Obsessive Compulsive Disorder (OCD)

INTRODUCTION

Obsessive Compulsive Disorder (OCD) is not unique to this millennium; it was identified as early as the seventeenth century. OCD was once considered rare, sufferers endured their condition in silence, treatment was without effect, life chances limited and families often became trapped in the ritualistic features of the illness. Today, OCD is recognised as being a common anxiety disorder with a lifetime prevalence of 2.5%. The good news is that OCD can be treated effectively.

DIAGNOSTIC FEATURES

OCD is characterised by the presence of obsessions and/or compulsions that are distressing and have a significant impact upon one’s life. Obsessions are defined as recurrent and persistent thoughts, ideas and images that are intrusive, unwanted, distressing and inappropriate. They are considered the product of one’s own mind, are difficult to suppress, cause distress, fearfulness and are accompanied by feelings of anxiety, disgust and shame. Common themes found in the obsessions are listed in Table 1.

Compulsions are repetitive, purposeful and stereotyped behaviours, which the person feels a strong desire to perform, although little pleasure results. The behaviours are intentional and excessive recognised as irrational and unrealistic in terms of what they are expected to achieve. The compulsions are designed to reduce anxiety and discomfort generated from the obsessions. For most, compulsions are time consuming, exhausting and elaborate. They may manifest overtly or covertly as mental rituals performed in the mind. Some experience overt and/or covert rituals. Common compulsions are listed in Table 2.

Most with OCD have multiple obsessions and compulsions, the symptom constellation often changing; however, for some specific symptoms are constant. Up to 15% of adults, experience obsessions in the absence of compulsions.

ONSET AND COURSE

Insidious onset is the norm with no specific precipitant for most. Micro-episodes of OCD, which do not interfere with daily life or cause distress, often occur prior to symptoms meeting the diagnostic criteria for OCD. Males have a mean age onset of 19.5 +/- 9.2 years, significantly earlier than for females (22 +/- 9.1 years). Sixty percent develop the illness prior to the age of twenty- five with 30 - 50% reporting childhood onset of symptoms at a mean age of 10.1 years. Generally, OCD is continuous, however, for some, it is episodic or deteriorative. Spontaneous remission is rare, when it does occur, OCD may reoccur later. Exacerbation of symptoms can be triggered by puberty, pregnancy, childbirth and in times of stress.

TYPES OF OCD

Contamination

Contamination fears are the most common obsessions in OCD. The obsessions are characterised by the fear of dirt, germs, specific diseases, environmental toxins and bodily waste. Where there is a concern about a specific disease, the type of disease may change over time. The most common rituals associated with contamination obsessions are cleaning, washing, showering and avoidance of persons, areas or objects that are perceived as a source of contamination.

Checking

Checking is the second most common form of OCD. Pathological doubt underlies checking; the sufferer is plagued by the thought that they will be responsible for a catastrophic event because of carelessness. Checking is undertaken in the belief that it will prevent a catastrophe. Items commonly checked include: - if the windows are closed, electrical and gas appliances switched off, doors locked and car ignition off. Once checked, doubts emerge over whether the checking has been completed properly and perhaps a chance remains that a catastrophe will occur. Re -checking follows, often triggering a cycle of checking and doubting that may last for hours before certainty is felt that harm is unlikely. For some, checking is of a personal nature aimed to prevent mistakes being discovered by others so that a sense of perfection is maintained.

Repeating

Repetitive actions seek to prevent catastrophe, but unlike the checkers, there is no logical connection between the obsession and compulsion. A sufferer may tap his fingers ten times in the belief that his grandmother will not die in a car smash or that the opening and closing of the letterbox fifteen times will guarantee safe travel.

Symmetry (order)

Those who have a need for symmetry possess a desire for order, i.e., arranging objects perfectly or performing actions precisely. If order or performance is disrupted, uneasiness occurs. For some, objects in rooms or spaces must be in ‘just the right places’. Vigilance is constant in knowing that objects are indeed in their perfect positions and repositioning prevented. The obsession underlying symmetry or preciseness is the belief that if the objects are not exactly positioned, negative consequences will follow.

Bodily (Somatic)

Those with somatic obsessions have concerns over contracting a disease or diseases. They frequently check their body for signs of an illness, seek medical tests to confirm the absence of disease and repeatedly ask for reassurance from medical and non-medical persons about the disease and the risk of contracting the feared disease.

Sex and Aggression

OCD sufferers with sexual or aggressive obsessions have a concern with the possibility of behaving inappropriately in a sexual or aggressive manner. They are often embarrassed by their obsession and reluctant to reveal. The most common compulsions associated with this type of obsession are checking that the event has not occurred and asking others for reassurance, which may include religious figures where forgiveness is sought.

Religion (Scrupulosity)

Scrupulosity affects 24% of sufferers and centres on religious and ethical issues. While scrupulosity may develop in people of all religions, its onset is most likely if a strong religious background is evident. Common obsessions include doubting the existence of significant religious figures, indecisiveness over whether an act is sinful, whether one's state of mind is "just right" to participate in a religious ceremony and if a certain action will nullify a religious belief.

Obsessions Alone

For those who experience obsessions alone, the obsessions are often repetitive, uncontrollable and distressing with episodes of obsessional thinking lasting for hours. The focus of the obsession may be a past or present phenomenon, imagined or real; the orientation of the obsession regardless of kind is negative.

Hoarding

About 22% of those with OCD admit to being hoarders, i.e. collecting and storing specific items in the belief that they will be required by them in the future. Regardless of how trivial the collected item, distress is experienced if they need to rid themselves of their possessions. Hoarders, at times, undertake extensive checking to assure that no item is missing. Although hoarding is common, it rarely dominates the clinical presentation.

For more information on compulsive hoarding click here

OCD DOES NOT OCCUR ALONE

Most with OCD have a coexisting illness. Depression occurs in one third of those at presentation, while two thirds will have a lifetime history of major depression. Most report onset of depressive symptoms after the onset of the OCD symptoms. Anxiety disorders are also common, as shown in Table 3 with specific phobia and social anxiety disorder being the most common.

Refer to the Panic Anxiety Mood Guide home page for more information about depression and the anxiety disorders.

Alcohol abuse and eating disorders are common, the onset of which also occurs after OCD. Psychotic features are also found in 10% of those with OCD. Of interest, OCD symptoms are found in up to 68% of those with Tourette’s syndrome and in 10% of those who have schizophrenia. Common personality disorders coexisting with OCD are dependent, avoidant, schizo - typical, borderline and obsessive - compulsive. OCD is more severe and resistant to treatment when there occurs a personality disorder. A personality disorder is defined as a chronic enduring illness characterised by a set of inflexible and maladaptive traits that lead to significant distress.

NEUROBIOLOGY OF OCD

OCD is now viewed as a neuropsychiatric disorder. Results from structural and functional neuroimaging studies have altered our understanding of this illness. Structural studies using Magnetic Resonance Imaging (MRI) scans show structural changes in the brain. Functional studies using Position Emission Tomography (PET) scans show hyperactivity in several brain sites; reversal of this hyperactivity occurs with specific pharmacological and cognitive behavioural treatments for OCD. Recently, a causative gene for OCD has been identified that is specifically connected with serotonin, a neurotransmitter.

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