During a family dinner conversation where my teenage children were talking about the possible impacts of the lockdown during the Covid-19 pandemic, one asked the question of what is going to happen to people who were diagnosed with Obsessive-Compulsive Disorder (OCD).
Obviously, the family turned to the in-house psychologist for an answer.
When I turned the question around and asked them what they thought was going to happen, the husband replied that this consistent washing of hands might make things worse for them. Then the others followed with answers about the increasing fear of germs, turning to extreme measures of wrapping up furniture and increasing refusal to step out of the house.
Their comments raised some questions in my own mind about how this period would impact some of my clients with their multiple and complex issues. More importantly, it also brought out some misconceptions people might have about Obsessive-Compulsive Disorder as a mental health problem.
What is Obsessive-Compulsive Disorder?
In order to understand how OCD affects behaviour, we must first recognise that obsessions and compulsions are two separate manifestations of an illness that has similar biological roots. The Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) defines obsessions as “recurrent and persistent thoughts, urges, or images that are experienced as intrusive or unwanted”. On the other hand, compulsions are “repetitive behaviours or mental acts that an individual feel driven to perform in response to an obsession or according to rules that must be applied rigidly”
Compulsions are the outward manifestations of the hidden obsessive thoughts. They are like the tip of an iceberg, whereas obsessions are the part of the iceberg that is hidden beneath from the surface. This means that when a person is not acting out the compulsion, it does not necessarily mean the obsessions are also gone. From research, we have come to know that obsessions are more resistant to treatment than compulsions. They are also the source of profound distress in both patients and their caregivers.
I have encountered teenagers who were badly affected by obsessive thoughts that have got nothing to do with hygiene, like the persistent fear of having bad luck or being jinxed.
Do they manifest their obsessions? Not in all situations and not in ways that are particularly obvious to people around them.
For example, they would choose not to walk along the path where there was a wake or to avoid coming face-to-face with a black cat. And if they failed, the fear would disturb them so profusely that they would be worried for days or weeks. They would want to talk about it consistently, just to be assured that they would not be cursed with bad luck.
I have also heard stories of very young children, and seen one case personally, who would be obsessed with cleanliness or routines, that they would not be able to function if they did not get changed or they could not perform their routines. Some would have meltdowns and long-lasting tantrums, while others would simply keep asking to be changed, to be washed and cleaned.
For those who did not act out excessively, adults tend not to regard that behaviour as a problem. They explained it as childish fussiness, or some would even think it was great that the child understood the concept of cleanliness and hygiene. I knew of a grandmother who was absolutely proud that the grandson would insist on washing himself or even bathe each time he had finished pooping, or that he would want to change and bathe once he got any stains on his clothes, even if it was just water.
Such behaviour might not appear to be problematic when they are toddlers or pre-schoolers, but if the obsessions persist, it would increase the child’s anxieties and the compulsive behaviours that result might start to become problematic.
In my university days, when I was doing my research on compulsive disorders, I have also learnt that children or adults engaged in weird behaviours like eating non-food substances – better known as Pica, an eating disorder – could also trace the root of the problem to anxiety resulting from obsessive thoughts. Patients have shared how they feel they would die if they did not swallow the mud from their back garden or eat the sponge on the sink.
Is it true that individuals with Autism are more prone to OCD?
Research[i] has revealed that ASD shares similar genetic roots with Obsessive-Compulsive Disorder (OCD), and Attention Deficit Hyperactivity Disorder (ADHD). All three conditions share some common features, one of the most observed is that of impulsivity.
In terms of similarity in brain architecture, it has been found that there are disruptions in the structure of the corpus callosum in all three conditions. The corpus callosum is the bundle of nerve fibres that connects the brain’s left and right hemispheres.
The rate for comorbid diagnoses of OCD in individuals with ASD differed from 1.5% to 81%. Studies focusing on children with High-functioning Autism, or what used to be known as Asperger’s Syndrome, found that these children may experience varying levels of impairment from OCD symptoms that are similar to children diagnosed with OCD alone.
OCD symptoms and behaviour also contribute significantly to the distress faced by adults with ASD[ii]. Individuals with ASD share common traits with OCD patients, like ritualistic and avoidance behaviours, the inflexibility of thoughts, and repetitive thoughts. On the other hand, research has also shown that individuals with OCD also present with ASD traits. It is estimated about 3% to 7% of patients with OCD also meet the criteria for mild to moderate ASD2.
Having said that, we must also understand that the neuroscience of OCD traces the root of the problem to disruptions in the communication between three core brain structures: the cortex, striatum and thalamus, also known as the cortico-striato-thalamic pathwayi.
The cortico-striato-thalamic pathway controls movement execution, habit formation and reward. When there is too much activity in the cortico-striato-thalamic pathway, a person gets stuck in the repetitive loops of thoughts and behaviour, which is the commonly manifested behaviour seen in OCD patients.
OCD is a result of disintegration within the physical brain system, leading to faulty communications between different brain structures. This disintegration is not unique only to individuals with Autism, but it can happen to anybody, at any stage of their life.
Can OCD be treated?
Presently, medication like Selective Serotonin Reuptake Inhibitors (SSRI) are common first-line treatment method for OCD[iii]. However, research has also shown that Cognitive Behavioural Therapyiii is equally effective as a mode of treatment for OCD.
In re-training the brain to reinterpret what is considered as “dangerous”, we aim to contest the obsessive thoughts embedded in the mind and create new definitions and meaning to these obsessions. For young children, helping the parents, caregivers and family members to understand about the condition and enabling them to help the child re-focus and reinterpret the obsessive thoughts would help with treatment and recovery.
Most importantly, some individuals might need to struggle with the obsessions for life but with proper help and training given, they would be able to self-regulate better and function effectively, with or without additional support with medication.
List of references:
[i] Jacob, S., Landeros-Weisenberger, A., & Leckman, J. F. (2009). Autism specturm and obsessive-compulsive disorders: OC behaviors, phenotypes and genetics. Autism Resource, 2(6), 293-311. doi:10.1002/aur.108
[ii] Stone, W. S., & Chen, G. (2015). Comorbidity of autism spectrum and obsessive-compulsive disorders. North American Journal of Medicine and Science, 8(3), 109-112. doi:10.7156/najms.2015.0803109
[iii] Hirschtritt, M. E., Bloch, M. H., & Mathews, C. A. (2017). Obsessive-Compulsive Disorder: Advances in Diagnosis and Treatment. JAMA, 317(13), 1358–1367. https://doi.org/10.1001/jama.2017.2200
Contributed by Dr Pamela Lim, Senior Psychologist, MindChamps Allied Care