Chapter 17 Review 17.1 : Psychoanalysis At his friends’ urging, Barney has decided to seek help for the depression he has been struggling with ever since moving away from home and starting college two months ago. He’s heard a lot about Sigmund (1) Freud’s therapy, called (2) psychoanalysis , in which patients use (3) free association to express whatever comes to mind in order to un
Microsoft word - ocd paper.docObsessive Compulsive Disorder as an Outgrowth of Normal Behavior "Let yourself go with the disease, be with it, keep company with it -- this is the way to be rid of it." Introduction
In an influential paper, Fiske and Halsam (1997) begin with a description of a man in an
unfamiliar country. We observe him to be dressed all in red in a red doorway, washing his
hands six times in six different basins that have been arranged meticulously. His
eyebrows are plucked bare, and as he washes, he repeats the same phrase, occasionally
tapping his earlobe with his right index finger. Their question to the hypothetical
observer is: Is this man a priest performing a sanctified ritual? Or is he afflicted with
obsessive compulsive disorder? Is he normal, or mad?
The question resides in a space between clinical psychiatry and anthropology and is much more far-reaching than the surface implication that normality is culturallyconstructed. The striking similarities between the form and content of normal ritual andthe ritualistic behavior of obsessive compulsive disorder (OCD) invite a deeper analysis.
This paper is concerned with the implications of a common ground between normal ritualas a basic and necessary component of human cultural behavior, and the behaviors ofOCD as pathology. Do they share a common etiology? How can cultural theory informour understandings of the clinical presentation of OCD and its trajectory in patients livingwithin cultural boundaries? What can mental illness reveal for us about humanpropensities in a social world? I wish to address the possibility that the human abilityand drive for ritual may be influenced by a neurochemistry that is in part the result ofnatural selection. By this, I do not mean to imply that human behavior is in any wayprogrammed, determined, or controlled by genetics. My intention is to highlight theinfluence of biology both as an instigator and an environment in brain development, andrelate these processes to the social contexts in which they unfold. Finally, I will raise thehypothesis that the large scale shift in focus of ritual behavior in the US from the civic tothe private sector may be a contributing factor to the increased prevalence of OCD inrecent years.
The Anthropology of Ritual
Most people know a ritual when they see one. The hallmarks in a general folk definition
include formalized behavior, a set sequence of actions that are usually repeated, and often
a religious or otherwise solemn content. A wider definition of the term would tend to
incorporate repeated actions that we think of as menial, but that we repeat every day,
such as toothbrushing or financial transactions. The scripting and performance of these
formalized, repeatable activities are useful and informative for the anthropologist, who
seeks to characterize a group of people by their outward social behavior. Because of
these features of ritual, it is an excellent source of data. To this end, ritual has become a
standard category of description and analysis for traditional ethnography, and has
spawned several specialized treatises.
Although there is no universal agreement on the precise definition of ritual behavior in anthropology, most authors agree on several key features. In addition to theabove outlined features, ritual actions most often take on great depth of social meaning,and typically are performed in response to some perceived need, desire, or intent on the part of an individual or the group. Most ethnographies concerning ritual have focused oneither its selective use of symbols, its function as a mediator of social relations, or itsplace in religious life. These treatments tend to examine the multifaceted social nature ofrites, and the ways in which individuals and societies both shape and are shaped by theirexistence. Each researcher emphasizes one or more of these facets, and it is worthwhile tobriefly review some of the major contributions in order to flesh out a anthropologicaldefinition of ritual.
Geertz defines ritual as "consecrated behavior" in his essay on religion as a cultural system (Geertz 1973). He examines ritual as a performance that makes use of a discreteset of cultural symbols, all of which can be interpreted both by the participants in theritual and by the anthropologist. He does not further elaborate his definition of theconcept, perhaps subscribing to the above outlined general anthropological understandingof ritual. His definition is decidedly centered on religion, and while there is no doubt thatGeertz would agree that secular rituals are also quite common in all groups, he is notconcerned with them explicitly. Nevertheless, this definition is useful to us in that it putsemphasis on the heavy association of meaning with ritual action. While everyday ritualsmay not be seen as deeply solemn or consecrated per se, we may envision them assomewhat apart, following different rules than improvised behavior.
A similar definition is provided by Turner, who is considered by many to be the classic authority on ritual symbolism. In his work with the Ndembu, Turner definesritual as, ".formal behavior for occasions not given over to technological routine, havingreference to beliefs in mystical beings or powers" (Turner 1967:19). This is a much moreprecise definition focusing on religious content and explicitly excluding the routine ritualsdescribed above. Both Geertz and Turner can be described as symbolic anthropologists,and it is possible that their definitions are influenced by the relative frequency of thosefeatures that they are interested in studying. Religious ritual tends to be heavily reliant onsymbolism, and while secular ritual may also draw on symbols, they may not be as highlyvisible, and therefore, interpretable.
Luhrmann (1989) studied ritual in the context of contemporary British who participated in magical or "alternative" religions such as Wicca or other pagan systems ofreligion. Ritual for her informants was formalized, stereotyped and redundant (pp. 221),corroborating the definitions proposed above. She adds another component: that ofdistinctiveness. Rituals are carefully circumscribed in the groups she studied so as to beset apart from normal, everyday life. This is an echoing of the symbolic anthropologists'separation of banal ritualizing from the more sacred.
The aspect of ritual as directed action is particularly highlighted by Malinowsky (1922). Ritual for the Trobriand islanders he studied is magical, consisting of spellsdirected toward the achievement of good fortune, or perhaps more accurately, theaversion of bad fortune. This particular sort of ritual is primarily linguistic, but isaccompanied by patterned gestures and actions. Interestingly, Malinowsky notes thatthis magical ritual is often dispassionate. This is not to say that it is conducted withoutmeaning, but rather that it is performed mostly by rote and so often as to erode theemotional power of the words for the performer. The actions are still consideredimportant, but mostly because they serve to avert consequences that would be highlynegatively charged with emotion rather than containing that emotional impact in themselves. This definition might also provide insight into the dispassionate nature ofcommon secular ritual and superstitious warding behavior.
Shore (1996) provides possibly the most useful discussion of ritual for the purposes of this analysis. He defines ritual performances as highly complex action sets.
On a simple level, action sets are stylized body and/or gestural movements that areincorporated into such diverse activities as conversations, children's games, and gesturalscripts such as bowing or hand-shaking. From here, Shore goes on to highlight acommunicative and coordinating function of rituals in social contexts. In his definition,rituals provide the substrate for complex social communication: a common ground forindividuals to come together and express solidarity, as in team huddles and cheers, or tore-enact histories, as in the complex rituals of the Murngin that he describes. Thefunctions of rituals, as Shore defines them, are myriad and culturally specific, but at theirroot, they are stylized action sets.
Common threads in all of the above definitions are those of action and directedness. Ritual is always acted out, and may also involve prescriptiveverbalizations. The formalized nature of the behavior seems to be a commondenominator, a necessary but not sufficient condition for identifying behavior asritualistic. "Improvised ritual" would seem to be at most an oxymoron, and at least afarce. Ritual is also universally purposeful, and could not be said to include motor tics orunconscious fidgeting. Whatever the ritualistic actions may be, they are directed towardthe accomplishment of some goal that is consciously imagined on the part of theperformer or performers.
From here, the definitions diverge and the actions that are acceptable as ritualistic vary from author to author. It is possible that this reflects variation in the expression ofritual both within and between groups. At times, rituals may be full of emotion andmeaning, and at other times banal. Some are social and some are private. Various actionsets can be classified as rituals and can be performed by the same group of peoplewithout losing the common denominator. While what most anthropologists have foundintriguing have been the meanings and social implications ascribed to rituals by the groupsthat perform them, it is the stripped-down, universal definition of "normal" ritual that Iam concerned with here. Is this aspect of human behavior similar in form and content tothe pathology of OCD, and if so, what does this mean? Obsessive Compulsive Disorder as Pathology
Enter bathroom, with left foot firstClose door with left hand, then touch door handle with Take towel from rail and keep it on edge of bath with left Take toothbrush from cabinet and place it on edge of washbasin with left hand, then touch it with righthand Take toothpaste tube from cabinet with left hand, then Squeeze tube to get enough toothpaste on brush with left Replace cap of tube with left hand, then touch it with Put tube back in cabinet with left hand, then touch it with Pick up brush with left hand, then start brushing; teeth brushed in twos, from left to right, top row first,bottom row next, outside first, inside next, each set oftwo eight times; then repeat whole process withbrush in right hand, then again with left hand,followed by the same again with right hand Open taps with left hand, then touch them with right Wash brush under hot tap, held in left hand, then touch it Put brush back in cabinet with left hand, then touch it Rinse mouth, taking water with left hand, then with right Look at self in mirror first with left eye, then with right Begin to wash face, using left hand to splash water on Rub left side of face with left hand followed by right side of face with left hand, then rub left side of face withright hand, followed by right side of face with righthand Apply soap to face, in the same sequence as aboveRinse face, splashing water on face with left hand, then Look at self in mirror, first with left eye, then with right Close taps with left hand, then touch them with right Pick up towel with left hand, then touch it with right Dry face with towel, left side holding towel in left hand, then right side holding towel in left hand, then leftside holding towel in right hand, and then right sideholding towel in right hand Look at self in mirror, first with left eye, then with right Put towel back on rail with left hand, then touch it with Open door with left hand, then touch handle with right (Compulsive ritual reported by man in his mid- Quoted in de Silva and Rachman 1992, pp. 17-18) The DSM IV guide to psychiatric diagnosis (American Psychiatric Association 1994) defines obsessions and compulsions in OCD as discrete phenomena that may ormay not co-occur. Specifically, obsessions are classified as repetitive or intrusivethoughts, impulses, or images that cause marked anxiety or distress. Compulsions aredefined as repetitive and ritualistic behavior or mental acts that the patient feels driven toperform that are aimed at reducing distress, but that are not realistically connected withthat distress. Whereas obsessions and compulsions were originally thought to be causallylinked, epidemiological research has shown that one set of symptoms can occur in theabsence of the other (Antony et al. 1998, Pigott, 1998). That is: obsessions do notalways generate compulsive behavior, and compulsions are not always precipitated byobsessions, although this is often the case. Because of this observation, and becauseoutward behavior is much more easily studied in cultural anthropology than ruminationsin an individuals mind, I will concentrate primarily on the compulsive behavioral aspect ofOCD.
The DSM IV specifies several aspects of compulsive behavior that are critically important in its diagnosis, but nevertheless remain entirely subjective. The criteria are: 1) The actions are repetitive and formalized2) The patient feels driven to perform them3) The acts are performed to reduce distress, and are not ends in themselves4) The patient may recognize the behavior is unreasonable and unrealistic5) The patient finds the behavior to be disturbing and attempts to resist and/or avoid situations where ritualizing will become necessary The first criterion deals with the observable characteristics of OCD behavior.
Beyond this general definition, there are no specified types of action that are alwaysattributed to OCD, although many common categories have been identified. Typically,OCD behavior involves excessive washing, checking, ordering, concern with symmetry,counting, hoarding, and/or repeating words silently or aloud. I will return to this commonspectrum of behavior and its significance below.
The second and third criteria concern the patient's perceived motivation for performing the behaviors. The term "motivation" is used here loosely: the patient oftendoes not see that he/she has any will in the matter, the drive to perform the acts is sointense. Furthermore, the acts themselves do not produce pleasure, but instead providerelief from discomfort or distress. In this sense, once the behavior pattern has beenestablished, it seems to be maintained strongly by operant conditioning: specifically, theavoidance of punishment. This feature distinguishes OCD from other behavior disorders,such as compulsive gambling or eating, in which the behavior itself provides reinforcement or pleasure. OCD behaviors are not gratifying. Rather, they are seen to beuncomfortable, at yet simultaneously irresistible.
The final two criteria are the most important for distinguishing OCD-like behavior from normal ritualizing. When the patient realizes that the behaviors that act to reducedistress are not reasonably connected to real-world concerns, yet feels compelled toperform them anyway, OCD is the usual diagnosis. Other disorders that involveunreasonable behavior (delusional disorders) are not usually accompanied by patientinsight into the unreasonable nature of their actions. Conversely, individuals involved innormal rituals do not feel their actions to be unreasonable, but rather see them asnecessary, pleasurable, or natural. It is important to note that some patients diagnosedwith OCD do not interpret their actions as unreasonable, but instead develop elaborateexplanations for them. This minority of cases is classified as "OCD with poor insight"and is particularly common in children. Insight is therefore one possible feature of OCDthat is useful in diagnosis but need not be present for the diagnosis to be confirmed.
OCD is currently officially classified as an anxiety disorder, but there is marked disagreement among psychiatrists as to whether this reflects its proper place in thediagnostic spectrum (Montgomery 1992, Freeman 1992). Marks (1987) aligns OCDclosely with the phobias, while others maintain its close association with mood disordersand depression (Antony et al 1998). The latter view is in line with recent advances inpharmacological treatment, a subject that will be taken up later in this paper. In a recentstudy, Antony and co-workers (1998) found several syndromes were commonlycomorbid, such as major mood disorder (29.1%) and specific phobia (27.9%). Tourette'ssyndrome, Sydenham's chorea, and other tic disorders are probably also closely related toOCD and commonly comorbid (Lopez-Ibor Jr. 1992, Freeman 1992). Personalityfeatures have also been studied in relation to OCD, and while these are difficult toquantify and test accurately, it is likely that specific personality features (perfectionism,feelings of responsibility and harm avoidance) are important in its expression andepidemiology (Summerfeldt et al. 1998).
Treatment of Compulsive Ritualization
Because of the questions that remain concerning the neurobiology of OCD, treatment
regimens are not strongly based on cause-effect models, but rather on the relative efficacy
of different medications in clinical trials. Prior to 1966, the only known effective
treatment for OCD was psychosurgery, which was only performed in extremely severe
cases due to the risks involved (Greist 1992, 1998). This surgery usually involves either
cingulotomy, subcaudate tractotomy, stereotactic limbic leucotomy, or anterior
capsulotomy, all of which function to sever connections between the frontal cortex and
basal ganglia (incidentally, further supporting the hypothesis that OCD is at least in part
the result of basal ganglia dysfunction, an idea that is discussed further below). These
procedures are still sometimes indicated when patients respond to no other treatment and
their condition is life-threatening (Hay et al. 1993, Mindus and Jenike 1992). For the vast
majority of patients, however, some relief from symptoms occurs with behavior therapy,
medication, or a combination of the two. Here, I will briefly outline the most frequently
prescribed treatment modalities.
Cognitive-Behavioral TherapyThe most common type of cognitive-behavioral therapy used in the treatment of OCD isexposure and ritual prevention (Marks 1997, Overholser 1995). As the name suggests,the treatment involves encouraging patients to expose themselves to situations thatnormally trigger a need to ritualize, and then prevent the behavior until the discomfortsubsides. This therapy is conducted initially in the presence of the therapist, and thenthe patient is instructed to try the technique increasingly on his or her own. This gradualincrease in exposure frequency and duration has been found to be more effective thanflooding techniques, and is most successful when accompanied by cognitive therapydesigned to equip the patient with alternative techniques for coping with distress (Marks1997). In vivo exposure has also been found to be more efficacious than role play orimagery (Overholser 1995, Marks 1981).
Usually, patients are reluctant to undergo guided exposure to cues that normally trigger rituals, and de Araujo and co-workers (1995, de Araujo et al. 1996) report that 15-25% of patients recommended for cognitive-behavior therapy either refuse to comply ordo not complete treatment. Patient self reports indicate that this high refusal and drop-out rate is due to the massive increase in discomfort and depression associated withexposure and ritual prevention. However, for those patients who do complete cognitive-behavioral therapy, 60-85% show some improvement (Foa et al. 1983, Franklin et al1998).
A recent variation in cognitive-behavioral therapy has included the use of computer simulation or guidance in exposure to behavior triggers (Bachofen et al. 1999,Baer and Greist 1997, Clark et al. 1998, Marks et al. 1998). The emphasis on computer-aided self-help programs is precipitated by research indicating that only about 35% of theestimated 2-3% of the population affected by OCD seek treatment (Clark et al. 1998,Karno et al. 1988). In this light, computer-assisted assessment and treatment has beenshown to be effective in conjunction with clinical consultation, and shows a decreaseddrop-out rate relative to self exposure to behavior triggers in an unguided environment.
PharmacotherapyThe other major focus of treatment for OCD is medication-based. The discovery in 1966that clomipramine (Anafranil) is effective in reducing OCD symptoms sparked a flood ofresearch into the neurobiology of OCD and its management with prescription drugs(Zohar and Insel 1997). The hypothesized central role of serotonin in OCD isunderscored by the clinical emphasis on serotonin reuptake inhibitors (SRIs) in itspharmacological treatment. While there is considerable overlap in the sorts of medicationsprescribed for OCD and major depression, the responses to the drugs are remarkablydifferent. Fineberg et al (1992) note that while depressive patients treated withclomipramine show high placebo response rates (up to 50%) and require up to four weeksbefore improvement is measurable, OCD patients treated with the same drug show lowplacebo response and rapid response to treatment. While depression is often comorbid,Goodman and colleagues (1990) report that OCD-associated depressive symptoms donot respond to non-serotogenic antidepressants, indicating a separate mechanism forcomorbid depression. This suggests that while SRIs are also effective antidepressants,their antiobsessive-compulsive effects are independent.
Other drugs have subsequently been shown to be effective in the treatment of OCD (Saiz et al 1992, Montgomery and Manceaux 1992). These drugs includefluvoxamine (Luvox, Faverin, Floxyfral), fluoxetine (Prozac), and sertraline (Zoloft). Theadvantage to this group of drugs over clomipramine is that they are selective of receptorsites in vivo (Goodman et al. 1992), and are therefore referred to as selective serotoninreuptake inhibitors (SSRIs). Selectivity in receptor sites is an improvement over non-selectivity due to the vast array of functions that the neurotransmitter serotonin has onthe nervous system. Across the board down-regulation of serotonin can bedisadvantageous and can result in harmful side effects in addition to improvement in OCDsymptoms. The SSRIs target only those receptors that seem to be involved in depressionand OCD, although which receptors those are is still unknown. Individuals vary in theirresponse to these drugs, and this renders comparison of efficacy difficult, especially sincedose response is not constant across individuals (Dominguez 1992).
McDougle et al (1994) report that where SSRIs are ineffective alone, dopamine antagonists may be successful if they are administered in conjunction. These drugscompete for dopamine receptors in the brain, but do not trigger the response that thenatural chemical would, thus lessening dopamine's effect without actually lowering levelsin the body. This observation raises the question of the role of dopamine in thepathogenesis of OCD, and indicates a fruitful area for new research.
Combined ApproachesEach of the SSRIs and clomipramine has also been shown to be compatible withconcurrent cognitive-behavioral treatment and the most common recommendation is acombination of the types of therapy (Greist 1998, Simpson et al. 1999). Relapse iscommon upon withdrawal of the medication, suggesting the need for long termprescriptions, while cognitive-behavioral therapy is still effective even if administered in atime-limited fashion (Franklin et al. 1999). Baer (1996) raises the interesting question ofwhether cognitive-behavioral therapy is actually a form of endogenous serotonin therapy.
Baer cites neuroimaging research indicating that behavior therapy serves to normalizeglucose metabolism producing similar effects to serotonergic medications. Thisfascinating finding also merits additional research.
It should be emphasized that no "magic bullet" exists in the array of available treatments for OCD. While the above outlined therapies have been shown to besuccessful in reducing the severity and frequency of OCD symptoms, no one treatment orcombination has been shown to consistently and completely eradicate the disorder. Infact, even in the most successful cases, usually only 60-80% improvement in symptomsis achieved (Greist 1998) In this sense, there is no "cure" for obsessive compulsivedisorder, although it is clinically manageable.
Pathophysiology of OCD
The study of OCD pathophysiology was begun in response to the observation that the
serotonergic anti-depression drugs were also effective in managing OCD. Our
understanding of the underlying neurochemistry of this disorder has grown from the
results of clinical drug trials, instead of the reverse. Directly following the demonstrated
effectiveness of clomipramine and the SSRIs, the hypothesis that low levels of the
neurotransmitter serotonin are involved in the pathogenesis of OCD became popular.
It is important to recognize the limitations of inferring neurophysiology by observing patient responses to drugs. This method does not accurately excludecompeting models of the OCD mechanism, since it does not test for the existence of onemechanism over another. This method can only indicate that a proposed model is eitherconsistent or inconsistent with the available evidence. Unfortunately, attempts to gatherdirect evidence of serotonin levels in OCD patients versus controls have been equivocal(Pigott 1996), and we must make do with what evidence is available to us.
Currently, the serotonin insufficiency hypothesis of OCD pathogenesis adequately explains what we observe, but many questions remain (Barr et al. 1992). DoOCD patients have more or hyper-sensitive receptor sites for serotonin than normalindividuals? Is the biological underpinning for OCD something else entirely, buteffectively masked by administration of drugs blocking the natural loss of serotonin?Does dopamine interact with serotonin in OCD patients, as Goodman and colleagues(1992) suggest, and studies with animal models (Szechtman et al 1998) support? Wise and Rapoport (1989) propose that OCD is the result of basal ganglia dysfunction, noting that OCD-like behaviors occur in some post encephalitic patientswho have sustained lesions in the basal ganglia and other neural structures. They also citeevidence from CT scanning research revealing increased volume in basal ganglia structuresin OCD patients (Luxenberg, et al 1988) and a study that shows through PET scans thatOCD patients have increased metabolic activity in their basal ganglia (Baxter et al. 1987).
Additionally, the fact that all currently known effective types of psychosurgery involvesevering connections between the basal ganglia and frontal cortex would seem to supportthis hypothesis (Greist 1992, 1998).
Although the commonly accepted function for the basal ganglia is motor control, there is evidence from Parkinson's disease patients that the structures are also involved inhigher cognitive functioning. Wise and Rapoport present a model that integrates thisevidence: [Our hypothesis] is based on a simple model of an innatereleasing mechanism in the basal ganglia: a detectionmechanism for recognizing specific aspects of stimuli (keyor sign stimuli) and a releasing mechanism for the species-typical behavior response (sometimes known as a fixed-action pattern). Usually, detection of the key stimuluscauses release (i.e. execution) of the appropriate behavior.
But two sorts of behavior can occur in the absence of a keystimulus. Vacuum behaviors, for example, are often actionsthat would appropriately be directed toward a specificobject when the object is not present. Similarly,displacement behaviors are released when there are conflictsbetween two strongly activated drives or when the normaloutlet for a certain motivation is blocked. (1989: 269-70) This hearkens back to Lorenz and the early ethologists and behaviorists, who have sincegone out of style in the development of behavior theory (Swedo 1989). However, whilethis proposed mechanism still contains many holes and the theory may not entirely support it, it is unwise to dismiss it out of hand. It also does not preclude culturalshaping of the behaviors performed, making them less "fixed-action patterns" and more"urges" or behaviors that act to relieve tension. If we must cast about for a suitabletheory to explain the evidence, it is perhaps more acceptable than searching for evidenceto fit our preferred theories.
The Place of Cultural Theory in Psychiatry
Several theories have been suggested to explain the etiology of obsessive compulsive
disorder, and these can be placed into two broad categories. The first category deals with
biological causal explanations, which were outlined in the above section on
pathophysiology. The second category focuses on psychology, and includes
psychoanalytic theory and learning theory. These categories of explanatory mechanisms
are not mutually exclusive, as is evidenced by the compatibility of the cognitive-
behavioral and drug therapies outlined above. In fact, a combined theory of etiology is
perhaps the most plausible explanation for OCD.
In classic psychoanalytic theory, OCD was proposed to grow out of the anal phase of childhood, with its concerns over issues of control. OCD behaviors wereconsidered to be controlling mechanisms for hostile feelings toward the individual'sparents, particularly the mother. Whether or not these theories are valid, nearly allpsychiatrists who have written on the subject are in agreement that psychodynamictheory is particularly unhelpful in the treatment of OCD (Greist 1992, 1998; Jenike 1986;de Silva and Rachman 1992; Turbott 1997; but see Sifneos 1985). As such, it remains aninteresting, but unproved theory.
In its most basic form, learning theory suggests that OCD is acquired due to a traumatic event, in which a young individual associates fear and anxiety with an event thatis in reality harmless (de Silva and Rachman 1992, Leonard 1989, Marks 1987).
Compulsive rituals are then associated in some way with reduction in this unrealisticanxiety, and perpetuated in an ever increasing cycle (Francis and Gragg 1996). Someauthors have proposed that OCD is learned directly from previously affected individuals(Rachman 1985), although this seems unlikely since OCD is often a cryptic disorder.
Rasmussen and Eisen (1992) found that many probands were unaware when their siblingsalso suffered from OCD, and that adults also go out of their way to conceal theircompulsions from others. At the moment, learning theory does not appear to explainOCD completely, but it does account for many features of its progression in theindividual.
The Perspective of the Pathological Mind
Here, I wish to return to the broader questions I raised in the introduction: is OCD a disorder of magnitude and not of kind? Are OCD patients not so much pathological ashyper-normal? Can the pattern of illness shed any light on human propensities toritualize? Epidemiological studies have shown that OCD behavior clusters nicely intocategories, that on initial observation may seem rather odd. If OCD is at least in part theresult of some kind of neural dysfunction, why should the behaviors fall out into suchclean culturally specific categories? For example, Rasmussen and Eisen (1992) note thatwhile most individuals report experiencing multiple types of compulsions, the categoriesare discrete. In their study of clinical cases, 63% of individuals have compulsions that involve checking, 50% have washing compulsions, 36% counting, 31% need to confess orask, 28% need for symmetry or precision, and 18% hoarding of objects.
Two ideas would explain this clear categorization. Either these behavior sets are analogs of the "fixed-action patterns" the behaviorists described in non-human animals inthe 1960's, or the urges are "filtered" through culturally informed expectations. These,again, are not mutually exclusive, and neither is probably sufficient to explain the data.
There have been very few studies of OCD in non-Western cultures, but the few that existare extremely informative. Mahgoub and Abdel-Hafeiz (1991) studied the observedpattern of OCD in Eastern Saudi Arabia, and found that of 32 subjects, 78% displayedcompulsions. These fell out in slightly different categories than Rasmussen and Eisenreport: 87% had religious compulsions (50% repeating and 37% washing), 9% hadcompulsive avoidance, and 9% had non-religious cleaning rituals. 12% of the individualshad compulsions that the authors labeled as "miscellaneous". Religious aspects of OCDhave also been noted by authors studying observant Orthodox Jews (Greenberg 1984,Hoffnung et al. 1989), and Catholics (Suess 1989). The existence of a strong religiousfocus of compulsions in some groups would seem to indicate that culture has much to dowith the spectrum of actions typically expressed in OCD patients. However, there is noindication that groups who are more heavily religious have a higher incidence of OCD(Greenberg 1984, Marks 1987). Thus we may infer that culture may have an effect onthe way OCD manifests itself, but does not increase its prevalence in a population.
Religious content may also be a convenient way for the members of certain groups to either rationalize or conceal their ritualizing. Rationalization, though usually occurringin children and individuals classified as having "poor insight" into their conditions, doesplay a role in many OCD cases. Rationalization may also play a part in individuals whoare fully cognizant of the pathological nature of their need to ritualize, but convincethemselves that this need is stronger than the need to appear "normal" to others.
Concealment is also a particularly important feature of OCD, since most individuals withthe illness attempt, at least perfunctorily, to hide their abnormal behaviors from others.
One of the hypothesized reasons only an estimated one-third of OCD afflictedindividuals seek treatment is that no friends or family members are aware of the problem(Rasmussen and Eisen 1992). In both of these cases, religion, when it is sanctioned bysociety, provides an excellent mode of concealment and/or rationalization.
Allowing for the differential religious content of rituals cross-culturally, the specific focus of compulsions is remarkably similar. Washing, repeating, checking, andordering all figure prominently in OCD rituals, and cannot be explained by a need toconceal or rationalize although the significance of these categories is unclear(Mavissakalian et al. 1985). It is interesting to consider this pattern in light of the effectof the rituals for the performer: the reduction of tension. Years of research havedocumented the tendency of animals under stress to perform repetitive behaviors that areremarkably similar across species: grooming, swaying, and manipulating the externalenvironment are all common in birds, rodents, and primates (Marks 1987), and show anuncanny similarity to human OCD behaviors.
Szechtman and colleagues (1998) investigated the effect of the dopamine agonist quinpirole on rat behavior. Their striking results indicate that by enhancing the naturaleffects of dopamine in the body, quinpirole induces checking behavior in rats treated withit. In their study, compulsive checking behavior was defined as excessive returning to one or two places in an open-field test area, where the time between returns is excessivelyshorter than returns to other places. Their definition also required that the placesreturned to would be markedly few, and a characteristic set of acts would be performed atthe preferred place (Szechtman et al. 1998:1477). They found that rats treated with adrug designed to enhance the effect of dopamine induced this checking behavior, andeffectively eliminated grooming behaviors. They note this last observation as remarkablefor two reasons. Normal rats usually establish one or two preferred areas in a confinedfield as "home bases" where they practice comfort behaviors, notably grooming andcrouching. The observation that the quinpirole rats did not groom or crouch at the placesthey compulsively checked (nor anywhere, for that matter) suggests that these behaviorsdid not provide the relief from anxiety that they would under normal circumstances.
More importantly, it suggests a separate mechanism for OCD patients who wash (read:groom) versus those who check.
In 1986, Jenike had suggested that OCD checkers may be suffering from a pathology that differs in mechanism from other OCD types. His theory was thatcheckers cannot effectively retrieve meaningful information from memory (whether theyactually locked the door or not) in the same way that non-checkers can. It remains to beseen whether the differences between the sub-types of compulsive behavior are basedheavily on chemical levels or receptor sensitivity or on higher cognitive function. Theymay also be the result of variation between individuals in the types of comfort behaviorthat function most effectively to relieve a general kind of anxiety, and these may bepersonality based. What is clear is that different sub-types of compulsive behavior arehighly comorbid (Rasmussen and Eisen 1992). If different mechanisms do exist, they arelikely linked or the result of a higher chain of causal interactions.
Biological Bases of Ritualization
Ritual has very rarely been studied as a human universal tendency with biological bases. This is perhaps due in part to the chasm that currently exists in most of academiabetween cultural and biological approaches to anthropology. This situation isunfortunate, particularly in psychological anthropology, where we have the opportunityto examine the same subject with both interpretive and neurochemical approaches in orderto find the links between biological and cultural precursors to behavior. Because of mystrong commitment to the compatibility of cultural and biological anthropology, I willpropose an etiological theory of OCD that is quite opposed to the separatist politicalclimate of post-modern anthropology.
Given the evidence outlined above, one of our primary questions ought to be: do the rituals of OCD really qualify as rituals in the anthropological sense of the term?Perhaps I could be accused of arranging my pared-down anthropological definition ofritual to bring it into line with the behaviors of OCD. However, I believe that the sameeffects would be produced if any anthropologist were presented with the task ofgenerating a definition of ritual that would be applicable universally. Doing so wouldrequire that the definition not be content-based, since groups vary tremendously in thetypes of things they find appropriate for ritualizing. The universal ritual would also needto be based on observable actions, since only these can be swiftly and easily comparedboth within and between groups. In fact, the only criterion separating OCD from normal ritual in the DSM IV definition is the nature of OCD behavior as excessive or intrusive onthe life of the performer. Officially, OCD is a disease of degree, not of kind.
But what about the question of the meaningfulness of the rituals? Another feature of OCD is that most patients are aware that their rituals do not actually produce anytangible effect (other than the reduction in their own tension, which is not insignificant),and are usually disconnected realistically from normal cause and effect. Most OCDpatients will tell you that they know it's crazy, but they simply must check the doorlocks exactly 28 times before leaving, or whatever their compulsions happen to be. Onthe other hand, normal ritual may be ascribed great meaning (as in religion) or may bemundane (getting money from an ATM), but in both cases the actors are likely to tell youthat performing them makes sense on some level. This is clearly a point of divergence,but it is possible even here that what we see is a matter of degree and not of kind.
OCD compulsions are not devoid of meaning. On the contrary, they are highly saturated with meaning. The difference is that in compulsive behavior, the meaning doesnot appropriately fit the context, whereas in normal ritual, there is an observed fit. I amdrawing a distinction here between "having meaning" and "making sense". I define anaction that has meaning as one that can be rationalized, or explained to some degree toanother human being in such a way as to resonate with them at least in part. An actionthat makes sense is one that is appropriate to larger context, be it social or environmental.
Compulsive rituals have meaning, but do not make sense in context, whereas normal ritualdoes both. OCD patients may clean excessively because they fear contamination, or maycheck compulsively because they have pathological doubt that they have done thingscorrectly. Neither the fear of contamination or the doubt is an alien emotion to normalindividuals: they mean something, they are merely misplaced. Clinically, this distinctionis vital because it acts to diagnostically separate OCD patients from delusional patients.
Obsessive compulsives do not suffer from delusions, and are quite capable of analyzingtheir own actions. Here, the distinction helps us grapple with the blurred boundaries ofpathology and normalcy.
The function of normal ritual for the individual also has distinct parallels with the function of ritual for the OCD patient. Most ritual is either focused on aversion of badluck, problem solving, or transformation. Examples of the first are the Trobriandislanders warding rituals or the European's superstitious "knock on wood." Often,ritualistic sacrifices to deities are made in order to bring about a desired end (as is theATM transaction). Transformation rituals are largely referred to as rites of passage, andencompass puberty rituals, incorporation into specialized societies and the like, all ofwhich are focused on change in the individual in relation to their world. All of thesesubtypes can be discussed as directed action. Normal individuals tend to perform ritualsin order to make things right with the world, either in alignment with a past, present, orfuture desired state of affairs.
On a basic level, compulsions in OCD are also performed to bring the world back into alignment. Almost every study of OCD has shown that when patients are allowedto perform their rituals in the way that they desire, there is a reduction in tension and/oranxiety. Conversely, when prevented from doing so, patients can become quite agitated,and this accounts for the high drop out rate of cognitive-behavioral therapy. Althoughtheir methods are not socially sanctioned, and seem even to the patients to be non-sensical, the bottom line is that they produce the intended result: tension reduction. It is for this reason alone that they continue to be performed. This would also seem to be abasic reason for the continued performance of normal ritual. Heinz (1999) has pointedout, quite correctly, that one of the differences between compulsions and normal ritual isthat the latter is not accompanied by fear or anxiety. I would argue, however, that in asituation where an individual was not allowed to carry out a normal ritual, in a case wherethat individual clearly felt the need to perform it, considerable anxiety would ensue.
Of course, once a ritual becomes social, many other factors become layered upon it. Anthropologists who study ritual in all its complexities have rightly pointed out thatas a social phenomenon, ritual is the amalgam of individual agencies. This does not,however, negate the importance of the function of ritual as problem-solver, averter, and/ortransformer. Social aspects may have become layered on top of a more basicphenomenon.
A fascinating ethnographic account that may be helpful here is Gmelch's work with professional baseball players (1994). Like the rituals of Malinowsky's Trobriandislanders, the behaviors observed by Gmelch are a form of "insurance": actions theyconsider important in order to avoid bad luck. These rituals may involve taboos, fetishesor charms, or very commonly a set sequence of behaviors performed in an exacting way.
These behaviors are notoriously common, and may be taken to extremes.
A seventeen-game winner in the Texas Rangersorganization, Mike Griffin begins his ritual preparation afull day before he pitches, by washing his hair. The nextday, although he does not consider himself superstitious, heeats bacon for lunch. When Griffin dresses for the game heputs on his clothes in the same order, making certain heputs the slightly longer of his two outer, or "stirrup" sockson his right leg. "I just wouldn't feel right mentally if I did itthe other way around," he explains. He always wears thesame shirt under his uniform on the day he pitches. Duringthe game he takes off his cap after each pitch, and betweeninnings he sits on the same place on the dugout bench. (pp.
356) In another time and place, the behavior described above might be taken for OCD.
However, in baseball, it is permitted, and even encouraged, because team players andmanagers observe that to interfere with the behavior may cause mental unbalance anddistress, resulting in poor performance. Gmelch explains the establishment of theserituals as the result of Skinnerian or Pavlovian association. Players are said to be castingabout for behaviors that are associated with poor or stellar performance, in an attempt toidentify something that they might later repeat or avoid in order to bring about a desiredresult. Since professional baseball provides an environment where such behavior isaccepted and encouraged, it may provide the closest we can come to an experimentalsituation. Otherwise mentally healthy individuals, when given societal sanction, willritualize almost to a pathological degree.
Finally, I wish to address the special place of physical movement as a method of tension reduction, both in normal people and in OCD patients. As referenced above, there is a general acceptance in behavioral studies that the repetitive movements ofstressed animals are in part performed as an attempt to reduce tension. Increases inaggression, grooming, pacing and swaying are all commonplace across taxa. There seemsto be a link between anxiety and repetitive motion that has remained unstudied, althoughit has been remarked on extensively (reviewed in Schilder 1997). The presence offidgeting and other rhythmic movements in a wide variety of species is consistent with ahypothesis that such a link is ancient in origin. Study is urgently needed in this area if weare interested in the human propensity to ritualize.
If we can accept that OCD is a pathology of normal behavior taken to an excessive degree and applied to the world in ways that are non-sensical, the next question must be:does this imply that, like OCD, normal ritualizing behavior is in part biologically based?It is nearly impossible to test this hypothesis in humans for ethical reasons, since anexperimental protocol would necessitate the treatment of humans with psychoactivedrugs. However, as I have shown in this paper, OCD is commonly accepted as having aetiology that is at least in part biologically based, and is likely on a continuum withnormal ritualistic behavior. It is therefore not unreasonable to presume that normal ritualis predicated on a similar neurochemistry. If OCD is an excessive tendency to ritualize,we have much to learn about the underpinnings of normal ritualistic behavior, its origins,and its intended results.
Epidemiological studies of the prevalence of OCD across populations and through time have been woefully inadequate. Yaryura-Tobias and Neziroglu (1997) report that inthe "general white population" (pp. 18) OCD prevalence has ranged from .05% to 2.5%.
Most other studies are similarly sloppy when discussing the distribution of OCD evenwithin US national boundaries. Consequently, it is difficult to address the ways in whichOCD differs in its expression across heterogeneous groups. Similarly, it is a challenge todiscuss secular change, as the methods and theories that diverse authors have employedhave strongly affected reported results. The most popular scale for diagnosis is the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), which consists of 16 items, only 5 ofwhich are related to compulsions. The use of scales such as the Y-BOCS may bequestioned when the goal of the study is to measure population prevalence, since thescale requires a highly trained analyst to interpret the results of each individual. Studiesof population prevalence usually require enormous numbers of interviews, whichprecludes the detailed analysis of each individual by trained professionals.
These problems aside, we can probably still be confident that the prevalence of OCD has risen in recent years. The shift from .05% to 2.5% lifetime prevalence reportedby Yaryura-Tobias and Neziroglu (1997) reflects a fifty-fold increase in OCD cases overa 20 year period from the mid sixties to the mid eighties. This huge shift cannot beexplained away by simple measurement error.
What caused this shift? It is possible that the increased visibility of OCD in the popular media has encouraged self-recognition of symptoms. The increase in prevalencemight also be explained by slight changes in the definition of OCD to include a largerpercentage of individuals as cases. An intriguing possibility is that increasing numbers ofOCD cases reflect a displacement in the normal human need to ritualize that hasaccompanied a larger societal secular trend. Over the last half of the 20th century in the United States, the number of culturally sanctioned civic rituals has declined dramatically.
In the absence of socially explicit rituals available for participation and fulfillment of thisintrinsic human need to ritualize, it is possible that a larger percentage of people maybecome clinically obsessive compulsive.
This is not incompatible with a biological basis for this disorder. As Baer has hypothesized (1996), serotonin levels and function in OCD behaviors may be acutelysensitive to external phenomena. This draws a crucial distinction between the biologicaland the genetic. While all human beings may have some genetic proclivity towards ritual,social environments may encourage changes in neurochemistry, tipping the balancetoward or away from pathological expression of behavior. In this sense, biology is notfixed or deterministic. On the contrary, by definition it is dynamic, plastic, andresponsive to changes in a social environment.
This is certainly not the first attempt to compare and contrast the rituals of OCD with normal ritualistic behavior. Fiske and co-workers (Dulaney and Fiske 1994, Fiskeand Halsam 1997) have examined the question, finding similar content and form in bothnormal and pathological ritualization. Muris et al. (1997) report a high degree of OCD-like rituals in normal people who do not consider themselves the sufferers of a disorderthat interferes with their daily functioning. Turbott (1997) has gone so far as to say thatan analysis of OCD indicates that all ritual is sociobiologically determined, only tovarying degrees, that we ascribe as pathological or normal, depending on cultural context.
This is a rather simplistic reading of the evidence, but one that emphasizes OCD as oneend of a continuum of ritual behavior proclivities.
What is surprising is that this is the limit of the literature. The authors are, without exception, psychiatrists and psychologists who have ventured cautiously intothe realms of anthropology in order to investigate the question. Anthropology has notreciprocated the interest, perhaps because the proposed combination of biology andculture is repellent. If this is the case, than the loss is catastrophic. Instead of openingup new research paradigms, the hostile political climate has served to shut them downbefore they come into being. This paper is presented in the spirit of consolidating riftsand venturing connections between otherwise diametrically opposed subdisciplines. Myhope is that there is more to come, for both anthropology, and OCD patients.
Diagnostic and Statistical Manual of Mental Disorders. Author, Antony, Martin M., Fiona Downie, and Richard P. Swinson Diagnostic issues and epidemiology in obsessive compulsive disorder. In Obsessive-Compulsive Disorder: Theory, Research, and Treatment, edited byRichard P. Swinson, Martin M. Antony, S. Rachman, and Margaret A. Richter.
The Guilford Press, New York.
Bachofen, Martin, Akiko Nakagawa, Isaac M. Marks, Je-Min Park, John H. Greist, Lee Baer, Keith W. Wenzel, J. Richard Parkin, M.R.C.Psych, and Susan L. Dottl1999 Home self-assessment and self-treatment of obsessive compulsive disorder using a manual and a computer-conducted telephone interview: Replication of a
U.K.-U.S. study. Journal of Clinical Psychiatry 60:545-549.
Behavior therapy: Endogenous serotonin therapy? Journal of Clinical Psychiatry 57:33-35.
An interactive computer-administered self-assessment and self-help program for behavior therapy. Journal of Clinical Psychiatry 58:23-28.
Barr, Linda C., Wayne K. Goodman, Lawrence H. Price, Christopher J McDougle, and The serotonin hypothesis of obsessive compulsive disorder: Implications of pharmacologic challenge studies. Journal of Clinical Psychiatry 53:17-28.
Local cerebral glucose metabolic rates of obsessive compulsive disorder compared to unipolar depression and normal controls. Archives of General
Clark, Augustino, Kenneth C. Kirkby, Brett A. Daniels, and Isaac M. Marks A pilot study of computer-aided vicarious exposure for obsessive compulsive disorder. Australian and New Zealand Journal of Psychiatry 32:268-
de Araujo, L.A., L.M. Ito, and I.M. Marks Early compliance and other factor predicting outcome of exposure for obsessive compulsive disorder. British Journal of Psychiatry 169:747-752.
de Araujo, L.A., L.M. Ito, I.M. Marks, and A. Deale Does imagined exposure to the consequences of not ritualizing enhance live exposure for OCD? A controlled study 1. Main Outcome. British Journal of
Obsessive Compulsive Disorder: The Facts. Oxford University Press, Serotonergic antidepressants and their efficacy in obsessive compulsive disorder. Journal of Clinical Psychiatry 53:56-59.
Cultural rituals and obsessive compulsive disorder: Is there a common psychological phenomenon? Ethos 22:243-283.
Fineberg, N.A., T. Bullock, D.B. Montgomery, and S.A. Montgomery Serotonin reuptake inhibitors are the treatment of choice in obsessive compulsive disorder. International Journal of Pyschopharmacology 7:43-47.
Is obsessive compulsive disorder a pathology of the human disposition to perform socially meaningful rituals? Evidence of similar content. The Journal of
Nervous and Mental Disease 185:211-222.
Foa, E. B., J. B. Grayson, and G.S. Steketee Success and failure in the behavioral treatment of obsessive compulsives.
Journal of Consulting Clinical Psychology 51:287-297.
Childhood Obsessive Compulsive Disorder. SAGE Publications, Franklin, Martin E., Edna B. Foa, and Michael J. Kozak Time-limited cognitive-behavioral therapy and pharmacotherapy of obsessive compulsive disorder. Crisis Intervention 5:37-57.
Franklin, Martin E., Michael J. Kozak, Laurie A. Cashman, Meredith E. Coles, Alyssa A.
Cognitive-behavioral treatment of pediatric obsessive compulsive disorder: an open clinical trial. Journal of the American Academy of Child and Adolescent
What is obsessive compulsive disorder? The clinical syndrome and its boundaries. International Clinical Psychpharmacology 7:11-17.
Religion as a cultural system. In The Interpretation of Cultures. Harper Ritual and magic in American Baseball. In Conformity and Conflict: Readings in Cultural Anthropology, edited by James P. Spradley and David W.
McCurdy, pp. 351-361. Harper Collins, New York.
Goodman, Wayne K., Christopher J. McDougle, and Lawrence H. Price 1992a Pharmacotherapy of obsessive compulsive disorder. Journal of Clinical
Goodman, W.K., C.J. McDougle, and L.H. Price 1992b The role of serotonin and dopamine in the pathopysiology of obsessive
compulsive disorder. International Journal of Psychopharmacology 7:35-38.
Goodman, W.K., L.H. Price, P.L. Delgado, J. Palumbo, J.H. Krystal, L.M. Nagy, S.A.
Rasmussen, G.R. Heninger, and D.S. Charney1990 Specificity of serotonin reuptake inhibitors in the treatment of obsessive compulsive disorder: Comparison of fluvoxamine and desipramine. Archives of
General Psychiatry 47:577-585.
Are religious compulsions religious or compulsive? A phenomenological study. American Journal of Psychotherapy 38:524-532.
An integrated approach to treatment of obsessive compulsive disorder.
Journal of Cinical Psychiatry 35:38-41.
The comparative effectiveness of treatments fo obsessive compulsive disorder. Bulletin of the Menninger Clinic 62:A65-A81.
Hay, P., P. Sachdev, S. Cumming, J. S. Smith, T. Lee, P. Kitxchener, and J. Matheson Treatment of obsessive compulsive disorder by psychosurgery. Acta Psychiatrica Scandinavica 87:197-207.
Neurobiological and anthropological aspects of compulsions and rituals.
Hoffnung, R., D. Aizenberg, H. Hermesh, and H. Munitz Religious compulsions and the spectrum concept of psychopathology.
1986a Theories of etiology. In Obsessive Compulsive Disorders: Theory andManagement, edited by Michael A. Jenike, Lee Baer, and William E. Minichiello.
PSG Inc., Littleton, MA.
1986b Neurobiology and neuropsychology of obsessive compulsive disorder. InObsessive Compulsive Disorders: Theory and Management, edited by Michael A.
Jenike, Lee Baker, and William E. Minichiello, pp. 165-177. PSG Inc., Littleton,MA.
Karno, M., J.M. Golding, S.B. Sorenson, and A. Burnham The epidemiology of obsessive compulsive disorder in five US communities. Archives of General Psychiatry 45:1094-1099.
Childhood rituals and superstitions: Developmental and cultural perspective. In Obsessive Compulsive Disorder in Children and Adolescents,edited by Judith L. Rapaport. American Psychiatric Press Inc., Washington D.C.
Obsessive compulsive disorder and other disorders. International Journal of Psychopharmacology 7:25-26.
Persuasions of the Witch's Craft: Ritual Magic in Contemporary England.
Harvard University Press, Cambridge, MA.
Luxenberg, J.S., M. Flament, and S. Swedo Neuroanatomic abnormalities in obsessive compulsive disorder detected in quantitative x-ray computed tomography. American Journal of Psychiatry
Mahgoub, Osama Mohamed, and Hassan Babiker Abdel-Hafeiz Pattern of obsessive compulsive disorder in Eastern Saudi Arabia. British Journal of Psychiatry 158:840-842.
Argonauts of the Western Pacific, London.
Review of behavioral psychotherapy, I: Obsessive compulsive disorders.
American Journal of Psychiatry 138:584-592.
Behaviour therapy for obsessive compulsive disorder: A decade of progress. Canadian Journal of Psychiatry 42:1021-1027.
Fears, Phobias, and Rituals: Panic, Anxiety, and Their Disorders. Oxford Marks, I.M., L. Baer, J.H. Greist, J.M. Park, M. Bachofen, A. Nakagawa, K.W. Wenzel, J.R. Parkin, P.A. Manzo, S.L. Dottl, and J.M. Mantle1998 Home self-assessment of obsessive compulsive disorder: Use of a manual and a computer-conducted telephone interview, two UK-US studies. British
Journal of Psychiatry 172:406-412.
Mavissakalian, Matig, Samuel Turner, and Larry Michelson Future directions on the assessment and treatment of obsessive compulsive disorder. In Obsessive Compulsive Disorder: Psychological andPharmacological Treatment, edited by Matig Mavissakalian, Samuel M. Turner,and Larry Michelson. Plenium Press, New York.
McDougle, C.J., W.K. Goodman, J.F. Leckman, N.C. Lee, G.R. Henninger, and L.H.
Haloperidol addition in fluvoxamine-refractory obsessive compulsive disorder: A double-blind, placebo-controlled study in patients with and without
tics. Archives of General Psychiatry 51:302-308.
Neurosurgical treatment of malignant obsessive compulsive disorder.
Psychiatric Clinics of North America 15:921-938.
The place of obsessive compulsive disorder in the diagnostic hierarchy.
International Clinical Psychopharmacology 7:19-23.
Fluvoxamine in the treatment of obsessive compulsive disorder.
International Journal of Psychopharmacology 7:5-9.
Muris, Peter, Harald Merckelbach, and Michel Clavan Abnormal and normal compulsions. Behavioral Research Therapy 35:249-
Cognitive and behavioral aspects of the treatment of compulsive rituals.
Journal of Contemporary Psychotherapy 25:89-103.
OCD: Where the serotonin selectivity story begins. Journal of Clinical Psychiatry 57:11-20.
Obsessive compulsive disorder: Symptom overview and epidemiology.
Bulletin of the Menninger Clinic 62:A4-A32.
An overview of clinical and research issues in obsessional compulsive disorders. In Obsessive Compulsive Disorder: Psychological andPharmacological Treatment, edited by Matig Mavissakalian, Samuel M. Turner,and Larry Michelson. Plenium Press, New York.
The epidemiology and differential diagnosis of obsessive compulsive disorder. Journal of Clinical Psychiatry 53:4-10.
Saiz, J., JJ. Lopez-Ibor Jr., R. Vinas, and M. Hernandez The clomipramine challenge test in obsessive compulsive disorder.
International Journal of Psychopharmacology 7:41-42.
The organic background of obsessions and compulsions. In Essential Papers on Obsessive Compulsive Disorder, edited by Dan J. Stein and MichaelStone, pp. 241-259. New York University Press, New York.
Culture in Mind: Cognition, Culture, and the Problem of Meaning. Oxford Short-term psychotherapy for patients suffering from an obsessive compulsive disorder. In Obsessive COmpulsive Disorder: Psychological andPharmacological Treatment, edited by Matig Mavissakalian, Samuel M. Turner,and Larry Michelson. Plenum Press, New York.
Simpson, H. Blair, Kenneth S. Gorfinkle, and Michael R. Liebowitz Cognitive-behavioral therapy as an adjunct to serotonin reuptake inhibitors in obsessive compulsive disorder: An open trial. Journal of CLinical Psychiatry
Obsessive compulsive disorder: A religious perspective. In Obsessive Compulsive Disorder in Children and Adolescents, edited by Judith L. Rapaport.
American Psychiatric Press, Inc., Washington D.C.
Summerfeldt, Laura J., Veronika Huta, and Richard P. Swinson Personality and obsessive compulsive disorder. In Obsessive-Compulsive Disorder: Theory, Research, and Treatment, edited by Richard P. Swinson,Martin M. Antony, S. Rachman, and Margaret A. Richter. The Guilford Press,New York.
Rituals and releasers: An ethological model of obsessive compulsive disorder. In Obsessive Compulsive Disorder in Children and Adolescents, editedby Judith L. Rapoport, pp. 269-288. American Psychiatric Press Inc.,Washington D.C.
Szechtman, Henry, William Sulis, and David Eilam Quinpirole induces compulsive checking behavior in rats: A potential animal model of obsessive compulsive disorder (OCD). Behavioral Neuroscience
The meaning and function of ritual in psychiatric disorder, religion and everyday behaviour. Australian and New Zeland Journal of Psychiatry 31:835-
The Forest of Symbols: Aspects of Ndembu Ritual. Cornell University Obsessive compulsive disorder: It is basal ganglia disfunction? In Obsessive Compulsive Disorder in Children and Adolescents, edited by Judith L.
Rapoport, pp. 260-276. American Psychiatric Press, Washington D.C.
Yaryura-Tobias, José A., and Fugen A. Neziroglu Obsessive-Compulsive Disorder Spectrum. American Psychiatric Press, Obsessive compulsive disorder: Psychobiological approaches to diagnosis, treatment, and pathophysiology. In Essential Papers on Obsessive CompulsiveDisorder, edited by Dan J. Stein and Michael Stone, pp. 277-303. New YorkUniversity Press, New York.
CONVOCATORIA PÚBLICA No. _____ DEL ________ DE 2010 INVITACIÓN PÚBLICA SUBASTA INVERSA PARA CONTRATO INFERIOR AL 10% DE LA MENOR CONFORMIDAD CON LO ESTABLECIDO EN EL DECRETO 3576 DE 2009, INFORMA A LOS INTERESADOS QUE APARTIR DEL VEINTIUNO (21) DE ABRIL Y HASTA EL NUEVE (23) DEL MISMO MES DE 2010, ESTÁ ABIERTA LA CONVOCATORIA PÚBLICA A PRESENTAR PROPUESTAS PARA LA ESCOGENCIA MEDI