Obsessive Compulsive Disorder is an example of an anxiety based disorder linked to repetitive obsessive and compulsive behaviors. The biological basis of the disease is illustrated with high hyperactivity in some parts of the brain, reduction in repetitive behavior after intake of serotonin inhibitors and the presence of OCD in monozygotic twins. The disease commonly manifests itself during the childhood phase compared to adulthood. Nonetheless, it is difficult to distinguish OCD within common childhood developmental phases and as a result, the management of the disease during the childhood phases is normally neglected. Other environmental factors which limit the treatment of the disease include spiritual beliefs and feelings of embarrassment within cultural setups. Also, OCD shares common signs with other diseases including tic disorders, autism spectrum disorders and psychosis further making the diagnosis of the disease difficult. Nonetheless, differential diagnosis can be used to uniquely identify OCD before the application of various treatment measures such as cognitive behavioral therapy and pharmacological measures like the use of selective serotonin reuptake inhibitors. Overall, the combined use of cognitive behavioral therapy and pharmacological methods is considered as the most effective method in the management of OCD.
Obsessive Compulsory Disorder
Introduction
Obsessive Compulsive Disorder (OCD) is a type of anxiety disorder characterized by an individual’s uncontrollable obsessions (reoccurring thoughts) and compulsions that generate an urge to repeat the same behavior over and over again (Browne, Gair, Scharf, " Grice, 2014). Obsessions are defined as a repetitive image or thoughts which are experienced as being unwanted and intrusive (Boileau, 2011). Obsessions are marked with increased incidences of distress and anxiety. On the other hand, compulsions or rituals are considered as repetitive mental or behavioral acts that an individual with OCD perform in a bid to reduce the amount of anxiety felt (Browne et al., 2014). OCD patients tend to hide the aforementioned symptoms due to shame and, as a result, the amount of time taken to identify the associated symptoms as well as applying the required type of treatment is often years. The common pathogenic features of the condition include senseless thoughts, persistence, and intrusive impulses that are repetitive (Eisen et al., 2013). Patients diagnosed with OCD admit that their behaviors and thoughts are unreasonable and excessive and in turn such patients struggle to resist such thoughts. The lifetime prevalence of the condition currently ranges from 1-3% although it differs per country. Nonetheless, OCD remains a common disease amongst all ages, with the childhood showing the greatest risk to the disease compared to the adulthood (Ruscio, Stein, Chiu, " Kessler, 2010). Patients may experience episodic or chronic symptoms which may gradually impair occupational, social and academic functioning (Jaisoorya et al., 2017). It is due to the above reasons that the World Health Organization considers OCD among top ten most disabling conditions across the globe (Rintala et al., 2017). Moreover, OCD stresses and places an inconsiderable burden on family members due to vast amount of resources required in the treatment process. Management of OCD is further complicated by a lack of a cure with behavioral therapies and medication being used only to partially control most symptoms.
Biological Basis for OCD
There is a compelling evidence pointing towards OCD as a biological disease. First, compulsions and obsessions are common among many other medical conditions including Parkinson’s disease, Schizophrenia, certain epilepsies, encephalitis lethargica, Huntington’s chorea, Sydenham’s chorea, Tourette disorder and insults which occur to the brain regions during incidences of ischemia, trauma and tumors (Browne et al., 2014). Secondly, the occurrence of OCD in individuals is associated with hyperactivity in certain parts of the brain including the thalamus, striatum, anterior cingulate, and orbitofrontal cortex as revealed by various functional imaging studies which indicated the increase in metabolic activity in the aforementioned regions (Fornaro et al., 2009). Various genetic factors are involved in the development of OCD. Browne et al., (2014) studies of monozygotic twins indicate that monozygotic twins are more likely to exhibit OCD symptoms compared to dizygotic twins. Furthermore, first-degree relatives, especially family members, are also implicated in being at greater risk of having OCD. As a result, it has been argued that OCD occurs through an autosomal dominant mode of transmission. An association has also been found a correlation between the development of OCD and pregnancy with 39% of 59 female OCD patients describing symptoms associated with the onset of OC during pregnancy (Boileau, 2011; Browne et al., 2014). Common symptoms described include head trauma and striatal lesions. Fourthly, a decrease in metabolic activity in the brain hyperactive circuit also occurs after the selective administration of serotonin reuptake inhibitors or during cognitive behavioral therapy (Patel et al., 2014). For example, clomipramine, a serotonin reuptake inhibitor and sertraline, fluvoxamine, and fluoxetine-selective serotonin reuptake inhibitors have shown efficacy in controlling compulsions and obsessions. Some patients have also shown to develop OCD symptoms on being diagnosed with beta-hemolytic streptococcal infection (Pittenger, Kelmendi, Bloch, Krystal, " Coric, 2005). The existing presumption is that antibodies produced within the body cross-react with ganglia proteins resulting in the exacerbated symptoms associated with OCD.
History of Obsessive Compulsory Disorder
Compulsive actions and obsessive thoughts are part and parcel of life. It is more common for an individual to check if the door is locked after switching off the light. These events are considered the essence of the normal feedback loop which controls the thoughts and actions of an individual. It is only when such obsessive thoughts become intense or frequent or in some cases compulsive that they affect the individual functioning of a person. Some descriptions of compulsions and obsessions can be found in past historical documents documenting that OCD has been in existence for centuries. A 15th
century compendium document described OCD as a form of witchcraft and psychopathology. In the past, it was believed that individuals with obsessive thoughts were partially possessed by the evil. With time, explanations for compulsions and obsessions changed to a medical view from a religious view. Compulsions and preoccupations were described for the first time medically by psychiatric literature in 1838 by Esquirol and by the beginning of the 20th
century they were regarded as a manifestation of depression or melancholy (Foa, 2010). The Freud’s publication in 1909 examining obsessional neurosis and the successful treatment of some compulsive traits was among the first advancements that elucidated OCD in the medical world (Foa, 2010). Freud’s analysis indicated that obsessions occurred due to the conflict between unconscious thoughts and other emotional components. The shift succeeded in pointing out some motivating factors associated with OCD.
The rise of behavioral therapy in the 1950 and other learning theories was essential to conceptualize the treatment of OCD symptoms. Nonetheless, such theories were insufficient in accounting for all cases of OCD. During the 1980s, the research was primarily focused on the connection between neurological issues such as epilepsy and OCD (Fornaro et al., 2009). 1980’s findings also indicated that Tourette syndrome and memory disorders were closely linked to OCD. The 1994 DSM-IV created a divide between anxious-avoidant/phobic dimensions and some obsessive variables which had been previously categorized under DSM-III. The current DSM-IV characterized OCD with repetitive images, thoughts and impulses that keep on disturbing a patient. Today, most psychiatrists agree that OCD includes specific manifestations of phobic and anxiety symptoms. Nonetheless, a greater number of psychologists indicate the need to provide a clear definition of obsessive and anxiety symptoms and as anticipated under DSM-V (Ruscio et al., 2010). Anxiety phobia significantly differs from OCD, although both disorders are characterized be fear and excessive avoidance behaviors (Ruscio et al., 2010). Nonetheless, phobics tend to be more upset of coming into contact with anything that instills past fears while OCD patients are worried about rituals.
Incidence and Prevalence of Obsessive Compulsory Disorder Internationally and in the US.
The incidence and prevalence rates of OCD differ per country with some countries displaying significantly higher rates than others. Within the US, the prevalence of OCD is estimated to be between 2.3% among adults and 1-2.3% among children and the adolescent population (Jaisoorya et al., 2017). The prevalence rate also takes into consideration the fairly substantial number of subclinical cases of OCD which approximately make up about 5% of all cases. The subclinical cases are composed of individuals whose symptoms have not yet been discovered or classified as OCD under the current existing systems of classification of the disease.
There is a strong evidence showing the role of culture in determining the presence of OCD across different countries, according to which the differences occur at varying magnitudes in different parts of the world and more so in Asian and European populations (Pittenger et al., 2005). Some cultural differences are directly implicated in some of the commonly observed symptoms. For example, within the Bali community, a heavy emphasis on some of the body conditions has been placed on social networks. In other religious upbringings, the presence of OC symptoms in individuals is associated with some form of religious beliefs, for instance, the link between obsessions and cleanliness is stressed in Judaism.
OCD as a disease condition is equally present in males and females during the childhood, adolescence and adulthood. Nonetheless, the disease is more manifested during the childhood and, as a result, more management of the disease is placed towards dealing with the symptoms during this phase. Specific symptoms are commonly used to identify the difference between OCD in men and women with men often being linked to tic disorders. In women, body dysmorphic disorders, high anxiety levels, PTS, skin picking and nail biting constitute some of the major-observed symptoms (Jaisoorya et al., 2017). Despite all this, presentation of OCD symptoms among children and adults is considered to be relatively the same. Unlike many children, adults are able to recognize obsessive and compulsive disorders faster compared to children who may struggle explaining some actions. For example, children may not understand the difference between the normal washing of hands which takes approximately two to three minutes and the extreme washing of hands which is estimated to take approximately 15-20 minutes.
Differential Diagnosis
Differential diagnosis is essential in differentiating OCD from a host of other disease conditions. Differential diagnosis is also critical in early detection and management of the disease. Like many psychiatry disorders, OCD bears a close resemblance to some other mental health conditions including autism spectrum disorders, tic disorders and psychosis. Differential diagnosis identified the set characteristics of the aforementioned diseases and their unique differences with OCD (Lack, 2012). Stereotyped behaviors and restricted interests tend to be some of the common features associated with autism spectrum disorders. These behaviors tend to be repetitive in nature and as a result tend to be in conflict with common OCD symptoms. Stereotyped behaviors tend to manifest themselves in a manner similar to compulsions, especially in arranging and ordering of toys among children (Lack, 2012). A unique difference between autism-related spectrum of stereotyped behaviors and OCD is the preceding obsession, relief in anxiety and an unwanted behavior deemed as not being pleasurable by an individual. Nonetheless, young individuals may exhibit both symptoms of OCD and autism spectrum disorders with the prevalence slightly being elevated among individuals with ASD.
Tic disorders are also commonly confused with OCD. Up to 59% of cases of OCD among children and adolescents meet the criteria set forth in tic disorders. Individuals with the comorbid form of the disorder display an earlier onset of OCD characterized by a unique different profile compared to children without tic disorder (Patel et al., 2014). Comorbid tic disorders are essentially difficult to discriminate from compulsions due to the close similarity with some autism-related stereotyped behaviors resembling compulsions such as tapping and touching. However, tics are considered to be mainly involuntary while compulsive actions are done deliberately to reduce anxiety levels. The frequency in complexity of the two behaviors may also be essential in differentiating compulsions from tics. Complex tics tend to be relatively straightforward such as the brief tapping action while compulsions tend to be intricate and performed based on specific rules such as tapping three times with the right hand followed by tapping four times with the other hand (Fornaro et al., 2009). Differentiating OCD from tic disorders is essential in the effective treatment of OCD in children.
Psychosis is also indicated to show a close similarity to OCD. The bizarre nature of an individual being controlled by obsessive thoughts tends to raise enquiries of psychotic occurrences, particularly in instances involving limitations in insights associated with irrationality of obsessions. For instance, more young people with OCD show transformational obsessions, which denotes fear of showing unwanted characteristics (Pittenger et al., 2005). Such unusual symptoms tend to be often confused with delusion resulting in wrong and inappropriate treatments. Similarly, individuals showing aggressive symptoms tend to be confused with paranoids. Individuals exhibiting signs of OCD have insights into the rationality of their behavior and as a result their obsessional thought is unlikely to represent broader delusional beliefs. Furthermore, individuals exhibiting OCD symptoms rarely show some common symptoms associated with psychosis such as thought disorders and hallucinations.
Diagnostic Criteria
OCD diagnosis among young people is generally different compared to adults based on the International Classification of Diseases (ICD) diagnostic criteria. Some of the common symptoms in children show that compulsions and obsessions tend to be present on a daily basis for a duration of two weeks. The obsessions which include unwanted impulses, images and ideas repeatedly enter the mind of an individual while the compulsions including repetitive stereotype behaviors as well as mental acts tend to be driven by the applied rigidly rules (Lack, 2012). Individuals diagnosed with OCD tend to be aware that the compulsions and obsessions are originating from their minds, which, nevertheless, causes them a great mental distress. At least one of the behaviors is also considered excessive or unpleasant and is resisted unsuccessfully whereas others may be resisted fully. Some disorders are deemed to be disabling even for children as some of them cannot control their senseless behaviors and thoughts. Although the aforementioned symptoms may be present in children, it remains difficult for children to have full insights into most of these compulsions and obsessive behaviors presumably because of the underdeveloped meta-cognitive skills (Seibell " Hollander, 2014). Furthermore, it is difficult to discriminate between compulsions in children and normal routines or some of the common ritualized behaviors which are considered normal in a family setting. For instance, children tend to perform some routine actions during bedtime such as playing with toys or saying goodnight. For such a behavior to be considered a compulsion, it needs to be impairing or distressing to the child, a feature that is currently too difficult to determine.
Historically, OCD falls under anxiety disorder. It is currently listed among neurotic stress-related disorders together with other anxiety disorders such as anxiety disorder ICD-10, which is similar to other classification of such disorders as classified under Diagnostic and Statistical Manual of Mental disorders (DSM)-III-R, DSM-III and DSM-IV. Nonetheless, in the light of some pieces of accumulating evidence for individual differences such as etiology and phenomenology of OCD its classification under DSM-V incorporated other related disorders characterized by repetitive thinking and behavior.
OCD goes undetected during the childhood before an accurate and proper diagnosis is made. Most delays in detection during the adolescence reflects the attempts to conceal some of the prominent symptoms, poor awareness of the disease, embarrassment and difficulty in differentiating the true symptoms of the disease from other common behaviors and traits characteristic of this period of life. Furthermore, OCD tends to be linked to a distinct set of symptoms including frequent checking and excessive washing which are strikingly dissimilar to common behaviors. OCD symptoms also tend to overlap with other clinical symptoms increasing the diagnostic challenge further. Nonetheless, the majority of pediatric OCD cases a six question screening tool was used, for it has proven to have a high sensitivity in detecting OCD. However, since the instrument is not classified as a diagnostic tool, further assessment is normally required for individuals who have a history of compulsions and obsessions (Ruscio et al., 2010). The use of an interview becomes essential in elucidating compulsive and obsessive ideas, especially among young people who feel reluctant to disclose symptoms in front of the relatives or parents who may view OCD symptoms as taboo or some sort of sexual obsessions.
Evidence-Based Treatment of Obsessive-Compulsive Disorder
Established evidence-based treatment incorporates two common approaches used in the management of pediatric OCD. The first method involves cognitive behavioral therapy while the second approach involves the use of selective serotonin reuptake inhibitors. Cognitive behavioral therapy is a relatively short-term treatment option applied for a duration of 12-20 weeks (Patel et al., 2014). The therapeutic strategy involves an individual gradually confounding feared situations such as touching dirty door knobs and desisting from the common compulsions including handwashing in a bid to neutralize anxiety. Individuals diagnosed with OCD are normally encouraged to wait until the anxiety levels drop before repeating some of the practices to a point that the anxiety extinguishes completely. Randomized controlled trials demonstrate that cognitive behavioral therapy remains one of the most effective method used in managing pediatric OCD. The use of CBT is associated with a 40-65% decline in symptoms and has proven to be effective in children if the method is applied for 18 months (Seibell " Hollander, 2014). Similar outcomes have also been reported when CBT has been utilized in non-clinical settings indicating the effectiveness of the treatment method. As a result, there is an international consensus that CBT should be considered as the first line of treatment of mild to moderate cases of OCD. In severe cases, the combined use of CBT and selective serotonin reuptake inhibitors such as citalopram, paroxetine, sertraline, fluoxetine and citalopram should be encouraged (Foa, 2010). The combined employment of cognitive behavioral therapy and selective serotonin reuptake inhibitors is notable for reducing common symptoms associated with OCD by 29%-44% which is within the tolerable and safe standards (Lack, 2012). It is important to point out that fewer studies regarding the use of selective serotonin reuptake inhibitors have been done, and thus there is less evidence suggesting the effectiveness of one drug over the other. However, different clinical guidelines allow for the use of different drugs. For example, within the United Kingdom only the use of Fluvoxamine and sertraline is permitted in children (Mancebo, Eisen, Sibrava, Dyck, " Rasmussen, 2011). A study comparing the effectiveness of cognitive behavioral therapy to selective serotonin reuptake inhibitors showed that both use of sertraline and CBT had comparable effects in reducing the effect of OCD. However, the combined effect of using both drugs displayed a superior outcome compared to the use of a single approach. Mancebo et al. (2011) investigated the effect of cognitive behavioral therapy among young people receiving serotonin reuptake inhibitors. The study indicated that young individuals who only received cognitive behavioral therapy with medication had better outcomes compared to individuals who only received brief CBT instructions.
Meta-analysis and reviews examining the use of five selective serotonin reuptake inhibitors and non-selective inhibitors indicate differences between the two forms of the drugs in the management of OCD. The treatment of OCD primarily revolved around the use of pharmacotherapy and CBT, although the instances of resistant OCD having occurred in the recent past resulted in the new method of treatment of OCD among its patients (Rintala et al., 2017). Treatment-resistant OCD occurs in individuals who have failed trials associated with the use of SRIs; whereas treatment-refractory OCD occurs among individuals who have failed to obtain a greater degree of medical outcome after the employment of common approaches. As a result, a number of new methods have been developed to manage various OCD. These new methods include alternative monotherapies, invasive procedures and well as augmentation strategies. Alternative monotherapies include the use of agents, which increases the dosage of previously used medical drugs targeting serotonin inhibitors. Invasive procedures include methods which aim at the hyperactivity region of the brain neural system while the augmentation strategies imply the combination of current serotonin inhibitors with some of the new advanced drug methods. Most of these methods only specifically target the treatment of the resistant or refractory OCD.
Barriers to OCD Treatment
A number of barriers towards the management of OCD have been elucidated. Studies reveal that individuals with OCD failed to seek the required treatment for a number of reasons including not knowing the specific areas to get help, the ability to want to handle the disease management process on their own, or being afraid of the stigma associated with the management of the disease (Coles " Coleman, 2010: Marques et al., 2010). Other reasons include being unable to cater for the fees linked to treatment of the disease and minority status barriers within various healthcare systems (Coles " Coleman, 2010: Marques et al., 2010). A study conducted by examining some of the barriers related to the management of OCD revealed other numerous factors including the high cost of treatment and lack of insurance cover to cater for the medical needs of minority populations such as African Americans (Williams et al., 2012). The high costs coupled with the lack of an insurance cover reduced incidences of early diagnosis and detection of the disease and as a result increased the transition of childhood OCD to adulthood. Another unique barrier identified among African American communities indicated were the concerns related to the management of the disease. Some participants expressed negative attitudes towards current appropriate measures with other having a low sense of confirmation in a clinician’s ability to manage the condition. A number of participants also regarded some OCD symptoms as being normal and thus did not see the need to seek any form of alternative treatment.
Conclusion
OCD is a disease condition which commonly causes significant impairment and distress to an individual. It is ranked among the top ten disabling disease conditions by the World Health Organization and is considered a distressing illness. The condition primarily starts during the childhood and overtime persists during the adult stages. Although early diagnosis of the disease condition is essential in its management, it is limited by several factors including embarrassment of family members and other societal pressures as well as the symptoms overlapping with other anxiety-related disorders in the common developmental stages. Early detection of the disease requires individuals to heavily invest in the identification of obsessions and compulsions after the application of specific criteria described under DSM-V and ICD-10. Two major management methods are currently utilized in OCD with the combination of both cognitive behavioral therapy and serotonin inhibitors showing a synergistic effect. Nonetheless, several incidences of resistant and refractory OCD have been reported suggesting the need to develop newer methods which could aid in the treatment of the disease.
References
Boileau, B. (2011). A review of obsessive-compulsive disorder in children and adolescents. Dialogues in Clinical Neuroscience. Les Laboratoires Servier. https://doi.org/10.1542/peds.2009-0015
Browne, H. A., Gair, S. L., Scharf, J. M., " Grice, D. E. (2014, September). Genetics of obsessive-compulsive disorder and related disorders. Psychiatric Clinics of North America. NIH Public Access. https://doi.org/10.1016/j.psc.2014.06.002
Coles, M. E., " Coleman, S. L. (2010). Barriers to treatment seeking for anxiety disorders: initial data on the role of mental health literacy. Depression and anxiety, 27(1), 63-71.
Eisen, J. L., Sibrava, N. J., Boisseau, C. L., Mancebo, M. C., Stout, R. L., Pinto, A., " Rasmussen, S. A. (2013). Five-year course of obsessive-compulsive disorder: Predictors of remission and relapse. Journal of Clinical Psychiatry, 74(3), 233–239. https://doi.org/10.4088/JCP.12m07657
Foa, E. B. (2010). Cognitive behavioral therapy of obsessive-compulsive disorder. Dialogues in Clinical Neuroscience, 12(2), 199–207. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20623924
Fornaro, M., Gabrielli, F., Albano, C., Fornaro, S., Rizzato, S., Mattei, C., … Fornaro, P. (2009, May 18). Obsessive-compulsive disorder and related disorders: A comprehensive survey. Annals of General Psychiatry. BioMed Central. https://doi.org/10.1186/1744-859X-8-13
Jaisoorya, T., Janardhan Reddy, Y., Nair, Bs., Rani, A., Menon, P., Revamma, M., … Thennarasu, K. (2017). Prevalence and correlates of obsessive-compulsive disorder and subthreshold obsessive-compulsive disorder among college students in Kerala, India. Indian Journal of Psychiatry, 59(1), 56. https://doi.org/10.4103/0019-5545.204438
Lack, C. W. (2012). Obsessive-compulsive disorder: Evidence-based treatments and future directions for research. World Journal of Psychiatry, 2(6), 86. https://doi.org/10.5498/wjp.v2.i6.86
Mancebo, M. C., Eisen, J. L., Sibrava, N. J., Dyck, I. R., " Rasmussen, S. A. (2011). Patient utilization of cognitive-behavioral therapy for OCD. Behavior Therapy, 42(3), 399–412. https://doi.org/10.1016/j.beth.2010.10.002
Marques, L., LeBlanc, N. J., Weingarden, H. M., Timpano, K. R., Jenike, M., " Wilhelm, S. (2010). Barriers to treatment and service utilization in an internet sample of individuals with obsessive–compulsive symptoms. Depression and Anxiety, 27(5), 470-475.
Patel, S. R., Humensky, J. L., Olfson, M., Simpson, H. B., Myers, R., " Dixon, L. B. (2014). Treatment of Obsessive-Compulsive Disorder in a Nationwide Survey of Office-Based Physician Practice. Psychiatric Services, 65(5), 681–684. https://doi.org/10.1109/EBBT.2017.7956766
Pittenger, C., Kelmendi, B., Bloch, M., Krystal, J. H., " Coric, V. (2005). Clinical treatment of obsessive compulsive disorder. Psychiatry (Edgmont (Pa. : Township)), 2(11), 34–43. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21120095
Rintala, H., Chudal, R., Leppämäki, S., Leivonen, S., Hinkka-Yli-Salomäki, S., " Sourander, A. (2017). Register-based study of the incidence, comorbidities and demographics of obsessive-compulsive disorder in specialist healthcare. BMC Psychiatry, 17(1), 64. https://doi.org/10.1186/s12888-017-1224-3
Ruscio, A. M., Stein, D. J., Chiu, W. T., " Kessler, R. C. (2010). The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Molecular Psychiatry, 15(1), 53–63. https://doi.org/10.1038/mp.2008.94
Seibell, P., " Hollander, E. (2014). Management of Obsessive-Compulsive Disorder. F1000Prime Reports, 6, 68. https://doi.org/10.12703/P6-68
Williams, M. T., Domanico, J., Marques, L., Leblanc, N. J., " Turkheimer, E. (2012). Barriers to treatment among African Americans with obsessive-compulsive disorder. Journal of Anxiety Disorders, 26(4), 555-563.
