Obsessive Compulsive Disorder

Obsessions are recurrent persistent thoughts, impulses, or images that enter the mind despite efforts to exclude them. The feeling of compelled to undergo the intrusion of a thought, impulse, or image and the resistances produced against them are key characteristics of an obsession. [1]

In India, obsessive compulsive disorder (OCD) is more common in unmarried males, while in other countries, no gender differences are reported.

This disorder is commoner in persons from upper social strata and with high intelligence. The average age of onset is late third decade (i.e. late 20s) in India, while in the Western countries the onset is usually earlier in life.

A summary of long-term follow-up studies shows that about 25% remained unimproved over time, 50% had moderate to marked improvement while 25% had recovered completely. [2]

An obsession is define as:

• An idea, impulse or image which intrudes into the conscious awareness repeatedly.
• It is recognise as one’s own idea, impulse or image but is perceive as ego-alien (foreign to one’s personality).
• It is recognise as irrational and absurd (insight is present).
• Patient tries to resist against it but is unable to.
• Failure to resist, leads to mark distress.
• An obsession is usually associate with compulsion.

A compulsion is define as:

• A form of behaviour which usually follows obsessions.
• It is aim at either preventing or neutralising the distress or fear arising out of obsession.
• The behaviour is not realistic and is either irrational or excessive.
• Insight is present, so the patient realises the irrationality of compulsion.
• The behaviour is perform with a sense of subjective compulsion (urge or impulse to act).
• Compulsions may diminish the anxiety associate with obsessions. [2]

OCD is characterize by obsessional thinking, compulsive behaviour, and varying degrees of other psychiatric symptomatology.

The feeling of being compell to undergo the intrusion of a thought, impulse, or image and the resistances produced against them are key characteristics of an obsession.

They may come in the form of any of the following:

Obsessions:

Obsessional thoughts i.e.:

These intrude forcibly into the patient’s mind and the patient attempts to exclude them. Obsessional thoughts may be single words, phrases, or rhymes; they are usually unpleasant or shocking to the patient, obscene, or blasphemous.

Obsessional images i.e.:

They typically appear as vividly imagine scenes, often of violence or of a kind that disgusts the patient, such as abnormal sexual practices.

Obsessional ruminations i.e.:

They are internal debates in which continuous arguments reviewed endlessly.

Obsessional doubts i.e.:

They thoughts about actions that may have completed inadequately, such as failing to turn off a gas tap completely, or about actions that may have harmed other people.

Obsessional impulses i.e.:

These are urges to perform acts, usually of a violent or embarrassing kind; for example, leaping in front of a car or shouting blasphemies in church. The urges are resist strongly, and are not carried out, but the internal struggle may very distressing.

Obsessional rituals:

• These are repeat but senseless activities.
• They may mental activities, such as counting repeatedly in a special way or repeating a certain form of words, or behaviours, such as excessive hand washing or lock checking.
• Rituals are usually follow by temporary release of distress. The ritual may follow by doubts whether it has completed in the right way, and the sequence may be repeated over and over again.
• Patients are aware that their rituals are illogical, and usually try to hide them.

Anxiety and depressive symptoms:

• Symptoms are often present in patients with OCD. In some patients these are an understandable reaction to the obsessional symptoms, but in others there are recurring depressive moods that arise independently of the other symptoms.
• Depersonalization occurs sometimes, adding to the patient’s disability. Although they share the same name, obsessional personality and OCDs do not have a simple one-to-one relationship.

Obsessional personality:

• It is over-represent among patients who develop OCD, but about a third of obsessional patients have other types of personality.
• Moreover, although people with obsessional personality may develop OCDs, they are more likely to develop depressive disorders.

Genetics:

The lifetime risk for OCD increase tenfold in first-degree relatives of patients diagnosed with OCD.

It is not certain whether this familial pattern indicates genetic causes rather than family environment, because the necessary large-scale twin and adoption studies have not carried out.

Neurobiological mechanisms:

Structural organic abnormalities i.e.:

Parents with OCD have an increase rate of minor, non-localizing neurological signs but no specific neurological lesion has identified.

Positron emission tomography (in other words; PET) and functional MRI have shown increased activity in the frontal lobes, caudate nucleus, and cingulum in OCD patients.

Neurotransmitters i.e.:

Generally, The clinical benefits of SSRIs in OCD suggest that a dysregulation of the 5HT pathways may play a role in its aetiology.

Furthermore, A variety of randomized controlled challenge studies have undertaken and have shown that giving a 5HT antagonist increased anxiety levels in OCD.

Lastly, Evidence for the involvement of dopaminergic pathways in OCD comes from the fact that disorders of the basal ganglia (for example; Tourette’s, post-encephalitic parkinsonism) show a high level of obsessive symptoms.

Autoimmune factors i.e.:

For many years it has known that Sydenham’s chorea—an autoimmune disease of the basal ganglia—is associated with OCD in two-thirds of cases.

Besides this, These patients have autoantibodies to the caudate nucleus. Additionally, More recently, an association has made between Group A streptococcal infections and OCD/tic disorders.

Early experience:

In brief, Obsessional mothers might expected to transmit a tendency to obsessional symptoms to their children through social learning.

Psychological causes:

Obsessions can thought of as a conditioned response to an anxiety-provoking event.

The patient develops avoidant behaviours (of which compulsions are part) to try also avoid experiencing the anxiety provoking event.

Sigmund Freud’s psychoanalytic approach suggests that the symptoms of OCD reflect unsolved conflicts or impulses of either a violent or sexual nature.

All in all, These impulses create anxiety, which avoid by the use of defence mechanisms. [1]

Washers:

• Basically; This is the commonest type.
• Here the obsession is of contamination with dirt, germs, body excretions and the like.
• Additionally; The compulsion is washing of hands or the whole body, repeatedly many times a day.
• It usually spreads on to washing of clothes, washing of bathroom, bedroom, door knobs also personal articles, gradually.
• The person tries to avoid contamination but is unable to, so that washing becomes a ritual.

Checkers:

• In this type, the person has multiple doubts, e.g. the door has not been locked, kitchen gas has been left open, counting of money was not exact, etc.
• The compulsion, of course, is checking repeatedly to ‘remove’ the doubt.
• Any attempt to stop the checking leads to mounting anxiety.
• Before one doubt has cleared, other doubts may creep in.

Pure Obsessions:

• Generally, This syndrome is characterize by repetitive intrusive thoughts, either impulses or images which are not associated with compulsive acts.
• The content is usually sexual or aggressive in nature.
• The distress associated with these obsessions is dealt usually by counter-thoughts (for example counting) and not by behavioural rituals.
• A variant is obsessive rumination, which is a preoccupation with thoughts.
• Here, the person repetitively ruminates in his mind about the pros and cons of the thought concerned.

Primary Obsessive Slowness:

A relatively rare syndrome, additionally it is characterize by severe obsessive ideas and/or extensive compulsive rituals, in the relative absence of manifested anxiety.

This leads to mark slowness in daily activities. This sub type is quite difficult to diagnose in the routine clinical practice, unless the possibility of this subtype is keep in mind.

In clinical practice, one of the most useful scales is the Y-BOCS (Yale-Brown Obsessive Compulsive Scale). It can use to elicit the symptomatology and rate the severity of OCD.

The Y-BOCS classifies the symptoms and signs of OCD as follows:

1. Aggressive obsessions
2. Contamination obsessions
3. Sexual obsessions
4. Hoarding/Saving obsessions
5. Religious/Scrupulous obsessions
6. Obsession with need for symmetry or exactness
7. Somatic obsessions
8. Miscellaneous obsessions
9. Cleaning/washing compulsions
10. Checking compulsions
11. Repeating rituals
12. Counting compulsions
13. Ordering/arranging compulsions
14. Hoarding/collecting compulsions
15. Miscellaneous compulsions. [2]

General measures for all patients:

Psychoeducation

Problem-solving techniques and relaxation

Self-help books

Psychotherapy:

Psychoanalytic psychotherapy is use in certain selected patients, who are psychologically oriented.

Supportive psychotherapy is an important adjunct to other modes of treatment. Supportive psychotherapy is also need by the family members.

Behavior Therapy and Cognitive Behavior Therapy (in other words; CBT):

Behavior modification is an effective mode of therapy, with a success rate as high as 80%, especially for the compulsive acts. It is customary these days to combine CBT with BT at most centers.

The techniques used are listed below:

• Thought-stopping (and its modifications)
• Response prevention
• Systematic sensitization
• Modelling

Electroconvulsive Therapy (ECT):

In presence of severe depression with OCD, ECT may be needed.

ECT is particularly indicated when there is a risk of suicide and/or when there is a poor response to the other modes of treatment. However, ECT is not the treatment of first choice in OCD.

Drug Treatment:

1. Benzodiazepines (e.g. alprazolam, clonazepam) have a limited role in controlling anxiety as adjuncts and should be used very sparingly.

2. Antidepressants: Some patients may improve dramatically with specifi c serotonin reuptake inhibitors (SSRIs).

• Clomipramine (75-300 mg/day), a nonspecifi c serotonin reuptake inhibitor (SRI), was the first drug used effectively in the treatment of OCD. The response is better in the presence of depressive symptoms, but many patients with pure OCD also improve substantially.
• Fluoxetine (20-80 mg/day) is a good alternative to clomipramine and often preferred these days for its better side-effect profi le. Fluvoxamine (50-200 mg/day) market as a specific anti-obsessional SSRI drug, whilst paroxetine (20-40 mg/day) and sertraline (50-200 mg/day) are also effective in some patients.

3. Antipsychotics: These occasionally use in low doses (e.g. haloperidol, risperidone, olanzapine, aripiprazole, pimozide) in the treatment of severe, disabling anxiety.

4. Buspirone has also used beneficially as an adjunct for augmentation of SSRIs, in some patients.

5. Anxiolytic drugs are not recommending to use routinely in OCD, although they may be used in the short term whilst waiting for an SSRI to take effect.

Psychosurgery:

Psychosurgery can use in treatment of OCD that has become intractable, and is not responding to other methods of treatment. It is worth mentioning that psychosurgery is only available as a treatment choice at a very few centres throughout the world.

The best responders are usually those who have significant associate depression, although pure obsessives also do respond.

The main benefit is the mark reduction in associated distress and severe anxiety.

The procedures which can be employed are:

i. Stereotactic limbic leucotomy.

ii. Stereotactic subcaudate tractotomy.

Psychosurgery is usually followed by intensive behaviour therapy aimed at rehabilitation. [2]

Few of our amazing remedies in Homeopathic treatment of OCD include:

Arsenicum Album:

For persistent thoughts of death.

Indicated in people with fear of solitude, of spectres, and of robbers, with desire to hide oneself. Indecision and Changeable humour, which demands this at one time, that at another, and rejects everything after having obtained it.

Hyoscyamus Niger:

For persistent thoughts of sex.

Indicated in people who are obsessed with thoughts of sex. They constantly pick at clothes and resort to obscene gesturing.

Medorrhinum:

For persistent thoughts of washing hands.

Indicated when there is obsession to wash hands repeatedly. There is also an intense fear of going incomprehensible and the dark.

Natrum Muriaticum:

For compulsion to check locked doors repeatedly.

When there is such intense fear of being robbed that they keep checking locks. Obsessed about being in control of a situation.

Silicea:

For persistent thoughts of pins.

Obsessive fear of pins and needles. Keep collecting and counting them. These people are mentally very alert and oversensitive to sounds. [3]

Homeopathic treatment for OCD offers a minimum of 100 remedies effective against the disease.

THOUGHTS: Persistent: Disease, of: 1Alum, 1Aral, 3Ars, 1Aur, 1Chel, 1Cygn-c, 1Harp, 1Hura, 1Kali-p, 1Lepi, 1Loxo-r, 1Merc, 1Murx, 1Nat-m, 1Nat-p, 3Ph-ac, 1Phos, 1Sabal, 1Sep, 1Sulph, 1Tax-br, 1Zinc

WASHING, GENERAL: Hands, always, washes the: 1Allox, 1Ars, 2Carc, 1Coca, 1Cur, 2Lac-c, 2Med, 2Nat-m, 1Nat-sil, 1Plat, 2Psor, 1Sep, 1Sil, 2Sulph, 3Syph, 1Thuj

HOUSEKEEPING, GENERAL: Obsessed, with house cleaning: 3Ars, 2Calc, 3Carc, 1Lac-f, 2Nux-v,1Rhus-g, 1Sep, 1Sil, 1Sulph, 1Syph, 1Thuj

FEARS, PHOBIAS, GENERAL: Contamination, germs, of: 3Ars, 1Bor, 1Bov, 3Calc, 2Carc, 1Cur, 1Lac-c, 2Lach, 1Med, 1Nat-m, 1Psor, 1Sil, 3Sulph, 1Syph, 3Thuj

The remedy abbreviations with

• 4 marks- most effective,
• 3 marks- quite effective,
• 2 marks- less effective,
• 1 mark- least effective. [4]

Frequently Asked Questions

What is Obsessive Compulsive Disorder?

Obsessive compulsive disorder (OCD) is a condition characterized by obsessions and/or compulsions that the person feels driven to perform according to specific rules in order to prevent an imagined dreaded event.

Homeopathic Medicines used by Homeopathic Doctors in treatment of Obsessive Compulsive Disorder?

• Arsenicum Album
• Hyoscyamus Niger
• Medorrhinum
• Natrum Muriaticum
• Silicea

What causes Obsessive Compulsive Disorder?

• Genetics
• Structural organic abnormalities
• Neurotransmitters
• Autoimmune factors
• Early experience

What are the symptoms of Obsessive Compulsive Disorder?

• Obsessional thoughts
• Obsessional images
• Obsessional ruminations
• Obsessional doubts
• Obsessional impulses
• Anxiety and depressive symptoms
• Obsessional personality