OBSESSIVE COMPULSIVE

NEUROSIS

Obsessions & CompulsionsObsessions are recurrent (and persistent)

contents of consciousness (words, ideas, beliefs, thoughts, images, impulses), which are intrusive and are recognized as senseless.

Compulsions are obsession changed to action (repetitive, purposeful and intentional behaviours that are carried out according to certain rules or in a stereotyped way.

Epidemiology

• A very rare disorder. • Prevalence rates are around 0.05% of overt

disorder though • Unrecognized milder forms may be more common. • Obsessional symptoms are much more prevalent

(14%), particularly children (eg. rituals )• Sex distribution is equal • Onset in adolescence or young adults;

presentation delayed (7yrs). • Higher social class, intelligence and educational

attainment.

Aetiology- Genetic

• up to 1/3 of relations have obsessional traits • Predisposition. - Obsessive (or Anankastic)

personality: excessive cleanliness and order, conscientious, strict ethical code, rules, rigid, methodological, punctual, indecisive or doubts. Pedantic, thorough, consistent, attention to detail, perfectionist; dislikes half done tasks or interruptions; inflexible, non-adaptable, likes predictable & secure world; intolerant. Devoted to work instead of pleasure (advantageous in certain professions and occupations).

Aetiology-Environmental

• Psychoanalytic - According to Freud regression to anal stage.

• Parental over-concern with toilet training, cleanliness, and order; strict discipline & control of sexual & aggressive impulses. Reared in atmosphere where approval depends on conformity, model behaviour, academic performance rather than love and affection.

• Obsessional orderliness may be a defensive mechanic to hope with stress, loss of control or deterioration in cognitive capacity due to organic brain disease or injury.

CLINICAL PICTURE- Obsession

• Obsessional symptoms- Thoughts, ideas, beliefs, ruminations, images, impulses that repeatedly intrude into consciousness against the patients will. Though (s)he recognizes them as his/her own (viz. schizophrenia thought insertion), (s)he regards them as senseless or silly (good insight, reality sense); and tries to resist their occurrence.

• The common obsessional contents or themes are to do with:– Contamination - dirt, germs, poison, toxins, catching an illness.– Harm - accidental or deliberate impulse, such RTA or stabbing a child,

committing suicide (may take precaution or avoidance behaviour).– Doubt - repetitive, inconclusive, and circular arguments and counter

arguments (to do or not to do); ponders endlessly about decisions, ruminates and worries.

– Hypochondriacal - disease or illness: repeated checking for signs (e.g. lump in breast)

– Other - ideas, phrases, music, images of violent or sexual torture, death, decay, insects, snakes, obscenities or blasphemy (religous); which causes distress.

CLINICAL PICTURE- Compulsion

• Compulsions are repetitive acts or rituals based on obsessional thoughts. Their performance may transiently relieve some tension and anxiety (which builds up if the action is resisted) and is never pleasurable. – The action usually has a symbolic value in undoing, preventing,

neutralizing or dispelling an obsessional fear or thought (e.g. hand washing to clean contamination); may be magical thinking (Superstition) (e.g. rituals such as counting to a certain number will prevent an accident)

– Rituals may consist of repeating, checking, cleaning, avoiding or striving for perfection. (e.g. hand washing rituals, personal hygiene, dressing, checking doors and windows, counting)

– Recognized as senseless, silly, absurd; tries to resist but anxiety and tension builds up (severe struggle); gives into action but relief of anxiety only transient. Causes considerable distress, are time-consuming (hours) and significantly interfere with daily life or relationships. Incapacitating.

Differential Diagnosis

• Depression - secondary to obsessional illness, coincidental or primary (with obsessional symptoms)?

• Anxiety - underlies OCD (Obsessive Compulsive Disorder).

• Schizophrenia -Thought insertion, bizarre rituals and obsessions (insight in OCD).

• Other compulsive activities - eating disorders, pathological gambling, alcohol and drug abuse, certain sexual activities. These are pleasurable but not OCD.

• Organic illness -post encephalitic state, brain injury, dementia-"Organic orderliness".

Treatment

• Physical - – Drugs – Antidepressants, particularly if depression

present • Pure 5-HT uptake blockers have specific action in obsessional

disorders (i.e. serotonergic system may be involved in obsession e.g. Clomipramine, SSRI. )

– ECT - specially when depression is present.• Behaviour therapy

– Thought stopping technique – Response prevention (Apotrepic therapy )– Modelling / Flooding-exposure (in imagination, vivo) to

feared object e.g. dirt. – Rubber band– Paradoxical intention

• Surgery - stereotactic limbic Leucotomy

Course & Prognosis

• Usually continuous course with fluctuations. • Exacerbations with stress or

depression. • May decrease with age.• Believed to be poor prognosis but 40%

become symptom free • 10-15% deteriorate (give up

resistance)