Undiagnosed Obsessive-Compulsive Disorder (OCD)?

What is Obsessive-Compulsive Disorder? 

Obsessive-compulsive disorders or OCDs in short consists of the following two components: 

1. Obsessions: Repetitive and unwanted thoughts or sensations eg: thoughts of harming others, undue awareness of one’s own heartbeat, breathing, and other normal bodily sensations.

2. Compulsions: the uncontrollable urge to do something over and over again eg: repeatedly counting objects such as coins, biting nails continuously.

DSM-5 criteria for diagnosis 

The Fifth Edition of The Diagnostic and Statistics Manual has defined OCD as persons having either obsessions, or compulsions, or both. Individuals must satisfy all the criteria to be diagnosed with the disorder.

A. Presence of Obsessions, Compulsions or Both

1. Obsessions are defined as: 

• Recurrent thoughts, urges, and impulses that are intruding with the person’s day to day work and causing significant anxiety.

• There is an attempt on the part of the individual to suppress these thoughts/urges or to neutralize them using an alternate defence mechanism (a compulsive act).

2. Compulsions are defined as: 

• Repeated thoughts or acts that the individual has an uncontrollable urge to act upon which can be due to the response to an obsessive thought or a preconceived set of rules.

• These actions are aimed at reducing the anxiety and stress produced by obsessive thoughts or due to the irrational notion that not acting upon the same would lead to an ill effect. However, the act in question is excessive and unrealistic in proportion to the situation.

B. The obsessions and compulsions have to take up more than an hour daily or cause significant distress in day-to day activities and hinder the normal living of the individual.

C. The symptoms are not explained by the consumption of any other prescribed or unprescribed substance use.

D.  No alternate explanation exists for the exhibited set of behaviors.

Specifications:

1. Insight: The individual realises that the beliefs are untrue (Good Insight) or unsure (Poor Insight).

2. Insight/delusional beliefs: Whether the patient thinks that his beliefs are completely realistic.

3. Tic-related: The individual has a current or past history of a tic disorder.

The Types

1. Cleaning and Contamination: This type can lead the individual to have an uncontrollable urge to clean and disinfect everything around them. “Germaphobes” fall into this category wherein they fear the idea of contracting an illness.

2. Symmetry and order:  Individuals diagnosed with symmetry type of OCD have intrusive thoughts or the urge to have items around them lined up in a particular manner. These individuals seem to exhibit a stereotyped manner of behaviour, showing extreme signs of distress when the “order” is misaligned.

3. Harmful thoughts: Individuals have intrusive thoughts of causing harm to others or themselves, thoughts that may be considered “deviant” to society, or perhaps, thoughts that incline them to question their sexual orientation. Such thoughts cause significant distress to the individual and can cause them to withdraw from society.

4. Hoarding: In this type, the person might have an intense fear of getting rid of their possessions, and hold onto all items they have owned in the past for fear of “ill effects”. Such individuals may also have an urge to continually keep buying multiple items of the same type, and do not want to throw their items away to avoid contamination. 

Although there are many more subtypes, experts are yet to come to a common consensus of the main types, thereby contributing to a lack of an official classification system.

Risk factors and vulnerable groups:

OCDs haven’t been attributed to a specific cause, however, there have been a number of linkages between the following factors and increased vulnerabilities to the disorder: 

1. Age: Most of the OCDs first manifest during adolescence and early adulthood.

2. Gender: OCDs are more common among females than males. The age at which women develop symptoms of the disease is also found to be earlier than men (middle age).

3. Employment and socio-economic status: Prevalence of the disease has been found to be higher among those who are currently unemployed and belong to lower socio-economic groups.

4. Educational Status: Interestingly, in numerous studies, a higher education level was found to have a positive correlation with the prevalence of OCDs. Those with high school diplomas were found to have a higher risk of developing the disorder than the illiterate.

5. Genetic and family history: Twin studies show that genetic makeup contributes to a significant amount of vulnerability to the disease. Those who have parents suffering from the disorder are also at high risk.

6. Birth Order: Though not definitive, firstborn and only borns are more vulnerable to develop OCDs in their lifetime. Psychologists have attributed this trend to parental influences, precocious ego development, and familial pressure.

7. Antenatal factors: Conditions of the pregnancy also influence the risk of development of the disorder. Maternal smoking, intrauterine infections, difficult labour are some of the factors which have been associated with OCD.

8. Substances: Higher incidence of OCDs are found among those who are cocaine users and amphetamine consumers. Stereotypic behaviours are more common among this sub-group.

9. Stress: Stressful life events have been correlated to acute attacks of the disease, recurrences, and precipitating latent symptoms.

10. Streptococcal Infections: Infliction with acute streptococcal illness has also been associated with a post-infection acute OCD-like disorder, which may manifest into a full-blown disorder.

11. Other Psychiatric comorbidities: There is a link between schizophrenia and schizophreniform disorders and OCDs which state that compulsive behaviors and obsessive thoughts are used as a defense mechanism by those afflicted with psychotic disorders. 

Similarly, those diagnosed with OCDs are more likely to also have other psychiatric

conditions like Major depressive Disorders, Anxiety Disorders, etc. 

Symptoms 

A. Obsession symptoms 

1. Inability to tolerate uncertainty 

2. The need to have things in a specific order 

3. Intrusive thoughts of harming oneself or others 

4. Deviant thoughts

5. Unwanted thoughts- sexual, religious or taboo in nature 

6. Fear of dirt, contamination (Germaphobia)

7. Urge to keep checking door locks, stove to ensure that they are in the right order or turned off 

B. Compulsive Symptoms 

1. Stereotypical action and a need to follow a strict “odd” routine 

2. Continual handwashing- to the point of injury 

3. Continuously sanitizing objects around you and wanting to clean 

4. Counting items 

5. Repetition of words, sentences, and phrases 

6. Arranging items in a certain way to make them symmetrical and orderly

C. Implications 

These thoughts and actions are associated with high levels of stress and anxiety. An inability or hindrance in carrying out the urges is associated with unbearable amounts of anxiety and can also precipitate panic attacks. Simply being a perfectionist doesn’t warrant a diagnosis – a person ailing from OCD has significant impairment of function. The symptoms handicap the individual to the point of inability to carry of day to day activities. They have a significant impact on the social life of the individual, with withdrawal being a very common occurrence among the OCD community.

Diagnosis 

After any alternate causes for behaviour have been eliminated, a psychological assessment must be carried out. Remember that the diagnosis is made only when the obsessions and compulsions take up more than 1 hour of the individual’s day. The symptoms should cause significant impairment to the individual functioning both psychologically and physiologically.

Treatment 

The treatment of OCD follows a multidisciplinary approach involving counsellors, psychologists, and psychiatrists. Emotional support for the patient has a significant impact on the outcome of treatment. 

1. Exposure and response prevention therapy (ERP) 

ERP is a type of Cognitive Behavioural therapy that has been proven to be of maximum benefit to those suffering from all grades of Obsessive-Compulsive disorder. This type of therapy follows the principle of “habituation” which involves repeated exposure to the anxiety and stress associated with not following up with the compulsions and obsessions. Over time, as the patient fights the urge to engage in incriminating behaviours, they also exhibit decreased levels of anxiety with the helped of a trained mental health professional. 

2. Medications 

Medications can only be prescribed by a psychiatrist or a medical graduate. These comprise antianxiety and antidepressant medications to control the distressing symptoms. They have also been associated with a decrease in compulsive and obsessive symptoms. Sometimes, in severe cases, antipsychotic medications can also be prescribed. 

3. Other treatment modalities 

ERP can be carried out in group and telecommunication settings as well. There is some evidence on the usefulness of Acceptance and Commitment therapy. As a last resort to severe OCD not affected by the other modalities, there are a number of physical resorts that a trained medical professional can try, such as Knife and in extremely rare cases, brain surgery. 

Prevention is better than cure…. 

Deep Brain Stimulation, Gamma Although there has been no set way to prevent the disorder, vulnerable groups can be screened, and proper facilities can be provided to get help at the first sign of distress. Parental and familial support and influence can also change the outcome drastically, with good parenting and warmth having a protective effect, not only against OCDs but also other psychiatric morbidities.