OCD: When there’s too much of one thing

Cleanliness is universally appreciated. Checking that doors are locked, windows shut and electrical appliances turned off before leaving a place are good safety measures. Tidy work stations and well-maintained homes are a sign of good organisation.

Sometimes the tendency to clean, check or organize can go well beyond what is necessary and become exhausting and counterproductive. This is called Obsessive Compulsive Disorder.

Time and energy are wasted and things that need to be done are neglected. ‘Obsessive’ refers to repetitive, intrusive thoughts, and ‘compulsive’ refers to repetitive actions; either one or both may be present in one individual.

Obsessive thoughts, images and impulses are impossible to drive out, ignore or suppress. They repeatedly intrude into the patient’s consciousness, derail his line of thought and impair his concentration.

Studying for an examination with a parallel track of obsessions constantly vying for your attention can be extremely difficult.
Compulsive symptoms differ from person to person but fall into one of these clusters: cleaning, checking, hoarding/collecting or ordering. Essentially, a normal action, for example washing hands or checking a lock, is repeated several times.

The mind of a person with OCD is constantly at odds with itself.
Imagine a patient whose primary symptom is the need to wash his hands and get them ‘completely clean’ before eating. He washes them several times, maybe even a set number of times, then closes the tap. He feels that the tap has contaminated his hands, and washes them again. Finally he wipes his hands on a towel. He has a doubt that the towel is dirty and feels compelled to wash his hands again. Finally he sits down to eat. He worries that the plate and silverware are not clean. The underlying cause is doubt, or an absence of a feeling of goal completion.

About 2% of people worldwide have OCD. It usually presents in adolescence but can occur later, or even in childhood. There could be a genetic basis as other people in the family often have OCD or a related disorder.

Sometimes a patient decides to meet a doctor after several years of worrying and coping.

Other times, someone who spends a lot of time with him points out that his actions don't make sense, and suggests seeing a doctor.

Curiously, couples sometimes present with marital disputes about one partner’s excessive cleanliness and the other’s sloppiness, often because of undiagnosed OCD in the former!

What happens in OCD?
Let’s take an example. If you were preoccupied when you left home for work, you may have a sudden doubt that you have forgotten to lock the front door. It is a vague thought to begin with. A moment later it becomes a conviction with a strong feeling attached, impelling you to go back and check. Once you have checked you feel satisfied. However, if your doubt was a result of OCD, you may check several times and still not be totally satisfied.

Why does this happen?
The anterior cingulate cortex, or the part of the brain that generates the doubt, normally receives feedback when an action is complete from the striatum, which is the part that causes the strong feelings. A break in this pathway is the basis of lingering doubt. The break is a chemical one involving different neurotransmitters and works much like a loose connection in an electrical circuit.

How do you deal with OCD?
OCD is associated with a high level of anxiety. Therefore, apart from alleviating the distressing symptoms of OCD, it is necessary to control the anxiety that can otherwise cause high blood pressure and stomach ulcers over time.

There are two approaches used to control the symptoms of OCD, viz. medicines and psychotherapy.

Medicines, known as SRIs, need to be taken regularly for at least three months, in the right dose, for a significant response to occur. They have to be continued for at least two years, after which the treating psychiatrist will evaluate the case and decide whether to continue with the medication or stop it.
In addition to medicines, Cognitive Behaviour Therapy can help the patient modify his way of interpreting and reacting to obsessions.

What can you expect once you are diagnosed to have OCD?
Patients with mild obsessive symptoms of short duration, no compulsions, no past or family history of psychiatric problems have a good chance of complete remission.

In most patients, however, OCD is a chronic illness.

Symptoms wax and wane, almost disappearing for a few days-weeks, making the patient question the very need for treatment. Sometimes a symptom may go away and be replaced by another, for example the need to touch alternate lamp-posts may be replaced by a need to step on alternate stone slabs on the sidewalk.

In other words, once a patient develops OCD, some obsessions/compulsions will usually be present, though their intensity and expression may vary.

— Dr Shyamala Vatsa is a consultant psychiatrist