Physical complications of severe enduring obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a common psychiatric illness, with a lifetime prevalence in the general population of 1.9 to 3% 1. The World Health Organization estimated it to be the 11th leading cause of non-fatal burden in the world in 1990, accounting for 2.2% of total years lost to disability 2. Most patients with OCD can be effectively treated, but a subgroup develops a severe enduring illness despite treatment. The National Inpatient Unit based at South West London and St. George’s Mental Health NHS Trust has been treating patients with the most disabling OCD conditions for over 20 years 3,4.

There is a dearth of papers reporting on physical illness in people with OCD. We carried out a study on successive admissions with the diagnosis of severe, chronic disabling OCD. Ninety-eight patients with profound OCD were admitted. These comprised 52 men and 46 women who had an average age of 39±13 years (range 19-70). On admission these individuals had an average Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score of 35±3. Using intention to treat analysis, these scores had reduced by an average 29% to a mean of 25±9 at discharge (p<0.0001), thus demonstrating that even these seriously ill patients can improve.

Severe self-neglect with inability to perform basic activities of self-care and hygiene was found in 75 patients (76.5%). In addition, 40 patients (40.8%) were incontinent most of the time. This was most commonly urinary incontinence (29.6%). Self-neglect was found to be correlated with increasing severity of OCD measured by Y-BOCS (Pearson’s correlation coefficient 0.65; p<0.0005).

Fifty-eight patients (59.2%) had clinical evidence of severe dehydration on admission. Most patients who had this described either difficulties in performing the act of drinking or preparing drinks due to compulsive rituals or deliberately avoiding drinking as a way of reducing trips to the toilet. Worryingly, 21 patients (21.4%) had evidence of renal failure with a raised blood urea and 48 (49.0%) had a raised serum creatinine. The degree of dehydration was correlated with severity of illness measured by Y-BOCS, despite all having profound OCD symptoms (Pearson’s correlation coefficient 0.28; p<0.01).

Twenty patients (20.4%) were underweight and 48 (49.0%) were overweight. In patients who were overweight, the mean body mass index (BMI) was 30±6; in those who were underweight, it was 18±1. Forty-two patients (42.8%) had evidence of high blood cholesterol. In addition, three patients were being treated for raised cholesterol with medication.

This study demonstrates that patients with the most severe OCD have significant physical morbidity. Indeed, factors such as renal impairment had almost universally gone unnoticed during the patient’s previous psychiatric and physical treatments.

Most of the patients demonstrated severe self-neglect, which in itself seemed to result in some serious health consequences. Many of them did not appear to have received full physical assessment in the recent past.

This study confirms the need to ensure that physical illness is not overlooked in psychiatric patients 5. OCD patients appear to be particularly prone to renal damage and hyperlipidaemia, which may be related to their tendency to restrict fluids and eat erratically. Further studies examining the physical status of less severely ill patients with OCD are indicated.