OCD
Obsessive-compulsive disorder (OCD) is represented by a diverse group of symptoms that include intrusive thoughts, rituals, preoccupations, and compulsions. These recurrent obsessions or compulsions cause severe distress to the person. The obsessions or
compulsions are time-consuming and interfere significantly with the person’s normal routine, occupational functioning, usual social activities, or relationships. A patient with OCD may have
an obsession, a compulsion, or both.
An obsession is a recurrent and intrusive thought, feeling, idea, or sensation. In contrast to an obsession, which is a mental event, a compulsion is a behavior. Specifically, a compulsion is a
conscious, standardized, recurrent behavior, such as counting, checking, or avoiding. A patient with OCD realizes the irrationality of the obsession and experiences both the obsession and the compulsion unwanted behavior. Although the compulsive act may be carried out in an attempt to reduce the anxiety associated with the obsession, it does not always succeed in doing so. The completion of the compulsive act may not affect the anxiety, and it may even increase the anxiety. Anxiety is also increased when a person resists carrying out a compulsion.
Symptoms of OCD
1. Contamination : The most common pattern is an obsession of contamination, followed by washing or accompanied by compulsive avoidance of the presumably contaminated object. The feared object is often hard to avoid (e.g., faeces, urine, dust, or germs). Patients may literally rub the skin off their hands by excessive hand washing or may be unable to leave their homes because of fear of germs. Patients with contamination obsessions usually believe that the contamination is spread from object to object or person to person by the slightest contact.
2. Pathological Doubt : The second most common pattern is an obsession of doubt, followed by a compulsion of checking. The obsession often implies some danger of violence (e.g., forgetting to turn off the stove or not locking a door). The checking may
involve multiple trips back into the house to check the stove, for example. These patients have an obsessional self-doubt and always feel guilty about having forgotten or committed something.
3. Intrusive Thoughts : In the third most common pattern, there are intrusive obsessional thoughts without a compulsion. Such obsessions are usually repetitious thoughts of a sexual or aggressive act that is reprehensible to the patient. Patients obsessed with thoughts of aggressive or sexual acts may report themselves to police or confess to a priest. Suicidal ideation may also be obsessive.
4. Symmetry : The fourth most common pattern is the need for symmetry or precision, which can lead to a compulsion of slowness. Patients can literally take hours to eat a meal or shave their faces.
5. Other Symptom Patterns : Religious obsessions and compulsive hoarding are common in patients with OCD. Compulsive hair pulling and nail biting are behavioral patterns
related to OCD. Masturbation may also be compulsive.
Causes/ risk factors of OCD
Biological factors
1. Neurotransmitters : Neurotransmitters are chemicals in the brain found between neurons & they help in the transmission of signals from one neuron to another. Neurotransmitters like Serotonin, Norepinephrine & Dopamine – the balance of which
are found disturbed in OCD, thus altering the signal transmission & thereby the connectivity between different brain regions.
2. Receptors : Different Neurotransmitters bind to specific receptors on the neurons to transmit the signals. In OCD, these receptors may be upregulated or downregulated or hypo-functional or hyper-functional for specific neurotransmitters in specific brain
regions.
3. Second Messengers and Intracellular Cascades : Each Neurotransmitter after binding to its specific receptor on the neuron, triggers the G Proteins & some enzymes causing
the production of 2nd messengers such as cAMP & cGMP, which in turn regulate the function of neuronal membrane ion channels; thereby regulating the transmission of signals across neurons. In OCD, this complex machinery is found to be deranged. Alterations of Hormonal Regulation: Various hormones like BDNF, Cortisol, Thyroid hormone, Growth hormone are found to be dysregulated in Mood disorders. Immune factors: association of OCD with autoimmune disorder- Sydenham’s chorea has been
noted. This complication of rheumatic fever is accompanied by obsessive–compulsive symptoms in over 70%of cases.
4. Structural and Functional Brain Imaging:
• CT & MRI Scans have shown changes in different parts of the Brain, especially the Caudate, which is smaller in OCD.
• PET Scans has demonstrated the presence of increased activity (i.e. metabolism and blood flow) in particular areas of the Brain- frontal lobes, the basal ganglia (especially the caudate nucleus), and the cingulum of patients with OCD. Pharmacotherapy and Psychotherapy reverse those abnormalities.
Genetic Factors
1. Family Studies: The rate of OCD among first degree relatives of adults with OCD is 2 times higher than first degree relatives of those without OCD.
2. Twin Studies: If one Monozygotic (identical) twin has a mood disorder, there is 57% risk that the other twin will develop the same disorder. In the case of Dizygotic (fraternal) twins, the risk is about 22%.
Psychosocial Factors
1. Life Events and Environmental Stress: Stressful life events may precede the development of OCD. Stress results in long-lasting changes in the brain’s biology- alter the Neurotransmitter balance, intraneuronal signalling systems & even loss of neurons and synaptic contacts.
2. Personality Factors: Persons with certain personality disorders— Anankastic personality disorder— may be at greater risk for OCD than persons with antisocial or paranoid personality disorder.
Diagnosing OCD
Depression is diagnosed by conducting a –
1. Psychiatric interview- of the client (patient) & informants (relatives). A detailed history of the complaints & the present illness, past history of psychiatric illness, family history to see if there are any genetic predisposing causes, personal history to see if any marital/relationship problems or any substance use like alcohol or if there are any external stressors like job loss contributing to the present illness, general medical history to rule out any possibility of any physical illness contributing to the illness (like hypothyroidism/ vitD3 deficiency/parkinsonism/Dementia), assessment of personality to see if any personality traits or personality disorder is contributing to the current episode of illness.
2. Mental Status examination- General appearance & behaviour, Psychomotor activity, Talk, Thought, Mood, Affect, Perception, Cognitive functions- attention & concentration, memory, intelligence, abstractability, judgment & insight are assessed.
3. Physical Examination- to see if the patient has any undiagnosed medical condition like hypothyroidism, parkinsonism or any other neurological condition causing or contributing to the present psychiatric illness.
4. Neuro-Psychiatric assessment scales- OCD rating scales to have an objective measurement of the severity of OCD.
Investigations
Blood levels of Thyroid hormones, Blood vitamin D3 levels, Blood sugar levels etc to see if any physical illness is contributing or causing the depression.
Treatment of OCD
A. Pharmacotherapy- It’s the treatment by using medicines- Medicines correct the neurochemical imbalances, the receptor dysregulations, 2nd messenger & intracellular disarray, stops neuronal loss, increases neuronal dendritic spines and reestablishes neuronal synaptic connections and thus improves and normalises connectivity of different brain regions, thus improving the OCD symptoms. CT, MRI, PET & FMRI studies have shown that treatment with drugs have a positive rebuilding effect on the brain. OCD medicines are safe, efficacious and are not addictive. Most of the medicines have no to minimal side effects. The duration of treatment depends on the duration of the illness, its severity etc. It’s important to complete the full course of treatment and not to stop treatment after mere resolution of symptoms as premature termination of treatment can lead to illness recurrence.
B. Psychotherapy- Psychotherapy is the treatment by psychological means to overcome the patient’s problem. Some commonly used techniques are
1. Exposure and response prevention
2. Desensitization
3. Thought stopping
4. Flooding
Reference :
1. Oxford – Psychiatry
2. Kaplan & Sadock’s – Psychiatry
3. The ICD-10: Classification of Mental and Behavioural Disorders
4. Diagnostic and Statistical Manual of Mental Disorders (DSM–5)
5. https://www.ncbi.nlm.nih.gov/pmc/
Self-Assessment
