Anxiety disorders: obsessions and compulsions


Defining obsessions and compulsions

  • Obsessions are distressing thoughts, images or impulses that occur repeatedly and feel uncontrollable.
  • Compulsions are repetitive thoughts or actions that a person engages in to neutralise, counteract or get rid of their obsessions.

Obsessive-compulsive disorder, commonly called OCD, is an anxiety disorder characterised by obsessions and compulsions.

Case studies/examples

There have been many case studies on this mental illness.

‘Charles’ by Judith L. Rapoport:
Rapoport authored the book “The Boy Who Couldn’t Stop Washing” which was centred on the topic of OCD. Charles, the boy the book was about, would take showers for three or more hours every day and then take another two hours just to get dressed. He was obsessive-compulsive.

Another example of OCD – does this man need an introduction?


There are numerous measures available to assess the symptoms of OCD. Some examples of such measures are: the Yale-Brown Obsessive-Compulsive Scale, the Obsessive-Compulsive Inventory, and the Padua Inventory.

Maudsley Obsessive-Compulsive Inventory:
In clinical psychology, the M-OCI is a commonly used test that checks for obsessive-compulsive symptoms. This is a self-report questionnaire and was developed by Hodgson and Rachman. It has a ‘true or false’ format with 30 dichotomous items. The original version has four sub-scales: checking, cleaning, slowness and doubting. The test has been adapted to different languages and cultures, making its use much more widespread.



As you should be well aware of by now, the brain structure, genetic studies and biochemical abnormalities are all discussed in this model.

Neuropsychological findings have found evidence for a relationship between OCD and the brain. Most OCD patients have an increase in their brain activity in the frontal lobe of their brain’s left hemisphere, otherwise known as the “orbital frontal cortex”.

According to the biochemical model, OCD could be the result of a serotonin deficiency or a malfunction in its metabolism, for example: blocked serotonin receptors. Joseph Zohar found that some tricyclic drugs that inhibited the re-uptake of serotonin were beneficial for about 60% of his sample of OCD patients. However, Robert Lydiard found that drugs only provided a partial alleviation (reduction) from the symptoms of OCD.

Also, some studies have found that SSRIs reduce the symptoms of OCD.


According to the model that draws a link between cognitions and behaviour, OCD patients are unable to ignore certain thoughts that they have. They may label these thoughts as dangerous or uncontrollable, making them even more aware of the presence of such thoughts, and may actually “prove” the dangerousness of them to the patients. This confusing process results in the patient becoming trapped in a cycle of thought monitoring. They will be unable to focus on anything except these distressing thoughts, thus giving birth to an obsession.

Compulsions, such as hand washing or cleaning, are interpreted as a learned process (this is where behaviourism comes in). For example: in response to feeling dirty, you may wash your hands. This reduces the anxiety of being dirty, makes you feel good and positively reinforces the hand washing behaviour (I washed my hands, I’m clean now, yay, happy days again!)

Because of that reinforcement, an OCD patient would engage in their compulsion whenever they experience an obsession. They do this to reduce the anxiety that comes from the obsession. After engaging in the compulsion, they would feel relief.


The psychodynamic explanation of OCD states that obsessions and compulsions are indicators of suppressed, unconscious conflicts. These conflicts arise when an unconscious desire is incompatible with society’s norms and values; in Freudian terms, the id is at odds with the ego. It has also been suggested that when these conflicts are particularly distressing, they are dealt with by transferring the conflict onto something more manageable, such as: hand washing, checking, cleaning or hoarding.

Freud believed that OCD was linked to the anal stage of development, when children are being toilet-trained (for a quick reminder on Freud’s psycho-sexual stages of development). At this age and stage, children’s erogenous zone is the bladder. They get a form of satisfaction from bowel movements but are taught by parents to delay this gratification.

Freud said that if parents overuse punishment or are too harsh during toilet-training, the id of the child will become aggressive or messy and stubborn. If the parents make the child feel shameful and dirty, the child would attempt to control their id impulses. The result would be an anal-retentive personality in which toilet use becomes equated to messy behaviour. Anal-retentive personalities are rigid, orderly and obsessive; an obsessive-compulsive personality is formed.

The opposite of an anal-retentive personality is the anal-expulsive personality. It is wasteful, messy and destructive and it is the result of parents who are too lenient with their child’s toilet training in this developmental stage.


Drug therapy

Modern drug therapy for OCD began in the late 1960s when it was seen that Clomipramine (Anafranil), an antidepressant, was effective in treating this illness. Clomipramine was the first drug to receive FDA approval as a treatment for OCD. Antidepressants are thought to be helpful in OCD treatment because they raise serotonin levels which may have been lacking in patients’ brains.

Clomipramine affects a person’s sexual abilities and patients have also complained of fatigue, weight gain and seizures. This drug has the ability to latch itself onto the serotonin uptake pump and thus prevents the movement of serotonin into its home neuron. Medicines like this are called SSRIs.

SSRIs must be taken every day for eight to 12 weeks before the OCD symptoms begin to recede. After improvement, the medication is continued for at least another six to 12 months. Nearly two-thirds of OCD patients feel significant symptom relief with SSRIs. Several SSRIs have been proven as effective treatments for OCD, including: Luvox, Prozac, Paxil and Zoloft.

Studies have shown that SSRIs are more effective than antidepressants that do not interact with the serotonin uptake pump. So although all SSRIs can be used to treat depression, not all antidepressants can be used to treat OCD. This specificity supports the idea that OCD is rooted in a biochemical imbalance.

Cognitive-behavioural therapy

Patients who successfully have CBT for their OCD usually see a 60-80% reduction in their symptoms; this is one of the most effective treatments because of its high success rate, lack of adverse side effects and low risk.

CBT does not involve teaching the patient to escape from intrusive thoughts because they cannot actually be avoided in the first place. It focuses more on helping the patient to identify and modify any thoughts that cause anxiety, distress or compulsions. Rather than looking at the topic of the thoughts, this therapy aims to put importance on how a person is responding and reacting to these thoughts.

During CBT, the patient may be asked to remember a recent and specific example of their OCD. They would be asked to provide details and focus on what they had been thinking at the time. The therapist will use newly modified cognitions to modify the compulsive behaviour of the patient.

Psychoanalytic therapy

Psychoanalytic therapy involves the patient talking to a therapist; it aims to basically solve predominantly subconscious or unconscious conflicts. In light of recent research, this method has been seen as unlikely to achieve anything other than a placebo effect. Psychoanalytic treatment is not generally used to treat OCD because it is relatively ineffective when used alone. Simply becoming aware of your inner conflicts or suppressed desires is not always enough to reduce symptoms of OCD.