JK SCIENCE

REVIEW ARTICLE

Phenomenology of Obsessive Compulsive Disorder

Ajit Avasthi, Deepak Kumar

Introduction
Sunil, an engineer in his late 20s, was obsessed with workers have attempted to describe OCD from a
cleanliness. Tormented by thoughts of dirt and germs phenomenological point of view. Phenomenology refers
contaminating him, he would waste hours washing his to the exact study and precise description of psychic
hands- something that eventually cost him his job. Ritu, a events, which are a primary requisite for the
college student, would invariably miss the first class in understanding of psychiatric disorders.
the morning. She would change her clothes umpteen times Tracing the history
till she felt that she wore was just right. Every time Deepak
OCD has been variedly described as:-
had to leave the house, he would check, then recheck if
- Monomanie raiso nante - Esquirol
the lights and gas stove were off. It all had to be done in
- Folie de doubte - Janet
a certain order. Things reached such a point for Sunil,
- Abortive Insanity - Westphal
Ritu and Deepak that they had to seek psychiatric help.
- Obsessive Compulsive Neurosis - Fenichel
And they are not alone. A large number of people suffer
from what is termed as obsessive compulsive disorder Esquirol in 1838 was probably the first person to
(OCD). Even though there is a tendency among OCD recognize obsessional disorder as a form of mental illness.
sufferers to keep their illness a secret, they are He used the term monomania to describe a chronic
disease of the brain, without fever, characterized by partial
increasingly seeking psychiatric help, often without the
lesion of intellect, emotions or/and will. Pierre Janet in
knowledge of their family. OCD is not a rare disease as
1903 described 3 stages in the development of OCD -
was believed in former times. It figures among the most
psychasthenia, forced agitations and stage of obsessions
common of mental disorder. A startling two percent of and compulsions, in his highly regarded work ''Les
the world's population suffers from OCD. The percentage Obsessions et al Psychasthenie''. Freud in 1935 described
in India is smaller (about 0.6%). But even this would obsessional neurosis as a self sufficient and independent
translate into substantial numbers considering our disorder. Jaspers in 1963 in his phenomenological analysis
population. identified five essential characteristics of obsessional
OCD is a chronic and potentially disabling symptoms:-
psychological syndrome characterized by obsessional a) A nonsensical, meaningless and absurd quality
thinking and compulsive behaviour with varying degrees to the thoughts and actions of the obsessive that
of anxiety, depression and depersonalization. It has been is recognized by the obsessive himself.
described as ''the hidden disease''. Only a few research b) The thoughts and acts having a compelling force.

From the Department of Psychiatry, Post-Graduate Institute of Medical Education and Research, Chandigarh.
Correspondence to : Dr. Ajit Avasthi, Deptt. of Psychiatry, Post-Graduate Institute of Medical Education and Research, Chandigarh.

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c) A belief that thoughts and actions can influence unusual is going on in the patient unless he/she
events (magical thinking). chooses to disclose his/her purely private
d) Need for order. experience. Only the patient's compulsive acts
e) Unacceptable impulses. can be observed and noticed by family members.
Obsessive phenomena can occur in normal
Mayer Gross outlined the boundaries of obsessions people, functional and organic psychosis, neurotic
with delusions and overvalued ideas. Recently this issue states, or as a constitutional trait (2, 3).
was reviewed by Kozak and Foa (1).
O-C Phenomenon in normal
Obsession Overvalued idea Delusion
Subjective feeling of Non-intrusive, unresisted False personal Frequently observed in children in prepubescent years,
compulsion over-riding acceptable idea pursued beliefs based much of the play of children takes a formalized and
internal resistance beyond bounds of reasons on incorrect
reference of repetitive quality e.g. to hop at every fourth step or tread
external on paving stone and not on cracks in between or enter
reality
home with a particular ritual. These modes of behaviour
Absurd, ego dystonic Ego syntonic Unshakeable
conviction become associated with fantasy and ideas of good and
Resistance Strong effective evil e.g. enter the home without the ritual would somehow
component be bad or unlucky.
Less than delusional
intensity Very similar to compulsive symptoms of a child are
Obsessions and Compulsions-Concept superstitions of an adult. Such harmless or meaningless
acts, such as path being crossed by a cat or called from
The psychiatric meaning of the word ''Obsessional'' is back while leaving the house or sneezed before initiating
closely related to its usual dictionary meaning of ''being the work, take on a popular tradition of symbolic meaning
harassed, pre-occupied or haunted by a thought or an for good or evil. The irrationality of the idea will be
idea''. The word obsession refers to a thought, an idea or admitted, but a sense of discomfort will be present and
impulse accompanied by a subjective feeling of the superstition-ridden may affirm that it is really better
compulsion which patient tries to resist but can't get rid to be safe. Such a superstition is genuinely compulsive in
of. The term compulsion refers to do things in a certain nature. Childish rituals and superstitious acts resemble in
number of times, touch various objects, carrying out
many ways the rituals of religious people.
cleaning operations by repeated washing and so on.
Certain features of obsession and compulsion are:- Another symptom experienced at some time by most
normal adults that bears a close resemblance to the
a) An idea/impulse intrudes itself persistently and compulsive, or is perhaps genuinely compulsive, is the
impelling into the person's conscious awareness. simple persistence of some content of the mind when it
b) A feeling of anxious dread accompanies and
has ceased to serve any adaptive purpose.
frequently leads person to take counter measures
against the initial idea/impulse. Occurrence of Obsessional Phenomenon as a
Constitutional Trait
c) Obsessions or compulsions are undesired,
unacceptable and uncontrollable. Outstanding features is its rigidity, inflexibility and lack
d) The person recognizes obsessions and of adaptability, and its persistence and endurance even in
compulsions to be absurd and irrational. face of obstacles; conscientiousness, love of order and
e) The person feels a strong need to resist them. discipline and moralistic values.
The symptoms may be manifested physically or Minor degrees of obsessional traits add a quality of
behaviourally. In the absence of behavioural worth and stability to a personality and prove as valuable
symptoms, nobody would know that anything assets. If, however, they are present in marked degree,

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they are usually hampering, lead to high level of mental (iv) Obsessional thought/compulsion must not be
inertia, indecisiveness and clinical decompensation and pleasurable in itself i.e. obsessional thought or
liability to clinical syndromes like OCD, anxiety disorders, compulsion provides relief from anxiety but
depression, hypochondriasis and depersonalization. doesn't give patient enjoyment.
Nosological issues (v) Symptoms may cause either distress or some
Both ICD-10 and DSM-IV define OCD in terms of kind of interference with social/individual
its characteristic symptoms and not, as in case with function, usually by wasting time.
depression, in terms of a syndrome. OCD is classified However, ICD-10 criteria do not include a ''bench
among anxiety disorders because:- mark'' to which levels of distress/time wasting can be
A) Anxiety is often associated with obsessions and compared. Moreover, they do not actually state how to
resistance to compulsions. make the judgement that the obsession/compulsion are
B) Anxiety or tension is often relieved by yielding not result of, for example, mood disorders or
to compulsions. schizophrenia.
C) OCD often occurs in association with other
DSM-IV Criteria of OCD (APA, 1994)
anxiety disorders.
Though it appears similar to ICD-10 criteria, it
ICD-10 Criteria of OCD
represents a slightly better definition of OCD. A patient
It states that a person has obsessions, compulsions or
presenting with either obsession, compulsion or both will
both. Symptoms need not be present for prolonged periods,
be diagnosed as having OCD, and obsessional symptoms
although definition specifies atleast 2 weeks. In practice,
are defined within the definition of the disorder. The
most patients would have suffered symptoms for
considerably longer periods. It states that symptom should threshold for defining OCD in DSM-IV is slightly higher
be ''present on most days'', although again, in practice, than that in ICD-10. It recognizes that 0-C symptoms
most symptoms are present everyday. ICD-10 recognizes are time consuming and take more than 1 hour/day
3 subtypes-predominantly obsessions, predominantly implying a relatively severe level of OCD. Exclusion
compulsions and mixed type. criteria are also clearer than those of ICD-10 in that the
Obsession and compulsion share following features, content of obsession/compulsion must not be wholly
all of which must be present:- restricted to the presence of another Axis-1 disorder.
(i) They must be acknowledged as originating within DSM has introduced a new subcategory called ''with poor
the mind (patient's own thoughts) and not imposed insight'' based on empirical data, using expanded Yale
by outside persons; this distinguishes OCD from Brown Obsessive Compulsive Scale (YBOCS) (4).
thought insertion and schizophrenia. Obsessional Phenomenon in OCD
(ii) The obsession and compulsion must be repetitive Obsessions and compulsions are important features
and unpleasant and atleast one obsession should of OCD and can be studied under 2 major headings-
be acknowledged as either excessive or
form and content. ''Form'' refers to the structures of the
unreasonable.
''phenomena'' and ''content'' refers to be meaning
(iii) Patient must try to resist thoughts coming into
reflected by it.
their mind and try to resist performing the
compulsive act; resistance to very long-standing A. Forms of obsessions: (5,6)
obsession may, however, be minimal. Atleast one (i) Obsessive doubt (60-70%): Lingering
obsession that has been unsuccessfully resisted inclination not to believe that a task has been
should be present. satisfactorily accomplished.
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(ii) Obsessive thinking (30-50%): Thoughts other excretions of the body, germs, bacteria,
which repeatedly intrude into conscious virus etc.
awareness, interfere with normal train of thought (ii) Inanimate and impersonal (26%):
and cause distress to the patients and/or prolonged Mathematical figures, orderliness in arrangement
inconclusive thinking about a subject usually or performance of certain tasks, locks, bolts,
pertaining to future. mechanical or electronic devices etc.
(iii) Obsessive magical thinking (30-40%): Idea (iii) Sex (10%): Sexual advances towards self or
that is based on a magic formula of thought equals others, incest, masturbation, sexual competence
an act, frequently encountered in children (~10% etc.
of OCD subjects). It has been termed ''obsessive (iv) Religion: Existence of God, religious practices,
conviction'' by some authors (7). mythological stories etc.
(iv) Obsessive fear (25-40%): A fear losing (v) Aggression (30%): Physical or verbal assault
control and thus an apprehension of continuing a on self or others, accidents, deaths, wars,
socially embarrassing act. mishaps, natural calamities etc.
(v) Obsessive impulse (10-15%): A powerful (vi) Miscellaneous: Not classifiable in any of the
urge to carry out actions that may be trivial or above-mentioned categories.
socially disruptive or assaultive. Phenomenologic Subtypes of OCD
(vi) Obsessive image (4-5%): Persistence before
mind's eye of something seen or images of violent, Inevitably, in the beginning, the clinician is struck by
sexual or disgusting nature that come repeatedly the diversity of the clinical presentations of OCD. This
into mind. initial impression, however, is soon replaced by the
(vii) Miscellaneous: When the phenomenon is realization that the number of types of obsessions and
obsessional in nature but cannot be classified into compulsions are remarkably limited and stereotypic. OCD
any of the six forms mentioned above. patients rarely have only one or two symptoms- multiple
B. Forms of compulsions: obsessions and compulsions are the rule although an
(i) Yielding compulsion (60%): A compulsive act individual's symptoms present at a given time exhibit
that gives expression to the underlying obsessive certain understandable patterns.
urge or thought e.g. a 29 year old clerk had an There are three common clinical presentations:
obsessive doubt that he had an important washers, checkers and pure obsessionals. Washing and
document in one of his pockets. He knew that checking alone or in combination constitute more than
this was not true, but found himself compelled to half the OCD phenomenon cluster. Insel and Arkiskal
check his pockets again and again.
(8) suggested 4 common presentations of OCD- washers,
(ii) Controlling compulsion (<10%): A
checkers and pure obsessionals and primary obsessive
compulsive act that tends to ward off and divert
the underlying obsession without giving slowness. Three core features may be more fundamental
expression to it e.g. A 16 year old boy with than symptom clusters; abnormal risk assessment,
incestuous impulses controlling the anxiety. These pathological doubt and incompleteness. Socio-
arouse by repeatedly and loudly counting to ten. demographic variables can have a pathoplastic effect on
Compulsions without associated obsessions have content of obsessions e.g. in Indian setting, ''Suchibai
been termed as autonomous compulsion. Syndrome'' is recognized in Bengali widows
C. Contents of Obsessions: (characterized by repeated washing and purity rituals) (9).
(i) Dirt and contamination (40-50%): Dirt, Different authors from India have given varying
dust, menstrual blood, human or animal excreta, percentages of obsessions and compulsions in their
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studies. Some of these are as follows:- encountering obsessions. The common

Authors Year N Common Common compulsions were yielding (60%), controlling
Obsessions Compulsions (14%) and autonomous compulsions (1%).
Akhtar et al 1975 182 Obs. Doubts Yielding
(5) Contamination Special symptoms of OCD:- Clinicians should be
Kulhara & Rao 1985 72 Obs. Doubts Yielding aware of certain less common symptoms of OCD as
(6) Obs. Thinking
well:
Khanna et al 1990 410 Obs. Fears Washing
(10) Obs. Thoughts Repeating 1. Hoarding: Hoarding behaviour can be defined
Girish Chandra 2000 202 ---- Washing as collecting and being unable to discard
(11) Checking
excessive quantities of goods or objects that are
Hoarding
Prakash et al 2000 1999 Doubts, fears Yielding
of limited value or worthless. Hoarding is a
(12) symptom encountered in both OCD and
obsessive compulsive personality disorder
Recent Indian Studies
(OCPD).
(a) Amitabh Saha and Sumeet Gupta (13). Studied 2. Intrusive music: Musical obsessions have been
phenomenology of OCD with a cross-cultural reported by authors in OCD. The patients
perspective. 40 patients of OCD (as per ICD- experience repetitive phrases, tunes or complex
10) were studied using YBOC checklist. The musical pieces that originate inside the head.
common obsessions noticed were contamination Advertising jingles or popular tunes are common
(52%) and aggression (32.5%). Washing triggers. Musical obsessions have been described
(57.5%) and checking (42.5%) rituals were the from Indian centres as well (5, 14, 15).
common compulsions.
3. Obsessional slowness: Rachman (16) first
(b) Girish Chandra (11). Studied phenomenology of described this in 1974. It was originally described
OCD using a factor analytic approach. Two as ''a meticulous concern for orderliness''. The
hundred and two consecutive subjects with OCD patient takes hours to complete ordinary self-
were evaluated using the Yale Brown Obsessive care tasks such as dressing or grooming because
Compulsive Scale- Symptom checklist and Scale each task must be performed correctly, in
for assessment of form and content. The data sequence and ''just right''.
was subjected to factor analysis. The results 4. Obsessions without insight or obsessions
suggest that there are factors that are broadly with psychotic symptoms: In some of the
common to the two scales. The main factors that earliest descriptions, obsessive symptoms have
emerged were washers, checkers, hoarding and been closely linked to psychosis. A shift from
two pure obsessional factors. Authors obsession to delusion occurs when resistance (the
commented that the cross-ritual validity of these internal struggle against obsessional urge or idea)
factors has been established for an Indian is abandoned and insight is lost. The shift is
population, and discussed the relevance of usually precipitated by the stressful event. In
specific items between scales. obsessive patients with long-standing and severe
(c) Prakash et al (12). studied the clinical profile of illness, insight and resistance are only marginally
OCD at NIMHANS, Bangalore in a sample of present. They may recognize obsessions as ego-
199 patients seen in the OCD clinic (the only dystonic or irrational but fail to resist against them
OCD clinic in whole of India). They reported and show no elements of anxiety. This
obsessional doubts (49%), imageries (20%), phenomenon is commonly seen in patients with
impulses (15%), thoughts (65%), as commonly schizotypal personality.

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Obsessive phenomenon in obsessive compulsion References

spectrum disorder (OCSD) 1. Kozak MJ, Foa EB. Obsession, overvalued ideas and
delusions in Obsessive Compulsive Disorder. Behavior
Over the past few years OC spectrum disorders have Research Therapy 1994; 32: 343-53.
emerged as a unique category of related disorders with 2. Ingram IM. Obsessive Illness in a Mental Hospital: J Men
overlap in symptom profile, demography, family history, Sc 1961; 107: 328-88.
neurobiology, clinical course, treatment response etc. 3. Kringlen E. Obsessional neurotics- a long term follow up.
Which diagnosis belong under the umbrella concept of Br J Psychiatr 1965; 111: 709-15.
4. Foa EB, Kozak M.J. Obsessive Compulsive Disorder: Am
OC spectrum disorders is a matter of debate (17-19).
J Psychiatr 1995; 152: 90-96.
Early advocates of the spectrum concept suggested the
5. Akhtar S, Vig N.N., Verma VK et al, A phenomenological
following collection (20): somatoform disorders (body analysis of symptoms in obsessive compulsive neurosis. Br
dysmorphic disorder and hypochondriasis), dissociative J Psychiatr 1975; 127: 342-48.
disorders, eating disorders, schizo-obsessive disorders 6. Kulhara P, Rao GP. Obsessive Compulsive Neurosis in
North-West India: A phenomenological study. Ind J
(OCD with loss of insight, OCD in patients with
Psychiatr 1985; 27: 243-48.
schizotypal personality disorder, OC symptoms in patients 7. Manchanda R, Sethi BB: Obsessive Compulsive Neurosis-
with schizophrenia), tic disorders, impulse control Phenomenological Aspects. Ind J Psychiatr 1978; 20: 250-
disorders, impulsive personality disorder. Others have 55.
suggested including certain habit disorders, phobias, 8. Insel TR, Akiskal HS. Obsessive Compulsive Disorder with
Psychotic Features: A Phenomenological Analysis. Am J
PTSD, intermittent explosive disorder, OCPD. The
Psychiatr 1986; 143: 1527-33.
spectrum can be viewed along a continuum with risk./ 9. Chakraborty A, Banerji G. Ritual, a Culture Specific
harm avoidance on the compulsive end and risk/pleasure Neurosis and Obsessional States in Bengali Culture: Ind J
seeking on the impulsive end. Psychiatr; 1975; 17: 273-80.
10. Khanna S, Kalia Perumal, V.G. Channabasavanna S.M. Clusters
Conclusion of Obsessive Compulsive Phenomena in Obsessive Compulsive
OCD has been known for quite sometime now and Disorder: Br J Psychiatr 1990; 156: 51-54.
has interested the researchers, but studies have been 11. Chandra G. Phenomenology of Obsessive Compulsive
mostly focused on treatment aspects and Disorder: A Factor Analytic Approach. Paper presented
at ANCIPS, (Bhagwat Award) 2000.
phenomenological studies have been few. Indian studies
12. Prakash, Chandra G, Kumar R et al. Clinical Profile of
have come from two centers largely (PGIMER and OCD. Poster Presentation at ANCIPS. 2000.
NIMHANS). Lately a unique category of disorders has 13. Saha A, Gupta S. Phenomenology of OCD: A Cross Cultural
emerged that share some common key features with Perspective. Poster Presentation at ANCIPS. 2000.
OCD. These are termed as ''obsessive compulsive 14. Andrade C, Rao NSK. Diagnostic and Statiscal Manual of
spectrum disorders''. The extension of obsessions and Mental Disorder. Am Psychiatr Asso 1997; 39: 178-80.
15. Pfizer N, Andrade C. Isolated Musical Obsessions. Ind J
related phenomenon in symptomatology of a host of
Psychiatr 1999; 41: 77-78.
disorders like impulse control disorders, eating disorders, 16. Rachman S. Primary Obsessional Slowness, Behavior
body dysmorphic disorders, hypochondrias, PTSD etc. Research Therapy, 1974; 12: 9-18.
underscores the importance of its clear understanding, 17. Phillips KA, McElroy SL, Hudson JI, Pope HC. Body
delineation of boundaries and recognition. This can have Dysmorphic Disorder: An Obsessive Compulsive Spectrum
Disorder, a form of Affective Spectrum disorder or both.
a significant impact on differential diagnosis, treatment
J Clin Psychiatr 1995; 56: 41-51.
alternatives and prognosis of the patient. More 18. Barsky, A.J. Hypochondriasis and obsessive-compulsive
transcultural studies are required to delineate the role of disorder: Am Psychiatr Clin NM 1992; 39: 791-801.
culture in pathogenesis of OCD and longitudinal studies 19. McElroy SL, Hudson JL, Philips KA et al. Clinical and
would be ideal to study changes of phenomena in OCD Theoretical Implications of a possible link between
Obsessive-Compulsive and Impulse Control Disorders.
over time. Clinicians must be aware of phenomenology Depression. 1993; 1: 121-32.
of OCD as it is no longer a disease and are commonly 20. Hollander E and Wong CM. Obsessive Compulsive Disorder:
presenting in psychiatric clinics around the country. J Clin Psychiatr 1995; 56: 3-6.

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