OBSESSIVE COMPULSIVE DISORDER AND ITS CARE AN REVIEW

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ABOUT AUTHORS
¹Anjani Srivarsha G , ³Nagavamsidhar M , ⁴Sai Teja D, ²Qadrie ZL.
^1,3,4Research Scholar, Department of Pharmacy Practice, Pratishta Institute of Pharmaceutical Sciences, Suryapet, Hyderabad, Telangana
² Professor and Head, Department of Pharmacy Practice, Pratishta Institute of Pharmaceutical Sciences, Suryapet, Hyderabad, Telangana

ABSTRACT:
Actually 14 to 16th century in Europe some people have experienced that sexual or other thoughts were by devil then the journey start. 1910, Sigmund Freud said that obsessions and compulsive behaviours are symptoms of OCD. Obsessive compulsory disorder (OCD) is an anxiety disorder. Obsessive compulsive disorder causes the brain stuck on a particular thought or urge. Actually  these  patients  are  having  a obsessive thoughts  means  they  always  occurring  of  images, several  thoughts or pictures over and over in the  mind. These thoughts or rituals can triggered more anxiety. These OCD patients can find out by the facts like washing, cleaning, checking and repeating. The  American  psychiatric  association said  that the females  are  more  affected  then  the  men. The  OCD is  a common , chronic  (long  lasting  disorder)  the  people  with  OCD can  feel  the  temporary  relief  from  the  anxiety if  the  person  can  untreated  then  they  cause  the  more  stress  and  the  effects  seen  on the  work, school  and  lead  to  serious  effects  on personal  relationships. Actually  obsessive compulsive disorder is a brain  injury , it involves  basal  ganglion (Eg: encephalitis  or  trauma) usually  there  is  no  neurologic  precipitant. The  evidence  suggesting  a selective  and  potent  serotonin(5-HT) reuptake  blocker drugs  are  successful  treatment in biological  basis of OCD. The drugs with the other mechanism of action have not been effective more. The neurotransmitter plays an important role in pathophysiology of obsessive compulsive disorder.

Reference Id: PHARMATUTOR-ART-2623

INTRODUCTION:
Obsessive compulsory disorder is anxiety (psychiatric) disorder. The person with uncontrolled or unwanted thoughts and always they are going to do the repeated things again and again, ritualised behaviours and also, we recognise that having obsessive thoughts. Obsessive compulsive disorder causes the brain stuck on a particular thought or urge.
For e.g: They always wash the hands repeatedly.
They check the door that they locked or not.

Actually, these patients are having obsessive thoughts means they always occurring of images, several thoughts or pictures over and over in the mind. (www.helpguide.org) The compulsions (rituals) are behaviours they do the things repeatedly and also, their thoughts are become very different. In some cases, we noticed that (i) They wash the hair 3times daily because of lucky number.(ii) They say like I put my alarm at night and i had to set it to a time it wouldn’t add up to a bad number and they are also going to much anxiety.(iii) They think that my parents going to die. These thoughts or rituals can trigger more anxiety. (https://www.nimh.nih.gov/index.shtml) These OCD patients can find out by the facts like washing, cleaning, checking and repeating. The American psychiatric association said that the females are more affected then the men. In this disorder some people can hide their symptoms they have doubt like if I lock the door or not. But some people can leave that because of fear and embarrassment (https://www.medicalnewstoday.com ). The OCD is a common, chronic (long lasting disorder) the people with OCD can feel the temporary relief from the anxiety if the person can untreated then they cause the more stress and the effects seen on the work, school and lead to serious effects on personal relationships (https://www.nimh.nih.gov/index.shtml). There is no clinical opinion about the classification.

The 4th edition of text revision DSM-IV-TR (www.psychiatry.org/psychiatrists/practice/dsm) (Diagnostic and statistical manual of mental disorder) said that OCD is an anxiety disorder and some clinician’s opinion is it is a spectrum of related disorders (Stein,2006). The broad spectrum includes the somatic form disorder symptoms, impulse control disorder and tic disorder. But drug induced and non-psychiatric disorder may show the similar pictures (Lysaker Ph, 2000). The common age for the OCD are mainly reported between 22-35yrs.

Then these affected people can diagnose and must take the treatment otherwise it may lead to serious problems (Jenike2004, Angst I 2005 ). The 3%of the kids is suffering with OCD. Same as usual the kids also cause to have the unwanted thoughts, feelings and fear which are obsessions. These obsessions make the kids very anxious and it leads to compulsions. The kids with OCD can’t stop there thinking about anyone and the kids may realise the thoughts but they don’t stop of feeling anxious.

They think like:
• They are sick, hurt and he/she is the one that going to die.
• They always having bad thoughts.
• They lead to make a mistake and going to done a bad thing.
• In the schools or any other places, the kids who are with OCD are going to break the rules.
• The kids who are with OCD they behaviours are also like seen in the adults that they always want to make sure if they are clean, safe, right or wrong. And that kids will have a power to stop the bad things but they can’t.

Kids with OCD rituals like:
• They always going to wash and cleaning the hands after eating.
• They are going to write their home work again and again.
• Going to do things repeatedly and re-reading.
• If the teacher asks the question of a kid they can repeat the word or answer more than necessary.
• Always they check the homework whether they done or not.
• They always want to do the things or counting 2or3 times because of lucky number.

The kids can avoid counting some numbers that which they think the numbers are un lucky to them. (https://kidshealth.org )

Actually, children with OCD then their parents must play an important role in treating the children. The cognitive behavioural therapy can be done. This therapy is called as exposure and response prevention. Exposure means the therapy involves that the child can allow exposing their anxieties in a systemic way and in a gradual. Thus, they can avoid the larger fears, and also avoid the anxious situations and objects. Response prevention means the parents try to make their children to expose their rituals. These parents of children with OCD can be involved in their children life to make the life safe because the research can show that parents are the co-therapists that can improve the effectiveness of life of children. (https://childmind.org/article/kid ) The children who are with the OCD are not allowed to sit alone because they can imagine the bad thoughts. One in hundred children has   OCD that the current estimates and can suggest that worldwide many children can be suffering with OCD. The most important thing is that is not the fault of parents who   the   children are suffering with OCD. Because, the brain of the children with OCD function differently compared to normal child.

As a parent you could help your child by:
• Understanding OCD like what is OCD.
• How to recognise with the correct symptoms.
• And provide the treatment correctly by the right therapist.

And the main thing is currently there is no cure for OCD, because it is a chronic condition. The children with asthma, allergies, diabetes can learn how to manage their condition with a treatment like that the children who are with OCD also can learn how to manage the symptoms of OCD. (www.beyondocd.org) And the kids who are with the OCD are feel so embarrassed to tell the parents that what is going on to them. So, it is more important that the parents must have a awareness about obsessive compulsory disorder and have the enough knowledge about OCD to detect the children if they are doing some differently and make your child to guide and recover the process step by step. ( https://psychcentral.com)

This OCD can also have seen in teens. Actually, the teens who are with the OCD are feeling so stressful life. And they stop the relieving and enjoyment of life, they cannot feel the rest if suppose they are relaxing also it is just a temporary relaxing. And it is very difficult to find out the obsessive-compulsive disorder patients in teens because they can try to hide their symptoms(elementsbehavioralhealth.com/mental-health).

HISTORY: 
First the OCD is no exception and in the 17th century the obsessions and compulsions were described as symptoms. The Oxford Don, Robert Burton, were reported a case and next modern concept of OCD was began in 19th century and in twenty century Janet proposed that obsessions and compulsions arise in the 3rd stage of psychiatric illness. As in 21st century the advances in pharmacology, neuroanatomy, neurophysiology and learning theory allowed more useful concept of obsessive compulsory disorder (http://med.stanford.edu/rodriguezlab/research/ocd-research.html) and in 1838 19th century the text book, Esquirol (1772-1840) described obsessive compulsory disorder is a form of monomania or partial insanity. Actually 14 to 16th century in Europe some people have experienced that sexual or other thoughts were by devil then the journey starts (Aardema.F,2007). In 1910, Sigmund Freud said that obsessions and compulsive behaviours are symptoms of OCD. (Maria Laura)

TYPES:
There are 4 main categories of obsessive compulsory disorder and there are the sub-types of the illness in each one. Typically, the person with OCD will fall into following.
a) Checking
b) Contamination /mental contamination
c) Rumination
d) Hoarding

Checking:
a) It includes to check the electric or gastric stoves (off or on)
b) Check the alarm (that they can put correct or wrong)
c) Checking the door again and again (locked or not) And also many other symptoms.

Contamination:
a) They always think that need to wash or clean the hands because they have a fear that it is going to contaminated which causes illness and leads to death. Like
b) By using public toilets.
c) Shaking hands.
d) Touching of door knows.
e) Visiting hospitals.
f) Eating in restaurants (because fear of germs).

Mental contamination: Means   always wash their hands repeatedly because they feel the mental contamination. That it is almost they are made to feel like dirt, that also creates the feeling of internal uncleanliness even they cannot contact with the dirty objects.
Hoarding: Means they are inability to discard the useless or worn out the items can be referred as Hoarding. Three main problems are:
a) They can feel difficult to discard the items.
b) They buy and collect or which they save the things are unable to throw out after the usage also.
Ruminations: Rumination means they always think about the thing or any question prolongly like they think link about the
a) Religious
b) philosophically
c) About universe
d) life after birth
e) life before born (https://www.Ocduk.Org/types)

Epidemiology:
OCD in the United States among adults has been estimated that 12 months prevalence of 1.2%and 2.3% prevalence of life time can be estimated. (Kessler RC 2005, Ruscio AM, 2010 ). Actually, in the adulthood the females are affected slightly higher rate that males and the males are more commonly affected in childhood (Ruscio AM 2010, Bland RC, 1944).
Aetiology:
The cause of OCD can include the 3 theories
• Biology: In the body, the changes in the brain function and own natural chemistry can be seen in the OCD.
• Genetics: Genetic component may have in the OCD but specific genes have to be identified.
• Environment: In obsessive compulsive disorder, some environmental factors such as infections can be suggested ( www.mayoclinic.org).

Actually, the exact cause of obsessive compulsory disorder is not known. (www.nih.gov) both environmental and genetic factors can play an important role. The genetic components with the identical twins can more affect then in the non-identical twins. (www.psychiatry.org). In cases of obsessive compulsory disorder when develops in the childhood are have the more familial link in disorder than the OCD develops in the adulthood. 45-65% of the kids are easily diagnosed by the symptoms. (Abramowitz,2009 ) The cases in the rapid onset of obsessive compulsory disorder in children and adolescents may cause by a group A streptococcal infection this is known as pediatric auto immune neuropsychiatric disorder this can associated with the streptococcal infection. (Ab Boileau B,2011, Amoretto,2008) and in the environmental factors may also causes a worsening of symptoms includes.
• Abuse
• Illness
• Living situation become changes.
• Death of loved one.
• Work or school problems. (www.webmd.Com)

Clinical manifestations:
Some people may have the unwanted thoughts or obsessive thoughts or perform compulsive behaviours it means that they don’t have the OCD.  Almost in every people we can obsorb this type of behaviours but it is not going to occur OCD because the people who are with the OCD are feeling very stressful and it symptoms may interfere in daily life and relationships. Most of the people with OCD can have the both obsessions and compulsive behaviours but some people may have one or other.

COMMON OBSESSIVE THOUGHTS:
They feel that they are losing their central and harmful to themselves or others.
They are always feeling fear because of germs, dirt or contamination.
They can always imagine the violent images or thoughts.
Thinks that loved ones are losing or going to die.
Superstitions and they give more attention to the lucky and unlucky. (www.helpguide.org)

COMPULSIONS:
Always checking /praying.
Always in confusion whether they right or wrong.
They repeatedly cleaning the rooms.
Washing hands repeatedly.
Most of can check the door locks and gas stoves.

EMOTIONAL SYMPTOMS:
The people who are with the OCD are very anxiety and emotional. They feel excessive worry, tension. They can feel that which they can do the things is never ever right.
Physical symptoms: The people who are with the OCD may develop the physical problems like they can always wash their hands because of fear of germs but their hands will become very dry, raw and painful. (www.psychguides.com)

• In children:
The OCD in the children can be easily find out because they can’t hide their symptoms compare to teens and adults.
The main symptoms like they can check their homework (right or wrong)
Repeatedly doing there works
Giving prolong and repeat the answers.
Temporary peacefulness.

• In teenagers:
The teenagers can hide their symptoms because it is so difficult to find out the obsessive compulsory disorder.
There symptoms are similar to the adults.

PATHOPHYSIOLOGY:
Actually, obsessive compulsive disorder is a brain injury, it involves basal ganglion (e.g: encephalitis or trauma) usually there is no neurologic precipitant. The evidence suggesting a selective and potent serotonin (5-HT) re uptake blocker drugs are successful treatment in biological basis of OCD. The drugs with the other mechanism of action have not been effective more (seen in trails).The neurotransmitter plays an important role in pathophysiology of obsessive compulsive disorder. (www.pubmed.com , Greist JH,1995)

Serotonergic  probes:
Important evidence for an abnormality in 5-HT functioning comes from pharmacologic challenge studies that assess serotonergic responsiveness in OCD patients (Hollander E,1992, Barr LC,1992) The most frequently used probein studies of OCD has been m-chlorophenyl piperazine (m-cpp). A non-specific post synaptic 5-HT agonist and metabolite of the anti-depressant trazodone, m-cpp produced very limited behavioural effects in normal volunteers. In untreated patient m-cpp produced a marked, increase in obsessions, depression and symptoms (Barr LC,1992 , Robertson . Pato MT,1992). Several other 5-HT probes have been studied in the OCD patient (metergoline, ipsapirone). However, the serotonergic probes have been disappointing in their failure to identify a consistent 5-HT defect in OCD (Barr LC,1992 ).

Brain imaging studies:
The using of single photon emission computed tomography and positron emission tomography is used to assess the biochemical and psychological function of the brain this can produced that identify the three areas of increased /abnormal metabolic activity- They are orbito frontal (cortex, cingulative cortex and head of caudate nucleus (Baxter LR,1995). These areas are involved in the pathologic origin of OCD symptoms. However, these areas can increase the metabolic activity may be decrease the brain activity. Successful treatment can return to normal functioning.

Dopamine model:
Some patients have a family history of tourette’s syndrome and a dopamine dysfunction.  Some forms of obsessive compulsive disorder can contribute a dysregulation of dopamine. In the caudate nucleus was found the high concentration of dopamine that the area believed to be hyperactive in OCD. Then the anti-psychotic treatment will be given. (Barr LC,1992 , McDougle CJ,1994 ).

DIAGNOSIS:
The diagnosis of OCD in follows
Physical examination – This will have done to rule out if you have any other problems that causing symptoms and check whether have any related complications.
Lab tests- In this test they can done (CBC).
This test can reveal if you any problems like thyroid and also Screening for alcohol and drugs.
Psychological evaluation – In this test, the professional is going to discuss with you about your thoughts, behaviours, symptoms, daily routine life. And also, the discussion will be done with family and friends. (www.mayoclinic.org )
X-rays will be done. The professionals like doctors, psychiatrist they must have a special training to diagnose the OCD 
In this they put a tool called structured clinical interview – to notice the symptoms that related to OCD or not it contains the standardised questions.
It can help to provide the best treatment.(https://www.keyword-suggest-tool.com/search/treatment+of+ocd/  )
The standardised questions can include about the behaviours, works, daily routine life. Etc

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TREATMENT:
First step is to talk about your symptoms with your doctor. Next OCD is going to treat with cognitive behavioral therapy, medication. Sometimes both will be done.
Cognitive behavioural therapy: Generally, it tells you about the obsessions and compulsions in the different ways of thinking, behaving and reacting. And the exposure and response prevention are a specific form of CBT. In this the patient is allowed to exposing the fears or obsessions and teaches you about the anxiety they cause and healthy ways and habit reversal training can help to overcome the compulsions.
Medication: Doctors can prescribe the different drugs to treatment of OCD like (SSRIs) or (SRI) called clomipramine. These are commonly used for depression, and symptoms of OCD. These SSRIs can take 10-12weeks to start working.  Suppose if depression extra longer time may take. (https://www.nimh.nih.gov/index.shtml) Medications like SRIs
 

Pregnancy and lactation: -
Generally, CBT is given alone to a pregnant patient except in risk of treating of OCD (Gary S .Sachs,1997) These symptoms may exacerbate in 1st trimester   and these symptoms may improve in 2nd and 3rd trimester.  (Diaz SF,1997 )
Drug used fluoxetine cannot increase the risk. (Gold stein,1995, Pastuszak,1993 ).it is the safest choice.

All SRIS are excreted into the breast milking lactation also fluoxetine is the safest drug. Several infants have been safety breast feed during maternal fluoxetine use. (Burch KJ,1992, Taddio A,1966)
There are 3main therapies
a) Medication therapy
b) Family therapy
c) Group therapy [www.helpguide.org]
Self-help for OCD:  
Don’t avoid your tears
Refocus your attention.

When you are having OCD thoughts then you can try to shift your attention to something else.

Challenge obsessive thoughts:
• Take a pencil and write your thoughts on the keypad, phone, or something else by writing it hundreds of times it will help you.
• Create an   OCD worry period: In this you can put some time like during this time you don’t think anyone or don’t anxious or don’t worry about anything and slowly continue to about the day.
• Create a tape of your OCD obsessions: you can record your obsessions or worries in the recorder and by listening that it comes to your mind. you can listen at least every 45min each day. By continuously doing this you will become less anxious and can repeat this to avoid.
• Take care of yourself
• Practice relaxation techniques. By doing mediation, yoga, deep breath or other techniques can help you to lower the stress and manage the tensions also. For best results it can do regularly.
• Get enough sleep: Insomnia occurs not only because of anxious and worry and also for lack of sleep. When you will take rest, it can must easier to keep your mind relax.
• Avoid alcohol and nicotine.
• Reach out for support
• Stay connected to family: By talking about your thoughts to your friends can feel less worries and urges and become less threatening.
• Join in OCD support groups: In this group there are so many members who are with the same symptoms they can discuss each other and come out by facing the problems. (www.helpguide.org)

CONCLUSION
Although there is no cure for OCD, and its exact origins are not specifically known by science or medicines at this time, there is help for those who suffer from compulsions obsessions, and severe or intense anxiety created by unwanted thoughts and inaccurate beliefs .The first step toward feeling better is to seek out the help of a therapist through a medical clinic, mental health facility or with the help of family members or friends.OCD anxiety and activities can be reduced through different types of management.

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