A Disorder in Dispute: Ongoing OCD Debates

Obsessive-compulsive disorder (or OCD) walks the line between being a heavily-researched mental health condition that has recently been drawing a great deal of attention, to remaining, by and large, a mysterious ailment. But while the specifics of its root causes are still slowly being uncovered, scientists and mental health professionals continue to disagree over key aspects of this highly disputed condition. Read on to learn more about current, ongoing OCD debates.

OCD debates

OCD: Disturbing Thoughts and Actions

Experts on obsessive-compulsive disorder have been battling it out over recent years, seemingly unable to agree on almost anything when it comes to this condition: is OCD an anxiety-based condition, or does it stem from distress? Does it have a genetic base, or is it more learned? And what types of OCD do we know to exist?

In fact, just about the only thing mental health researchers, practitioners, and the patients contending with this disorder agree on, is that OCD symptoms are mainly composed of obsessive thoughts, compulsive reactions, or both. And so, before detailing the above-mentioned points of contention, a short explanation on the consensus of OCD-related obsessions and compulsions is in order.

OCD-related obsessions are defined as highly unpleasant, unwanted, and disturbing thoughts that attack the individual experiencing them at an almost relentless pace. While the themes of these obsession may vary, the four most common ones are:

  • Cleanliness and contamination.
  • Counting, organizing, orderliness, and “just right” thinking.
  • Catastrophizing or great concern that a tragic event will occur to the individual or a loved one.
  • Taboo thoughts, usually over an immoral, socially unacceptable, or sacrilegious action.

OCD-related compulsions are defined as repetitive or ritualistic responses that take up a great deal of time and energy from the individual. Often, these compulsions begin as a way to calm the unpleasant sensations that arise due to OCD-related obsessions: someone exhausted from non-stop thoughts of their partner getting into a horrific accident might develop a little ceremony of touching the doorknob three times before exiting the house, as a way to “protect” them. Such an action can take place even if the individual does not actually believe it has the power to safeguard their partner; they may continue to do so because they find they have become agitated when they do not perform this ritual. In such cases, the OCD-related compulsion becomes part of the disorder, causing the individual undue stress despite initially offering a temporary sense of relief. OCD-related compulsions are far more diverse than obsessions, and can include anything from a hand gesture, dance routine, uttering a specific word, and even conjuring a certain image in one’s mind.

A Disorder in Dispute Ongoing OCD Debates

A brief summation on the statistics behind OCD is also important, as it conveys why this disorder has received so much attention over the past several years. According to the American Psychiatric Association (APA), 2.3% of US adults and 1%-2.3% of US children and adolescents are officially diagnosed with OCD. The condition can appear at any age, usually becoming apparent between the ages of ten and early adulthood. That said, patients are usually only diagnosed (and begin receiving treatment) from the ages of 14-17: this is due to OCD at times being an elusive and hard to diagnose disorder, with its symptoms often rationalized as eccentricities, rather than a mental health condition.

And now, the conflicts:

How Does OCD Relate to Anxiety?

For decades, the APA had insisted that OCD is part of the anxiety disorders family and listed it as such. However, when it published its latest Diagnostics and Statistical Manual (the DSM-V) in 2013, OCD had been given a chapter of its own, together with other OCD-related disorders, such as hoarding and body dysmorphic disorder. The reason? More recent research, which found that not only did OCD seem to be related to its own, separate neural structures (such as the anterior cingulate cortex and frontal striatal pathways), but it also responded significantly better to certain medications (namely, specific serotonin reuptake inhibitors, aka SSRIs). All of this information has not deterred the APA from continuing to view OCD as an anxiety-based disorder—albeit one that deserves more of the spotlight.

OCD: Is It Anxiety or Distress?

Scientific revelations have continued shaping how OCD is viewed, with even more recent research coming out against the APA’s official “OCD-as-anxiety” stance. This growing voice is framing distress as the emotional bedrock out of which OCD sometimes evolves. The difference between these hypotheses pulls OCD toward two different positions: anxiety is considered a survival mechanism pushed into overdrive, and as such, OCD-as-anxiety is viewed as a case of excessive fear over a non-threat. Distress, on the other hand, is considered an adverse nagging sensation, with OCD-as-distress viewed as a case of disturbing thought content that will not allow the individual to relax. The jury is still out on this tug-of-war, as it remains to be seen which way the more established policy makers, such as the APA and the similarly minded World Health Organization (WHO) will lean in the coming years.

A Case of Genetic Determinism?

Studies remain inconclusive regarding the concrete causes of OCD. That said, a genetic predisposition has been implicated, with the APA finding that individuals with a first-degree relative diagnosed with OCD are twice as likely to develop the disorder themselves. The likelihood increases even further in cases where one’s relative had developed OCD during childhood: in such instances, the risk of developing OCD is ten times more likely, compared to individuals without a first-degree relative diagnosed with this condition. In addition to genetics, temperament and environmental factors have also been found to be associated to OCD: in regard to temperament, a tendency to internalize (rather than express) what one is going through, behavioral inhibition during childhood, and intense negative emotionality have been linked to increased risk of developing OCD. In regard to environment, experiencing abuse or other stressful or traumatic events have also been found to increase the chances of developing OCD.

A One-Trick Pony?

For the majority of the population, OCD is probably best-known for its most prevalent expression, cleanliness OCD. However, present-day research and field reports have been reporting on a much more diverse array of OCD themes than what was previously believed to exist: specifically, in addition to the more common OCD themes, such as cleanliness or orderliness, recent research has highlighted two previously overlooked areas: relationships and religion.

Relationship OCD, or ROCD, occurs when the individual constantly questions the qualities of the relationship they are in. It can revolve around their romantic relationship, with nagging questions such as whether their partner is truly “the one”. Or it can involve their parent-child relationship, and constantly trouble them with concern over whether their mother ever loved them. Just like with other types of OCD, doubt is a major component of ROCD, with the individual experiencing it suffering from a disquieting feeling that prevents them from feeling secure or appreciated within the targeted relationship.

Religion-based OCD, also known as scrupulosity, focuses on questions of faith or religion. Found to be more common within more devout countries, individuals who battle this type of OCD are plagued with the fear that God might strike them down due to their blasphemous thoughts, actions, or because they do not possess the requisite amount of faith. As a result, they may start compulsively praying, constantly seeking out reassurances from a respected religious figure, or participating in acts of self-sacrifice to “balance out” their perceived sins. Since religion-based OCD is culture-specific, it is important to consider whether their approach to religion and religious acts are considered the norm within their own community, or whether they stand out and cause them undue stress when compared to others within the society of which they are a part.