Obsessive Compulsive Disorder

Definition

Obsessive-compulsive disorder (OCD) – codding according to DSM 5: 300.3/ICD 10: F42 – is a psychiatric disorder where patients feel the urge to perform repetitive actions or rituals and/or repeating thoughts. In the course of the illness the actions could evolve to sometimes very complex rituals. In case the patient resists t performing such actions he develops a severe anxiety. In some patients the OCD creates only compulsive thoughts which the patient is not able to resist. The most disturbing aspect of the compulsions is that the person affected is not able to stop them despite the knowledge that the compulsions are irrational. The patient feels that the compulsion is overwhelming him and doesn’t depend on his will. The OCD rituals/intrusive thoughts usually run in cycles frequently taking a big part of the day interfering with normal life activities. The untreated obsessive-compulsive disorder tends to increase in severity trapping the patients in a vicious cycle of reciprocal rituals and intrusive thoughts which can lead to full invalidism. In contrary to patients affected by schizophrenia who are usually not able to recognize that their behavior/thinking is irrational, patients with OCD are fully aware of the fact that their thoughts/actions don’t make any sense and that they are – so to say- over imposed on them.

OCD

Diagnosis

Using a careful clinical interview and taking in consideration the above listed diagnostic criteria the diagnosis may be performed by a psychiatrist or psychologist with good clinical experience. OCD can resemble few other psychiatric conditions with impulse control.

The compulsions can be developed also by healthy individual such as ordering or collecting items, highly organized, restrictive daily routine and compulsive thoughts. The compulsions become clinically relevant if the person feels urged to perform them as an effect of an obsession, or the compulsions appear with a particular rigidity affecting significantly patient’s life. The compulsions can be qualified as a psychiatric disorder (OCD) if the person has to perform these actions to avoid severe distress. Other important criterion is that the compulsions are time-consuming (according to DSM 5 taking up more than one hour per day) and/or cause impairment patient’s social and professional functioning.

Differential diagnosis

Obsessive compulsive disorder is often confused with other impulse control disorders such as Obsessive Compulsive Personality Disorder (OCPD), Trichotillomania and some phobias.

In compare to Obsessive Compulsive Personality Disorder (OCPD), OCD is ego-dystonic which means that the compulsions are incompatible with patient’s ego consciousness (self-concept of patient’s personality) while in Obsessive Compulsive Personality Disorder they are ego-syntonic which means that the content of the compulsions goes along with patient’s self-concept. Patients suffering of Obsessive Compulsive Personality Disorder are not able to recognize that there is something abnormal on their behavior.

Other disorder with symptoms resembling OCD is Trichotillomania. Trichotillomania (TTM) is also known under the description: Hair pulling disorder (TTM). The patients with TTM experience a long term urge of pulling out their hair and they are not able to resist the impulse.

Some phobias are also accompanied by impulse control and/or other body focused repetitive behaviors. One of such phobias is Body Dimorphic Disorder (Dysmorphophobia). Patients with Body Dysmorphic Disorder (BDD) are preoccupied with an imagined defect of their physical appearance. The patients can spend hours checking and rechecking their appearance in the mirror. They undergo frequently surgery trying to reach the perfect appearance of their face or body. They tend to repeat the surgery while still being unhappy with the effect. The series of surgery often end with a devastating effect with full body deformation.

Symptoms

Obsessive-compulsive disorder can appear as variety of symptoms such as washing compulsions, checking countless times things (e.g., locks on doors), performing rituals, arranging objects in certain way, repeating words and phrases or experiencing reciprocal thoughts often with disturbing content. Other symptoms are counting in certain way or performing some actions/rituals before being able to move to the normal life routine.

The obsessive-compulsive disorder symptoms are related to such themes as symmetry, cleanliness, collecting and grouping objects as well as forbidden thought contents. The symptoms related to symmetry correlate with obsessional ordering, counting, grouping objects in certain – perfect and highly symmetric – way. The thought contents related to taboo subjects include intrusive and distressing thoughts of violent, sexual or blaspheme content. The symptoms grouped around cleanliness correlate with obsessions related to washing hands or excessive bathing up to dozen times per day, cleaning objects and fears of contamination. The hoarding compulsion and obsessions appears as obsessive collection of items with often not value.

Patients with OCD perform tasks, rituals or follow the intrusive thoughts to escape the unbearable anxiety in case they would try to stop the compulsion.

Some patients with obsessive-compulsive disorder could experience sexual obsessions with intrusive thoughts or images related to sexuality. Those obsessive thoughts can question patient’s sexual orientation or create highly disturbing images of sexual relationship with parents, children, family members or friends. Such sexual compulsions will be never put in action and are unrelated to patient’s sexual orientation or preferences. The patients could be extremely scared doubting themselves regarding whether they might act upon their woozy ideas.

Causes

The causes of the obsessive-compulsive disorder are multifactorial. Genetic, biological and environmental factors play a role.

The genetic factors: Twin studies showed that the appearance of OCD happens more often by identical twins compared to non-identical twins. There is further evidence supporting the influence of genetics on OCD prevalence: individuals who suffer of OCD have more frequently first-degree family members affected by the same disorder. About 25% of OCD patients have an immediate family member with the same disorder. The OCD symptoms can be passed on from parents to children. It means that the biological vulnerability to OCD can be inherited.

The neurobiological factors such as the brain structure and – on a deeper level – the neurotransmitters, are interlinked with genetics. Using neuroimaging technologies allows brain mapping including the detection of functions in certain brain areas. The neuroimaging studies have shown that particular areas in the brain function differently in people with OCD compared to control group without OCD. This research suggests that OCD symptoms are related to communication errors among different parts of the brain in particular the frontal part of the brain such as the orbitofrontal and the anterior cingulate cortex. OCD could be caused by errors in the brain pathways which link areas responsible for judgment and planning with those involved in the autonomous reactions linked to the brain structure called amygdala. OCD sufferers show also abnormalities in neurotransmitter systems especially the serotonergic, dopaminergic and glutamate system.

Environmental factors: There are environmental stressors which can trigger the onset of OCD. These stressors include: major, stressful changes in living situation, illnesses, death of a loved one, professional or school-related problems or relationship concerns.

Prevalence

OCD is the fourth most common psychiatric disorder after depression, substance abuse (alcohol and drugs abuse) and anxiety disorders. The life prevalence of OCD (the probability of developing OCD during the entire life) varies in different countries and societies between 1 and 2 %. Half of people develop OCD before twenty. There is no gender difference in people affected by this disorder. OCD frequently co-occurs with other psychiatric disorders such as bipolar and major depressive disorder, anxiety disorder (social phobia, generalized anxiety and panic disorder) as well as ADHD.

Treatment

The treatment of Obsessive Compulsive Disorder – especially such with very severe life affecting symptoms- can be long and difficult. The evidence based studies show that the best treatment results can be achieved by using psychiatric medication in combination with psychotherapy.

Medication

Historically the first effective medication used in the treatment of OCD was a tricyclic antidepressant called clomipramine. Nowadays the first line medications are the antidepressants belonging to the group of selective serotonin reuptake inhibitors (SSRIs). Recent research showed also a good efficacy of some antidepressants from the group of selective serotonin- norepinephrine reuptake inhibitors (SNRIs). There is also evidence that atypical antipsychotics can be helpful. In severe cases in order to suppress the OCD symptoms a combination of an antidepressant, antipsychotic and/or mood stabilizer could be necessary.

Psychotherapy

The main therapeutic technique used in treatment of OCD is a variation of the Cognitive Behavioral Therapy (CBT) called Exposure and Response Prevention (ERP) which gradually expose the patients to situation triggering the compulsions trying to block the usual compulsive act associated with the obsession. In the course of treatment the level of exposer is increasing and the patient has to learn how to suppress the compulsion and tolerate the discomfort and anxiety caused by not following the compulsion (“response prevention”). ERP has a strong evidence base, and it is considered the most effective treatment for OCD.

In the past the psychoanalytical/psychodynamic psychotherapy has been used with good effect but there is little evidence based data related to this psychotherapeutic technic.

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Perinatal complications associated with increased risk for OCD
(Source: Brander G, et al. JAMA Psychiatry, 05.10.2016)
Recent findings showed smoking 10 or more cigarettes per day during pregnancy, breech presentation, delivery by cesarean section, preterm birth and other perinatal factors were associated with increased risk for obsessive-compulsive disorder.

According to Gustaf Brander, MSc, of Karolinska Institutet, Stockholm, and colleagues, complications in the perinatal period, including delivery by cesarean section, delivery using vacuum extraction, preterm birth, and low birth weight, have been associated with a range of psychiatric disorders, such as schizophrenia, bipolar disorder, autism spectrum disorder, and attention deficit/ hyperactivity disorder.

To assess potential perinatal risk factors for OCD, researchers conducted a population-based birth cohort study of 2,421,284 children born in Sweden between 1973 and 1996. Study participants were followed through 2013. Overall, 17,305 participants were diagnosed with OCD. Mean age at first diagnosis was 23.4 years. Increased risk for OCD was associated with smoking 10 or more cigarettes per day during pregnancy, breech presentation, delivery by cesarean section, preterm birth, birth weight between 1,501 g to 2,500 g and 2,501 g to 3,500 g, being large for gestational age and Apgar distress scores at 5 minutes. These remained when controlling for shared familial confounders and measure covariates, including sex, birth year, maternal and paternal age at birth and parity.

Children with a shorter gestational age and lower birth weight had an increasingly higher risk for OCD.

Researchers found a dose-response association between the number of perinatal events and increased risk for OCD, with hazard ratios ranging from 1.11 (95% CI, 1.07-1.15) for one event to 1.51 (95% CI, 1.18-1.94) for five or more events.

According to Thomas V. Fernandez, MD, and James F. Leckman, MD, PhD, of Yale University School of Medicine, New Haven, Connecticut, the findings presented in this issue of JAMA Psychiatry are certainly intriguing and have great public health significance. In addition, they bring us one step further in our understanding of OCD risk and underlying biological mechanisms and are likely to influence the design of future genetic, epigenetic, and environmental investigations. The findings of the study will continue to increase our understanding of the etiology of OCD and inform novel interventions to alleviate and potentially prevent the debilitating effects of OCD.