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When you attempt to eliminate risk from your life, you eliminate along with it, your ability to function.
When you attempt to eliminate risk from your life, you eliminate along with it, your ability to function.
- Fred Penzel
I once watched a man
attempt to cross Belgravia Road. He approached the traffic light, turned away.
He approached it again, and again he turned away. He repeated this process at
least six times. Eventually he reached out to touch the button that would
activate the pedestrian crossing light. Then he withdrew his hand, wiped it
vigorously on his shirt and attempted to do it again. Again he withdrew. The
next time he covered his figure with his shirt, but still he could not touch
the button. The car behind me hooted, and I was forced to pull off. I was not
convinced that this man would ever make it across the road. Such is the nature
of OCD – obsessive, compulsive and utterly debilitating.
OCD is a relatively
common disorder with a lifetime prevalence from 2-3%. OCD usually begins before
the age of 25. Some studies have reported onset as young as 9.6 in girls and 11
in boys (Swedo et al, 1989) while others report full diagnosis at 21 for boys
and 22 for girls. This would indicate the likelihood of a bimodal distribution
of age onset.
There is no racial or
ethnic differentiation although different ethnic or religious groups may
express different obsessions according to schema. OCD is equally common to both
sexes, although pregnancy has been known to precipitate the onset of symptoms.
29% of patients in a
study by Rasmussen and Eisen reported a precipitating event, but in the
majority of cases there is no clear indicator of what may have triggered the
onset of symptoms.
There is little concrete
knowledge as to the causes of OCD. Recently, however, children have been seen
to develop OCD as a result of an autoimmune response to group A beta-haemolytic
streptococcal infection, and investigations into this may bring about a deeper
understanding as to the causes of the disorder.
Signs and Symptoms
Those who suffer from
OCD have recurrent thoughts, ideas, images, impulses, fears or doubts. These
obsessions emerge from, apparently, nowhere and seem to increase with attempts
at resistance. On the compulsive side, sufferers feel compelled to touch,
count, check, arrange things symmetrically or wash their hands repeatedly.
In spite of
recognising or being made aware of the ridiculousness of their behaviour, and
even though their lives are paralysed, patients are unable to stop.
Often the themes for
the obsessions are violent or sexual in nature, which can add to the shame of
the disorder and the increasing fear of acting out, and so they may become
increasingly isolated.
Box 1:
DSM-IV Criteria for Obsessive Compulsive
Disorder
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A. Either obsessions
or compulsions:
Obsessions as defined by (1), (2), (3), and
(4):
1) recurrent and
persistent thoughts, impulses, or images that are experienced at some time
during the disturbance, as intrusive and inappropriate and that cause marked
anxiety or distress
2) the thoughts,
impulses, or images are not simply excessive worries about real-life problems
3) the person
attempts to ignore or suppress such thoughts, impulses, or images, or to
neutralize them with some other thought or action
4) the person
recognizes that the obsessional thoughts, impulses, or images are a product
of his or her own mind (not imposed from without as in thought insertion)
Compulsions as defined by (1) and (2):
1) repetitive behaviours
(e.g., hand washing, ordering, checking) or mental acts (e.g., praying,
counting, repeating words silently) that the person feels driven to perform
in response to an obsession, or according to rules that must be applied
rigidly
2) the behaviours or
mental acts are aimed at preventing or reducing distress or preventing some
dreaded event or situation; however, these behaviours or mental acts either
are not connected in a realistic way with what they are designed to
neutralize or prevent or are clearly excessive
B. At some point
during the course of the disorder, the person has recognized that the
obsessions or compulsions are excessive or unreasonable. Note: This does not
apply to children.
C. The obsessions or
compulsions cause marked distress, are time consuming (take more than 1 hour
a day), or significantly interfere with the person’s normal routine,
occupational (or academic) functioning, or usual social activities or
relationships.
D. If another Axis I
disorder is present, the content of the obsessions or compulsions is not
restricted to it (e.g., preoccupation with food in the presence of an Eating
Disorder; hair pulling in the presence of Trichotillomania; concern with
appearance in the presence of Body Dysmorphic Disorder; preoccupation with
drugs in the presence of a Substance Use Disorder; preoccupation with having
a serious illness in the presence of Hypochondriasis; preoccupation with
sexual urges or fantasies in the presence of a Paraphilia; or guilty
ruminations in the presence of Major Depressive Disorder).
E. The disturbance is not due to the
direct physiological effects of a substance (e.g., a drug of abuse, a
medication) or a general medical condition.
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Diagnosed OCD
sufferers who receive treatment may be as low as 7% (Nestadt et al.,1994). Most
sufferers delay seeking treatment long after onset, often due to stigma or
embarrassment and the perception that little can be done to improve the
symptoms. As with most psychiatric disorders there are both pharmacological and
psycho-social interventions.
Pharmacological Interventions
5-HT uptake inhibitors
have been shown to be effective in the treating of OCD. Examples of this are
the non-selective serotonin uptake inhibitor clomiprmine and the SSRIs
citalopram, fluoxetine, etc. 40-60% of patients will respond to these forms of
medication. In some cases, particularly in Europe, multiple SSRIs are being
prescribed and some success has been reported on the combination, but research
is as yet inconclusive.
With these treatments
it is very rare that all symptoms will completely disappear and benefits are
only noted after 6-8 weeks.
Those that do not
respond to these first-line drugs may respond to certain anti-psychotics.
In the case of
severely anxious patients a benzodiazepine may be prescribed.
Psycho-social Interventions
The only evidence
based psychotherapy proven to work with OCD is Exposure and Response Prevention
Therapy. Most literature is limited to cleaning or checking rituals. Only about
50% will benefit from therapy in the absence of medical intervention. 25% of
those that respond to therapy will show no lasting benefit.
Although there are a
number of negative reports about psychotherapy in OCD, these are
misconceptions. There are, however, some contra-indications that predict a poor
response: severe depression, hypomania or mania and schizotypal personality
disorder.
Conclusion
In the words of Jimmy
Carr: “There is a thin line between Obsessive and Compulsive; it’s called a
hyphen.” This disorder may often seem amusing to outside observers in its
absurdity, but to the sufferer it is more debilitating than physical pain.
Although there has been a better prognosis for sufferers since the 1980s, the
disorder is still poorly understood. New research into associated disorders
such as addiction and other compulsive disorders may unlock the areas of the
brain responsible for OCD, bringing about an effective and reliable cure that
will allow sufferers to do what they’ve always wanted - simply get on with
their lives.
Bibliography
Brown University. (2012). OCD.
Retrieved from Brown University Courses:
http://www.brown.edu/Courses/BI_278/Other/Clerkship/Didactics/Readings/ocd.pdf
Greenberg, W., & et al. (2011). Obsessive-Compulsive
Disorder. Medscape.
Mayo
Clinic. (2012). OCD. Retrieved from Mayoclinic.com: http://www.mayoclinic.com/health/obsessive-compulsive-disorder/DS00189/DSECTION=treatments-and-drugs
Sasson, Y., Zohar, J., Chopra, M., & et al. (1997). Epidemiology of
obsessive-compulsive disorder: a world view. Journal of Clinical
Psychiatry , 12: 7-10.
Stanford
University. (2012). OCD. Retrieved from Stanford School of Medicine:
http://ocd.stanford.edu/about/