Obsessive compulsive disorder is a common mental illness that causes a person to have recurrent obsessional thoughts and repetitive behaviors or else known as compulsions. Obsessional thoughts are ideas, images, or impulses which arise in an individual’s mind in a stereotyped form which causes invariable distress in the patient. Compulsive acts or rituals are stereotyped behaviors that are repeated continuously by the patient.
Examples of common obsessions are,
- Fear of contamination
- Pathological doubt
- A need for symmetry
- Aggressive obsessions
Common compulsions are checking, washing, symmetry, the need to ask or confess, and counting.
Diagnostic Criteria
According to ICD-11, to diagnose Obsessive Compulsive Disorder, the obsessions, and compulsive acts must be time-consuming which means that they take more than an hour per day while resulting in prominent distress or impairment in personal life, family, social, educational, occupational, or other significant areas of functioning in life.
Management
It is essential to identify the form of obsession which may be images, thoughts, or impulses, and the content of obsession as the initial step in management. Common themes of obsession are contamination due to the fear of dirt, germs, and HIV, checking due to fear of accidental harm to self or others such as accidentally knocking down someone while driving the car, excessive concern with order or symmetry which includes thoughts as clothes must be worn in a particular order and things have to be kept in a specific place, religious or blasphemous thoughts or sexual thoughts. ,
Next, it is important to identify the type of compulsion the patient is having. Different types of compulsive acts normally OCD patients are
- Washing hands.
- Cleaning the house.
- Checking if doors are locked.
- Stopping cars and checking that no pedestrian has been run over and arranging things.
- Carrying out activities in order.
After identifying the types of obsession and compulsion, the next step is pharmacological and psychological management of the patient.
Pharmacological Management
Selective serotonin reuptake inhibitors (SSRI) are recommended as the first line of pharmacological treatment. Starting fluoxetine 20 mg/day and titration to a maximum of 80 mg/day according to response is the commonly used initial management. It will take 10-12 weeks for the response. The treatment must continue for 1-2 years and be tailed off over several months.
Pharmacological treatment can reduce the severity of symptoms too and improve the cooperation of patients with psychological therapy. Apart from SSRI, evidence suggests that venlafaxine which is a serotonin noradrenaline reuptake inhibitor may also be effective in the treatment of OCD patients. Tricyclics other than clomipramine and benzodiazepines are not recommended for the treatment of OCD.
Psychological Management
Initially patient and family education along with setting goals for treatment is essential. Before starting the patient on behavioral cognitive therapy which is a type of psychological therapy patient must be educated about the rationale of the treatment, illness, available treatment, and prognosis.
Psychological Therapy
- Exposure
- Prevention therapy
The patient will be exposed to a triggering factor that causes discomfort to the patient. In the beginning, when the patient refrains from the compulsion the anxiety level will increase. However, after 30-60 minutes, the anxiety will automatically decrease. When you keep repeating this, the anxiety will gradually become less and the obsessions and compulsions will be reduced. This will have to be done for 13-20 weeks continuously. Self-monitoring and avoidance of triggers are other methods of psychological therapy.
References
- ICD -11, Classification of Mental and Behavioral Disorders- Diagnostic Criteria for Research
- Handbook of Clinical Psychiatry – A Practical Guide- Second Edition – Varuni De Silva, Raween Hanwella
