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Obsessions and compulsions in pakistani community of adults

Obsessive compulsive disorder (OCD) is an Anxiety Disorder, the core features of OCD are obsessions and compulsions. According to DSM-IV-TR, obsessions are recurrent and persistent intrusive thoughts, images, or impulses that enter the mind of individual for no apparent reason, and are experienced as disturbing and inappropriate (American Psychiatric Association, 2000). People who have such obsessions try to resist or suppress them, or to neutralize them with a few other thoughts or acts. Compulsions are the acts and rituals which are performed by the individual to neutralize the obsessive thoughts or images or to evade some anxiety provoking situation. Compulsions can entail either overt repetitive behaviors (such as washing, checking, ordering or hoarding) or more covert mental acts (such as counting, praying or saying certain words silently). A person with obsessive compulsive disorder usually feels driven to perform this compulsive ritualistic behavior in response to an obsession and there are often very rigid rules regarding

how the compulsive act should be executed. The aim of performing the compulsive behaviors is to prevent or reduce the distress or avert some dreadful event or situation (Carson et. al., 2008).

Apart from the presence of obsessions or compulsions, the diagnosis of OCD is predicated on the impairment and distress caused by the symptoms, the etiological basis of the symptoms and to some extent, the presence of insight. For instance, the diagnosis of OCD is applicable only when the obsessions or compulsions trigger significant distress, take more than one hour a day, or markedly interfere with the individual’s daily schedule, work & academic functioning, social activities or relationships. The diagnosis of OCD is not applicable if the symptoms are due to the direct physiological effects of a substance or general medical condition, or are restricted to another Axis 1 disorder that is present (American Psychiatric Association, 2000). Finally, for adults, the diagnosis of OCD is relevant only for individuals who realize and understand that the obsessions and compulsions are excessive or unreasonable (American Psychiatric Association, 2000).

The empirical structure of OCD symptoms has received a great deal of attention given the heterogeneous nature of the disorder. Various methods have been used to identify the subtypes of OCD including demographic and clinical characteristics (age, gender, comorbidity with other conditions) and phenomenological consistencies. The dichotomy between obsessions and compulsions has also been a popular approach to symptom classification (Summerfeldt, Richter, Antony & Swinson, 1999). More recently the research to identify specific subtypes has focused primarily on symptom presentation. The symptoms to define OCD are diverse and include a range of obsessions and compulsions (Lochner & Stein, 2003). Largely the widespread obsessions are repeated thoughts about contamination, repetitive doubts about having made a mistake or being careless, a drive to retain things in a particular order, horrific or aggressive impulses and sexual imagery (American Psychiatric Association, 2000).

The most common obsessions relate to the concerns about contamination, obsessive doubts, need for symmetry, aggression or harm. The most common obsessions involve checking, washing and counting (Samuel & Nesdadt, 1997).

There are various ways in which obsessions are experienced. Researchers have employed a wider range of constructs such as fears and conviction in defining obsessions. For instance, Girishchandra and Khanna (2001) reported an array of obsessional phenomena in their sample of OCD participants, including doubts, thoughts, fears, urges, images and convictions. Akthar et al. (1975) reported that among 82 Hindu obsessional patients in Northern India, 75% reported doubts, 34% thoughts, 25% fears, 17% impulses, and 7% images. Reed (1985) found that in his sample of 50 non-depressed OCD patients, 65% complained of fears, 40% of rumination and 38% of doubts.

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Individuals with OCD usually have multiple obsessions (Akhtar, Wig, Verma, Pershod, & Verma, 1975; Rasmussen & Tsuang, 1986). Reed (1985) summarizes his clinical observations saying “obsessionals seldom suffer from a single, discrete obsession” but have a “veritable network of obsessional ideas, doubts and fears” just as a “cancer which can extend in all directions”.

According to DSM-IV TR, compulsions are recurring and ritualistic practices or at times mental acts that the individual feels driven to carry out in response to an obsession, and in accordance with the characterized rules that must be followed decisively. Compulsions are conducted generally in order to prevent a dreaded event or situation, or to alleviate distress, but they are usually not associated in a reasonable way with whatever they are intended to neutralize or restrain, or are evidently excessive. Further, compulsions are never performed for pleasure (American Psychiatric Association, 2000).

Chiefly the prevalent compulsions involve cleaning and washing, counting, checking, ordering, repeating actions and requesting or demanding assurances. In a review of 65 studies within the behavioral treatment literature, 75% of OCD treatment population was found to have cleaning or checking compulsions (Ball, Baer, & Otto, 1996).

Researches indicate that nearly half of patients of obsessive compulsive disorder suffer from more than one ritual. Rasmussen and Tsuang (1986) found that 41% of their OCD sample exhibited more than one ritual. Reed (1985) found that two thirds of his sample of 36 OCD patients suffered from more than one compulsion, with each patient having an average of 2.3 rituals. Saha & Gupta (2000) studied phenomenology of OCD with a cross-cultural perspective. 40 patients of OCD (as per ICD- 10) were studied using YBOC checklist. The common obsessions noticed were contamination (52%) and aggression (32.5%). Washing (57.5%) and checking (42.5%) rituals were the common compulsions. Gadit (2003) reported regarding the compulsions in the fisherman community in Pakistan that checking, washing and counting were the most common.

The present study aims to increase the understanding of Phenomenology and prevalence of various types of obsessions and compulsions suffered by the OCD patients in Pakistani community. The Literaturere view illustrates that the studies examining the structure of obsessions and compulsions have contributed substantially to the understanding of the heterogeneity in OCD (McKay et al. 2004). On going investigations of specific types of OCD is considered important for elucidating etiological processes of disorder and improving treatment outcomes (Calamari et al, 2004).

METHOD

Sample

The sample of the present study involved 80 patients (40 male and 40 female), ranging from ages 25 to 40 years, selected according to the criteria of DSM-IV TR for obsessive compulsive disorder. The sample included literates (till matriculation). This study was carried out at the Outpatient and Inpatient Psychiatry Department of the government and private hospitals/clinics of Rawalpindi and Islamabad (Armed Forces Institute of Mental Health, Rawalpindi General Hospital, National Institute for Handicaps and Pakistan Institute of Medical Sciences) from September 2009 to December 2010 (as a part of MS Clinical Psychology thesis).

Instruments

Following instruments were used in the present study:

Demographic Data Sheet

A demographic data sheet was created to collect comprehensive data from the respondents. It consisted of variables related to the characteristics of the sample population as used in the study. The demographic data sheet comprised of variables like age, gender, education, occupation, salary income, socio-economic condition. The demographic data sheet also included some attributes of clinical profile; types of obsession and compulsion.

Yale- Brown Obsessive Compulsive Scale (Y-BOCS)

The Yale- Brown Obsessive Compulsive Scale (Y-BOCS) developed by Goodman et, al. is a standardized, scale for measuring the severity of symptoms of obsessions and compulsions. It consists of 10 items relevant to obsessions and compulsions, presented with a 5-point Likert scale. The rating scale ranges from 0 (no symptoms) to 4 (severe symptoms). The total score of the scale is 40, which is the sum of 1-10 items. The total scoring reveals the severity of the symptoms of obsessions and compulsions. Each scoring range is categorized as: 0-7 sub clinical; 8-15 mild; 16-23 moderate; 24-31 severe; and 32-40 extreme.

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Procedure

This study involved reading of literature, clinical files and interviews of patients and administration of Yale Brown Obsessive Compulsive Scale (Y-bocs) to find out the common types of obsessions and compulsions. The objective was to explore the frequency of the types of obsessions and compulsions, of patients with obsessive-compulsive disorder.

The respondents were informed that the study involved looking at the patient’s symptoms and types of obsessions and compulsions. The total sample size of the study was 80, including male (n=40) and female (n=40). The sample was collected from the Outpatient Department and Inpatient Department of various government and private hospitals/clinics of Islamabad and Rawalpindi with a primary diagnosis of obsessive compulsive disorder according to DSM IV-TR. The verbal informed consent of the patients was taken prior to the administration of the instruments for the research. The instruments were administered to measure the demographic variables and clinical characteristics of the sample patients. The patients were administered the self-designed Demographic Data Sheet to measure demographic variables. All patients completed the Yale-Brown Obsessive Compulsive Scale (Y-BOCS).

RESULTS

Table 1

Frequency & Percentage of Types of Obsessions. (N=80)

Types of Obsessions

Total Sample

(N=80)

f

%

Dirt & Contamination

50

62.5

Fear of losing & insecurity

6

7.5

Checking

3

3.8

Religious thoughts

2

2.5

Arrangement & order

2

2.5

Miscellaneous Obsessions

8

10.0

Multiple Obsessions

9

11.3

Total

80

100.0

Table 1 reveals the obsessional patterns of the 80 patients. The results indicate that 62% patients displayed obsessions related to dirt and contamination, Fear of losing & insecurity 7.5%, Checking 3.8, Religious thoughts 2.5, arrangement & order 2.5, Miscellaneous Obsessions 10%, Multiple Obsessions 11.3 % (Multiple obsessions i.e percentage of sample exhibited more than 1 obsessions).

Table 2

Gender wise Frequency & Percentage of obsessions (N=80).

Types of Obsessions

Gender

Males

(n=40)

Females

(n=40)

f

%

f

%

Dirt & Contamination

24

30

26

32.5

Fear of losing & insecurity

3

7.5

3

7.5

Checking

1

2.5

2

5

Religious thoughts

2

5

0

0

Arrangement & order

1

2.5

1

2.5

Miscellaneous Obsessions

2

5

6

15

Multiple Obsessions

7

17.5

2

5

Total

40

100.0

40

100.0

Table 2 indicates the different patterns of obsessions among males and females. The most common obsession among the males and females appears to be regarding dirt and contamination i.e 30% and 32.5% respectively. A minor presentation of data exhibits a pattern of multiple obsessions. The results show that males and females have no major marked difference in the frequency of the various types of obsessions. But as far as multiplicity of obsessions is concerned, males have relatively high trends of multiple obsessions as compared to females.

Table 3

Frequency & Percentage of Types of Compulsions (N=80).

Types of Compulsions

Total Sample

(N=80)

f

%

Washing & Cleaning

51

63.8

Checking

7

8.8

Arrangement & Ordering

6

7.5

Hoarding

2

2.5

Miscellaneous Compulsions

3

3.8

Multiple compulsions

11

13.8

Total

80

100.0

Table 3 reveals the representation of compulsions. The results indicate that 63.8% patients displayed compulsions related to Washing & Cleaning, Checking 8%, Arrangement & Ordering 7.5%, Hoarding 2.5%, Miscellaneous Compulsions 3.8% and Multiple compulsions 13.8% (Multiple compulsions i.e % of sample exhibited more than 1 ritual).

Table 4

Gender wise Frequency & Percentage of Compulsions (N=80).

Types of Compulions

Gender

Males

(n=40)

Females

(n=40)

f

%

f

%

Washing & Cleaning

27

67.5

24

60

Checking

2

5

5

12.5

Arrangement & Ordering

2

5

4

10

Hoarding

1

2.5

1

2.5

Miscellaneous Compulsions

2

5

1

2.5

Multiple compulsions

6

15

5

12.5

Total

40

100.0

40

100.0

The table 4 indicates the different patterns of compulsions among males and females. The most frequent compulsion found among the males and females of the present study emerges out to be washing and cleaning, 67.5% and 60% respectively. A minor occurrence of multiple obsessions is also revealed by the results. The table shows that males and females have no major marked differences in the frequency of the various types of compulsions.

DISCUSSION

To receive a diagnosis of Obsessive Compulsive Disorder according to DSM IV-TR an individual must present with either obsession or compulsions (American Psychiatric Association, 2000). The present research explored while collecting the data that more than half of the OCD patients present their complaints with obsessions and compulsions. There were very few who had only obsessions or compulsions. The data sample included the patients who had had both obsession and compulsions. Researches indicate that the majority OCD patients present with both obsessive and compulsive symptoms (Samuel & Nestadt, 1997).

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The findings of the present study reveal that the prevalence of obsessions related to dirt and contamination was the highest. The common obsessions indicated by the results were fear of losing & insecurity, checking, religious thoughts, arrangement & order, multiple obsessions, which are similar to the obsessions reported in other researches. Saha & Gupta (2000) studied phenomenology of OCD and conclude that the most common obsessions were dirt and contamination (52%) and aggression (32.5%). Another study by Foa et al. (1995) focused on types of obsessions experienced by the OCD patients and acknowledged a few common types of obsessions: contamination from dirt (37.8%), fear of harm (e.g. door locks are not safe) (23.6%), unnecessary concern regarding order or symmetry (10%), body or physical symptoms (7.2%), religious thoughts (5.9%), sexual thoughts (5.5%), hoarding (4.8%), thoughts of aggression or violence (4.3%).

Predominantly the compulsions revealed by the results of the present study included washing & Cleaning, checking, arrangement and ordering, counting, checking, repeating actions, hoarding and multiple compulsions. The most frequent compulsion found was washing and cleaning. Literature review of 65 studies within the realm of the behavioral treatment researches indicate that, 75% of OCD treatment population was found to have cleaning or checking compulsions (Ball, Baer, & Otto, 1996). According to Gadit (2003) the most common compulsions in Pakistan community are checking, washing and counting.

The frequencies in a survey of 431 individuals with OCD conducted by Foa and his associates (1995) revealed a prevalence of compulsions, checking (28.8%), cleaning/washing (26.5%), repeating acts (11.1%), mental compulsions (e.g. special words or prayers repeated in a set manner) (10.9%), Ordering, symmetry or exactness (5.9%), Hoarding/collecting (3.5%) and Counting (2.1%). Some similar sort of results for common compulsions were found by Laura and associates (1994), arranging (56%), counting (41%), collecting (38%), and washing (17%).

An occurrence of multiple compulsions is also revealed by the results of the present study. Researches indicate that nearly half of patients of obsessive compulsive disorder suffer from more than one ritual (Reed, 1985; Rasmussen and Tsuang 1986). A study in Pakistan revealed that the types of obsessions and compulsions were similar to those reported in other foreign studies, but the form and the content of obsessions seemed to be influenced by social and religious backgrounds (Saleem & Mahmood, 2009).

The results of preset study indicated different gender wise patterns of obsessions and compulsions. A significantly higher frequency of obsessions related to dirt and contamination in males and females was found. There was no significant difference in terms of the frequency of types of obsessions between the two groups. A minor presentation of data exhibited a pattern of multiple obsessions. But as far as multiplicity of obsessions is concerned, males had relatively higher trends of multiple obsessions as compared to females. Similar trends of higher frequency of fear of impurity and fear of contamination were found by Tükel, Polat, Genç, Bozkurt, & Atlı (2004).

The most frequent compulsion found among the males and females of the present study emerged out to be washing and cleaning. A less significant occurrence of multiple obsessions was also found by the results. The males and females had no major marked differences in the frequency of the various types of compulsions.

Conclusion

It was observed that there was no significant difference in terms of the frequency of obsessions and compulsions between the two groups (males and females). Considering our results in combination with those of other studies,



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