The ABCDE of Obsessive Compulsive Disorder

When I was young, I would spend my holidays with my cousins at my grandmother’s house. It was great fun but I would wonder why my grandmother would interrupt our play and wash the verandah repeatedly with water mixed with antiseptic lotion. I would ask my mother and she would reply that my grandmother ‘always did it’ on daily basis because she wanted to protect us from getting infected.  

I also have a vivid childhood memory of one of my helpers pulling the lock and counting aloud from 1 to 10, every time my family went out. I found it very amusing and would laugh but the helper would always say that it was necessary to count till 10 to be sure that the door was locked properly and for my family’s safety.

These were ‘just memories’ until I started studying medicine and read about obsessive compulsive disorder (OCD). I was surprised by its relative commonality with a prevalence rate of 1-2% (regardless of gender or social or cultural background) and yet its lack of awareness. Despite, it being so debilitating and disabling that the World Health Organisation (WHO) has actually ranked it in the top ten of the most disabling illnesses of any kind; I wondered why many individuals with OCD didn’t seek treatment. After years of experience and having interviewed several hundred patients, I realised that Individuals with OCD found it very embarrassing to reveal their ‘stupid behaviours’. Average time to seek treatment was over a decade from the time of onset of development of symptoms. 

Over the years, I assessed and managed patients with OCD with varied presentations ranging from simple compulsion like repeated washing to complex obsessional images of having sex with goddesses.  

What is OCD?

One often hears people commenting ‘I am obsessed with my iPhone’, ‘I am obsessed with Kardashians’, ‘he is a compulsive liar’ etc. but these are just expressions of love, preoccupation and repetitiveness, and not obsessive compulsive disorder.

Obsessions are repeated, unwanted, anxiety provoking one’s own thoughts, urges or images while compulsions are repeated acts (whether actual and or mental) to reduce the anxiety or to prevent some imagined dreaded event or situation. Individuals with OCD may have either obsessions or compulsions or both set of symptoms. Presence of symptoms does not necessarily means a presence of disorder; symptoms must be either time consuming or cause clinically significant distress or impairment in important areas of individual’s functioning to be deemed as a disorder. 

How does OCD present?

Obsessions of Contamination such as excessive worry about germs, dirt, bodily wastes and secretions, and environmental contaminants (e.g., asbestos, radiation, toxic waste).

Obsessions with Need for Symmetry or Exactness such as a near and dear one will have accident unless things are in the right place and or symmetry.

Sexual Obsessions such as unacceptable sexual thoughts, images or impulse about one’s own children, siblings, gods and goddesses. 

• Aggressive Obsessions such as fear of harming others, shouting vulgarities, obscenities or insults or harming self.
• Somatic Obsessions such as excessive concern with body part or aspect of appearance or illness. 
• Cleaning/Washing Compulsions such as excessive or ritualised handwashing, bathing, showering, cleaning and grooming. 
• Checking Compulsions such as checking locks, stoves, appliances, written work and their body.  
• Counting Compulsions such as counting up to a particular number or set of numbers, before and or after certain tasks. 
• Ordering Compulsions such as arranging and re-arranging items. 
• Mental Compulsions such as special words, images, numbers, repeated mentally to neutralize imagined bad.   

What causes OCD? 

As with most of the psychiatric disorders, the exact cause of OCD is still not fully understood. It is believed to be the result of a combination of genetic, neurobiological, behavioural or environmental factors that trigger the disorder in a specific individual at a particular point in time. As it runs in families, it is sometimes inherited but the exact gene has not been identified yet. Numerous research have found imbalance of neuro-chemicals especially serotonin in brains of individuals with OCD. Though the qualities like perfectionism, tidiness and meticulousness are helpful, individuals with these qualities are likely to develop OCD, if they become too extreme. Life changes such as attaining puberty, the birth of a child or a new job or stressful life events can trigger OCD. 

Is it treatable?

Yes; however, receiving and sticking to appropriate treatment is the key to long term recovery. Left untreated and unchallenged, OCD may proliferate and feed upon itself and can have the power to consume. The treatment consists of medications, psychotherapy (talking therapy) or both. 

Many of the celebrities, including Alec Baldwin, Megan Fox, Cameron Diaz and Jennifer Love Hewitt, who have publicly admitted to having OCD have managed to lead successful lives.

Antidepressant medications SSRIs (Selective Serotonin Reuptake Inhibitors) such as sertraline, fluoxetine, paroxetine, escitalopram and fluvoxamine can help to reduce obsessions and compulsions, even if one is not depressed. Often, high doses of these medications for several months to years are required to treat OCD.

Cognitive Behavioural Therapy (CBT) is a form of psychotherapy that helps you change the way you think and behave so you can feel better and get on with your life. Exposure and Response Prevention (ERP) has been found to be most effective form of CBT technique for individuals with OCD. It refers to exposing yourself to the thoughts, images, objects and situations that make you anxious and/or start your obsessions. While the Response Prevention part of ERP refers to making a choice not to do a compulsive behaviour once the anxiety or obsessions have been “triggered.” All of this is done under the guidance of a therapist at the beginning and you will eventually learn to do your own ERP exercises to help manage your symptoms. 

Tips for family and friends

• My advice to family and friends of OCD sufferers is ABCDE. 
• Accept that they need help
• Be a Co-therapist under supervision of a psychiatrist and psychotherapist – you may help the patient in performing ERP at home.
• Discourage to taking part in rituals
• Encourage and Educate patient to seek treatment and tackle feared situations