How can I tell if I'm OCD?| Obsessive Compulsive Disorder (OCD)

What is Obsessive–compulsive disorder (OCD)?

 Obsessive–compulsive disorder (OCD) is a mental disorder in which patients experience a group of obsessions and/or compulsions. Obsessions are defined as repetitive, intrusive, and unwanted impulses, thoughts, images or urges. Obsessions mostly occur with anxiety. Compulsions are defined as repetitive behaviours performed in response to obsessions that patients feel driven to do so in order to feel a sense of relief. According to multiple cognitive behavioural theories, obsessions are often associated with anxiety and discomfort and compulsions are performed in response to them. It is difficult for children to recognize obsessions. Most OCD patients want to control their compulsions and admit that these compulsions are excessive. One of the main features of OCD is avoidance as patients tend to avoid obsessions through limiting multiple activities that may trigger these obsessions. OCD affects about 1% to 3% of global population.

What are the risk factors and aetiology of OCD?

1-GENETIC:



The aetiology of OCD is unclear however, multiple factors may play a role. About 45 to 65% of OCD is due to genetic factors in children and 27% to 45% in adults. Studies on mice and humans showed that mutations in NMDA especially the NMDA subunit “NR2” were related to OCD-like behaviour such as fear of contamination and compulsive cleaning. Family history of OCD increases the risk of OCD in relatives.
Most genetic studies examined the genes of neurotransmitters involved in the pathophysiology of OCD such as serotonin, dopamine, and glutamate. Studies of animal models of OCD-like behaviours identified several candidate genes such as SAPAP3 and SLITRK5. Another OCD candidate gene encodes the neuronal glutamate transporter EAAT3 is SLC1A1 and is considered the strongest OCD candidate gene. However, SLC1A1 is still not a definitive risk gene for OCD. 

2-THOUGHTS:


Increased sense of responsibility, inability to cope with uncertainty and magical thinking.

 

3-INFECTION:


Streptococcal infection may be related to OCD. The PANDAS (paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) is characterized by early onset of sudden OCD following a streptococcal infection. This may be attributed to the autoimmune antibodies against basal ganglia which is known as "molecular mimicry" leading to obsessive thoughts and compulsive behaviour. Another term is CANS (childhood acute neuropsychiatric symptoms) that attributes OCD in children to metabolites, toxins, and multiple factors other than streptococcal infection.


4-NEUROLOGICAL:


Some neurological disorders are related to OCD especially disorders affecting the cortico-striato-thalamo-cortico tracts including  Sydenham chorea, Huntington disease, Parkinson disease, Traumatic Brain Injury (TBI), and Epilepsy.



What are the symptoms of OCD?

Examples of Obsessions include:



-Intrusive sexual or aggressive thoughts
-Uncertainty about memory or perception
-Fear of Contamination
-Excessive worrying about safety of the person itself or the surroundings
-Excessive care to arrange things according to symmetry
-Scrupulosity (Doing the right thing in the right way)



Examples of compulsions include:



-Repeated cleaning or hand washing due to fear of contamination
-Making lists and arranging objects in a specific order
-Frequent checking of locks, stove, lights ..etc. and excessive care about safety
-Seeking reassurance
-Repeated and frequent touching objects
-The action of counting numbers until feeling relieved.


In addition to these common symptoms, OCD patients may present with less common manifestations including:
-Obsessional jealousy
-Musical obsessions



Signs found in the skin in case of OCD include:

-Loss of hair due to trichotillomania or compulsive hair pulling
-Eczema due to excessive washing
-Excoriations due to neuro-dermatitis or compulsive skin picking



How to Diagnose OCD?

Diagnosis of OCD includes determination of the severity of symptoms for example using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and identifying comorbid disorders through complete mental examination. Imaging tools are mainly used for research purposes of OCD rather than diagnosis of the disease.
In 2013, The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) was released and included OCD and other disorders such as trichotillomania, hoarding disorder, excoriation disorder, and body dysmorphic disorder.


1-According to the American Psychiatric Association, OCD is defined as the presence of obsessions, compulsions, or both and this is explained as the following:



-Obsessions:


The presence of the following:
-Intrusive, unwanted, recurrent, and persistent thoughts, urges, or images that cause distress and anxiety to the person.
-Attempts to ignore or suppress the experienced thoughts or images are performed by the person.



-Compulsions:


The presence of the following:
-In response to obsessions, repeated actions or behaviours such as checking, hand washing, counting, ordering, and praying are performed by the person who experienced these obsessions.
-These actions or behaviours are performed mainly to achieve a sense of relief or to reduce the distress but they are obviously excessive which can be easily noticed




2-Imaging modalities:



Diagnosis of OCD using imaging modalities such as functional MRI and PET scan, have shown right sided predominance and increase in metabolic activity and blood flow of certain areas including thalamus, limbic structures, caudate, and orbitofrontal cortex. Normalization of these areas after treatment with Selective Serotonin Reuptake Inhibitors (SSRIs)  or Cognitive Behavioural Therapy  (CBT) was proven by some studies.




3-The Yale-Brown Obsessive Compulsive Scale (Y-BOCS):



The Y-BOCS is used for assessment of the severity of OCD symptoms and to monitor the response to treatment. It is formed of 10 items with total score = 0-40. Items distributed equally, 5 items for obsessions and 5 items for compulsions. Each item is scored 0-40. The items of the scale measure distress, interference with functions, the time spent, the resistance and control.



4-A complete Mental Status Examination:



Orientation, mood and affect, memory, judgment, delusions, hallucinations, suicidal and homicidal risks should be evaluated.


5-Other associated disorders should be considered and evaluated such as tic disorders. Neurological and cognitive examination is usually normal in case of OCD, however, if impaired other disorders should be evaluated. 

Management and Treatment of OCD: 

The American Psychiatric Association (APA) Practice Guidelines indicated pharmacotherapy particularly “SSRIs” along with CBT as first-line treatment of OCD.



1-Psychotherapy:



One of the first-line evidence-based treatments for OCD is Cognitive Behavioural Therapy (CBT) with exposure and response prevention (E/RP). Studies showed obvious reduction in the symptoms of OCD with remission of about 42-52% of patients undergoing psychotherapy. Other studies detected more improvement in patients after CBT compared to patients receiving pharmacological treatment such as SSRIs confirming that CBT is more efficient than pharmacological treatment with fewer side effects and relapses.
However, SSRIs remain the most cost-effective treatment in clinical practice. Some patients SSRIs due to the anxiety experienced during CBT sessions. A systematic meta-analysis showed that more 15% of patients refused CBT and about 16% dropped-out. Rates of dropouts are lower in internet based CBT, acceptance and commitment therapy (ACT), and group CBT. Better results were found in the treatment of OCD using ACT alone or combined with E/RP.




2-Pharmacological treatment:

*Serotoninergic agents:


Serotonin disturbance was found as a contributor to the mechanism of OCD:
-A hypothesis suggested that the sensitivity of 5-HT2 receptors increased in OCD patients as patients showed more significant neuroendocrine effect in response to stimulation with an agent having high affinity for 5-HT2 receptors compared to the healthy control group.

 
This explains the higher efficacy of antidepressants with a serotonergic action compared to antidepressants with primary norepinephrine action. It is recommended to use SSRI monotherapy as anti-obsessive agents for patients who are non-compliant for psychotherapy. The dosage and latency of SSRI until a response becomes noticed in the treatment of OCD, are different compared to using SSRIs for depression in which they are more efficient in higher doses. The action and response of SSRIs are complex. A review of seventeen randomized clinical trials showed an effective SSRIs response after only 2 weeks, a meta-analysis identified 10-12 weeks as a minimum time to see a clinical improvement, and some studies suggested waiting for longer periods (up to 28 weeks) to see improvement after starting SSRIs.
A Frequent medical monitoring is required when using high doses of serotonergic agents including: -ECG monitoring due to the risk of QT prolongation.
-Liver enzymes and electrolytes monitoring at 1, 2, 3, 6, and 12 months after starting the treatment and then once a year if no side effects are detected.
-If serotonergic agents are combined with other drugs such as monoamine oxidase B inhibitors, serotoninergic syndrome may be a side effect requiring a careful administration of the combination.



OCD tends to overlap with other mental disorders however, biology and assessment can differentiate between these disorders in order to implement the proper management which also differs according to each disorder.



References:

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