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Obsessive Compulsive Disorder (OCD) Obsessive-Compulsive Disorder (henceforth OCD) is an anxiety related disorders and is a potentially disabling condition that can persist throughout a person s life. The key features of OCD are obsessions and compulsions. Obsessions can be defined as persistent ideas, thoughts impulses or images that are experienced as inappropriate and intrusive. This then causes the person high levels of anxiety and distress.
Compulsion on the other hand, Are repetitive behaviors like hand washing, ordering and checking. The reason for doing this is to prevent or to reduce the anxiety or distress felt. The cause of OCD is no longer solely attributed to the attitudes the patient learnt as a child. The search for cause now focuses on the interaction of neuro-biological factors and environmental influences and cognitive processes. It has been fond that OCD affects 1 to 2 % of the population in Malaysia and the United States. It cuts across all ethnic groups and effects both males and females.
The onset of OCD is earlier in males i. e. between 6 to 15 years of age while the disorder affects females in the age range of 20 to 29. Bob saw his psychiatrist for treatment of depression for six months before he finally had the courage to bring up his other secret problem. Since childhood he had a compulsion to count things. He had to count the letters in words and in people s names.
If the letters added up to any number except 9, he felt a sense of release and could stop counting. He knew it was silly but nevertheless he had a fear that if he did not do this, something bad could happen to his mom or dad. He seemed unable to stop doing this. He did poorly in school because he was distracted by his secret compulsion to count letters when he should be paying attention to the teacher s lessons. He was later bothered as a teenager by upsetting sacrilegious mental images when he was in church.
Having these sacrilegious images made him feel that he had lost his souls for eternity. In addition to these two problems, he was having trouble driving. When he felt a bump as his tire rolled over a little stone, he would think that he may have accidentally run over a pedestrian. He would instantly check his rearview mirror for the injured person he feared was lying on the road. Relived to not see an injured person, he would start driving forward.
Obsessing that the injured person might have been flung entirely off the road by the impact, he would then stop, and back up his car to the scene, and search the ditch and the weeds. These obsessions and compulsions were taking over his life but he was too embarrassed to tell anyone about them, even his psychiatrist, up till now. (Internet 1) OCD is an anxiety related disorder and is a potentially disabling condition that can persist throughout a person s life. An individual who suffers from OCD becomes trapped in a pattern of repetitive thoughts and behaviors that are senseless and distressing but are extremely difficult to overcome. OCD occurs on a continuum from mild to severe. At the severe continuum, if left untreated, it can destroy a person s capacity to function at work, at school or even at home. What is OCD?
The key features of OCD are obsessions and compulsions as stated in DSMIV. Obsessions are persistent ideas, thoughts, impulses or images that are experienced as inappropriate and intrusive and that cause a high level of anxiety or distress. The individual is unable to control the content of his / her obsession which, the individual feels is not the kind of thought that he / she would expect to have. However, the individual is able to recognize that the obsessions are a product of his / her own mind.
The most common obsession are: - &# 61623; repeated thoughts about contamination (becoming contaminated by shaking hands) &# 61623; repeated doubts (wondering whether one has hurt someone in a traffic accident or having left the door unlocked) &# 61623; a need to have things in a particular order, aggressive or horrific impulses (to hurt one s child) &# 61623; sexual imagery (recurrent pornographic image) The individual with obsessions usually attempts to ignore or suppress such thoughts or to neutralize with other thoughts and actions. For e. g. an individual plagued by doubts about having turned off the stove attempts to neutralize them by repeatedly checking to ensure it is off. (Internet 2) Compulsions are repetitive behaviors like hand washing, ordering and checking or mental acts like praying, counting and repeating words silently.
The reason for doing this is to prevent or reduce anxiety and distress, not to provide pleasure or gratification. The person feels driven to perform the compulsion to reduce distress that accompanies an obsession or to prevent some dreaded event from happening. In some cases individuals perform rigid acts according to elaborate rules without being able to indicate why they are doing them. By definition, compulsions are either excessive or not clearly connected in a realistic way with what they are designed to neutralize or prevent.
The most common forms of compulsion include washing, checking, counting, cleaning, requesting or demanding assurances and ordering. (Internet 2) When an individual attempts to resist a compulsion, he / she may experience a sense of mounting anxiety or tension that is often relieved by yielding to the compulsion. After repeated failed attempts to resist the compulsion, the individual finally gives in to them and may no longer experience a desire to resist them. After a while, these compulsions are incorporated into the individual s daily routine. (Internet 2) For such a behavior to be considered a disorder, these obsessions and compulsions must cause marked distress, be time consuming, (take more than an hour per day), or significantly interfere with the individual s normal routine, job and social activities i. e. relationships with others. (Internet 2) People with OCD show a range of insights into the senselessness of their obsessions. Often, especially when they are not having an obsession, they can recognize that their obsession and compulsions are unrealistic.
At other times, they may be unsure about their fears and even believe them to be valid. (Internet 3) Most people with OCD struggle to get rid of their unwanted obsessive thoughts and to prevent themselves from engaging in compulsive behaviors. Many are able to keep their obsessive-compulsive symptoms under control at work and at school. But over months and years, their resistance may weaken and when that happens, OCD may have become so severe that time consuming rituals take over the individual s life, making it almost impossible to function normally outside the home, Most suffers of OCD hide their disorders rather than seek help. An unfortunate consequence of this secrecy is that people with OCD do not receive help until years after the onset of the disease.
By that time, they may have learnt to work their lives and the lives of their family members, around the rituals. (Internet 3) What Causes OCD? The old believe that OCD was the result of life experience has been weakened as before it was perceived that growing evidence that biological factors are a primary contributor to the disorder. OCD is no longer attributed only to attitudes the patient learned in a childhood e. g. an over emphasis on cleanliness, or a belief that certain thoughts are dangerous or unacceptable. The search for causes of OCD now focuses on the interaction of neuro-biological factors and environmental influences, as well as cognitive processes. (Internet 3) In an effort to identify specific biological factors that may be important on the onset or persistence of OCD, investigators from the National Institute of Mental Health (NIMH) have used a device called the Positron Emission Tomography (PET) scanner to study the brains of patients with OCD.
Findings from the PET scan suggests that OCD patients have pattern of brain activity that differs from those without mental illness or with some mental illness. Brain imaging studies of OCD showing abnormal neuro-chemical activity in regions known to play a role in certain neurological disorders suggest that these areas may be crucial in the origins of OCD. (Internet 3) There is also evidence that treatment with medication or behavior therapy induce changes in the brain coincident with clinical improvement. (Internet 3) Magnetic resonance imaging has been used in preliminary studies of the brain. These studies have shown that the subjects with OCD had significantly less white matter than did normal control subjects, suggesting a widely distributed brain abnormality in OCD. Understanding the significance of this finding will have to be further explored by functional neuro-imaging and neuro-psychological studies (Internet 3). In addition to that, investigators are currently studying the hypothesis that a genetic relationship exists between OCD and the tic disorders.
There seems to be an increased rate of OCD in people with Tourette s syndrome, an illness characterized by involuntary movements and vocalizations. Other theories of OCD focus on the interaction between behavior and the environment and on beliefs and attitudes as well as how information is processed (Internet 3). How Prevalent is OCD? For many years, mental health professionals thought of OCD as a rare disease because only a small minority of their patients had the condition. The disorder often goes unrecognized because of many of those afflicted with OCD, in efforts to keep their behavior secrets, failed to seek treatment. This led to underestimates of the number of people with the illness.
A survey conducted in the early 1980 s by NIMH showed that OCD affects more than 2 percent of the population, meaning more than 5 million people in the United sates alone suffer from this disorder. The survey showed that OCD is more common than severe mental illness such as schizophrenia, bipolar disorder or panic disorder. OCD strikes people of all ethnic groups, males and females both being equally affected (Internet 3). Recent studies also point out that less than half of the 5 million people affected with OCD are treated, due mainly to the fact that these suffers feel ashamed by their symptoms and keep them a secret.
Therefore, a delay of 5 to 10 years before receiving psychiatric treatment for OCD is not uncommon (Internet 4). Not unlike the United States, Malaysia statistics of people with OCD range from approximately to 1 to 2 percent of the population, affecting as many as 210, 000 to 240, 000 people (Robert, The Star, p. 11). These statistics may not be very accurate because such maladaptive behavior is not frequently reported. In the Malaysian context, people in the various cultural settings have developed concepts of what mental illness is and have devised means of coping with these affected individuals. These involve the use of charms, magic and divine interventions.
It is the common experience of local physicians that relatives of rural and urban people would bring their ill members to indigenous healers first (Tan and Wagner, (1971), p. 3) In addition to that, most cultures within the Malaysian context would consider it a taboo to talk or even acknowledge any form of mental illness that may have inflicted a particular members of the family. The onset of OCD is earlier in males than in females; between the ages 6 to 15 years for males and between ages 20 to 29 for females. Onset is gradual for the most part, but acute onset has been noted in some cases (Internet 2). Although OCD symptoms typically begin during the teenage years or early adulthood, recent studies have shown that some children develop the illness at earlier ages, even during the preschool years. Studies indicate that at least one-third of all OCD cases in adults began in childhood (Internet 3). Dr.
Cheap Wing Yin, the president of the Malaysian Mental Health Association and a consultant psychiatrist stated that, It is not unusual for children to be victims of OCD. In fact, approximately a third of all OCD victims are affected by this disorder by the age of 15, with the majority of additional cases emerging before the age of 30. (Robert, Sunday Star, p. 11) The fact that OCD affects people in the age range of 15 to 30 is a cause for serious concern. People in this age range consists of the younger workforce and it would be a waste to have 120, 000 to 240, 000 of these people affected by this disorder. If these people were left untreated the number of OCD suffers might even increase.
This will definitely incur social and economic costs. As the NIMH survey in the United States showed, of OCD were estimated to be USD 8. 4 billion in 1990. With so little research done in Malaysia where OCD is concerned, it is difficult to say exactly how much costs will be incurred. Treatments for OCD The treatment that is most commonly used are psychotherapy and pharmacotherapy. The psychotherapy most commonly used is behavior therapy and cognitive therapy, usually a combination of both. In behavior therapy, the techniques used are systematic desensitization and flooding.
Systematic desensitization involves gradually exposing the client to over-increasing anxiety provoking stimuli. Flooding on the other hand, allows the client to face the most anxiety-provoking situation. Additional behavior and cognitive-behavior techniques including saturation and thought stopping. Pharmacotheraphy is mainly about medication. The commonly prescribed medication for OCD patients are Prozac, Zoloft, Paxil and Luvox. Though medication may help to control symtoms of OCD, a relapse can occur if the medication is discontinued.
Current strategies for treatment resistant OCD focuses on patients who are not responding to common types of medication and psychotherapy. Through an interview with a local psychologist, it has been found that techniques used here in Malaysia are similar to that used in the US but what lacks in Malaysia is the expertise and the man power. I always had to say thank you to everybody after everything I said. I would walk all the way back to the store to say thank you. I bothered people terribly.
ON the telephone, I d call people back. Did I say thank you? If I didn t say thank you, thank you. Today for the first time in probably a year, I actually put my shoes and socks on and I didn t wash my hands.
But if I were to touch the bottom of my shoes, I would definitely still wash my hands. Sandy (internet 5) Sandy is a real person. She has been obsessed with verbal rituals and with anxieties about cleanliness for seven years. She has only recently ventured out of the house and into therapy.
One very effective treatment for OCD is called systematic desensitization or exposure therapy. In this form of therapy, the person with obsessions and compulsions is gently exposed to situations that anxious him / her . The person is helped to confront and manage that particular fear. Sandy s compulsions and obsessions, however have been so pervasive that she has not been able to tolerate exposure therapy.
For Sandy, medication has made her anxieties much more manageable. She begins exposure therapy with the aid of medication to control her anxieties, She touches a file folder that has touched the floor and she even touches the rim of a waste basket. Foe fear that the hand that touched the waste basket is now contaminated and could do someone harm, Sandy balks, however, at resting her hand on the arm of the chair. (Internet 5) As Sandy s exposure therapists points out, OCD is frightening. People think they are no longer in control of their thinking and behavior. And that, in our culture, is associated with being crazy. (Internet 5) Psychotherapy For many years, OCD was seen as a purely psychological disorder, related to a desire to control one s environment or to undo some perceived wrong action.
Insight oriented psychotherapy has been singularly unsuccessful in treating this group of disorders, however. Behavior therapies have had more success, especially those with specific small steps geared to the exact obsessions and compulsions involved in the individuals case. Two most common and popular techniques are systematic desensitization and flooding. Systematic desensitization techniques involve gradually exposing the client to ever-increasing anxiety provoking stimuli. It is important to note that such a technique should not be attempted until the client has successfully learnt relaxation techniques and can demonstrate their use to the therapist. Exposing the patient to either of these techniques without increased coping skills can result in relapse and possible harm to the client.
Relaxation techniques may include imagery, breathing skills and muscle relaxation. It is important that the client find a relaxation technique that works best for them before attempting something like systematic desensitization or flooding. Flooding allows the patient to face the most anxiety-provoking situation, while using the relaxation skills learnt. Systematic desensitization is the preferred technique of the two. Flooding is not recommended except in rare cases. Flooding s potential harm outweighs its potential benefits e.
g. traumatizing the individual further. (Internet 6) It has been found that 60 to 70 percent of OCD s patient s symptoms were greatly improved after behavioral treatment. The first step of behavior therapy is the education of the patients and their families. To maximize the potential for success of the therapy, family members should be recruited to participate in the therapy. Role-playing under the supervision of the therapist can help the family members and the patients themselves to understand which interventions are helpful and which might be counterproductive. With regard to homework, patients should keep a diary of self-exposure, to serve as a reminder, a subtle reinforce and a tangible means of monitoring efforts and progress while helping to identify areas of resistance.
A fair trial of behavioral therapy should include at least 20 hours of actual exposure and response prevention. In general, pure obsessions are more resistant to behavioral treatment whereas compulsions are more responsive. (Internet 4) Additional behavior and cognitive-behavior techniques which may have some effectiveness for people who suffer from OCD include saturation and thought stopping. Through saturation, the client is directed to do nothing but think of one obsessional thought which they have omplained about. After a period of time concentrating on this one thought (e.
g. 10 - 15 minutes at a time) over a number of days (3 - 5 days), the obsession can lose some of its strength. Through thought stopping, the individual learns how to halt obsessive thoughts through proper identification of the obsessional thoughts and then averting it by doing an opposite response. For example, a client could respond to an obsessive thought by yelling the word, Stop! loudly.
The client can be encouraged to practice this in therapy and then transplant this behavior to the privacy of the home. (Internet 6) Pharmacotherapy Clinical trials in recent years have shown that drugs that affect the neuro-transmitter serotonin can significantly decrease the symptoms of OCD. The first of these serotonin reuptake inhibitors (SRI s) specifically approved for the use in the treatment for OCD was the tricyclic antidepressant clomipraine (Anafranil). It was followed by other Sri's that are called selective serotonin reuptake inhibitors (SSRIs). Those that have been approved by the Food and Drug Administration for the treatment of OCD are fluoxetine (Prozac), fluvoxamine (Luvox) and paroxetine (Paxil) (Internet 3) A plethora of studies have shown that more than three-quarters of patients are helped by these medications at least a little.
In more than half of the patients, medications relieved symptoms of OCD by diminishing the frequency and the intensity of the obsession and the compulsions. Improvements usually takes three weeks or longer. If patient does not respond well to one of these medications, or has unacceptable side effects, another SRI may give a better response (Internet 3). Often the first medication tried will not work for a particular patient with OCD.
That should not discourage the patient or the doctor, since other medication may work better. Side effects vary considerably depending on which type of medicine is being used. Each medicine is unique and may behave differently especially with respect to side effects. Anafranil, though having slightly more chance of effectiveness, has more disruptive side effects than the others listed. For that reason it is not used by some clinicians as first choice (Internet 7). Prozac, Zoloft, Paxil and Luvox are convenient remedies that usually have minimal effects (about 10 %- 20 % of people have either nausea, headaches, delayed orgasm or ejaculation, decreased sexual interest or insomnia) There are some prescription medicines that must not be used with Luvox.
Sometimes a psychiatrist may advice adding a second medicine to the SSRI to boost the power of treatment if OCD id not responding. Neuroleptic and benzodiazepine medicines are two commonly employed booster medicines (Internet 7). For those who are only partially responsive to these medications, research is being conducted on the use of medications as an additional drug (an augmenter). Medications are of help in controlling the symptoms of OCD, but often, if the medication is discontinued, relapse will follow. Even after the symptoms have subsided, most people will need to continue with medication indefinitely, perhaps with lowered dosage (Internet 3). Some patients actually need nothing more than medication.
They make full recovery and need no further treatment. Other OCD patients would definitely benefit from behavioral treatment called systematic desensitization and response prevention (Internet 7) The first step in treatment was to find out what was happening to Harry. This required two individual sessions with Harry and another two family sessions. Harry gradually explained that he was checking everything hundreds of times before he would leave for school. He would check to see if the oven was switched off, if the lights in every room and if the computer is turned off. He will make sure that the faucets in the bathrooms and kitchen were tightly closed Harry also described how he had to wash his hands in order to make sure he was clean. (Internet 8) Treatment consisted of a combination of pharmacotherapy, individual therapy and family therapy.
Initially Harry tried clomipramine (Anafranil) and within three weeks, he began to have significant improvement in his symptoms. He had a bit of difficulty adjusting to the dry mouth that accompanied the drug. Harry was also started on cognitive behavior therapy. Treatment consisted of individual sessions with Harry and sessions with his parents. Harry and Dr.
Mc Goo developed situations where he would likely check or wash and then Harry was exposed to these situations and he stopped himself from checking or washing. They started with relatively easy situations and he stopped himself from checking or washing. They started with relatively easy situations and moved on to more difficult situations. At first he would become agitated with simple situations but after many sessions he was able to do these without difficulty. Harry made good progress and after many sessions, he was able to do these without difficulty. Harry made good progress and after 4 weeks, he was not missing school.
He was discharged to follow up after 12 weeks. His medication was tapered and he coped very well (Internet 8). Harry s situation is an illustration of how medication and psychotherapy are used side by side in an attempt to overcome OCD. Behavioral therapy with medications seems to offer the best long term improvements but even then no treatment is curative for OCD. Most treatment can be expected to reduce symptoms by 50 %- 80 % or more but one is not to expect the disorder to diminish completely (Internet 6). Current Strategies for Treatment Resistant OCD Although the majority of patients with OCD can be helped through medication, usually in combination with behavioral techniques of exposure and response prevention some remain very ill and refractory to treatment.
Harvard researchers, Michael A. Jenike, MD and Scott L. Rauch, MD recommend the following approach for managing patients with treatment-resistant OCD Step 1: Augmentation of SSRI with clonazepam (Klonopin) Clonazepam is a benzodiazepine widely used for anxiolytic or anti convulsive properties and has effects on the serotonergic system which has been implicated in the pathophysiology of OCD. Clonazepam may be a good choice in patients who are anxious or agitated. Step 2: Two additional serial augmentation trials (i. e.
buspirone (BuSpar) and neuroleptic) There are some evidence that additional of buspirone to fluoxetine or another SSRI is beneficial. Neuroleptic's has been shown to be particularly useful in patients where OCD is accompanies tics and Frank Tourette s disorder, body dimorphic disorder or trichotillpmania. Step 3: Consider modifications to behavior therapy (i. e. inpatient) Step 4: Consider monotherapy trial of clonazepam Although the time course of clonazepam s anti obsessional effect has not been formally studied, there are suggestions that its effects may be evident within days, rather than weeks, as with SSRIs. Step 5: Consider monotherapy trial of monoamine oxidase inhibitor.
Recent studies suggests that MAOIs may be most effective in cases of OCD characterized by comorbid anxiety or depression disorders. Step 6: Consider intravenous clomipramine This strategy is considered experimental and is only available at a few institutions in the US. Step 7: Consider Neurosurgery For patients who have failed an exhaustive array of behavioral and pharmacological treatments, neurosurgical intervention should be considered. These procedures are only formed at two research facilities in the United States. (Internet 4) Treatments in Malaysia It would be uncommon to have Malaysians consulting traditional forms of therapy before approaching more western forms of therapy. Take a Malay village for example, it is not an uncommon experience to find a person who has been very disturbed for some time but has never consulted a specialist at a hospital for help. These persons are retained in the village, treated by books and are often secured by chains and ropes to the trunk of coconut trees or stilts of the Malay house.
The Indians would seek the interventions of various deities of the Hindu pantheon. Chinese on the other hand would resort to temple mediums, Chinese senses and even Malay books before seeking treatment at a hospital (Wagner and Tan, 1971, pp 4 - 5). Although more and more people have begun to accept the effectiveness of newer methods of dealing with mental illness, there are still many who rely on these traditional methods. An interview with Dr. Edward Chan from the Taman Desa Psychological Counseling center revealed that treatment methods used here to treat OCD are similar to that used in the US. Dr.
Chan uses cognitive behavior therapy in treating his clients with OCD. He has found this to be the most effective form of treatment. He uses flooding and systematic desensitization in particular and emphasizes the importance of the client mastering a relaxation technique before being subjected to this form of therapy. When asked if he uses thought-stopping, he answered saying that he has not found it to be helpful. He feels it is important that the family of the client is present at the therapy sessions. This would help them to be better equipped in dealing with a family member with OCD such as providing them with reassurance.
Most often clients who come in for therapy would also be seeing psychiatrist for medication. He medication most commonly used here is Prozac. The limitations of therapy is the time and costs. Dr.
Chan uses a sliding scale whereby clients can pay according to their income level. At the least he charges RM 100 per hour and clients have to come in on a regular basis for a few weeks (depending on the severity of the disorder. Sessions are usually once a week. It would be difficult for those from the lower income group to afford such a fee and trying to see a specialist at a government would require one to wait their turn for a few months before being able to see the psychiatrist.
Medication does not come cheap and has to be taken over a long period of time to keep the obsessions and compulsions under control. There is a great need for more psychologists and psychiatrists in Malaysia. According to Dr. Chan, there is one clinical psychologist who attends to the needs of 1000 patients in Hospital Bahagia. One actually wonders, if patients are actually getting the help they so badly need. I agree with Dr.
Chan that therapeutic communities should be set up to make therapy more accessible and less threatening to the common people. Therapy using a combination of medication, individual therapy, family therapy and support groups would be ideal for an OCD patient. Not only would the patient s biological needs be met but the patient would be able to maintain resilience with the help of support groups and the family. Cognitive-Behavior therapy should be used as it seems to be the most effective treatment so far, but I would not go so far as to use flooding unless the case is very severe. I would prefer to use systematic desensitization where the patient is exposed to the anxiety provoking situation gradually. For homework, I would have the client keep a diary of all the efforts he / she has made to overcome the disorder.
Then if ever the client feels discouraged, the diary can be used to encourage the client further. Also it helps keep tab on the progress the client is making. Families with members who are suffering from OCD must be supportive. OCD should be discussed and the concerns of the patients listened to.
It would be a bonus point if the family members recognized gains made during treatment and be supporting, encouraging and motivating during stressful times (internet 10). One individual lamented, My family doesn t understand why I cannot just stop, as though it s a matter of will power or positive thinking. Even the fact that I spend US$ 300 a month for medication and therapy, it just does not convince them that I can t just get it under control or snap out of it on my own. Of course if I could do that, I would have saved myself countless hours of agony (internet 10). It is important to always encourage and be patient with suffers of OCD. Tell them that they are making good progress and continue to be supportive.
Being consistent is another factor to take note of. Set rules for behavior and stick to them. Maintain your normal family routine and keep communication clear and simple. Modifying routines to suit someone with OCD may further reinforce the disorder. Also remember to be positive.
OCD is not anyone s fault. Try to not react to OCD s thoughts and behavior critically or as if they are part of your family member s personality. The individual with OCD may already have a low self image, self worth and self-esteem. The more critical you are the worst they will feel. (internet 9) Research into treatment for OCD is ongoing in several areas ways of increasing availability of effective behavior therapy; cognitive therapy; relapse prevention; methods of reducing medication in patients who have a history of being unable to tolerate medication; and neurosurgery.
Clearly a lot more research need to be done especially in the Malaysian context. The public needs to be made aware of such a problem so that OCD sufferers would not have to feel stigmatized by society. BIBLIOGRAPHY Books Tan, E. S. and Wagner, N. N. (1971).
Psychological problems and Treatments in Malaysia. Kuala Lumpur: University of Malaya Press. Interview Dr. Edward Chan.
Taman Desa Psychological Counselling Center. Personal Interview. 12 th November, 1999 Newspaper Robert, C. weighed down by a compulsive disorder. Sunday Star, Kuala Lumpur, malaysia 22 August, 1999, p. 11 Internet Internet 1: web Internet 2: web Internet 3: web Internet 4: web Internet 5: web Internet 6: web Internet 7: web Internet 8: web Internet 9: web Internet 10: web
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Research essay sample on Serotonin Reuptake Inhibitors Obsessive Compulsive Disorder
