Melomed Articles

14 February 2019 - Dr. Surayah Zardad

Obsessive Compulsive Disorder, are these tics of the mind?

Obsessive Compulsive Disorder (OCD) is one of the more prevalent psychiatric disorders that often goes unrecognised and hence untreated. It can be extremely disabling and interfere significantly with the individual's ability to function effectively. It has been popularised in television series like Monk, so it tends to conjure images of cleanliness and excessive hand washing in the layperson's mind. But what it fails to capture, is the all too often debilitating distress that accompanies this condition. OCD is also much more than just excessive hand washing. And whilst we all from time to time have the urge to double-check that stove has been switched off, the doors have been locked and windows closed, it does not mean that we all suffer from OCD. What about the housewife who insists that the house remain in pristine condition and that everybody else conforms to her exacting standards of cleanliness? In other words, when do every day preoccupations become the disorder that we recognise as OCD?

In essence OCD has 2 components:
1. Obsessions and
2. Compulsions

Obsessions are intrusive thoughts, images or urges which increase anxiety.

Compulsions are repetitive and ritualistic behaviours (which can be exclusively mental), which may decrease anxiety to some extent.

The individual with OCD may recognize that the obsessive thoughts and compulsive behaviours are excessive and irrational, but may still not be able to resist them. The analogy of the stuck gramophone record is very apt, with the individual being stuck in some sort of mental loop, with the obsessions going over and over in their minds. The person is unable to break free from the thoughts or resist the compulsions. The thoughts or images intrude themselves into the individual's mind, even though he doesn't want them and they are highly anxiety-provoking. Usually compulsions are performed in an attempt to make the obsessions disappear. In fact OCD may be described as a form of magical thinking, where words, thoughts and rituals are believed to have the power to influence your external reality. In many instances the cause and effect between events is irrational and subject to an inner personalised logic e.g. if my shoes don't face the door, my grandmother will die.' Things need to be done in a very specific way to prevent a catastrophe from occurring.

Persons with OCD often experience both obsessions and compulsions, although one may occur without the other. It typically starts in childhood or adolescence, but it may have a later onset.  The illness tends to wax and wane, but a subset of patients can have a deteriorating and chronic course. It can also appear for the first time in the postpartum period. In the latter instance the mother may have images of infanticide i.e. throwing the baby down the stairs. She may also fear that the baby may die suddenly. This may lead her to avoid holding the baby, or she may need to check up on the baby many times at night to make sure he is still breathing.

The specific content of the obsessions and compulsions vary widely from person to person. However, there are certain recognizable themes or categories of symptoms. Some of the symptom categories may include:
1. Fears of contamination and resultant cleaning compulsions
2. Obsessions with symmetry and resultant counting, ordering, repeating compulsions
3. Forbidden or taboo thoughts such as aggressive, sexual and religious obsessions and related compulsions
4. Harm (e.g. thoughts or images of harm occurring to oneself or loved ones and avoidance or checking compulsions)

Some common Obsessions include the following:
  • Worry about contamination i.e. dirt or germs affecting self or others often via relatively benign methods i.e. touching a doorknob can cause you to contract HIV
  • Sexually explicit or taboo thoughts or images e.g. paedophilia or sexual assault
  • Blasphemous thoughts or images usually in a religious person
  • Worry about losing control or harming others
  • Worry that everything must be just right' i.e. order and symmetry
  • Worry about religious or moral correctness, to the extent that it interferes with everyday functioning
  • Worry about losing things or not having what you may need

  • Some common compulsions include the following:
  • Excessive double-checking of things such as doors, locks or appliances. This would not just be once or twice, but the individual may need to check things 20 to 100 times
  • Calling on loved ones to check that they are safe
  • Spending an inordinate amount of time cleaning or disinfecting the surroundings
  • Senseless rituals like counting or tapping to prevent a catastrophe from occurring
  • Arranging things till they feel right'
  • Hoarding junk items such as old newspapers or empty tin cans in case they might be needed at a later time

  • So how do we differentiate ordinary preoccupations from OCD? The frequency, amount of time consumed by the obsessions and compulsions i.e. more than an hour a day and the extent to which the symptoms cause distress or interfere with his life, are pointers that help make the distinction between OCD and occasional intrusive thoughts and repetitive behaviours common in the general population (e.g. double-checking that the refrigerator has been closed to prevent the cat accidentally being locked inside).

    Individuals with OCD vary in the degree of insight they have regarding the accuracy of their symptoms. Many individuals have good or fair insight i.e. he believes that he probably will not contract HIV or lead poisoning from touching the doorknob. But insight paradoxically is not sufficient to prevent the symptoms from occurring. Others have poor insight i.e. he believes that he will probably contract HIV from touching the doorknob even though rationally he knows that this is not the route of transmission of the virus. Less than 4% of OCD sufferers have absent insight. Here the person believes that he definitely will contract HIV from touching the doorknob. When insight is absent it is important to distinguish this from a psychotic disorder. This form of OCD is also referred to as delusional OCD.

    Given the bizarre nature of the symptoms, many patients think they must be morally defective for having these thoughts. The person experiences a great deal of shame in relation to the symptoms and thus avoids seeking help. Many people unnecessarily suffer in silence for many years, before consulting a health professional for treatment.

    It can be seen therefore that OCD is a cunning and wily opponent. Little wonder therefore, that it is often described as the dance with the devil. It has the uncanny ability to find an individual's weakness with unerring ease and attack him from that angle. That is why religious people often have blasphemous thoughts, gentle people will have violent imagery, a concerned mother will worry that she might harm her baby etc. And when the individual seems to overcome the first wave of OCD, it finds a way of reasserting itself, even in individuals with good insight and intelligence.



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