September 2012, Volume 62, Issue 9

Opinion and Debate

Obsessive-Compulsive Disorder (OCD): Is this disorder under-recognized?

Amin A. Muhammad Gadit  ( Discipline of Psychiatry, Memorial University of Newfoundland, Canada. )

Obsessive-Compulsive disorder is much more common than it was initially assumed. It can be a part of a major mental illness or can occur on its own. It was found that 1-year prevalence is in the range of 0.8-2.2 % in a study.1 There are some interesting figures on this mental disorder:2 1 in 200 young people at any time are suffering from OCD, boys are more likely to have an onset before puberty than girls, boys are also more likely to have a family member with OCD or Tourette Syndrome, 1-3% of population suffers from it, sexual obsessions are common in people with OCD, strong genetic basis has been revealed, five times more likely in first degree relatives of someone with OCD, 75% of patients with OCD have a secondary or co-morbid diagnosis, these patient benefit with therapy.The global incidence of OCD from W.H.O. indicate:" the smallest frequency is in China, Korea, Southeast Asia, Australia, New Zealand and Japan followed by India, Pakistan, Afghanistan, Bangladesh, Thailand, Indonesia, then, Western Europe and North America. A higher occurrence is found in Russia, Eastern Europe, Middle East, Africa, South and Central America with most severe incidence in Argentina and Uruguay."3 The World Health Report 2001 depicts the estimated burden of OCD to 2.5% of the total global YLDs.4
An extensive review reveals that OCD is generally similar in prevalence, socio-demographic characteristics and clinical features in both western and non-western countries for adult populations.5
Some studies were conducted in Pakistan. One such study6 was done in an island named Manora. The target population was a fishermen community. Out of the total population of 5,000, 3% were found to be suffering from OCD. Among these 56% (n=150) were females and 50% of the cases were under age 25. Contamination, pathological doubt and need for symmetry were the major obsessions while checking, washing and counting were common compulsions.In a local study,7 the most frequent obsessions were found to be dirt andcontamination, fear of losing and insecurity, checking, religious thoughts, arrangement and order. There were no major gender based differences found regarding obsessions and compulsions in the same study. Another study8 revealed that the types of obsessions and compulsions were similar to those reported in other foreign studies but the form and content of obsessions seemed to be influenced by social and religious backgrounds. In another local study,9 themes of obsessions and compulsions were religious (60%), contamination (28%) and safety (20%) in decreasing order of frequency. It was said that role of religion was reflective in OCD and role of Cognitive behavioural therapy was identified in the local cultural context.
Effectiveness of Selective serotonin reuptake inhibitors (SSRIs) and Cognitive-behavioural therapy (CBT) was reported in treatment of OCD.10 Another local study11 indicated the association of low self-esteem with OCD. Parkinson\\\'s disease was found to be associated with OCD requiring early detection and treatment.12 Stein D13 described this disorder as a chronic, costly and disabling disorder but under-recognized and untreated. Generally, in psychiatric out-patient clinics, the problem with OCD is mostly under or unrecognized. At times, the depressive features are so prominent that a clinician would display a careless oversight in asking few basic questions like: Do you wash or clean a lot?, Do you check things a lot?, Is there any thought that keeps bothering you that you would like to get rid of but cannot?, Do your daily activities take a long time to finish? The magnitude of OCD must be quite huge in Pakistan especially with the turbulent scenario of violence and political upheaval. The reported literature and research is quite low in volume that gives a wakeup call.The possible reasons for under-recognition may be the complex presentations like that of a cyclothymic OCD which is a specific variant.14
It may also be possible to dismiss the diagnosis in favour of Obsessive personality disorder.Some obsessional thoughts are related to sexual themes and patients may feel embarrassed in discussing their problem. Hence, there are many possibilities for missing the diagnosis.
OCD is a disorder that need prompt and appropriate recognition and immediate treatment. Not treating the disorder may result in chronic disability by virtue of its symptoms.
In Pakistan, there is a need for developing more insight into the existence of this disorder. Continuing Medical Education Programmes (CME) for both psychiatrists and family practitioners will go a long way in helping to identify the problem of OCD. More research and publications are needed in order to assess the magnitude of this disorder. On surface, it appears that OCD is under-recognized and under-treated.
What do you think?

References

1. OCD Research. Stanford University School of Medicine. (Online) (Cited 2011 Dec 2). Available from URL: http://ocd.stanford.edu/about/prevalence.html.
2. Obsessive Compulsive Disorder Statistics. (Online) (Cited 2011 Dec 2) Available from URL: www.charlote-anxiety-and-depression-treatment.com/ObsessiveCompulsiveDisord.
3. WHO. Obsessive-compulsive disorder, worldwide 2002. (Online) (Cited 2011 Dec 2) Available from URL: http://en.wikipedia.org/wiki/File:Obsessive-compulsive_disorder_world_map_-_DALY_-_WHO2002.svg.
4. WHO. World Health Report 2001. (Online) (Cited 2011 Dec 7) Available from URL: http://www.who.int/whr/2001/en/whr01_en.pdf.
5. Staley D, Wand RR. Obsessive-Compulsive Disorder: A Review of the Cross-Cultural Epidemiological Literature. Transcultural Psychiatry 1995; 32: 103-36.
6. Gadit AA. Obsessive-compulsive disorder in a fishermen community. J Coll Physicians Surg Pak 2003; 13: 581-3.
7. Saleem T, Gul S. Prevalence of obsessions and compulsions among adults of Pakistani community. Int J Acad Research 2011; 3: 348-53.
8. Saleem S, Mahmood Z. OCD in a cultural context: a phenomenological approach. Pak J Psychological Research 2009; 24: 27-42.
9. Nazar Z, Haq MM, Idrees M. Frequency of religious themes in obsessive compulsive disorder. J Postgrad Med Inst 2011; 25: 35-9.
10. Irfan U, Abramowitz S. Effectiveness of psychological and pharmacological treatments for Obsessive-Compulsive Disorder: A qualitative Review. J Consult Clin Psychol 1997; 65: 44-52.
11. Rahman RU, Husain N. Self-esteem in obsessive-compulsive disorder. European Psychiatry 2009; volume 24: S1036. (Online) (Cited 2011 Dec2). Available from URL: http://linkinghub.elsevier.com/retrieve/pii/S0924933809712696.
12. D\\\'Souza A. Obsessive-compulsive symptoms in Idiopathic Parkinson\\\'s disease. J Pak Psychiatry Soc 2008; 5: 13.
13. Stein D. Obsessive-compulsive disorder. Lancet 2002; 360: 397-405.
14. Hantouche EG, Demonfaucon C, Angst J, Perugi G, Allilaire JF, Akiskal HS. [Cyclothymic obsessive-compulsive disorder. Clinical characteristics of a neglected and under-recognized entity]. Presse Med 2002; 31: 644-8.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: