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\begin{document}


\def\RunningAuthor{Sivabalan E et al.}
\firstPage{7572}
\articleType{Original Article}
\receivedDate{23 Sep 2020}
\acceptedDate{29 Oct 2020}
\revisedDate{25 Oct 2020}
\journalVolume{2020, 11}
\journalIssue{4}
\journalDoi{ijrps.v11i4.3964}
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\title{\textbf{A cross-sectional study of the phenomenology of obsessive-compulsive disorder}}
\author{Sivabalan~E\textsuperscript{*},  
            Amritha~Prasad, 
            Thirunavukarasu~M~\\[5pt]{Department of Psychiatry, SRM Medical College Hospital \& Research Centre, SRM Nagar, Potheri, Chengalpattu, Tamilnadu-603203, India}}

\begin{abstract}
Obsessive-compulsive disorder (OCD) is a clinical syndrome whose hallmarks are excessive, anxiety-evoking thoughts and compulsive behaviours that are generally recognised as unreasonable, but which cause significant 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 hospital-based cross-sectional study. Two hundred consecutive OCD patients attending psychiatry OPD analysed for the various social-demographic features and phenomenological findings. In our study, 48\% of the sample had only obsessions, 19\% had only compulsions, while 33\% had a mixed 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. 
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Cleaning,\newline Fear of contamination,\newline Intrusive thoughts,\newline Subtypes of Obsession,\newline Symptom cluster of OCD
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Sivabalan~E~\\ Phone:\ 9962017274~\\  Email:\ sivabalanela@gmail.com
        \par}\vspace*{-11pt}\hrulefill\par{\fontsize{12}{14}\selectfont ISSN: 0975-7538}\par% 
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\section{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 \unskip~\citep{923030:20678629}. It is diagnosed in 2\% of the population and is associated with considerable socio-occupational and personal impairment \unskip~\citep{923030:20678624,923030:20678628}\textit{. } 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 \unskip~\citep{923030:20678627}. 

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 specificity. This points to clear evidence that there is excellent heterogeneity of symptoms in OCD \unskip~\citep{923030:20678630}.  

Over several decades, a significant 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 afflicted with the disease.

A right proportion of these studies have found evidence for a small number of symptom dimensions, usually three to five \unskip~\citep{923030:20678622}. The most frequently found answer to address the heterogeneity of symptoms in OCD includes the following: 


  
  \begin{enumerate}
  \item \relax Contamination obsessions and cleaning compulsions
  \item \relax Aggressive, sexual, religious, and somatic obsessions with checking-related compulsions;
  \item \relax Obsessions regarding symmetry, exactness, and the need for things to be ``just right'' paired with compulsions relating to ordering, arranging, and counting, and
  \item \relax Hoarding obsessions and compulsions. 
  \end{enumerate}
  Further attempts have been made to subgroup patients afflicted with OCD based on specific 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. 
    
\section{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.

\textbf{Sample size}

Number of Patients {\textendash} 200 (n = 200).  

\textbf{Inclusion criteria}


  
  \begin{enumerate}
  \item \relax Patients diagnosed to have primary OCD based on DSM IV-TR criteria.
  \item \relax Aged 18 - 65 years. 
  \item \relax Able to give fully informed, written consent for the study. 
  \end{enumerate}
  \textbf{Exclusion criteria}


  
  \begin{enumerate}
  \item \relax Patients with OC symptoms not fulfilling the DSM IV-TR criteria.
  \item \relax OCD with any other illness which might distort the phenomenology. 
  \item \relax Substance-induced and drug-induced OCD.
  \end{enumerate}
  \textbf{Instruments and tools used}


  
  \begin{enumerate}
  \item \relax Socio-demographic and Clinical proforma. 
  \item \relax Mini-International Neuropsychiatric Interview (MINI) Scale for asses the comorbid diagnosis \unskip~\citep{923030:20678620}.
  \item \relax Yale-Brown Obsessive-Compulsive symptoms checklist (YBOCS) and Yale-Brown Obsessive Compulsive severity scale \unskip~\citep{923030:20678631,923030:20678626}.
  \end{enumerate}
  \textbf{Procedure}

Two hundred consecutive OCD patients attending psychiatric OPD were included in the study after fulfilling the inclusion criteria. Initially, socio-demographic 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 qualified Psychiatrist Then Y-BOCS symptom checklist was administered to study phenomenology, i.e. type of obsession or compulsion or whether it was 


\begin{table*}[!htbp]
\caption{\boldmath {Age-wise distribution} }
\label{tw-e38aa969af89}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.3681999999999999\linewidth-2\tabcolsep}p{\dimexpr.3592\linewidth-2\tabcolsep}p{\dimexpr.27259999999999998\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Age  & Number of Patients & Percentage \%\\
\tblmidrule 
Less than 45 years  &
  166 &
  83\% \\
More than 45 years  &
  34 &
  17\% \\
Total  \mbox{}\protect\newline  &
  200  \mbox{}\protect\newline  &
  100\% \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Sex wise distribution} }
\label{tw-aadfc108eeb2}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.5629\linewidth-2\tabcolsep}p{\dimexpr.4371\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Sex  & Percentage \\
\tblmidrule 
Male &
  56\%\\
Female &
  44\%\\
Total &
  100\%\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Mean age of onset} }
\label{tw-9ad4943be82a}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.5008\linewidth-2\tabcolsep}p{\dimexpr.22209999999999997\linewidth-2\tabcolsep}p{\dimexpr.2771\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Age of onset & Male & Female\\
\tblmidrule 
Mean age of onset (years) &
  29 &
  24\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Duration of illness} }
\label{tw-9141aa155cf8}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.57050000000000004\linewidth-2\tabcolsep}p{\dimexpr.2558\linewidth-2\tabcolsep}p{\dimexpr.1737\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Duration of illness & Male & Female\\
\tblmidrule 
Mean Duration of illness (years) &
  6.5 &
  7.6\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Frequency of obsessive and compulsive phenomenology } }
\label{tw-e43c625b1435}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.4506\linewidth-2\tabcolsep}p{\dimexpr.5494\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Phenomenology  & Percentage \\
\tblmidrule 
Only Obsession &
  48\%\\
Only Compulsion &
  19\%\\
Mixed &
  33\%\\
Total &
  100\%\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Frequency of obsessive phenomenology } }
\label{tw-e4e16d77ada2}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.1353\linewidth-2\tabcolsep}p{\dimexpr.3489\linewidth-2\tabcolsep}p{\dimexpr.295\linewidth-2\tabcolsep}p{\dimexpr.2208\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}S. No.  & Obsession  & Total number of obsession  & \% of Obsession\\
\tblmidrule 
1   &
  Aggression &
  11 &
  11.5\%\\
2   &
  Contamination &
  35 &
  36.5\%\\
3   &
  Sexual &
  9 &
  9.3\%\\
4   &
  Hoarding &
  8 &
  8.3\%\\
5   &
  Somatic &
  7 &
  7.3\%\\
6   &
  Religious &
  9 &
  9.3\%\\
7   &
  Symmetry &
  11 &
  11.4\%\\
8   &
  Miscellaneous &
  6 &
  6.4\%\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Frequency of Compulsive phenomenology} }
\label{tw-c7fdfa45226c}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.14439999999999998\linewidth-2\tabcolsep}p{\dimexpr.3286\linewidth-2\tabcolsep}p{\dimexpr.277\linewidth-2\tabcolsep}p{\dimexpr.25\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}S. No.  & Compulsion & Total number of compulsion & \% of Compulsion\\
\tblmidrule 
1  &
  Cleaning &
  25 &
  69.5\%\\
2  &
  Checking &
  28 &
  77.8\%\\
3  &
  Repeating &
  18 &
  50\%\\
4  &
  Counting &
  6 &
  16.8\%\\
5  &
  Ordering &
  4 &
  11.1\%\\
6  &
  Collecting &
  4 &
  11.1\%\\
7  &
  Miscellaneous &
  15 &
  41.7\%\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
mixed. The YBOCS severity scale was administered to assess the severity.

\textbf{Statistical analysis}
  
  \begin{enumerate}
  \item \relax Descriptive statistics were applied to study the socio-demographic variables
  \item \relax Mean values were obtained for age, age of onset of illness and duration of illness.
  \end{enumerate}
  
    
\section{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~\ref{tw-e38aa969af89}), regarding sex 56\% were males and 44 \% were females (Table~\ref{tw-aadfc108eeb2}). Mean age of onset 29 years for male and 24 years for females (Table~\ref{tw-9ad4943be82a}). 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~\ref{tw-9141aa155cf8}).

In our study, 48\% of the sample had only obsessions, 19\% had only compulsions. In comparison, 33\% had a mixed presentation (Table~\ref{tw-e43c625b1435}), 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 (Table~\ref{tw-e4e16d77ada2}). 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 were 15(42\%) (Table~\ref{tw-c7fdfa45226c}). 

Among subtypes of OCD, only obsession subtype is more common \unskip~\citep{923030:20678625}, in our study group; also, 48\% of the sample had only obsessions. On the phenomenology of OCD unlike previous studies \unskip~\citep{923030:20678623,923030:20678621} 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 find whether there is any role of culture in the phenomenology of obsessive-compulsive disorder. 

\textbf{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 fulfilling the inclusion criteria who were attending psychiatric OPD were included in the study. Initially, socio-demographic 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 significant. 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.
    
\section{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. 
    
\section{Acknowledgement}
We would like to thank all the study participants and the SRM Institute of Science and Technology for providing constant support to carry out this study.

\textbf{Conflict of Interest} \textbf{\space }

The authors declare that they have no conflict of interest for this study. 

\textbf{Funding Support} \textbf{\space }

The authors declare that they have no funding support for this study.


    

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