Obsessive-Compulsive Disorder (OCD)

By Mohd Hasheem Khan

Obsessive-Compulsive Disorder (OCD) is a widespread or commonly occurring psychological disorder that affects 1% to 3% of people worldwide. (1) It involves having unwanted thoughts, called obsessions, and feeling the need to repeat certain actions again and again, called compulsions. Obsession are unwanted, repeated thoughts which are hard to control. Compulsions are actions or thoughts that people with OCD perform repeatedly to relieve their anxiety or to prevent something bad from happening.(2) These symptoms takes a lots of patient’s time and make them feel very upset due to which they face difficulty in performing daily activities. People with OCD tend to avoid situations that trigger their obsessive thoughts. (3)

OCD is a diverse condition that is caused by a complex interplay of genetic and environmental factors. (4) Most adults feel upset by their unwanted thoughts or actions and they know that they repeat their actions again and again. Children often have difficulty in explaining their unwanted thoughts. In OCD, common fears and actions include fear of germs, excessive cleaning, concern about danger, having disturbing thoughts that lead to mental rituals, and things to be organized which leads to arranging or counting.(5,6) OCD can also present with less common symptoms such as excessive concerned with moral issues, intense jealousy, or a passion for music.(7,8)

The perception of OCD (obsessive-compulsive disorder) has changed a lot over time. In the past, people thought it was related to moral problems or even evil spirits. A doctor named Esquirol was the first to describe it medically. Later, Freud, a famous psychologist, called it “obsession neurosis” and suggested that it began due to issues during early childhood development, particularly at the stage when children are learning to control their bowel movements. (9)

CAUSES

The causes of OCD are complex and involve many different factors such as thinking patterns, genes, molecules, environment, and brain function. Studies of twins show that genetics play a big role, with about 48% of the risk coming from genes. (10, 11) But, the genetic effect is reduced to about 35% when maternal influences during pregnancy, such as stress or infection, are considered. (12)OCD in children is more influenced by genetics than in adults. (13) This suggests that OCD that begins in childhood may be a distinct form of the disorder. The results of extensive genetic studies (14, 15) and combined research on specific genes (16) indicates that OCD is affected by multiple genes, each of which has a small effect. Together, these genes contribute to the development of the disorder. Research shows that many different factors can cause OCD in people of all ages. These factors include problems with behavior, brain function, infection, and the immune system, all of which may be linked. (17-22)

Researchers are looking at how genes affect OCD and how these genes relate to other mental and immune problems. (23) One gene being studied is SLC6A4, which influences OCD through genetic changes and processes such as DNA methylation. (24)In addition to the SLC6A4 gene, researchers are also studying other genes related to the serotonin system for their role in OCD. These include the HTR2A, HTR1B and HTR2C genes. (25)

  EPIDEMIOLOGY

At first, obsessive-compulsive disorder (OCD) was thought to be quite rare. However, when detailed community surveys were conducted using specific criteria for diagnosing mental disorders, they revealed that OCD is actually one of the most common mental disorders. (26) These studies revealed that OCD contributes significantly to the global burden of disease. (27)

OCD is more common in women than men in the general population. However, in treatment clinics, the numbers of men and women with OCD are approximately equal. OCD affects people of all income levels and is found in both poor and rich countries.

The US National Comorbidity Survey found that about 20% of people with OCD develop symptoms by age 10 or earlier. (28,29) Researchers say OCD usually begins around age 11 and then into early adulthood.(30) Children with OCD are more commonly boys than girls, but not all studies agree. (31,32)

CYCLE OF OCD

There are four stages in OCD cycle:

• OBSESSION
• ANXIETY
• COMPUSION
• TEMPORARY RELIEF

Fig.1.1 Stages of OCD cycle

OBSESSION

OCD thoughts can cover many topics, such as germs or violence, and they are different for everyone. These thoughts can be very disturbing and do not match your own beliefs, especially if you think about them too much or do not understand them.

ANXIETY

OCD thoughts are extremely distressing which causes a significant anxiety and fear. OCD was considered as an  anxiety disorder for many years. People with OCD often believe that their intense anxiety indicates that something terrible is happening, and this makes their fear true To get relieve from this anxiety, they feel compelled to perform specific tasks or rituals.

COMPULSIONS

Compulsions are the  actions or thoughts that you used to reduce the anxiety from OCD. They can be things you do physically or just in your mind. For example, if you’re worried that your thought may cause a disaster, you may feel the need to mentally remove the thought many times to keep everyone safe.

TEMPORARY RELIEF

After meeting your obligations, you may feel better for a while, but it won’t last for a long time. OCD will constantly add new worries in your mind, this cycle will continue as long as you are afraid and try to avoid these thoughts.

Categories of OCD symptoms:

• Symmetry and arranging
• Contamination symptoms
• Unacceptable thoughts
• Risk and hesitation

FIG.1.2 Types of OCD symptoms

TREATMENT OF OCD

Many individuals can get benefit from treatment, including those which have severe OCD. Healthcare providers use medications, psychological therapy, or a combination of the two to treat OCD. A mental health professional can help you choose the most appropriate treatment and explain the advantages and disadvantages of each option.

Psychological therapy

1. Cognitive Behavioral Therapy (CBT)

It is a proven and first-choice treatment for OCD. It helps by changing the harmful thoughts and behaviors of the patients. This therapy focuses on rewiring the way that person thinks and acts. CBT aims to replace the unhealthy thoughts and behavior patterns with the healthier ones.

In CBT, exposure and response prevention (ERP) method is very successful approach to treat OCD. It involves exposing patients to things that causes anxiety and they are taught that they should not act on their compulsive behaviors. (33)

PHARMACOTHERAPY

1. Serotonin reuptake inhibitors

Selective Serotonin reuptake Inhibiters (SSRIs): These are the best medicine to treat OCD because they are highly effective and show very less side effects.

In 1989, Goodman and his team discovered that fluvoxamine was very effective in managing OCD. (34) After that, over 20 studies proved that SSRIs are more effective in the treatment of OCD. (35, 36)

Side effects of SSRIs are:

• Weight gain
• Sleep disturbance
• Nausea
• Low libido
• Diarrhea

• Tricyclic antidepressants

CLOMIPRAMINE: It was very useful medicine in the 1980s, which is used to treat depression. The effectiveness of clomipramine is similar to SSRIs, but it shows  more side effects like sedation, weight gain, etc. which makes it less suitable for the treatment.(37,38) The active metabolite of clomipramine is desmethylclomipramine. Clomipramine affects serotonin and Desmethylclomipramine affects the norepinephrine neurotransmitter. It is metabolized in liver with the help of CYP1A2 enzyme. People who have low level of CYP1A2 enzyme they need small or low dose of clomipramine. It is not allowed to prescribed Clomipramine in combination with MAO inhibitors or CYP 450 2D6 because it will show some toxic symptoms like arrhythmia, low blood pressure, seizures, etc.

Sometimes Clomipramine is also used in the treatment of many other diseases which is not officially approved like:

• Depression (39)
• Sudden muscle weakness (40)
• Anxiety (41)
• Neuralgia (42)
• Premature or early ejaculation (43)
• Panic attacks (44)
• Sleep disorder (40)

Side effects of antidepressants are:

• Sweating
• Dry mouth
• Tachycardia
• Headache
• Nausea

• Antipsychotics

Antipsychotics and other classes of drugs are recommended by the doctors to OCD patients when antidepressant does not show their actions properly.

DEEP BRAIN STIMULATION (DBS)

It is a flexible and reversible method which is used in the treatment of severe OCD. It shows action upto 40 to 70% of the patients who get this treatment. In this procedure, an electrode is placed in the deep brain by surgical method, then the electrode stimulates the nearby area of the brain. DBS target only some specific regions like the anterior limb of the internal capsule and the ventral striatum. It is a safe and impactful treatment authorized by the U.S. Food and Drug Administration (FDA). (1,2)

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