Obsessive compulsive disorder

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Obsessive compulsive disorder
Classification and external resources
DiseasesDB = 33766
ICD-10 F42
ICD-9 300.3
eMedicine med/1654 
MeSH D009771

Obsessive-compulsive disorder (OCD) is a neurobiobehavioral anxiety disorder characterized by distressful, time-consuming thoughts (obsessions) followed by repeated behaviors (compulsions) undertaken in the (often sub-conscious) "belief" that they will lessen the stress and anxiety of the sufferer. While all of us have routines in our life that we undertake repeatedly, in the case of OCD the subject's obsessive, and intrusive thoughts and their accompanying related "tasks" or "rituals" interfere with the afflicted person being able to maintain a balanced or healthy lifestyle.

OCD is distinguished from other types of anxiety, including the routine tension and stress that appear throughout life by its excessiveness. However, a person who shows signs of fixation or displays traits such as perfectionism, does not necessarily have OCD, a specific and well-defined condition. As with other disorders there may be varying degrees of intensity and a proper diagnosis is warranted in order to match appropriate treatment to the person. While the cause of OCD is unknown, some studies suggest the possibility of brain lesions while others explore a more psychiatric analysis such as the impact of major depression, organic brain syndrome or schizophrenia.

Although there is no known cure recent developments in brain research, medications, and behavior therapy have all resulted in Obsessive Compulsive Disorder becoming a treatable condition.

Contents

Diagnosing and defining OCD

Mental health professionals rely on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) which states the following, "The essential features of OCD are recurrent obsessions or compulsions that are severe enough to be time consuming (that is they take more than one hour a day) or cause marked distress or significant impairment. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable" (American Psychiatric Association [APA] 2000 456-457).[1] Obsessions are defined as recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress. These thoughts, impulses, or images are not simply excessive worries about real-life problems, and the person in an attempt to ignore, suppress or neutralize the thoughts with some other action, perpetuates a cycle of obsessive/compulsive behavior. In most cases, the sufferer of OCD recognizes that the obsessional thoughts are a product of his or her own mind, and are not based in reality. In cases where the sufferer does not recognize that his thoughts are extreme an analysis of psychosis or "a break with reality" needs to be evaluated.

Compulsions are defined by repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly. The behaviors are aimed at preventing or reducing distress or preventing some dreaded event or situation from occurring; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.

OCD, like some other disorders such as anorexia nervosa can be difficult to detect or diagnose if the sufferer keeps such thoughts and behaviors to him or herself, due to feelings of either shame and/or denial about their condition.

Prevalance

According to the National Institute of Mental Health (NIMH) OCD affects both men and women equally and some estimates say that as many as 3.3 million Americans ages 18 to 54, an estimated 2.3 percent of the population, may have OCD at any one time. If children were included in this figure it would increase to seven million. The onset of symptoms usually occurs between the ages of 20 and 30 with 75 percent of patients being diagnosed before the age of 30.[1] About 18 percent of American adults have anxiety disorders, and although children may also have anxiety disorders such as OCD, they can go undiagnosed for a long period of time or appear in conjunction with a constellation of symptoms such as Attention-deficit hyperactivity disorder (ADHD), dyslexia or depression.

OCD and children

As the understanding of mental illness grows, along with better and more effective treatments, children can be diagnosed earlier, thus preventing future problems. A child psychiatrist or other qualified mental health professional usually diagnoses anxiety disorders in children or adolescents following a comprehensive psychiatric evaluation. Parents who note signs of severe anxiety or obsessive or compulsive behaviors in their child or teen can help by seeking an evaluation and early treatment.

In order for a diagnosis of OCD to be made, the obsessions and compulsions must be pervasive, severe, and disruptive enough that the child or adolescent's daily routines are adversely affected. While most adults can judge their activities as inappropriate, often, children and adolescents do not have the critical ability to judge this type of behavior as irrational and abnormal. [2]

The average onset age for OCD in children is around 10.2 years of old. The disorder tends to develop earlier in boys than in girls and most often symptoms occur between ages nine and 13. Nearly half of all adults with OCD have had an onset in childhood, although they may have received help much later (March and Mulle 1998).[1]

Possible causes of OCD

The brain

Research into OCD focuses on the brain structure, circuitry, and neurochemical factors that may distinguish people with OCD from the general population. The area of the brain in question is the basal ganglia located in the center of the brain, where information that has entered from the outside world is sorted and unnecessary information is discarded. These areas also control impulsiveness. People with OCD can become overwhelmed with intrusive thoughts that they cannot easily disregard.

The orbital cortex located in the front of the brain and above the eyes is where we interpret information coming in from the senses and to which we apply moral and emotional judgment. Overstimulation in this area of the brain seems to keep people with OCD "on alert," causing an extra sense of unease.

The cingulate gyrus is also located in the center of the brain and alerts us to danger. This part of the brain also helps us to shift from one thought to another and it's possible that this area is what gives trouble to the OCD person who becomes a slave to his repeated behaviors. Through PET scan studies Dr. Jeffrey Schwartz and Dr. Lewis Baxter demonstrated that there was an increased energy use in this area of the brain with people who had OCD. Their studies and subsequent treatment breakthroughs with medication and cognitive behavioral therapy actually proved to decrease the overactivity in this area. This new research combined with technological advancements, such as brain imaging, prove a positive link between the disorder and the brain circuitry and demonstrates that people with OCD have slightly more hyperactivity in their brains that can be controlled successfully.

Chemical imbalance

The neurochemical imbalance that appears to be associated with OCD involves serotonin, an important neurotransmitter. A neurotransmitter is a chemical messenger that enables communication between nerve cells. Serotonin controls many biological processes including sleep, mood, aggression, appetite and even pain. Medications that increase the amount of serotonin for OCD sufferers appear to make a marked difference in their quality of life. Serotonin imbalance has been implicated in other afflictions, as well, such as self mutilation, eating disorders, and depression.

Strep connection

Some cases of OCD in children have been associated with streptococcal infections (called PANDAS or pediatric autoimmune neuropsychiatric disorder). Other autoimmune diseases have also been associated with OCD symptoms such as lupus, Sydenham's chorea, and rhuematic fever. These are more rare and OCD generally occurs without such a precipitating or traumatic event.

Genetic basis

Although the presence of a genetic link has not yet been definitely established it appears that either differences in specific genes or possibly several combinations of genes predispose a person to OCD. There appears to be more of a genetic link in childhood-onset OCD (Geller 1998), and there are findings of higher rates of OCD when Tourette's syndrome and/or tics is experienced by related family members (Alsobrok and Pauls 1998).[1]

OCD symptoms

The typical OCD sufferer performs tasks (or compulsions) to seek relief from obsession-related anxiety. While obsessions are persistent thoughts compulsions are repetitive behaviors that are performed in response to them. To others, these tasks may appear odd and unnecessary, but for the sufferer, such tasks can feel critically important, and must be performed in particular ways to ward off dire consequences and the build up of stress. Examples of these tasks are repeatedly checking that one's parked car has been locked before leaving it, turning lights on and off a set number of times before exiting a room, or repeatedly washing hands at regular intervals throughout the day.

Obsessions and their related compulsions may include but are not limited to the following:

  • Fear of dirt or germs/repetitive washing and cleaning
  • Fear of disorder/arranging things in a certain way, over concern with symmetry (balance) and exactness
  • Worry that a task has been done poorly, even when the person knows this is not true/checking it over and over
  • Irrational fear of harm coming to them or a loved one/checking locks, household appliances, or on the safety of others, etc.
  • Fear of thinking evil or sinful thoughts/developing superstitious rituals
  • Recall and review of distressing situations/ thinking about certain sounds, images, words or numbers repeatedly

There are many other possible symptoms, and it is not necessary to display those described in the list above to be considered as suffering from OCD.

Often the person with OCD will truly be uncertain whether the fears that cause him or her to perform their compulsions are irrational or not. After some discussion, it is possible to convince the individual that their fears may be unfounded. It may be more difficult to do ERP therapy on such patients, because they may be, at least initially, unwilling to cooperate. For this reason OCD has often been likened to a disease of pathological doubt, in which the sufferer, while not usually delusional, is often unable to realize fully what sorts of dreaded events are reasonably possible and which are not. Since fear and doubt can feed the cycle of obsessive compulsive behavior the person will often seek continual reassurance.

OCD is different from behaviors such as addiction to gambling or overeating. People with these disorders typically experience at least some pleasure from their activity; OCD sufferers do not actively want to perform their compulsive tasks, and experience no pleasure from doing so. OCD is, likewise, not to be confused with Obsessive Compulsive Personality Disorder which is a separate syndrome.

OCD is placed in the anxiety class of mental illness, but like many chronic stress disorders it can lead to clinical depression over time if the patient is not able to find the necessary supports and strategies for coping. OCD's effects on day-to-day life, particularly its substantial consumption of time, can produce difficulties with work, finances, and relationships.

Treatment

For years, people with OCD suffered in secret and even when their behaviors were brought into the open adequate treatment was unavailable. Today, with improvements in neuropsychiatric research OCD is quite treatable and those who suffer from it can live productive and normal lives.

What seems to be most effective is a combination of cognitive behavioral therapy (CBT), and medications, with medication being the first line of treatment until symptoms are under control, and a patient is feeling motivated to change the behavioral patterns that contribute to OCD. While medications provide immediate relief for OCD, behavioral therapy is long lasting and will teach strategies that can be implemented for a lifetime.

Medication

Antidepressants called serotonin reuptake inhibitors (SRIs) and selective serotonin reuptake inhibitors (SSRIs) are used to treat OCD. In addition to reducing the obsessive/compulsive urges they can also improve related depression which can work to contribute to a person's sense of well being and motivation towards getting well. Medications found to be effective include: clomipramine (brand name: Anafranil), fluoxetine (brand name: Prozac), sertraline (brand name: Zoloft), paroxetine (brand name: Paxil) and fluvoxamine (brand name: Luvox). A newer mediaction that has found success is Lexapro.[3] Other medications such as riluzole, memantine, gabapentin (Neurontin), lamotrigine (Lamictal), and low doses of the newer atypical antipsychotics olanzapine (Zyprexa), quetiapine (Seroquel) and risperidone (Risperdal) have also been found to be useful as adjuncts in the treatment of OCD. However, the use of antipsychotics in treating OCD must be undertaken carefully.[1]

Cognitive Behavioral Therapy

At the core of Cognitive Behavioral Therapy is the belief that changing the way a person thinks can change the way they feel. Cognitive therapy focuses not only on thoughts that contribute to depression and anxiety, but also on beliefs that serve the same function. The difference between thoughts and beliefs is that thoughts are events in time lasting only for a moment, whereas beliefs are more stable and long-lasting.

The cornerstone of the specific cognitive behavioral therapy that has proven to be effective in treating OCD is a technique called exposure and ritual prevention (also known as exposure and response prevention). Exposure and Response Prevention involves deliberate exposure to anxiety producing situations for the OCD patient who responds without performing his usual rituals. Cognitive therapy alone refers to the learning of strategies that help change distorted thinking and faulty belief systems. Cognitive techniques help people analyze how they respond to situations and how they could react more positively. There are workbooks designed for the OCD patient that can help support cognitive behavioral strategies and also give suggestions for ways that the family can provide support. It is important to distinguish that supporting someone's irrational fear and response to OCD is different than supporting the patient in letting go of inappropriate responses. Cognitive therapy without medication may be appropriate for those with mild to moderate OCD.

"Natural" cures

The naturally occurring sugar inositol may be an effective treatment for OCD. Inositol appears to modulate the actions of serotonin and has been found to reverse desensitization of the neurotransmitter's receptors.[4]

St. John's Wort has been claimed to be of benefit due to its (non-selective) serotonin re-uptake inhibiting qualities, and studies have emerged that have shown positive results. However, a double-blind study, using a flexible-dose schedule (600-1800 mg/day), found no difference between St. John's Wort and the placebo.[5]

Studies have also been done that show nutrition deficiencies may contribute to OCD and other mental disorders. Certain vitamin and mineral supplements may aid in the treatment of such disorders and provide the nutrients necessary for proper mental functioning.[6]

Recent studies at the University of Arizona using the tryptamine alkaloid psilocybin have shown promising results.[7]

Spiritual approach

Buddhist teachings about mindfulness are finding their way into the mainstream treatments for OCD. In most mainstream discussions of psychiatric disorders, including OCD, the philosophical and spiritual dimensions of these conditions and the related treatment and care tend to be ignored.

In Brain Lock by Jeffrey Schwartz and Beverly Beyette, in the article Buddhism, Behavior Change, and OCD by Tom Olsen that appeared in the Journal of Holistic Nursing (June 2003) and in the article Buddhism and Cognitive-Behavioral Therapy (CBT) by Dr. Paul Greene, Ph.D., the argument is made that sharing the philosophical and spiritual foundations of Buddhism are relevant to effective treatment.[8][9][10]

Extreme cases of OCD

Psychosurgery and Transcranial magnetic stimulation

For some, neither medication, support groups nor psychological treatments are completely successful in alleviating obsessive-compulsive symptoms. These patients may choose to undergo psychosurgery as a last resort. In this procedure, a surgical lesion is made in an area of the brain (the cingulate bundle). In one study, 30 percent of participants benefited significantly from this procedure.[11] Deep-brain stimulation and vagus nerve stimulation are possible surgical options which do not require the destruction of brain tissue, although their efficacy has not been conclusively demonstrated.

Though in its early stages of research, Transcranial magnetic stimulation (TMS) has shown promising results. The magnetic pulses are focused on the brain's supplementary motor area (SMA), which plays a role in filtering out extraneous internal stimuli, such as ruminations, obsessions, and tics. The TMS treatment is an attempt to normalize the SMA's activity, so that it properly filters out thoughts and behaviors associated with OCD.[12][13]

The anti-Alzheimer's drug memantine is being studied by the OC Foundation in its efficacy in reducing OCD symptoms due to it being an NMDA antagonist. One case study published in The American Journal of Psychiatry suggests that "memantine may be an option for treatment-resistant OCD, but controlled studies are needed to substantiate this observation."[14].

In popular culture

The 1997 movie, As Good As It Gets features a somewhat realistic portrayal by Jack Nicholson of a man with Obsessive Compulsive Disorder[15] who is diagnosed with OCD and displays some of its key features like; fear of germs, repetitive behavior, and an awareness of his unreasonableness. In the movie, he develops a relationship with a waitress, Carol, who is used to catering to some of his idiosyncrasies. It is through her that he comes to understand how his behavior impacts others.

In 2004 the movie The Aviator, starring Leonardo DiCaprio as Howard Hughes, addressed his struggles with OCD.

In a poll conducted by Patricia Perkins, executive director of the Obsessive-Compulsive Foundation, OCD respondents to the TV series, Monk, about a New York City detective with Obsessive Compulsive Disorder found it to be "very funny." In fact, obsessive compulsive disorder seems to be not only a central part of what makes the character funny and endearing, but it is also what contributes to making him a good detective.[16]

Notes

  1. 1.0 1.1 1.2 1.3 1.4 Landsman, Karen and Kathleen M. Rupertus, and Cherry Pedrick. Loving Someone with OCD. New Harbinger Publications, 2005. ISBN 9781572243293
  2. Lucile Packard Children's Hospital at Stanford, Lpch.org. Retrieved January 5, 2009
  3. NIMH National Institute of Mental Health, Nimh.nih.gov. Retrieved January 6, 2009.
  4. Inositol in Psychiatry, Biopsychiatry.com. Retrieved January 22, 2009.
  5. Kobak KA, et al St. John's wort versus placebo in obsessive-compulsive disorder: results from a double-blind study, Ncbi.nlm.nih.gov. Retrieved January 22, 2009.
  6. Nutritional therapies for mental disorders, Pubmedcentral.nih.gov. Retrieved January 22, 2009.
  7. Psilocybin in the Treatment of Obsessive Compulsive Disorder, Maps.org. Retrieved January 22, 2009.
  8. Westwood Institute for Anxiety Disorders, Hope4ocd.com. Retrieved January 24, 2009.
  9. Buddhism, Behavior Change, and OCD, Citeulike.org. Retrieved January 24, 2009.
  10. Buddhism and Cognitive-Behavioral Therapy (CBT), Anxiety-ocd.info. Retrieved January 24, 2009.
  11. D. H. Barlow and V. M. Durand, Essentials of Abnormal Psychology. California: Thomson Wadsworth, 2006.
  12. Transcranial Magnetic Stimulation (TMS) and Obsessive Compulsive Disorder (OCD), ClinicalTrials.gov. Retrieved January 22, 2009.
  13. Treating Refractory Obsessive Compulsive Disorder With rTMS - Full Text View - ClinicalTrials.gov., Clinicaltrials.gov. Retrieved January 22, 2009.
  14. Poyurovsky M, Weizman R, Weizman A, Koran L (2005). Memantine for treatment-resistant OCD. The American Journal of Psychiatry 162 (11): 2191-2192.
  15. Diagnosis in Psychotherapy - Portrayed in a Movie, Cinematherapy.com. Retrieved January 21, 2009.
  16. People with OCD Find 'Monk' Funny , Healthyplace.com. Retrieved January 21, 2009.

References

Further reading

  • My Worktime Routine, ISBN 1591139015, by David Vince.
  • Brain Lock: Free Yourself from Obsessive-Compulsive Behavior, ISBN 0060987111, by Jeffrey M. Schwartz.
  • Treatment of the Obsessive Personality, ISBN 0876688814, by Leon Salzman
  • Freedom From Obsessive Compulsive Disorder: A Personalized Recovery Program for Living with Uncertainty'' (2003), ISBN 1585422460, by Jonathan Grayson.
  • Just Another Day, ISBN 1591139015, by Shadi Srour.
  • The Treatment of Obsessions, ISBN 0198515375, by Stanley Rachman.
  • The Mind and the Brain: Neuroplasticity and the Power of Mental Force, ISBN 0060988479, by Jeffrey M. Schwartz, Sharon Begley.
  • The Imp of the Mind: Exploring the Silent Epidemic of Obsessive Bad Thoughts, ISBN 0452283078, by Lee Baer.
  • Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2000), ISBN 0195140923, by Fred Penzel.
  • What you can change... and what you can't, ISBN 0449909719, by Martin E.P. Seligmann, chap. "obsessions"
  • Tormenting Thoughts and Secret Rituals: The Hidden Epidemic of Obsessive-Compulsive Disorder, ISBN 0440508479, by Ian Osborn.
  • A Return to Innocence: Philosophical Guidance in an Age of Cynicism. (1998) ISBN 0060392401 by Schwartz, Jeffrey, Annie Gottlieb, and Patrick Buckley.
  • The Art of Meditation ISBN 8179921646 by David A. Cooper, Jaico Publishing House
  • Overcoming Obsessive Compulsive Disorder: A self-help guide using Cognitive Behavioral Techniques (2005) ISBN 1841199362 by David Veale and Rob Willson

External links

All links retrieved January 20, 2009.



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