Obsessive Compulsive Disorder


by Dr. Milton Lum

There are some people who cannot stop thinking about, or doing, certain things, for example, washing hands. Whether these repetitive thoughts or behaviour are normal or otherwise depends on their effects on a person's relationships and social life.

Many normal individuals, particularly children, have occasional obsessional thoughts or repetitive behaviours, but they do not cause distress or impair daily functions. If they do, then it is no longer within the realms of normal mental functioning.

An obsession is an unwanted, unpleasant or frightening thought, image, or urge which occurs repeatedly and results in anxiety and distress. A compulsion is a repetitive, intentional behaviour or mental act that a person feels compelled to do to avoid or undo the effects of an obsession.

For example, a person who is obsessed about acquiring a disease may feel compelled to wash his hands on every occasion he touches any object.


Obsessive Thougts, Compulsive Behaviour

Obsessive compulsive disorder (OCD) is a chronic condition which is usually associated with obsessive thoughts and compulsive behaviour. OCD is diagnosed if it causes distress, occurs for more than an hour a day, and/or interferes with activities of daily living.

OCD is a common mental health condition. It usually occurs in young adults, but can occur in older people. However, it can occur at any age, including childhood. Males usually develop symptoms earlier than females.

Many cases of OCD are undiagnosed because the sufferers do not know that it is a treatable condition. Some of those who realise that OCD is an illness may be reluctant to seek help or cannot accept that they have a mental condition.


Causes

The causes of OCD are unknown, although several theories have been put forward.

There is evidence suggesting that OCD may be due to genetic factors. Although no specific gene has been found, there is evidence that OCD occurs in families, with a sufferer having 4 times the likelihood that another family member has OCD. OCD has been shown in studies to be associated with tics, which are rapid, repeated involuntary muscle contractions.

OCD sufferers have been shown to have abnormalities in the parts of the brain that deal with emotions, e.g. increased blood flow and activity in these areas of the brain.

These abnormalities return to normal following successful treatment.

Although the role of serotonin, a brain chemical that transmits information from one brain cell to another, in OCD is unknown, medicines that increase brain serotonin have been used successfully in its treatment.

There have been reports of OCD developing in children and young people following a streptococcal infection. This may be due to interaction between antibodies and a certain part of the brain.

Adverse life events like divorce or bereavement may trigger OCD in people who are predisposed to it. Stress worsens OCD, although it is not causative by itself.

Overprotective parents may increase the likelihood of developing OCD.


Clinical Features

Although OCD affects people differently, there are particular cycles of thought and behaviour. They usually consist of :

* Obsession, in which there is an overwhelming, constant concern or fear

* Anxiety that results from the obsession

* Compulsion, in which there is compulsive behaviour to decrease the anxiety and distress

* Compulsion brings relief, but this is temporary as the obsession recurs, causing the cycle to start all over again

The types of obsessions vary, but the common ones include fear of acquiring a disease, fear of causing harm to own self or others through a deliberate act, mistake, or accident, and a need for orderliness or symmetry.

The compulsions are varied, but the common ones include hand washing, cleaning, checking, counting, arranging, repetition of words or thoughts, and seeking reassurance.


Consult Doctor

There is nothing shameful about consulting a doctor. During the consultation, the doctor may use a questionnaire to determine if a person has OCD. The questions may include:

# Is there a lot of washing or cleaning?

# Is there a lot of checking things?

# Is there any troublesome thought that does not go away?

# Do daily activities take a long time to finish?

# Is there concern about putting things in a particular way order?

# Are these problems troubling?

If the initial screening suggests OCD, an assessment of its severity will be carried out. There are various methods which assess the impact of OCD on a patient's daily life. It is vital that there is openness and honesty when undergoing the assessment as it will ensure appropriate treatment.


There are three levels of severity of OCD :

* Mild functional impairment, which occurs less than 1 hour in a day

* Moderate functional impairment, which occurs 1 to 3 hours in a day

* Severe functional impairment, which occurs more than 3 hours in a day

The complications of OCD include depression and poor quality of life.

Management

The treatment modalities for OCD are behavioural therapy and/or medication.

Cognitive behavioural therapy (CBT) involves graded exposure and response prevention. This involves identification of situations that cause anxiety in order of severity. There is, then, an identification of tasks leading to the situation that cause anxiety to a level that a patient can cope with without carrying out the compulsion. This exercise is repeated a few times daily. With each exercise, the anxiety decreases and lasts for a shorter time.

Upon overcoming a step, the patient proceeds to a more difficult task exposure until all the situations leading to the anxiety has been overcome.

CBT is a proven and effective treatment for about 80% of patients with OCD.

Medications

The medications used in the management of OCD are selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs). They can take about 12 weeks before their effects are obvious. It is usual for the doctor to advise treatment for at least 12 months.

Sometimes, the doctor may carry out blood pressure measurements, electrocardiograms (ECG) and regular blood tests for patients on medications.

The SSRIs and TCAs can only be taken under a doctor's supervision. It is essential to keep the doctor's appointments to monitor progress and response to medication. It is advisable to consult the doctor if there are troublesome side effects of the medications and/or prior to cessation of medication.


Selective Serotonin Reuptake Inhibitors (SSRIs)

SSRIs increase the brain's levels of serotonin, a compound which is thought to improve a person's mood. They are as effective as the older TCAs, but have fewer side effects. The side effects of SSRIs, which include dry mouth, nausea, poor appetite, headaches, blurring of vision, sweating, feelings of agitation, inability to sleep, and decreased sex drive, ease off with time.

As there are reports of increased risk of self-harm and suicidal tendencies with SSRIs, it is important to let family member(s) or a close friend know and ask them to inform the doctor if they notice changes in the patient's behaviour. The doses of SSRI prescribed in OCD are usually higher than in depression as there is evidence that lower doses are ineffective.

There may be a temporary increase in anxiety at the commencement of SSRIs, but this will go away within a few days in most patients. If this does not occur, or worsens, consultation with a doctor is advisable.

An alternative SSRI may be prescribed if there is no improvement after about 3 months of the initial medication. The duration of treatment depends on a patient's response.

When a decision is made to cease taking SSRIs, the dose will be gradually reduced. Sudden cessation or the missing of a dose of SSRI may result in withdrawal symptoms like nausea, vomiting, headache, sweating, dizziness, numbness, tingling and sleep disturbances, which may be severe.


Tricyclic Antidepressants (TCAs)

TCAs increase the brain's levels of serotonin and noradrenaline. Their side effects include dry mouth, blurred vision, constipation, problems passing urine, blurring of vision, drowsiness and sweating, and these ease off after about 10 days.

TCAs are usually prescribed if SSRIs do not help because they have more side effects than the SSRIs.

OCD with mild functional impairment is usually treated with cognitive behavioural therapy (CBT). OCD with moderate functional impairment is usually treated with a more intensive CBT or SSRIs. The doctor may refer such cases to a specialist.

OCD with severe functional impairment is usually managed by a specialist with a combination of intensive CBT and SSRIs or TCAs. OCD in children is usually managed by a specialist who is experienced in treating them.


Surgery

Surgery has been used as a last resort in selected cases of OCD in some countries. The surgery involves using an electric current or a pulse of radiation to destroy (ablation) a small part of the limbic system which is involved in emotions, behaviour, and memory.

Although this procedure has not been subjected to clinical trials, the Royal College of Psychiatrists of the United Kingdom found improvement in more than 50% of patients. However, there was no improvement, or worsening, in about 15% of the patients. The risks include memory loss and confusion, which could be severe and irreversible.

OCD is a treatable condition. The majority of patients will be completely cured with treatment. The severity of OCD would be reduced in others, with a positive impact on their quality of life.



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