Symptoms and treatment methods of obsessive compulsive syndrome

Obsessive Compulsive Disorder (OCD) is a disorder characterized by repetitive, obsessive thoughts (obsessions) and/or actions (compulsions) that are difficult to resist because trying to refrain from them leads to severe anxiety, stress, and suffering.

Short information about Obsessive Compulsive Disorder (OCD)

Short information about Obsessive Compulsive Disorder (OCD)

How common is OCD?

The prevalence of OCD in society can be considered significant as it reaches about 2.5% of the population. If this disorder is present in the family, the risk of its development in an individual is higher and even reaches 9-10%.

How does OCD manifest?

Obsessive thoughts (obsessions) - have a pronounced, intense character and are almost always perceived by the patient as “unpleasant”, “shameful”, “absurd”, “unwanted”. Although obsessions appear against the will and cause resistance in the patient, they, however, are perceived by them as their own thoughts.

Obsessions can be divided into the following categories:

- Obsessive insecurity - most often concerns everyday things – e.g. repeated and constant, despite repeated and various checks, uncertainty about whether the door was closed, whether the lights were turned off, whether the water taps were closed, whether the objects were correctly and evenly laid out, whether the hands were washed correctly and effectively, etc .;
- Intrusive, unwanted, and often contradictory thoughts of a blasphemous, obscene or vulgar nature - often intensified in places or circumstances in which they are especially inappropriate (e.g. church, prayer, meeting with loved ones, etc.);
- Obsessive impulses – e.g. intense, overwhelming thoughts about yelling or undressing in public, committing an embarrassing act, or also behaving aggressively towards people towards whom individuals have no ill intentions. For instance, it could be pushing the mother, kicking the child, etc. It is important to understand that in OCD, these impulses are never realized by the patient, although they are accompanied by strong anxiety that they will soon come true, and intensified attempts to prevent this;
- Rumination - continuous, many hours, useless, pseudophilosophical and hard to interrupt “chewing” one topic, question or thoughts without the possibility of making a decision and reaching constructive conclusions;
- Obsessive fear of dirt, uncleanness, thoughts about being dirty or thinking of others as dirty;
- An obsessive need to maintain an ideal, unreal order, symmetry, a certain arrangement of objects in the environment, etc.

Obsessive actions (compulsions) - like obsessions, are felt by the patient as meaningless and awkward or embarrassing, but at the same time inevitable - it is difficult to resist them. They can take different forms:

- Obsessive checks (doors, water taps, etc.) as a response to obsessive insecurity;
- Repeated cleaning, washing (e.g. hand washing), laying, etc. - associated with the uncertainty whether these actions were performed correctly, in accordance with the procedure imposed on oneself and whether they were effective;
- Repetitive correction, laying, ordering associated with the obsessive desire for order, symmetry, a certain arrangement of objects;
- Complex actions reminiscent of bizarre rituals that the patient must perform in order to prevent the growing tension or the threat of catastrophe, albeit with very incredible consequences, despite the fact that they realize the meaninglessness of their actions and thinking (for example, “I must jump on one leg twice around the car in the parking lot, otherwise something bad may happen to my daughter ”);
- Collection and hoarding of objects.

OCD can sometimes be accompanied by other additional symptoms:

- Symptoms of anxiety disorders – e.g. panic attack or generalized anxiety;
- Symptoms of depression - resistant to treatment or long-term untreated OCD can be a source of significant distress for the patient and very serious disorders of their functioning at home, work, school or university. Responses to such consequences can lead to decreased mood, decreased self-esteem, the development of feelings of helplessness and hopelessness, and even the development of a complete episode of depression;

- Depersonalization and derealization - sometimes the anxiety and tension accompanying obsessive states or trying to resist them are so great that they lead to a periodic feeling of unreality of the world. Then they may get the impression that there is no full contact with the world, that the people and objects around them are unreal, artificial, that they are like decorations (derealization) or also that the patient’s thoughts are separated from them, as if these thoughts do not belong to them, that their feelings, emotions, actions or parts of their body are not theirs(depersonalization). These symptoms are usually very disturbing to the patient and can generate fear of “madness”.
- Tics are involuntary, repetitive movements (e.g. blinking eyes, shrugging shoulders, grimaces, etc.) or vocal phenomena (coughing, barking, hissing, etc.), just as compulsions are felt as something that is impossible or very difficult to resist;
- Aichmophobia is an increased fear of sharp objects in combination with avoiding contact with them and hiding them;
- Misophobia is the heightened, excessive fear of dirt, combined with an increased need to avoid contact with it, remove it and avoid “defiling” with it;
- Bacillophobia is a fear of microbes similar to misophobia.

What to do if you have symptoms of OCD?

If you notice symptoms or suspect you have them, you should contact a psychiatrist. You should not delay the visit to the doctor. Firstly, the symptoms are very burdensome, interfere with functioning and cause great suffering, and secondly, if they persist for a long time, they can become fixed. This happens, among other things, because the person with OCD wants to cope with the discomfort and takes actions that bring only temporary relief, but ultimately support and enhance some of the mechanisms for maintaining the disorder. Such actions are, for example avoiding specific situations or engaging in rituals and activities that reduce mental stress.

Initiation of treatment helps to stop such a vicious circle. For instance, it can be done through the use of cognitive-behavioral therapy (CBT). In addition, a quick start of treatment minimizes the risk of complications such as depression.

How does a doctor diagnose obsessive-compulsive disorder?

The psychiatrist bases the diagnosis, first of all, on an anamnesis (history) accurately collected from the patient, as well as after examining his or her mental state, consisting of asked questions, conversation and observation. The doctor may also ask for additional psychological evaluation and provide the patient or complete with him or her  specialized questionnaires that serve to assess the severity of symptoms.

The doctor can also decide to conduct basic biochemical tests (blood) to assess the general state of health and carry out the so-called differential diagnosis, i.e. exclude other pathologies that can cause the same or similar symptoms. Sometimes, a doctor may also decide to conduct additional studies - electroencephalography (EEG), computed tomography or magnetic resonance imaging - and consult a neurologist.

What are the treatments for OCD?

Treating OCD is a long and complex process. Patience is very important because obsessions and compulsions tend to respond slowly and gradually to the treatments used. Medication, psychotherapy, and complementary techniques are used to treat OCD.

People experiencing mild symptoms can be treated with only psychotherapy or pharmacotherapy. In severe symptoms, it may be necessary to use these methods simultaneously. The main drugs used for OCD are antidepressants: selective serotonin reuptake inhibitors (e.g. sertraline, paroxetine, fluvoxamine, citalopram, fluoxetine), and tricyclic antidepressants - Clomipramine.

Pharmacotherapy lasts from several months to many years. Sometimes an attempt to stop the medication leads to a relapse or intensification of obsessions - in this case, the patient takes the medication for life.

Pharmacological treatments usually use much higher doses of antidepressants than those recommended for patients with depression. Sometimes - to reduce the intensity of anxiety and tension - at the start of treatment, the doctor adds sedatives or sleeping pills to antidepressants. For associated tics, an antipsychotic agent (e.g. haloperidol, risperidone) is added to the antidepressants. The best-documented psychotherapeutic treatment for OCD is cognitive behavioral therapy. During therapy sessions, the patient learns to tolerate the stimuli that cause or increase obsessions, and also learns to gradually refrain from obsessive actions. In some patients, psychodynamic psychotherapy can also be of significant benefit.

Is full recovery possible?

It should be remembered that every patient - regardless of the severity, duration, nature, and amount of obsessions - can significantly benefit from treatment. A positive response to treatment is observed in 75% of patients. A large proportion of patients (approx. 25%) can achieve complete recovery or complete symptomatic or functional remission.

What should be done after the end of treatment?

The duration of treatment, including taking medications, is determined individually. After proper treatment has ended, it may be advised to repeat the skills and exercises acquired during cognitive behavioral therapy.

As in the case of other mental disorders, it can be helpful to take care of general mental hygiene and health: cultivating skills to cope with stress and solve problems, working on positive formation of interpersonal relationships, avoiding use of psychoactive substances (drugs, alcohol), proper nutrition, physical activity. An important issue is also the acquisition of the ability to recognize the signs of recurrence of the disorder and prompt pharmacological and/or psychotherapeutic intervention when it occurs.

A detailed algorithm of action should be determined by the doctor for each patient individually.

What to do to avoid getting sick?

There are no methods that specifically prevent the onset of OCD.

OCD in children and adolescents

OCD in people of developmental age are characterized by a similar picture and course as in adults. But the younger the child - there more significant is the difference. Symptoms of these disorders often appear before puberty, and boys are more likely to be affected. In adolescence, the proportion of sick girls and boys is gradually evened out.

The causes of this disorder, as in adults, are complex and include: disorders in the anatomical structure and/or functioning of the central nervous system, perinatal stress, genetic factors and environmental factors.

It is also believed that OCD can develop as a result of an autoimmune reaction as a consequence of streptococcal infection.
In children, obsessive thoughts usually take the form of fears for the life and health of loved ones, which intensify in the event of separation from these people, fear of getting dirty, contracting various microbes, getting sick with a serious illness, committing a sin. Obsessive thoughts often relate to the sexual sphere and are associated with the experience of strong feelings of guilt.

Among obsessive actions, rituals associated with avoiding infection prevail (not touching objects, frequent washing, repeated changing of clothing during the day, etc.), arranging objects in a certain order, collecting items, multiple checks (for instance, are the doors closed or not).

Usually neglected sign that is not usually associated with OCD is repeating the same questions multiple times. The child's environment often perceives their actions as a search for a sense of security, seeking attention or even that they do it on purpose to annoy adults and not as a symptom of the disease.

In kids, contrary to adults, there are forms of the disorder, in which, mainly, obsessive actions are present, practically without the participation of obsessive thoughts of a specific content.

About half of the cases of OCD in kids and teens occur with other comorbid mental disorders: tics, depressive, anxiety disorders, ADHD, behavioral disorders, and/or specific developmental.

Diagnostic methods are the same as for adults, but the diagnosis process can be more complex. Children tend to hide, mask symptoms, or deny symptoms because they are often ashamed of them. On the other hand, relatives of children suffering from this disease often participate in their rituals, for example. They open the door for the child, give objects when the child  does not want to touch them because of fear of getting dirty. They do this most often unconsciously, interpreting the child's behavior as “quirks” or, noticing the child's anxiety and discomfort, try to help them in this way.

In the treatment of kids and teens with OCD, the same methods are used as in adults. For less intense symptoms, psychotherapy is often sufficient, while pharmacological treatment should also be considered if symptoms are more intense and adversely affect the child's functioning. Family therapy is very often indicated as part of non-pharmacological treatment.

Finally, remember that children in preschool and primary school age often have a tendency to repeat certain actions (e.g. counting, placing objects) or they have their own “rituals” associated with everyday activities (e.g. jumping over certain steps on the stairs, prepare for bed in a certain way). Such actions do not cause suffering in the child and do not disrupt their functioning, because the child can interrupt him without much mental discomfort. This natural behavior should be distinguished from the compulsive, coercive actions that are a symptom of the disease.

Post by: Christopher Ames, MD, pshychiatrist, Medibank, Sydney, New South Wales, Australia