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Multiple symptoms and common co-morbidities in OCDs: Study

  • Psychiatrists note need for suspicion to detect co-morbidities when assessing patients with OCDs

BY Ruwan Laknath Jayakody

In obsessive compulsive disorders (OCDs), there are a multiplicity of symptoms and the common occurrence of co-morbidities, which have implications on choosing management options and for evaluating the prognosis, a local study found.

This finding was made in an original paper on the “Phenomenology of OCDs in a Sri Lankan patient population”, which was authored by C. Kapugama (attached to the National Hospital’s Colombo University’s Psychiatry Unit) and V. de Silva (attached to the Colombo University’s Medical Faculty’s Psychological Medicine Department) and published in the Sri Lanka Journal of Psychiatry 5 (1) in June 2014.

OCDs, Kapugama and de Silva noted, are chronic and disabling conditions characterised by recurrent intrusive thoughts and compulsive acts. OCDs have been associated in terms of phenomenological similarity with conditions such as trichotillomania (an obsessive, compulsive, and related psychiatric disorder where the individual pulls out their hair from various body sites, as per D.J. Stein, D. Simeon, L.J. Cohen, and E. Hollander and Y.A. Ferrao, E.C. Miguel, and Stein), Tourette’s syndrome (a condition of the nervous system which causes people to have repetitive tics which are sudden twitches, movements, or sounds, as per Ferrao et al.; P.J. Lombroso, and L. Scahill; and Miguel, B.J. Coffey, L. Baer, C.R. Savage, S.L. Rauch, and M.A. Jenike), hypochondriasis (a chronic illness anxiety disorder where the patient has a persistent fear that they have a serious or life-threatening illness despite having only few or no symptoms, as per J.S. Abramowitz), eating disorders (as per L.K. Hsu, W.H. Kaye, and T. Weltzin and K.A. Phillips and Kaye), and body dysmorphic disorder (where one cannot stop thinking about one or more perceived defects or flaws in one’s appearance, which appear minor or cannot be seen by others, as per Phillips and Kaye).

The onset of OCDs may be early, before the age of 18 years or late, after 18 years, with implications in the severity of the illness, according to the “Phenomenology of patients with early and adult onset OCDs” by U. Albert, C. Picco, G. Maina, F. Forner, E. Agugha, and F. Bogetto, while postpartum onset has also been described (L.M. Arnold).

  1. Akhtar, N.N. Wig, V.K. Varma, D. Pershad, and S.K. Verma’s “A phenomenological analysis of symptoms in obsessive compulsive neurosis” identified and demonstrated six forms of obsessions – obsessive doubt, obsessive thinking/thoughts/ruminations, obsessive impulses, obsessive fears/phobias, obsessive images, and miscellaneous forms; two categories of compulsions – yielding compulsions and controlling compulsions; and six broad varieties of thought content – dirt and contamination, aggression, inanimate impersonal, sexual, religious, and miscellaneous forms. Further, M.L. Berthier, J. Kulisevsky, A. Gironell, and J.A. Heras’ “OCDs associated with brain lesions: Clinical phenomenology, cognitive function, and anatomic correlates” showed that the phenomenology of obsessive compulsive symptoms secondary to brain pathology is similar to that of the commoner idiopathic (unknown cause) illness.

Therefore, Kapugama and de Silva conducted a descriptive study of outpatients at a tertiary care centre in Colombo, from January to November 2013. Those who fulfilled clinical criteria for OCDs as per the 10th Revision of the International Classification of Diseases were selected from clinic records, and a detailed clinical interview using a semi-structured questionnaire was done with those who agreed to participate.

Of the 61 patients with OCDs who were registered at the outpatient clinic during the study period, 55 responded, among whom 32 (58.18%) were male, with the mean (average) age of males being 26.03 years and the same for females being 22.43 years. The mean duration of the illness was 31.93 months. Co-morbidity with other psychiatric illnesses (depressive disorders [mood disorder that causes a persistent feeling of sadness and loss of interest], social phobia, bipolar affective disorder [causes extreme mood swings that include emotional highs or mania or hypomania and lows, or depression], specific phobias, mental retardation, Asperger’s syndrome [neuro-developmental disorder characterised by significant difficulties in social interaction and non-verbal communication, along with restricted and repetitive patterns of behaviour and interests], alcohol dependence syndrome, hyperkinetic disorder, fetishism, hypochondriacal disorder) was present in 25 (45.45%).

Obsessional thoughts were the commonest, with 31-33 (56.36-60%) reporting at least one obsessional thought with 13 (23.63%) reporting obsessional ruminations, followed by 23 (41.81%) reporting obsessional doubts (41.81%, n=23) while obsessional phobias were the least common with only one (1.81%) reporting such. Multiple types of obsessions were seen in 24 (43.63%), with the commonest being thoughts and doubts (11 – 20%), while one patient had obsessional thoughts, images, ruminations, and urges. In terms of the themes of the obsessions, the following findings were made: Dirt and contamination (21 – 38.18%), orderliness (10 – 18.18%), sexual themes (seven – 12.72%), aggression (five – 9.09%), blasphemy (five – 9.09%), fidelity of the partner (three – 5.45%, the trio had multiple obsessions and none of them initially presented with this symptom which was revealed only upon specific inquiry, with Kapugama and de Silva pointing out further that detecting this symptom is important due to the risks it pose), and others (four – 7.27%).

While the majority (35 – 63.63%) had only overt compulsions (checking [21 – 38.18%], cleaning [19 – 34.54%], arranging [nine – 16.36%], and dressing [two – 3.63%]), 13 (23.63%) had only covert compulsions and five (9.09%) had both types. The compulsion of counting rituals was not identified. No compulsion was identified in two (3.63%). Multiple types of compulsions were common (14 – 25.45%), with checking and cleaning being the commonest combination (nine – 16.36%), while two (3.63%) experienced checking, cleaning, and arranging compulsions. A significant proportion had a wide range of co-morbid psychiatric diagnoses. 

The commonest co-morbid condition was depression (eight – 14.54%, easily detected when routinely inquired after) while there were three each (5.45%) with bipolar affective disorder (one patient developed bipolar affective disorder only upon him being treated for OCDs with antidepressants. Also, A. Ameiro, A. Odone, C.C. Liapis, and S.N. Ghaemi questioned the diagnostic validity of this co-morbidity based on the premise that OCDs symptoms occur as a secondary phenomenon of bipolar affective disorder as opposed to as a separate entity) and social phobia, and one each (1.81%) who had co-morbid intellectual disability, alcohol dependence syndrome, hyperkinetic disorder, hypochondriacal disorder, schizophrenia (symptoms can include delusions, hallucinations, disorganised speech, trouble with thinking, and lack of motivation), fetishism, and Asperger’s syndrome. Obsessional slowness, which impairs day-to-day functioning, is a documented accompaniment of OCDs, as per D. Veale.

Kapugama and de Silva explained that the significant finding of a wide range of psychiatric co-morbidities suggests the need to have a high index of suspicion for the presence of co-morbidities when assessing patients with OCDs. The management of challenging co-morbidities such as bipolar disorder and OCDs, Kapugama and de Silva added, may be difficult, thus making detection key. In conclusion, Kapugama and de Silva emphasised that these findings could serve as markers for the further exploration of the phenomenology of OCDs within South Asian settings.