Introduction

Obsessive compulsive disorder (OCD) involves the presence of obsessions or compulsions or both. Obsessions are defined as intrusive thoughts or images (for example, thoughts about harming others or becoming contaminated) and compulsions are defined as repetitive behaviours that are overt (for example, hand-washing), or mental acts which are covert (for example, silent counting). The obsessions cause distress and the compulsions are carried out to try to reduce the distress, or prevent a feared consequence of the obsession. The DSM-IV field trial found only two-thirds of OCD sufferers could identify consequences that they feared would follow from abstaining from rituals. The obsessions and compulsions must be repetitive, unpleasant and interfere with functioning. The person must also recognise that the obsessions or urge to perform a compulsive act originate within their own mind. Traditionally the person must acknowledge the obsessions and compulsions as excessive or unreasonable and must try to resist them. However DSM-IV includes a subtype of OCD 'with poor insight' recognising that in a minority of sufferers this is not the case. Lelliot et al. (1988) found 12 % of 49 OCD sufferers made no attempt to resist rituals and a third thought their obsessive thoughts were rational.

There are minor differences in the DSM-IV and ICD-10 criteria for OCD. DSM-IV requires symptoms to cause marked distress, be time consuming (take more than one hour per day) or significantly interfere with the person's normal functioning. ICD 10 requires symptoms to be present on most days for two weeks. However it is usual for symptoms to be present for much longer before presentation, as OCD sufferers are often secretive about their problems. Rasmussen & Tsuang (1986) found that sufferers first presented over seven years after the onset of significant symptoms. Sufferers of OCD may not report all their symptoms unless specifically asked. They may present in primary care (for instance with somatic obsessions) or to specialists (for example compulsive handwashers presenting to dermatologists) without OCD being identified as the underlying cause. Some sufferers are embarrassed about their symptoms (such as intrusive sexual thoughts) whereas others are

Handbook of Evidence-based Psychotherapies: A Guide for research and practice. Edited by C. Freeman & M. Power. Copyright © 2007 John Wiley & Sons, Ltd.

unaware that their thought patterns or actions are outwith normal experience. General open questions about recent mood may pick up co-morbid conditions, such as depression. More specific questions should be asked if OCD is suspected, such as 'Have you had distressing thoughts or images that keep coming into your mind even though you try to stop them?' or 'Have you felt driven to repeat things or do things in a particular way?'

Manageable obsessions and compulsions do commonly occur in the general population and there is no clear dividing line between this occurrence and clinical OCD. In the subclinical form, although the content of obsessions and compulsions is similar, the symptoms are usually of shorter duration, less severe and ego-syntonic (Muris, Merckelbach & Clavan, 1997; Salkovskis & Harrison, 1984). The content of obsessions and rituals is affected by the prevailing concerns of the time or place (illness concerns have changed over time from plague or syphilis to cancer or AIDs) and usually involves themes that are particularly upsetting for the individual (such as blasphemous thoughts in a religious person).

Obsessive compulsive disorder commonly presents with co-morbid depression or anxiety disorders. Many disorders present with co-morbid obsessive-compulsive symptoms, including major depression, Tourette's disorder, schizophrenia and organic mental disorders. In these cases the obsessional and compulsive symptoms are probably secondary to the primary illness. There is also a related group of impulse control disorders and syndromes similar to OCD (including monosymptomatic hypochondriasis and body dysmorphic disorder), which sometimes respond to similar treatment approaches. Obsessive compulsive disorder is over-represented in Tourette's disorder and vice versa. The revised Obsessive-Compulsive Inventory is a reliable diagnostic screening tool (Foa et al., 2002). The Yale-Brown Obsessive Compulsive Scale (observer-rated) and the Maudsley Obsessive Compulsive Inventory (self-rated) are validated assessment tools that measure symptom change (Taylor, 1995). Most clinical trials use the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and classify a reduction of 25 % from the baseline score as a measure of clinically significant improvement. The self-report version of the Compulsive Activity Checklist (CAC) (Steketee & Freund, 1993) has been found to be reliable, valid and sensitive to change in treatment. Salkovskis, Forrester & Richards (1998) highlighted difficulties with the Y-BOCS measuring change in obsessional thinking and made suggestions about changes.

Eliminating Stress and Anxiety From Your Life

Eliminating Stress and Anxiety From Your Life

It seems like you hear it all the time from nearly every one you know I'm SO stressed out!? Pressures abound in this world today. Those pressures cause stress and anxiety, and often we are ill-equipped to deal with those stressors that trigger anxiety and other feelings that can make us sick. Literally, sick.

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