Obsessive compulsive disorder
GP Dr Stephan Cembrowicz talks with consultant psychiatrist Dr Paul Dedman about advances in the management of obsessive compulsive type disorders
n obsessive compulsive disorder there are obsessions which are recurrent, persistent ideas, thoughts, impulses or images. These are experienced by the patient as intrusive and inappropriate and cause marked anxiety and distress. The person recognises them as their own thoughts, but they are alien to their personality and to their better nature. They may attempt to ignore, suppress, or neutralise them.
The obsession is often linked to compulsions or rituals. These are repetitive or seemingly purposeful behaviours that are not irrational in themselves, but are exaggerated in frequency or duration. The person is compelled to perform them in response to an obsession or according to rigid rules, and there is usually a desire to resist performing these rituals. The obsession increases anxiety, but the ritual decreases it.
Examples of obsessive compulsive disorder include habitual washing. Sufferers have obsessions that they've been contaminated or dirtied in some way, either by faeces or by chemical contaminants or something that would harm them, and so they feel the need to wash repeatedly. Other examples include habitual checkers: people who can't leave the house in the morning without checking that the cooker and all taps, plugs and switches are turned off. They tend to check these things several times.
These rituals can take considerable amounts of time, and can grow to dominate the whole day. I've had patients who don't get to their appointments on time because it may take them several hours to actually get out of the house.
I've known patients who have found it hard to keep a job because their morning routine involves having to get up at four in order to shower in the way that they feel is right, and if something minor happens to upset the progress for example if they touch something that they consider to be dirty they might have to repeat the whole process again.
How can this phenomenon be explained?
I don't think there's any single all-encompassing theory of OCD. Obviously checking, to some extent, is part and parcel of human functioning and obviously in some situations, and indeed in some occupations, it is quite vital. But in these people the mechanism is obviously out of kilter. We know from functional imaging that there is over-activity in certain parts of the brain such as the cingulate cortex, caudate nucleus and frontal lobes. This has led to the so-called fronto-striatal hypothesis of OCD.
We know there also seems to be a link with serotonergic brain pathways and this has stemmed from the relative success of treatments involving SSRI antidepressants, which work on these pathways. There are also some interesting imaging studies showing the over-activity in these areas being altered by successful drug or behavioural treatment.
How common is it, and who gets it?
Estimates of prevalence range from 2 to 3 per cent of the population in the USA down to 1 per cent in the UK. The mean age of onset is about 20, although there appears to be both an early-onset group where it occurs in childhood and adolescence, and then a later-onset group in the 20s or 30s. The sex ratio is about one to one, although males tend to have an earlier onset and sometimes more severe symptoms. OCD is the fourth most common psychiatric disorder behind phobias, substance misuse and depression.
The course of the illness appears to be chronic, and there is a precipitant identified in about a third of cases. An early finding was that there appeared to be a remission during military service. OCD is often also related to mood and coexists with depression.
There appears to be a group of other disorders that have become known as OCD spectrum disorders, as they are often found in close relatives. In Tourette's syndrome, 11 per cent of patients have family members with OCD. Other spectrum disorders include pathological gambling, trichillotomania, body dysmorphic disorder and anorexia nervosa. Almost all patients with anorexia nervosa can be considered to have OCD.
What modes of treatment are effective?
There are two main approaches. First, medication: drugs that affect the serotonin system are generally effective. These include clomipramine, and the more modern SSRIs such as paroxetine or fluoxetine. When using these medications with OCD, response is often delayed by three to four months. Doses need to be quite high, often higher than in depression, for example 200mg of chlomipramine, or 50mg of paroxetine. Drug treatment seems to be effective in around 50 per cent of cases.
The second major strand of treatment is cognitive behaviour therapy. This derives from the theory that as an obsession is anxiety-provoking, anxiety levels will rise until the individual feels the need to perform the ritual in order to be comfortable. The reduction in anxiety acts as a reinforcer and brings about further ritualistic behaviour.
Behaviour therapy consists of exposure (to the anxiety produced by the obsession) and response prevention (not performing the anxiety producing ritual) so that anxiety levels rise and have to be endured. Habituation occurs and the anxiety slowly falls. Once this process has been repeated several times the person is less likely to feel the increasing anxiety with the obsessional thinking, and the obsessional thoughts themselves become less intrusive.
It works particularly well where there is a defined ritual or behaviour that can be prevented. It is not so easy when there is no clear ritual, as for example with obsessional fears. In these cases cognitive therapy is useful, and the person is helped to work through a rational system of thinking to get their obsessional thinking in perspective.
Not all obsession is pathological. Some people with obsessional personalities fit very well into certain professions. It's really a question of whether the individual is distressed by the amount of time they spend on obsessions and compulsions.
Although some therapists prefer to adopt either a medication or a behaviour approach, I'm happy using both.
I start with behaviour principles to give the individual an understanding of their condition and how they are perpetuating it. This may mean involving companions who unwittingly contribute to the problem, for example by helping people do their checking.
It's a good idea for patients to read as much as possible about the condition. Often, after one or two sessions there is a big improvement. I don't have any problem about prescribing medication and using behaviour therapy together. It is often possible to break the habit initially with medication and go on to behaviour therapy. As this is a chronic condition patients must expect it to wax and wane, and I look for ways of helping them cope rather than promising a cure.
How successful can treatment at GP level be?
This condition is so common it's probably impractical for everyone who has OCD to be referred to a consultant. There is a lot GPs can do if they have some basic knowledge of the condition, and if there is somebody in the practice with behaviour therapy skills, such as a counsellor, they can help too.
But the condition can be very severe and I have certainly seen individuals who are as incapacitated by it as any schizophrenic. These people certainly need specialist psychiatric input.
Clinical psychologists and nurse cognitive behaviour therapists can also do a lot to help OCD sufferers in conjunction with the GP, so it's not always necessary to involve a psychiatrist.
I would also stress the importance of self-help books for a well-motivated patient. Living With Fear by Isaac Marks and Stop Obsessing by Edna Foa and Reid Wilson are good ones.
What is the outlook for patients with OCD?
The outlook has changed considerably since the days where psychoanalytic treatment was the only treatment offered, and success rates were very low. Most patients can now be helped considerably, and some do very well.
It's important to realise it is a chronic condition and it's likely to change its form over the years and to recur. But the principles of treatment remain the same, and people who have been through the process are often able to help themselves when they suffer a relapse.
What future developments are emerging?
Neuro-imaging studies are developing some very exciting ways of looking at the pathogenesis, and together with the coexistence of OCD spectrum disorders do point to an organic cause.
But we're a long way from a
definitive medical treatment, and the main gains in the next few years will be to increase the availability of psychological treatment. Innovations include computer programs on the internet and a telephone-based system.
Obsessive compulsive disorder
UK-based website with a wide range of information for patients, family and doctors
Dublin-based website, wide variety of resources
UK treatment guidelines
US-based self-help organisation
International self-help organisation with 10,000 members
·De Silva P, Rachman S. Obsessive-compulsive disorder: the facts. Oxford: Oxford University Press, 1992
·Foster CH. Polly's Magic Games: A Child's View of Obsessive-Compulsive Disorder. Ellsworth, MA: Dilligaf, 1994
·Foa EB, Wilson R. Stop obsessing. New York: Bantam, 2001
·Marks I. Living with fear. Maidenhead: McGraw-Hill Education, 2001