Description and analysis of academic content

Obsessive Compulsive Disorder

Researchers have concluded that current thinking regarding the etiology of Obsessive Compulsive Disorder (OCD) can be traced to the theories of Sigmund Freud. He postulated that obsession defenses function to control unacceptable sexual and hostile feelings. Regression from the oedipal phase of development to the anal period is driven by castration anxiety. Character traits of orderliness, parsimony, and obstinacy are related to early conflicts and struggles with parental figures. A strong punitive superego dominates. The defense mechanisms of displacement, reaction formation, isolation of affect, intellectualization, symbolization, and undoing are used by the patient with OCPD ("Obsessive-Compulsive Personality Disorder History and Theoretical Perspective," 2006, p. 1).

Burgy explained in the research conducted that the oedipal conflict is at the center of Freud's thinking. Once the genital phase has been reached, the ego's defense struggle sets in, fuelled by the suppressed castration complex. Using a whole series of defense mechanisms, such as isolation, denial, magic thinking, intellectualization, and rationalization, the ego withdraws to the former anal-sadistic level of development. Regression is seen as the successful defense of a mature and stable ego structure. From the point-of-view of structural dynamics, regression of the ego leads to increasing severity and lack of love on the part of the superego, as more and more id-impulses have to be fended off. These impulses are anal-sadistic (antisocial, aggressive), anal-libidinous (pleasurable soiling) and genital (homosexual and heterosexual desires). The ego develops obedience towards the superego and identifies itself by reacting accordingly with the traits of the analytic character as indicated. The compulsive symptom develops into the ego's compromising symbolic way of solving conflicts between the superego and the id. Freud, therefore, is of the opinion that in the form of obsessive-compulsive actions "the masturbation that has been suppressed approaches ever more closely to satisfaction (Burgy, 2001).

Subsequent theorists have stressed the desire for security and caretaking and the avoidance of being seen in a shameful light as significant in the development of OCD. Patients with OCD are seen as experiencing inadequate love from their parents, leading to rage and intense desires for care and nurturance. Their attempts at being better to the point of perfectionism represent an attempt to be deserving of a more caring response. Dynamic theories of etiology continue to predominate ("Obsessive-Compulsive Personality Disorder History and Theoretical Perspective," 2006, p. 1).

Freud's intrapersonal concept of anal-sadistic regression is set against the interpretation of obsessive-compulsive neurosis as a structural ego deficit. The interpersonal dimension that comes to the forefront as a result of this becomes clear if we focus on obsessive-compulsive behavioral disorder: Persons suffering from obsessive-compulsive neurosis lack the self-assessment factor. It needs another person as part of their own ego who accepts and supports them in their behavior. A clinical example illustrates this narcissistic function of compulsion together with the changes in the psychodynamic approach and resulting therapy. Against DSM-classification with the concept of obsessive-compulsive disorder, which contains an unspecific symptomatology that occurs both in neurosis, schizophrenia, melancholia, and organic psychosis, this article advocates the specific and differentiated concept of obsessive-compulsive' neurosis (Burgy,2001).

Sigmund Freud theorized that OCD symptoms were caused by punitive, rigid toilet-training practices that led to internalized conflicts. Other theorists thought that OCD was influenced by such wider cultural attitudes as insistence on cleanliness and neatness, as well as by the attitudes and parenting style of the patient's parents. Cross-cultural studies of OCD indicate that, while the incidence of OCD seems to be about the same in most countries around the world, the symptoms are often shaped by the patient's culture of origin. For example, a patient from a Western country may have a contamination obsession that is focused on germs, whereas a patient from India may fear contamination by touching a person from a lower social caste (Jane, n.d).

OCD is a relatively common, chronic illness associated with considerable morbidity and economic and social burden. OCD is characterized by intense anxiety caused by unwanted, intrusive, persistent thoughts, images, or impulses (obsessions), which lead to repetitive behaviors or mental acts compulsions that the person feels driven to perform to prevent or reduce his or her distress or anxiety. Obsessions and compulsions are time-consuming and cause significant functional impairment and/or distress (Berlin, Hamilton & Hollander, 2008).

OCD is in many ways a homogeneous disorder. The disorder has a prevalence of around 2% to 3% of the population, and this prevalence is likely underestimated in many different countries / and descriptions of obsessions and compulsions have been remarkably consistent over time and place. Neurobiological studies have consistently found evidence that cortical-striatal-thalamic-cortical (CTSC) circuits play a crucial role in mediating the disorder and treatment research has invariably demonstrated that serotonin reuptake inhibitors selectively reduce the symptoms of OCD (Stein, Andersen, & Overo 2007; O'Connor, Todorov, Robillard, Borgeat, & Brault 1999).

The most common treatments for OCD are pharmacological and cognitive behavioral interventions. According to the American Psychiatric Association treatment practice guidelines for OCD, selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatments for OCD. However, SSRIs are often associated with delayed onset of therapeutic effect (8 -- 12 weeks), only partial symptom reduction, and response failure or intolerability in 40% to 60% of patients. Pharmacological options for SSRI refractory cases include increasing drug dose, changing to another SSRI or clomipramine, combining SSRIs, or changing the mode of drug delivery. Augmentation with second-generation antipsychotics has demonstrated efficacy as a second-line treatment (Berlin, Hamilton & Hollander, 2008).Obsessive-compulsive disorder shows a slow, gradual improvement, which starts within a few days after the initiation of treatment and continues for months thereafter. Published consensus guidelines consider an adequate SRI trial in OCD to consist of 10 -- 12 weeks with at least 4 -- 6 at the maximum tolerated dose (Dell'Osso, Altamura, Mundo, Marazziti, & Hollander, 2007).