What are the symptoms of OCD? How does OCD manifest itself?

The character of Howard Hughes in the biographical film “The Aviator,” provides a compelling narrative to illustrate how OCD symptoms can manifest themselves to become devastating in a person’s life. The film vividly portrays the challenges Hughes faces as he grapples with the overwhelming impact of the disorder. Through the character of Howard Hughes, “The Aviator” powerfully demonstrates how OCD symptoms can manifest in ways that are both distressing and invalidating, underscoring the profound impact that the disorder can have on an individual’s life and well-being.

Howard Hughes’ OCD symptoms are depicted as all-consuming and deeply distressing. His relentless need for cleanliness and fear of contamination leads him to spend hours scrubbing his hands raw, often to the point of bleeding. His compulsion for order and control drives him to meticulously repeat certain actions, such as lining up his peas on a dinner plate, or repeatedly checking and rechecking locks and switches. These behaviors are shown to dominate his thoughts and actions, causing significant distress and impairing his ability to function in his personal and professional life. The film highlights the invalidating nature of Hughes’ symptoms. His struggles are often met with skepticism and misunderstanding from those around him, including his colleagues and partners, who fail to grasp the severity of his condition. This lack of empathy and support only serves to exacerbate his suffering, deepening the sense of isolation and hopelessness that accompanies his OCD.

How can we discriminate OCD from other similar disorders?

An Obsessive-Compulsive Disorder (OCD) can be defined by the presence of intrusive and unwanted thoughts or images, and also an overwhelming compulsion to perform behaviors or thoughts in a repetitive and ritualized manner. OCD typically involves both obsessions and compulsions. Obsessions are distressing thoughts, images, or urges that cause significant anxiety or distress. Compulsions are repetitive behaviors or mental acts that are performed in response to an obsession, with the view of reducing the anxiety or preventing a feared event or situation (such as excessive handwashing, checking, counting, or arranging objects (Gibson, Portelli, Papantuono , 2022). Yet compulsive behaviours can be also carried out to help the person achieve some specific pleasurable feeling (Nardone, Portelli, 2005, 2016 ). In fact, compulsivity is not only a central characteristic of obsessive-compulsive disorder (OCD) which are often fear-based, but is also crucial to addictions, which are pleasure based.

OCD has been proposed to be part of the concept of behavioral addictions (Figee et al., 2015) such as compulsive shopping, pathological gambling, skin-picking, trichotillomania, compulsive eating and new addictions (Papantuono, Portelli, 2017). Compulsive behaviors are driven by repetitive urges with limited voluntary control, a diminished ability to delay or inhibit these behaviors, and a tendency to perform repetitive acts in a habitual or stereotyped manner. In pleasure-based compulsion, the compulsion becomes the obsession, as in the case as binge watching, on-line shopping, selfie mania, and other addictive behaviour aggravated by the over-use of social media (Gibson 2023). Thus, it is important to discriminate if the compulsion is fear-based or pleasure-based cause this can lead to better understanding of the problem so as to choose the most appropriate intervention (Papantuono et al., 2014).

Discriminating OCD from other anxiety-based problems can be challenging because OCD shares some similarities with other anxiety disorders, such as generalized anxiety disorder (GAD), social anxiety disorder, and specific phobias. However, there are some key differences that can help in distinguishing OCD from other anxiety-based problems.

In OCD, individuals experience intrusive and unwanted thoughts, images, or urges (obsessions) that lead to the performance of repetitive behaviors or mental acts (compulsions). These obsessions and compulsions are time-consuming and cause significant distress. In contrast, other anxiety disorders may involve excessive worry, fear of specific situations or objects, with avoidance behaviors, and do not involve the same type of specific and repetitive rituals seen in OCD.

Individuals suffering of OCD may have very specific fears, which make use of compulsions as an attempt to manage this underlying fear. For example, a person may fear contamination and engage in extensive hand washing rituals. A person might need to carry out a specific sequence before leaving the house as to reassure himself that all is safe. In contrast, other anxiety disorders may involve broader fears or worries of losing control but do not use the specific compulsive behaviors or rituals to reduce the underlying fear.

Individuals with OCD often experience significant impairment in their daily functioning due to the time-consuming nature of their obsessions and compulsions. These rituals can interfere with work, school, relationships, and other activities. Anxiety disorders may also cause impairment, yet not because it is time consuming but because it paralysis the person, blocking him from performing appropriately.

Often, patients but also professionals are misguided by the term Pure-O, also known as Purely Obsessional OCD or Pure Obsessional OCD, which are both subtypes of OCD. While traditional OCD involves both obsessions and compulsions (which can be either observable or mental acts), Pure-O is characterized by the presence of obsessions without obvious, external compulsions. In a 2011 study, Williams and her colleagues reveal that individuals who experience the “pure obsessions” also engage in mental rituals as a way of managing their distress. These rituals might include: Mentally reviewing memories or information; Mentally repeating certain words; mentally un-doing or re-doing certain actions. Distressed by obsessive thoughts they may also compulsively seek reassurance. Recognition of compulsions performed by those previously considered purely obsessional can aid in the improved diagnosis and treatment of people with OCD. It is imperative to carry out a thorough operative diagnosis, to reveal the presence of compulsions, their function and how they manifest themselves, so that the most appropriate treatment is chosen (Portelli, 2005, Gibson et al. 2022).

So how can compulsions be manifested?

Back in 2004, in my article “Advanced brief strategic therapy for obsessive-compulsive disorders” I explored the different ways, compulsions or rituals can be manifested. Compulsions based on fear can be behavioural or mental. Mental compulsions can be the mere repetition of a words to actual mental calculations and formulas. Compulsions might be rational, such as washing one’s hands to remove dirty or contamination but also magical, like repeating specific words so as to propitiate that nothing happens to loved ones. Compulsions can have a specific sequence which need to be followed to the letter or it can be numerical, that is, it needs to be repeated a specific number of times to feel reassured. Compulsions can be carried out in specific moments or else are present in various moments when the person is overwhelmed by his fears or obsession. Compulsions can be carried by the individual or involve others for further reassurance.

In OCD, rituals can have either a reparative function, i.e. to repair something that has happened (wash way the dirt, correct a mistake, redeem from a sin, etc) but also a preventive, to avoid something from happening (to avoid to contaminate the temple of cleanliness, check that the door is closed, etc.) or proprietary to make things happen (where the yellow t-shirt to bring good luck to pass the exam, etc). Thus, when working with OCD, besides holding a thorough diagnosis to discriminate from other disorders, it is imperative to carry out an operative diagnosis to understand the function (preventive, proprietary or reparative), the modality (numerical or holds a sequence) and medium (action or mental) to find the most adequate means to interrupt the compulsion that further feed the obsessions. A comprehensive evaluation by a mental health professional is necessary for an accurate diagnosis and effective treatment planning to help the person break free from obsessive-compulsive vicious circle.

Caught in a vicious circle: when the actual reassuring compulsion exasperate the obsession

The compulsion gives the illusion of control, and that is what brings the person ’to do more of the same’ (Virty et al, 2021). If we analyze the mental prison represented by Obsessive Compulsive Disorder, we observe that the very attempt to seek reassurance in order to manage a fear or the irrepressible tendency to feel a specific sensation, structures a very rigid and persistent problem (Nardone, Portelli, 2005, 2016)

In conclusion, obsessive-compulsive disorder (OCD) can indeed create a vicious cycle of intrusive thoughts and compulsive behaviors. People with OCD experience persistent, unwanted thoughts (obsessions) and feel driven to perform repetitive actions or rituals (compulsions) to try to ease their anxiety or prevent a feared event or situation. However, these compulsions typically provide only temporary relief and can actually reinforce the obsessive thoughts, leading to a cycle of escalating anxiety and compulsive behavior. Even though the person rationally come to recognize that his compulsive behaviour is of no use and thus would like to stop his compulsive behaviour, he is not able to do so because his underlying fears overwhelm him and bring him to carry out his compulsion (Papantuono, 2007).

The same compulsive behavior or ritual that worked to reassure or cease the fear, over time loses their effect, thus the same behavior needs to repeated more and more times. What seems to have given the person a sense of control over his fear brings to entrap the person in a compulsive behavior that further fuels once obsessive thought and brings him to lose control (Nardone, Portelli, 2005, 2016).

Often OCD patients describe themselves like a hamster running on a wheel in a cage. No matter how much the hamster runs, it doesn’t escape the cycle, and similarly, individuals with OCD often feel trapped in a cycle of obsessions and compulsions, unable to break free. They feel stuck in a relentless and unproductive cycle, trapped in a seemingly no-way-out condition. Today, media and schools are helping to generate more awareness on mental health and on effective and efficient therapies to help people suffering of OCD to manage and actually get out of OCD traps.

REFERENCES

Figee, M, T. Pattij , Ingo Willuhn a c, Judy Luigjes a, Wim van den Brink a d, Anneke Goudriaan a d, Marc N. Potenza e g h, Trevor W. Robbins f, Damiaan Denys: Compulsivity in obsessive–compulsive disorder and addictions. European Neuropsychopharmacology: Volume 26, Issue 5, May 2016, Pages 856-868

Gibson, P ., Pietrabissa, G., Manzoni GM, et al. (2018) Brief strategic therapy for obsessive– compulsive disorder: a clinical and research protocol of a one-group observational study. BMJ Open 2016;6:e009118. doi:10.1136/bmjopen-2015- 009118

Gibson, P., Portelli, C. Papantuono, M., (2022) The OCD Clinic: A New Approach to Understanding and Treating Obsessive-Compulsive Disorders. Strategic science books

NARDONE G., PORTELLI C. (2005) KNOWING THROUGH CHANGING. WALES: CROWN HOUSE

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NARDONE, G, PORTELLI, C., (2016) OSSESSIONI, COMPULSIONI, MANIE. PONTE ALLE GRAZIE

Portelli C. Advanced brief strategic therapy for obsessive-compulsive disorders. Brief Strateg Syst Ther Eur Rev 2004;1:88–97

Portelli, C. Brief strategic interventions for obsessive compulsive disorders: acquiring the maximum with the minimum in the first session. Brief Strat Syst Ther Eur Rev 2005;2:56–70.

Portelli, C. Papantuono, M (2017) Le Nuove Dipendenze: Riconoscerle, capirle e superarle. Edizioni San Paolo Milano

Papantuono M., (2007), Identifying and exploiting the patient’s resistance to change in brief strategic therapy, in Brief Strategic and Systemic Therapy: The American Review, Vol. I, Issue I.

Williams MT, Farris SG, Turkheimer E, et al. Myth of the pure obsessional type in obsessive-compulsive disorder. Depress Anxiety. 2011;28(6):495-500. doi:10.1002/da.20820