Obsessive Compulsive Disorder: Changing Views

Obsessive compulsive disorder is a common personality disorder characterized by obsessive thoughts and outward behaviors used to reduce anxiety or stress caused by these intrusive thoughts and feelings (Deepthi et. al 2018). OCD occurs on a spectrum from mild to severe, with moderate to severe cases experiencing a decline in their adaptability to daily life and efficiency at performing even basic tasks, due to their need to perform obsessive actions. These actions can be hand washing, folding clothing, turning lights off and on, hoarding, or an obsession with performing a task a particular number of times or any other physical action (Hoffner & Cohen 2017). Obsessive thoughts can be a preoccupation with cleanliness, religiosity or a feeling of impending doom if the particular task is not carried out (Deepthi 2018). Even with the lessening of mental health disorder stigma, people with conditions like OCD are often regarded as burdensome, frightening or even comedic. This view devalues patients with OCD as people and helps lead to further shame and impediment of treatment.

OCD Prevalence

OCD can affect people of all ages. Studies suggest it is more common in younger adults with onset occurring in early twenties. However, there are cases of pediatric OCD. OCD in children is often misdiagnosed as a developmental disorder, so the prevalence may be more frequent than previously thought. Symptoms become apparent earlier in men than in women by only a couple of years. Overall, it affects 1-1.5% of the general population. This is possibly an underestimation in adults as well because OCD is often misdiagnosed due to patients' tendency to feel shame regarding their obsessive thoughts and rituals. It is the fourth most common occurring psychiatric disorder in the United States, with 46% of those being refractory OCD, meaning resistant to treatment. Refractory OCD can impede activities of daily living, making work, school and social interaction nearly impossible (Sayyah & Rahim 2018).

Diagnosis and Treatment of OCD

Diagnosis of Obsessive Compulsive disorder is usually reached after a one on one interview with a therapist using various tools, such as the Yale-Brown Obsessive Compulsive Scale. This process can take years sometimes. Early diagnosis of OCD is critical because it usually indicates a better prognosis for treatment (Chacon et al 2018). Traditional models of diagnosis, such as the DSM-IV and the YBOCS, regarded OCD as a one dimensional set of symptoms. Recent study and criticism of this definition have found that OCD is actually a complex personality disorder linked to other comorbidities like anorexia, anxiety, borderline personality disorder and even schizophrenia. This suggests a possible hybrid diagnosis approach with other conditions maybe be a more accurate way to diagnose and define OCD ( Liggett & Sellbom 2018).

Often times, OCD is misdiagnosed as mental retardation, attention deficit conditions or maladaptive anxiety disorders. The onset of symptoms is often worsened after a particular trauma or stressful situation (Chacon 2018).

Combined therapies have shown to be the most effective methods. Because OCD is commonly seen with other anxiety related disorders, anxiety medications are used to treat the condition. Generally an SSRI is used in conjunction with therapy like Cognitive Behavioral Therapy. In cases where psychosis related behaviors are also treated with antipsychotics, although this is less common. When CBT was initiated as soon as pharmalogical measures were started, patients saw the greatest improvement and the least occurrence of relapse. CBT involves challenging the patient's sequence of relating the obsessive action with averting negative consequences and stressing logical thought process. For example, a therapist would encourage the realization that locking the door to a patient's house seven times does not affect the likelihood that they will be robbed or experience damage to property. However the majority of patients still only saw a 25% decrease in symptoms, this is not considered an acceptable level of independent function (Chacon 2018). Continued progress in treatment methods and criteria for early diagnosis is still necessary, especially in those with refractory OCD.

Correlating Factors

Environmental

Studies have shown a strong correlation between certain beliefs, such as religiosity and superstition and compulsive behaviors. This is seen, to a lesser extent, even in the general population. Control groups showed sensory-motor responses to stressors even without the presence of a psychiatric disorder. These physical actions serve as a defense mechanism to lessen anxiety (Olatunji et al 2018). Those with OCD have a harder time regulating the intrusive thoughts associated with stressors and the outward actions linked to those thoughts. This was especially so in religious or cultural groups that emphasizes order, perfectionism and the avoidance of physical intimacy (Olatunji 2018). However, self-reporting was relied on heavily for these studies, leaving room for error or missing data. Participants were asked to report on beliefs, behaviors, social interaction and activities of daily living. They were also asked to respond to specific questions related to beliefs about subjects like cleanliness. (Hirose et al 2017).

Biological

In an MRI study the thalamus was linked to OCD pathology. When provoked with images linked to contamination or dirtiness, patients with OCD and hand washing behaviors showed decreased activity in the thalamus compared with subjects not diagnosed with OCD. Since the thalamus is linked to sensory and motor function along with communication with the cerebral cortex, there is reason to believe this decrease in thalamus function holds a strong link to obsessive behaviors (Cho et al 2013). Increased actions like hand washing and hoarding were linked to a decreased volume of grey matter and white matter in the brain (Hirose 2017). In another study, MRIs revealed nucleus accumbens dysfunction in patients with OCD. The nucleus accumbens and thalamus are key in the aversion/reward process of brain function (Xie et al 2017).

There was also a correlation found between earlier onset of anxiety and depression and the emergence of activity limiting behaviors in OCD patients. This could be due to the way early onset of certain mental disorders are thought to change the development of the brain and its function. Additionally, a high correlation between first degree relatives and OCD has been found, adding to the theory of a possible biological as well as cultural link (Deepthi 2018). Children with siblings with obsessive compulsive symptoms were more likely to exhibit symptoms themselves. However this could be due to similar environmental factors as well as biologic factors, especially in sibling (Chacon 2018).

OCD in the Media

In 2018 a study was done concerning the portrayal of people with mental disorders in television and movies. Specifically the show Monk and its portrayal of the titular character, a detective with obsessive compulsive disorder was reviewed by actual patients with OCD. The show received mixed feelings about the character and how realistic of a depiction the show provided. Overall 15.9% reported positive evaluations, 27.3% gave negative and 27.3% expressed neutral feelings. This was in a study of 37 participants.

In those with a positive response to the show, four participants stated a realistic portrayal of life with a mental disorder. In contrast, half of the participants overall felt that the show was unrealistic concerning daily life with OCD. The majority of those in the study found that the show would at least open doors to public awareness of the condition and leave room for further discussion. What received the most positive feedback was the character himself. Monk is portrayed as intelligent, respected and effective as a detective, despite his OCD behaviors. Viewers felt this could lessen stigma surrounding the disease and mental health disorders as a whole (Hoffner & Cohen 2018).

As with any physical or mental condition, as studies increase and knowledge grows, treatment gains efficacy and understanding increases. This evolution of the concept of OCD as a mental disorder within the medical community will help to better serve those suffering from this condition. Along with a better clinical grasp, hopefully the public will gain a better view of those with OCD and OCD as a whole. Media portrayals such as Monk and other compassionate representations can serve as a bridge between those with the disorder and those with an outside perspective. While not the most scientifically accurate, the portrayal of those with OCD as human beings with equal value to those who do not experience mental health issues. With increased understanding comes greater compassion and a greater capacity to care for those with OCD and that is the ultimate goal of psychiatric care.

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