Over and over
Though a relatively minor psychiatric illness, the suffering that Obsessive Compulsive Disorder causes is immense. The patient's ability to work, study or enjoy leisure is impaired. DR. S. MOHAN RAJ examines its cause and treatment.
DEVAKI has been having constant blasphemous thoughts for a year. They increased whenever she went to the temple or saw a religious symbol. Though they were not intentional, she felt very guilty. She prayed to be forgiven but no matter how much she tried, she couldn't control the thoughts. They interfered with her routine activities.
Jawahar has repetitive doubts whether he has locked the door properly. He tries to resist it but ultimately yields and goes back to check the lock again. He repeats it few times.
Obsessive Compulsive Disorder (OCD) gets its name from two of its main symptoms Obsession and Compulsion.
Obsession is a thought with the following characteristics.
Repetitive: The thought keeps coming again and again. Its frequency varies with severity of the illness. For some, the thoughts are almost continuous.
Intrusive: No matter what the person does, the thoughts intrude into his mind. The thoughts intrude irrespective of whether the person is reading, writing, watching TV, praying, etc.
The thought is considered "silly".
The person tries to control or suppress the thoughts, but without success.
The thoughts interfere with his work, studies and leisure.
As a response to the thoughts, he may become anxious or depressed.
Obsessions are different from worrying. In the latter case too, the person has repetitive thoughts but considers them as relevant to the issue at hand. An obsessive thought is considered irrelevant and absurd.
Obsessive thoughts can come with any theme. It could be a particular word, a phrase or a thought sequence. The commonest obsessive themes are religion, sex, blasphemy, aggression or contamination.
Obsessions are not limited to thoughts alone. It also includes images and impulses. Tilak has an obsessive impulse to touch everything that is blue. He knows that it is absurd and has great difficulty controlling it. At times, he yields and gets into embarrassing situations.
Compulsion is a repetitive behaviour, which is invariably in response to an obsessive thought or impulse. There are two types of compulsions. The commonest is "yielding" compulsion where a person yields to his obsessive thought. Divya always feels that her hands are dirty and, in response, she washes again and again. Each wash relieves her anxiety for a short while. But slowly, the obsessive thought builds her anxiety and she has to wash again. The commonest compulsions are washing, checking and counting rituals.
David has a blasphemous thought and he tries to control it by a praying gesture. He brings his right hand to the forehand and the chest. This gesture is repeated in an effort to control the thought. This is called a "controlling" compulsion.
Some have elaborate compulsive rituals. Sandeep takes bath in the same pattern everyday. He has to start with washing his bucket and a mug a specific number of times. After pouring water, he starts applying soap, starting from left little finger and works his way in an orderly sequence. Any change in the sequence or a doubt about it will make him start again. His bath thus requires 60 to 90 minutes.
OCD occurs in two to three per cent of the population. It affects all age groups. Both sexes are equally affected. Though a relatively minor psychiatric illness, the suffering it causes is immense. The patient's ability to work, study or enjoy leisure is impaired.
Compulsions are obvious to an observer and can cause considerable shame and embarrassment. Not all obsessions are followed by compulsions. Others would know of the obsession only if the person chooses to tell them. Most of the time, he doesn't tell others, as he fears ridicule. At times when he confides in family members, they try to downplay it by saying, "Don't imagine things. There is nothing wrong with you".
Some people have obsessive-compulsive personality traits. Traits are enduring patterns of perception, thinking and relating to the environment and self. The traits are not suggestive of illness. Orderliness, neatness, punctuality and rigidity are some of the obsessive traits. Everything is kept in a particular place in a specific order. Routines are followed diligently and there is immense attention to detail. These are beneficial to those who have them but can become a liability when stretched too far. Perfectionism, if pursued to the extreme, would hinder the completion of the task before the deadline. This leads to anxiety as the person is also used to being punctual. Being too meticulous with minute details can, at times, draw away attention from the larger picture. Inflexibility adds to the liability.
Obsessive traits and OCD are not directly related. Though some persons with obsessive traits develop OCD, not all of them do so. Similarly, a large number of persons with OCD do not have past history of OC traits.
Why does OCD occur? Current understanding has it that OCD is due to lesser turnover of a neurotransmitter called Serotonin in specific brain pathways. A class of medication called "Specific Serotonin Reuptake Inhibitors" (SSRIs) helps in increasing the turnover of serotonin and this coincides with clinical improvement. Some experimental chemicals, like "m-CPP" which reduces serotonin turnover, worsen the obsessive-compulsive symptoms.
Localisation in the brain is not conclusive. Some researchers postulate that OCD involves a brain circuit, which runs through the frontal lobe and certain basal brain structures. Recent studies show that a small subgroup of children develops obsessive symptoms following rheumatic fever, which is caused by a bacterium called B-haemolytic streptococci. The other well-known consequences of rheumatic fever are cardiac valve lesions and a movement disorder called chorea. It is important for paediatricians to look for obsessive-compulsive symptoms in children who have had rheumatic fever.
Treatment: Advent of SSRIs in the 1980s had a significant impact on the treatment of OCD. Medication along with specific behaviour therapy is effective in controlling the symptoms. Lack of awareness remains an obstacle that delays treatment. Devaki says, "I have been having this problem for a while. I have confided in others but nobody told me that it was an illness".
Names have been changed.
The writer is a consultant psychiatrist based in Chennai. E-mail: email@example.com
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