A cross-sectional study of the phenomenology of obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a clinical syndromewhose hallmarks are excessive, anxiety-evoking thoughts and compulsive behaviours that are generally recognised as unreasonable, but which cause signi icant distress and impairment. Heterogeneous nature of OCD presentation makes its conceptualisation as a complicated one. Phenomenological studies are needed to understand various heterogeneity OCD. This study is intended to see various phenomenological subtypes of OCD in the local population. This is a hospitalbased cross-sectional study. Two hundred consecutive OCD patients attending psychiatry OPD analysed for the various social-demographic features and phenomenological indings. In our study, 48% of the sample had only obsessions, 19%had only compulsions, while 33%had amixed presentation, studying the subtypes, the study revealed that 36.5% of the sample who presented with fear of contamination and 11.5 % samples have an aggressive obsession and another 11.5 % samples have symmetry obsession. 28% had contamination obsessions, 9% had sexual obsessions, 7% had somatic obsessions while 9% had religious obsessions, and 6% had various types of obsessions. When compulsion was assessed, it was found to be checking 28(77.8%), cleaning 25 (69%), repeating 18(50%), counting 6(16%), ordering 4 (11%), collecting 4(11%) and miscellaneous 15(42%) when subtyped. Studying the phenomenological pattern in OCD patient would help in better understanding of the illness of the patients, it also tries to attempt the relationship between sociocultural issues and OCD. Though the neurobiology is similar in all individuals, phenomenology differs between individuals concerning gender, religion and culture.


INTRODUCTION
Obsessive-compulsive disorder (OCD) is a clinical syndrome that is typically characterised by repetitive thoughts that provoke anxiety and compulsive behaviours which, though recognised as irrational, leading to distress and functional impairment (American Psychiatric Association, 2013). It is diagnosed in 2% of the population and is associated with considerable socio-occupational and personal impairment (Angst et al., 2004;Kessler et al., 2005). It is ranked among the top 20 causes of years of life lived with disability among 15-44-year-olds as determined by the World Health Organization (Mur-ray and Lopez, 1997). Our conventional diagnostic system is often changing to keep up with the conceptualisation of obsessive-compulsive disorder. In DSM 5, OCD has been taken out from the anxiety disorders category and reformulated as a separate diagnostic entity. The heterogeneous nature of OCD presentation makes its conceptualisation a complicated task.
OCD's core symptoms of anxiety-provoking obsessions and compulsive behaviours are hallmarks of its presentation; however, the content of the symptoms can be widely varying in their speci icity. This points to clear evidence that there is excellent heterogeneity of symptoms in OCD (Hasler et al., 2005).
Over several decades, a signi icant number of studies have used methods such as factor, cluster and latent variable analysis of OCD symptom inventories to bring down the variability of the symptom groupings in the different populations af licted with the disease.
A right proportion of these studies have found evidence for a small number of symptom dimensions, usually three to ive (Mataix-Cols et al., 2005). The most frequently found answer to address the heterogeneity of symptoms in OCD includes the following: 1. Contamination obsessions and cleaning compulsions 2. Aggressive, sexual, religious, and somatic obsessions with checking-related compulsions; 3. Obsessions regarding symmetry, exactness, and the need for things to be "just right" paired with compulsions relating to ordering, arranging, and counting, and 4. Hoarding obsessions and compulsions.
Further attempts have been made to subgroup patients af licted with OCD based on speci ic phenomenological characteristics, such as severity, whether the disease runs in the family, the age of its onset, gender of the patient, and comorbid conditions.
Evidence also suggests that childhood-onset OCD is different from that of adult-onset, in that there are differences in several factors that include gender and co-morbidity (for instance, there is a higher prevalence of tics and Tourette syndrome in childhood-onset OCD).
With this background in mind, this study attempted to ascertain the phenomenology of OCD in the local population.

MATERIALS AND METHODS
This study was done at OPD Unit of the Department of Psychiatry, SRM Medical College Hospital and Research Centre, Kattankulathur, Chengalpattu district, Tamilnadu.

Inclusion criteria
1. Patients diagnosed to have primary OCD based on DSM IV-TR criteria.
3. Able to give fully informed, written consent for the study.

Exclusion criteria
1. Patients with OC symptoms not ful illing the DSM IV-TR criteria.
2. OCD with any other illness which might distort the phenomenology.

Instruments and tools used
1. Socio-demographic and Clinical proforma.

Procedure
Two hundred consecutive OCD patients attending psychiatric OPD were included in the study after ful illing the inclusion criteria. Initially, sociodemographic details were collected which included name, age, sex, religion, age of onset of illness, duration of illness, type of the family, marital status, family history of psychiatric illness, and family history of comorbid medical illness. Mini International Neuropsychiatric Interview scale was administered to rule out other psychiatric co-morbidities. OCD is diagnosed based on DSM IV-TR Criteria by a quali ied Psychiatrist Then Y-BOCS symptom checklist was administered to study phenomenology, i.e. type of obsession or compulsion or whether it was

RESULTS AND DISCUSSION
This study was conducted at the SRM Medical College Hospital Psychiatric out-patient department.
The study population was those who attended the OCD clinic of the department. One hundred patients who attended the clinic during the study period were assessed after obtaining informed consent. They were both new and reviewed patients.
Among 200 patients with OCD, 166 patients were less than 45 years old, and 34 patients were more than 45 years old (Table 1), regarding sex 56% were males and 44 % were females (Table 2). Mean age of onset 29 years for male and 24 years for females (Table 3). Females have a longer mean duration of illness when compared to men. Males have 6.5 years mean duration, where females have 7.6 years mean duration of illness (Table 4).
Among subtypes of OCD, only obsession subtype is more common (Girishchandra and Khanna, 2001), in our study group; also, 48% of the sample had only obsessions. On the phenomenology of OCD unlike previous studies (Parmar and Shah, 2014;Rajashekharaiah and Verma, 2016) fear of contamination is a more common obsession in our group, likewise more than the cleaning compulsion checking the type of compulsion is more common in our study population.
We need more trans-cultural studies to ind whether there is any role of culture in the phenomenology of obsessive-compulsive disorder.

Summary
This study was conducted in 200 consecutive OCD patients attending SRM Medical College Hospital in Psychiatric OPD to study the phenomenological pattern of OCD in our population.
Two hundred consecutive OCD patients ful illing the inclusion criteria who were attending psychiatric OPD were included in the study. Initially, sociodemographic details were collected which included name, age, sex, religion, age of onset of illness, duration of illness, type of the family, marital status, family history of psychiatric illness, family history of comorbid medical illness after obtaining informed consent. Mini International Neuropsychiatric Interview scale was administered to all the patients (MINI) to diagnose OCD. Then the Y-BOCS symptom checklist was administered to study phenomenology, i.e. type of obsession or compulsion or mixed features. Then the YBOCS severity scales were administered to assess the severity.
In this study, 48% had only pure obsessions, 19% had pure compulsions, and 33% had mixed obsession and compulsion. Among obsessions, contamination obsession was the commonest obsession, i.e. 36.5%, followed by aggressive and symmetry obsessions which were 11.5%. Under compulsive phenomenology, the commonest compulsion was checking compulsion which was 77.8%, 69.5% had cleaning compulsions, 50% had repeating compulsions.
The mean age of onset in males was 29 years, and for females, it was 24. Though the onset was earlier in females, the difference was not statistically signi icant. The mean duration of illness of the total sample was 9.16 years (SD 7.63). Men had a slightly lesser duration of 6.5 years compared to women who had a duration of 7.6 years.

CONCLUSION
Studying the phenomenological pattern in OCD patient would help in better understanding the illness of the patients, and it also could be used to attempt to draw the relationship between sociocultural issues and OCD. Though the neurobiology is similar in all individuals, phenomenology differs between individuals concerning gender, religion and culture. While delivering non-pharmacological treatment, phenomenology helps to create better insight in patients concerning their gender, religion and culture.