OBSESSIVE-COMPULSIVE DISORDER

Obsessive-compulsive disorder (OCD) was considered a relatively rare disorder until about two decades ago. Since then, considerable advance has been made in understanding the various aspects of OCD that include epidemiology, clinical features, co-morbidity, biology and treatment. In the last one decade, there has also been interest in a group of related disorders called obsessive-compulsive spectrum disorders.

OCD is characterized by the presence of obsessions and/or compulsions. Obsessions are repetitive and persistent thoughts, images, impulses or urges that are intrusive and unwanted, and are commonly associated with anxiety. Compulsions are repetitive behaviors or mental acts that the individual feels driven to perform in response to an obsession according to rigid rules, or to achieve a sense of ‘completeness’.

An epidemiological study by Khanna et. al (1993) in India reported a lifetime prevalence of 0.6%. This rate is considerably lower compared to the 2-3% rate reported in the European and North American studies. In all the studies of OCD in children and adolescents reported from India, males have outnumbered female subjects. The most common age of onset of OCD is reported to be between 22 and 35, while affected patients spend an average of 17 years before receiving a correct diagnosis and treatment, with most OCD and OCRDs often showing a waxing and waning course, frequently increasing in severity when left untreated. Etiology A number of aetiological factors play a role in the onset of OCD, including behavioral, cognitive, and environmental factors. Learning theorists, for example, suggest that behavioral conditioning may contribute to the development and maintenance of obsessions and compulsions. More specifically, they believe that compulsions are actually learned responses that help an individual reduce or prevent anxiety or discomfort associated with obsessions or urges.

Many cognitive theorists believe that individuals with OCD have faulty or dysfunctional beliefs, and that it is their misinterpretation of intrusive thoughts that leads to the creation of obsessions and compulsions. According to the cognitive model of OCD, everyone experiences intrusive thoughts. People with OCD, however, misinterpret these thoughts as being very important, personally significant, revealing about one’s character, or having catastrophic consequences. The repeated misinterpretation of intrusive thoughts leads to the development of obsessions. Because the obsessions are so distressing, the individual engages in compulsive behavior to try to resist, block, or neutralize them. Environmental factors may also contribute to the onset of OCD. For example, traumatic brain injuries have been associated with the onset of OCD, which provides further evidence of a connection between brain function impairment and OCD.

A serotonergic hypothesis of OCD was suggested originally by the observed differential efficacy of SRIs in alleviating OCD symptoms. Since then, numerous studies of peripheral receptor binding in the blood or concentrations of serotonin metabolites in cerebrospinal fluid have been performed but have yielded inconsistent results. Pharmacological challenge studies provide another indirect approach. By administering serotonergic agents and measuring endocrine and behavioral responses, investigators have attempted to study the central serotonergic functioning in OCD. It is observed that OCD patients become significantly more anxious and dysphoric after administration of meta-chlorphenyl-piperazine (mCPP), a 5-HT receptor agonist. In addition, obsessive-compulsive symptoms worsen. However, there appears to be blunted cortisol and prolactin response in response to mCPP. 

Diagnostic Criteria 

    According to DSM V the diagnosis can be made if

• A. Presence of obsessions, compulsions, or both:

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

                 1. Recurrent and persistent thoughts, urges, or impulses that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.

                 2. 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):

                 1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.

                2.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 (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).

According to ICD-10,

         For a definite diagnosis, obsessional symptoms or compulsive acts, or both, must be present on most days for at least 2 successive weeks and be a source of distress or interference with activities. The obsessional symptoms should have the following characteristics:

(a) they must be recognized as the individual's own thoughts or impulses;

(b) there must be at least one thought or act that is still resisted unsuccessfully, even though others may be present which the sufferer no longer resists;

(c) the thought of carrying out the act must not in itself be pleasurable (simple relief of tension or anxiety is not regarded as pleasure in this sense);

(d) the thoughts, images, or impulses must be unpleasantly repetitive.

Treatment and Management

• Drug treatment using medications with marked effect on serotonergic neurotransmission has been shown to be effective in decreasing both obsessions and compulsions, while combining this pharmacological approach with CBT has been reported as the most effective strategy for most OCD and OCRDs cases.     
• Drug treatment using medications with marked effect on serotonergic neurotransmission has been shown to be effective in decreasing both obsessions and compulsions, while combining this pharmacological approach with CBT has been reported as the most effective strategy for most OCD and OCRDs cases.
• In behavior therapy patients are asked to find and face the things they fear ('exposure') and then to refrain from carrying out compulsive rituals ('rituals or response prevention'), but other techniques may be employed as well.
• Since the combination of CBT and SRI drugs seems to achieve the best results in clinical settings, this has been proposed as evidence based first-line approach in most of cases. 

Authors: Jaspreet Kaur Mangat, MPhil. 2nd year (Clinical Psychology) Trainee. (Under the supervision of Dr. Ranjita Kumari, Assistant Professor of Clinical Psychology, Department of Clinical Psychology, CIIMHANS, Chattisgarh)