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New Treatment Method for Obsessive -Compulsive Disorder
DR. ZAHIR UDDIN AHMAD MBBS, MCPS, DPM, MD, MPH, PHD Dhaka, Bangladesh. dr.zababar01@gmail.com

ABSTRACT A descriptive cross sectional study was conduct to investigate the disease obsessive compulsive disorder as this disease has general reaction and in influence in the society, so huge that the person who is suffering from this condition that the condition that person he/she persists so rigid personality that it drags people to compel his / her idea and compulsion. Obsessive-compulsive disorder (OCD) of course a psychiatric illness but it was found that conventional treatment might not improve the condition as desired. In a recent  personal  study  conducted  at  the outpatient  of Psychiatry department at city hospital and doctors clinic that different medicine with different out skirt of treatment has improved the condition magically. During study 100 people were collected those who already known suffering from (OCD) among this 100 people 80 were female 20 were male. The study period was 3 years from January 1999 to April	2001. The age rate was from 18 years to	54 years These sampled	100 people were divided into 2 groups,50 member in each group. Among	50 people 40,were female, 10 were male. The study finding revealed that 80% responded were female & 20% were male. Among 80 female the religion group was 40 Muslim and 40 Hindu. Among male out of 20, all were Muslim. It is found that Majority of patient who is suffering is female. This clinical study and trial provided that anti epileptic medicine has much more well effect than, The  conventional  medicine. It also proved that Obsessive-Compulsive Disorder in curable by new trial of medicine, which was used only for epileptic seizure.

BACKGROUND OF STUDY The psychiatric illness obsessive-compulsive disorders disease which has influence in the family and society. A number or divorce happened due to this sickness. Due to lot of family conflict the relations remains apart from the patient due to the sickness.The situation  became  further complicated  who  is a boss of a company and is suffering from illness and who has rigid personality and false idea regarding environment which can ruin the life of employees since this condition has bad influence in the community. This study evaluating the effects of conventional medicine and new trial of anti-epileptic medicine has changed effect of the condition and attitude.The overall idea of the study shows that once OCD was known as non-curable disease,  but  this  new  medicine  trial  study  proved  that obsessive-compulsive disorder is curable. This unique study proved that medicines used  for the treatment of epileptic seizure  also can  cure obsessive compulsive disorder. Historically and culturally people to some extent had accepted OCD more easily. They were to show respect bowing of head, or touching the forehead at ground of kissing feet.In other words, people used to show cleanliness taking off shoes before entering the main door of the house, walking barefooted inside kitchen and bedroom.

During feudalism regime, people used to accept this rituals. Now-a-days, these are known as ritualistic or pathological. As rituals have no scientific ground. People used to believe that the was sickness due to influence of evil sprit, therefore, anything to contribute to the sprit that may satisfy him and leave the person, it could be, prayer, money, worship, sacrificing animal even human life. People used to perform all rituals to make happy the evil sprit. From medieval history to  Renaissance every time's people used to think of unknown  fears  and  other  side  of the  darkness. After education  and reforming in culture people started realizing the sickness changes the mood and acceptance of attitude. Therefore, these signs and symptoms of OCD are originated from mind or Psycho-genic origin.Obsessive-compulsive behavior was due to totally on acceptance of environment. The clinical feature  was  depression. To remove these depressive ideas they started changing behavioral pattern from own ideas, which proved thought disorder or undoing or reaction formation Obsessive-compulsive behavior previously treated with psychotherapy, counseling and  medication  of different types,  but total improvement was not availed. After performing Electroencephalogram 	(EEG) in every patient of OCD, it came in conclusion that basically these people are suffering from epilepsy, though they were not watched by people, since it was not grand-mal seizure, people could not see any convulsion of tonic-clonic type or any fit or fall. Without EEG it would very difficult to find out that OCD patients are actually suffering from Epilepsy.

JUSTIFICATION OF THE STUDY A group of patients who were diagnosed suffering from obsessive compulsive disorder and treated with conventional medicine but did not show any clinical improvement.Later on they were collected together for the treatment at out-patient clinic at Urban Hospital in city with different medicine or treatment with other than regular medicine  for treatment  of  OCD. That showed  dramatic changes in their behavior and clinical symptoms, which was a milestone in clinical psychiatry. These patients were very keen to work and were also very much neat and clean which formed habit of repeated washing and cleaning. Ultimately they were' suffering from different skin disease, abdominal discomfort and irritable bowel  syndrome. They also  suffer from  migraine, high  blood pressure and ischemic heart diseases. To understand the association between their idea and thought their behavioral pattern was flourished. Their mental status was very much rigid with strong personalities. It becomes difficult to make them understand that they were really suffering from any sickness or behavioral disorder. Their socioeconomic  status  was   solvent,   regular   and   remarkable. Few investigations were done and conducted health care behavior. This study should be a new era of medical professional study, as well as clinical study in psychiatric field.

Introduction The Obsessive Compulsive Disorder (OCD) is a sickness originates from depression,  suspicion  and  phobia. This type  of  patient  cannot differentiate between the reality and compulsion. Therefore, these people may be controversial to general people and with their rigid  idea and thoughts. They always persist in a fixed idea, biased and preoccupied which make them phobic, panic and obsessive. As for example, when the person suffering from this condition of doubtfulness he/she may not feel easy to enter some body's room or may not use others bathroom. As this person always feels dirt in everything, they feel hesitate to seat someone's beds or seats; or may not use others utensils or towels. When this person suspects that food were not properly cleaned or prepared he/she may not take that food even with request of every one. These people  are  always  suspicious. they may  not  have confidence in anything or any person. The relatives of these people may try to adjust with patient but others may not accept this arrogant attitude. Therefore, this sickness not only suffers alone but the whole family even community. During our study most of the patient were female (80%), therefore, if the patient is a mother, wife or mother-in-law, in that case the husband, the children even the housemates have a disgusting and unhappy life. Since repeated washing is a feature of this disease therefore, most of the patients suffer from skin infection and nail bed ulcer. These people suffer from unknown panic attack; so, they may suffer from nervous diarrhea, acidity and belching and a series of gastrointestinal disorder. They also  suffer from  migraine headache,  hypertension and ischemic  heart  disease. They always try to be  perfect in everything Therefore, they try to remain regular and particular as word of honors.

These people always keep clean everything, including their house, floors, furnishes; utensils must be well polished and shiny. The shoes, clothes, and dress changing places must be separate. Whenever anyone comes to House from outside, must take shower even the minor children, doesn't matter if it is mid-night or winter season. They always try to fulfill their demands either by ordering, shouting or crying. As a result people try to avoid these persons so these people ultimately losses sympathy from relatives and people. Naturally they became isolated and depressed. They become psychic and sometimes try to commit suicide. These people do not want to believe that they are suffering from any psychiatric illness because they are intelligent, perfect, religious and with a strong personality. This disease obsessive-compulsive disorder was known from long time. In Shakespeare, the play of 'Lady Mac Beth' after killing the king the lady used to see blood in her hand and she used to shout 'Blood! Blood! again in my hand' than she to run for washing her hands. This is an example of repeated hand washing is one of the symptoms of obsessive-compulsive disorder. There fore our study is to prove that this disease could be cured completely in a new way of medical trial and treatment.

KEY VARIABLES

Assessment of People those who are suffering from Obsessive-compulsive disorder.

Age of the respondents:

Starts at early age at youth but, could not demonstrate properly before age 18 years.

(i)	Knowledge about the study of environment (ii)	Knowledge about mental development (iii)	Knowledge about nutritional status (iv)	Knowledge about education (v)	Knowledge about immunization (vi)	Knowledge about health (vii)	Knowledge about sanitation (viii) Knowledge about job and responsibility (ix)	Knowledge about deviation, crime and religion (x)	Attitude towards life

Operational Definition used in this study

Age of the respondents The sampled study collected 100 people among then there were different aged people. Those sampled people were showing obsessions, ideas in amilies in which relations bound to bring these people for the treatment. Among the age ratio of these people started from 18 years to 54 years. 18-30 years age group were 10 people, 30-40 age group were 50 people and 40 to 50 years group were 40 people. It was found that middle age group of people are suffering more from this condition. (Rasmussen and Eisen 1998)

Knowledge about the Environment-

Knowledge of Mental Development These people were responsible at work and punctual in their times but their rigid and biased ideas were always keeping them apart from families and friends. In the society people knowingly avoid as they always finds defect and wrong in others work and word. Even though they are matured enough, their rigid personality prohibited their mental development nourishment. (Foa and Kozak 1995)

Knowledge about nutritional status Though these people gather very good knowledge about nutrition but knowingly or unknowingly they avoid certain food habit which can bring some nutritional problems. They have firm believe about some food items, which may produce stomach upset, even those foods are helpful in nutrition but they will always avoid for their rigid attitude. (Ayub and Wanamaker 1996) Knowledge about Immunizations The basic immunizations are complete in their childhood before developing this condition. Some of them have some fantasy about natural healing and spiritual healing. Few of them expressed about herbal healing, homeopathy and religious healing with some ritualistic idea and fantasy. ( Swedo etal. 1998).

Knowledge about Education These people are perfectionist. They are educated; some of them have higher University degree. Most of them were clear about study and educational guidance. Those who did not get chances or opportunity for study, they  also  persist  a  clear  conception  about  education. (W.K. Goodman, SA. Rasmussen 1991)

Knowledge about Health Everyone knew this fundamental knowledge about health. But knowingly they persist different fantasy about health sometimes, which dangerous and injurious to health partly they believe spiritual healing better than regular treatment. Sometimes obsessed patients are filthy, Non-co- operative and non-compromising.(Eisen et.al 	1998)

Knowledge about Sanitation Regarding sanitation they used to act as over reaction. They try to .wash hand clean for simple reason. Which is not necessary always? About sanitation they keep some fear, which may persist and making problems in Neighbors and society. (Kozak and Foa 1994)

Knowledge about Job and Responsibility As this people are perfectionist, they are very much responsible about job and their work. At home these people one always alter and panic so that nothing goes wrong. Over alertness sometimes makes simple mistake due to picky habits.

Knowledge about deviation, crime and religion Deviation not shown in the character of obsessed people. They always try not to get involved in any sort of crime. Some of them have ritualistic idea about religion. Some of them do not follow any religion as they think they are perfect. (Foaa and Kozak 1995)

Attitudes towards life These people are mixed typed persons. They always keeps positive as well as negative attitude in their life.

Positive attitude:

1.	Always responsible 2.	Punctual 3.	Take Risk in life 4.	Maintains Promise and keeps word 5.	Perfectionist 6.	Neat and Clean 7.	Person of Principle 8.	Sexual Deviation absent.

Negative attitude:

1.	Always rigid in thought 2.	Do not believe any one 3.	Lack of confidence, 4.	Unknown fear and panic 5.	Repeated washing 6.	Nervous diarrhea 7.	Skin disease and nail bed ulcer 8.	Ritualistic and fanatic.

Limitation of the Study This is a descriptive type of cross-sectional study. This could reveal the statistically evidence between clinical condition and behavior pattern, knowledge about education, responsibility and health pattern. The findings of they study may not necessarily reflect the entire population of the country because this study was carried out only outpatient sample who attended themselves for their treatment. Those who did not attend the clinic, they were not focused group. If this study could build in comparison group or Control group of people who were no focused, then the effect and relationship could be established. Due to constrains of time the sample size were determined purposely and due to no other researches done or verified in this type of study; therefore could not carryout large scale study.

Hypothesis of OCD The scheme of cortico-striatal circuitry fits well with emerging data implicating the elements of those circuits. Convergent result from neuro- imaging studies indicated hyperactivity of the orbito-frontal cortex.Anterior cingulate cortex and caudate nucleus at rest and attenuation of this abnormalities with effective treatment (Rauch and Baxter,1998). Neuro-psychological studies were consistent with subtle deficits involving front-straital  functions	(Rauch   and   Savage,	1997). Neuro-surgical procedures that interrupted this circuit appeared to reduce OCD symptoms (cosgrove and Rauch, 1995, Mindus et al. 1994). There was also heuristic appeal to the hypothesis that positive feedback loops between the cortex and the thalamus might mediate circular, repetitive thoughts. Whereas striatum might  mediate fixed  action  patterns in the from of repetitive behaviors or compulsions (Baxter et.al. 1990 1992; Insel 1992; Modell et al. 1989; Rauch and Jenike 1993; Rauch et al. 1998). Modell et al. (1989) proposed that a hyperactive caudate nucleus might be cause of net excitation of the thalamus. Baxter et al. (1990) hypothesized  that   the   apparent   hyperactivity   in   caudate   nucleus represented insufficient compensation for intrinsic striatal dysfunction, such that inhibition of the thalamus via the cortico-striato-thalamic collateral was inadequate. As researchers come to appreciate the ramifications of the direct and indirect systems within cortico-straiato-thalamic co-lateral branch, the models evolved.

A revised version suggest that in healthy individuals, an appropriate balance between the direct and the indirect systems enable the co-lateral to optimally modulate activity at the thalamus, whereas in OCD, a shift towards dominance of the direct system could result in excitation or dis- inhibition at the thalamus, thereby overdriving the corticothalamic branch. Insel (1992) provided'a complimentary model of OCD, which focused on the role of orbitofrontal cortex as the primary component of a 'worry circuit'. Thus corticostriatal models of OCD accommodated much of the available data as of 1993, (cummings 1993; Rauch and Jenike, 1993). The striatal  topography  model  has  further  implications  when elaborated via a cognitive neuro-science perspective. One scheme for under standing information  processing,  in the context of learning and memory,  distinguishes  between  explicit  ie,  conscious  and  implicit  ie unconscious operations (Rauch et al. 1995; 1997, AS Reber 1989, 1992, Reber and squire, 1994; schacter and Tulving,1994) Apparently, these  various  information-processing  functions  are performed by distinct and dissociable brain systems. Explicit learning and memory are primarily mediated via dorso-lateral  prefrontal cortex and medial temporal structures, such as hippocampus (schacter et al. 1996). There are several types of implicit learning and memory. Classical Conditioning especially with regard to aversive stimuli is mediated in part by the amygdala. Implicit learning of procedures, skills or stereotyped serial operations is purportedly mediated Via Corticostriatal systems (Mishears and Petri, 1984, Rauch and Savage 1997-2000).

Therefore,if obsessive-compulsive spectrum disorders and fundamentally referable to striatal dysfunction, their phenomenology might best be understood as a consequence of implicit processing deficit (Rauch and savage 2000; Rauch et al. 1998) From the cognitive neuroscience perspective, it is plausible that the intrusive events  that  are the  hallmark  of  OCD and  related disorders represent failures in filtering at the level of the thalamus, attributable to deficient modulation via the cortico-striato-thalamic co-lateral pathway. The information normally  processed  efficiently  via  cortico-striatal  system, outside the conscious domain instead finds access  to explicit processing systems because of striatal dysfunctions.

This theory could explain the cognitive intrusions of OCD and the sensori-motor intrusions of Tourette's disorder or trichotilomania. In fact, imaging studies shown that the striatum is reliably recruited during learning and sequential behavior (Rauch et.al. 1995). Patient with OCD do not show this normal pattern of striatal activation when confronted with an implicit sequence-learning task and instead of show requirement of medial temporal structures typically associated with conscious information processing (Rauch et al. 1997)

Objectives and Hypothesis of the Study

General Objectives The patients who attended the outpatient are mostly city dwellers who in-migrated from rural areas to city as a rapid urbanization effect. Those who had high ambition and expectation may not fulfill their desired goal; as a matter of fact they suffered from depression, insecurity and phobia at different environment and opportunities. To investigate the factors associated with their clinical co-relation and behavioural problems of people who are suffering from OCD and ritualistic attitude, which could minimize by better treatment and medication.

Specific Objectives

Specific objectives are classify that the objectives not only investigate their cause but also knows the history of sickness which originate from internal structure  of  Brain  which  transmit  through  the  or via  neuro- transmitter.

(i)	To demonstrate conventional medicine has less effect (ii)	To assess the nutritional knowledge and nutritional status. (iii)	To examine physically and mentally (iv)	To assess change of characteristics after effect of treatment (v)	To assess their insight and cognitive ideas about their sickness (vi)	To assess the knowledge of relations about the sickness.

Hypothesis

Hypothesis: The Sampled population were total 100 people; they were divided into two groups Group A and Group B. During formation of the grouping it was not biased with age, sex or religion if any disarrangement occur with age or sex were not proportional, it was accidental sampling. They were selected according to their early response at out patient.

Group A was formed with fifty patient and group B were also formed by fifty people. Group A were given treatment with epileptic drugs; Group-B were given treatment with previous conventional medicines. During study period it was observed the after treatment with anti-epileptic drugs for 4-6 weeks, group-A patients were responding better in their symptoms than group B. After the study period (1999 to 2001) it was proved that group A people had 90% cure rate with anti-epileptic drug whereas group B people did not show basic improvement, their cure rate was only 5% Therefore, the study and the hypothesis proved that anti-epileptic drugs has much better and accurate effect in obsessive compulsive disorders because there medicines has better approach, in the midbrain, Para limbic system, hippocampus and cingulated gyrus (Zahir Ahmad 1999 & 2000)

Literature Review Obsessive-compulsive disorder is an intriguing and often debilitating syndrome characterized by the  presence  of two  distinct  phenomena obsession and compulsion.Knowledge of the clinical features of the disorder also has explained significantly in the last 10 years. Treatment centers specializing in OCD have succeeded in enrolling many patients, allowing more sophisticated analysis of phenomenology and co-morbidity and the relation of these variables to treatment outcome. In more recent study, Han touché et al 	(1995) found that 9.2% of 4364 psychiatric out patients had a diagnosis of OCD. And 17% had obsessive-compulsive Symptoms. This higher figure most likely represents a combination of improved recognition by clinicians and increasing numbers of patient coming into treatment. Woman appears to develop OCD highly more frequently than do men. In the DSM-IV field trial, 51% of the 431 subjects OCD were women (Foa and Kozak 1995). In clinic population 55% of 830 subjects with DSM-III OCD evaluated over the past 10 years were women. Patterns of co-morbidity may affect sex ratio. A study that assessed the presence of co-morbidly disorders characterized by Psychosis (Schizophrenia, delusional disorder or psychotic like features) in 475 patients with OCD found a different sex ratio, 56% were women, whereas 85% of those with one of those co-morbid psychotic disorders were men (Eisen and Rasmussen). Ina study of	250 subjects with OCD	43% were never married	52% were married and 5% were divorced (Rasmussen and Eisen	1991). A study comparing marital status in OCD patients with that in matched group of patients with major depression found no significant difference between two groups (Coryell .1981).

Some evidence suggests that age at onset may be significant in terms in familial transmission. In a study that examined the frequency of OCD in first degree relatives of 100 proband with OCD, 82% of the proband reported onset of OCD before age 18 years (Paul et. al 1995) in this study. The rate of OCD and sub threshold OCD among relatives of the proband with onset of OCD proband before age 18 was approximately twice as high as the rate of OCD in relative of OCD problems with the onset. DSM-IV describes the course OCD as typically chronic with some fluctuation in the severity of symptoms over times (American Psychiatric Association 1994). Although terminology and definition vary from study to study. Overall this appears to be supported, both by studies conducted retrospectively and by more recent follow-up and prospective studies. In a cross-sectional follow up study. Thomson 	(1995) interview 	47 patients with OCD aged 6-22 years after they had been treated for OCD as children and compared their characteristics with those of group of non-OCD psychiatric control subjects. All subjects were as least 18 years old at time of follow-up  interview. The majority  of  subjects  had  either  no  OCD symptoms (27.7%) or only sub-clinical OCD (25.5%) at follow-up. Ten subjects (21.3%) had chronic course of OCD. This study also assessed outcome by measuring global Assessment Scale scores (Endicott et al. 1976). Although the difference was not statistically significant, males with childhood onset OCD appeared to have a poorer outcome than did females. 9 of 10 patients with Global Assessment Scale scores below 50 at follow up were males. Obsessions 	(intrusive, inappropriate and disturbing ideas, thoughts, or images) and compulsion (respective behaviours to reduce  anxiety) constitutes the core clinical symptoms of OCD. Description of obsession and compulsion  beginning  with  scrupulosity  and  continuing  into 20th century writing of Janet and Freud as striking consistent with current clinical presentation of OCD.

The obsession categories are aggressive, Sexual, religious, somatic, symmetry, contamination, hoarding and miscellaneous. The compulsive categories are  checking  ordering  and  arranging,  counting,  repeating, cleaning  hoarding  collecting  and  miscellaneous. The most common obsession is fear of contamination followed by pathological doubt somatic obsession and need for symmetry. Contamination obsession are most frequently encountered obsession in OCD, Such obsessions are usually characterized by fear of dirt or germs. Contamination fears also may involve toxins or environmental hazards (eg. asbestos, lead) or bodily waste or secretion. Patient usually describes a feared consequence for contracting to contaminated objects. The content of contamination obsession and the feared consequence commonly changes overtime, eg. a fear of cancer may be replaced by a fear of sexually transmitted diseases. They may worry that they will start a fire because they neglected or forgot to turn off stove before leaving house. Excessive doubt associated feeling of excessive responsibility frequently lead to checking rituals. Patients may spend several hours checking their house before they leave or go to sleep. Patients may adopt several strategies to limit the times they spend checking including counting the number of times they check or involving a family member to observe the checking rituals so that the patient can be reassured later that he / she actually completed the checking task. Somatic obsessions i.e., irrational fears of developing a serious life threatening illness may be seen in OCD. Patient in OCD usually have other past or classic obsession such as checking and reassurance seeking and generally somatic and visceral symptoms of illness.

The coexistence of mood disorder, other anxiety disorders and psychotic symptoms with obsessive-compulsive symptoms were reported early psychiatric literature (Kringlin 1965 Pollitt 1957, Stengel 1945). Depressive symptoms have been most common co-morbid syndrome both in clinical studies completed before 1985 and in more recent studies that assessed co-morbidity more systematically. In our study of 100 patient 62% had a lifetime's history of major depression and 30% current depression. A minor 8% had concurrent onset of obsessive- compulsive symptoms. This co-morbidity also has been assessed by reporting the frequency of anxiety disorder in clinical OCD samples relatively life time social phobia (18%) panic disorder (12% and specific phobia 22%) were reported in sample of 100 patient with primary OCD. This high frequency and current and lifetime anxiety disorder suggests that OCD patients are vulnerable to many types of anxiety. The high prevalence of anxiety states in there patients may be caused by common development and temperamental trails whose phenotypic expression is secondary to share genotypes and psychosocial factors. Particular interest in this regards in the high lifetime’s prevalence of separation anxiety in this group of patient (14%) a finding that also has been well documented in panic disorder (Lipsitz et.al. 1994). Several studies have examined the co-morbidity with Anorexia Nervosa and OCD. 17% of 100 OCD patient were found have lifetime history of eating disorder (Rasmussen and Eisen 1988). Rastam et. al in 1995 also rep6rted a high rate of OCD in 16 years old girls with anorexia nervosa. Several recent studies have examined the frequency of OCD in patient with schizophrenia. Frequencies ranges from 7.8% to 40.5% (Berman et.al. 1995, Eisen et. al. 1997) regardless of this range it seems clear that a sub-group of patient with schizophrenia has co-occurring obsession and compulsions. This obsessive-compulsive schizophrenics tendency to have more chronic course and a greater frequency of social or occupational impairment compared with match sampled of schizophrenic without obsessive-compulsive features.

A study that conducted neuro-psychological testing in two groups of patient with schizophrenia with or without OCD performed that the group with co-morbid OCD formed worse in Visio-spatial skills,  delayed  non-verbal  memory and cognitive shifting abilities cognitive areas of thought to be impaired in OCD (Berman et.al 1998).

Finally co-morbidity between Axis II disorders and OCD has been report. The most commonly encountered personality disorder diagnosis in OCD are dependent, avoidant, passive-aggressive and obsessive-compulsive, schizo-typal, paranoid and border-line personality disorders are found less commonly in OCD but appear to be associated with poor outcome (Baer at al, 1992). The co-morbidity between obsessive compulsive personality disorders and OCD is of particular interest Janet (1904) viewed all obsessional patients as having pre-morbid personality causally related to pathogenesis of the disorder, several studies found that a significant percentage of OCD patients do not have pre-morbid personalities. The classic distinction of compulsions being ego-syntonic as opoosed to ego-dystonic in OCD is useful but no absolute. Some patient with cleaning or hoarding compulsions and  those with need for symmetry  and  precision or obsessive slowness who strive for perfection or completeness find their rituals ego-syntonic until they began to impair social and occupational function. Whether these patients should be classified as having obsessive-compulsive personality disorder or sub threshold OCD to a subject for further empirical study.

Literature Review and Conceptual Framework

Conceptual Framework

Obsessive Compulsive Disorder

Sub-Normal

Demographic Factor (a) Age (b) Sex (c) Marital Status

Knowledge, Attitude & believe (a) Knowledge of awareness (b) Family Concept of transmission (c) Family Communication (d) Attitude to work (e) Joint Family Factor

Cultural Factor (a), Religious Festival (b) Religious Thought (c) Negative Attitude (d) Strict Toilet (e) Phobia of Dirt.

Normal

Socio-Economic Factor (a) Income (b) Education (c) Residence

Reproductive Behavior (a) Fertility Preference (b) Decision (c) Marriage (d) Divorce (e) Sexual Attitude Health Care Factor (a) Antenatal Care (b) Knowledge of Immunization (c) Knowledge Nutrition (d) Maintaining Daily Health Demographic Factor (a)	Age (b)	Sex (c)	Marital Status

1.1	Age at onset : Some evidence suggests that age at onset may be significant in terms of familial transmission. In a study that examined the frequency of OCD in first degree relatives of 100 probands with OCD, 82% of the probands reported onset OCD before age 18( Paul et.al, 1995). In this study the rate of OCD and sub-threshold OCD among relatives of the proband with onset of OCD before age 18 has approximately twice as high as the rate of OCD in relatives of OCD probands with late onset. At age onset of OCD also may be a predictor course. The vast majority of patients endorse having chronic course once OCD occurs. However Swedo and colleague (1998) described a subtype of OCD that begins before pubertyand  is  characterized  by  an  episodic course with intense exacerbation.

1.2	Sex Distribution : Women appear to develop OCD more frequently than do men. In the DSM-IV (American Psychiatric Association in 1994) in field trial 51% of 431 Subjects with OCD were women (Foa and Kozak 1995) A study that assessed the presence of co-morbid disorders characterized by psychosis or psychotic like features found a different sex ratio. Of the OCD patients without one of these co-morbid disorders. 56% were women and 44% were men. Whereas 85% of those other psychiatric disorders were men (Eisen and Rasmussen 1993). In a National Institute of Mental Health Study 70 Subjects with OCD between ages 6 and 18 years, 47 (67%) were males (Leonard et. al. 1989). These findings may be a result of the fact that males develop OCD at a younger age than do females.

1.3	Marital Status	: A study comparing marital status in OCD patients with that in a matched group of patients with major depression found no significant differences between two groups (Coryell 1981). Although marital status was not found to be predictor of course in several follow-up studies. A recent prospective study of 107 subjects with OCD found that being married significantly increased the probability of partial remission, with maried patients more than twice as likely to remit as unmarried ones (Steketee et.al. 1999).

Socio-Economic Factor

(a)	Income (b)	Education (c)	Residence 2.1	Income: OCD patients usually possessing obsession of expectation about earning and standard of living. If otherwise they as expectation may fail to gain achievements properly, they certainly got depressed and maintain a lone some life, avoiding responsibilities of family having ritualistic activity delusion with  preservation  of insight involved to answer them seen appropriate or even bizarre to the patient and clinician. As from background usually they are well off financially and able to live properly whatever they earn of source of income.

2.2	Education : Performing education is one of the positive sign of OCD patients.' Since there patients are very curious and picky. They always try to get and know the whole truth, not half-truth. Therefore the OCD patient always tries to be perfectionist and usually always tries to prove as good student. Most of them try  to  perform  university level. At work they try to remain perfectionist, to somewhat over attentive, and rituals.

However 1% -2% of obsessive-compulsive individuals to have no visible, mental or rituals. For them, ritual prevention is impossible and the only available behavioral technique is extensive exposure using massed practice. Patents need an understanding of OCD, an explanation for how exposure in vivo and ritual prevention can lead to habituation and as out line of general plan of treatment. Clinicians need to learn about the patients experiences with naturalistic exposure and ritual prevention preferences regarding speed of treatment, time available for treatment, effects of anxiety  or  other  discomfort  and  supports while  behavior therapy is proceeding and thoughtful treatment plan caring topics will shorten overall treatment time and improve outcome.

2.3	Residence: Regarding resident of house of OCD patients sometimes known as no mans land, due to ritualistic behaviors about their cleanliness reported working and fixed stereotyped behaviors. As rituals become the chosen way for managing discomfort, patients usually are discomfited by failure of those around them to confirm to their rituals. Ultimately, they may ask others to carry out certain rituals to decrease their discomfort. A patient with concern of contamination may ask family members to take off their shoes before they enter into house, or at least patients living space. If the family acquiesces, the next request may include a distinction between inside clothing's and outside clothing's. Out clothes to  remove  before  entering  inside  the  house. Again on the obsessive-Compulsive rationale diet that contamination may thereby be avoided. The most common kind of ritual is a request for reassurances regarding the risks or behaviors that one thought of OCD individuals. The patient may ask. "Did I lock the door?" to which family members or friends might assure "yes, you locked the door". The patient feels reassured momentarily but soon obsesses and worries allowed and repeat the request  for  reassurance  "Are  you  sure?  I  locked  the  door?". The reassurances repeat many times but only a limited benefit in relieving distress. They may worry and doubt with events as a carelessness. They may worry that there will start a fire because they forgot to turn off the stove before leaving the house. Such patient doubt in their perception so they may come back for checking rituals. Repeated checking, counting and asking unwanted question to the tenants by the house owner makes irritating and annoyed feelings to the OCD patient. As a matter of fact people and neighbors of the person always try to avoid him and inadvertently harmed particular person without knowing that this patient is suffering from aggressive obsession.

Knowledge, Attitude & believe

(a)	Knowledge of awareness (b)	Family Concept of Transmission (c)	Family Communication (d)	Attitude to work (e)	Joint Family Factor

3.1	Knowledge of Awareness: Over the past decades, several studies on course of illness in childhood onset OCD have been conducted in which a prospective design was assessed. In one study all students in a high school were screened for the presence of obsessions and compulsions fifty-nine of 5,596 high school students screened were identified as h.aving OCD, Sub-clinical OCD, other psychiatric disorder with obsessive-compulsive symptoms or obsessive- compulsives personality disorder (Filament et.al 1985). These teenagers  were  re-interviewed 	2  years  after  the  initial interview by rates blind to the baseline diagnosis (Berg et.al., 1989) of the 12 subjects with initial diagnosis of OCD, 	5 (42%) still met full criteria for OCD. Those subjects with initial diagnosis of OCD baseline and sub-clinical OCD at 2 years interview (8%)  might be 'analogous to the subjects described in other studies as being much improved or partial remission. only one subject with an initial diagnosis of OCD had no diagnosis after 2 years. Of interest is the development of psychiatric symptoms in the 	15 students with sub clinical OCD at baseline, at follow-up 27% met full criteria for OCD, 27% continued to have sub-clinical OCD, 27% developed other psychiatric disorders with obsessive compulsive features and only one subject had no diagnosis.

3.2	Family Concept of Transmission: To the extent of OCD has a genetic origin it is foreseeable at the gene or genes responsible for conferring increased risk ultimately will be identified and fully characterized.

Few twin studies of OCD and related disorders have been done. Inouye (1965) reported obsessive compulsive symptoms concordances rates of 80% (4 of 110) in mono zygotic twin pairs compared with 50% ( 2 of 4) in dizygotic twin pairs :.Carey and Gottsman (1981) reported rates of 87% (13 of 15) and 47% (7 of 15) respectively. More recently Pauls and colleagues 1995 performed several exemplary family genetics studies of OCD & tourette disorder. In 1995 they compared prevalence rates in first degree relatives of OCD probands with rates in first degree relatives of psychiatrically normal control subjects; significant differences were formed with respect to OCD (10.3% Vs 1.9%) sub-threshold OCD (7.9%-Vs 2.0%) OCD plus sub-threshold OCD 14.2% Vs 4.0%) and ties(4,6% Vs 1.0%).

The current data suggest that the risk of developing OCD in often inherited. Specifically, there appear to be at least two familial forms of OCD-One that is characterized by an early age at onset and associations with chronic tic disorders and one that is not tic related (Also brook and pauls 1997, Paul et. al. 1995) Thus pathogenic models of OCD and related disorders must account for an inherited compound together with epigenetic influences on expression. Pathogenic models should explain the spectrums of clinical presentation in terms of both phenomenology and treatment response.

3.3	Family Communication : Family Communication  with   OCD  patient  most  of  times  is negativistic attitude from patient's side. Patients' suffering from OCD has no clear-cut mission & vision. Therefore they try to remain preoccupied most of the period. Most adults and children with .OCD have multiple obsessions and compulsions over time, with particular fear or concern dominating the clinical picture at any time. Patients who appear to have obsession alone frequently  who   have   reassurance   rituals  or  unrecognized  mental compulsion  such  as  repetitive,  ritualized praying  in addition to their obsession. Patients describe an urged to repeat motor acts until they achieve a just-right feeling that the act has been completed perfectly. These patients can be divided into two groups: I) Those with primary magical thinking and 2) Those with primary obsessive slowness. Individuals with primary magical thinking reports obsess ional worries about feared consequence to their loved ones. They perform certain ordering and arranging compulsion to prevent harm to loved ones from other family members. Which could give miscommunication from other family members. That is one of reason that the OCD patients do not have good family communication and interaction from other members in family.

3.4	Attitude to work : The patients suffering from OCD one very much choose and fusty about their work. People from different age group show attentiveness and sincerity about their duties. But too much demanding from others regarding perfection according to their choice. Very much demanding  and  commanding rituals with obsessive attitude very soon makes them unpopular to the working place and among colleagues, but the patients need an understanding of OCD, an explanation for how exposure in vivo and ritual prevention can lead to habituation. The surroundings need to know about patient's experiences with naturalistic exposure and ritual prevention, preferences regarding need of treatment.

Patients can be helped to understand that exposure and rituals prevention need not fully occupy the time that they have allocated to the task. Thus a patient could touch a contaminated doorknob. Which triggers a compulsion to wash but resist the urge to carry out the rituals for an hour or longer, while carrying on other activities. It is important that the individual does not use the activities to distract him or her form discomfort initiated by exposure because this would be a firm of avoidance. Patients suffering from OCD maintain behavioral rituals not to prove they one perfect but they always suffer from unknown fear of mistake and sin, which urges than to perform ritualistic pattern of behaviors.

3.5	Joint Family Factor : OCD patients at joint family remains isolated and preoccupied which hampers social interaction. Interest in the role of insight in OCD patients has been  increasing  over  the  past 5  years. Traditionally of  the senselessness or un-reasonableness of obsessions has been generally accepted as fundamental to the diagnosis of OCD. Numerous descriptions of OCD who are completely convince the reasonableness of their disease and need to perform compulsion, have appeared in literature and they should appear in front of psychiatrist to discuss and get solution of this condition  and  take  treatment  properly. In a joint family or  in joint collaboration. People suffering from OCD had excess fear of humiliation and de-socialization from family. Which could be one of the reason, they refused to treatment and involved in ritualistic behaviors. In follow-up studies course of illness has been evaluated with different criteria form previous and earlier studies. Patients were retrospectively assigned to 'continuous' Waxing and waning' detoriative and episodic with full remissions between episode categories. (Rasmussen and Tsuang 1986).

Reproductive Behavior (a)	Fertility Preference (b)	Decision (c)	Marriage (d)	Divorce (e)	Sexual Attitude

4.1	Fertility Preference OCD patients usually much worried about in ability of or not to become pregnant. Doubt and confusion may arise it could not become pregnant within a your after marriage. The patient may become suspicious about the activity of husband and may easily doubtful at any work or promises of husband)' patient may even think that her fertility period may have ended after meeting with unfertile man. These patients may think of ritual practices  to  develop  fertility,  taking  different foods,  or fruits, maintaining different worship and behaving strange posture and gesture.

OCD patients may develop both positive and negative attitude to sexual practice and fertility. Some patients developed ritualistic in sex practice and idea of increased fertility and conception. Some of them reported interrupted coitus and some buccal coitus. Some believe that final discharge should be rectal coitus.

West Africans Yoruba tribal people believe that women must get pregnant before their marriage. Hence they go for fertility test; as the girl, became pregnant, social culture confirmed that she is a fertile girl, therefore she can get married.

4.2	Attitude for Decision : OCD is a disorder with some migration of symptoms and signs example from   obsession   about   contamination   of  the  doubt  and correspondingly from washing rituals and cleaning to checking. This normal variability of OCD should not be seen as failure of behavior therapy but rather as an occasion for extension of behavior therapy techniques i.e. from washing to checking rituals.

At times of increased situational stress and sometimes without obvious reason,  obsession  and  corresponding  rituals  may  increase transiently. These lapses as (Foa 1994) has called them, should alert the patient to a need for great structure and systematic applications of behavior therapy to regain control. Often, no therapist intervention is needed. Relapses however, with a return toward baseline levels of severity of obsessions discomfort and rituals suggest a need for therapist evaluation to assess for factors that may explain the loss of benefit. Finally planned, booster, treatments, improvement, long-term out come in one study (Foa 1994).

4.3	Attitude to Marriage : The patient suffering from OCD before marriage they try to avoid marital bonding, or afraid of responsibility after marriage. As avoidance disorder they even do not want to keep any firm or cordial relation and sincerity with opposite sex. Once married their conjugal life sometimes disrupted with partners idea, which may turn them into ritualistic behavior. But patient with OCD found that being married significantly increased the probability of partial remission, with married patients more than twice as likely to remit as unmarried ones (steketee et. al. 1999).

4.4	Attitude to Divorce : Patients who have been suffering from OCD they always resists any new ideas from patients and may not want to remain separate as they basically suffering from phobia and panic disorder. On the other side due rigid attitude and fixed ideas the spouses may not like to attitude and behavior of OCD patients or may not like to stay together, They readily get divorce from partners. Though they remain submissive about divorce, the divorce rate among OCD patient are less in number than other peoples who are suffering from other psychiatric illness (weissman et. al. 1994).

4.5	Sexual attitudes: Patients with sexual or aggressive obsession are plagued by fears that they might commit a sexually unacceptable act, such as molestation, or harm others. They after fear not only that they will commit a dreadful act in the future but also they have already committed such an act. Patients usually are horrified by the content of obsession and are reluctant to divulge them. Patients with these highly obsession frequently have checking and confession or reassurance rituals. They may report them selves to the police or repeatedly seek out priests to confess their imagined crimes. Patients also may use extensive avoidance to prevent obsession eg. removing  all sharp implements such as scissors and knives, from the house or avoiding all television programs with references to violence, such as news about killing.

Cultural Factor

(a)	Religious Festival (b)	Religious Thought (c)	Negative attitude (d)	Strict Toilet (e)	Phobia of Dirt.

5.1	Religious Festival: The patients suffering from OCD has few ritual behaviors which term's them cultural figure. During Ramadan people  usually fast and remain involved in religious programs. OCD patient instead of performing regular prayer, they may avoid these programs or they show their own self- style programs. Instead of listening religious services, they react with ritualistic behaviors. Which may disturb others. During Bengali New year's day, OCD patient may find this program has no scientific basis and try to shout and giving controversial ideas what people do not accept. During language day, which is one of root of cultural festival, instead of participating the program they try to suggest alternate program. In religious  program,  without  maintaining  the  quorum,  making features  of  ritualistic  behavior. As it  is  very difficult to make them understand with reassurance repeatedly More recently patients were asked if they feared consequences others then anxiety if they did not perform their compulsions. Fifty eight percent believed that harmful consequences would occur. The degree of certainty that their obsessions were reasonable ranged across the entire spectrum of insight; most were uncertain whether they needed to perform their compulsions to avoid ham. (Foa & Kozak 1995). DSM-IV established a new OCD specifier. "When for most of the time during current episode, the individual does not recognize that the obsessions or compulsions are . excessive or unreasonable".

5.2	Religious Thought and attitude: Individuals with OCD often hide their rituals because they know that others would find them unusual or even bizarre. hey tell themselves repeatedly that their rituals are incorrect but con not turn their attention from them. People suffering from OCD may show shoes to unseen objects or paying respect to trees or stones. Which is associated their cognitive dysfunction. Cognitive therapies aimed changing faulty cognition about risk and responsibility seen logical, but most studies have not found them effective (James and blackburn 1995). A patient with concerns about contamination with animals or people may ask other family members to take off their shoes as they enter in the house and at patients living space, and next request may include a distinction between 'outside' and 'inside' clothing's so that no contamination as it' violates the religious ideas thought and places.

5.3	Negative Attitude production: During study period only 3 person (3%) refused to take issues, i.e. the children and so, there will be no disturbance as the children may hamper their peaceful life. They were married with good under standing with partners but no issue.

Regarding their sexual practice also said very little interest in sexual act; OCD patents are very busy regarding cleanliness. They had to clean after sexual act, means washing all clothing even beddings. Therefore some patients even may participate in sexual act inside their bathroom, so that their sexual residues do not drop in bed, so that droppings easily that could be washed & cleaned instead of washing bed sleets and clothing, Negativistic attitude do not only effect in sexual life but it influences personality, so that these people change in the behavioral practice.

5.4	Strict Toilet Behavior: OCD patient demonstrate few somatic compl6ints, IBS is one of the main complaints. They are always preoccupied about their bowel habit & stool formation. Always complaints of consistent of stool are either slippery or Greasy or marble shaped. OCD patient mainly visit to gastrointestinal specialist frequently that's why G.I. tract specialist have very good practices of somatic patient. The out come results poor but the purpose of visiting is very rich (Husain et.al 1993) Patients with IBS also complaints of belching, barbing, distension, and nervous diarrhea. Always complaining always showing samples in public the consistency of stool and narrating type of bowel movements. Patients were retrospectively assigned to "continuous" "waxing and waning" detoriative, and episodic with full remission between episodes categories (Rassmussan and Tsuang 1996). Most of the patient 44 (84%) described as chronic or continuous 6 subjects (14%) had a detonating course only 1 (2%) had on episodic course. The average duration of illness was more than 15 years even it can run 30 years (Rasmussin and Eisan 1998). Patient of OCD usually refuse to use others toilet as a fear of contamination and  dirt contracting  a  contaminated  object (Spreading disease  or contract  illness  like  S.T.D  or AIDS). The content of the contamination obsession and the feared consequences commonly charges in time, a fear of cancer may replace by fear of AIDS.

5.5	Phobia of Dirt. Contamination obsessions or Dirt Phobia are the most frequently encountered obsession in OCD. Such obsession usually characterized by fear of dirt or germs. Contamination fears also may involve toxins or environmental hazards, dust, fumes, asbestos or lead or bodily waste or secretions. Patients  usually   described  feared   consequences  from contracting contaminated objects eg. Contracting fear is occasionally based not on fear of disease but on fear of sensory experience of not being clean.

Health Care Factor

(a)	Antenatal Care (b)	Knowledge of Immunization (c)	Knowledge Nutrition (d)	Maintaining Daily Health

6.1	Antenatal Care Somatic obsessions  i.e.  the  irrational  and  persistent fears  of developing a serious life threatening illness may be seen in variety of disorder in the patient of OCD, hypochondriac, panic disorder etc. Unknown fear or phobia can cause multiple system involvement when  a  person  become pregnant and  if that subject is daughter or daughter-in-law of on OCD patient, they start to believe many rituals and fantasy   of pregnancy and became to much conscious  about particular subject who needs antenatal care. The clinician may ever feel nervous due to undue worry ness and useless questions regarding the antenatal care. Patient Suffering  from  OCD  may  try  to  dictate  physician  for unnecessary investigation or may refuse to follow the medical instruction. They also may ask the doctor not to go for operation or not necessary for any medication. They may even suggest some prayer or fantasy will heal the critical condition.

6.2	Knowledge of Immunization The knowledge of immunization persists among OCD patient. Since they were immunized at the childhood. But when their won children are going for immunization they easily reach to any inoculation phobic idea may come as pain, injury or fever of the child. Due to fear they may resists before inoculation or may create some disturbing situation at clinic where the program being done. Though OCD patients have knowledge about this inoculation but due to fear they may not take anything easily. Fear of infection, fear of dirt and ideas of pollution may create such phobias. Patients need to understand this OCD an explanation for how exposure in vivo and ritual prevention can lead to habituation and an out line of general plan treatment. Rituals evolve to control discomfort after exposure to triggers for example patients can write down on cards specific things that they can say themselves such as "This distress is uncomfortable but not unbearable and it will diminish if I continue exposure without giving in to my rituals". " When discomfort mounts during exposure and ritual prevention. I will try to heighten it further by repeating the exposure".

Coping tactics should be individualized, but always have a good of maintaining exposure and ritual prevention until habituation occurs.

6.3	Knowledge of Nutrition:

The patients with OCD are perfectionists, sinc	-good knowledge about nutrition. Their theoretical knowledge is rich. But these people always have fixed idea about some element of food, which they may think harmful. They will try to find out that element from everything and every food are harmful, but which is really healthy item of food. Researcher found that Soya protein milk was very helpful and nutritious for those children who can not tolerate normal milk or milk product. But the mother who is OCD patient will never give that food to the child, as smell of Soya protein milk may be uneasy to the mother. That why knowingly the OCD. patients make mistake due to their rituals and false fixed believe. But during desensitization therapy, patients often can be helpful to understand this by simple analogy, if one is remove adhesive tape from one's body,  it can  be taken  off one  or all  at once. Discomfort is approximately same but choice is up to the person. The essential element is to engage in exposure, then to reduce and eliminate rituals that decrease the discomfort and fear. The most target triggers and corresponding goals must be dealt with directly by exposure and ritual prevention.

6.4	Maintaining Daily health: The OCD  patients  sometimes  biased  and  rigid  about  daily cleanliness and showers. Many occasion OCD patients pass maximum their time in bathrooms Initially they will start cleaning the bathroom doors, windows, walls, the water faucet, bathtub, basin, commode, before taking shower. After shower they try to come out of the bathroom, without touching or holding any thing even clothing or towels. They usually enter bathroom nude and also come out nakedly. If any wall or door touches their body they will again go to shower and start again the same old compulsion.

Sometimes they intentionally stop brushing teeth everyday as well as stop taking shower even on very hot day.

Therefore, daily healthcare may not be done by OCD patients. They may occasionally declare that clothing are not properly washed in Dry cleaners, so they want to wash themselves again. But very bitterly, all those clothes may be found under the bed or corner of room, They some times maintain some rituals that washing hand and face after taking some which food should not be done, it become very difficult to make them understand even with behavior therapy. Rituals, evolve to control discomfort after exposure to triggers, and ritual prevention removes this source of solace. From Janet's time it has been widely agreed that therapist serves and guide or coach. Therapists must assists the patient by encouraging the modeling the exposure and ritual prevention (Van Bolkom et.al 1994).

Research Methodology

Study Design :

The study design was cross sectional descriptive type of study.

Sample Size : 100 patient were included who were already diagnosed suffering from obsessive compulsive disorder.

1.	The availability of resource 2.	The requirement of proposed plan and plan of analysis.

Duration of Study The study was conducted for the period of 3 years from mid 1999 to 2001 at outpatient clinic in urban Hospital and Doctors office at private practice. For the sake of convenience a work schedule was prepared and task were accomplished accordingly.

Sampling Technique / Sampling Method: Purposive sampling method was used for data collection from certain age group who are living almost same environment. Total number of patient age (18-50) years interviewed, examined and treatment served. Informed consent was taken from each patient about the study and medicine to be applied. These patients were also reassured  that if any reaction or damage happens to them during the procedure, the drugs will be withdrawn immediately and they will be compensated due to any damage.Freedom of withdrawal paper or Inform consent was taken from each patient before providing prescription.

Data collection procedure Those patients who were voluntarily gave consent for the application of new medicine, They were also  given freedoM of choice of ,withdrawal of this medicine and procedure if they want to withdraw   any time during the study period. Data collection tools :

1.	Structured Prescribed Questionnaire to collect information

2.	History of biased and rigid personality

3. .	History of socially isolated ritual-habits.

4.	History of adjustment disorder in family and work.

5.	Presence of physical problems.

Place of Study : In out patient psychiatric clinic at Urban Hospital and also who attended private Doctor's Office for their voluntary participation escorted and monitoring by relatives.

Data analysis plan:

1.	Data analyzed, finding processed any prepared for dissemination.

2.	Recommendation alone through table formation during and after

study / treatment period.

Results and Observations This prospective study was conducted in the selected hospital of Dhaka city and also the patients attended the with private practice in Doctor's office. A total of 100 patients were studied. Among them 50 patients were treated by anti-epileptic drugs and the rest were treated by conventional drugs.

Table 1: Age and sex distribution of the patients

Age in	Sex	Total	P years	Male	Female	value No. %	No. %	No. <20	0	0.0	11	13.8	11	11.0 20-29	0	0.0	22	27.5	22	22.0 30--39	1	5.0	15	18.8	16	16.0 40-49	5	25.0	14	17.5	19	19.0 50+	14	70.0	18	22.5	32	32.0 Total	20	100.0	80	100.0	100	100.0 Mean±SD	51.21-6.6	36.21-12.9	39.21-13.3	0.001 Range	30.1-55.3	17.8-55.3	17.8-55.3

p value reached from un paired student's t test The mean age of the patients was 39.2±13.3 years. The mean age of the male was 51.2±6.6 years and the female was 36.2±12.9 years. Analysis revealed a statistically significant mean age difference between male and female patients (p<0.001). It was found that the proportion of patients with age 50 years were in male patients (70.0%) whereas the proportion of higher aged female patients were higher in the age range of 20-29 years (27.5%).

Table 2: Age distribution of the patients Age in	Study patients	Total years	Group A	Group B	value No. No. No. <20	4	8.0	7	14.0	11	11.0 20-29	7	14.0	15	30.0	22	22.0 30--39	7	14.0	9	18.0	16	16.0 40-49	14	28.0	5	10.0	19	19.0 50+	18	36.0	14	28.0	32	32.0 Total	50	100.0	50	100.0	100	100.0 Mean±SD	41.9112.2	36.5±13.9	39.2±13.3	0.004 Range	17.8-55.3	18.7-55.3	17.8-55,3

N.B. Group A: Patients treated by anti-epileptic drugs Group B: Patients treated by conventional drugs p value reached from un paired student's t test The mean age of the group A patients was 41.9±12.2 years and group B patients was 36.5±13.9 years  and  the  mean  difference was  statistically  significant (p<0.05). Among group A patients, highest percentage were in the age group 50 years and above (36.0%) followed by 40-49 years (28.0%), whereas among the group B patients, highest percentage were in the age group 20-29 years (30.0%) followed by 50 years and above (28.0%). It was found that among group A patients, 80.0% were Muslim and 20.0% were Hindu, whereas among the group B patients, 62.0% were Hindu and 38.0% were Muslim and the difference was statistically significant (p<0.001).

Table	3:	Distribution  of   the   patients   by   socio-demographic characteristics Variables 	Study patients Group A (n=50)  Group B (n=50) No. % 	No. % Religion Muslim 	40 	80.0 	19 	38.0 Hindu 	10 	20.0 	31 	62.0 Marital status Married 	29 	58.0 	13 	26.0 Unmarried 	9 	18.0 	11 	22.0 Divorcee-	12 	24.0 	26 	52.0 widow Residence Urban 	32 	64.0 	25 	50.0 Rural 	18 	36.0 	25 	50.0 Education Primary 	12 	24.0 	12 	24.0 Secondary 	15 	30.0 	16 	32.0 University 	23 	46.0 	22 	44.0 Occupation No Job 	21 	42.0 	3 	6.0 Sex worker 	3 	6.0 	24 	48.0 Non-specific 	26 	52.0 	23 	46.0 Father's education Illiterate 	10 	20.0 	6 	12.0 Primary 	6 	12.0 	11 	22.0 Total(N=100) 	value          No.

59 	       59.0 	        0.001; 41 	        41.0 	        df=1 42 	       42.0 	        0.003; 20 	        20.0 	         df=2 38 	       38.0 57 	        57.0 	        0.157; 43 	        43.0 	        df=1 24 	       24.0 	        0.973; 31 	        31.0 	        df=2 45 	       45.0 24 	        24.0 	        0.001 27 	        27.0 49 	        49.0 16 	        16.0 	        0.289 17 	        17.0 	        df=2 Secondary and above 34 	       68.0 	        33 66.0 	        67 	        67.0

Mother's education- Illiterate Primary Secondary and above 25 	50.0 	18 13 	26.0 	17 12 	24.0 	15 36.0 	43 	43.0 	0.367; 34.0 	30 	30.0 	df=2 30.0 	27 	27.0 Father's occupation Dead	39	78.0	29	58.0	68	68.0	0.046; Retired	8	16.0	19	38.0	27	27.0	df=2 No Job	3	6.0	2	4.0	5	5.0 Mother's occupation Dead	30	60.0	23	46.0	53	53.0	0.026; House wife	18	36.0	16	32.0	34	34.0	df=2 Dependent	2	4.0	11	22.0	13	13.0

Among the group A patients, 80.0% were Muslim and 20.0% were non-Muslim whereas among the group B patients, 38.0% were Muslim and 62.0% were non- Muslim and the difference was statistically significant (p<0.001) indicating the proportion of Muslim patients were higher among the group A patients compared to group B patients. No statistically significant difference was found between two groups of patients in terms of level of education residence (p>0.05), however, the proportion of patients with urban background was higher among the group A patients (64.0%) compared to group B patients (50.0%). But statistically significant difference was found between two groups of patients in terms of marital status and occupation (p<0.05) indicating the proportion of divorce/widow was higher in group B  patients (52.0%)  compared  to  group A patients (24.0%)  whereas proportion of married patients was higher in group A (58.0%) compared to group B patients (26.0%). In terms of occupation of the patient, unemployed was higher in group A patients (42.0%) compared to group B (6.0%), but the proportion of sex. worker was higher in group B patients (48.0%) compared to group A patients (6.0%). Analysis found that no statistically significant  difference was found between two groups of patients in terms of parental education (p>0.05). But significant difference was found between two groups of patients in terms of parental occupation (p<0.05) indicating the proportion of parental death (78.0%) was higher in group A patients, but the proportion of retired father was higher in group B patients (38.0%). It was also observed that the proportion of dependent mother was higher among the group B patients (22.0%) compared to group A patients (4.0%). But the maternal death was higher among the group A patients (60.0%) than the group B patients (46.0%).

Table 4: Distribution of the patients by personal history of disease and its treatment

Variables	Study patients	Total(N=100	p Group A	Group B(n=50)	)	value (n=50) No. %	No. %	No. Complaints Phobia of dirt	21	.42.0	12	24.0	33	33.0	0.051. Strict toilet 23	46.0	35	70.0	58	58.0 habit Phobia of food	6	12.0	3	6.0	9	9.0 Duration of complaints One to five yrs	29	58.0	28	56.0	57	57.0	0.839 Five to fifteen 21	42.0	22	44.0	43	43.0 yrs Previous treatment Spiritual healer	22	44.0	24	48.0	46	46.0	0.686 General 20	40.0	16	32.0	36	36.0 practitioner Medicine 8	'	16.0	10	20.0	18	18.0 specialist Previous cure Much improved	1	2.0	0	0.0	1	1.0	0.475 Slight improved	1	2.0	0	0.0	1	1.0 No 48	96.0	50	100.0	98	98.0 improvement

Analysis revealed that no statistically significant difference was found between two groUps of patients in terms of complaints,  duration of complaints,  previous treatment and previous cure (p>0.05). However, the proportion of street toilet habit was higher in group A patients (70.0%) than group A patients (46.0%), but phobia to dirt (42.0%) and phobia to food (12.0%) was higher in group A patients than the group B patients. About half (46.0%) of the patients got treatment from spiritual healer followed by general practitioner (36.0%) and medicine specialist (18.0%). Regarding the improvement from disease, 98.0% had no history of improvement from disease.

Table 5: Distribution of the patients by knowledge, attitude and beliefs

Variables	Study patients	Total Group A	Group B(n=50)	(N=100)	value (n=50)

Social interaction Very good	5	10.0	0	.0	5	5.0	0.011 Reluctant	19	38.0	31	62.0	50	50.0 Suspicious	26	52.0	19	38.0	45	45.0 Communication with family member Good	11	22.0	1	2.0	12	12.0	0.001 Non-co-	14	28.0	7	14.0	21	21.0 operative Suspicious	25	50.0	42	84.0	67	67.0 Attitude to figure Good	1	2.0	0	0.0	1	1.0	0.945 Neglected	15	30.0	15	30.0	30	30.0 Suspicious	33	66.0	35	70.0	68	68.0 Others	1	2.0	0	0.0	1	1.0

Above table shows the percentage distribution of knowledge, attitude and beliefs of social. interaction, communication and attitude to figures of his or her own. It was found that the proportion of suspicious behavior was higher in group A patients (52.0%) compared to group B patients (38.0%), whereas the reluctant social interaction was higher among the group B patients (62.0%) than the group A patients (38.0%) and the difference was statistically significant (p<0.001). Similarly, group communication with family members were found among group A patients (22.0%) whereas suspicious communication was observed among group B patients and the difference was statistically significant (p<0.001). No statistically significant difference between two groups of patients (p>0.05), the proportion of suspicious attitude was higher in group B patients (70.0%) compared to group A patients (66.0%).

Table 6: Distribution of the patients by reproductive behavior

Variables	Study patients	Total(N=100	p Group A	Group B(n=50)	value (n=50) No	No.	No. Attitude of marriage Good & happy	6	12.0	2	4.0	8	8.0	0.009 Unhappy	16	32.0	9	18.0	25	25.0 Paranoid	23	46.0	39	78.0	62	62.0 Depressed	1	2.0	0	0.0	1	1.0 Widow	3	6.0	0	0.0	3	3.0 Unmarried	1	2.0	0	0.0	1	1.0 Attitude to sex Good & co-	0.001 7	14.0	4	8.0	'	11	11.0 operative Non- 19	38.0	3	6.0	22	22.0 cooperative Paranoid	19	38.0	16	32.0	35	35.0 Widow	2	4.0	0	0.0	2	2.0	- On payment	3	6.0	23	46.0	26	26.0 Excess sex	0	0.0	3	6.0	3	3.0 Homo sex	0	.0	1	2.0	1	1.0 Attitude to pregnancy Co-operative	3	6.0	1	2.0	4	4.0	0.001 Negative	13	26.0	39	78.0	52	52.0 Suspicious	21	42.0	10	20.0	31	31.0 Unmarried	10	20.0	0	0.0	10	10.0 Widow	2	4.0	0	0.0	2	2.0 Menopause	1	2.0	0	0.0	1	1.0

Regarding the attitude towards the reproductive behavior, statistically significant difference was found between two groups of patients (p<0.001) in terms of attitude towards marriage, attitude to sex and attitude to pregnancy. Analysis indicated that  happy  attitude was  noted  among  group A patients (12.0%) compared to group B patients (4.0%), on the contrary, paranoid attitude was observed in group B patients (78.0%). Similarly, good and cooperative (14.0%) sexual attitude was observed among group A patients (8.0%) than the group B patients. It was also noted that cooperative attitude was observed to become pregnant among group A patients (6.0%) whereas negative attitude was observed among group. B patients (78.0%).

Table 7: Distribution of the patients by cultural factors Variables 	Study patients Group A 	Group 13(n=50) (n=50) No. % 	No. % Attitude to religion Co-operative 	4 	8.0 	0 	.0 Reluctant 	35 	70.0 	46 	92.0 Suspicious 	11 	22.0 	4 	8.0 Attitude to others Co-operative 	0 	0.0 	1 	2.0 Reluctant 	26 	52.0 	31 	62.0 Suspicious 	24 	48.0 	18 	36.0 Attitude to toilet May use Total(N=100 	p value

No.

4 	4.0 	0.012 81 	81.0 15 	15.0

1 	1.0 	0.224 57 	57.0 42 	42.0

0 001 common toilet Personal toilet only Refuse to use unknown toilet Attitude to bathing Many times a day Once daily Once weekly 3 	6.0 	23 30 	60.0 	22

17 	34.0 	5

6 	12.0 	21 22 	44.0 	25 22 	44.0 	4 46.0 	26 	26.0 	' 44.0 	52 	52.0

10.0 	22 	22.0

42.0 	27 	27.0 	"01 50.0 	47 	47.0 8.0 	26 	26.0 Attitude to environment Very sensitive Tolerable Very much choose Asking help Yes No 11 	22.0 	6 18 	36.0 	24 21 	42.0 	20

48 	96.0 	34 2 	4.0 	16 12.0 	17 	17.0 	0.308 48.0 	42 	42.0 40.0 	41 	41.0

68.0 	82 	82.0 	0.001 32.0 	18 	18.0 Attitude to relations Friendly	4	8.0	4	8.0	8	8.0	0.016 Suspicious	9	18.0	0	0.0	9	9.0 Paranoid	34	68.0	46	92.0	80	80.0 Others	3	6.0	0	0.0	3	3.0 Attitude to visitors Friendly	9	18.0	4	8.0	13	13,0	0.239 Suspicious	12	24.0	10	20.0	22	22.0 Paranoid	27	54.0	36	72.0	63	63.0 Others	2	4.0	0	0.0	2	2.0

Regarding the cultural factors of the studied patients, no statistically significant difference was found between two groups of patients in terms of attitude towards others, attitude to environment, attitude towards visitors (p>0.05), but statistically significant difference was found between two groups of patients in terms of attitude towards use of toilet, attitude to bathing, asking help from others and attitude to relations (p<0.05). This indicated that cooperative attitude was more among the group A patients whereas reluctant attitude was higher among the group B patients (92.0%). The proportion of use of personal toilet was higher among the group A patients (60.0%) than the group B patients (44.0%), but use of common toilet was higher among the group B patients (46.0%). Analysis indicated that the proportion of number of bathing was more among the group B patients (42.0%) than the group A patients (12.0%). It was also noted that the asking help from others were more among the group A patients (96.0%) compared to group B patients (68.0%). The proportion of suspicious attitude was higher among the group A patients (18.0%) whereas the paranoid attitude was higher among the group B patients (92.0%) compared to group A patients (68.0%).

Table 8: Distribution of the patients by health care factors Variables

Attitude to health Co-operative Avoid medical help Selective only Attitude to food Co-operative Selective only Self prepared only Study patients Group A (n=50)  Group B(n=50) No. % 	No. %

0 	0.0 	1 	2.0 25 	50.0 	12 	24.0 25 	50.0 	37 	74.0

0 	0.0 	1 	2.0 34 	68.0 	43 	86.0 16 	32.0 	6 	12.0 Total(N=100) 	p value No.

1 	1.0 	0.013 37 	37.0 62 	62.0

1 	1.0 	0.015 77 	77.0 22 	22.0 Knowledge of nutrition Very good	7	14.0	4	8.0	11	11.0	0.621 Moderate	11	22.0	11	22.0	22	22.0 Selective	21	42.0	25	50.0	46	46.0 Others	11	22.0	10	20.0	21	21.0 Knowledge of sickness (OCD) Clear	4	8.0	4	8.0	8	8.0	0.028 Cloudy	21	42.0	9  '	18.0	30	30.0 Biased	25	50,0	37	74.0	62	62.0 Knowledge of physical fitness Clear	2	4.0	0	0.0	2	2.0	0.002 Cloudy	32	64.0	46	92.0	78	78.0 Biased	16	32.0	4	8.0	20	20.0 Mental status Clear	4	8.0	0	0.0	4	4.0	0.004 Cloudy	38	76.0	29	58.0	67	67.0 Biased	8	16,0	21	42.0	29	29.0 Cognitive ideas Clear	5	10.0	0	0.0. 5	5.0	0.001 Cloudy	30	60.0	17	34.0	47	47.0 Biased	12	24.0	31	62.0	43	43.0 Others	3	6.0	2	4.0	5	5.0 Attitude to sanitation Very good	1	2.0	0	0.0	1	1.0	0.086 Care-less	21	42.0	35	70.0	56	56.0 Self confined	28	56.0	15	30.0	43	43.0 Attitude to immunization Co-operative	2	4.0	0	0.0	2	2.0	0.475 Reluctant	7	14.0	0	0,0	7	7.0 Suspicious	41	82.0	50	100.0	91	91.0

Regarding the health care factors, statistically significant difference was found between group A and group B patients in terms of knowledge on nutrition, attitude to sanitation  and  attitude  to  immunization (p>0.05),  but  analysis  revealed significant association between two groups of patients in terms of attitude to health, attitude to food, knowledge of sickness (OCD), knowledge of physical fitness, mental status, cognitive ideas (p<0.05). Proportion of avoiding medical was higher among the group A patients (50.0%) whereas selective medical care was higher among the group B patients (74.0%). Similarly selective food habit was higher among the group B patients (86.0%) whereas preference of self prepared food habit was higher among the group A patients (32.0%) compared to group B patients (12.0%). Proportion of biased knowledge was higher among the group B patients (74.0%) whereas cloudy knowledge was higher among the group A patients (42.0%). But biased knowledge of physical fitness was higher among the group A patients (32.0%) whereas cloudy knowledge on physical fitness was higher among the group B'patients (92.0%). But the proportion of cloudy mental status and cognitive ideas were higher among the group A patients whereas biased mental status and cognitive ideas was higher among the group B patients.

Table 9: Distribution of the patients by personal habit Habit	Study patients	Total(N=100)	p value No. No. %	No. Watching	46	92.0	49	98.0	95	95.0	0.358 movies Watching	31	62.0	34	68.0	65	65.0	0.529 games Betel-nut	39	78.0	44	88.0	83	83.0	0.183 Playing cards	36	72.0	40	80.0	76	76.0	0.348 Buying	27	54.0	20	40.0	47	47.0	0.160 Singing	30	60.0	43	86.0	73	73.0	0.003 Alcohol	12	24.0	38	76.0	50	50.0	0.001 Extra-sex	20	40.0	36	72.0	56	56.0	0.001 Dating	23	46.0	35	70.0	58	58.0	0.015 Smoking	10	20.0	33	66.0	43	43.0	0.001 Drugs	9	18.0	32	64.0	41	41.0	.0.001 Dancing	19	38.0	32	64.0	51	51.0	0.009 Going club	15	30.0	28	56.0	43	43.0	0.008 Betting	42	84.0	30	60.0	72	72.0	0.007 Taking land	48	96.0	20	40.0	68	68.0	0.001 Fighting	27	54.0	14	28.0	41	41.0	0.008 Spending	32	64.0	10	20.0	42	42.0	0.001 money Buying land	16	32.0	6	12.0	22	22.0	0.015

Regarding the personal habit no statistically significant difference was foUnd between two groups of patients (p>0.05) in terms of habit of watching movies, games, betal nut chewing, playing cards and buying habit. On the statistically significant difference was found between two groups of patients in terms of habit of singing, alcohol, extra sex, dating smoking, drugs, dancing going club (p<0.05) which were significant higher among the group B patients whereas betting, taking land, fighting, spending money and buying land was higher among group A patients (p<0.05).

Discussion

In a personal study for the last three years from 	1999 to 2001 the patients attended outpatient clinic in Urban Hospital in Dhaka City, those who were already diagnosed suffering from OCD; 100 people were selected for this study program. Among this hundred people 80 were female 40 were Muslim and 40 were Hindu. Males were all Muslim. Among the age ratio of these hundred people were from 18 years to 50 years age, females & 10 males. Among the groups One group was treated with the conventional treatment for depression with Tab clomiperarnine and Tab Amitryptallin. Which were marked as B group. Another group which.was levels as A group were treated with Anti-epileptic drugs with Tab divalporate and Tab Carbamazepine. The both group will be focused later on after the study period. We should compare the effect of drugs after the result.

Preparation for the study :

In group A	:	50 people sub divided into	5 groups	: each group has	10 people. 9 female and one male. Among this groups everyone suggested for one type of investigation i.e. test of EEG (Electroencephalogram) in which electrodes placed in the scalp to trace wave length of Brain. In each group of 10; seven people found positively suffering from seizure disorder. But these people never complained of epilepsy or convulsion. They had complained of excessive washing and repeatedly counting or undoing things. Meanwhile 35 people were given anti epileptic drug, Divalporate alone it was shown that the OCD characters started charging with in 3 to 6 weeks. Among this 35 people 20 people got cured within 3-5 month period than the 35 people those who should positive at EEG seizure disorder, they were given treatment of epilepsy and result 15 people who were did not show rapid cure, they were given carbamazepine with valporic acid. It shows synergistic action within 3 weeks. All these 35 people were relived from their clinical features of OCD.

The rest 15 from 50 people were given valporic acid, carbamazepine and clonazerripam, all medicine were used to treat epilepsy. As a result combination of these anti epileptic drugs the, cure rate 100% of treatment this magic improvement of treatment was highly appreciated by those people who was volunteered personally this theory proven that OCD can be cured by treating with anti epileptic medicine, which has effect on neurotransmitter at the receptor of humeral junction at the midbrain and hypothalamus. Through this treatment out of total 	50 people 45 people 40 female and 5 male cured completely. Only remaining 5 people shown slight improvement from OCD. These people had history of birth trauma and genetically problems, which shown in their chromosome.

The other group of 50 people who were in group B, those were placed only on conventional medicine treated' before, for OCD Anti-depressive medicine Clomiperamine, Amitryptalline but at the end of study period out of 50 only 10 people shown slight improvement and rest 40 remain some as their previous clinical feature of OCD.

OCD can present many feature, Fear of serious illness, Irritable  bowel syndrome, Panic disorder, strict toilet habit, and ritualistic behavior. But cure rate and improvement shown with new trail of anti- epileptic medicines.

Conclusion Research regarding phenomenological aspects of OCD has focused on various areas, including identification of subtypes, investigation of role of insight and patterns of co-morbidity. Several studies shown that examined the course of illness in  OCD  found  that  the  course  usually  chronic  in  adults. Another hypothesized subtypes involves patients with both OCD and chronic tic disorder. Evidence of familial transmission and treatments suggesting that co-morbidity may identify a meaningful subtype. The patients with OCD have a range of insight has been increasing. It remains to be seen whether patient with poor insight have different treatment response and different course than patients with better in sight. Co-morbidly between  OCD  and  schizophrenia  has  been a recent of interest. Evidence to emerging that obsessions and compulsions are more common in patients with schizophrenia than was previously thought. The effect of obsessions with  schizophrenia than was  previously thought. The effect of obsessions and compulsion on schizophrenia in terms of both treatment response and course is currently investigated. The recent trial study and treatment followed with anti epileptic medication the success rate was 90% which proved the newer study trail and treatment is more effective than only other medicine treated before. Immediate improvement shown after onset of treatment with in 3-6 weeks. Therefore follow up treatment must continue at least for three to five years. If the course do not follow in regular cheek up and clinic visit for treatment than the result may not be up to satisfaction. So co-operation must be ensured before starting the treatment. The family therapy and supportive psychotherapy to necessary in the course of treatment parental guidance, social organization and community health services can also should participate the treatment program. General awareness  and  motivation to the people  must fulfilled. Otherwise treatment program may turn into unsatisfactory and unsuccessful.

Recommendation.

1. Based on the  study findings future research program strongly recommendation to find the function of neurotransmitter at the thalamic region of mid brain.

2. An empowerment  program  should  be  included  to  verify  the symptoms and clinical futures of OCD with anti-epileptic drugs.

3. Research and social worker should be promoted to participate with population to increase general awareness and co-morbidity of the OCD within population.

4. There was a limitation of the research instrument standard regarding self care, self esteem and self efficacy should be tested in ad-mining methodology.

5. This study can be follow up if possible every three months in order to asses sustainability or ritualistic behavior and their thought disorder.

BIBLIOGRAPHY

01.  American Psychiatric Association: Diagnostic & statistical manual of Mental Disorder,4th  Edition,	and   Washington   D.C.   American   Psychiatric Association 1994.

02. 	American Psychiatric Association: Diagnostic & statistical manual of Mental Disorder, 4th Edition, Text Resision, Washington D.C. American Psychiatric Association 1994.

03. 	Baer L.   Personality  disorder  in  Obsessive-compulsive  disorder,  in Obsessive-compulsive Disorder; Practical Management, 	3rd edition Edited by Jenike MA, Baer L. Minichiello WE, St. lows, MO, C.V Mosby 1998.

04. 	Baer L. Jenike MA. Black DW et al. Effect of Axis II diagnoses on treatment out-come with clonipranum  in 	55 patients with Obsessive-compulsive disorder, Arch Gen. Psychiatry 40:862-866,1992.

05. 	Baer L. Breites  HC,  go oman WK,  et. at. : Identifying Sub-types in Obsessive-compulsive disorder and their relationship to Tousle and tic disorder, a factor analytic study. Jousol Abnormal Psychology.

06.	Bellodil, Sciuto G. Diaferia G. et.al	: Psychiatric disorders in the families of patients with obsessive-compulsive disorder. Psychiatry Residency 42:111-120,	1992.

07.	Breier A, Charney DS,  Heninges GR. Agrophalia and panic disorder development, diagnostic stability and courses of illness. Arch General Psychiatry 43:1029-1036; 1986

08.	Eisen J L. Rasmussen SA. Obsessive-compulsive with psychotic features clinical Psychiatry 54:373-379,	1993.

09.	Eisen J L. Beer D. Pato MT. et. al: Obsessive-compulsive Disorder in patients with schizophrenia.

10.	Eisen J L. Phillips KA, Rasmussen SA, et. al	: The Brown Assessment of beliefs scale	(BABS)	: Reliability and validity. Am J Psychiatry	155:102- 108,	1998.

11.	Foa EB, Kozak M J : DSM IV field trial : Obsessive-compulsive Disorder. A J Psychiatry 152:90-96,	1995.

12.	Grim Shaw J L : The out come of Obsess Iona! disorder. A follow up study of 100 Cases. Br. J Psychiatry	111:1051-1056,	1965.

13.	Kruger S, Cooke  RG. Hasey GM. et.al	: Co-morbidity of Obsessive- compulsive disorder  in  Bipolar disorder,  J Affective Disorder	34:117- 120,1995.

14.	Lelliott PT, Norsirvani HF Basoglu M.et. al	: of Obsessive-compulsive and treatment out-come, Psychological Medicine 14:697-702, 1988.

15.	Myers Jk. weissman MM, Tischler GL. et. al: Six-month prevalence of Psychiatric in three communities	1980 to	1980. Arch General Psychiatry 41:949-958,	1984.

16.	Ranchman S. Hodge son RL: Obsessive-compulsive. Englewood cliffs, NJ, Prentice-Hall,	1980.

17.	Rasmussen SA, Eisen	: Clinical and Epicleniologic findings of significance to neuopharmacologic trials of OCD. Psychopharmaco Bulletin 24:466-470, 1988.

18. 	Rasmussen SA. Tsivang MT : DSM III of Obsessive-compulsive disorder: clerical characteristics and family history. Am J Psychiatry 	143:317-322. 1986.

19.	Steketee G, Eisen J. Dyck I, et. al. Predictors of course in of Obsessive- compulsive disorder, Psychiatry Residency 89-229-238, 	1999.

20. 	Ssedo SE,  Rapoport. JL. Leonasd H,  et.al:  of Obsessive-compulsive disorder in  children  and  adeloseents:  Clinical  Phenomenology of to consecutive case, Arch Gen Psychiatry 46: 335-41, 1989.

21. 	American Psychiatric Association: Diagnostic and statistical manual of mental  disorders. 4th Editions,  Text  Revision,  Washington  American PSychiatric Association, 2000.

Dear Patient,

I am preparing a thesis for my Ph. D Program. I need some information from you. I shall keep these information secrete and confidential. I'll use this information for academic purpose only. During study period, if any damage occurs that will be compensate and drugs will be withdrawn immediately.

INTERVIEW QUESTIONNAIRES

1.	Name/ID No.:

2.	Age

3.	Sex a.	Male b.	Female

Religion a.	Muslim b.	Hindu c.	Christian d.	Others

5.	Education a.	Primary b.	Secondary c.	University level d.	Others

6.	Occupation a.	No job b.	Student c.	Business d.	Others

7.	Marital Status a.	Married b.	Unmarried c.	Divorce d.	Others

8.	Residence a.	Urban b.	Rural c.	Destitute d.	Others

9.	Father a.	Dead b.	Retired c.	On Job d.	Others

10. Mother a. Dead b. Housewife c. On Job d. Others

11. Father's Education a. 	Illiterate b. 	Primary c. 	Secondary d. 	Others

12. Mother's Education a. 	Illiterate b. 	Primary c. 	Secondary d. 	Others

13. Monthly Income a. 	Up to Tk.30,000/- b. 	30,000-50,000/ c. 	50,000 to 1,00,000/- d. 	Others

14. Complaints a. 	Phobia or Dirt/ b. 	Strict toilet habit c. 	Phobia of food items d. 	Others

15. Duration of Complaints a. 	Less than one year b. 	One to Five years c. 	Five to fifteen years d. 	Others

16. Previous treatment a. 	Spiritual healers b. 	General Practitioner c. 	Medicine specialist d. 	Psychiatrist.

17. Previous Cure a. 	Very much improved b. 	Slight improvement c. 	No improvement d. 	Others

18. Social Interaction a. 	Very Good b. 	Reluctant c. 	Suspicious d. 	Others

19. Communication a. 	Good b. 	Non-co-operative c. 	Suspicious d. 	Others

20. Attitude of Marriage a. 	Good & happy b. 	Unhappy c. 	Paranoid d. 	Others

21. Attitude of Sex a.	Good & co-operative b.	Non-cooperative c.	Paranoid d.	Others

22. Attitude of pregnancy a.	Co-operative b.	Negative c.	Suspicious d.	Others

23. Attitude of Religion a.	Co-operative b.	Reluctant c.	Suspicious d.	Others

24. Attitude of Sanitation a.	Very good b.	Care-less c.	Self confined d.	Others

25. Attitude of Immunization a.	Co-operative b.	Reluctant c.	Suspicious d.	Others

26. Attitude of others a.	Co-operative b.	Reluctant c.	Suspicious d.	Others

27.	Attitude of Toilet a.	May use common toilet b.	Personal toilet only c.	Refuse to use unknown toilet d.	Others

28. Attitude of bathing a.	Many times a day b.	Once daily c.	Once weekly d.	Others 29. Attitude of environment a.	Very sensitive b.	Tolerable c.	Very much choose d.	Others

30. Attitude of health a.	Co-operative b.	Selective only c.	Self prepared only d.	Others

31. Attitude of food a. 	Co-operative b. 	Selective only c. 	Self prepared only d. 	Others

32. Knowledge of Nutrition a. 	Very good b. 	Moderate c. 	Selective d. 	Others

33. Knowledge of Sickness a. 	Clear b. 	Cloudy c. 	Biased d. 	Others

34. Knowledge of Physical fitness a. 	Clear b. 	Cloudy c. 	Biased d. 	Others

35. Mental Status a. 	Clear b. 	Cloudy c. 	Suspicious d. 	Others

36. Attitude of relations a. 	Friendly b. 	Suspicious c. 	Paranoid d. 	Others

37. Attitude of visitors a. 	Friendly b. 	Suspicious c. 	Based d. 	Others

38. Attitude of figure a. 	Good b. 	neglected c. 	Suspicious d. 	Others

39. Cognitive ideas a. 	Friendly b. 	Suspicious c. 	Paranoid d. 	Others

40.	Habit of smoking	 a.Yes      b.No. 41.    Habit of Alcohol	 a.Yes       b.No 42. Habit of Drugs	        a.Yes       b.No 43. Habit of Betel-nut	 a.Yes      b.No 44. Habit of watching movies a.Yes      b.No 45. Habit of watching games a.Yes       b.No 46. Habit of singing	 a.Yes      b.No 47. Habit of fighting	 a.Yes      b.No 48. Habit of betting	 a.Yes      b.No 49. Habit of playing card   a.Yes       b.No 50. Habit of going club	 a.Yes      b.No 51. Habit of dancing	 a.Yes      b.No 52. Habit of extra-sex	 a.Yes      b.No 53. Habit of betting	 a.Yes      b.No 54. Habit of spending money	 a.Yes      b.No 55. Habit of buying land	 a.Yes      b.No 56. Habit of taking loan	 a.Yes      b.No 57. Habit of asking help	 a.Yes      b.No

Patient started treatment with vaporic acid, did not show change within 3 weeks. Added carbimazepine, improved gradually then added clonazepine. Rapidly improved with in 3 months. gradually tapered and only valporic acid continued. patient improved completely. Presently doing good.

Patient started treatment with vaporic acid, did not show change within 3 weeks. Added carbimazepine, improved gradually then added clonazepine. Rapidly improved with in 3 months. gradually tapered and only valporic acid continued. patient improved completely. Presently doing good.

DR. ZAHIR UDDIN AHMAD MBBS, MCPS, DPM, MD, MPH, PHD Dhaka, Bangladesh. dr.zababar01@gmail.com