Out damned spot!

Saturday, 31 May 2014 00:03 - - {{hitsCtrl.values.hits}}

Obsessive Compulsive Disorder – they know their thoughts and rituals are irrational, but they have very little control over them

When I first read Shakespeare’s ‘Macbeth’ in Literature class back in high school, I just summed up Lady Macbeth’s obsessive washing of her hands as her being overcome by massive feelings of guilt after the murder of King Duncan. From her famous quote: “Yet here’s a spot...Out damned spot! Out, I say!” I understood that she was suffering from an intense degree of mental anguish; she would sleepwalk and start rubbing her hands frantically as she imagined that they were stained with the blood of the murdered king. Little did I know however that what she was doing (the hand-washing ritual) was a typical act of someone suffering from Obsessive Compulsive Disorder (OCD). I had never heard of OCD back then and neither had my peers. Sadly, even to this date, there are still many people who are unaware of this illness. In an interview with the Daily FT, Consultant Psychiatrist and National Council for Mental Health Director Dr. Nirosha Mendis shared some information about OCD and added that although given a separate name, OCD can be interrelated with other illnesses. A person suffering from OCD is more likely to suffer from depression as well. He may then have trouble sleeping, be lethargic, have joint pains, sexual dysfunction, suicidal thoughts and loss of appetite; all these go hand in hand as very complex biological changes take place in the brain. Following are excerpts of the interview. Q: What is Obsessive Compulsive Disorder? A: It is an anxiety disorder; there are a number of such disorders: generalised anxiety disorder, social phobia, panic disorder, etc.; these are all a part of this whole anxiety disorder spectrum. Obsessive compulsive disorder is one of these anxiety disorders. Essentially what happens is in OCD you have recurrent obsessions and and/or compulsions. You can have intrusive thoughts which can be thoughts alone or they can be coupled with compulsions as well. Or you can have purely compulsions. This keeps changing, for instance, you can start off by having intrusive obsessive thoughts, on something that may not be very kind to you – some people may have religious obsessions, for example they may want to harm a particular religious leader – they have these intrusive thoughts that keep bombarding them. They don’t want to do it. They know that these are intrusive thoughts and that they should not be entertained but these thoughts keep coming in. They have very little control over it. If they do try to control themselves, they get severe symptoms of anxiety, such as palpitations, the heart starts beating very fast, they start sweating and experience various other somatic symptoms like a churning sensation in the stomach, giddiness, and they feel very uncomfortable. Then there are the compulsions: One example is recurrent hand-washing. They would wash their hands up to 25-30 times a day and can come to the point where they get severe ulceration of the hands. They know their action is irrational and doesn’t serve a purpose but are compelled to do it. If they try to control it they get severe symptoms of anxiety (like those mentioned earlier). They think that if they don’t, something bad will happen like someone may die. Some people have the checking ritual: After they lock the car door they keep checking the car door several times to make sure that it is really locked. Another example is people working in an office maybe in a bank – they will have to check or sign or fill a form. They will keep checking it repeatedly. This causes personal distress as well as problems at work. They can’t focus on their work. Is they take so much time to do things like washing hands and checking papers repeatedly it prevents them from doing their work and it becomes very difficult for them to function. These people are then more likely to suffer from depression as well. When they are depressed they have trouble sleeping, become lethargic, suffer from joint pains, sexual dysfunction, suicidal thoughts and loss of appetite; all these go hand in hand. So although we give them separate names – we say it is OCD, panic disorder, depression, etc.; we can see there is an interrelation – because very complex biological changes are taking place in the brain. It’s not a psychotic illness where the person isn’t aware of what he is doing. Here he is aware and realises that they are counter-productive thoughts, so in other words, they are sane, they are not insane, they know what they are doing but they can’t control it. Q: What causes this condition? A: Any condition is caused by genetic as well as environmental factors interacting. Now let’s say if you ask what causes heart attacks, it can be genetic factors interacting with environmental factors; for example, if a person’s father or someone in his family has a history of heart disease, there is a genetic pre-disposition of him developing heart disease. If that person smokes, does not exercise or his blood pressure is not controlled, then he’s much more likely to have a heart attack. It’s like that for any disease. So it’s always genetics and environment interacting. That is how you get any illness. So there are some people who are genetically pre-disposed to develop anxiety disorder. Under those circumstances, if there are certain environmental triggers then that can result in an illness. The environmental triggers are:

Psychological stress
Drugs and alcohol
Trauma to the head/injury

Some people develop OCD symptoms after having a stroke, but then technically we don’t call it OCD because it is following a stroke where there’s blood clot and bleeding in the brain. But we have to be careful – Just because someone has symptoms of OCD – we can’t say it’s OCD – if that person has a brain tumour he may display symptoms of OCD – if we don’t investigate and we treat him for OCD alone, he could end up dying of the brain tumour. If we remove the tumour there is a good chance he can recover. I had a patient, an elderly person in his 70s; about a year ago he had started having this hand washing issue and was treated for OCD with medicine. When we took a brain scan, we found that he had a brain tumour and that was what was causing it. It was successfully removed and his OCD symptoms subsided. The brain is something that is very complex. We can get 10 people with 10 different presentations. So it depends on the individual, the region of the brain that’s affected; it will be different for each person and there are a lot of interconnections. We can’t follow a strict protocol. We must always remember that OCD could be symptoms due to various other conditions. Q: In that case, to avoid the risk, if someone comes in thinking that she has OCD, would you do the brain scan because of the various possibilities? A: Ideally we should investigate them properly. With any patient who comes in, first of all their history needs to be taken, they should be examined and we have to do the necessary investigations. Only then can we come up with an accurate diagnosis. That doesn’t mean that every person who comes needs a brain scan. Sometimes by seeing the person’s history and by investigating him we can say, ‘This is definitely OCD’. We don’t have to unnecessarily spend money and do scans but that would depend on the doctor and what he sees as appropriate at the time.

Q: Can children get this too? A: Yes. The onset is usually during adolescence but it could be younger; can be later as well. Q: How high are the chances of a child inheriting it from the parents? Will the child necessarily get it? A: It’s very difficult to predict. For example, if both parents have schizophrenia, then there’s an approximate 50% chance that the child can get it but there’s also a 50% chance that he won’t. So it’s very difficult to give a percentage – those are highly variable. There are people whose parents have diabetes but they are perfectly healthy because they take care of their health – they eat healthy, exercise and relax, so their chances of falling ill are much less even though they have a strong family history. Therefore it’s not an exact science. A lot of parents come and ask us, “Since I have it will my child have it,” and I say, “Don’t worry about it because there’s nothing you can do about it; let’s focus on the child’s health: let’s make sure he eats healthily, he’s not stressed out and does not smoke.” We should take a more pragmatic approach when it comes to treating people and educating them. People take genetics too seriously. But to answer your question, there is a link. The chances are higher of developing any condition – not just OCD, if you have a family history. Q: What is actually going on in the brain of a person suffering from OCD? A: The front part of the brain is the part that is affected in a person who has OCD. So what happens is the control mechanism doesn’t work properly, so they repeat the cycle. Let’s take the example of an iron – after it reaches a particular temperature point, it automatically switches off; otherwise it will get overheated. Similarly here the control mechanism is not there, so everything has to be repeated. We therefore give drugs and that will bring it under control. When we treat the person with medication he gets better.

Q: So medical intervention is imperative? If it’s a very mild case of OCD, can the patient handle it on his own through self-help techniques such as telling himself: ‘This is not real, it’s irrational, ignore it’; since he’s aware of what’s happening? A: It’s like this – if you have mild blood pressure and you exercise, reduce salt intake, lose weight, stop smoking, it could help to control the pressure. If it’s high then you have to take medication. Classic OCD needs to be treated. If it’s mild then sometimes control is possible through self help – but then you wonder: ‘Is it really OCD’? Or is it secondary to something else? If its clinical OCD, most certainly it needs to be treated otherwise it can get worse. It can seriously affect a person’s life. Q: Is the medication costly? A: No, it’s actually quite affordable.

Q: What is the worst case of OCD you have come across in Sri Lanka? A: There was a man who came in his early 30s. He had it for 10 years and it hadn’t been successfully treated. It was partially treated because whenever he gets a bit better, he stops taking his medication, his lifestyle was not good either and he was very stressed. The first thing we had to do was send him to a dermatologist because both his hands were severely ulcerated. His skin was peeling off from repeated hand-washing and he didn’t just use ordinary soap – he used a detergent because he had this severe obsession that he had germs on his hands. His family had to practically drag him to the hospital because he was totally out of control. However after treatment, he made a good recovery. So this could be very rewarding because after the treatment, once they are well, they can live very normal lives. Q: What are the treatment and facilities available in Sri Lanka? A: We have what it takes to treat people. We are not short of anything. Q: Is the method of treatment through medication or is it through controlling of thoughts by means of therapy? A: It’s not just medication; its medication and therapy – you have to take a holistic approach. For example, if a person has a bypass surgery and continues to smoke, then he’ll have to have a bypass again very soon, or he’ll die of a second attack. He needs to be educated about the whole thing, take medication, psychological therapies (for certain people), biological and cognitive behaviour treatment. Biological/social/environmental factors – they are all interconnected. If one has cancer he is more likely to suffer from depression as a result. Anything in medicine is not just about taking the medication, it’s a total package. For me it’s early detection, treatment and relapse prevention. Doctors may help but if the patients go back to the same practices then it’s pointless. They need to continue the medication and lifestyle changes for the long term. The best advice is if you think you have a condition, go to a doctor; don’t take advice from every Tom Dick and Harry. You need to get the proper help. There’s a lot of good information on the internet but sometimes it can be misleading, because each person produces different presentations. A lot of people try to treat things in isolation. People need to have a healthy lifestyle, practice abstinence from alcohol and tobacco and try to relax. Pix by Lasantha Kumara

Do we have enough psychiatrists in Sri Lanka?

In post-conflict Sri Lanka, there exist many people who were traumatised by the brutality of the 30-year-war and are in dire need of psychiatric help. Do we have enough psychiatrists to meet the needs of these victims and so many other people in the country who suffer from psychiatric illnesses? Dr. Nirosha Mendis says: “It’s not quantity that matters, its quality. I think with anything in medicine it’s like that. Of course it would be nice to have an abundance of clinics; in Sri Lanka we have a limited amount of resources, I don’t think we’ll have a proper amount of anything – no country has. I don’t think there’s a perfect health system anywhere in the world. I think we need to focus on quality: proper training, quality drugs and other biological treatment, and general health – people should be educated on how to live their lives healthily. “Most people don’t know the importance of exercise, abstinence from drugs and alcohol, healthy diet, organic produce, relaxation and stress management. Everyone is eating salty, sweet, fatty food. Another 5-10 years down the line they’re going be ‘finished’. We always talk about the curatics. We should focus on prevention. Prevention is better than cure. If these things are not happening in the first place, we don’t t need so many clinics. We are a small country and we can easily do very well without wasting unnecessary money. “For any country the biggest resource is health – a healthy population. Rather than paying money in treating the patients it would be better to spend money on preventing them from falling ill in the first place. That is what we do here. We conduct a lot of awareness programs. People should be made aware of the importance of good health. Schools also have to be involved, for example, once a year they can have an awareness program – on good health habits. There is too much pressure on children, leading to psychological problems. “Everyone is in a rush – students are in a rush, parents are in a rush, there’s peer-pressure and pressure from teachers. We must educate people – that would be at the school level – not when they’re 65! I’m sure we can do with more doctors but that’s not something that we can suddenly achieve – no country can. And I think our system is generally pretty good. People can have access to a doctor very quickly. Even the private sector is quite affordable compared to some of the other countries. I’m not saying we shouldn’t get more psychiatrists; don’t get me wrong, I’m saying we should think more laterally.”