Etiology and Treatments

Because of the distressing yet fascinating nature of the symptoms, several
theoretical positions have attempted to explain how obsessive-compulsive
disorder develops. From an applied perspective, each theoretical position
has evolved into a treatment or intervention strategy for eliminating the
problems caused by obsessions and compulsions. According to psychoanalytic
theory, as outlined by Sigmund Freud in 1909, obsessive-compulsive rituals
are the product of overly harsh toilet training which leaves the patient
with considerable unconscious hostility, primarily directed toward an authoritarian
caregiver. In a sense, as uncomfortable and disconcerting as the
obsessions and compulsive behaviors are, they are preferable to experiencing
the intense emotions left from these childhood incidents. Obsessions
and compulsions permit the patient to avoid experiencing these emotions.
Furthermore, obsessive-compulsive symptoms force the patient to become
preoccupied with anxiety-reduction strategies which prevent them from
dealing with other hidden impulses, such as sexual urges and desires. Based
upon the psychoanalytic formulation, treatment involves identifying the
original unconscious thoughts, ideas, or impulses and allowing the patient
to experience them consciously. In his classic case report of an obsessive patient,
Freud analyzed a patient known as the “rat man,” who was plagued by
recurrent, horrifying images of a bucket of hungry rats strapped to the buttocks
of his girlfriend and his father. Although periodic case reports of psychoanalytic
treatments for obsessive-compulsive disorder exist, there is very
little controlled empirical work suggesting the effectiveness of this treatment
approach.

Behavioral theorists, differing from the psychoanalytic tradition, have proposed that obsessive-compulsive disorder represents a learned habit that
is maintained by the reinforcing properties of the anxiety reduction that occurs
following ritualistic behaviors. It is well established that behaviors that
are reinforced occur more frequently in the future. In the case of compulsive
behaviors, the ritual is always followed by a significant reduction in anxiety,
therefore reinforcing the compulsive behavior as well as the preceding
obsessive activity. Based upon the behavioral perspective, an intervention
strategy called response prevention, or flooding, was developed to facilitate the interruption of this habitually reinforcing cycle. Response prevention
involves exposing the patient to the feared stimulus (for example, a doorknob)
or obsession (for example, an image of leaping from a bridge) in order
to create anxiety. Rather than allowing the patient to engage in the subsequent
compulsive activity, however, the therapist prevents the response
(for example, the patient is not permitted to wash his or her hands). The patient
endures a period of intense anxiety but eventually experiences habituation
of the anxiety response. Although treatments of this nature are anxiety
provoking for the patient, well-controlled investigations have reported significant
reductions in obsessive thinking and ritualistic behavior following
intervention. Some estimates of success rates with response prevention are
as high as 80 percent, and treatment gains are maintained for several years.
Theories emphasizing the cognitive aspects of the obsessive-compulsive
disorder have focused on information-processing impairments of the patient.
Specifically, obsessive-compulsive patients tend to perceive harm (for
example, contamination) when in fact it may not be present and to perceive
a loss of control over their environment. While most individuals perceive a
given situation as safe until proved harmful, the obsessive-compulsive patient
perceives situations as harmful until proved safe. These perceptions of
harm and lack of control lead to increased anxiety; the belief that the patient
controls his or her life or the perception of safety leads to decreased
anxiety. Accordingly, compulsive rituals represent a patient’s efforts to gain
control over his or her environment. Cognitive interventions aim to increase
the patient’s perception of control over the environment and to
evaluate realistically environmental threats of harm. While cognitive approaches
may serve as a useful adjunct to behavioral treatments such as response
prevention, evidence for their effectiveness when used in treating
obsessions and compulsions is lacking.

Finally, biological models of obsessive-compulsive disorder have also been
examined. There is some indication that brain electrical activity during information
processing, particularly in the frontal lobes, is somewhat slower
for obsessive-compulsive patients in comparison to other people. For example,
metabolic activity of the frontal brain regions measured using positron
emission tomography (PET) scans differentiates obsessive-compulsive patients
both from normal people and depressive patients. Further, a deficiency
in certain neurotransmitters (for example, serotonin, and norepinephrine)
has been implicated in the etiology of the disorder. Several interventions
based upon the biological model have been employed as well. Pharmacotherapy,
using antidepressant medications that primarily act to facilitate
neurotransmitter functioning (for example, clomipramine), has been shown
to be effective in treating from 20 percent to 50 percent of obsessivecompulsive
patients. More drastic interventions such as frontal lobotomies
have been reported in the most intractable cases, with very limited success.
Among the interventions employed to rid patients of troublesome obsessions
and compulsions, response prevention holds the most promise. Because of the intensity of this treatment approach, however, the cost may be
substantial, and many patients may not immediately respond. A number of
predictors of poor treatment response to behavioral interventions (characteristic
of those most refractory to treatment) have been identified. These
include a coexisting depression, poor compliance with exposure/responseprevention
instructions, the presence of fears that the patient views as realistic,
and eccentric superstition. In these cases, alternative forms of treatment
are typically considered (for example, pharmacotherapy).