Kamal called me during the lockdown. The 24-year-old IIT graduate, preparing for the civil services, was anxious and restless. He needed respite from his own self. Thoughts rained on him. He went numb under the weight of all the unpleasant thoughts. He could not stop the constant chatter in his mind. When he remarked, “The only way I can stop these thoughts is if I cease to exist,” I knew that the situation was critical. He wanted a “label” for what he was experiencing. Was this normal, he thought. Could this be brought under control? I explained to him that he was having an obsessive-compulsive disorder (OCD) with secondary depressive symptoms.
OCD is a common, chronic, relapsing disorder in which an individual has uncontrollable, recurrent, distressing thoughts or mental images, collectively called obsessions. These may result in the person having an urge to engage in certain behaviours repeatedly. These are termed as compulsions. Obsessions may occur in isolation or with accompanying compulsions. They interfere with many aspects of life, such as work, school and personal relationships. OCD runs a chronic waxing and waning course, if untreated. Despite it being so common, most people with OCD seek treatment after several years of putting up with it. This is partly because sufferers of OCD are overcome with shame, guilt and embarrassment. Studies show that less than a third of OCD patients receive appropriate evidence-based treatment.
“I shut myself in the bathroom for hours on end, and come out only when I am fully convinced that my body is clean,” said Kamal. “I keep washing myself repeatedly, and in a certain sequence. If the sequence gets disrupted, I restart the whole ritual. I spend two to four hours in the bathroom. I feel exhausted by the end of it. The pandemic has only added to my distress.” It highlights another key aspect that has come to the attention of mental health professionals, and that is, worsening in the course of pre-existing OCD.
Common obsessions include fear of germs or contamination, forbidden thoughts around the constructs of sex, religion, or harm, aggressive thoughts towards others or self, and thoughts about having things in symmetry or in a perfect order. The accompanying compulsions include excessive cleaning or handwashing and repeatedly checking on things. Engaging in compulsions relieves the anxiety temporarily, and this becomes a vicious cycle.
Three months ago I had to examine a patient who had presented with a worsening of her pre-existing germaphobia. She had left her apartment only 15 times in the last six months. She had come to see me wearing all possible protective gear. Those with an anxious temperament have found themselves being more prone to obsessive doubts about contracting Covid-19. I also see patients who fear contracting Covid-19, and have obsessive ruminations about infecting family members.
People with OCD cannot control their thoughts or behaviours despite recognising that they are excessive in nature. They do not find compulsive behaviours and rituals to be pleasurable, but find themselves to be helpless without engaging in them. Most people are diagnosed by about age 19, and boys typically have an earlier age of onset. Late-onset OCD should alert the clinician towards an organic cause, and brain imaging then becomes mandatory. Research has shown that the brain of an OCD patient looks different from a person who does not have it. Although some studies report an association between childhood trauma and later life OCD, larger studies are needed to establish this association.
OCD is generally treated with medication, therapy, or a combination of both. Combined treatments are significantly more effective. Medications may take 8-12 weeks to produce optimum results, and have to be gradually increased in dosage. These need to be taken for a minimum of 9-12 months, and depending on the patient’s response, a decision about gradually tapering down the medication is made. A specialised form of talking therapy called exposure and response prevention (ERP) is employed to treat OCD.
ERP encourages the patient to confront his obsessions, and consequently resist the urge to carry out compulsions. It aims to break the vicious cycle of obsessions and compulsions. ERP can be challenging for some patients, and they may benefit from a low-dose short-term anxiolytic during their initial sessions. Mild OCD responds to ERP alone, but moderate and severe OCD need medications along with ERP.
In 2018, the US FDA approved a form of brain-stimulation therapy called repetitive transcranial magnetic stimulation (rTMS) to treat OCD. It involves delivering pulsed magnetic stimulation to specific brain parts. For severe, chronic OCD that is resistant to all forms of treatment, deep brain stimulation or ablative neurosurgery is considered. OCD is a treatable condition and it is vital to create awareness around it so that its sufferers may stand to benefit.
The author is senior consultant psychiatrist, Manas Institute Of Mental Health, Hubli, Karnataka.