Volume 2 Issue 12 December, 2012
Mr.X is a 22yr graduate belonging to middle socioeconomic family was admitted in medical ICU with fatal suicidal attempt. He was evaluated by the psychiatry team. Mr.X had Obsessional thoughts that he can get infected by any source and can transfer it to many, so had compulsions for cleaning repeatedly for hours. For last one year he had depressive symptoms, socio occupational dysfunction and prior suicidal attempt. He was diagnosed as Obsessive compulsive disorder, treated adequately which resulted in improvement of his functional status and wellbeing.
Obsessive compulsive disorders (OCD) have a long history. In the 17th century, obsessions and hand washing rituals were immortalized by Shakespeare in the guilt ridden character of ‘Lady Macbeth’. Obsessive‐compulsive disorder is the fourth commonest mental disorder leading to disability and poor quality of life. Prevalence of OCD is around 1‐3 % (Rasmussen, 1994). It is usually found to be equal in males and females (Phillips et.al 1998). It is seen in children with distinct phenomenology than adults. Phenomenology of OCD consists of obsessional ideas, thoughts, images and impulses which are unwanted, repetitive, intrusive and irrational, also ego alien (Own thought but occurring against wish ) resisted unsuccessfully by the suffering person leading to significant anxiety. Compulsions are thoughts or actions (Behavior) preceded by obsessions which will reduce anxiety temporarily. The commonest obsessions are fear of contamination, aggressive thoughts, images & impulses, need for symmetry, sexual, religion and doubts. The common compulsions are cleaning, washing, Checking and Hoarding. Most patients have multiple obsessions and compulsions over time although a particular obsession may dominate the clinical picture at any one time.
Etiology of OCD is biological with genetic predisposition lead by abnormalities at specific genes (Andrew, 1990), altered levels of various neurotransmitters like Serotonin, noradrenaline, dopamine, glutamate and their receptor abnormalities. Others are Behavioral and cognitive models on the basis of which CBT (cognitive behavioral therapy) techniques have been developed. There are many brain structures implicated in relation to OCD which is the basis of psychosurgeries, like Basal ganglia (Cummings, 1993). Some infectious causes implicated like the production of certain antibodies, when directed to parts of the brain might be linked in some way to Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection (PANDAS)(Swedo1998).
Course of OCD Varies from person to person, but it has waxing and waning course with depressive episode as common comorbid illness. Underlying Obsessive compulsive personality can also worsen the course of OCD (Samuels’s et.al 2000). There are various modalities of treatments ranging from Pharmacological to psychosurgeries. More useful is combination is CBT and Pharmacological (Chamberlein 2007). SSRI (selective serotonin reuptake inhibitors) are most commonly used drugs but tricyclic antidepressants especially Clomipramine can be beneficial. CBT includes ERP (Exposure and Response Prevention), thought stoppage (Foa, 2005) etc. Psychosurgeries like stereotactic cingulotomy are indicated rarely in treatment resistant cases.
Its needs to be emphasized that OCD is severely disabling condition and doctors should make an effort to identify OCD early to help individuals to improve their quality of life by early interventions.
MVJ Medical College, Bangalore
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