Obsessions are defined as imperative and distressing thoughts and impulses that persist in the patient’s mind despite a desire to resist and to get rid of them. They take various forms; the most common are intellectual obsessions, in which phrases, rhymes, ideas, or vivid images (these are often absurd, blasphemous, obscene, and sometimes frightening) constantly intrude into consciousness; impulsive obsessions, in which the mind is dominated by an impulse to kill oneself, to stab one’s children, or to perform some other objectionable act; and inhibiting obsessions, in which every act must be ruminated upon and analyzed before it is carried out—a state that is cleverly called doubting mania. Every effort at distraction fails to rid the patient of the obsessive thought. It engulfs the individual’s mind, rendering the person dysphoric and, often, inefficient. Probably the most disturbing obsessions are the impulsive ones, in which patients constantly struggle with the fear that they will put some terrible thought into action. Even as they tell of the obsession, they reveal a severe underlying anxiety and seek reassurance that they will not yield to it. Fortunately, such patients rarely obey their pathologic impulses. Phobias, as mentioned earlier, are considered by some authorities to be essentially obsessive fears and are included in this category of neurosis.
Compulsions are acts that result from obsessions. These are single acts or a series of acts (rituals) that the patient must carry out in order to put his mind at ease. Examples are repeated checking of the gas jets or the locks on doors, adjusting articles of clothing, repeated hand washing, using a clean handkerchief to wipe objects that have been touched by others, tasting foods in specific ways, and touching or arranging objects in a particular sequence. The most common of these obsessions and compulsions center around contamination concerns that lead to repeated hand washing or bathing. Other obsessions and compulsions can be identified as clusters of thoughts that derive from the above-mentioned concern about harm to oneself or to others and consequent checking on others. Less common clusters involve excessive focus on symmetry, precision, and ordering, and on saving and hoarding.
Certain motor disturbances—namely, habit spasms or tics—are, in a sense, motor compulsions. They consist of repetitious movements of the shoulders, arms, hands, and certain of the facial muscles (see Chap. 4). One feature that separates quasivoluntary tics from involuntary movements of extrapyramidal type is the patient’s feeling that the tics must be carried out to relieve an inner tension. Unlike compulsions, however, tics are not usually based directly on obsessive thoughts—except perhaps the Gilles de la Tourette syndrome, in which multiple tics are combined with compulsive utterances, often offensive ones (see later).
In all these obsessions and compulsions and in the phobias, patients recognize the irrationality of their ideas and behaviors, yet are powerless to control them. It is this insight into the obsessional experience and the struggle against it that distinguish obsessions from delusions. After the condition has persisted for a time, they may become depressed and suffer from typical anxiety attacks.
Mechanisms of Obsessive Disorder