Obsessive-compulsive disorder - Symptoms

Symptoms of Obsessive Compulsive Disorder

According to DSM-IV, obsessive-compulsive disorder is a type of anxiety disorder characterized by obsessive repetition of unwanted, unpleasant thoughts, images, or impulses (obsessions) and/or repetitive actions that a person performs compulsively and according to certain rules (compulsions). The presence of both obsessions and compulsions is not necessary for a diagnosis. However, in most patients they are combined, and only in a small number of cases are they observed separately from each other. The patient usually tries to actively suppress or neutralize obsessions, convincing himself of their irrationality, avoiding provoking situations (if any), or implementing compulsions. In most cases, compulsions are performed to relieve anxiety, but often they only increase anxiety, since they require significant expenditure of energy and time.

Common types of obsessions include fears of contamination or contamination (e.g., obsessive fear of dirt, germs, non-hazardous waste), concerns about one's own safety, the possibility of causing harm (e.g., starting a fire), impulsively committing aggressive acts (e.g., harming a beloved grandchild), inappropriate thoughts about sexual or religious themes (e.g., blasphemous images of Christ in a devout person), and a desire for symmetry and perfect precision.

Common compulsions include excessive cleanliness (e.g., ritualized hand washing), rituals involving checking and tidying, arranging objects in a certain order, compulsive counting, repetitive daily actions (e.g., entering or leaving a room), and hoarding (e.g., collecting useless newspaper clippings). Although most compulsions are observable, some are internal ("mental") rituals - for example, silently saying meaningless words to drive away a frightening image.

Most patients with obsessive-compulsive disorder have multiple obsessions and compulsions. For example, a patient who actively complains only of an obsessive fear of asbestos contamination may, upon detailed interview, also have other obsessive states, such as obsessive counting of floors or collecting unnecessary mail. Therefore, during the initial examination, it is recommended to use special questionnaires that allow identifying the entire complex of symptoms in the patient, such as the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS).

The key feature of the disease is that at a certain stage of its development the patient becomes aware of the meaninglessness or at least redundancy of his thoughts and actions. Thus, the presence of criticism helps to distinguish obsessive-compulsive disorder from a psychotic disorder. Although the symptoms are sometimes quite bizarre, patients are aware of their absurdity. For example, one patient was afraid that he would accidentally mail his 5-year-old daughter, so he checked the envelopes several times before throwing them in the mailbox, making sure that she was not inside. He understood intellectually that this was impossible, but he was so overwhelmed by painful doubts that he could not cope with the growing anxiety until he checked. The degree of criticism is expressed to varying degrees in different patients and can even change over time in the same patient depending on the situation. Taking this into account, DSM-IV allows for the diagnosis of obsessive-compulsive disorder in a patient who is currently not critical of his or her symptoms (defined as “insufficient criticism”) if criticism has been noted previously.

Where is the line between normal concern about the correctness of one's actions and obsessive checking of one's actions? The diagnosis of obsessive-compulsive disorder is established only when the symptoms of the disease cause anxiety in the patient and require significant time (more than one hour a day) or significantly disrupt his life. If a person who, when leaving the house, must check six times whether the door is locked, but does not have any other manifestations, then he can be diagnosed with compulsions, but not obsessive-compulsive disorder. Disorders of life associated with obsessive-compulsive disorder vary from mild, minimally affecting the level of social adaptation, to severe, when the person is literally disabled.

There are several additional conditions necessary for the diagnosis of obsessive-compulsive disorder in childhood, although in general the clinical manifestations of obsessive-compulsive disorder in children and adults are similar. Although most children are aware of the undesirable nature of the symptoms, it is more difficult to identify a critical attitude towards obsessive manifestations in them than in adults. Not all rituals observed in children can be regarded as pathological, since the need for uniformity and constancy can be dictated by a sense of security, for example, when going to sleep. Many healthy children have certain rituals when preparing for sleep: for example, they put themselves to bed in a particular way, make sure that their feet are covered, or check for "monsters" under their bed. In the presence of childhood rituals, obsessive-compulsive disorder should be suspected only if they disrupt adaptation (for example, take a lot of time or cause anxiety in patients) and persist for a long time.

Conditions that indicate the possibility of obsessive-compulsive disorder and related disorders

• Anxiety
• Depression
• Concern about having a disease (e.g. AIDS, cancer, or poisoning)
• Tiki
• Dermatitis of unknown origin or alopecia of unknown origin (trichotillomania)
• Excessive concern about appearance (dysmorphophobia)
• Postpartum depression

Abuse of psychostimulants (e.g., amphetamine or cocaine) can induce repetitive behaviors that resemble rituals in obsessive-compulsive disorder. "Panding" is a term taken from Swedish drug slang for a condition in which a patient intoxicated with psychostimulants compulsively performs purposeless actions, such as assembling and disassembling household appliances. In laboratory animals, stereotypical behaviors can be induced by administering psychostimulants and dopamine receptor agonists.

One explanation for why obsessive-compulsive disorder often goes unrecognized is that sufferers often hide their symptoms for fear of being considered “crazy.” Many sufferers eventually learn to mask their symptoms by performing compulsive behaviors only when alone or by avoiding situations that might trigger them. In cases where compulsions can only be performed in public, they make them seem like meaningful actions by “integrating” them into their daily activities. Patients with obsessive-compulsive disorder are often hesitant to admit to having embarrassing, unacceptable thoughts unless specifically asked about them. Therefore, the physician should actively inquire about the presence of obsessive-compulsive symptoms in patients with depression or anxiety, two conditions that are often found in patients with obsessive-compulsive disorder (comorbid with it) and may act as its "masks". Obsessive-compulsive disorder may be suspected in patients who do not have risk factors for AIDS but insist on repeated HIV testing. Persistent unfounded concerns about possible toxins and other hazards in the environment may also signal the presence of contamination fears. Somatic manifestations of obsessive-compulsive disorder are uncommon. They include unexplained dermatitis caused by constant hand washing or use of detergents, or alopecia of unknown origin, which may indicate obsessive hair pulling. People who frequently seek plastic surgery but are never satisfied with the results of their operations may suffer from body dysmorphophobia and obsessive-compulsive disorder. Postpartum depression is well known and is a very serious complication. However, obsessive-compulsive disorder may also occur along with postpartum depression, and its recognition is extremely important for proper treatment.

Comorbid conditions

The most common comorbid mental disorder in patients with obsessive-compulsive disorder is depression. Two-thirds of patients with obsessive-compulsive disorder are diagnosed with major depression during their lifetime, and one-third of patients with obsessive-compulsive disorder have depression during the first examination. Often, it is the development of depression that prompts a patient with obsessive-compulsive disorder to seek medical attention. There is also significant clinical overlap between obsessive-compulsive disorder and other anxiety disorders, including panic disorder, social phobia, generalized anxiety disorder, and separation anxiety disorder (fear of separation). Patients with obsessive-compulsive disorder are also more likely than the general population to have anorexia nervosa, trichotillomania, and body dysmorphic disorder.

On the other hand, symptoms of obsessive-compulsive disorder may manifest themselves within the framework of another primary mental disorder. Thus, it has been established that obsessions and compulsions are observed in 1-20% of patients with schizophrenia. It has been noted that when taking some new-generation neuroleptics, such as clozapine or risperidone, some patients with schizophrenia experience an increase in obsessive-compulsive symptoms. Data from specialized literature indicate that obsessive-compulsive symptoms in schizophrenia respond favorably to drugs that are usually used to treat obsessive-compulsive disorder, but these drugs can increase psychotic symptoms. Symptoms of obsessive-compulsive disorder are often detected in patients with autism and other common (pervasive) developmental disorders. They are traditionally not classified as OCD due to the impossibility of assessing the patient's level of criticism of his condition.

[ 1 ], [ 2 ], [ 3 ], [ 4 ], [ 5 ], [ 6 ]

The course of obsessive-compulsive disorder

Obsessive-compulsive disorder most often appears in adolescence, young adulthood, and early adulthood. Less than 10% of patients over the age of 35 develop their first symptoms. The earliest age of onset reported is 2 years. Almost 15% of cases of obsessive-compulsive disorder appear before puberty. Boys are more likely to have obsessive-compulsive disorder than girls, and on average, they develop obsessive-compulsive disorder earlier. In adults with obsessive-compulsive disorder, the gender ratio is approximately 1:1. This contrasts with depression and panic disorder, which are much more common in women than in men. Over the course of a person's life, obsessive-compulsive disorder will develop in 2-3% of the population.

The course of the disease is usually chronic, with 85% of patients experiencing a wave-like development with periods of worsening and improving, and 5-10% of patients experiencing a steadily progressive course. Only 5% of patients experience a true remittent course, when symptoms periodically disappear completely. But persistent spontaneous remissions are even rarer. It should be noted that these data were not obtained from an epidemiological study, but from long-term observation of a group of patients who may have initially had a tendency toward chronicity. It is possible that many patients who experience spontaneous remissions do not come to the attention of doctors or are not observed by them. In most cases, the clinical debut of obsessive-compulsive disorder is not associated with any external events.