Questions and Answers
Question # 34
Are persons with NLD prone to develop Obsessive Compulsive Disorder
(OCD)? If so, what may account for this?
Definition. In its most general sense, OCD can be viewed as a disorder in which a person has an obsessive compulsion to perform meaningless acts repeatedly. In many psychodynamic theories of personality, the compulsive (ritualistic) behaviour is viewed as being triggered by obsessive, unpleasant thoughts. Engaging in the compulsive behaviour is seen as providing some temporary relief from these disconcerting, even painful, thoughts. One reflection of the psychic importance of the compulsive behaviour is the high level of anxiety that occurs when the person is prevented from exhibiting it.
Background. Typically, persons with NLD do not adapt well to novel situations (see Content & Dynamics; Questions 4 and 27). Sometimes, they react with anxiety, even to the point of panic (see Questions 18 and 33), in situations that strike them as new and different. Indeed, they have a very marked preference for the routine and the predictable. They feel most comfortable in situations that are familiar and they often exhibit appropriate behaviour in such situations.
Developmental Dynamics. Given this marked difference in responses to novel versus familiar situations, it would seem reasonable to infer that persons with NLD may be inclined to exhibit rote, over-learned (i.e., comfortable) behaviours in novel situations-- this, instead of going through the process of learning new behaviours appropriate for them. In a behavioural sense, the youngster with NLD may "trot out" a well-practiced behaviour that may have no relevance for the situation at hand. With reference to our definition of OCD, such behaviour would be judged as clearly "meaningless."
Taking this reasoning one step further, it would seem probable that the comfort that overlearned behaviours offer in these novel, anxiety-provoking situations would lead to their repetition any number of times rather than learning new modes of coping to meet challenging circumstances. Indeed, the person with NLD may "latch on to" a single behaviour that is rewarding and that has the effect of reducing uncertainty and anxiety. This provision of "psychic comfort" may result in many repetitions of a single behaviour (ritual) in anxiety-provoking situations. In a word, the behaviour in question has all of the elements of a compulsive behaviour.
This scenario contains the following elements: a trigger, ritualistic (meaningless) behaviour of high frequency in response to that trigger, and momentary relief from anxiety when the ritual is performed. The final "ingredient" in this mix is the occurrence of high levels of anxiety, even panic, when the ritual cannot be performed (see Question 33). It would appear that the only difference between the person with NLD and others who develop this ritualistic/meaningless/ compulsive behaviour is that its predominant trigger for persons with NLD is likely to be confrontation with novel circumstances rather than obsessive thoughts.
Clinical Implications. Care-givers should be aware that this type of repetitive behaviour can develop and become very solidly entrenched in the behavioural repertoire of the person with NLD. Just as the care-giver should recognize and deal with panic attacks when they occur (see Question 33), there is good reason to infer that exiting the triggering situation before the ritual unfolds completely would be beneficial in the current context--as would fairly immediate attempts to build coping skills designed to decrease the frequency of, or even eliminate, this ritual. This is, by no means, as simple as it may sound. Thus, most care-givers would be expected to require consultation with a clinical psychologist who has a cognitive-behavioural orientation for the purpose of designing a treatment programme to deal with this complex set of problems. Most often, it is found that cognitive-behavioural intervention aimed at skill building, re-framing, cognitive and behavioural rehearsal, and the like, is effective. On the other hand, attempts to address these problems through the exclusive application of various types of dynamic psychotherapy are most unlikely to meet with any significant success
(see Question 23).
(1) Some have proposed a neurophysiological etiology for OCD. And there are other, reasonable, hypotheses about its origins. I have focussed only on one common psychodynamic hypothesis regarding the etiology of OCD. This was done because my main object was to demonstrate, through a comparison of two "functional" theories, that the content and neurodevelopmental dynamics of NLD yield a sufficient explanation for compulsive behaviours in persons with NLD. Thus, a comparison with a widely- held view regarding the exclusively psychological origins of OCD was an obvious choice.
(2) It is certainly possible that a person with NLD may exhibit a comorbidity that a colleague of mine is wont to characterize as "measles (in this case, NLD) and a broken leg (OCD)." (See Question 7 for another instance of this.) One example of this would be a person whose NLD constitutes the etiological ground for the scenario detailed above, and who also exhibits OCD that arises from a quite different etiology. I must say that I have never encountered this precise comorbidity. Indeed, I would think it highly likely that the compulsive behaviour of persons who present with apparent OCD and who also exhibit NLD could be shown to arise from the developmental dynamics of NLD rather than from (say) a psychodynamic position involving obsessive thoughts as a principal trigger.
That said, it would be very interesting to study cases in which an actual
comorbidity can be demonstrated.