JUST HOW COMMON IS OCD?
RAJ PERSAUD CONSULTANT PSYCHIATRIST
EMERITUS VISITING GRESHAM PROFESSOR FOR PUBLIC UNDERSTANDING OF PSYCHIATRY
The study, lead by authors based at the Institute of Psychiatry in London, is part of a longitudinal investigation of the health and behavior of all the children born during a one-year period in 1972–1973 in Dunedin, New Zealand.
This means that 1,037 participated in being assessed at the age of 3 and then again at 5, 7, 9, 11, 13, 15, 18, 21, 26, and most recently at age 32.
The first astonishing finding, from this unique study, is that while the prevalence of a formal OCD diagnosis is just 2.4% at age 26 and 1.8% at age 32, the investigators found that 21%–25% of the cohort (including 13%–17% of those without a mental disorder) reported obsessions and/or compulsions at age 26 or 32. These very high rates are also consistent with findings from another major study of the community elsewhere in the Western world, so it looks like these high rates really do reflect the fact that serious OCD symptoms are extremely common in the general public.
31%–42% of the general public with no diagnosed mental disorder reported having been bothered by obsessions for periods of over 2 weeks, 25% reported experiencing obsessions for more than an hour a day, and approximately 15% reported being emotionally upset by them.
Regarding compulsions, 33%–45% of the whole cohort reported performing them
for periods of over 2 weeks; 11%–12% of healthy individuals reported being upset by having to perform such rituals.
However, only OCD symptoms of fears of harming others and shameful obsessions appeared strongly linked with going to the doctor or seeking some kind of help. This important finding has not been reported previously in the research literature and accords with my own clinical experience.
Exactly why these are the symptoms of OCD, which most drive sufferers to seek help, remains a mystery, but one theory advocated is that these types of intrusive thoughts may be perceived by people as pathological or “morally wrong,” and this may be a strong drive for seeking help.
According to some Cognitive Behavioral Therapy theories of OCD, the central feature of this disorder is an exaggerated sense of personal responsibility for the prevention of
harm to oneself or others.
However another mystery that emerged from the study is that while nearly 45% of study members who reported obsessions said these got them very emotionally disturbed, only 20% of those who reported compulsions were actually upset by them. Why should thoughts, which are an inner experience and therefore easier theoretically to keep private, be more upsetting than the enactment of a compulsion? Maybe it’s because a compulsion is usually performed as a way of gaining respite from a troubling obsession, and is therefore associated with relief and a sense of control over the disorder?
In his accompanying editorial in the American Journal of Psychiatry commenting on this important study, Dr Murray Stein, from the University of California, suggests we should be asking, “What, in addition to the propensity to have obsessive-compulsive symptoms (which are common), leads to expression of OCD (which is rare)?”
This is a key question, because it was clear from this research that suffering from an OCD symptom was strongly predictive of developing other psychological problems. OCD symptomatology is clearly very corrosive to your mental health.
For example, another critical finding from this study is that suffering from a cluster of obsessive-compulsive symptoms was strongly associated with other anxiety and mood disorders.
The cluster of symptoms that would get you labeled as suffering from “shameful thoughts” in this study, is as strongly associated with posttraumatic stress disorder (and panic disorder) as it is with OCD.
According to Dr Murray Stein’s editorial, this observation raises several questions. Might the “shameful thoughts” endorsed by the individual be intrusive thoughts about prior traumatic experiences, he argues? In other words, he suggests, are these really pure obsessive-compulsive symptoms, or are they symptoms of posttraumatic stress disorder that are being reported by (at least some) individuals?
Clearly clinicians and researchers still have a way to go in deciding the essential difference between pure OCD and OCD like symptoms.
Regardless of whether having an OCD symptoms means you have the actual illness, one of the most interesting findings about OCD from an academic psychiatric standpoint is the sheer longstanding nature of these symptoms. This means that although they tend not to get the attention from research councils and university departments that they should, OCD features have the potential to cause much more suffering than other psychiatric symptoms that gain much more attention from doctors.
Once considered to be rare in children, recent studies indicate that at least one-third of those who present with OCD as adults actually had the onset of symptoms in distant childhood.
This current study found that stability over extended time since childhood was strongest for the cluster of symptoms around contamination/cleaning and symmetry/ordering dimensions, and slightly weaker for the harm/checking and shameful thoughts dimensions.
That these supposedly counter-productive aspects of behaviour can endure for so long, and also can start in childhood, raises naturally the question of whether they are under genetic control, and it also follows from that theory, that they may indeed have an evolutionary benefit.
Is it possible that hundreds of thousands of years ago in dirtier and more dangerous, chaotic times, those of us who washed and checked and ordered things more than usual were at an evolutionary advantage compared to the less fastidious, more careless and chaotic? Hoarding is a classic OCD symptom and is it beyond the bounds of possibility that hoarding at times when famine was not infrequent and life more precarious was of positive benefit to survival?
Where these ideas flounder, is to explain why OCD symptoms, as found in this study, are so strongly linked with so much suffering and other psychiatric disorder.
For example this study by Miguel Fullana, based at the Institute of Psychiatry found that aggressive, sexual, religious and somatic obsessions, as well as checking compulsions not only tended to cluster together but were generally associated with other anxiety disorders and depression.
Obsessions of symmetry, and repeating, counting and ordering/arranging compulsions were more associated with bipolar disorders and panic as well as agoraphobia.
Contamination obsessions and cleaning compulsions tended to be linked with eating disorders.
A rejoinder might be that it’s the way these OCD drives come up against society that produces suffering and these other psychiatric problems.
But the mystery of why so much OCD symptomatology remains hidden from the view of doctors, when treatments are available, is perhaps deepened by the Fullana and colleagues finding that only fears of harming others and shameful obsessions were predictive of help-seeking behavior. Shame is precisely the motivation which is frequently conjectured inhibits the population from seeking help for ‘stigmatised’ psychiatric problems.
As a General Adult Psychiatry clinician working at the interface between primary care and referrals to secondary care, I am personally familiar with high levels of OCD remaining untreated in the community, or held within in primary care. This experience leads me to tentatively advocate a model which accounts for when those suffering from OCD for many years, ‘transistion’, into seeking formal psychiatric care.
For me there is a common underlying theme here and it’s that of the issue of control.
I contend that those with OCD experiences will finally be prompted to seek help when they believe that they now verge on an inability to control their symptoms, so harm to others is likely, if another strategy is not adopted imminently. This loss of perceived control may be secondary to rising levels of anxiety or depression precipitated by a life event. Co-morbidity, in our model, largely interacts through a sense of control.
When a patient with OCD experiences believes their grip on control over thoughts and behaviour is weakening, they finally become galvanized to urgently seek help. Fears over harming others because of loss of control, and also a sense that they are on the verge of being overwhelmed by symptoms kept in bay due to previous control strategies are, we contend, the two key predictors of help-seeking.
The paradox, I believe, at the heart of OCD, is that control over various aspects of their lives and mind is much more important for this group, than for the general population. This value in itself produces distress, yet on top of which, they also frequently adopt strategies which are only precariously successful.
Just how precarious is the OCD life, is obviously open to debate, given Stein argues in his editorial; ‘we must consider the very real possibility that the reason so many people with obsessive-compulsive symptoms fail to get treatment is that they manage quite well despite their symptoms’.
DR RAJ PERSAUD IS A CONSULTANT PSYCHIATRIST WORKING IN THE NHS AND IN PRIVATE PRACTICE WITH AN INTEREST IN OCD. www.drrajpersaud.com
HE IS THE CONSULTANT EDITOR OF THE BEST-SELLING BOOK PRODUCED BY THE ROYAL COLLEGE OF PSYCHIATRISTS ‘THE MIND: A USERS GUIDE’
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