Compulsion refers to stereotyped, repetitive behaviors or mental acts that an individual feels driven to perform, often in response to obsessions or according to rigid rules. The person recognizes the irrationality or excessive nature of these actions but is unable to resist performing them.

Common examples include:

• Repeated hand washing or cleaning

• Checking locks or appliances multiple times

• Counting, tapping, or ordering objects in a specific sequence

Compulsions are a hallmark of obsessive-compulsive disorder (OCD) and may occasionally occur in schizophrenia or other psychiatric disorders.

Pathophysiology

The neurobiological mechanisms underlying compulsions involve:

• Cortico-striato-thalamo-cortical (CSTC) circuit dysfunction: Hyperactivity in the orbitofrontal cortex, anterior cingulate cortex, and striatum leads to impaired inhibitory control.

• Serotonin dysregulation: Reduced serotonergic signaling contributes to difficulty suppressing intrusive thoughts and repetitive behaviors.

• Dopamine imbalance: Overactivity in basal ganglia circuits can reinforce stereotyped actions.

• Cognitive-behavioral mechanism: Repetitive behaviors temporarily relieve anxiety caused by obsessions, reinforcing the cycle.

Examination technique

Patient Observation

• Note repetitive or ritualistic behaviors during clinical interaction.

• Assess whether behaviors are ego-dystonic (recognized as unreasonable) or ego-syntonic (perceived as reasonable).

Structured Assessment

• Yale-Brown Obsessive Compulsive Scale (Y-BOCS) to quantify severity.

• Behavioral tasks or exposure-response assessments to evaluate compulsive tendencies.

Clinical features

Differential Diagnosis

Pediatric considerations

• Onset often occurs in childhood or adolescence, typically around ages 10–12.

• May affect school performance, social interactions, and daily functioning.

Geriatric considerations

• Compulsions are less common but can persist in older adults with lifelong OCD.

• Must differentiate from cognitive impairment-related repetitive behaviors.

Limitations

• Insight may vary: some patients perceive compulsions as rational (poor insight), complicating assessment.

• Behaviors can be covert (mental rituals), requiring careful history taking.

Patient counseling

• Explain the difference between obsessions (intrusive thoughts) and compulsions (repetitive behaviors).

• Reassure patients that compulsions are treatable with behavioral therapy and/or medication.

• Emphasize the importance of early intervention to prevent functional impairment.

Conclusion

Compulsion is a neuropsychiatric phenomenon characterized by repetitive, ritualized behaviors performed in response to obsessions or anxiety. It is most prominently observed in OCD but may occur in other psychiatric disorders. Understanding its neurobiological and behavioral underpinnings aids in accurate diagnosis and targeted therapy.

References

1. American Psychiatric Association. DSM-5: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: APA; 2013.

2. Abramowitz JS, McKay D. The Wiley Handbook of Obsessive Compulsive Disorders. Wiley; 2014.

3. Kandel ER, Schwartz JH, Jessell TM. Principles of Neural Science. 5th ed. New York: McGraw-Hill; 2013.

4. Fineberg NA, et al. Brain circuits, neurotransmitters, and obsessive-compulsive disorder: Pathophysiology and treatment. J Psychopharmacol. 2015;29(1):1–14.