Dr Ambreen Ahmad is a Diplomate of the American Board of Psychiatry and Neurology and has practiced Adult, Child and Adolescent Psychiatry in both the United States and Pakistan and is a founder member of Rozan, an NGO that works with people with mental and emotional health concerns

The News on Sunday (TNS): Obsessive Compulsive Disorder (OCD) is not a fatal mental condition but it is said to be highly disabling. Could you kindly help define OCD for the lay readers? What are the early signs of it?

Dr Ambreen Ahmad (AA): Although both obsessions and compulsions are part of OCD, and most people with the disorder have both, it is simpler if one looks at them separately.

Obsessions are unwanted thoughts, images and/or feelings that come again and again in a person’s mind. The nature of these thoughts is such that they cause fear, shame, and/or intense anxiety. Most of the time, even though they may try very hard, people who have OCD are unable to get rid of their obsessions. Some times obsessions have been called hiccups of the mind because the brain seems to get stuck on a particular thought or urge and do not stop even though the person desperately wants them to.

Obsessions vary from person to person. Some people have repeated thoughts about getting sick or being contaminated by germs. Others get images of hurting a loved one. Others are frightened and ashamed of negative thoughts they may have about religion or their brain may get stuck with the idea that everything must line up ‘just right.’ Some people get obsessed that they may lose something important.

Whatever the content of the obsession, the important thing to remember is that they are unwanted and are severe enough to cause intense anxiety and discomfort.

Compulsions are strong urges to act or think in a way to reduce or undo the discomfort that is caused by the obsession. Compulsions like obsessions also vary from person to person. A person who has obsessions about being contaminated with germs or being unclean may spend hours in the shower, use strong cleaning products or a whole bar of soap at one time, wash their hands excessively to the point of making them bleed all in an attempt to get rid of the obsession. Another person may refuse to shake hands with anyone or touch household items. Some people may spend hours checking and rechecking stoves, or locks. Others may feel they have to place things in a specific pattern and if they do not do that, they fear something catastrophic may happen.

Some compulsions are mental and involve reciting prayers or a word or phrase repeatedly. At times, people with OCD can spend several hours trying to finish one prayer because each time they say it, they fear that they have not said or done it ‘right’.

It is important to keep in mind that obsessions and compulsions are very different from everyday worries, superstitions or cautious habits that many people have. People who have OCD spend a lot of time on their obsessions and compulsions, e.g. at least one to several hours a day and in addition these symptoms interfere to a major extent with their day-to-day life, including their relationships.

The early signs of OCD will vary according to the nature of the obsessions and compulsions. When the onset is in childhood, parents are often able to observe the compulsions. A child may erase their homework repeatedly to the extent of tearing the paper in order to do the work ‘perfectly’. They may stay up till late at night checking and rechecking the door and window locks of their house. Often, younger children will ask their parents the same question repeatedly seeking reassurance again and again. However, as children get older they will often start hiding their obsessions or compulsions because they become aware that they are not normal. Children when talking about it will sometimes say that they think they are dumb or stupid to do this but they cannot help it.

In adults the onset can be gradual. It may start with doubts about losing something important leading to some checking or some amount of washing because the person doubts that she or he have washed thoroughly enough. It may begin with an attempt to avoid places or situations or things that cause the person anxiety. It may start with a needle prick and the fear that one has got some lethal disease. With time, these fears and rituals grow to become OCD.

TNS: What is the multi-factorial nature of the illness? It is believed that genes also play a role. What are the other factors?

AA: You are right that there seem to be several factors that can cause OCD. Although genetic factors do play a part and we see a higher prevalence of the disorder in children and first-degree relatives of people who have OCD, these factors are not the only cause. There is some evidence that childhood OCD can be caused by certain kinds of infections, such as strep throat. Several studies suggest that people who develop OCD have some abnormalities in specific areas of the brain. Other studies point to changes in certain neurotransmitters or chemical in the brain. Some temperamental factors such as, low self-esteem or a tendency towards guilt or shame can also make a person more vulnerable to OCD as is a history of physical and sexual abuse in childhood or other stressful or traumatic events.

TNS: Is there a scientific/lab test method of diagnosing OCD or is it just based on your clinical assessment of a patient? How far should this assessment be trusted?

AA: There are no specific blood or other objective medical tests to diagnose OCD. However, there is a lot of research with brain imaging and scanning techniques that, at some point, may prove to be useful diagnostic tools. At this time, mental health professionals do rely on the patient’s history and their clinical judgment to make this diagnosis. Many times the patient’s family can provide very useful information. In addition, there are standardised manuals, checklists, and rating scales, which help clinicians not only to diagnose but also to evaluate the severity of the obsessions and compulsions.

Although there are other mental health conditions that may be confused with OCD. It is not an exceptionally difficult disorder to diagnose as long as the clinician is qualified and trained as a mental health professional. At the same time, because fighting this disorder requires so much trust and cooperation between patient and clinician, it is very important that if a person feels uncomfortable for whatever reason, they try and seek a second opinion.

TNS: Is OCD a specialised field of study in psychiatry or applied psychology? Why do we not find any OCD specialists in Pakistan whereas we do find them in other countries of the world?

AA: In Pakistan, there are approximately one to two psychiatrists per million people. I think it would be difficult to expect that they would specialise in only one disorder. In the West, where there are more resources, both human and financial, there are psychiatrists and psychologists who once they have completed their training, go on to focus on OCD and it’s treatment. Hence, they do have a lot of expertise about this disorder. There are also research centres focusing exclusively on OCD, it’s causes, and treatment. Again, I think we have a long way to go before we can reach that stage.

TNS: How many patients do you generally see at your clinic who come to you with complaints specifically of OCD?

AA: It is hard for me to give you numbers but over the years, I have seen many patients both children and adults with this disorder. Almost always, when they come in they are not aware that what they are suffering from is OCD. Instead, the reason for seeking help is because they are being unable to function or are experiencing intense distress.

TNS: How can people who suffer from OCD successfully manage it on their own?

AA: The most important thing that people who suffer from OCD can do for themselves is to realise that it is not a weakness, nor is it their fault.

OCD is a brain disorder just like diabetes is a disorder of the pancreas. Most people, although they feel distressed or unhappy about having diabetes, do not feel ashamed or embarrassed of having this condition. People who suffer from OCD also must not feel shame or embarrassment about having this disorder. It is hard enough to have OCD -- they must not make the burden heavier for themselves by feeling that they have to hide it from others or not get help for it.

Sometimes because the obsessions and compulsions are so unreasonable and excessive, many people start thinking of themselves as "crazy" -- this stops them from talking about their condition. Educating themselves about this disorder will empower them to deal with it. They will also realise that they are not alone and there are many others who also suffer like them. This is important because many times people who have OCD feel very alone.

Whether they manage their condition themselves or with the help of mental health professionals, the crucial thing is that they know that there are treatments available for this disorder and they must not give up. There are some excellent websites such as, www.ocdfoundation.org as well as some very good self-help books. One which I would particularly recommend is S.T.O.P Obsessing by Edna Foa, Ph.D. and Reid Wilson, Ph.D. both leading experts in this field.

Families can also play a very important role in helping patients who are struggling with OCD. Often family members, because they do not understand the disorder, will end up being infuriated and frustrated with the patient or they may become part of the rituals that are demanded by the patient just because that seems like the easier thing to do rather than to argue or resist. Both of these reactions are not helpful to the patient in the long run.

TNS: What are the treatments considered effective for OCD patients?

AA: There are currently two forms of treatments that are considered to be effective for OCD.

Behaviour therapy helps patients deal with and manage the anxiety arising from their obsessions as well as to reduce or eliminate compulsive rituals. This sort of treatment requires a lot of trust and cooperation on the part of the patient, as it is something they themselves do with the guidance and support of a trained professional.

The other form of treatment is with medications. These medications specifically affect the chemicals in the brain, which are thought to contribute towards obsessions and compulsions. Many times, both forms of treatment are used in combination to get the best result.