Obsessive Compulsive Disorder

Introduction

According to the Diagnostic Statistical Manual 3-revised (DSM-III-R), obsessive compulsive disorder (OCD) is classified under Anxiety Disorders or Anxiety and Phobic Neurosis. The essential feature of obsessive compulsive disorder is recurrent obsession or compulsion sufficiently severe to cause marked distress, to be time consuming or to significantly interfere with a person's normal routine, occupational functioning, usual social activities, or relationships with others ^[1].

Recognition of obsessional traits dates back to the 17th century ^[2,3]. The term “obsessional neurosis”, however, originated with Karl Westphal (1833–1890) ^[4]. The same term was adopted by Kraepelin in his textbook during the early part of the 20th century, and Freud who described the classical picture of the disorder ^[5].

Obsessive compulsive disorder is believed to be a rare syndrome with a prevalence of 0.05% in the general population ^[6]. Recent epidemiological studies showed that this disorder is more common than what was initially thought ^[7]. Less than 5% of psychiatric inpatients or outpatients receive the diagnosis ^[8,9].

Phenomenology of obsessive compulsive disorder, like its prevalence, was reported to be strikingly similar in various Western and non-Western cultures ^[9,10]. In this study, it is intended to examine the phenomenology of obsessive compulsive disorder in the Moslem culture of Saudi Arabia.

SUBJECTS AND METHODS

Records of patients carrying the diagnosis of obsessive compulsive disorder who attended the psychiatric outpatient clinic at King Khalid University Hospital (KKUH) between 1983-1990 were reviewed. There were a total of 57 cases. Five files could not be located and were therefore excluded from the study. Seven other patients were excluded from the study because they did not fulfill the DSM-III-R criteria for obsessive compulsive disorder. Therefore, only 45 patients were included in the study. A data gathering sheet was designed to collect information such as demographic data, age of onset, history of precipitating factors, course and type of onset of the illness, and previous psychiatric history, co-morbidity, and treatment methods. The Yale-Brown Obsessive Compulsive Symptom Checklist was used to help gather and classify information about phenomenology of the disorder ^[11].

RESULTS

During the period 1983-1990, the total number of patients seen at the psychiatric clinic of KKUH was 3,080. The study group of 45 subjects comprised about 1.5% of this figure. In this group of 45 patients, there were 26 males (57.7%) and 19 females (42.2%). The age range was 15–61 years with a mean age of 27.5 years. SD = 11.1 years. One-third of our subjects had high quality jobs and one-half had at least 12 years of education. Mean age of onset was 23 years. SD = 10.7 years. There was no significant difference between males and females with regard to age at presentation or age of onset of symptoms. Demographic data are shown in Table 1.

Table 1. Sex distribution of demographic data.

The onset of obsessive compulsive disorder was described to be insidious in 23 cases (51.1%), acute in 14 cases (31.1%), and unreported in the rest. More males reported insidious onset of their illness compared to females (85% versus 33.3%, P < 0.002). Ten patients (22.2%) reported a precipitating factor to their illness such as marital or family conflicts. Eighteen patients (40%) denied precipitating factors and there was no report of such factors in the rest. The course of the illness was described as continuous in 30 patients (66.7%), episodic in five patients (11.1%) and deteriorative in seven patients (15.6%).

Obsessions only, were reported in 21 patients (46.7%), compared to compulsions which were reported in five patients only (11.1%). Nineteen patients (42.2%) reported both obsession and compulsion. Past history of psychiatric illness and co-morbidity are shown in Table 2. The frequency of reported obsessions and compulsions are shown in Table 3.

Table 2. Past psychiatric history and co-morbidity.

Table 3. Frequency of obsessions and compulsions.

Religious obsessions are defined as obsessions with a religious content, whether the direction is toward over-religiosity or anti-religiosity. Anti-religious obsessions are a subtype of religious obsessions where the content is ego-dystonically anti-religious. Sexual obsessions are those obsessions where the content is a sexual thought, idea, image or impulse that is unacceptable to the patient.

A total of 37 patients (82.2%) were pharmacologically treated while psychological therapies were used in eight patients only (17.7%).

DISCUSSION

Similar to the only study reported from Saudi Arabia ^[12] and other Western studies, age of onset was < 30 years in 76% of the subjects with an average delay of 5.5 years prior to seeking help ^[13,14]. However, females in our group seemed to seek help earlier than males (P < 0.03). This finding could be explained by the greater quantity of reports of acute onset of symptoms in females. Also, similar to other Western studies, 50% of our subjects reported insidious onset of symptoms and 65% had a continuous course of illness ^[13,15]. The preponderance of males in our group is compatible with other psychiatric service utilization studies found in Saudi Arabia ^[16]. Depression was the most common co-morbidity in our group, supporting the long documented association between obsessive compulsive disorder and depression. Almost all types of obsessions and compulsions reported by our subjects were colored by religion, some more than the others. Similar to the findings of Mahgoub and Abdel-Hafeiz ^[12], obsessions in our group were mostly religious in nature (46.7%). There were no reports of religious obsession by Rasmussen and Eisen ^[15] or Stern and Cobb ^[17], to compare to our findings, but the great emphasis on religious adherence in the Saudi Moslem culture leads us to believe that religious obsessions may be more prevalent in our culture compared to the West. Given this clear role of religion, anti-religious obsessions such as blasphemous thoughts are explained culturally as being indicative of poor faith, hence make the person an easy prey for the Satan. Although this explanation may sound painful, many patients do find it comforting to project their ego-dystonic obsessions to the Satan. Therefore, obsessive compulsive disorder may not be recognized as a mental illness and traditional healers or religious leaders may be consulted for its diagnosis and treatment. Those who seek help from psychiatric facilities are probably the most severely ill. The most encountered religious obsessions in our patients were either anti-religious such as blasphemous thoughts and atheistic ruminations or over-religious such as doubts about the quality of prayers and the strength of faith. Sexual obsessions were less common in our group than in the West (8.9% versus 26%) ^[15] which could be explained by the more sexual freedom in the West compared to the modest Saudi culture where patients may even refuse to talk about sexual matters. Examples of sexual obsessions include incestuous and pedophilic impulses. The poor awareness about the health hazards of contamination in developing countries may explain the low prevalence of contamination obsessions in our group compared to the West ^[14]. Somatic obsessions are thoughts or ruminations related to bodily functions and physical symptoms and are recognized by patients as irrational, unrealistic, and excessive. This is in contrast with hypochondriasis and somatization disorders where the somatic symptoms are considered real and rational. Somatization is a common mode of seeking help, especially among Saudi females. Surprisingly, somatic obsessions were not reported in our group ^[16,18], compared to the 36% frequency reported by Rasmussen and Eisen ^[15]. Subjects with somatic obsessions however, would probably seek help from non-psychiatric physicians.

Again, similar to Mahgoub and Abdel-Hafeiz ^[12], the most common compulsion in our group is the act of repeating. Although this is similar to figures reported by Stern and Cobb (42.2% versus 40%) ^[17], most of the repeated behaviors in our group are related to prayers and ablution. Prayers and its associated washing are repeated five times a day in a group setting and at a specific time and sequence of behavior. Dissatisfaction with their proper execution in some OCD subjects would easily lead to repetition compulsions. This can be quite disabling since they may interfere with performance of these duties. This disability may be more apparent in males in relation to the highly valued group prayers which are usually performed in the mosque. Since Moslems have to perform their daily prayers with a clean body, clothes, and place; cleaning and washing obsessions in our subjects were also related to religion. Aggressive obsessions were directed mainly towards parents and other immediate relatives. The Koran instructs Moslems to treat their parents in a most tactful and kind manner. Some of our patients were quite tormented by their aggressive impulses against their parents.

The finding that half of our subjects had at least 12 years of education is an important one knowing that the same level of education is obtained only by 7% of the general population ^[19]. This is in accordance with the observation that obsessive compulsive disorder patients tend to have above average intelligence and high levels of education and jobs ^[6].

Apart from the finding that females in our group reported more acute onset of symptoms and sought help sooner than males, there were no sex differences with regard to precipitating factors, type of obsession or compulsion, course of illness, co-morbidity or past history of psychiatric illness.

The finding that most patients were treated with medications partly reflects the difficulty of incorporating psychological theories in the belief systems of both patients and therapists ^[20].

CONCLUSION

Although this study is retrospective in nature, it is in great agreement with the only prospective study from Saudi Arabia ^[12]. Despite cultural differences, both have more similarities than differences with studies from the West. This may be taken to support the biological etiology of obsessive compulsive disorder. The influence of religion on phenomenology of obsessive compulsive disorder in Saudi Arabia indicates the need of mental health professionals to be aware of cultural differences if they are to be of help to their patients.