Obsessive Compulsive Disorder (OCD)
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OCD is a relatively rare disorder. Whilst minor obsessional symptoms may occur in around 14% of a general population sample ,OCD itself has a point prevalence of only 0.05% (6 month prevalence 1.3-2%; lifetime prevalence 1.9-3.3%). It is distributed equally between both sexes and may only present late on after many years of active symptoms.
Symptoms.
Obsessional
thoughts:
- These come repeatedly into the subjects mind against their will.
- They are unpleasant and often abhorrent.
- They are recognised as being the subjects own.
- They may be resisted (usually early, in around 50% at the time of presentation). This causes an increase in anxiety.
- Examples: contamination, doubting, images...
Compulsive
acts (a.k.a. obsessional acts):
- Repetitive actions based on obsessional thoughts.
- Not directly pleasurable (different from relieving the distress of the thoughts).
- Temporary relief of the tension and anxiety caused by the provoking thought.
- May have a symbolic quality (c.f. Lady Macbeth).
- Examples: checking, cleaning...
Aetiology.
- This has the strongest evidence for a biological aetiology for any of the anxiety disorders. There is a strong link with Gilles de la Tourette syndrome and thus basal ganglia pathology.
- 33% of those with OCD do not have premorbid obsessional (anankastic) personality traits, indeed those with these traits are more likely to develop depression.
- There are a number of theories predicated on the role of learning and development. The former considers the role of negative reinforcement and the reduction of anxiety caused by the obsessional rituals. The latter psychoanalytic theory emphasises the role of repression of unacceptable impulses and regression to the anal stage of development, with thought patterns dominated by magical thinking.
Treatment:
Psychological.
- Obsessional thoughts can be challenged using a technique known as thought stopping, where a distraction is used to interrupt the thought.
- Compulsive acts are treated by graduated exposure to the environmental stimulus, either in vivo or using imagery, whilst the patient resists the rituals. This is known as response prevention.
- Anxiety management is useful as can be cognitive behavioural therapy with strategies being taught to help people cope with the anxiety evoked, and the support of therapist and/or relatives is often crucial.
Physical.
- Clomipramine, SSRIs, lithium and tryptophan all are used in the pharmacological management of OCD. This is the most effective management technique in the short term but its efficacy and duration of action is increased when used in conjunction with behavioural or cognitive behavioural techniques.
- ECT has been used in cases where the disorder is severe, unresponsive to medication and/or there is significant depressive symptomatology.
- In the most severely disabled patients neurosurgery may be considered.
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