“If you could just leave your shoes by the door” was how a good friend greeted me as I visited her new home - even before the hello hugs and kisses. Once inside, I was escorted around the house with detailed instructions pertaining to which coaster to put my coffee cup on. As if that wasn’t enough, the moment I stood up from the sofa, a vacuum cleaner swiftly came out for a thorough cleaning of the radius around the spot I’d sat. “It’s not you” she tried to reassure me. “It’s me. It’s hard for me when the house is dirty”.
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It can be obsessive cleaning. Or biting one’s nails. Sometimes it’s repetitive thoughts; rituals before leaving the house; trying to remember if you turned off the gas; organizing food on your plate, or never-ending viewing of your ex’s Facebook profile. We all have our quirks, those things that make us who we are. But how can we know when our behavior and thoughts turn from something quite natural and ordinary into an “obsessive-compulsive disorder” (OCD)?
“Around 2.5% of the general population suffers from OCD at some point in their lives“ explains Dr. Asaf Caspi, Deputy Director of the psychiatry department at the Sheba Medical Center at Tel Hashomer Hospital. “It can appear at any age and is characterized by involuntary thoughts, impulses or images evoking anxiety. To reduce them or to control the anxiety, people develop compulsions – uncontrollable urges expressed through rituals, behavior or thoughts that a person feels the need to constantly repeat. Although this contains the anxiety resulting from these involuntary thoughts, it generally takes up a significant amount of time and headspace and can detrimentally affect one’s quality of life.
As for further psychiatric disorders, there are a variety of theories attempting to explain what in the structure or functioning of the brain causes OCD. Dr. Caspi tells us that the received physiological explanation is the levels of serotonin hormone in certain parts of the brain. Serotonin controls the processing of information that allows the brain to favor relevant information. It also performs a central role in feelings of well-being – anything from elation to depression, aggression and impulsivity.
“We assume that low serotonin levels in the brain also contribute to anxiety and depression” explains Dr. Caspi. “This theory is based on the effectiveness of medication that increases serotonin activity in the brain. However, there’s also further medication that doesn’t do this that has proven effective for treating OCD. So, this theory is somewhat limited. At the end of the day, our understanding of people’s happiness and mental state is very restricted when we’re talking about the normal range – even more so with illnesses.“
Genetic makeup also plays a part. If you have a family member who diagnosed with OCD, your chances of developing it stand at 25%. Nonetheless, Dr. Caspi stresses the complexity of the connection between heredity and psychiatry. Unlike with physiological illnesses, with OCD the environmental aspect plays an important part. “A good example would be identical twins with the same genetics, but where only one twin develops OCD.”
What are the chances of a person one fine day just developing OCD?
“In most cases, symptoms don’t appear out of nowhere and won’t worsen overnight. It’s usually a gradual process that can take up to seven years to develop from the moment these intrusive thoughts first appear. Some people spend their whole lives with intrusive thoughts without ever developing OCD. I should also explain that repetitive thoughts are not necessarily intrusive.”
Researchers in the fields of cognitive science explain the obsessive compulsion that appears in OCD as ordinary thought mechanism getting out of control. “Anxiety can distort thought processes for people not suffering from OCD and they may well find themselves troubled by their own repetitive thoughts“ explains Dr. Caspi. “These are usually doubts regarding actions we’re not sure we’ve carried out. The way to reduce the anxiety, even temporarily, is by various compulsive behavior patterns.”
Give an example of a repetitive behavior pattern
“Repeatedly asking the same question, checking whether we’ve done something, engaging oneself in a repetitive and monotonous activity like biting one’s nails, cleaning, superstitions etc.”
Maybe it’s just perfectionism?
“Perfectionists and people suffering from OCD differ in that perfectionism will apply to all areas of life, not just to one specific aspect.”
OCD is a disorder with a series of interconnected and peripheral symptoms. How do you make a precise diagnosis?
“OCD generally has two components: Firstly: intrusive thoughts that are generally classified by the patient as irrational or thoughts they’ve never had in the past, but which take up a lot of space and evoke significant emotional responses including a great deal of tension and anxiety.
“Secondly: in most cases, the ritual element manifested by repeating the same action over and over, in thought or action - repeating the same sentences or words, or repeating the situation either vocally or in one’s mind. It’s a kind of ritual that may not appear behavioral, but can take up a lot of space in one’s head.“
“But we have to be honest and say that the diagnosis is based on the psychiatrist’s impression by observing the patient and the things they’re saying. In most cases, a person suffering from some kind of disorder knows what’s disturbing them. An OCD diagnosis depends on the force of thoughts and actions that follow. How much time does it take up? Does it impair their functioning and do they repeatedly focus on one specific aspect?”
There’s an objective test for classic OCD: “People are often obsessive about washing or cleaning and don’t shower for weeks on end for fear they won’t be able to stop. In severe cases, people shower all day long. So, one of the few objective psychiatric ways to diagnose OCD is simply by asking the patient about their water bill.“
Alongside cleaning and tidying obsessions, a sub-type of OCD was recently discovered – and it involves romantic relationships. Intrusive thoughts about one’s relationship, known as Relationship Obsessive Compulsive Disorder (ROCD). It was discovered a decade ago by Israeli clinical psychologists Guy Doron, senior lecturer in psychiatry at Reichman University and Dr. Danny Derby of Cognetica Israeli Center for Cognitive Behavioral Therapies.
ROCD is a manifestation of OCD in which people are overcome by pathological jealousy and are preoccupied with the degree of trust they have in their partners and how much their partners trust them. Their thoughts include thinking they that have just settled for their current partner and could have done better and whether their exes were better for them“ explains Prof. Doron. “A further manifestation is obsessing over one’s partner’s faults – their physical appearance or social skills. This can also appear between a parent and child, leading to extreme distress and feelings of guilt and possibly depression. There’s also obsessiveness between Man and God.“
Like in classic OCD, the ROCD disorder is based on the connection between anxiety and the desire to suppress it by rituals and intrusive thoughts. “Research suggests that people suffering from ROCD have intrusive thoughts, disturbing images in their minds, and sometimes impulses that cause them to have particularly disturbing feelings,” explains Prof. Doron.
How are rituals manifested in this disorder?
“If, let’s say, a thought such as ‘maybe I was better off with my ex’ evokes high levels of anxiety, a person may try dealing with it by impulsive behavior. It might be practical like obsessively surfing social network sites to find information about their exes or trying to see if there’s anyone out there smarter than their present partner. They also have repetitive thoughts about the last time they felt love for their partners. Others will simply avoid any anxiety triggers while continuing with the repetitive thoughts and rituals such as avoiding friends and relationships or even not watching romantic TV shows.“
After a breakup, people tend to look for information about their exes. How can you tell when it’s natural and when it’s clinical?
“It’s important to understand whether a person does these things for fear of something bad happening or out of anxiety, or whether it’s born out of temporary distress that will pass. It must meet clinical criteria to be classified as obsessive: How long it occupies you, the level of distress it’s causing and the affect it has on other areas of your life – like if you’re searching for information on line instead of going to work. As a rule, if it takes up three hours of your day, you’ll be diagnosed with OCD. And if it carries on for more than six months, it requires clinical evaluation.
Are there OCD triggers we can watch out for?
“Yes. Perfectionist beliefs - that if your actions are not perfect, you sense a feeling of low self-worth. A trigger can also be manifested around the importance of thoughts - that every thought is important and that it says something about me as the person who thought it. Some people suffer from high levels of basic anxiety. These vulnerabilities can send people into vicious cycles that stagnate them inside the disorder and begin affecting their whole lives. Some people experience this after their children are born. OCD can develop after the birth of a child – for both men and women.”
I have a friend who describes herself as an “obsessive cleaner”. It doesn’t look very healthy from the outside. How can we tell if we need to think about treatment?
“With OCD, a person usually doesn’t want to carry out these actions. They only do them to avoid the anxiety that something bad will happen. This isn’t the same as people who are diligent about doing certain things due their worldviews – like people who believe that the house needs to be clean and hygienic at all times. In the latter, their thorough cleaning is born out of a belief in certain values. A person suffering from OCD performs actions that if they only could, they’d stop.”
“I should also mention that a lot of people suffering from OCD receive incorrect diagnoses and there are some people hide the disorder. There’s still a lot of shame around mental health disorders.”
Why are some people obsessive about cleaning and others about relationships?
“We’re not quite sure, but we do know that people can be obsessive about anything. Some people are obsessive about very defined, contained issues. Some people can shift their obsessions. Obsessive people are not in touch with their inner feelings. This leads them to the ongoing need for outward approval and a tendency to monitor. If you check your heart rate during sex to see how much you love, you’ll experience less passion as you’re busy deconstructing it. “
Can children also suffer from OCD?
“Yes, like most disorders, generally during adolescence. We can diagnose children from about the age of seven. Children have developmental rituals that are regarded as normal, but there are stages when you can see they’re developing OCD symptoms. For children, it’s also the source of enormous distress and can take over their lives. In children, it can be manifested in almost anything. It can involve only walking in precise straight lines, repetitive hand washing, bed-time routines – that if they’re not done, it’s catastrophic for the child. Either way, when people feel these actions have crossed a certain threshold and disturb the child’s life – that’s the time to get diagnosed and start treatment.”
The most recommended treatment, whether for classic OCD or for ROCD, is cognitive behavior therapy which helps people identify thought patterns and understand how it’s affecting their behavior and their feelings. This is hard for a lot of people: Most only seek out treatment for OCD when they feel their functioning is being impaired, which may be several years from the time the disorder first develops.”
“People are often ashamed of the disorder and avoid treatment. They’re also afraid that the treatment will require them to part with their coping mechanisms” explains Dr. Caspi.
Can one overcome OCD?
“Yes. But these things aren’t total. It can take time before the thoughts and rituals disappear completely, if at all. Significantly reducing symptoms, however, can make a person feel more in control - enough to change their feelings and make them function much better.”