Obsessive Compulsive Disorder

A brief overview of Obsessive Compulsive Disorder for addictions counsellors

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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.

Epidemiology
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

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.


Treatment
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/

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