regarding
what the sources of dys- function in this circuit are. For example, Baxter and colleagues
(1991, 2000) cited evidence that when this circuit is not func- tioning properly, inappropriate
behavioral responses may occur, including repeated sets of behaviors stemming from
territorial and social concerns (e.g., checking and aggressive
behavior) and from hygiene concerns (e.g., cleaning). Thus, the overactivation of the orbital
frontal cortex, which stimu- lates the “stuff of obsessions,” combined with a dysfunc- tional
interaction among the orbital frontal cortex, the corpus striatum or caudate nucleus, and the
thalamus (which is downstream from the corpus striatum) may be the central component of
the brain dysfunction in OCD. According to Baxter’s theory, the dysfunctions in this circuit in
turn pre- vent people with OCD from showing the normal inhibition of sensations, thoughts,
and behaviors that would occur if the circuit were functioning properly. In this case, impulses
toward aggression, sex, hygiene, and danger that most peo- ple keep under control with
relative ease “leak through” as obsessions and distract people with OCD from ordinary
goal-directed behavior. Evidence suggests that at least part of the reason that this circuit
does not function properly may be due to abnormalities in white matter in some of these
brain areas; white matter is involved in connectivity among vari- ous brain structures
(Szeszko et al., 2004; Yoo et al., 2007).
Considering these problems, Baxter and colleagues pro- posed that we can begin to
understand how the prolonged and repeated bouts of obsessive-compulsive behavior in
people with OCD may occur (Baxter et al., 1991, 1992, 2000). Several other slightly different
theories have also been pro- posed as to the exact nature or source of the dysfunctions, but
there seems to be general agreement about most of the brain areas involved (Friedlander &
Desrocher, 2006; Harrison et al., 2009; Saxena & Rauch, 2000).

234 Chapter 6
NEUROTRANSMITTER ABNORMALITIES Pharmaco- logical studies of causal factors in
OCD intensified with the discovery in the 1970s that a tricyclic drug called clomip- ramine
(Anafranil) is often effective in the treatment of OCD even though other tricyclic
antidepressants are gen- erally not very effective (Dougherty et al., 2007). Research shows
that this is because clomipramine has greater effects on the neurotransmitter serotonin,
which is now strongly implicated in OCD (Pogarell et al., 2003; Stewart et al., 2009).
Moreover, several other antidepressant drugs from the SSRI category that also have
relatively selective effects on serotonin, such as fluoxetine (Prozac), have also been shown
to be about equally effective in the treatment of OCD (Dougherty, Rauch, et al., 2002, 2007).
The exact nature of the dysfunction in serotonergic systems in OCD is unclear. Current
evidence suggests that increased serotonin activity and increased sensitivity of some brain
structures to serotonin are involved in OCD symptoms. Indeed, drugs that stimulate
serotonergic sys- tems lead to a worsening of symptoms. In this view, long- term
administration of clomipramine (or fluoxetine) causes a downregulation of certain serotonin
receptors, further causing a functional decrease in the availability of sero- tonin (Dolberg,
Iancu, et al., 1996; Dolberg, Sasson, et al., 1996). That is, although the immediate
short-term effects of clomipramine or fluoxetine may be to increase serotonin levels (and
exacerbate OCD symptoms too), the long-term effects are quite different. This is consistent
with the find- ing that these drugs must be taken for at least 6 to 12 weeks before significant
improvement in OCD symptoms occurs (Baxter et al., 2000; Dougherty, Rauch, et al., 2002,
2007). However, it is also becoming clear that dysfunction in sero- tonergic systems cannot
by itself fully explain this complex disorder. Other neurotransmitter systems (such as the
dopaminergic, GABA, and glutamate systems) also seem to be involved, although their role
is not yet well under- stood (Dougherty et al., 2007; Stewart et al., 2009).
In summary, a substantial body of evidence now impli- cates biological causal factors in
OCD. This evidence comes from genetic studies, from studies of abnormalities in brain
function, and from studies of neurotransmitter abnormali- ties. Although the exact nature of
these factors and how they are interrelated is not yet fully understood, major research efforts
that are currently under way are sure to enhance our understanding of this disorder, which is
often very serious and disabling.
Treatments
Treatment for OCD includes behavioral and cognitive- behavioral approaches as well as
medication.
BEHAVIORAL AND COGNITIVE-BEHAVIORAL TREAT- MENTS The most effective
treatment for OCD is a behav- ioral treatment called exposure and response prevention
(Franklin & Foa, 2007; Stein et al., 2009). The exposure com- ponent involves having
individuals with OCD repeatedly expose themselves (either in guided fantasy or directly) to
stimuli that provoke their obsessions (e.g., for someone with contamination fears this may
involve touching a toilet seat in a public bathroom). The response prevention com- ponent
requires that they then refrain from engaging in the rituals that they ordinarily would perform
to reduce their anxiety or distress. Preventing the rituals is essential so that they can see
that if they allow enough time to pass, the anxiety created by the obsession will dissipate
naturally down to at least 40 to 50 on a 100-point scale, even if this takes several hours. This
is often as distressing as it sounds, and so the treatment typically starts out with manageable
first steps in the person’s fear hierarchy (e.g., touching the bottom of their shoe) and only
over time, gradually works up to more intense exposures (e.g., sitting on the floor of a dirty
public restroom).
Exposure and response prevention treatment for OCD involves having the patient encounter
the source of their obsessions, such as the germs imagined to lurk in a dirty bathroom, and
preventing them from engaging in compulsive behaviors, such as repetitive cleaning. The
treatment is often not fun for the patient, but can be very effective in decreasing OCD
symptoms.
In intensive versions of this treatment, clients who, for example, are used to spending 2 to 3
hours a day shower- ing and hand washing may be asked to not shower at all for 3 days at a
time (and when they finally do, to spend no more than 10 minutes in the shower). Later in
treatment they are encouraged to shower for only 10 minutes a day,

with no more than five 30-second hand washings at meal- times, after bathroom use, and
after touching clearly soiled objects. In addition to the exposures conducted during therapy
sessions, “homework” is liberally assigned. For example, on one occasion well into
treatment, a therapist drove a patient who was terrified of being contaminated by “dog dirt,”
bathroom germs, garbage, and dead animals in the road to a place where she had observed
a dead cat on the roadside. The therapist insisted that the patient approach the “smelly”
corpse, touch it with the sole of her shoe, and then touch her shoe. A pebble lying close by
and a stick with which she had touched the cat were presented to the patient with the
instruction that she keep them in her pocket and touch them frequently throughout the day.
(Franklin & Foa, 2008, pp. 192–205).
Although some people refuse such treatment or drop out early, most who stick with it show a
50 to 70 percent reduction in symptoms (Abramowitz et al., 2009; Steketee, 1993), as well
as improvement in quality of life (Diefenbach et al., 2007). Approximately 50 percent are
much improved or very much improved, and another 25 percent are moder- ately improved;
about 76 percent maintain their gains at several-year follow-ups. These results are superior
to those obtained with medication (Abramowitz et al., 2009; Franklin & Foa, 2008). There is
also evidence that d-cycloserine (the drug known to facilitate extinction of fear) enhances the
effectiveness of CBT; however, this enhancement is blocked if the person is also taking an
antidepressant (Andersson et al., 2015). Finally, during the past 20 years a form of cognitive-
behavioral therapy has also been developed by Salkovskis and colleagues (Salkovskis &
Wahl, 2003). Some of the goals were to determine whether it might help a higher percent-
age of people with OCD, or help increase the degree of symptom improvement, or decrease
dropout rates. Current evidence suggests that this form of treatment can also be quite
effective, but unfortunately it has not been shown to be superior to exposure and response
prevention therapy in any of the predicted ways (Abramowitz et al., 2009; D. A. Clark, 2005).
Moreover, some researchers have concluded that exposure and response prevention
treatment might be enhanced by the addition of cognitive therapy (Abramowitz et al., 2009).
Given that OCD rarely remits completely, leav- ing the client with some residual obsessional
problems or rituals (Abramowitz et al., 2009; Franklin & Foa, 2007), there is clearly a need to
improve further the efficacy of these treatments.
The successful use of this exposure and response pre- vention treatment in the case of
Mark, the young artist with severe OCD, is described here briefly.
Mark’s Treatment
Mark was initially treated with medication and with exposure and response prevention. He
found the side effects of the medication
(clomipramine) intolerable and gave it up within a few weeks. For the behavioral treatment,
he was directed to get rid of the tape recorder and was given a series of exercises in which
he exposed himself to feared situations where he might confess to a crime or cause harm to
others, including making phone calls, mailing letters, and enter- ing stores and public
bathrooms (all things he had been unable to do). Checking rituals (including the tape
recorder) were prevented. Although the initial round of treatment was not especially helpful,
in part because of difficulty in getting to treatment, he did eventually make a commitment to
more intensive treatment by moving to a small apartment closer to the clinic. Thereafter, he
did quite well.
MEDICATIONS Whereas the other anxiety disorders respond to a range of drugs, OCD
seems to respond best to medications that affect the serotonin system. These medi- cations,
such as clomipramine (Anafranil) and fluoxetine (Prozac) reduce the intensity of OCD
symptoms, with approximately 40 to 60 percent of people showing at least a 25 to 35
percent reduction in symptoms (relative to 4 to 5 per- cent on placebo; Dougherty et al.,
2007; Iancu et al., 2000). Some clients show greater improvement than this, but about 30 to
50 percent do not show any clinically signifi- cant improvement (Mancebo et al., 2006). In
approximately one-third of people who fail to respond to these serotoner- gic medications,
small doses of certain antipsychotic medi- cations may produce significantly greater
improvement (Bloch et al., 2006).
A major disadvantage of medication treatment for OCD, as for other anxiety disorders, is that
when the medication is discontinued relapse rates are generally very high (as high as 50 to
90 percent; Dougherty et al., 2007; Simpson & Liebowitz, 2006). Thus, many people who do
not seek alternative forms of behavior therapy that have more long-lasting benefits may have
to stay on these medi- cations indefinitely. Studies in adults have generally not found that
combining medication with exposure and response prevention is much more effective than
behavior therapy alone (Foa et al., 2005; Franklin & Foa, 2002, 2007), although one large
study showed that a combination treat- ment was superior in the treatment of children and
adoles- cents with OCD (March & Franklin, 2006; Pediatric OCD Treatment Study, 2004).
Finally, because OCD in its most severe form is such a crippling and disabling disorder,
psychiatrists have begun to examine the usefulness of certain neurosurgical tech- niques for
the treatment of severe, intractable OCD (which may afflict as many as 10 percent of people
diagnosed with OCD; Mindus et al., 1994). Given the invasiveness of this intervention,
before such surgery is even contemplated, the person must have had severe OCD for at
least 5 years and must not have responded to any of the known treat- ments discussed so
far (medication or behavior therapy). Several studies have shown that approximately 35 to
45 per- cent of these intractable cases respond quite well (at least a
Panic, Anxiety, Obsessions, and Their Disorders 235

236 Chapter 6
one-third reduction in symptoms) to neurosurgery designed to destroy brain tissue in one of
the areas impli- cated in this condition (Dougherty, Baer, et al., 2002; Jenike, 2000; Rück et
al., 2008). However, a significant number of these have adverse side effects. The results of
these tech- niques are discussed in greater detail in Chapter 16.