The Biological Perspective

Past research of family and twin studies suggest that OCD has a moderate genetic component. OCD is five times more frequent in the first-degree relatives of people with OCD than in people without the disorder (Nestadt et al., 2000); the concordance rate of OCD among identical twins is around 57% and 22% for fraternal twins (Bolton, Rijsdijk, O’Connor, Perrin, & Eley, 2007). Studies have implicated about two dozen potential genes that may be involved in OCD; these genes regulate the function of three neurotransmitters: serotonin, dopamine, and glutamate (Pauls, 2010).

Furthermore, research also suggests that there may be differences in the brain structures of those with OCD versus those without. The orbitofrontal cortex is part of a series of brain regions that, collectively, is called the OCD circuit; this circuit consists of several interconnected regions that influence the perceived emotional value of stimuli and the selection of both behavioral and cognitive responses (Graybiel & Rauch, 2000). People with OCD show more brain activity in these areas when asked to do things that provoke symptoms, such as looking at crookedly hung pictures or touching a dirty counter; because of this, it is believed that abnormalities in these regions may be the cause for OCD symptoms.

For PTSD, and other stress-related disorders, researchers have found that genetics and environment play an important role in one’s risk for developing PTSD due to trauma; estimates for the genetic influences for PTSD account for 30–73% of vulnerability for the disorder. Some of the hereditary traits or genes that affect the increased risk for developing PTSD are common to those linked to a higher rate of susceptibility to major depression, anxiety, and panic disorder. One study actually identified 17 gene variants that were associated with PTSD.^[1]

Figure 1. Recent studies have shown that smaller hippocampal volume has been correlated with PTSD.

Genes may not be the only thing affecting the risk factor for PTSD. In fact, the very structures of a person’s brain, like in the case of OCD, may have something to do with this. Recent studies have shown that smaller hippocampal volume has been correlated with PTSD—the relationship between PTSD and smaller volume in this region of the brain is associated with negative effects of stress hormones; what’s interesting is that smaller hippocampal volume was found not only in the brains of combat veterans diagnosed with PTSD but also in their twins who hadn’t experienced combat, and thus never developed the disorder. This biological factor implies that someone could be predisposed to developing this disorder should they experience a traumatic event.^[2]

The Sociocultural Perspective

The sociocultural perspective looks at a person’s behaviors and symptoms in the context of their culture and background.

Some cultures in which religion and customs are held to a very high standard may be connected to OCD; these factors are so ingrained and so varied that they can influence the onset, outcome, and response to treatment for OCD. Among Egyptians, for example, there is an emphasis on religious rituals that involve repeated phrases—it appears that the prevalence of religious obsessions and compulsions are hard to distinguish between those with OCD and those simply practicing their religion. Types of obsessions among study participants in Egypt and Jerusalem were similar, mostly associated with religion and cleanliness or purity, whereas themes among Indian and British participants related more to being orderly and avoiding aggressiveness.^[3] Understanding social influences on behavior is important; for example, how might you tell the difference between someone who is working hard to “purify” themselves via the strict adherence of religious rituals—possibly washing their hands frequently, praying, or performing specific tasks several times a day—and someone who has a diagnosis of OCD?

In regards to PTSD, different cultures and belief systems may help or hinder the prevalence of the disorder. Cultural beliefs may influence an individual’s personal meanings of trauma and their attempts to come to terms with trauma memories in helpful and unhelpful ways. The meanings linked to PTSD show cultural variations: in individualistic cultures appraisals about a vulnerable or inadequate self are common; in collectivistic cultures appraisals about social functioning or evaluation by others. Cultural beliefs may also influence the reactions of significant others and the community and can thus facilitate or impede recovery from trauma.^[4]

In a 2013 study that examined the prevalence and determinants of PTSD and post-traumatic stress symptoms following the 2004 tsunami in Indonesia and India, Rajkumar et al. credited the absence of avoidance symptoms among tsunami survivors to the cohesive social bonds and religious rituals that facilitated talking about the event and collective mourning in the community. Religious and spiritual beliefs may also influence trauma susceptibility.^[5] Research has indicated that locus of control plays a role in susceptibility to PTSD. While an internal locus of control—the belief that the outcomes of events in your life are in your own control—seems to provide a protective role in people subjected to traumatic experiences, an external locus, in which events in one’s life are believed to be controlled by outside forces, tends to instill a sense of helplessness and lack of control in victims of trauma. In India, where the role of religion and strong beliefs in karma are highly predominant, society is generally characterized by an external locus of control.^[6]

The Psychodynamic Perspective

Figure 2. According to Freud, our personality develops from a conflict between two forces: our biological aggressive and pleasure-seeking drives versus our internal (socialized) control over these drives.

Psychodynamic theory suggests that there are three areas at work in determining a person’s personality and behavior: the id, superego, and ego. The id represents our unconscious, primitive drives or urges. The superego is what we learn as we grow—societal rules, what is or isn’t acceptable—our “moral compass” essentially, and when we fail to live up to the standards of the superego, we may experience shame or guilt. The ego is the most rational part of our personality that balances the two by satisfying the desires of the id in a realistic way.

When there is an imbalance of these three interacting parts of our personality, the psychodynamic approach says that we are likely suffering from neurosis (a tendency to experience negative emotions), anxiety disorders, or unhealthy behaviors. For example, a person who is dominated by their id might be narcissistic and impulsive. A person with a dominant superego might be controlled by feelings of guilt and deny themselves even socially acceptable pleasures; conversely, if the superego is weak or absent, a person might become a psychopath. An overly dominant superego might be seen in an over-controlled individual whose rational grasp on reality is so strong that they are unaware of their emotional needs, or, in a neurotic who is overly defensive (overusing ego defense mechanisms).

To view OCD in light of this perspective, obsessions and compulsions are, in actuality “unconscious conflict” that you may be trying to stop or cope with, and this conflict comes from a clash between the id (usually a sexual or aggressive urge) and the superego (the desire to do the right thing and follow socially

Figure 3. Researcher David Malan proposed the triangle of conflict, which holds that true feelings can be blocked by defenses and anxieties.

acceptable behavior). A good way to illustrate this would be to picture in your mind’s eye that common image of a devil and an angel on each shoulder, whispering in each ear. A person with OCD is stuck between “right” and “wrong,” no longer able to function within normal limits. When these two (id and superego) are at odds, especially in extreme circumstances, a person is forced to manage them via repeated task(s), such as hand-washing or frequent checking.^[7]

The psychodynamic perspective attempts to bring repressed traumatic experiences out of the unconscious, where they are perceived as more toxic, and address them by helping patients to understand the relationship between hidden impulses, anxiety, and defense mechanisms.^[8]

The Humanistic Perspective

From the humanistic perspective, with its emphasis on the potential for good and self-actualization in all people, those suffering OCD and PTSD are likely undergoing an existential crisis. People with these disorders are attempting to work toward self-actualization but finding themselves “stuck” and unable to move forward. For those with OCD, it manifests in obsessions and compulsions, they are trapped in a vicious, never-ending cycle, unable to move higher on Maslow’s hierarchy. These obsessions and complusions could stem from a basic need that wasn’t met in the early years, or from a feeling of insecurity. Similarly, those with PTSD have had a traumatic experience, one in which a basic need was severely threatened (i.e., their life), and therefore, they may feel helpless to move forward because of the difficulty with never truly feeling safe.

The Cognitive Perspective

Cognitive psychology focuses on studying our thoughts and their relationship to our experiences and our actions. The cognitive model of OCD, as proposed by Paul Salkovskis, proposes that everyone will experience intrusive thoughts from time to time, but those with OCD falsely assume that “(i) thinking about an action is the same as doing it; (ii) failing to prevent harm is morally equivalent to causing harm; (iii) responsibility for harm is not diminished by extenuating circumstances; (iv) failing to ritualize in response to a thought about harm is the same as an intention to harm; and (v) one should exercise control over one’s thoughts.^[9] The idea that thinking about an action is the same as doing it, is known as thought-action fusion. If someone with OCD has the sudden thought of robbing a bank, their mind acts as if they’ve already done it—the thought, in turn, is just as bad as the action itself.^[10] Cognitive behavioral therapy (CBT) attempts to address and end the patterns of thinking that connect a thought with a compulsion.

In regards to PTSD, cognitive theory takes the following approach: traumatic events disrupt a person’s perspective on life and the world around them, which ultimately creates a negative viewpoint that has lasting damage, resulting in chronic stress symptoms seen in PTSD. When you can’t help but view the world as an unpredictable, dangerous place, it’s hard to move forward without high levels of stress. People with PTSD may have a hard time believing that anyone or anything can be trusted, to the point where they may even struggle with their own self-worth.^[11]

The Behavioral Perspective

According to the behavioral approach, for someone with OCD, a neutral event comes to elicit fear or stress when it is paired with a stressful event (an unconditioned stimulus, or UCS). The conditioned stimulus (CS) could be a thought or something physical, such as a doorknob or a bathroom, and for someone with OCD, the stress caused by the conditioned stimulus is only reduced through compulsions.^[12] Unfortunately, these rituals a person with OCD uses to neutralize the problem actually reinforce this notion that the obsession is bad and they must do something to stop it, which results in becoming “stuck” in the constant cycle of obsession compulsion.

Figure 4. The Little Albert Experiment: Through classical conditioning, Little Albert came to fear furry things, including Watson (the researcher) in a Santa Claus mask.

PTSD learning models suggest that some symptoms are developed and maintained through classical conditioning. The traumatic event may act as an unconditioned stimulus that elicits an unconditioned response characterized by extreme fear and anxiety. Cognitive, emotional, physiological, and environmental cues accompanying or related to the event are conditioned stimuli. These traumatic reminders evoke conditioned responses (extreme fear and anxiety) similar to those caused by the event itself (Nader, 2001). Differences in how conditionable individuals are help to explain differences in the development and maintenance of PTSD symptoms (Pittman, 1988).