AJ is a 30 year old executive who engages in extensive checking behaviour which occupies up to two hours each day and significantly interferes with his life. Whenever AJ leaves his house, and before he goes to bed at night, he is plagued with doubts that he has switched off electrical appliances and locked the doors and windows. AJ is terrified that if something was left on accidentally, there could be a fire and something terrible might happen. He does not want to be inadvertently responsible for harm befalling his loved ones, neighbours, or other people, and so he checks “dangerous” items repeatedly to be certain that they are safely turned off. This checking is performed in a ritualized manner because over the years, the doubt that he has turned things off properly has gradually strengthened, and now just looking at the stove is not reassuring enough. He must stare at each knob on the stove to be sure it is aligned in the “off” position, and say to himself “it’s off” over and over again. Then he must place his hand on each hotplate and count to ten to be sure that each hotplate is cold. If this ritual is interrupted, or if he loses his concentration, he has to start all over again, so it can take up to fifteen minutes just to check the stove. Then he has to check the kettle, the toaster, the microwave, and the iron to be sure that they are all turned off and unplugged at the wall.
He also checks repeatedly to be sure that all the doors and windows are locked. Getting out of the house can take up to an hour, and the rituals leave him feeling anxious and exhausted. He is constantly running late and he was once asked to resign from his job as a result of his frequent tardiness.
AJ presents a history of Obsessive Compulsive Disorder.
Obsessive Compulsive Disorder (OCD) is the 4th most common psychiatric disorder after phobia, substance related disorders and major depressive disorders. It is classified under Anxiety Disorders as per the Diagnostic and Statistical Manual of Mental Disorders [DSM – IV].
We may recollect a time when we checked the knob of the stove or experienced a momentary fear that something terrible may happen when we go on a vacation, but it is important to distinguish between normal and pathological anxiety. People with OCD experience marked distress. Their thoughts or behaviours are time consuming; that is, they take up more than 1 hour a day or they significantly interfere in their normal routine, activities, and relationships.
What is Obsessive Compulsive Disorder (OCD)?
People with OCD have repeated and unwanted thoughts, impulses or images called obsessions. They are disturbing, inappropriate, and cause noticeable anxiety and distress. The person attempts to hold back such thoughts or impulses or counteract them with other thoughts or actions. To make these thoughts or images go away and to relieve the anxiety they cause, people with OCD perform some action repeatedly. This is called a compulsion. E.g. – washing hands repetitively due to fear of being contaminated, or travelling back home to check the locks. It can even be a mental act. E.g. a person distressed with a offensive thought may find relief in counting to 10 backward and forward a 100 times for each thought. The aim is to prevent or reduce anxiety or prevent some dreaded event.
Obsessions increase anxiety whereas carrying out the compulsive behaviour reduces it, but when a person resists carrying out the compulsion, the anxiety increases. In most cases, people know their obsessions do not represent true dangers and realize their compulsive behaviour is strange or bizarre. However, deep down they are afraid that their fears might be real, and that something bad might happen if they don’t act on them. E.g. a person may feel compelled to take exactly 12 steps to reach the car.
Due to their insight into the abnormal nature of their compulsions, most OCD sufferers will meticulously hide their behaviours from others in order to avoid negative attention.
Some researchers claim that obsessive thoughts do occur without compulsions and that 75% of clients show both obsessive thoughts and compulsive acts. However, other researchers claim that if mental acts of compulsion like reciting a prayer are to be studied, then 100 % would show both.
The mean age of onset of the disorder is 20 years, although men have a slightly earlier age of onset than women. Among adults, men and women are equally likely to be affected. However, amongst adolescents, boys are more likely to be affected than girls.
Most common symptom patterns are related to fear of being contaminated, followed by washing or compulsive avoidance of the presumably contaminated object. The second most common pattern is pathological doubt (not locking the door) followed by compulsive act (of checking the locks). Intrusive thoughts without a compulsion that are guilt ridden for the person, e.g. of a sexual or aggressive nature, like to shout obscenity in a church, is the third most common symptom pattern. The fourth pattern is the need for symmetry, e.g. in placement of objects or where, if one hand gets wet, the sufferer may feel very uncomfortable if the other is not.
What causes Obsessive Compulsive Disorder?
· Research indicates that some parts of the brain work differently in people with OCD. In some cases, there is increased activity/structural irregularity in a certain part of the brain (frontal lobe/basal ganglia). Or there is a chemical imbalance. Because certain drugs that affect the levels of serotonin in the brain are effective in treating OCD, there appears to be a link between OCD and serotonin levels [serotonin is a neurotransmitter, one of the ‘brain’s messengers’, which is responsible for feelings of emotional well-being]. However, the role is not very clear.
· Available data does suggest a significant genetic component. In approximately 35% of all cases of OCD, another family member also has the disorder. But it does not differentiate the effect of culture and behaviours in the transmission of the disorder.
· The techniques of behaviour therapy are built on the theory that obsessions and compulsions are the result of abnormal learned responses and actions. Obsessions are produced when a previously neutral object (e.g. chalk dust) is associated with something that produces fear (e.g. seeing a classmate have an epileptic fit). Chalk dust becomes connected with a fear of illness even though it played no causative role. Compulsions (e.g. hand washing) are formed as the individual attempts to reduce the anxiety. Avoidance of the object and performance of compulsions makes the fear stronger and then, is responsible for the vicious cycle of OCD.
· Sigmund Freud has outlined role of defence mechanisms and conflict of the unconscious mind in the development of the symptoms. The symptoms of OCD symbolize the patient’s unconscious struggle for control over impulses/drives that are unacceptable at a conscious level. E.g. the need to cancel out the ‘bad’ thought - an aggressive impulse to harm a person.
The prevention of obsessive-compulsive disorder remains largely unexplored, due to uncertainty regarding the causes of the problem. OCD can be relentless. If untreated, OCD is usually chronic and follows a waxing and waning course. That is, symptoms may get somewhat better for months or even years, only to get worse again before returning to a lower level of severity.
How is it diagnosed?
People with OCD often avoid seeking treatment because they are embarrassed by the condition.
The clinician listens to a history of symptoms and asks questions. S/he will want to know the types of obsessions and compulsions experienced, and whether they interfere with everyday life and relationships in any way. S/he will also ask about any medications taken to be sure that it is not causing the symptoms. It is important to answer the doctor’s questions openly and honestly.
Based on presenting complaints and complete detailed information on background history, the clinician attempts to distinguish it from other clinical conditions like tics, depression, delusions etc. As the disorder usually begins in adolescence or early adulthood, the family physician might consider screening patients in this age group who show anxiety symptoms, depression or parental complaints of excessive meticulousness, cleanliness or behaviour peculiarities (e.g. refusal to touch certain objects, rigid rules regarding the ways food must be prepared). Early identification of obsessive-compulsive disorder may provide opportunity for early intervention.
How is it treated?
Pharmacotherapy and behaviour therapy may be applied either individually or in combination. A referral to a mental health professional is indicated when therapy is desired.
· Medication - Clinical trials have shown that drugs that affect the neurotransmitter serotonin significantly decrease the symptoms of OCD.
· Trying to help the patient develop insight into his/her problem is generally not helpful for OCD. But, a specific behaviour therapy approach called “exposure and response prevention” is effective for people with OCD.
In this approach, with the help of a qualified and professional therapist, the patient deliberately and voluntarily faces the feared object or idea, either directly or by imagination. Also, the patient is encouraged to avoid the compulsive act, with the support and structure provided by the therapist. Treatment then proceeds on a step-by-step basis, guided by the patient’s ability. As treatment progresses, most patients gradually experience less anxiety from the obsessive thoughts and are able to resist the compulsive urges.
· Cognitive-behavioural therapy may prove effective for those with OCD. This emphasizes changing the OCD sufferer’s beliefs and thinking patterns. Further studies are required before cognitive-behavioural therapy can be adequately evaluated.
· A technique like thought stopping – the process by which a person is able to discontinue the bothersome thought and divert the mind – or other such techniques are also helpful.
What is the prognosis?
Obsessive-compulsive disorder is a serious and common disorder that can easily escape the family physician’s attention and is seldom voluntarily disclosed by patients. Although once considered highly unresponsive to treatment, the physician now has a number of treatment options and can offer the patient a hopeful prognosis for significant improvement. People with OCD will do best if they attend therapy, take all prescribed medications, and seek support of family, friends, and a discussion group. When a family member suffers from obsessive-compulsive disorder, it’s helpful to be patient about their progress and acknowledge any successes, no matter how small.
What contributes to a good prognosis is good social and occupational functioning, presence of a precipitating event and episodic nature of symptoms. If there is another co-existing psychiatric condition like major depressive disorder, or if the person does not resist the need to carry out the compulsion, if the onset is in childhood, then the prognosis can be poor.