The term obsession is used quite liberally in current popular vernacular to indicate an intense interest in or preoccupation with a subject. Despite the prevalence of this connotation, psychologists generally use the term to indicate a more severe disturbance in cognition. As defined by the American Psychological Association’s Diagnostic and Statistical Manual of Mental Disorders, obsessions are "recurrent and persistent thoughts, impulses, or images that are experienced … as intrusive and inappropriate and that cause marked anxiety or distress" (2004, p. 457). This definition indicates that obsessions are identified in part by their effect on the thoughts and feelings of afflicted individuals. That is, obsessions are cognitive in content and result in negative emotions. Furthermore, obsessions are involuntary in nature and may intrude into one’s consciousness unexpectedly. Therefore, true obsessions exert a measure of control over the individual that nonpathological obsessive thoughts do not. Obsessions can have a profound impact on one’s ability to form and nurture interpersonal relationships and can lead to conflict with friends, coworkers, and family.
Delineations between normative behavior and abnormal obsessions can be somewhat difficult to ascertain. Showing an enthusiastic interest in a particular activity, topic, or person need not reflect psychopathology. Likewise, persistent worries about realistic problems do not qualify as obsessions. However, when such a thought occurs at a very high rate and is associated with significant distress to oneself or others, it is more likely to be considered an obsession. Differentiating obsessions from normative behavior also requires that one consider the developmental stage of the individual. For example, although it is not uncommon for young children to develop intense preoccupations with or fears of specific objects or interests, such behavior would be more worrisome in older individuals. Landmark studies by researchers in the 1970s and 1980s demonstrated that many people experience intrusive thoughts in the absence of any psychological impairment (e.g., Rachman and de Silva 1978). Therefore, the presence of unwanted thoughts alone neither qualifies as obsession nor confers a risk factor for mental disorder. Furthermore, marked emotional distress must accompany the thoughts in order for them to be considered obsessions. These emotional reactions can range, though many people report feeling anxious when confronted with obsessive thoughts.
Among the psychiatric disorders most relevant to obsessions are obsessive-compulsive disorder (OCD), body dysmorphic disorder (BDD), eating disorders, and delusional disorder. Individuals with obsessive-compulsive disorder usually have both obsessions and behavioral symptoms called compulsions, though an obsession-only subtype exists as well. Compulsions are ritualistic actions performed to neutralize the anxiety and distress created by obsessions. For example, a patient with obsessions about contamination may exhibit compulsive hand washing, and a patient with obsessions about harm may exhibit compulsive checking behavior. Individuals with body dysmorphic disorder have persistent unwanted thoughts about a perceived defect in their physical appearance. Common obsessions include concerns about parts of one’s body being misshapen, abnormally sized, or otherwise unattractive. Like obsessive-compulsive individuals, people with BDD also exhibit compulsions, such as repetitive grooming behavior. Researchers have linked obsessions to psychotic disorders such as schizophrenia and delusional disorder. A key feature of such disorders is that the afflicted individual suffers a severe impairment of his or her ability to experience rational thoughts and perceptions. If these irrational thoughts become intrusive and persistent, then one can be said to be experiencing obsessions. Eating disorders have been associated with obsessions, in that afflicted individuals often have persistent uncontrollable thoughts about food, dieting, body image, and exercise.
Obsessions can also affect one’s propensity to pursue and maintain social relationships via maladaptive means, such as stalking. Stalking is defined as the deliberate following and harassing of others, and victims are most commonly former intimate partners or celebrities. Although many individuals experience a desire to maintain contact following the dissolution of an intimate relationship, those who do so by threatening means or who act on uncontrollable thoughts about the loved one may meet criteria for stalking behavior.
The treatment of obsessions differs based upon the specific disorder in which the obsessions are couched.
Psychotherapeutic techniques are often augmented by medication, as in the case of OCD and BDD, or may serve as a primary means of treatment, as in psychotic disorders. For individuals with OCD, cognitive-behavioral therapy has proven to be more effective than other forms of talk therapy. The primary technique used in this therapy as it pertains to OCD is called exposure and response prevention. In this method, individuals are exposed to stimuli that raise anxiety and provoke obsessions. They are instructed to tolerate this anxiety and distress without performing any neutralizing compulsive behaviors. Although patients may experience a greater deal of distress at the onset of treatment, over time obsessions wane as individuals learn that they can tolerate the anxiety without performing a compulsion. Ideally, the obsessions themselves lose potency and become less impairing. This technique is also used to treat BDD in that patients are exposed to their obsessive body concerns and prevented from performing behaviors that combat anxiety. For example, one might be prevented from applying makeup, checking mirrors, or skin-picking if these are repetitive and anxiety-reducing strategies used by the patient.
Much of the research on the biology of obsessions has been conducted by examining individuals with OCD. Basal ganglia abnormalities are the most commonly reported structural correlates of the disorder. More specifically, the head of the caudate nucleus and the orbital gyrus may play a prominent role in the dysfunction. These structures are deep below the cerebral cortex and are implicated in the regulation and coordination of movement. In terms of neurotransmitter dysfunction, both the serotonin and dopamine systems have been implicated in OCD. Pharmacological treatments for obsessions include drugs that target the serotonin system and increase the amount of this neurotransmitter available in the brain. Serotonin reuptake inhibitors, such as clomipramine or fluoxetine, have been associated with both symptom reduction and improved quality of life for patients with both OCD and body dysmorphic disorder (McDonough and Kennedy 2002; Phillips 2002). About 40 to 60 percent of obsessive-compulsive patients report significant improvement from using a drug of this type. Combining these drugs with antianxiety drugs or neuroleptics may also be beneficial for patients, depending upon the initial response to serotonin reuptake inhibitors.
