Obsession and Cmpulsion

Obsession and compulsion   

Obsession is a recurrent thought, feeling, or idea or sensation which comes in mind repeatedly.

Where as compulsion is a conscious, recurrent behaviour such as checking, counting, or avoiding. Thus obsession increases the anxiety and by carrying out the compulsion reduces it 

How common is it? 

This is a common anxiety disorder and it is found in 10 percent of patients who attends to psychiatry clinics.

It affects all age groups, and both male and females are affected. Usually it starts in early age such as in adolescence or early adult age then progresses.

In western countries as in USA, blacks are less affected by obsession than white population. In India in popular terms the compulsion is known as “mania”, such as “hand washing mania”, “checking mania’, “or “repeating things” etc.  At times though it starts at an early age patients take help few years after until it becomes severe enough to affect the day to day activities. 

My experience working in Papua New Guinea and Bermuda or India, and in indegenous people in New Zealand, i have found fewer people having obsession and compulsion than the european population.

What are the issues? 

Obsession is a chronic anxiety disorder and usually it has a chronic progression.

At times symptoms are less and other times it gets worse when patients become stressed or deterioration of obsession increases the stress.  

Obsession is rarely found without any compulsion. So obsession leads to ways to reduce the anxiety by way of compulsion. At times compulsion is predominant and obsession remains in background.  

Patients with obsession may have other mental symptoms such as depression, phobias, alcohol abuse or addiction or psychosis etc.  

Obsessive patients finds difficult to adjust with the family or at work place. They may take a long time to do activities, thus affecting their work. Due to their obsessive thoughts sometimes they try to control the behaviour of the others to reduce their anxiety. They may be rigid and obsessive in maintaining the routine thus avoiding anxiety. They may hide the obsessive thoughts many years due to embarrassment. 

Obsessive persons are mostly single in western countries than in India, this may be due to the lack of social skills or difficulty in maintaining a relationship.  

Patients with obsession may not be able to do their day to day activities in required time thus delaying in attending to work or study etc. They may have poor self care, or may have infection or injury to hands or feet due to repeated washing. They may become irritable and angry towards those who do not comply with their wish. Often they may have low mood.   

Treatment is difficult and most of the patients remain symptomatic throughout their life despite available medicine and psychological treatment. 

Suicide is a risk for all patients with obsessive and compulsive disorders. Though they may have imagery or compulsive thoughts of injuring others, they would not do as they know those thoughts are irrational.  

What are the different types of obsession? 

Obsessive fear of dirt or contamination:

The affected person feels every object or thing is contaminated with dirt or bacteria or germs, thus they would wash their hands repeatedly whenever they touch anything. Washing hands is a compulsive activity, and the obsessive doubts that hands are not properly washed or cleaned make them repeat the act many times. Thus it causes wasting of time and water etc. When they try to stop, it increases anxiety so they resume the washing.  

Obsessive doubts:

Patient with this obsession is characterized by the thoughts that they have not done it properly, such as when they lock the door they would check many times and when at work they would check many times of their work delaying the pace of work. Most of the obsessive doubts are related to some danger of violence such as not licking a door or forgetting to switch off the stove etc. Checking involves multiple trips back home to check the stove or check the lock. Patients also have an obsessional self doubt and always feel guilty about having forgotten or committed something. 

Obsessive counting:

Counting many things such a light posts on the streets, or counting house, or things at home, etc. thus delaying to do other useful activities.  

Obsessive impulse:

This is characterized by intrusive obsessional thoughts without any compulsion. Patient may have intrusive thoughts of hurting self or killing somebody or have sexual thoughts such as shouting obscenity in public or sexual exposure in public. The thoughts are reprehensible to the patient and patients may report this to a police or to a priest. Sometimes they may pray many times to reduce the guilt or do religious rituals to get rid of those thoughts. 

Obsessive imagery:

Patients have imagery or have feelings that as if they could see people naked under their clothes, and they may have severe anxiety when they feel it with their own parents or family members. Thus they may have guilt and shame, they may do complex religious or spiritual activity to get relief from those unacceptable thoughts. In doing that they may avoid any social activity. There are reports of imagery in that they can see the death of some special people, or any accident, thus causing severe anxiety and avoiding any social contact.  Obsessive rumination: In this kind of obsession patient is preoccupied with thoughts which are simple and at times strange. They would think pros and cons of the idea and thus may not be able to do any other activity. The examples are: patient may have idea “why the earth is moving round the sun”, “why the chair has four legs, why not three” etc.  

Obsessive symmetry:

The patients present with precision or symmetry of the activity thus leading to slowness of any activity. Patient arrange their study table in a special manner, or make their beds in a symmetrical way, or does any activity is such symmetrical way that would lead to delay to do any activity. If there is any change of the symmetry by any means then they would become upset and resentful. They may take many hours to do simple activity such as eating a meal or shave their faces or take a shower.  

Other obsessions:  

Religious obsessions and compulsive hoarding is common in obsessive-compulsive disorders. Patients may collect many things, in multiple numbers, such as many pairs of shoes, electrical gadgets, household items, clothes, books etc, thus filling the house. They may not be able to move in the house and they would feel intense anxiety when asked to dispose unnecessary things. Due to too many things it can cause health hazards and fire hazards. Compulsive hair pulling also known as Trichotillomania, and nail biting are compulsions related to obsessive and compulsive disorder.   

What are the features of obsession and compulsion: 

Thoughts and actions in obsessions and compulsions are repetitive in nature.Individuals believe the thoughts are irrational and not acceptable.They also believe that those thoughts are their own thoughtsThoughts are anxiety provoking and the more they think the more anxiety becomes intense. To reduce anxiety and stress due to unacceptable thoughts they would do compulsive acts. Such compulsion acts reduce anxiety temporarily. Obsessive persons have complete understanding of their problems and they usually seek treatment. 

Other mental problems associated with obsession and compulsion:  

1)     Depression is common with patients suffering from obsession and compulsion. And the depression increases in intensity when they are unable to do their daily activity, not able to work. Patients may have thoughts of suicide also.

2)     Anxiety is also common when they try to avoid or restrain their obsessive thoughts. At times they may become panicky when the obsessive thoughts or imagery is intense.

3)     Obsessive patients may become preoccupied with bodily symptoms etc.  

Outcome of patients with obsession and compulsion:   

It was noted that more than fifty percent of obsessions start due to some stress such as pregnancy, sexual problem or due to death of a relative, and there is often a delay of five to ten years before patients come to a psychiatrist. Usually the course of illness is long. For some it is fluctuating meaning it increases in intensity when in stress, other times it is less. For others experience a constant one. Usually up to 30 percent improves significantly, and 40 to 50 percent have moderate improvement, the rest remain ill or worsens their symptoms.  

Good outcome of obsessions and compulsion: 

When the following conditions are present, it signifies the good outcome:

1)     Late age of onset signifies good outcome. Early onset such as at the age of adolescence or even earlier onset is bad outcome.

2)     When there is resistance to compulsion then the outcome is good.

3)     When there is depression and or anxiety associated with obsession and compulsion then the outcome is good.

4)     Good social and occupational adjustment is also a good outcome.

5)     When there is some precipitating stress then the outcome is good. If the obsession starts without any stress then the outcome is poor.

6)     When there is any personality disorder, then also prognosis is bad.   

Treatment of obsession and compulsion: 

Many patients avoid any treatment and so motivating somebody is a difficult task at times. When patients work and family life gets affected then they usually seek treatment or when they attempt any suicide or self harm.  They may also refuse to take medications, though only few following medications are helpful in treatment.  

The following medications may be used:

1)     Clomipramine: This is an antidepressant used to treat obsessive compulsive disorders. This medication is the most useful, but it takes usually four to weeks to have adequate effect. It also causes side effects such as dry mouth, constipation and dizziness due to lowering of Blood pressure, etc.

2)     Fluoxetine, Paroxetine, Fluvoxamine, Sertraline, all antidepressants also found to be useful. Those also has some side effects and all the medications must be taken under medical supervision.

3)     Some doctors also prescribe Lithium, venlafaxine, etc.

4)     ECT: Electro convulsive therapy also used when patients fail to improve with above medications, failed behaviour therapy and presents with suicidal risks and severely incapacitated with obsession and compulsion.  

Psychological treatments 

These treatments are almost as effective as medications. But psychological treatments are easily available in western countries. People living in Asian and developing countries have very limited service and also they have less understanding of the behavioural techniques.  The must be very committed to the therapy otherwise it won’t be successful. Some behavioural techniques are as follows: 

Exposure and response prevention: The persons are exposed to situation which increases the fear or anxiety, but they are prevented to escape, and thus causing the therapeutic effect. A patient with obsession of dirt is prevented to wash hands thus exposing to stress and preventing to escape, leads to improvement of obsession.

Desensitization: First the person is taught the relaxation techniques then he or she is exposed to the situation step by step. When the anxiety or compulsion arises they would do the relaxation techniques rather avoiding the situation. Thus with graded exposure the person becomes desensitized from dirt, or any impulsive thoughts etc. This technique is used mostly in treatment of phobias. 

Flooding: The patient is exposed to dirt or any anxiety provoking thoughts or situation, and then prevent the person’s escape from it. The feeling of anxiety will not last long if the exposure continues and thus reduce the symptoms. 

Thought stopping: When an unacceptable thoughts or imagery etc appears in mind then the individual learns how to reduce or stop the thought by doing an opposite or incompatible response, such as by shouting the word “stop” or by snapping a rubber band on wrist when unacceptable thoughts arise. This technique is more acceptable in the public than the previous one which should be practised at home.  

Thought saturation: The patient is directed to think out the obsessional thought which he or she complained about for, such as 10 to 15 minutes over a number of days (3 to 5 days). Doing this obsession loses its intensity.  

Family support Family members also get affected due to having a person in the family having obsession and compulsion. Patient’s behaviour becomes intolerable, such as obsession with dirt. When the patient may take many hours to wash or take a shower, and may clean any part of the house, and may prevent others to enter the house without being clean or a wash etc. The patient may be late in school or to work thus not able to complete study or to work. Family needs to know about the obsession and compulsion so that they would become sympathetic to the individuals symptoms and feelings. 

Cause of obsession and compulsion is not known. 

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