October 10 every year is celebrated as World Mental Health Day. However, mental health disorders are so prevalent and so incapacitating that the US president Barack Obama recently felt compelled to proclaim May, 2013 as the national mental health awareness month. This was in part due to the fact that mental health is a serious public health concern in the US. The situation in India is no different. Let us examine a mental health condition that is thought to be significantly under-diagnosed in India, obsessive compulsive disorder, in part due to the fact that there is very little awareness or understanding of its symptoms among the general population or even among health care providers.
Let us describe common symptoms in the words of a hypothetical patient to understand this condition better.
“Sonia, Sonia, Sonia – I repeated my mother’s name in my head as I got out of bed. I locked the door absent-mindedly and then immediately unlocked it, as I realized that now I was worried that my mother would get seriously ill, if I did not do so. I locked and unlocked it many more times while forcing myself to think about my school performance. I am a great student, I am a great student, I am a great student – I repeated this over and over again as I entered the shower to prevent something despicable from entering my mind. I tried to keep my thoughts pure, but found my mind wandering to the cigarette butt I had stepped on accidentally the previous evening. I had to rub my feet many times with soap before I was convinced that they were not contaminated. On the way to school, I spent a full ten minutes wiping the car door with a napkin to make sure that no germs lingered. Later in the day, I was trying to do my work only while thinking good thoughts and repeating it after each bad one; re-reading, re-writing, and re-drawing four times, sixteen times and even sixty four times till I was exhausted.”
Obsessive compulsive disorder is an anxiety disorder with onset of symptoms often during childhood. Patients have intrusive thoughts that they cannot control and that lead to severe anxiety. They are compelled to repeat behaviours aimed at stopping these thoughts from becoming a reality, but in turn result in more distress. These thoughts and behaviours become pervasive and take control of the lives of the sufferers. Patients typically are aware that the obsessive thoughts are irrational. The compulsions often may be related to the obsessions but may have nothing to do with them at all. Patients often become dysfunctional and socially isolated, if not diagnosed. With appropriate treatment consisting of medications and cognitive behavioural therapy, most patients achieve sustained remissions and are able to lead fulfilling lives.
However, only a limited number of child psychiatrists have expertise in diagnosing and treating this disorder and very few therapists are able to provide the necessary therapy. It is important to differentiate obsessive compulsive disorder from obsessive compulsive personality disorder which has similar symptoms but does not cause anxiety or distress to the patient.
The cause of obsessive compulsive disorder is not known. Genetic and biologic factors including relative lack of the neurotransmitter serotonin are hypothesized to contribute to it, as well as environmental factors.
The key to diagnosis of obsessive compulsive disorder is to recognize the symptoms which sufferers often do not want to share. So look out for those who may potentially be suffering from it. They may be someone struggling to survive in your class, at your workplace, or in your family. Encourage them to talk about their thoughts and behaviours, and you could save a life.
(Jay Desai is a diplomate of American Board of Psychiatry & Neurology and American Board of Paediatrics).