Obsessivecompulsive disorders

Patients feel a strong obsession to ruminate on a thought topic, and/or compulsion to carry out some practical action. Patients know that these symptoms come from within the self; in other words, that these are their own thoughts and actions. (Hence, they are quite distinct from the experiences of thought insertion or delusions of control sometimes seen in schizophrenia.) They also know that the thoughts or actions are irrational, and that they are contrary to their own beliefs and well-being; they are sometimes described as 'ego dystonic'. They realize that the thoughts and actions are inappropriate and should be under personal control, but attempts to resist them cause increased anxiety and are usually not successful. Common types of obsessional thinking include the following:

• fears of harming others (very rarely put into practice) or contracting a serious disease

• sexual or blasphemous thoughts which are abhorrent to the patient

• ruminations on insoluble problems in mathematics or philosophy.

Common types of compulsive rituals include:

• checking, for example, that the door is locked or lights switched off

• washing, often carried out in order to allay fears of contamination or harm

• cleaning, for the same reason.

Patients may spend so much time on their rituals that normal daily activities are neglected. Compulsive hand washers often develop skin rashes. The illness is particularly distressing because the patients are so well aware that their symptoms are irrational.

Community surveys indicate that obsessive-compulsive disorder is present in 2-3 per cent of the general population and, in contrast to other neurotic disorders, is equally common in men and women.

Similar symptoms may occur as a sequel to organic brain disease, and schizophrenic phenomena such as thought interference, passivity experiences, and delusions may also cause diagnostic confusion. However, in organic disease and schizophrenic cases, insight and resistance are usually absent.

Behaviour therapy with exposure and response prevention, and antidepressants, especially those such as clomipramine and SSRIs, which act on the 5-HT system, are effective treatments.

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