Documente Academic
Documente Profesional
Documente Cultură
– An Indian Perspective
Abbott
About the Authors
Dr. Sumant Khanna
Dr.Y.C.Janardhan Reddy
3. Comorbidity in OCD 23
Sumant Khanna, MD, PhD, MAMS, MRC Dr BM Suresh, MD, DNB, PGDMLE
PsychConsultant Psychiatrist, Senior Resident
New Delhi Former Additional Department of Psychiatry, NIMHANS,
Professor of Psychiatry, NIMHANS, Bangalore 560029
Bangalore E-mail: sbm@nimhans.kar.nic.in
Dr T. Jaideep,
Senior Resident
Department of Psychiatry, NIMHANS,
Bangalore 560029
PREFACE
i
Despite the progress made in the understanding and treatment of OCD,
the disorder continues to run a chronic course in a majority of patients with
waxing and waning of symptoms. Because of its high comorbidity with depression
and other anxiety disorders, and the secretive nature of the patients, the disorder
often gets misdiagnosed as depression and anxiety. Therefore, it is important
to correctly diagnose and treat OCD.
This book on OCD provides a comprehensive account of all aspects of OCD.
The book includes chapters on clinical features, comorbidity, biology, behavior
therapy, pharmacotherapy, and childhood OCD. The book tries to provide a
comprehensive summary of all aspects of OCD without attempting to give
exhaustive factual information and extensive references. Only important references
are provided. The book is primarily aimed at busy practicing psychiatrists,
and general physicians who need a ready and handy reference on OCD. Therefore,
the emphasis is on the clinical aspects of the disorder. Abbott India Ltd. (Lenbrook
Division) has to be thanked for having come forward to publish a book on
OCD, which will hopefully serve the needs of the intended users of the book.
Sumant Khanna
YC Janardhan Reddy
PREVALENCE
In the large epidemiological study, the ECA survey, conducted in the United
States in 1984, OCD was the fourth most common psychiatric disorder with
a lifetime prevalence of 2.5%. Another study examined the prevalence of OCD
in diverse cultures (Cross-National Collaborative Study) and reported lifetime
prevalence of 1.9% to 2.5% with the exception of Taiwan where for unknown
reasons the prevalence of OCD was low (Weissman et al., 1994). In contrast
2 CLINICAL FEATURES OF OBSESSIVE COMPULSIVE DISORDER
CLINICAL FEATURES
the dirt but one may not have to wash for hours to remove the dirt. This
is clearly excessive.
The diagnostic guidelines according to the International Classification of
Mental and Behavioral Disorders (ICD-10) are given below.
For a definite diagnosis, obsessional symptoms or compulsive acts, or both,
must be present on most days for at least 2 successive weeks and be a source
of distress or interference with activities. The obsessional symptoms should have
the following characteristics:
(a) They must be recognized as the individual’s own thoughts or impulses;
(b) There must be at least one thought or act that is still resisted unsuccessfully,
even though others may be present which the sufferer no longer resists;
(c) The thought of carrying out the act must not in itself be pleasurable (simple
relief of tension or anxiety is not recognized as pleasure in this sense);
(d) The thoughts, images, or impulses must be unpleasantly repetitive
Traditionally, awareness of the senselessness or unreasonableness of obsessions
and the accompanying resistance against the obsessions has been considered
to be the hallmark of the disorder. However, it is increasingly being recognized
that a substantial proportion of patients consider their obsessions to be somewhat
reasonable with varying degree of insight. For example, in an Indian study,
25% of the patients had poor insight (Ravikishore et al, in press). It is to
be noted here that although poor insight was not infrequent, lack of insight
amounting to delusional belief was rarely seen.
Obsessions % Compulsions %
Most patients have multiple obsessions and compulsions over time although
a particular obsession may dominate the clinical picture at any one time. The
presence of only obsessions without compulsions is unusual. Similarly, only
compulsions without obsessions are unusual particularly in adults. However,
4 CLINICAL FEATURES OF OBSESSIVE COMPULSIVE DISORDER
Contamination
Contamination obsessions are the most common type of obsessions in OCD.
They are typically characterized by a fear of dirt or germs. Patients frequently
fear that they may contract a disease or spread a disease because of exposure
to contaminants. However, the fear is occasionally not based on disease but
based on a subjective feeling of not being clean enough. Contamination obsessions
may also involve environmental contaminants (asbestos, radiation, pesticides),
household items (cleansers, solvents), bodily waste or secretions (urine, feces,
saliva), sticky substances (adhesives, grease, oil), and animal waste (feces, urine).
Most patients with contamination fears extensively avoid feared contaminants.
For example, they may not touch door knobs or light switches touched by others,
pick up fallen objects, or use money handled by others. They may even use
rubber gloves, don’t shake hands, not go anywhere near people whom they
consider dirty or sick, and won’t use articles used by others. There are also
patients who do not take bath for days to weeks because of the fear of
contamination associated with using the bathroom used by others. Exposure
to any of the feared contaminants causes intense anxiety and distress which
in turn results in excessive cleaning and washing. The cleaning compulsions
include excessive or ritualized hand washing, showering, bathing, tooth brushing,
and elaborate toilet routines. Patients may wash hands like surgeons scrubbing
before an operation, and use harsh detergents. It is also well known that many
patients indulge in elaborate cleaning rituals like repeated cleaning of the floors,
and household items particularly utensils used in kitchen. These washing and
cleaning rituals usually take long hours and exhaust the patient. It is not unusual
to find patients who brush their teeth for an hour and take bath for several
hours often emptying the water tank.
one might harm self or others on an impulse (fear of stabbing with a knife,
jumping in front of a car, leaping out of an open window) or because not careful
enough (fear of hitting a pedestrian because of not being careful), and fear
of blurting out obscenities or insults. Patients may also have violent or horrific
images such as images of family members involved in gruesome accidents. The
obsessions of sexual or aggressive nature cause intense guilt, shame and anxiety
because of the abhorrent nature of the thoughts. Patients often suffer for years
without revealing their thoughts to anyone because of the embarrassing nature
of the thoughts. Their constant fear is also that they may act out on their
obsessions. As a result of this fear, they tend to avoid anything that triggers
their obsessions. For example, a person harboring sexual thoughts about family
members may never look in to their eyes. Similarly, a mother who harbors
an urge to harm her child may remove all the sharp objects from the house
and may even not take care of the child. Patients with these obsessions also
seek repeated reassurance from others that they are actually not capable of
doing what they are worried about. The reassurance seeking behavior can be
a great annoyance to others, particularly family members, because the patients
are not happy if reassured once, they need to be reassured all the time.
Religion
Patients with religious obsessions typically experience intrusive unacceptable
thoughts or images about God or religion. For example, intrusive thoughts of
abusive nature towards God whenever one try to pray or on seeing the photographs
or when one visits places of worship. Similarly some experience intrusive images
of stepping on photographs of deities, and images of smearing feces. These
thoughts cause intense guilt and distress because it is considered blasphemous
to harbor such thoughts.
6 CLINICAL FEATURES OF OBSESSIVE COMPULSIVE DISORDER
Repeating rituals
Patients with repeating rituals repeat routine activities either due to doubt
or due to fear that some thing terrible may happen to self or others if not
repeated. Typical examples include taking clothes on/off, turning scooter on/
off, in/out of chair, going through doorway repeatedly and re-reading and re-
writing.
Hoarding
Hoarders have an urge to hoard or save things because they are worried that
they may discard things that is valuable or may be of some use in future.
They may pile up old newspapers, collect useless objects or may have problems
in discarding things that have no actual utility. Sometimes living rooms and
houses of hoarders can be cluttered with piles of trash making living difficult.
However, hoarding should be distinguished from hobbies and the practice of
preserving things for monitory or sentimental reasons.
ASSESSMENT
Rater-administered scales
The most widely used instrument is the Yale-Brown Obsessive Compulsive Scale
(Y-BOCS), the best scale available to assess severity of OCD (Goodman et al.,
1989). It is a clinician administered instrument. It has an exhaustive checklist
CLINICAL FEATURES OF OBSESSIVE COMPULSIVE DISORDER 7
Self-rated scales
The most widely used self-rating scales are the Muadsley Obsessive Compulsive
Inventory (MOCI) (Rachman and Hodgson, 1980), and the Leyton Obsessional
Inventory (LOI) (Cooper, 1970). The LOI has 69 yes/no questions. The scale
measures both symptoms and traits. The LOI is a useful screening instrument,
but it does not cover all obsessional symptoms. It may not be as good as Y-
BOCS to measure severity. The MOCI consists of 30 questions designed to yield
a total score and four subscale scores. A score of 18 out of 30 is indicative
of clinical OCD. The main disadvantage of MOCI is that it relies on specific
symptom sets and sometimes the chief obsessions of an individual are not listed.
COURSE
The OCD usually begins in adolescence or early adulthood although it can begin
in childhood. Nearly 65% of the patients have their onset before age 25 whereas
fewer than 15% have onset after age 35 (Rasmussen and Eisen 1998). In our
clinic samples a majority of patients had onset before 18 years (Jaisoorya
et al., 2003).
Although prognosis of OCD has traditionally been considered to be poor,
availability of effective treatments has considerably improved the prognosis.
8 CLINICAL FEATURES OF OBSESSIVE COMPULSIVE DISORDER
In a recent study of course of OCD in adults (Eisen et al., 1999) 47% of the
patients had remitted by the end of 2years (full remission in 12% and partial
remission in 31%). In a 40-year follow up, nearly 80% of individuals improved
with nearly full recovery in almost 50% of the patients (Skoog and Skoog 1999).
However, a synthesis of findings of various studies seems to suggest that about
25% of the patients recover completely and about 15% continue to suffer with
deteriorating course. Most follow a course marked by chronicity with some
symptom fluctuation over time, but without clear-cut remissions or deterioration.
It should be noted here that there is no follow-up data on adult OCD subjects
from India.
Following simple questions are suggested encourage OCD patients to talk about
their symptoms:
Do you wash or clean a lot more than others?
Do you check things a lot?
Are there any thoughts that keep bothering you and you would like to get
rid of but cannot? For example:
■ personally unacceptable religious or sexual thoughts
■ urges to harm self or others
■ thoughts of something terrible happening to self or loved ones (e.g.,
accidents)
■ worried that you may get some illness such as AIDS
Do your daily activities take a very long time to finish?
Are you concerned about orderliness and symmetry?
Do you repeat routine activities such as in/out of chair, walking through
doorway?
Do you collect useless objects and have difficulty in discarding them?
CONCLUSIONS
REFERENCES
1. Asberg M, Montgomery S, Perris C, Schalling D, Sedvall G. A comprehensive
psychopathological rating scale. Acta Psychiatr Scand 1978; 271 (suppl.):5.
2. Cooper J. The Leyton Obsessional Inventory. Psychiatr Med 1970; 1: 48-54.
3. Eisen JL, Goodman WK, Keller MB et al. Patterns of remission and relapse in obsessive-
compulsive disorder: a 2-year prospective study. J Clin Psychiatry 1999; 60:346-351.
4. Eisen JL, Phillips KA, Rasmussen SA et al. The Brown Assessment of Beliefs Scale
(BABS): reliability and validity. Am J Psychiatry 1998; 155:102-108.
5. Goodman W, Price L, Rasmussen SA et al. The Yale-Brown Obsessive-Compulsive Scale.
I. Development, use, and reliability. Arch Gen Psychiatry 1989; 46:1006-1011.
6. Jaisoorya TS, Janardhan Reddy YC, Srinath S. The relationship of obsessive-compulsive
disorder to putative spectrum disorders: results from an Indian study. Comprehensive
Psychiatry 2003; 44:317-323.
7. Janardhan Reddy YC, Srinivas Reddy P, Shobha S, Khanna S, Sheshadri SP, Girimaji
SC. Comorbidity in juvenile obsessive-compulsive disorder : a report from India. Canadian
Journal of Psychiatry 2000; 45:274-278.
8. Jenkins R, Bebbington PE, Brugha T et al. The National Psychiatric Morbidity Surveys
of Great Britain: I. Strategy and methods. Psychological Medicine 1997; 27:765-774.
9. Karno M, Golding JM, Sorenson SB, Burnam MA. The epidemiology of obsessive-
compulsive disorder in five US communities. Arch Gen Psychiatry 1988; 45:1094-1099
10. Khanna S, Kaliaperumal VG, Channabasavanna SM. Clusters of obsessive-compulsive
phenomena in obsessive-compulsive disorder. Br J Psychiatry 1990; 156: 51-4.
11. Neziroglu F, McKay D, Yariura-Tobias JA, Stevens KP, Todaro J. The Overvalued Ideas
Scale: development, reliability and validity in obsessive compulsive disorder. Behav Res
Ther 1999; 37: 881-902.
12. Rachman SJ, Hodgson RJ. Obsessions and Compulsions. Prentice-Hall, Englewood Clifs,
1980.
13. Ravikishore V, Samar R, Janardhan Reddy YC, Chandrasekahr CR, Thennarasu K. Clinical
characteristics and treatment response in poor and good insight obsessive-compulsive
disorder. European Psychiatry (in press).
14. Rasmussen SA, Eisen JL. Phenomenology and clinical features of obsessive-compulsive
disorder. In: Obsessive Compulsive Disorders: Practical Mangement, 3rd Edition. Edited
by Jenike MA, Baer L, Minichiello WE. St.Louis, MO, CV Mosby, 1998, pp 12-43.
15. Skoog G, Skoog I. A 40-year follow-up of patients with obsessive-compulsive disorder.
Arch Gen Psychiatry 1999; 56:121-132.
16. Weissman MM, Bland RC, Canino GJ et al. The cross-national epidemiology of obsessive-
compulsive disorder. J Clin Psychiatry 1994; 55 (Suppl. 3):5-10
17. World Health Organization. The ICD-10 Classification of Mental and Behavioral Disorders.
Clinical Descriptions and Diagnostic Guidelines, World Health Organization, Geneva.
JUVENILE OBSESSIVE COMPULSIVE DISORDER 11
INTRODUCTION
EPIDEMIOLOGY
Systematic studies have shown that from one third to one half of adult cases
with OCD have their onsets in childhood and adolescence (Flament & Cohen,
2002; Jaisoorya et al., 2003). Epidemiological studies on adolescent OCD have
shown varying rates ranging from 1% to 4%, possibly because of varying
methodologies and sample sizes but the rates are similar to those in adults
(Flament & Cohen, 2002). There is no community data on prevalence of OCD
in children, but the frequency in clinical samples is about 2%.
A study done in a school population in India showed a point prevalence
rate of 1.45%, which is comparable to the rates described in the Western literature
(Kirthi Kumar, Personal communication, 1998). Clinic based prevalence rate
12 JUVENILE OBSESSIVE COMPULSIVE DISORDER
ETIOLOGY
CLINICAL FEATURES
The diagnostic criteria for OCD in children and adolescents are not different
from the criteria in adults. The only difference in criteria between children
and adults is with regard to criterion B in the DSM-IV that specifies that
the person should at some point during the course of the disorder recognize
the obsessions and compulsions are excessive or unreasonable. However, this
does not apply to children where insight may be poor. The clinical presentation
of OCD in children and adolescents has been documented in various cultures
including India (Khanna & Srinath, 1989; Reddy et al., 2003; Jaisoorya et al.,
2003).The most common obsessions are related to contamination fears, often
accompanied by protracted or ritualized compulsive washing and avoidance of
“contaminated objects”, leading to increasing constriction of functioning. An
obsessive worry about safety, usually of parents or themselves, is common along
with obsessions related to morality or religiosity. A common feature of many
obsessive worries is an exaggerated perception of risk on the part of the child
that is decreased by the compulsive ritual.
Common compulsions are checking, washing, repeating, touching, counting,
and ordering. Similar to adults, children have compulsions with obsessions,
but compulsions in the absence of obsessions are often found in young children
or children with tic disorders who often describe their rituals as being performed
in response to an irresistible urge, an “empty” feeling, or an otherwise vague
sensation (the “just right” phenomenon).
Mental rituals may consist of silent praying, repetition, counting, or having
to think about or look at something in a particular way until it feels “just
right”. Unlike many adults children may be unable to specify the dreaded
consequences their compulsive rituals are intended to avert, beyond a vague
premonition of something bad happening. Simple compulsions such as touching
or ordering may lack a discernable ideational component and may be
indistinguishable from complex tics. The performance of the ritual transiently
reduces the obsessional worry, albeit at the potential cost of increasing impairment
and constriction of functioning.
14 JUVENILE OBSESSIVE COMPULSIVE DISORDER
Children like adults can have pure obsessions without compulsions. The
common themes include sex, aggression, and harm to self or others. Childhood
OCD is reactive to stress as in adults; many children experience worsening
of symptoms during times of stress (e.g., start of a school year, moving to
a new home, death of or separation from a family member) or illness.
CO-MORBIDITY
Comorbid psychiatric disorders are common in juvenile OCD. Though the rate
of comorbidity varies across studies, as many as 80% of children with OCD
meet diagnostic criteria for an additional Axis I disorder, and as many as 50%
experience multiple comorbid conditions. In an Indian study 69% of the subjects
had a comorbid disorder (Reddy et al., 2000)
Nearly one third to one half of the children with OCD seems to have a
current or past history of another anxiety disorder. In children, overanxious
and separation anxiety disorders are the commonest whereas in adolescents,
generalized anxiety and panic disorders are the commonest. Prevalence of
depression is in the range of 13% to 70%, adding to the dysfunction already
caused by OCD. Depression and anxiety can predate OCD or develop later.
Of particular interest is the high comorbidity between OCD and tic disorders
including TS. Tic disorders have been reported in 17% to 60% of juvenile subjects
(Reddy et al., 2000). At least 50% of children with TS develop OC symptoms
or OCD by adulthood. This and a biredirectional familial comorbidity between
TS and OCD suggest that some forms of OCD are genetically related to TS.
The relationship between putative obsessive-compulsive spectrum disorders
and OCD has been dealt with in a previous chapter on OCD. Children with
pervasive developmental disorders (PDD) (autism, Asperger’s and related
disorders) often manifest stereotypic behaviors and routines, as well as unusual
preoccupations and fixed interests that many describe as “obsessive-compulsive”.
The cognitive and language difficulties characteristic of PDD frequently makes
it difficult to assess the extent of personal distress, irrationality, intrusiveness
and excessive nature of the symptom characteristic of true obsessions. However,
the OC symptoms in PDD share certain common features with uncomplicated
OCD, in being highly prevalent in relatives of children with PDD and a good
response to SSRIs.
Rarely schizophrenia can co-occur with OCD. There are also reports suggesting
increased prevalence of bipolar disorder in children with OCD. It is important
to identify bipolar disorder since drugs used in the treatment of OCD can
precipitate mania.
JUVENILE OBSESSIVE COMPULSIVE DISORDER 15
DIFFERENTIAL DIAGNOSIS
ASSESSMENT
The successful diagnosis and treatment of OCD requires careful and systematic
evaluation. Initially, a thorough diagnostic evaluation is necessary to accurately
establish a diagnosis of OCD, to rule out phenomenologically similar conditions,
and to identify comorbid conditions that may influence treatment planning.
Baseline symptom severity and profile assessment is very essential for systematic
and serial evaluation of treatment response. These are also essential for developing
16 JUVENILE OBSESSIVE COMPULSIVE DISORDER
TREATMENT
Pharmacotherapy
The clomiprmaine is a SRI. The SSRIs include fluoxetine, sertraline, fluvoxamine,
paroxetine and citalopram. Of these, clomipramine, fluvoxamine, sertaline, and
fluoxetine are approved by the FDA for use in OCD although others are also
effective in treating OCD.
In the absence of direct head-to-head trials comparing the relative efficacy
of various SRI/SSRIs, it is not known whether one is more effective than others
in treating OCD in juvenile population although in metaanalytical studies of
JUVENILE OBSESSIVE COMPULSIVE DISORDER 17
TABLE 1
Pharmacological Treatment of OCD in children
prefer to use SSRIs for the first 2 trials and use clomipramine if the SSRIs
fail. If the response to SRI/SSRIs is inadequate augmentation with clonazepam,
risperidone, haloperidol or buspirone may be considered. In children with comorbid
tic disorder or schizotypal disorder, augmentation with low dose risperidone
or haloperidol is recommended since response to SRI/SSRIs alone is poor in
this subgroup of children.
The optimal duration of maintenance treatment is unclear. It is recommended
that medications be continued for 12 to 18 months after satisfactory improvement
is obtained. Once the decision to withdraw the medication is made, tapering
should be gradual, preferably overall several months since relapse following
discontinuation is frequent. In some children maintenance medication for longer
periods may be warranted in view of potential relapses. In such situations,
a potential alternative such as CBT has to be considered since CBT is associated
with lesser chances of relapse. However, it should be mentioned here that not
all children comply with CBT; therefore, medications may be the only option
in such children. The optimal maintenance dose is also unclear; however, after
prolonged remission, an attempt may be made to use the minimum effective
dose to prevent relapse.
Cognitive-Behavioral Therapy
The theoretical rationale and practice is similar to that in adults. March and
Mulle (1987) have developed a manualised approach to CBT in OCD children
with the aims of facilitating compliance. Treatment takes place over 4 steps
distributed across 16 weekly sessions. Each session would include a statement
of goals for that session, review of preceding week, introduction of new
information, “nuts and bolts practice”, and homework for the coming week,
and monitoring procedure.
Step 1 involves psychoeducation emphasizing to the child that it is the OCD,
and not the child, that is the problem. For young children, the OCD may
even be given a nasty nickname and the “good guys” (child, parents, and therapist)
work on getting rid of the “bad guys” (the OCD). This type of alliance helps
engage the child in treatment. Step 1 also explores the risks and benefits of
the behavior therapy programme and introduces story metaphors by placing
OCD in a narrative context. The use of story methodology facilitates the therapy
process. Step 2 and 3 map the child’s experience with OCD including avoidance
behaviors within a narrative context. They also include trial ERP tasks to gauge
the child’s level of understanding and willingness to comply with ERP. Step
4 implements both ERP and anxiety management. Anxiety management involves
JUVENILE OBSESSIVE COMPULSIVE DISORDER 19
Investigative treatments
Tramadol, Transcranial Magnetic Stimulation, Neurosurgery and ECT have been
reported to be useful for adults in OCD. However, data for children is lacking.
What happens to juvenile OCD in the long term? Several studies have attempted
to document the course and outcome of in OCD in children. Most well known
study is the prospective longitudinal follow-up of 54 children 2 to 7 years later.
All the subjects in this study were intensively treated with clomipramine and
other SSRIs and some of them also underwent behavior therapy, individual
20 JUVENILE OBSESSIVE COMPULSIVE DISORDER
psychotherapy and family therapy. At follow-up, 43% still had clinical OCD;
the remaining had shown varying degrees of improvement. Twenty eight percent
had obsessive-compulsive symptoms, 18% has subclinical OCD and 11% had
recovered. However, only 6% were in true remission (recovered and not on
treatment). A German study reported remission in 29% of the subjects (Wewetzer
et al., 2001). In contrast to the findings of these studies, a 2 to 9 year (mean
5 years) follow-up of largely self-referred, drug-naïve juvenile OCD subjects
reported from NIMHANS, Bangalore, India (Reddy et al., 2003), found clinical
OCD in only 21% of the subjects. In this study, after initial consultation, about
75% of the children were adequately treated with SRI/SSRIs. A majority did
not have OCD (62%) and 17% had subclinical OCD. The most interesting finding
of this study was that 48% of the subjects were in true remission (no OCD
and not on treatment) suggesting an overall favorable outcome. It is possible
that the poor outcome reported in previous studies could be because of some
kind of sampling bias. Another interesting observation of some studies is that
episodic OCD is common in children (Wewetzer et al., 2001).
A poor response to initial treatment, parental Axis I diagnosis, and lifetime
history of a tic disorder (Leonard et al, 1993; Wewetzer et al, 2001) have been
associated with a worse OCD outcome. In the Indian study (Reddy et al.,
2003), none of the earlier known potential predictors were significantly associated
with OCD outcome. Instead, earlier age-at-onset of OCD and longer follow-
up was associated with better outcome.
REFERENCES
1. Berg CZ, Whitaker A, Davies M, Flament MF, Rapoport JL (1989). The survey from
of the Leyton Obsessional Inventory-Child Version: norms from an epidemiological study.
Journal of American Acdemy of Child and Adolescent Psychiatry 27:759-763.
2. Flament MF, Cohen D. Child and adolescent obsessive-compulsive disorder: a review.
In: Obsessive-Compulsive Disorder 2nd edition Editors. Maj M, sartorius N, Okasha A,
Zohar J. WPA Series Evidence and Experience in Psychaitry, John Wiley & Sons, West
Sussex, 2002, pp 147-183.
3. Geller DA, Biederman J, Griffin S et al (1996). Comorbidity of juvenile obsessive-compulsive
disorder with disruptive behavior disorders. Journal of American Acdemy of Child and
Adolescent Psychiatry 35: 1637-1646.
4. Geller DA, Biederman J, Faraone S et al (2001). Developmental aspects of obsessive-
compulsive disorder: findings in children, adolescents, and adults. Journal of Nervous
and Mental Diseases, 189:471-477.
5. Jaisoorya TS, Janardhan Reddy YC, Srinath S (2003). Is juvenile obsessive-compulsive
disorder a developmental subtype of the disorder? Findings from an Indian study. European
JUVENILE OBSESSIVE COMPULSIVE DISORDER 21
COMORBIDITY IN OCD
Dr BM Suresh, Senior Resident
Dr YC Janardhan Reddy, Associate Professor of Psychiatry
Department of Psychiatry, NIMHANS, Bangalore 560029
MOOD DISORDERS
Bipolar disorder
It is a disorder characterized by episodes of mania and depression. A manic
episode is characterized by euphoria/elation, expansive or irritable mood, inflated
self-esteem or grandiosity, increased activity, decreased need for sleep,
overtalkativity, subjective experience that thoughts are racing, distractibility,
increased libido, and excessive involvement in pleasurable activities that have
a high potential for painful consequences (unrestrained buying sprees, sexual
indiscretions, or unrealistic business investments).
There is limited data on the comorbidity of OCD and bipolar disorder but
the available data suggests that nearly 15% of OCD patients have bipolar disorder,
mainly hypomania that is often precipitated by use of antidepressants (Freeman
et al., 2002). It has also been found that 21% of the bipolar patients in the
ECA sample had OCD (Chen et al., 1995). A comorbid diagnosis of bipolar
disorder in OCD has important clinical implication in that the mood stabilization
may have to be achieved before prescribing antidepressant medications to treat
OCD. Antidepressant medications are known to precipitate mania.
ANXIETY DISORDERS
Comorbidity of OCD with anxiety disorders is quite high, ranging from 25¯60%.
Conversely, studies in primary anxiety disorders have showed comorbid OCD
in 11-14% of the patients.
COMORBIDITY IN OCD 25
Panic Disorder
In order to fully describe panic disorder, it is first necessary to define panic
attacks. A panic attack is “a discrete period of intense fear or discomfort”,
associated with prominent somatic or cognitive symptoms such as sweating,
trembling or shaking, shortness of breath, a sensation of choking, chest pain,
palpitations, nausea or abdominal discomfort, dizziness or feeling faint, fear
of losing control or going crazy, fear of dying, numbness/tingling sensation, feelings
of being detached from reality, and feelings of being detached from oneself.
The primary feature of panic disorder is a history of panic attacks, as defined
above, followed by persistent anticipatory anxiety about having further panic
attacks, excessive concern about the implications and/or consequences of the
panic attacks (e.g., losing control, having a heart attack, “going crazy”) and
substantial modification of daily activities in an effort to avoid further panic
attacks. They may develop agoraphobia. Basically, they avoid any situation they
fear would make them feel helpless if a panic attack occurs. These include
fears of being outside the home alone, being in a crowd or standing in a line,
being on a bridge and traveling in a bus, train or automobile. Some patients
become house bound because of fear of traveling alone or going out alone.
26 COMORBIDITY IN OCD
Phobias
Phobias are characterized by recurrent, excessive, irrational fear of a specific
object or situation. Exposure to the feared object or situation results in an
immediate and intense anxiety, sometimes to the extent of having a panic attack.
Despite recognizing that the anxiety is excessive, individuals with a phobia
will go to great lengths to avoid exposure to the feared object or situation
in order to prevent the emotional distress it causes. The anxiety and associated
avoidance behaviors can cause significant emotional distress and may considerably
interfere with daily functioning. Some examples of phobias include fears of
flying, heights, water, elevators, insects, blood, darkness, tunnels, bridges, enclosed
spaces, and dental procedures.
There are various conditions that have shared features with OCD. These disorders
are frequently described as obsessive-compulsive spectrum disorders (OCSD)
(Allen & Hollander, 2000; Jaisoorya et al., 2003). They include hypochondriasis,
body dysmorphic disorder (BDD), anorexia nervosa, Tourette syndrome (TS),
trichotillomania, binge eating, compulsive buying, kleptomania, pathological
gambling, and sexual compulsions. The shared features include similarities in
symptom profile and treatment response and possibly somewhat similar
pathophysiology. The OCSDs are characterized by pathological preoccupations
COMORBIDITY IN OCD 27
Hypochondriasis
The fear or belief that one has a severe illness characterizes hypochondriasis.
This fear is based on an individual’s misinterpretation of signs and symptoms,
and results in multiple doctor visits and medical tests. Patients tend to indulge
in repetitive checking of the body for symptoms of an alleged medical condition,
and Internet searching for information about illnesses and their symptoms
(“cyberchondria”). This behavior persists despite medical reassurance that the
individual does not have a disease or illness. Recent studies have shown that
hypochondriasis and OCD are common comorbid conditions. Both the conditions
have similar clinical picture. OCD patients with somatic or illness obsessions
are often indistinguishable from patients with hypochondriasis. As in OCD,
hypochondriac fears are intrusive, distressing and not easily responsive to
reassurance. Patients with hypochondriasis also indulge in compulsive checking
of one’s body or with others. However, there are some differences, which
help in differentiating OCD from hypochondriasis. In OCD there is a fear of
getting an illness whereas in hypochondriasis there is a fear of having an illness.
Insight is fairly well preserved in OCD and patients often admit their fears
are unrealistic but in hypochondriasis there is a high degree of conviction that
they have a disease. An exception to this difference is the OCD patients with
poor insight. Lastly, hypochondriac fears are usually secondary to somatic
sensations.
Trichotillomania
Tic disorders
In the recent past, there has considerable interest in the relationship between
COMORBIDITY IN OCD 29
tic disorders, particularly the Gilles de la Tourette syndrome (GDLT) and OCD.
The group of tic disorders includes transient and chronic tic disorders and the
GDLT. In the transient tic disorder, tics usually do not persist for more than
12 months whereas in chronic tic disorders either motor or vocal tics persist
for longer periods. The GDLT is a classic syndrome consisting of multiple chronic
motor tics, and one or more vocal tics and coprolalia with onset during childhood
or adolescence.
Tics are defined as rapid, repetitive muscle contractions or sounds that usually
are experienced as outside volitional control and which often resemble aspects
of normal movement or behavior. Tics can be elicited by stimuli or preceded
by an urge or sensation. They are usually beyond attempts at suppression.
Examples of motor tics include eye blinking, head jerks, shoulder jerks, finger
and hand movements and stomach jerks. Vocal tics include throat clearing,
coughing, grunting sounds, repeating certain words and sentences, repeating
others’ speech, and coprolalia (repeating obscene or socially unacceptable words).
Some complex tics include facial gestures, grooming behaviors, jumping, touching,
stamping and hopping.
Patients with GDLT have a high rate (30-40%) of comorbid OCD and obsessive-
compulsive symptoms. Conversely nearly one fifth of OCD patients have a lifetime
history of multiple tics and 5% to 10 % have GDLT. Family studies of GDLT
and OCD clearly show a relationship between the two disorders. Relatives of
GDLT patients report a high rate of OCD and relatives of OCD patients report
a high rate of tic disorders and GDLT. In an Indian study, tic disorders were
present in 18% of OCD patients but the rate of GDLT was only 3% (Jaisoorya
et al., 2003). The subgroup of OCD plus tic disorder patients have an earlier
age-at-onset of OCD with high family loading for GDLT and OCD (Pauls et
al., 1995). In a study of children and adolescents with OCD, 56% had tics
and 14% has GDLT (Leonard et al., 1992). However, in an Indian study of
children and adolescents with OCD, tic disorders were present in 17% of the
subjects and GDLT in only 7% (Reddy et al., 2003). It appears that tic disorders
are not uncommon in Indian OCD patients but for some unknown reasons,
GDLT is a rare comorbid diagnosis.
Eating disorders
In anorexia nervosa, patients restrict their food intake to the point of being
underweight and experience distressing concerns about their shape and weight,
particularly intense fear of weight gain or being “fat” even though grossly
underweight for their age and height. They deny the seriousness of low body
weight and further feel driven to exercise for hours a day and use other extreme
30 COMORBIDITY IN OCD
PERSONALITY DISORDERS
Nearly a half of patients with OCD also have at least one diagnosable personality
disorder. The most frequently diagnosed personality disorders among patients
with OCD are avoidant, dependent, histrionic, passive-aggressive and obsessive-
compulsive personality disorders. Some researchers report no specific association
between obsessive-compulsive personality disorder (OCPD) and OCD but few
recent studies have reported high rates of OCPD in OCD. Less frequently
diagnosed were paranoid, borderline and schizotypal personality disorders, which
are found to be associated with poor outcome.
The issue of whether PD is the primary or secondary disorder is debatable.
Early onset OCD imparts its signature as traits on the development of personality
of an OCD patient. Recent literature shows that the number of personality
disorder diagnoses, and scores on personality disorder measures, declined in
half of the OCD patients following successful treatment. Now it becomes all
the more important to recognize it and treat it before it becomes enduring
personality trait.
PSYCHOSIS
CONCLUSION
REFERENCES
SEROTONIN: There are essentially three kinds of studies in this field. The
first approach is to study serotonin in peripheral tissues such as blood elements.
Platelets which are a major reservoir of serotonin in blood ,show normal uptake
or content of serotonin. One study found a decreased number of platelet sites
in OCD patients, this has not been replicated. In the second approach CSF
5-HIAA has been studied with largely normal results. Lastly serotonin challege
tests have shown blunted hormonal response. No changes have been noted with
L-tryptophan, fenfluramine, ipsapirone. mCPP produces behavioural exacerbation
associated with a blunted neuro-endocrine response in unmedicated OCD. The
strongest evidence to implicate serotonin continues to come from the fact that
serotonin uptake inhibitors are effective in its treatment, while drugs acting
at other receptor sites alone are not.
Other neurotransmittors nor-adrenaline and dopamine have been implicated
in the etiology of OCD.
NEUROANATOMIC CIRCUITS
observed in OCD.
In an attempt to unite the diverse biological findings in OCD mentioned
above, like altered activity and morphological changes in the basal ganglia,
increased metabolic activity in cortial regions controlling limbic and behavioural
functions, altered serotonergic dopaminergic markers, blunted or increased
neuroendecrine response to pharmacological probes and altered response illness
in serotogenergic, dopaminergic, nor adrenergic and endogenous opiate systems,
a model has been proposed to explain pathogenesis of SSRI reponsive OCD.
At the crux of this model lies the assumption that a single, midline regulatory
structure the dorsal raphe nucleus,which ramifies bilaterally to components
of the basal ganglia and frontal cortex,may not receive appropriate feedback
inhibition from components of the basal ganglia and cortex to simultaneously
regulate both a diseased hemisphere and a normal contralateral component.
Resultant dysregulation of the DRN may occur owing to decreased unilateral
inhibitory input from a damaged SNpc nucleus (substantia nigra pars compacta)
resulting in DRN disinhibition. Chronic dysregulation due to decreased SNpc
inhibition may produce increased activity in the DRN,followed chronically by
alterations in the receptor sub type population or increased inhibition from
the contralateral SNpc. Increased contralateral SNpc activity (as an effort
to regulate the basal ganglia by decreasing DRN trasmission) or resultant receptor
abnormalties may be the ultimate events that trigger over excitation of strial-
thalamic cortical-strial circuits. These changes could account for the over
stimulation of the basal ganglia and resultant obsessive compulsive symptoms.
GENETICS
Twin studies have been a valuable paradigm to help asses the genetic contributions
to a disorder. Rasmussen and Eisen summarised the literature on twin studies
relavent to OCD. They noted that 32 pairs of monozygotic twins concordant
for OCD and 19 pairs discordant for OCD have been reported and that there
is a general agreement about the diagnosis and monozygosity of 13 pairs of
concordant twins and seven pairs of discordant twins. The much higher proportion
of concordant compared with discordant pairs may be taken as evidence supporting
the genetic trasmission of OCD. Unfortunately there have been no adoption
studies on OCD and molecular genetics are just getting under way. Richter
et al recently reported that the dopamine D3 receptor gene polymorphism is
not involved in the susceptibility to OCD. A rare variant of the serotonin
transporter gene has recently been associated with OCD.
36 BIOLOGY OF OBSESSIVE COMPULSIVE DISORDER
Clinical investigations over the past few decades have repeatedly indicated
that OCD is familial. A consistent finding seems to be a multitude of other
psychopathologies also occur more frequently in families of OCD probands than
would be expected by chance. The genetic association with tics appear to be
very strong. Comings proposes that many individuals with Tourette may be
homozygous for a Tourette syndrome gene. They suggest the inheritance in
Tourette syndrome may be best described as semi dominent,semi recessive. The
absence of a large enough clinical population of Tourette syndrome in India
prevents a systematic study, but there is evidence to suggest that this genetic
pool of Tourette and OCD may be absent in India.
NEUROPSYCHOLOGICAL STUDIES
Studies can be divided into two groups: those which look for a regional dysfunction
and those which explored a neuropsychological paradigm. Majority of the studies
have demonstrated frontal deficits, although non-dominent tempro-parietal deficits
have also been seen. Functions tested include impaired associate learning,impaired
ability to change sets and attention failure during stress. These can be viewed
as frontal tasks. Laplane has shown that primary basilar gangliar diseases
may have frontal deficits. Refinement in neuropsychological testing will help
in further exploring the neurobiology of OCD. Most electrophysiological paradigms
implicate dysfunction of frontal lobes in OCD, but issues regarding laterality
have not been adequately addressed.
INFECTIOUS ETIOLOGY
Various case reports have been there about the co-morbidity with infectious
diseases, although no clear cut pattern had earlier emerged. One large study
from India suggested the association of herpes simplex viral infection with OCD.
Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal
infections (PANDAS) is a condition occurring after streptococcal infection in
childhood associated with obsessive compulsive symptoms, but again there are
no case reports from India.
CONCLUSIONS
In general the neurobiological evidence for OCD exists at two planes. At the
first level OCD seems to be a disease of serotonergic dysfunction. At the second
level it seems to affect only some parts of the brain, such as the caudate prefrontal
BIOLOGY OF OBSESSIVE COMPULSIVE DISORDER 37
cortex and cingulate regions, suggesting that there may be a circuit involved
linking these different regions which is dysfunction in OCD. Linking the first
hypothesis, it appears that these circuits are serotonergic. These specific pathways
seem amiable to remediation both by pharmacotherapy and cognitive behaviour
therapy.
REFERENCES
PHARMACOTHERAPY OF OBSESSIVE
COMPULSIVE DISORDER
Sumant Khanna, MD, PhD, MAMS, MRCPsych
Consultant Psychiatrist, New Delhi
Former Additional Professor of Psychiatry, NIMHANS, Bangalore
AUGMENTING STRATEGIES
Electroconvlsive therapy has been used in OCD but without sustained benefit.
There are a few open series in the literature which suggest that co-morbid
severe depression with suicidal risk may be one of best predictors for usage
in OCD. Earlier frontal lobotmies have given way to stereotactic procedures
in alleviating the symptoms of OCD. Although the sample sizes are small, and
the facilities limited, this seems to be an area of promise for the well-evaluated
refractory patient. Transcranial magnetic stimulation is a new emerging area
of academic and therapeutic relevance in OCD and although a recent Cochrane
review failed to find evidence of its efficacy in OCD, the final verdict is awaited.
Finally deep brain stimulation, a technique whereby needles are implanted in
chosen brain areas and stimulated whenever required, seems to be emerging
as a viable option in refractory OCD.
REFERENCES
I n the last three decades, much progress has been made in the
psychotherapeutic treatment of OCD. Although many behavioral techniques
have been tried in the past in treating OCD, exposure and response prevention
(ERP) has proved to be the most effective psychotherapy for OCD (Abramowitz,
1998). In ERP, the patients are persuaded to expose themselves to the anxiety-
provoking stimuli and prevented from doing compulsions or rituals. Repeated
and prolonged exposure without recourse to rituals or avoidance helps to
disconfirm the mistaken fears and beliefs and promotes habituation to previously
fearful thoughts and situations.
For example, one may not use the toilets, bathrooms or sinks used by others.
Because of extensive avoidance and compulsive behaviors, patients do not get
an opportunity to disconfirm their fears and fail to be habituated to the stimuli
that arouse anxiety. This leads to maintenance of obsessions and compulsions.
However, most patients are not able to recall conditioning events. Therefore,
the evidence for acquisition of obsessions by classical conditioning is weak.
However, the theory accounts well for the maintenance of symptoms by operant
conditioning.
Initially the compulsions are linked to the original cues that provoke anxiety.
Later the compulsions may be evoked by other cues that are in some way
linked to the original cue. In other words stimulus generalization occurs.
Technique of ERP
Case vignette:
Mrs. G, a 30-year-old married lady has been suffering from OCD for the
last 5 years. She has obsessive fears of dirt and contamination. She gets repetitive
thoughts that she will fall ill if she touches objects used by others (door knobs,
chairs, railings, public toilets etc). She knows that these thoughts are silly yet
is distressed by them. She has compulsive washing and avoidance. Every time
she touches any of the feared objects she washes hands for at least half an
hour applying soap 6 times. She takes 2 hours to shower, applying soap at
least 3 times. She avoids using public toilets and public transport. She makes
her husband and children to wash hands before touching her. She feels helpless
and guilty for troubling her family. Her husband thinks that she is “crazy”
and that she does not try to stop doing “silly acts”.
1. Psychoeducation of patient and family regarding OCD and the rationale behind
ERP is the first step in initiating ERP. It is extremely important that the
patient and family members understand that the intrusive thoughts and
compulsive behaviors are the symptoms of a disease. Patient should have
a clear understanding that OCD is a medical brain disorder and not a reflection
of one’s weakness or character. Mrs. G, and her family were informed that
OCD was a common mental illness affecting 2-3 people out of 100 i.e. she
46 BEHAVIOR THERAPY IN OCD
was not the only person suffering from it. They were told that the illness
was characterized by repetitive unwanted illogical thoughts that provoked
anxiety and repetitive acts to reduce anxiety. In her case, thoughts about
falling ill by touching objects used by others –although unrealistic would
provoke anxiety. In order to reduce anxiety she would wash repeatedly. She
was reassured that she was not responsible for these thoughts and acts, which
were actually symptoms of a disorder. This allayed her guilt. Her husband
developed a better understanding of her predicament.
2. Since motivation and compliance with ERP procedures are crucial to the
success of therapy, patients should be educated about the rationale behind
ERP. Many patients often wonder why doctors make them do things that
generate anxiety. Therefore, patients should be made to understand that
avoidance and compulsions maintain their obsessions and that habituation
is crucial to the ERP procedure. In other words, they should know how
ERP works. Mrs. G was informed that during ERP she would have to
expose herself to feared objects (touching door knobs) repeatedly till it no
longer provokes anxiety (habituation). In addition, she would have to stop
washing her hands (response prevention). This would break the link between
washing and anxiety reduction (extinction). Importantly, she would have to
overcome avoidance of feared situations (public toilets).
3. Behavioral analysis: This includes identification of specific triggers of
obsessions, compulsions and avoidance behaviors. In Mrs. G’s case, touching
objects used by others such as doorknobs is the trigger for the obsessive fear
“I will fall ill”. The obsession provokes anxiety making Mrs. G to perform
the compulsion of washing hands. Avoidance is seen in the form of her not
using public toilets, public transportation etc. At this stage, it is pertinent
to analyze the role of family members. It is not unusual for the family members
to be involved in the patient’s rituals. Often they perform rituals by proxy.
Mrs. G’s husband and children used to wash themselves thoroughly before
entering the house and before touching her. Her husband would do most
of the shopping so that she would not have to go out of the house. He would
also open doors for her, including the door to the ladies’ toilet. Assess the
degree of insight – how much does the patient believe that feared consequences
will really occur if rituals are not done? Mrs. G was asked how mush she
believed that she would really fall ill if she did not wash hands. She reported
that although she knew that the chances of falling ill were extremely low,
she found it very difficult to convince herself while in the feared situation.
This would be considered as good insight. Patients with poor insight may
BEHAVIOR THERAPY IN OCD 47
0 Anxiety 100
60
5. Make a hierarchy of triggers from the least anxiety provoking to the most
anxiety provoking. Exposure to triggers should be done in a graded manner
(graded exposure). Few patients are highly motivated to get exposed to
the most anxiety provoking triggers (flooding). Most patients prefer graded
exposure to flooding.
Mrs. G was asked to list situation and objects that provoked anxiety and
to arrange them based on the level of anxiety and avoidance. She came up
with the following list:
Activity Anxiety
6. To begin the therapy, select a target behavior by discussing with the patient.
This is usually one of the less anxiety provoking triggers. Once patient becomes
confident, move up the hierarchy. Mrs. G agreed to start with touching
her husband or allowing him to touch her before washing
48 BEHAVIOR THERAPY IN OCD
Combination therapy
The combination of SSRIs and ERP is believed to be more effective than either
treatment alone. There is limited evidence to support this belief. However, most
expert clinicians advocate combined procedures wherever feasible (Greist, 1992).
The addition of SSRIs to ERP helps in treating the comorbid depression especially
when severe. It also improves compliance with ERP.
Cognitive-behavior therapy
Cognitive-behavior therapy was developed in the context of refusal of ERP by
nearly one-quarter of patients and high rates of dropouts in the course of ERP.
There was also a need to develop an alternative conceptualization of OCD.
There are two models of cognitive-behavior therapy in OCD. The medical
model is based on the hypothesis that OCD is a medical brain disorder with
associated neurochemical, and neuroanatomical dysfunction (Schwartz, 1998;
Schwartz & Beyette, 1997). Therapy proceeds through four steps: (1). Relabel
obsessions as symptoms of medical illness, (2). Reattribute obsessions as false
brain messages, reduce personal responsibility, encourage patient to act as an
impartial spectator, (3). Refocus on working around the illness and (4). Revalue
symptom vs. patient as a whole. The classic model deals with correction of
mistaken beliefs and cognitive distortions by cognitive restructuring (Salkovskis,
1998). Here the main focus is on belief modification. The typical cognitive
distortions include overestimation of risk, inflated personal responsibility, thought-
action fusion, perfectionism and need to control thoughts and beliefs about religion,
morality and superstitions. Cognitive–behavior therapy lays the groundwork
for greater acceptance of ERP. ERP is an essential component of CBT.
REFERENCES
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93-115.
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theory to treatment. In Obsessive-Compulsive Disorders: Psychological and
Pharmacological Treatments. Ed. M. Mavissakalian. Plenum, New York, 1985, pp 49-
129.
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term Treatments of Anxiety Disorders. Eds. M. R. Mavissakalian, R.F. Prien. American
Psychiatric Press, Washington, DC, 1996, pp 285-309.
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Psychiatry 1992; 53 (Suppl. 4): 38-41.
6. Kobak KA, Greist JH, Jefferson JW, Katzlenick DJ, Henk HJ. Behavioral versus
pharmacological treatments of obsessive-compulsive disorder. Psychopharmacology. 1998;
136: 205-216.
7. Salkovskis PM, Forrester E, Richards C. Cognitive-behavioral approach to understanding
obsessional thinking. British Journal of Psychiatry 1998; 173: 53-63.
8. Schwartz JM. Neuroanatomical aspects of cognitive-behavioral therapy response in
obsessive-compulsive disorder. An evolving perspective on brain and behavior. British
Journal of Psychiatry 1998; 173: 38-44
9. Schwartz JM, Beyette B. Brain Lock: Free Yourself from Obsessive-Compulsive Behavior.
Harper Collins, New York, 1997.