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'I feel like something awful will happen' - managing OCD

Dr Laura Stevenson and Dr Ravindra Belgamwar discuss a common presentation of obsessive compulsive disorder

Case

A 40 year old lady was re-referred to psychiatry services by her GP after presenting with increased symptoms of anxiety. She had first developed difficulties as a teenager but these had remained relatively well-managed until the death of her husband three years ago. Since this time she has struggled with the recurrent unpleasant thought that something untoward would happen to her grandson if she did not perform tasks in certain ways or a repeated number of times. She found this very distressing and recognised the detrimental impact on her day to day functioning. Her mood was negatively affected and she had already been started on an antidepressant by her GP.

The problem

Obsessive compulsive disorder is categorised as an anxiety disorder according to the WHO’s International Classification of Diseases-10 (ICD-10).1 As with most mental disorders, its aetiology is multifactorial. The prevalence of OCD in the general population is reported to be 1.6%, with males and females affected equally.2 It commonly presents around the time of early adulthood and as well as being mentally distressing can lead to a significant decline in social functioning. Sufferers do often hide their symptoms, sometimes very effectively, therefore delaying diagnosis and treatment. It is not infrequently seen as a comorbidly with other mental disorders such as depression and substance misuse.

Clinical features

Obsessions and compulsions can occur in isolation but are frequently encountered together.3 Obsessions are defined as repeated, unwanted and intrusive thoughts or images that cause distress. They are often resisted as the suffered recognises their irrationality. Compulsions are repetitive, sometimes ritualistic behaviours that the sufferer feels compelled to do in order to try and alleviate this distress. Compulsions are much more difficult to resist and commonly involve the sufferer performing a mental or physical act.4 There is often a significant level of avoidant behaviour identified where the sufferer will distance themselves from situations likely to precipitate anxiety symptoms.

The most frequently reported obsessions are contamination, fear of harm, and order or symmetry, which are present in 37.8%, 23.6% and 10% of sufferers respectively.5 The most frequently reported compulsive behaviours are checking, cleaning and washing, and repetitive behaviours, which are present in 28.2%, 26.6% and 11.1% respectively.5

Diagnosis

In order for a diagnosis of OCD to be made, symptoms should be experienced on most days over a period of at least two weeks and be associated with distress or detriment to functioning.1 The obsessional thoughts should be recognised as the persons own, the thoughts or behaviours must be distressing and repetitive with at least one being irresistible and carrying out a behaviour must not in itself be pleasurable.1 A thorough history of the development and progression of symptoms is imperative, as is an understanding of the sufferer’s personal and social circumstances. Screening those potentially at increased risk, such as anyone already diagnosed with another mental disorder, or those attending with dermatological complaints, especially of the hands, is recommended.

Management

As with all mental disorders, an effective management strategy will involve a determination of the severity of symptoms, including the impact on day to day functioning as well as a comprehensive assessment of risk, with an emphasis on self-harm and suicide.3 For a large proportion of sufferers, treatment initially within the primary care setting with possible support from local Improving Access to Psychological Therapy (IAPT) services is appropriate, and referral to secondary mental health services should be reserved for those individuals who are more severely affected or who have failed to respond adequately.4

The main treatment approaches are psychological therapy and pharmacological.

Psychological therapy

This involves cognitive behavioural therapy that incorporates work on exposure and response prevention (EPR). This aims to challenge individuals’ thoughts and feelings to effect a change in behaviour. The EPR aspect involves gradually and safely exposing an individual to the situations that they find challenging while enabling them to manage distressing thoughts and feelings (which would usually lead to compulsive behaviours).

Pharmacological

The SSRIs are recommended as first line treatment, particularly fluoxetine, with the maximum treatment dose being 60mg.3 Prior to commencing, a full discussion about the risks and benefits of treatment should take place to allow the individual to make an informed choice. Regular monitoring is essential, particularly if there are concerns relating to self-harm or suicidal ideation and the dose should be adjusted according to response and the development of side effects. If effective, treatment should continue at the same dose for at least one year. If response is inadequate after a full trial of an SSRI (at least 12 weeks) then an alternative SSRI or clomipramine should be considered once compliance has been established. Other adjunct therapies should only usually be commenced under the supervision of psychiatry services.

Prognosis

While full recovery is achievable, it is recognised that for many individuals the course of OCD is relapsing and remitting. The use of a comprehensive relapse prevention plan, incorporating identification of early warning signs, may assist both individuals and professionals in acting quickly during times of increased difficulty.

Dr Laura Stevenson is a higher trainee in psychiatry at the North Staffordshire Combined Health Care NHS Trust

Dr Ravindra Belgamwar is a consultant psychiatrist/honorary lecturer at the North Staffordshire Combined Health Care NHS Trust

References

  1. http://www.who.int/classifications/icd/en/
  2. Kessler RC, Berglund P, Demler O et. al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry2005;62:593-602.
  3. Obsessive-compulsive disorder and body dysmorphic disorder: treatment Clinical guideline [CG31] Published date: November 2005. https://www.nice.org.uk/guidance/cg31
  4. David Veale, Alison Roberts. Clinical review: Obsessive-compulsive disorder. BMJ 2014;348:g2183
  5. Foa, E. B., Kozak, M. J., Goodman, W. K. et al (1995) DSM-IV Field trial: Obsessive Compulsive Disorder. American Journal of Psychiatry, 152:1, 90-96.

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Readers' comments (3)

  • I FEEL LIKE SOMETHING AWFUL WILL HAPPEN.

    This forty-year old woman, already started on an antidepressant by her GP, has "recurrent unpleasant thoughts that something untoward would happen to her grandson if she did not perform tasks in certain ways or repeated a number of times".

    "As with all mental disorders, an effective management strategy will involve a determination the severity of symptoms"

    Surely a safe and effective management policy must afford high priority in her differential diagnosis to the consideration that this presentation may be that of a serious adverse drug reaction to the "antidepressant" - presumably an SSRI, which the narrative implies may have been recently introduced?

    The first management recommendation for psychological therapy may be safer and more appropriate in this case?

    The introduction of Fluoxetine or other SSRI has the potential to increase SSRI-neurotoxicity and hence to precipitate violence.

    Were this to happen, this woman is vulnerable to a life threatening psychotropic drug-induced ADR being misdiagnosed as emergent "co-morbidity" with potential for detention and enforced "treatment" with antidepressants and antipsychotics increasing the neuro-toxicity

    SSRI induced:
    Emotional Blunting, Akathisia, Disinhibition, Disinhibited Aggression/Aggressiveness - in addition to SSRI induced risk of violence against self or others may be a precursor of a psycho-pharmcologically induced risk of unintended harm to her grandson and to herself. The management dilemma (were this to be the case) is intense.

    Something awful could indeed happen.

    The above potential aetiology of the presenting condition requires withdrawal of her SSRI which will potentially alleviate akathisia and its related violence against self and others, but only if the tapered reduction/dose titration is gradual enough to prevent SSRI-discontinuation induced exacerbation of akathisia, (and/or other features of SSRI-discontinuation syndrome).

    "The effects of psychiatric drugs are not specific. They impair higher brain functions and cause similar effects in patients, healthy people and animals"

    Ref: Professor Peter C Gotzsche. Nordic Cochrane Centre.
    10th January 2018. bmj.com/content/360/bmj.k9/rr-15

    (Responce to Editor's Choice: What Are Your Burning Issues For 2018). BMJ 2018;360:k9

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  • Vinci Ho

    I must say I yet to see the ‘superiority’ of ‘maximum’ dosages of antidepressant monotherapy , fluoxetine 60mg , Venlafaxine 375mg or Mirtazepine 45mg.
    I suppose the controversy narrative of antidepressants will go on forever.
    Even confining fluoxetine 60mg for 12 months as written in this article, has to be arbitrary and hence, subjected to variations in individual cases.
    OCD is a bloody difficult condition fundamentally especially under the clinate of poor investment in NHS mental health by government(s) forcing a low threshold to prescribe antidepressants in general practice.Even with CBTs , time is another essential resource to help these patients. Superimposed anxiety and secondary depression , with or without further adversities in life circumstances, just prolong the suffering.

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  • I feel something awful Has happened

    I’m an NHS doctor

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