Obsessive-Compulsive Disorder

History

The patients present with a history of unwanted obsessions and compulsions. They are hard to overcome and often cause the patient a lot of distress.

Other psychiatric disorders such as mood swings, anxiety, phobia, and feeling of guilt, eating disorders, occupational disorders and social disorders may also be present. There may be a history of substance abuse.

Physical exam

The findings in obsessive-compulsive disorder may be non-specific and vary from patient to patient. In general, the patient should be examined to look for the presence of eczema due to excessive hand washing, hair loss due to hair pulling and excoriations due to pin pricking.

• Magnetic resonance imaging and Pet scan show increased blood flow to primitive brain with right side predominance.
• Yale-Brown Obsessive Compulsive Scale is used to mark the severity of the disease. 5 obsession and 5 compulsions are taken into the account. Then from a scale of 0 to 4, each obsession or compulsion is graded. The total score is 40. The score out 40 then indicates the severity of obsessive compulsive disorder in any particular patient.
• A complete psychiatric exam to look for the presence of delusions, hallucinations or any judgmental or suicidal thoughts should be performed.
• Any associated tic disorder should be looked for.

Behavioral psychotherapy training with a professional psychotherapist should be considered in all the patients of obsessive-compulsive disorder. In exposure and response prevention, a person is exposed to increasing amount of stimulus and in turn person needs to suppress his impulse. This is stressful but quiet effective. A patient can use a self-help book. Other techniques such as thought stopping, habit reversal and saturation are also useful. In thought stopping, the patient is required to distract himself with obsessive or compulsive thoughts appear. In habit reversal, the patient replaces his compulsions with some other non-compulsive responses. In saturation, the patient has to think his obsession long enough so that he may lose interest in it. A definitive medication and eating plan can lead to improvement in outcome. Relaxation techniques can also help the patient.

Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs) are used as the first line drug therapy [5] [6]. The dose is given for 6 to 10 weeks and then the responses are noted. Usually, it takes up to 12 weeks for a noticeable response to appear. Drugs take more time to respond in this disorder as compared to other psychiatric disorders where the response is very rapid. Sometimes antipsychotics are also combined [7].

With obsessive-compulsive disorder that is resistant to treatment, the use of aggressive psychotherapy and aggressive pharmacological therapy may be considered.

In a small number of cases, we can use surgical interventions. These include small brain lesion, deep brain stimulation or stereotactic placement [8] [9] [10].

• Obsessive compulsive disorder is a chronic condition.
• With proper medication there is reduction in symptoms in 70 % of the cases.
• 15% of the cases worsen and have reduction of brain function despite proper treatment.
• 5% have no symptoms except for acute periods of exacerbation.
• A small number of candidates improve dramatically with use of surgery.

The factors contributing to the development of obsessive-compulsive disorder include the following.

• Brain trauma
• Genetic influences [1] [2] [3]
• Stimulant abuse
• Streptococcal type A infection
• Herpes simplex infection
• Carbon monoxide poisoning

Stress can aggravate the factors but doesn’t intrinsically cause obsessive-compulsive disorder. Problems in parenting and bringing up of the child have no role in the development of obsessive compulsive disorder.

The lifetime prevalence of obsessive-compulsive disorder is generally in the range of 1.7 to 4% of the population [4]. It is more common in orthodox Jew and Catholics due to firm beliefs. The peak age of obsessive-compulsive disorder is 10 to 24 years.

It is seen equally in males and females but presents at different ages. Males develop obsessive compulsive disorder during childhood. It usually associated with a tic disorder. Females get obsessive-compulsive disorder in their twenties. During pregnancy and premenstrual period, symptoms of obsessive-compulsive disorder usually worsen.

Obsessions can be defined as unwanted ideas, thoughts, images or impulses. Common obsessions are related to fear of contamination, doubting his/her memory, the need to do the right thing, the fear of committing a sin, the need for symmetry in everyday life, unwanted thoughts and aggressive thinking about sex.

Compulsions are repetitive and seemingly purposeful actions. Common compulsions are vigorous cleaning of the hands, checking locks and children, repeating actions until person feels satisfied, arranging objects, tapping objects (such as any desk or chair), unnecessarily accumulating food and seeking reassurance.
These obsessions and compulsions are recognized by the patient as unreasonable and are sufficiently severe to cause marked distress.

Some evidence suggests that there are abnormalities in serotonin (5-HT) neurotransmission in the brain and this leads to impaired intracortical inhibition of specific orbitofrontal-subcortical circuits. This causes strong emotions and the autonomic responses to them. In some cases of obsessive-compulsive disorder, a mutation has been found in the human serotonin transporter gene (hSERT).

In childhood, obsessive-compulsive disorder can be related to PANDAS and PANS. Extensive studies are being conducted in order to find the role of glutamate dysregulation in obsessive-compulsive disorders.

There is not a proven way of preventing the development of obsessive-compulsive disorder. With early diagnosis and management, the effects of the disease can be limited.

Obsessive-compulsive disorder is a psychiatric disorder characterized by recurrent and persistent obsessions and compulsions.

Obsession is any unwanted idea, thought or image; whereas compulsion refers to repetitive and seemingly purposeful actions. It usually occurs insidiously during childhood, adolescence or early adulthood. Males are affected in the early childhood and females are affected in adulthood.

Due to disturbance in serotonin neurotransmitter there is impaired intracortical inhibition of specific orbitofrontal-subcortical regions of the brain. There is usually marked distress in these patients due to unwanted thoughts and repetitive actions.

The patients of obsessive-compulsive disorder usually present in the childhood or early adulthood. The patient experiences unwanted thoughts, images or impulses and/or the desire to do repetitive and seemingly purposeful movements.

The treatment consists of a specific type of behavioral psychotherapy. Sometimes, drugs that reduce depression may be given. In rare cases, surgery may be needed.

1. Arnold PD, Sicard T, Burroughs E, Richter MA, Kennedy JL. Glutamate transporter gene SLC1A1 associated with obsessive-compulsive disorder. Archives of general psychiatry. Jul 2006;63(7):769-776.
2. van Grootheest DS, Cath DC, Beekman AT, Boomsma DI. Twin studies on obsessive-compulsive disorder: a review. Twin research and human genetics : the official journal of the International Society for Twin Studies. Oct 2005;8(5):450-458.
3. Dickel DE, Veenstra-VanderWeele J, Cox NJ, et al. Association testing of the positional and functional candidate gene SLC1A1/EAAC1 in early-onset obsessive-compulsive disorder. Archives of general psychiatry. Jul 2006;63(7):778-785.
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7. Bloch MH, Landeros-Weisenberger A, Kelmendi B, Coric V, Bracken MB, Leckman JF. A systematic review: antipsychotic augmentation with treatment refractory obsessive-compulsive disorder. Molecular psychiatry. Jul 2006;11(7):622-632.
8. Dettling M, Anghelescu IG. Subthalamic nucleus stimulation in severe obsessive-compulsive disorder. The New England journal of medicine. Feb 26 2009;360(9):931; author reply 932.
9. Greenberg BD, Malone DA, Friehs GM, et al. Three-year outcomes in deep brain stimulation for highly resistant obsessive-compulsive disorder. Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology. Nov 2006;31(11):2384-2393.
10. Jung HH, Kim CH, Chang JH, Park YG, Chung SS, Chang JW. Bilateral anterior cingulotomy for refractory obsessive-compulsive disorder: Long-term follow-up results. Stereotactic and functional neurosurgery. 2006;84(4):184-189.

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