Case Study

Some kids like to wash their hands, but Sarah does it too much. She wants to stop, but her hands just don't feel clean enough and she can't make herself turn off the water. Sometimes she scrubs her hands until they are red and raw. After eating, she feels she has to wash again.

Because she spends so much time washing, Sarah has to rush to get to school on time. At school, she tries not to touch doorknobs or handrails, worrying that if she does she may catch a serious disease. Sometimes, Sarah gets behind in her classwork because she feels that she needs to keep checking it over and over.

During a quiz or test Sarah checks and rechecks every answer and erases anything that isn't perfectly straight or neat. Sometimes she erases so hard it tears the paper, but she can't help it. Sarah gets a bad feeling that if everything isn't exactly right, something terrible may happen. All this worrying, checking, and fixing takes so long that Sarah hardly ever finishes the test before time is up. So even though she knows the work, she often gets an incomplete mark or even fails.

Sarah tries so hard to hide her habits. She worries that she might be going crazy or that people would think she's weird if they knew what she was doing. Sarah knows that the time she spends washing and checking could be spent having fun with friends or doing her schoolwork, but she can't seem to stop herself. That's because Sarah has obsessive-compulsive disorder (OCD).

What is OCD?

 “I could not touch any doors in public areas. I knew it did not make any sense, but I was afraid of getting germs that could kill me. I could not go out in public. If I thought I had touched anything, I would have to wash myself for hours. Sometimes, I washed so much until my skin would get red, raw as well as bleed”- patient with OCD

OCD or Obsessive-Compulsive Disorder is characterized by obsessions (instruisive, repetitive thoughts or images thet produce anxiety) or compulsions (the need perform acts or to dwell on anxiety).

• Obsessions can occur separately but usually they occur together.
• It can happen to everyone and affects both men and women equally, starting from childhood and adolescence.
• The impact of OCD on a person's life is remarkably high and it may affect every aspects of a person's life including the way a person thinks, feels and behaves.
• OCD is a psychiactric disorder that are troubled by recurrent obsessions and compulsions to the extent that they resulted in distress, occupy more than hour a day or significantly interfere with normal routines or occupational or social functioning.

OBSESSION

• Obsessions is an intruisive and repeatative anxiety-arousing thought or image. 
• People with OCD may realize that the thought is irrational but he or she cannot stop it.
• OCD can be persistent enough to interfere with daily life and can cause distress and anxiety. It may include the feeling of doubts, impulses and mental images.
• People with OCD will repeate the behavior or action frequently and it can be continuously.

 They are six common obsessions that afflicting people:

1. Contamination- fear of contamination (eg: germ, dirt)
2. Doubting- fear of not having done a specific act that could result in harm (eg: turning off the stove, leaving the door unlocked)
3. Perfection- a need for ferfection (eg: the person may take an hour or more in order to make sure everything he or she do is perfect)
4. Aggressive- fear of harming oneself and others people
5. Sexual- experiencing forbidden or unwanted sexual thoughts, images or urges.
6. Responsibility- exaggerated feeling of responsibility toward something.

COMPULSION

• Compulsion was defined as the need to perform acts or to dwell on mental acts repetitively.
• It may lead to distress and anxiety if the behavior are not perform or if it is not done 'correctly'.
• People with obsessions usually end up by engaging in extreme compulsions or so called as rituals
• However, acting out these compulsions does not give them pleasure but it may reduce the feeling of anxiety and distress.

They are four common type of compulsions:

• Washing or cleaning- excessive in cleaning or washing.(eg: showering, bathing, brushing teeth, grooming a lot or having detailed toilet routines, cleaning household items or objects)
• Compulsive checking- (eg: checking door)
• Ordering or arranging- (eg: make sure that everything they do are just right and consistent with a specific rule such as bed sheets or notes on the desk)
• Hoarding- belief that they cannot throw things away. they worry that they may need that item that they throw or that item is irreplaceable (eg: mug, paper)

Islamic point of view on OCD

Basically, there are six types of anxiety disorders. They include general anxiety disorder (GAD), panic disorder, specific and social phobia, obsessive-compulsive disorder (OCD), acute stress disorder (ASD) and posttraumatic stress disorder (PTSD). The anxiety can be explained through three basic patterns across these six disorders. The first pattern involves fear aroused by an identifiable object or situation as in specific phobia, ASD and PTSD. The second pattern involves an anxiety that is unfocused as can be seen in panic disorder and GAD. Lastly, in OCD, anxiety is seen if the person does not engage in a thought or behavior that otherwise serves no purpose. In Islam, Muslims believe that spiritual elements play a vital role in anxiety disorders. Being away from Creator can be a major reason behind the anxious and scared feelings. Feeling of impurity can lead to development of OCD, or what is called as waswasah which mean unwanted thoughts which are whispered into the minds and the hearts of people by satan. This idea is prove throughout the qur’an and hadith. Allah said in surah An-Nas, “say, I seek refuge with Allah, the Lord of mankind, the King of mankind, the God of mankind, from whispers of the devil, who whispers in the hearts of one of men”. And Prophet ( PBUH) said that, ‘ shaytan comes to one of you and says, ‘who has created so-and-so and so-and-so?’ till he says ‘who has created your Lord?’ so, when he inspire such a question, one should seek refuge with Allah and give up such thought” (Al-Bukhari and Muslim, narrated by Abu Hurayrah). Thus, a Muslims can gain strength and control if he or she lives by his faith according to the guidance provide by the Creator and seek His protection through prayers as well as others good deed and stay away from bad things.

The relationship between the brain and Obsessive-compulsive disorder

“In one extraordinary case a patient performed his own psychosurgery. Solyom, Turnbull, and Wilensky (1987) reported the case of a young man with a serious OCD whose ritual hand washing and other behaviours made it impossible for him to continue his schooling or lead a normal life. Finding that his life was no longer worthwhile, he decided to end it. He placed the muzzle of .22 caliber rifle in his mouth and pulled the trigger. The bullet entered the base of the brain and damaged the frontal lobes. He survived, and he was amazed to find that his compulsions were gone. Fortunately, the damage did not disrupt his ability to make or execute plans; he went back to school and completed his education, and now has a job. His IQ was unchanged. Ordinary surgery would have been less hazardous and messy, but it could hardly have been more successful.” (Foundation of Behavioral Neuroscience, Eight edition, page 472)

            From the story mentioned above we can conclude that Obsessive-compulsive disorder (OCD) is a disorder that closely related with the physical of the brain. For some reason the young man has fortunately cure his disorder by accidently severe the part of the brain that made him suffered, and he did successfully without any report of infection or brain dysfunction which hardly achieved even with proper brain surgery-well of course he had undergo some operation after the attempt. The question rose is which part was cut and how does this help?

            According to neuro-imaging studies, researchers found out that OCD is related to the anomalies along the frontal-subcortical brain circuit. The activity in this area exhibit increase activity in OCD patient compared to normal people. Treatment with drugs is the way to decrease the activities in the area.

            In the modern medical practice, psychosurgery is the last option in treating OCD. It is called cingulotomy (see link :http://www.cnsspectrums.com/aspx/articledetail.aspx?articleid=3594 ) The surgery will be carried out if the psychological therapies and pharmacological treatments had failed to treat. In the surgery, some part of the brain will be severe but it does not require an open skull operation. It uses a “gamma knife” to destroy the cingulum bundle which connecting the prefrontal cortex with the limbic system.

            The prefrontal cortex is the region which associated with the control of movement and more involved in formulating plans and strategies while the limbic system is a group of several brain structures involved in learning, emotion, memory, and motivation. By separating these two parts of the brain, it helps to reduce intense anxiety and the symptom of obsessive-compulsive disorder. This is possible since the plan that processed in the prefrontal cortex does not influenced by the emotion because in most cases, the patient trapped in the OCD due to the pattern of cognitive impairment. For example obsession about being responsible for causing harm or failing to prevent harm which lead to checking compulsion and reassurance-seeking. He or she will “play” with the toggle or switch button for many times until he or she fell assured that the microwave oven already been switch off.

There are several more types of neurosurgery to treat this disorder. However, all this surgery cannot be undo. That’s why it is often be the last resort in treating OCD.

 (see link:http://www.medscape.com/viewarticle/581635_2)

The Diagnosis

OCD is classified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) as an anxiety disorder. Based on DSM-IV, it says that for the person who suffers from OCD can be diagnosed to have the presence of either obsession or compulsion.

 There are the 4 criteria for obsession based on DSM-IV:

Recurrent and persistent thoughts, impulses, or images are experienced at some time during the disturbance as intrusive and inappropriate and cause marked anxiety and distress. Persons with this disorder recognize the pathologic quality of these unwanted thoughts (such as fears of hurting their children) and would not act on them, but the thoughts are very disturbing and difficult to discuss with others.

The thoughts, impulses, or images are not simply excessive worries about real-life problems.

The person attempts to suppress or ignore such thoughts, impulses, or images or to neutralize them with some other thought or action.

The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without, as in thought insertion).

Whereas for compulsion it can be based on 2 criteria through DSM-IV:

An individual performs repetitive behaviours (e.g., hand washing, ordering, checking) or mental acts (eg, praying, counting, repeating words silently) in response to an obsession or according to rules that must be applied rigidly. The behaviours are not a result of the direct physiologic effects of a substance or a general medical condition.

·       The behaviours or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation. However, these behaviours or mental acts either are not connected in a way that could realistically neutralize or prevent whatever they are meant to address or they are clearly excessive.

The Symptoms

The following are the symptoms of OCD:

•  People with OCD are usually aware that the obsessions and compulsions are nonsensical, but, great    effort, they cannot control them. 
•  The obsessions and compulsions usually are not bizarre. They typically have possible or even ordinary content
• There is marked cross-cultural consistency in the themes of the obsessions and compulsions, despite heterogeneity in specific symptoms.
• Some patients suffer mainly obsessions, others mainly compulsions, and still others both. Thus OCD can express itself as primarily a cognitive-affective disorder or primarily an executive-behavioral disorder.
• The obsessions and compulsions can go on for hours. For example, a “checker” checks, but cannot be sure and has to check again and again. The question “what if?” dominates, and there is no behavioral closure.

            

Treatment for Obsessive-Compulsive Disorder

There are no available cures for OCD. In the past, there weren't even many available treatments for OCD. Today, a variety of very effective treatments are available to those suffering from the disorder. It is important to find the right therapy for you and to begin therapy as soon as possible.

1) Medical Treatments

Medical treatments are available from your health care provider to help reduce your symptoms of obsessive compulsive disorder. Medical treatments work best in conjunction with other therapies to reduce symptoms.

2) Selective Serotonin Reuptake Inhibitors (SSRIs):

SSRIs work to improve mood and reduce anxiety by boosting levels of serotonin in the brain. If you are suffering from OCD, it is likely that you have low serotonin levels, which may be contributing to the disorder. SSRIs are associated with few side effects and are safe long-term treatment for OCD.

3) Tranquilizers

Tranquilizers are sometimes prescribed to people with more severe OCD symptoms. Tranquilizers relax the muscles in the body, reducing compulsive urges. Tranquilizers may be habit-forming so they should only be used for short periods of time.

4) Psychosurgery

Psychosurgery is performed only in extreme cases in which OCD symptoms are debilitating and unresponsive to all other treatments of OCD. Psychosurgery has replaced the lobotomy procedure, which often produced unexpected brain damage and memory loss in patients. Psychosurgery involves severing or disabling certain parts of the brain with an electrode. Unlike the lobotomy, psychosurgery uses magnetic resonance imaging in order to select an appropriate place in the brain for surgery. More than a third of all psychosurgery patients report dramatic improvements in their OCD.

5) Psychotherapy

Psychotherapy is an extremely effective treatment for obsessive compulsive disorder. It should always be the first-line treatment for OCD, especially in children. Psychotherapy can be done one-on-one with a trained specialist or within a group setting. Cognitive Behavioral Therapy (CBT) is the only proven form of psychotherapy for OCD.

Cognitive behavioral therapy for obsessive compulsive disorder is highly effective. It is a type of therapy that focuses on changing thought patterns by altering behavior. The patient will be gradually exposed to the obsession which causes fear and told not to engage in compulsive behavior. With increased exposure, the patient will experience less and less anxiety as she realizes that nothing bad is happening. After ongoing treatment, 50% to 80% of patients cease all compulsive behavior.

6) Inositol

Inositol is a naturally occurring isomer of glucose. It is part of the vitamin B family and is found in phytic acid, a component of fiber. When you consume phytic acid, the bacteria in your intestines release the inositol from the phytic acid. Inositol can naturally be found in nuts, seeds, whole grains and citrus fruits. But how does this help people with OCD?

Inositol has been found to work and help relieve OCD symptoms in much the same way as SSRIs. However, inositol does so without the same side effects, thereby making it an attractive alternative to conventional psychiatric medications. In clinical trials, patients who received 18grams of inositol showed a marked improvement in their symptoms, comparable to the results achieved by SSRIs, over those participants who received a placebo. While inositol has been shown to be effective in OCD sufferers who have already had a positive response to SSRIs, inositol should be avoided by women who are pregnant should.

7) Cingulotomy

Occasionally, surgical treatment of the cingulum may be beneficial to people who have severe symptoms and who do not respond to treatment. A cut is made between certain nerve fibers that trigger emotional arousal (cingulate gyrus) and the limbic system, which is involved in mood and intense emotion. About 30% of cingulotomies result in improvement. The procedure is relatively uncomplicated and is not thought to negatively affect memory, cognition, or intellect.