Obsessive Compulsive Disorder (OCD)

Clinical Picture

Obsessive Compulsive Disorder (OCD in short) is a mental health condition when a person gets caught in a cycle of obsessions and compulsions. It’s a common yet chronic, and lasting disorder in which a person cannot control their reoccurring thoughts (obsessions) and/or behaviors (compulsions). They feel the urge to repeat over and over.  Obsessive-compulsive disorder has two parts: obsessions and compulsions. 

Obsessions in simple terms are irrational thoughts, images, worries and doubt that frequently appear in mind. The person finds it uncontrollable to stop those thoughts.  For example, you may have sometimes worried about whether or not you had locked the door or off the stove?  Being obsessed with small frequencies is a protective technique. However some people with this disorder are even obsessed with being sure the door has been locked or the doors or stove has been off. The person thinks that maybe the door has been locked or broken or opened or the stove has been turned on by air, mouse. 

Compulsions in other hands are repetitive activities that a person performs to reduce the anxiety caused by the obsession. For example, in the above obsession example a person now checks the door or stops being closed or turned off. A person may only develop obsession or obsession and compulsion both. 

Bipin and ants……………..

Bipin Shrestha (29) is extremely worried about his left hand; He from past few years has been complaining that his left hand skin is frequently being attacked by ants. Every 8 hours he cries out loud that his hands are being attacked by ants. He tried to clean his hand with soup and water but it didn’t help him out. He asks his parents, friends, coworkers or whoever is available to put some sugar on it. He thinks that sugar pleases the ants and in return it itches him.

If not pour sugar he would rub his skin until it turns reddish. He had been obsessed and thinking about being attacked by ants most of his day and acted deviant by putting sugar on his left hands time and again to avoid being attacked.  

Obsessive Compulsive Disorder is a chronic disorder. A person who is working in an office may have an obsession and/or compulsion, and he/she would come back home to check if the door or stove is locked or off again and again. This would significantly affect their education/family/friends/work and occupation setting.    

Common form of obsession and compulsion are as follows:

OBSESSION

COMPULSION

Fear of not fulfilling obligation (worry about stove and door putting on  which might cause fire or theft)Sexual thought (worry about causing someone sexual harm)Fear of contamination (germs or dirt in parts of body, room or even in a toilet)Religious thoughts (belief of having thought which is against their religion)Illness or symptoms (fear of serious illness)

Repeated action (checking door, gas frequently )Focus on number (giving priority to certain number like number 7 or 3 )Washing and cleaning (washing hand or cleaning room frequently)Repeating specific word or phrase (repeating or chanting certain word like name of gods for preventing form something’s bad)Praying (repeating prayers preventing form something’s bad )Arranging (arranging books or organized kitchen materials)

Diagnostic Criteria (DSM)

A. Presence of obsessions, compulsions, or both:

Obsessions are defined by (1) and (2):

• Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals causes marked anxiety or distress.
• The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).

Compulsions are defined by (1) and (2):

• Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to performing response to an obsession or according to rules that must be applied rigidly.
• The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

D. The disturbance is not better explained by the symptoms of another mental disorder. 

Comorbidity 

Many people with Obsessive Compulsive Disorder have another disorder as well. Some of the common comorbidities that overlap with Obsessive Compulsive Disorder are depression and anxiety spectrum disorders like panic disorder, panic attacks, generalized anxiety disorder (GAD), eating disorders, body dysmorphic disorder (BDD) and features of perfectionism.

Epidemiology

Life time prevalence rate of Obsessive Compulsive Disorder is estimated in the range of 1.6 – 2.3 (Calamari, Chick, pontareli & DeJong, 2012).The twelve month prevalence of Obsessive Compulsive Disorder is 1,200 per 100,000 (1.2%) of the overall population (Hirschtritt, Bloch & Mathews, 2017). Obsessive Compulsive Disorder is observed in males and females in approximately equal proportions.

The onset of Obsessive Compulsive Disorder averages at 19.5 years old, but usually ranges from the late teenage years until the mid-20s in both sexes, however the age of onset for males tends to be younger in males than that in females (Antony, Downie &Swinson, 1998). Men more frequently present with checking rituals and women are more likely to display compulsive washing. One-third of affected adults first experienced symptoms in childhood. 

In a small scale study (n=60) conducted by Shakya during 2010 in BP Koirala Institute of Health Sciences Of 60 cases, 39 (65%) were male. The most common age groups were 20-29 (43%) and 30-39 (28%). Most of the subjects were relatively better educated and about half of them were married.  In another large study (n=911) by Shakya, Adhikari, Pandey, Sapkota, Niraula et.al in 2014 found that n=113 have some sort of psychiatric disorder and among them n=7 have Obsessive Compulsive Disorder.

Etiology 

In psychopathology there exists multiple theories which explain the aetiology of Obsessive Compulsive Disorder, but they can’t explain every person’s experience. However a cognitive and behavioral model of Obsessive Compulsive Disorder has larger empirical support than biological and structural brain abnormalities.

Obsessive Compulsive Disorder can run in families’ i.e. they may have a genetic component but specific genes have yet to be identified. Though, twin studies have shown that concordance rate for a monozygotic twin is higher than that of dizygotic twins. Obsessive Compulsive Disorder prevalence is higher if a 1st degree relative has OCD.  

Dysfunctional in brain structure and size has been seen in brain imaging studies (PET, SPECT, fMRI) in the patients of OCD, orbit frontal cortex, anterior cingulate cortex, thalamus, temporal cortex, parietal cortex , insula and others (Rehman, Singh & Jain, n.d). Abnormalities in neurotransmitter chemicals such serotonin, dopamine, glutamate that send messages between brain cells – are also involved in the disorder.

Similarly, obsessive fears and compulsive behaviors can be learned. Two stage learning theories classical and operant conditioning also explain the model of OCD. Obsession is resulted due to stimuli being paired up with anxiety thoughts. Whereas compulsion are neutral behaviors that have been associated with anxiety reduction and therefore reinforced. For example Jackon who has an obsession regarding germs, may reduce his anxiety by engaging in hand washing activities. 

Washing ritual here acts as reinforcement as it reduces his anxiety. He in future may perform an increasing habit of washing hands when his fear of contamination occurs.  Obsessive and compulsive can be learned from watching from family members, pairs or others and gradually learned over time.  

Another causative factor is our cognitive i.e. thought process. Cognitive theories believe that individuals with OCD have dysfunctional belief and misinterpretation of intrusive and disturbing thoughts. They attempt to underline unhelpful strategies to manage their dysfunctional belief. Biting or harming someone from next to you, leaving the stove on are normal and common thoughts, but for the people with OCD often have an inflated sense of responsibility and misinterpret these thoughts and engage in compulsive behaviour to resist or block their obsessive thoughts.  

According to psychosexual strategies OCD is caused due to fixation in anal stage. Freud believes that gratification during the anal stages shall result in certain personality traits including perfectionism (Phillips, Stein & Rauch, 2010). For example, if someone is neat and tidy with high standards; they may be more likely to develop OCD.

Treatment 

Psychological treatment is one of the best available treatments for anxiety disorder including OCD. Cognitive behavioral therapy is widely considered as the best psychological treatment; a special form of Exposure and response prevention (ERP) is commonly used during CBT sessions. This therapy believed that OCD is learned and can also be unlearned. Thus they directly confront an anxiety provoking situation and attempt to prevent the response (compulsion) of OCD by making them learn that the problem is with their intrusive thoughts. 

Relaxation, mindfulness technique or even yoga can help individuals to deal with their anxiety resulting from OCD, but this technique won’t be helpful in resolving obsessive thoughts. This certain technique helps to give attention to breathing, muscle to reduce anxiety. It also helps in relaxing the muscles resulting from tension and stress. 

References 

• Calamari, J.E., Chik, H.M., Pontarelli, N.K. & DeJon, B.L. (2011). Phenomenology and Epidemiology of Obsessive Compulsive Disorder. doi: 10.1093/oxfordhb/9780195376210.013.0016
• Hirschtritt, M.E., Bloch H.M. & Mathews,C.(2017). Obsessive-Compulsive Disorder: Advances in Diagnosis and Treatment. JAMA. 317. 1358. 10.1001/jama.2017.2200.
• Antony, M. M., Downie, F., & Swinson, R. P. (1998). Diagnostic issues and epidemiology in obsessive–compulsive disorder. In R. P. Swinson, M. M. Antony, S. Rachman, & M. A. Richter (Eds.), Obsessive-compulsive disorder: Theory, research, and treatment (p. 3–32). The Guilford Press.
• Shaya, D.R. (2010). Clinico-demography Profile in Obsessive Compulsive Disorders. Journal of the Nepal Medical Association. DOI: 10.31729/jnma.113
• Shakya, D.R., Adhikari, B.R., Pandey, A.K., Sapkota, N., Niraula, S.R., et.al (2014). Community Based Survey on Psychiatric Morbidity in Eastern Nepal. J Nepal Med Assoc 2014; 52(196):997-1004
• Phillips, K.A., Stein, D.J., Rauch, S.L, et al. (2010). Should an obsessive-compulsive spectrum grouping of disorders be included in DSM-V?. Depress Anxiety. 27(6):528-55. doi:10.1002/da.20705
• Rehman1, R. Singh, H., Jain, A. (2014). Obsessive-Compulsive Disorder : An Overview. Int J Dent Med Res 1 (2)