Clinical Picture

Obsessive-compulsive disorder (OCD) is characterized by obsessions or compulsions or both. The American Psychiatric Association's Diagnostic and Statistical Manual (Fourth Edition) describes obsessions as recurrent, persistent ideas, thoughts, images or impulses that are experienced at some time during the illness as ego-dystonic, i.e., intrusive, senseless, excessive, repugnant, or absurd. The obsessions are not simply worries about real-life problems. Common morbid themes are contamination, aggression, harm avoidance, distasteful or excessive sexual ideas, religious concerns, fears of offending others, a need to know, orderliness and perfection. The person recognizes these ideas as products of his or her own mind and tries to suppress or ignore them, without much success.

Frequency of Obsessional Themes
* Data were derived from a study conducted by Rasmussen and Eisen in 1992. N=560 Patients meeting DSM-III or DSM-III-R criteria.
** Data were derived from a study conducted by Foa and Kozak in 1995. N-425 patients meeting DSM-IV criteria.
*** Fear or doubt regarding responsibility for a terrible event.
Percent of Patients

Theme Study A* Study B**
Contamination 50 38
Pathologic Doubt*** 42 --
Somatic 33 7
Symmetry 32 10
Aggressive 31 24
Sexual 24 6
Multiple Obsessions 72 --
Religious -- 6
Hoarding -- 5
Unacceptable Urges -- 4
Compulsions are repetitive, seemingly purposeful behaviors or mental acts performed according to rigid rules. The acts are designed to prevent a future feared event, but are not realistically connected to the event, or are excessive. They carry a sense of subjective compulsion and bring no pleasure. Common compulsions are washing, checking, a need to ask or to confess, arranging, repeating, hoarding, and mental compulsions such as counting or praying.

Frequency of Compulsive Behaviors
* Data were derived from a study conducted by Rasmussen and Eisen in 1992. N=560 Patients meeting DSM-III or DSM-III-R criteria.
** Data were derived from a study conducted by Foa and Kozak in 1995. N-425 patients meeting DSM-IV criteria.
Percent of Patients

Compulsions Study A* Study B**
Checking 61 28
Cleaning-washing 50 27
Counting 36 2
Need to Ask/Confess 34 --
Symmetry/Exactness 28 --
Multiple compulsions 58 --
Ordering -- 6
Hoarding 18 4
Repeating -- 11
Mental Rituals -- 11

OCD patients rarely have one or two symptoms because most of them have both obsessions and compulsions. Moreover, obsessions and compulsions present as infinitely personalized variations on a small number of morbid themes: aggression, harm avoidance, contamination, distateful or excessive sexual ideation, religious concerns, collecting, need for symmetry or order, need to know, and fear of illness. The patient's inner experience is disturbed by persistent, intrusive fears, dread of being guilty, pathological doubt, repugnant images or urges, and/or a need to carry actions to completeness or perfection. Contamination fears and fears of harming oneself or others are the most common obsessional themes, while cleaning and checking are the most common compulsions. In the vast majority of instances, compulsions are motivated by obsessions and aim at reducing the associated anxiety or preventing a dreaded event.

Although an individual's symptoms often change over time, symptoms present at a given time exhibit certain understandable patterns. In a study conducted by Baer in 1994, current symptoms drawn from 107 patients' Y-Bocs symptoms checklist clustered into three groups:

  1. symmetry and exactness obsessions strongly correlated with ordering compulsions and mildly with repeating and hoarding rituals -- yet hoarding obsessions, which were weakly associated with symmetry obsession, were strongly correlated with hoarding compulsions and mildly with ordering rituals;
  2. Contamination obsessions were strongly correlated with cleaning compulsions, as would be expected, but surprisingly, given the clinical distinction often made between cleaners and checkers, these obsessions were also mildly correlated with checking rituals;
  3. Sexual and religious obsessions were mildly correlated, and clustered with aggressive obsessions.

A study using similar methods by Leckman et al. in 1997, but examining lifetime experience of symptoms, generally confirmed these relationships, but found a fourth cluster: in this analysis aggressive, religious and sexual obsessions clustered with checking compulsions, confirming the longstanding clinical impression that patients check to be sure they have not harmed others or exposed them to risk. In 1992, Rasmussen and Eisen suggested that three core features may be more fundamental that these symptom groups: abnormal risk assessment, pathological doubt and incompleteness. To date, no phenomenological sub-grouping of OCD symptoms has been found to confer clinically important prognostic information although the individual symptoms of harding and obsessional slowness seem particularly difficult to treat.

Cultural Influences on Symptom Content

The same morbid themes are found in Western and non-Western cultures. The frequency with which these themes are played out in life's secular and religious spheres may vary with the intensity of religious observance within a cultural group. Religious obsessions were quite common in a small series of ultra-orthodox Jewish patients, according to Greenberg and Witztum's study in 1994, and in three series of Moslem patients, according to Mahgoub and Abdel-Hafeiz in 1991. On close examination, the morbid themes embedded in the religious obsessions and compulsions were familiar: dirt, orderliness, aggression, sex, washing, checking, repeating and slowness.