Obsessive Compulsive Disorder

CHAPTER I

INTRODUCTION

Obsessive-compulsive disorder (OCD) is one of the most common psychiatric

disorders and can often cause impairment in everyday life with a prevalence of

around 1-3%. At least 92% of OCD sufferers have difficulty starting relationships

because of a lack of confidence, 58% have difficulties in education, 47% have

difficulties in working, and 40% are unable to work. Most OCD sufferers feel

ashamed and hide their complaints for years before seeking treatment, so very few

OCD sufferers receive appropriate pharmacological and psychotherapeutic therapy.

About 75% of people with OCD also have comorbid psychiatric disorders, such

as attention deficit hyperactivity disorder (ADHD), disruptive behavior disorder,

major depression, other anxiety disorders, and alcohol addiction in adults. 3

According to the Diagnostic and Statistical Manual for Mental Disorders 3rd edition

4 (DSM IV), OCD is classified as anxiety disorder along with social phobia, specific

phobia, panic disorder, post traumatic stress disorder (PTSD), and generalized anxiety

disorder. Then, in the 5th edition of the DSM (DSM V), OCD is classified as

obsessive compulsive related disorders (OCRD) which also includes excoriation

disorders, body dysmorphic disorder, and trichotillomania.

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 CHAPTER II

LITERATURE REVIEW

A. Definition

According to the DSM, obsessions are defined as thoughts or ideas that are

disturbing, difficult to control, and cause anxiety. Meanwhile, compulsions are

defined as the urge to do a habit over and over again in response to an obsession.

In general, the obsessions suffer from themes of contamination, preventing harm

to someone or something, uncertainty, taboo topics such as sex, violence, and

defamation, and the need for order and symmetry.

B. Epidemiology

Over a year, OCD in the United States has a prevalence of 1.2 percent, with

severe cases accounting for nearly one third of all cases. There is also a lifetime

prevalence of 2.3 percent in the United States. In an epidemiological sample, the

median age at onset was 19 years, with about a quarter of cases beginning at age

10. Onset in men usually occurs at a younger age than in women. A recent meta-

analysis reported that pregnant and postpartum women, compared with women in

the general population, are one and a half to two times more likely to have OCD.

Individuals who have had an autoimmune Group A Streptococcal infection have

also been associated with some cases of OCD that appeared suddenly in

childhood. Some cases of OCD have also been associated with a history of head

trauma

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C. Etiology

1. genetics

Most people with OCD have immediate family members who suffer from

the same thing. Studies on twin adults state that obsessive-compulsive

symptoms tend to be inherited with genetic factors contributing by 27-

47%. In children, genetic factors play a role of 45-65%.

2. Environment

53-73% of OCD sufferers are influenced by the surrounding environment.

For example during the COVID-19 pandemic, due to isolation and

restrictions on community activities, around 0.5-3% of children and

adults started suffering from OCD symptoms. 8

3. Gender

Among adults with OCD, the male:female sex ratio is 1:1.2. In children,

boys experience OCD more often than girls, 2:1 to 3:1, while the sex ratio

shifts after puberty to 1:1,4.9

D. Diagnosis

According to DSM V, the criteria for the diagnosis of OCD are as follows10:

1. Obsessions or compulsions:

Obsession as defined by (a), (b), (c), and (d):

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 a. Recurrent and persistent thoughts, impulses, or images experienced at

some time during the disturbance that are disturbing, inappropriate,

and cause marked anxiety or distress.

b. Thoughts, impulses, or images are not simply due to excessive

worrying about real life problems.

c. The person tries to ignore or suppress thoughts such as these impulses

or images, or tries to neutralize them with other thoughts or actions.

d. The person recognizes that the obsessive thoughts, impulses, or images

are a product of their own thoughts (not imposed from outside as in

thought insertion).

Compulsions as defined by (a) and (b):

a. Repetitive behaviors (eg washing hands, organizing, checking) or

mental acts (eg praying, counting, repeating words silently) that the

person feels compelled to perform in response to an obsession or

according to rules that must be applied rigidly.

b. Behaviors or mental acts aimed at preventing or reducing anxiety or

preventing some feared event or situation; however, these behaviors or

mental acts do not realistically relate to what they are doing to

neutralize or prevent or are clearly excessive.

2. At some point during the course of the disease, the person has: realized

that the obsessions or compulsions were excessive or outrageous

3. The obsessions or compulsions cause marked distress, are time

consuming (take up more than 1 hour a day), or significantly interfere

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 with the person's normal routine, occupational (or academic) functioning,

or social activities and relationships.

4. If another Axis I disorder is present, the content of the obsession or

compulsion is not limited to that disorder.

5. The disturbance is not due to the direct physiological effects of a

substance (eg, drug of abuse, medication) or another medical condition.

E. Differential Diagnosis

1. Schizophrenia spectrum

The boundary between OCD and schizophrenia spectrum disorders

(schizophrenia, other non-affective psychoses and schizotypal personality

disorder) is not clear. This ambiguity occurs through ideas such as OCD

“with psychotic features” or “with delusions” (DSM V). OCD symptoms

are often clinically striking in patients with schizophrenia spectrum

disorders. Therefore, it may be a differential diagnosis, especially in

young patients and first contacts

The diagnosis of OCD requires exclusion of schizophrenia and mania-

depressive illness. The compulsions in OCD require an underlying true

obsession. Obsessions in OCD are considered essential, as opposed to

obsessive-compulsive symptoms with a lack of resistance in

schizophrenia or organic disorders. To evaluate the possibility of an

underlying affective disorder, typical previous depressive or manic

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 episodes and episodic occurrences of obsessive-compulsive

symptomatology need to be emphasized.

2. Sexually oriented OCD

There have been many reported cases of sexually oriented OCD such as

OCD with the theme of pedophilia. For example, a parent changing a

baby's diaper experiences intrusive thoughts focused on the genitalia. So,

he checks if there are signs of sexual stimulation on him or also called

somatic checking symptoms. Excessive attention to the genitalia actually

causes little stimulation that results in fear and guilt. This case is quite

difficult because the wrong diagnosis can cause trauma to the sufferer and

his family. 12

3. Autism spectrum disorder

Obsessive-compulsive disorder is frequently reported in individuals with

autism, but repetitive and intrusive thoughts and behaviors exist in both

conditions and are difficult to distinguish. In autism spectrum disorders,

the repetitive behaviors vary in type and severity and include stereotyped

motor behaviors, such as hand flapping, swinging, shaking their fingers in

front of their eyes, or more complex behaviors, such as urges to follow

the same routines in everyday life. , arrange objects, and watch the same

videos over and over again. In contrast to OCD, some repetitive behaviors

in autism spectrum disorders may not cause distress, but may be activities

that they enjoy or entertain. 13

4. Generalized anxiety disorder

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 The worrying in generalized anxiety disorder is similar to the obsession in

OCD in that both refer to unwanted and time-consuming repetition of

thoughts. When OCD symptoms lack compulsions, OCD will be

mistaken for generalized anxiety disorder. The obsessions in OCD are

more likely to have whimsical themes while fears of generalized anxiety

disorder are more general and about realistic everyday life problems.

F. Management

Clinical recovery and full remission do not occur quickly. Thus, the goals of

ongoing treatment are to reduce the frequency and severity of symptoms,

improve the patient's function in daily life, and help the patient to improve

his/her quality of life. Treatment goals also include increasing the patient's ability

to cooperate with therapy, minimizing side effects of treatment, helping patients

develop coping strategies for stressors, and educating patients and families about

the disorder and its treatment.

Selective serotonin reuptake inhibitors (SSRIs) are the most common type of

medication prescribed for the treatment of OCD. SSRIs are often used to treat

depression and also help treat symptoms of OCD. With SSRIs, it may take 8 to

12 weeks before symptoms start to improve, and treatment for OCD may require

higher doses. Before the SSRI, the tricyclic antidepressant clomipramine was a

treatment for OCD. However, it has more side effects.16,17

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For some people, this drug has side effects such as headaches, nausea, and

difficulty sleeping. Each individual's response to treatment is different, but most

OCD sufferers find a combination of medication and psychotherapy helpful.

G. Prognosis

Current treatments for OCD are still effective in many patients. However, many

people with OCD experience partial remission of their symptoms with a course

that can fluctuate over time. Often, there can be a relapse of symptoms for no

apparent reason. One strategy is to record the progress of each individual and

mark potential stressors that can trigger patient relapse

Approximately half of patients with OCD fail to recover with SSRI treatment. A

9-year follow-up study of 142 children and adolescents with OCD found that the

main predictor for persistent OCD was disease duration at diagnosis. Adolescents

with less severe symptom severity, higher insight, and no coexisting psychiatric

disorder show better progress on treatment than those with coexisting disorders

such as ADHD, tic disorders, and defiant behavior disorder respond more poorly.

A study also reported that poor treatment response was found in patients with

older age of onset, worse quality of life at onset, shorter follow-up duration,

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 CHAPTER III

CONCLUSION

Obsessive-compulsive disorder (OCD) is a psychiatric disorder that causes unwanted

thoughts or sensations (obsessions) with the urge to do something repeatedly

(compulsions) in response to the obsession. The obsessions and compulsions in OCD

are characteristic and distinguishable from those of other psychiatric disorders. The

most common OCD themes are contamination, preventing harm to someone or

something, uncertainty, taboo topics such as sex, violence, and defamation, and the

need for order and symmetry.

OCD can occur in children to adults. Most OCD sufferers have nuclear families who

have similar complaints. The onset of symptoms, the presence or absence of

comorbidities, and adherence to medication can determine the outcome of OCD

therapy. It is also important to educate the patient and family about the disorder and

the stressors that can lead to a relapse.

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