Compulsion Symptom in Obsessive Compulsive Disorder

hand washing
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Compulsions are repetitive behaviors or mental acts an individual is driven to perform in response to an obsession or according to rigidly applied rules and are one of the two primary symptoms of Obsessive Compulsive Disorder, a psychiatric disorder that affects approximately 1% - 2% of the population.

Not all repetitive behaviors or routines are compulsions, however. For example, most people have morning routines, bedtime routines, or an order in which they shower each day, which are within the range of “normal” behavior and serve a positive purpose in daily functioning.  Similarly, those who are particularly orderly or neat in the way in which they prefer to keep their environment and who experience this in a positive way, do not have OCD either — this is more of a personality trait.

In OCD, compulsions are time-consuming and accompanied by significant anguish. Compulsions are typically carried out in order to neutralize or reduce the anxiety, disgust, or distress, or, minimize the perceived risk associated with an obsession or to prevent a feared outcome (i.e., something bad may happen) associated with an obsession (recurrent, persistent, intrusive, unwanted thoughts, images, or urges that cause anxiety or distress).  Compulsions may also be driven by internal tension and a feeling that a behavior has to be carried out in order to feel it is “just right.”

Common Compulsions

  • Washing/Cleaning (e.g., washing hands or other body part in a certain way, excessive use of sanitizers/soaps/other cleaning agents, excessive grooming or toileting routines, excessive cleaning of objects or items in environment, other behaviors aimed at removing germs/dirt/contamination); typically in response to obsessions involving germs/contamination
  • Checking (e.g., any form of checking behavior carried out to provide reassurance that one did not/would not harm oneself or others, make a mistake, or do something perceived as unethical or immoral; ensure nothing bad has happened, ensure health and safety of self and others).
  • Mental Rituals (e.g., thinking through things for clarifications or attempts to figure out or better understand something, mental review of events/communications, praying to prevent harm, counting in a specific way or to a specific number, verbalizing — aloud or in one’s mind- a specific word or phrase that feels “good” in order to replace or “fix” something that feels “bad”, imagining a “good” image to replace a “bad” image.)
  • Repeating (e.g., re-reading, re-writing, repeating routine actions/activities, repeating body movements, carrying out an action a certain number of times).
  • Ordering/Arranging (e.g., ordering or arranging until it feels “right”)
  • Need to Tell — (e.g., telling or confessing in detail, even innocuous information, statements of uncertainty in order to be certain that one has been entirely accurate and has not lied).
  • Rituals Surrounding Morality/Ethics (e.g., excessively rigid behaviors carried out in order to live according to specific values - such as practices around religion, environmental concerns, health, and wellness).
  • Other “Just Right”/ Tourettic / Tic-Related Compulsions — (e.g., counting, symmetry/evening up, arranging, ordering, positioning, touching, and tapping); there may be no elaborate obsession or feared outcome that drives these behaviors, but rather, intense somatic and/or psychological tension or discomfort, often described as something feeling incomplete or “not right” which is relieved by the behavior.
  • Avoidance (e.g., avoidance of any anxiety-provoking stimuli associated with an obsession in order to minimize harm or decrease anxiety or distress)

Diagnostic Criteria

Classified among the “Obsessive Compulsive and Related Disorders” in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the diagnostic criteria include:

  • The presence of obsessions, compulsions, or both
    • Obsessions are defined as:
      • Obsessions are defined by recurrent, persistent, intrusive, unwanted thoughts, images, or urges that cause anxiety or distress
      • Attempts to ignore or suppress such obsessions or neutralize them by performing a compulsion
    • Compulsions are defined as:
      • Repetitive behaviors or mental acts an individual is driven to perform in response to an obsession or according to rigidly applied rules
      • The behaviors or mental acts are aimed at reducing anxiety or distress, or preventing a feared outcome; however, they are clearly excessive or not connected in a realistic way to that which they are intended to address
    • The obsessions or compulsion are time-consuming (e.g., take more than 1 hour per day) or cause significant distress or impairment in one’s daily functioning
    • The symptoms are not better accounted for by the physiological effects of a substance, medical condition, or other mental disorder
      • It is noted that individuals may have good/fair or poor insight into the reasonableness of their symptoms. If poor insight, the individual’s symptoms may appear delusional in nature. It is also noted that symptoms may be tic-related in nature if the patient has a history of tic disorder.
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Article Sources

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  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 5thed. Washington, DC: American Psychiatric Association; 2013:251-4.
  • Goodman, W.K., Price, L.H., Rasmussen, S.A. et al.: “The Yale-Brown Obsessive Compulsive Scale.” Arch Gen Psychiatry 46:1006-1011,1989.
  • Mansueto, C.S. & Keuler, D.J. (2005). Tic or compulsion? Behavior Modification, 29(5): 784-799.
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