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CHAPTER 1

INTRODUCTION

1.1. Background

Obsessive-compulsive disorder (OCD) is a relatively common, if not always recognized,

disorder that is often associated with significant distress and impairment in functioning. Due to
stigma and lack of recognition, individuals with OCD often must wait many years before they
receive a correct diagnosis and indicated treatment. In severe presentations, this disorder is quite
disabling and is appropriately characterized as an example of severe and persistent mental
illness.

The obsessions are usually related to a sense of harm, risk, or danger. Common
obsessions include concerns about contamination, doubts, fear of loss or letting go, and fear of
physically injuring someone.

More than 95% of people with OCD feel compelled to performed rituals which is
repetitive, purposeful intentional acts. This rituals define what we called a compulsion is. Rituals
used to control an obsession or neutralize it for example people who afraid of contamination will
wash his hand repeatedly until he is satisfy with it no matter how many times he might wash his
hand. These people are also known as washers, there are also other types for example checkers
and hoarders. Most rituals can be observed while others might need a detail history taking and
observation. Obsessions are not always accompanied by compulsion.

Most people with OCD are aware that their obsessive thoughts do not reflect actual risk
and that their compulsive behaviors are ineffective. OCD, therefore, differs from psychotic
disorders, in which one’s lose contact with reality. OCD also differs from obsessive-compulsive
personality disorder, in which specific personal traits are defined.

It is often helpful to individuals suffering from OCD to point out that anxiety comes first,
before the obsession or compulsion which are seen as defense against anxiety. The patient may
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otherwise regard them as evidence of madness. It should also be noted that depression and
anxiety are common in OCD.
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CHAPTER 2

OBSESSIVE COMPULSIVE DISORDER

2.1. Definition

An obsession is defined as an idea, impulse, or images which intrude into the conscious
awareness repeatedly. It is recognized as one’s own idea, impulse or image but perceived as
absurd or alien and irrational to one’s personality. The patient tries to resist against it but unable
to do s. Thus failure to resist will lead to marked distress to the patient.

A compulsion is define as a form of behavior which usually follows or associated with

obsession. It is aimed to either preventing or neutralizing the distress or fear arising out of
obsession. The behavior or rituals usually is not realistic and is either irrational or excessive.
Insight of the patient is present and so the patient realizes the irrationality of compulsion. The
behavior is performed with a sense of subjective compulsion which is urge or impulse to act on
obsessive.

2.2. Epidemiology

The prevalence of OCD estimated in the general population are between 0.5 to 1 percent.
About 10 percent of patient with neurotic disorder suffer from OCD and 1 percent are among the
psychiatric outpatient population. Minor obsessive compulsive symptoms may be present in up
to 17 percent of the population. Studies from United States of America (USA) suggest that 2 to 3
percent of the population may suffer from it at sometime at their lives.

The overall prevalence of OCD is equal in males and females, although the disorder more
commonly presents in males in childhood or adolescence and in females in their twenties.
Childhood-onset OCD is more common in males and more likely to be comorbid with attention
deficit hyperactivity disorder (ADHD) and Tourette disorder.
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Two thirds of individuals have an age of onset in the early 20s, before 25s years, with the
mean age of about 22 years. It can even begin in childhood with peak age of onset of 10 to 14
years old. Those with checking rituals have earlier mean age of onset of 18 years, compared to
other groups with mean age of 27 years. The course tends to be chronic with exacerbation.

OCD appears to have a similar prevalence in different races and ethnicities, although
specific pathological preoccupations may vary with culture and religion.

2.3. Etiology

Several causative factors have been explored in the past but no clear etiology of obsessive
compulsive disorder is known yet. Some of the important theories have been proposed and these
theories include:

2.3.1. Biological Theories

There is an increased genetic predisposition in first degree relatives (5-7%) and greater
concordance between monozygotic as compared to dizygotic twins. However the types of
obsessive and compulsive are not always the same in different affected family members. There is
also genetic association between Tourette’s syndrome, chronic motor tic disorder and OCD.
Indeed, up to 20 percent of individuals with OCD may have tics, which in turn are suggestive of
basal ganglia disorder.

There is also an increased incidence of OCD in those who have suffered brain injury, for
example due to head injuries, encephalitis or syphilis. Evidence for a neurobiological basis has
been accrued from positron emission tomography (PET) and magnetic resonance imaging (MRI)
techniques, in which orbitofrontal and cingulated cortices and basal ganglia abnormalities have
been found, as have reductions bilaterally in the size of the caudate nuclei and retrocallosal white
matter. These findings all suggest structural abnormalities in the brain in at least some cases of
OCD.

There is also evidence for abnormalities in serotonin (5-HT) transmission in the central
nervous system. Some children and adolescents develop OCD after β-haemolytic streptococcal
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infections, suggesting an autoimmune etiology. However, at present moment, there is no

conclusive evidence for OCD having clearly proven organic etiology.

2.3.2. Psychodynamic Theory

In Freudian psychoanalytic theory OCD originates at the anal training stage development.
When in early childhood, the anal sadistic phase was disturbed while this is the stage when the
child began to understand self autonomy. Due to harsh toilet training this child began to confuse
his own autonomy and others. The anal sadistic phase will regress together with the anxiety
related to oedipal conflicts at present thus then began to build reinforcement of anal or
aggressive impulses.

The anankastic personality trait will be disguised by the reaction formation and when this
is not enough the new defenses mechanism is created. The defenses mechanism are isolation of
affect that contributed for the obsessive thought, undoing which then contributed for the
compulsion, and displacement that acted out as phobias.

In the isolation of affect, the ego removes the affect from the anxiety-causing idea. The
idea is thus weakened, but remains still in the consciousness. The affect however becomes free
and attached itself to other neutral ideas by symbolic associations. Thus these neutral ideas
become anxiety-provoking and turn into obsession. This happens only when isolation of affect is
not fully successful. When both the idea and affect are repressed and there is no obsession. The
undoing will leads to compulsion which prevents or undoes the fear consequences of obsession.

This mechanism has been explained in slight detail as this theory attempts to describe the
probable causation of OCD in remarkably systematic manner. However, it must be remembered
that this is only a theory and whether it is true or not, is a matter of conjecture.

Thus, the psychodynamic theory explains OCD by defensive regression to anal-sadistic

phase of development with the use of isolation, undoing, and displacement to produce obsessive
compulsive symptoms.

2.3.3. Behavioral Theory

The behavioral theory explains obsession as condition stimuli to anxiety that is similar to
phobias. While compulsions have been described as learned behavior which decrease the anxiety
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associated with obsessions. This decrease in anxiety positively reinforces the compulsive acts
and they become ‘stable’ learned behaviors.

Behavioral or learning theory is not able to explain the causation of OCD adequately but
is very useful in its treatment.

2.4. Diagnosis

OCD is classified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth

Edition, Text Revision (DSM-IV-TR) as an anxiety disorder.[1 ]It is characterized by distressing
intrusive obsessive thoughts and/or repetitive compulsive actions (which may be physical or
mental acts) that are clinically significant. The specific DSM-IV-TR criteria for OCD are as
follows:

A. The individual expresses either obsessions or compulsions.

1. Obsessions as define by (1), (2), (3) and (4):

1. Recurrent and persistent thoughts, impulses, or images are experienced at some

time during the disturbance as intrusive and inappropriate and cause marked
anxiety and distress. Those with this disorder recognize the craziness of these
unwanted thoughts (such as fears of hurting their children) and would not act on
them, but the thoughts are very disturbing and difficult to tell others about.
2. The thoughts, impulses, or images are not simply excessive worries about real-life
problems.
3. The person attempts to suppress or ignore such thoughts, impulses, or images or
to neutralize them with some other thought or action.
4. The person recognizes that the obsessional thoughts, impulses, or images are a
product of his/her own mind (not imposed from without, as in thought insertion).
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2. Compulsions are defined by the following 2 criteria:

1. The person performs repetitive behaviors (eg, hand washing, ordering, checking)

or mental acts (eg, praying, counting, repeating words silently) in response to an
obsession or according to rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing or reducing distress or
preventing some dreaded event or situation; however, these behaviors or mental
acts either are not connected in a realistic way with what they are meant to
neutralize or prevent or they are clearly excessive.

B. At some point during the course of the disorder, the person recognizes that the obsessions
or compulsions are excessive or unreasonable. This does not apply to children.
C. The obsessions or compulsions cause marked distress; are time consuming (take >1 h/d);
or significantly interfere with the person's normal routine, occupational or academic
functioning, or usual social activities or relationships.
D. If another Axis I disorder is present, the content of the obsessions or compulsions is not
restricted to it, such as preoccupation with food and weight in the presence of an eating
disorder, hair pulling in the presence of trichotillomania, concern with appearance in
body dysmorphic disorder, preoccupation with drugs in substance use disorder,
preoccupation with having a serious illness in hypochondriasis, preoccupation with
sexual urges in paraphilia, or guilty ruminations in the presence of major depressive
disorder.
E. The disorder is not due to the direct physiologic effects of a substance or a general
medical condition. Specify if : The additional "with poor insight" is made if, for most of
the current episode, the person does not recognize that the symptoms are excessive or
unreasonable.
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2.5. Clinical Syndromes

ICD-10 classifies OCD into three clinical subtypes which are :

1. Predominantly obsessive thought or ruminations,

2. Predominantly compulsive acts (compulsive rituals), and
3. Mixed obsessional thoughts and acts

Depression is very commonly associated with OCD. It is estimated at least half the
patient of OCD have major depressive episodes while many other have mild depression. There
are several clinical syndromes have been described in literature, although admixtures are
commoner than pure syndromes. Those major clinical syndromes are:

i. Washers (contamination)
This is the most common type. Here the obsession is of contamination with dirt,
germs, body excretions and the like. The compulsion is washing of hands or the
whole body, repeatedly many times a day. It usually spreads onto washing of
clothes, bathroom, bedroom, door knobs and personal articles, gradually. The
person tries to avoid contamination but unable to, so washing becomes a ritual.

ii. Checkers (doubt)

In this type the person has multiple doubts, for example the door has not been
locked, kitchen gas has been left open, counting of money was not exact and etc.
the compulsion, of course, is checking repeatedly to remove the doubt. Any
attempts to stop the checking leads to mounting anxiety before one doubt has
been cleared, other doubts may creep in.

iii. Pure obsession (intrusive thought)

This syndrome is characterized by repetitive intrusive thoughts, 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
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dealt usually by counter-thought for example praying, “undoing” actions, asking

for reassurance and counting but not with rituals.

iv. Primary obsessive slowness (symmetry)

It is characterized by several obsessive ideas and or extensive compulsive rituals,
in the relative absence of manifested anxiety. This leads to marked slowness in
daily activity. Usually the person demand on being need for symmetry and precise
arranging so in order to neutralize it they will continue Ordering, arranging,
balancing, straightening until "just right" or perfect in their eyes.

v. Other symptoms patterns

There are other types such as hoarders who will found it hard to give or throw
away their things even if it not valuable at all. Others include the religious
obsession.

2.6. Differential Diagnosis

OCD is sometimes difficult to distinguish from certain other disorders. Obsession and
compulsion may appear may appear in the context of other syndromes, which can raised the
question whether obsession and compulsion are a symptom of another disorder or whether both
OCD and another disorder are present.

2.6.1. Other Anxiety Disorder

Both OCD and other anxiety disorders are characterize by the used of avoidance to
manage anxiety. However OCD is distinguish from other anxiety disorder by the present of the
compulsion. In social or specific phobias, fears are circumscribed and related by specific triggers
or social situation. Although the circumscribed situations may initially trigger obsession and
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compulsion in OCD, triggers in OCD become more generalize over time, unlike the triggers
from social phobia and specific phobias the evoking situation will remain circumscribe.

2.6.2. Gilles de la Tourrete’s syndrome

Complex major tics of Tourrete’s syndrome may be difficult to distinguish from OCD
compulsions. Both tics and compulsions are preceded by an intensive urge and are followed by a
feeling of relief. However, OCD compulsion are usually preceded by both anxiety and
obsessional concerns. Whereas in Tourrete’s syndrome the urge to perform a tic is not preceded
by an obsessional fears

2.6.3. Hypochondriasis

Fears of illness that occur in OCD referred as somatic obsession may be difficult to
distinguish from Hypochondriasis. Usually, however patients with somatic obsession have other
current or past classic OCD obsession that unrelated to illness concerns. Unlike patient with
OCD, patient of Hypochondriasis experience somatic and visceral sensation.

2.6.4. Obsessive Compulsive Personality Disorder (Anankastic)

Obsessive compulsive personality disorder is a lifelong maladaptive personality style

characterized by perfectionism, excessive attention to details, rigidity, indecisiveness, restricted
affect, lack of generosity, and hoarding. Although perfectionist and indecisiveness are relatively
common traits in patient with OCD, the distinction between OCD and OCPD is important.
Unlike OCPD, OCD is characterized by distressing, time consuming ego dystonic obsessions and
repetitive rituals aim at diminishing the distress engendered by obsessional thinking. In contrast
OCPD features are considers ego syntonic.

2.6.5. Other conditions

OCD can be distinguishing from schizophrenia by the absence of other schizophrenic

symptoms, and patient with schizophrenia usually do not have a good insight and also more
bizarre symptoms. Other condition include other tics disorder, temporal lobe epilepsy and
occasionally trauma and post encephalitic complications.
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2.7. Prognosis

Obsessive compulsive disorder can now be effectively treated in up to 70% of cases. The
prognosis tends to be worse the more reasonable the preoccupation, for example checking that
the house is looked before leaving home has poorer prognosis than pointless rituals such as
walking between the cracks in the pavement.

Other than that the outcome is worse when individuals do not realize their obsessions and
or compulsions are not reality based. Although up to 25 percent of patient may refuse cognitive
behavioral therapy, those who complete it show a 50 to 80 percent reduction in OCD symptoms
after 12 to 20 sessions

2.8. Treatment

2.8.1. Psychotherapy

There are two types of psychotherapy that can be done to OCD patient. The first one is
the psychoanalytic psychotherapy. This type of psychotherapy is used in certain patients who are
psychologically oriented especially those with anankastic personality. Secondly, is the supportive
psychotherapy which is an important adjunct to other modes of treatment. Supportive
psychotherapy is also needed by the family members.

2.8.2. Behavior and Cognitive Behavioral Therapy

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 the cognitive
behavioral therapy with behavior therapy. This involves graded self exposure and self imposed
response prevention of ‘undoing’ of obsession through compulsions, and / or cognitive therapy.
The techniques that often used are thought stopping, response prevention, systematic
desensitization and modeling.
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2.8.3. Drug Treatments

i. Benzodiazepines
For example alprazolam and clonazepam, but they have limited role in controlling
anxiety as adjuncts and should be used very sparingly.
ii. Antidepressant
Some patients may improve dramatically with specific serotonin reuptake
inhibitors (SSRi)
 Clomipramine (75-300mg/day), non specific serotonin reuptake inhibitors
(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 (20-80mg/day), is a good alternative to clomipramine and often
preferred these days for its better side effects profile.
 Fluvoxamine (50-200mg/day), marketed as specific anti-obsessional SSRI
drug, while paroxetine (20-40mg/day), and setraline (50-200mg/day) are
also effective in some patients.

iii. Antipsychotics
These are occasionally used in low doses in the treatment of severe, disabling
anxiety. Some example are haloperidol, risperidone, olanzepine, aripiprazole and
pimazole.
iv. Buspirone
Has also been used beneficially as adjuncts for augmentation of SSRI, in some
patient.

2.3.4. Electroconvulsive Therapy (ECT)

In the 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.
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2.3.5. Psychosurgery

In severe, intractable, chronic and incapacitating cases, where all other treatments have
failed, streotactic site specific brain surgery has been reported to be successful. This has included
the used of radioactive yttrium implants and more recently, non invasive proton, electron and X-
ray techniques. Anterior cigulotomy, capsulotomy and limbic leucotomy have also been found to
be effective in 25-30 percent of such cases. All involve the separation of the frontal cortex from
deep limbic structures. Sadly, psychosurgery only available as a treatment choice at a very few
centers’ throughout the world.
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CHAPTER 3

SUMMARY

Obsessive–compulsive disorder (OCD) is a mental disorder characterized by intrusive

thought that produce anxiety, by repetitive behaviors aimed at reducing anxiety, or by
combinations of such thoughts known as obsession and behaviors or rituals that is compulsion.

There were several theories suggesting the etiology of OCD and the most systematic is
the Psychodynamic Theory purposed by Sigmund Freud. It describe if the anal sadistic phase is
disturbed in the early childhood it can cause OCD in the later life. Other than that, two other
theories are the biological and behavioral theories.

The best treatment for OCD is behavioral therapy (BT) and cognitive behavioral therapy
(CBT) which have high success rate at 80%. Other modes of treatment are drug treatment that is
SSRI, TCA, benzodiazepines etc. and psychotherapy which consist of supportive and
psychoanalytic. Only when this modes of treatment can’t be done the psychosurgery and ECT is
an option.
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REFERENCE

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Synopsis of Psychiatry Behavioral Sciences/Clinical Psychiatry 9 th Edition, United Stated
of America, Lippincott William and Wilkins; 616-623

2. Michael B. First, 1994: Obsessive Compulsive Disorder, Anxiety Disorder, Diagnostic

Criteria from Diagnostic and Statistical Manual of Mental Disorder 4th Edition (DSM-4),
United States of America, American Psychiatric Association; 207-209

3. William M.G., (2010, March 8). Obsessive Compulsive Disorder. Emedicine, from
http://emedicine.medscape.com/article/287681-overview

4. Puri B.K., Laking P.J., Treasaden I.H., 2002: Obsessive-Compulsive Disorder

(Obsessive-compulsive neurosis);Neurotic and Other Stress- Related Anxiety Disorder,
2nd Edition Textbook of Psychiatry, Philadelphia, Churchill Livingstone; 217-221

5. Ahuja N., 2006: Obsessive-Compulsive Disorder; Neurotic, Stress Related and

Somatoform Disorders, A Short Textbook of Psychiatry 6 th Edition, New Delhi,Jaypee
Brothers; 101-105
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