Obsessive Compulsive Disorder- The illness of doubts
View(s):By Prof. Raveen Hanwella Doctor:
What is it she does now? Look how she rubs her hands.
Gentlewoman:
It is an accustom’d action with her, to seem thus washing her hands. I have known her continue in this a quarter of an hour.
Lady Macbeth:
Yet here’s a spot.
Out, damn’d spot! out, I say!
(Macbeth Act 5, Scene 1)
"Out, damn’d spot! out, I say": Lady Macbeth's scene
In this famous scene from Shakespeare’s Macbeth, Lady Macbeth is sleepwalking in the castle rubbing her hands together as if washing them. The spot she is talking about is the imaginary blood on her hands of Duncan, the King of Scotland, who was murdered by her husband, Macbeth. Compulsive or repetitive hand washing is a hallmark of the condition known as obsessive compulsive disorder. It is also known as the Lady Macbeth syndrome.
Obsessive Compulsive Disorder or OCD is a common mental disorder affecting children, adolescents and adults throughout the world. The onset usually is in children or teenagers but more rarely adults too can get it for the first time. Repetitive hand washing is not the only symptom and there is a wide array of presentation. The central problem is unwanted and unpleasant thoughts, images or urges that repeatedly enter a person’s mind, causing feelings of anxiety, disgust or unease. These thoughts, images or impulses are called obsessions. Persons with OCD also have the need to perform certain actions repeatedly. These rituals are called compulsions. Hence the name obsessive compulsive disorder.
The obsessions are centred on themes. Common obsessional themes include:
Contamination – fear of dirt, germs, cancer, HIV
Checking – worry that a door has been left unlocked
Aggression – fear of accidental harm to self or others
Excessive concern with order or symmetry – clothes have to be worn in a particular order or symmetry or things kept in a specific manner.
Blasphemous thoughts concerned with religion Sexual thoughts – “I am a homosexual” or “I am a paedophile”
Persons with OCD find these thoughts extremely distressing but are unable to get rid of them easily. This leads to high levels of anxiety or even depression in the long term. Persons with obsessive thoughts engage in certain activities or rituals in a futile effort to reduce their anxiety. These rituals are the compulsive component of OCD. For example a person who fears contamination with germs may wash their hands repeatedly a specified number of times after applying soap in a particular manner.
A patient of mine after returning from work washed all her clothes including the bank notes in her wallet and hung them out to dry. She was compelled to do this even after returning late in the evening. When the clothes and notes were drying on the wash line if a person accidentally touched the items, she had to wash them again. Another patient, while driving his vehicle, had the obsessive thought that he had knocked down a pedestrian. He had the compulsion to go back and check whether there was anybody lying injured on the road. Yet another patient had the distressing thought that she might stab her baby. She locked up all the kitchen knives in a drawer and did not touch a knife if her baby was nearby.
There are rarer forms of OCD where the patients have obsessive thoughts only but no compulsions or rituals. These are called obsessional ruminations. The thoughts are usually about philosophical issues for which there is no answer. Sometimes these thoughts are about improbable or fantastical situations. One patient spent hours thinking what might happen if she was kidnapped or held hostage after a terrorist attack.
Having read this you might wonder whether you also might be having OCD. After all don’t we all check excessively at times, and worry too much about getting a dangerous disease such as cancer, dengue or HIV? Yes, all humans do have a touch of obsessions in them but usually these episodes are transient, cause minimum distress, or inconvenience to life. In contrast, people with OCD, in addition to severe distress spend a significant amount of time on rituals, seriously impairing their day-to-day functioning. Some, after having prolonged OCD become severely depressed and have thoughts of ending their life.
Can OCD be treated? Yes, there are effective treatments available. The therapy can be psychotherapy, drugs or both. Sometime ago scientists found that some of the medicines given for depressive disorder were also effective for OCD. These drugs however, needed to be given in higher doses, and for longer periods, than for depressive disorder. Even after resolution of symptoms the medicines need to be continued for a further period of time, usually two to three years. This is because OCD has a tendency to return over and over, if treatment is not continued after initial recovery.
The psychotherapy recommended is behavioural therapy or cognitive therapy in combination. The particular behaviour therapy method is called exposure and response prevention (ERP). For example, a person having a fear of contamination with germs is asked to touch the floor (exposure)with his or her hands and stay without washing for half an hour (response prevention). After the initial distress the patient is often surprised to find that the anxiety is reduced and the intensity of thoughts are less. One session is not sufficient however, and repeated sessions are necessary to have a lasting impact. Cognitive behaviour therapy is more complex and needs to be combined with behaviour therapy in more difficult cases of OCD.
What should you do if you think you have OCD? Is self-help possible? In milder cases this could be done. There are excellent resources on the web. A book I recommend is, The OCD Workbook by Hyman and Pedrick. But I would really urge you to see a psychiatrist for an evaluation. The psychiatrist will be able to advise you on the best course of action. If you are averse to taking medication they can offer non-medical options and direct you to where you can obtain these therapies. Therapy for OCD is specialised and simple counselling is not sufficient. Proper treatment will make a big difference to your life and the life of your family.