Obsessive compulsive disorder

"OCD" redirects here.

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 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.

Given recent developments in brain research, medications, and behavior therapy, Obsessive Compulsive Disorder is a treatable condition. It affects both men and woman equally and some estimates say that as many as two million Americans ages 18 to 54, an estimated 2.3 percent of the population, may have OCD at any one time. 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. As our understanding of mental illness grows, along with better and more effective treatments, children can be diagnosed early on preventing future problems.

Diagnosing OCD

Mental health profesionals 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). 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 mostly keeps such thoughts and behaviors to him or herself, due to feelings of either shame and/or denial about their condition.

OCD and children

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.

Average onset age of OCD in cildren 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 thirteen. Nearly half of all adults with OCD have had an onset in childhood, although received help much later (March and Mulle 1998).

Possible causes of OCD

brain structures circuity and merochemic factors orbital cortex singulate gyrus PET scans -Technological advancements have allowed for the possibility of brain imaging. Using tools like positron emission tomography (PET scans), it has been shown that those with OCD tend to have brain activity that differs from those who do not have this disorder. strep genetic basis- genetic mutation -the presence of a genetic link is not yet definitely established neorobiological-The discovery of these structural differences in the area of the brain associated with stopping motor response may ultimately aid researchers who seek to determine which genes contribute to the development of OCD.

Doubt and uncertainty feed it

It has been theorized that a miscommunication between the orbitofrontal cortex, the caudate nucleus, and the thalamus may be a factor in the explanation of OCD. The orbitofrontal cortex (OFC) is the first part of the brain to notice whether or not something is wrong. When the OFC notices that something is wrong, it sends an initial "worry signal" to the thalamus. When the thalamus receives this signal, it in turn sends signals back to the OFC to interpret the worrying event. The caudate nucleus lies between the OFC and the thalamus and prevents the initial worry signal from being sent back to the thalamus after it has already been received. However, it is suggested that in those with OCD, the caudate nucleus does not function properly, and therefore does not prevent this initial signal from recurring. This causes the thalamus to become hyperactive and creates a virtually never-ending loop of worry signals being sent back and forth between the OFC and the thalamus. The OFC responds by increasing anxiety and engaging in compulsive behaviors in an attempt to relieve this apprehension. This overactivity of the OFC is shown to be attenuated in patients who have successfully responded to SSRI medication.

OCD symptoms

The typical OCD sufferer performs tasks (or compulsions) to seek relief from obsession-related anxiety. 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.

Compulsions may also include but are not limited to the following:

• Fear of dirt or germs
• Concern with order, symmetry (balance) and exactness
• Worry that a task has been done poorly, even when the person knows this is not true
• Fear of thinking evil or sinful thoughts
• Thinking about certain sounds, images, words or numbers all the time
• Need for constant reassurance
• Checking drawers, door locks and appliances to be sure they are shut, locked or turned off
• Repeating, such as going in and out of a door, sitting down and getting up from chair, or touching certain objects several times

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 continually 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.

ALthough, there is no known cure for OCD as of yet, but there are a number of successful treatment options available.

Prognosis

In a 1980 study of 20,000 adults from New Haven, Baltimore, St. Louis, Durham, and Los Angeles, the lifetime prevalence rate of OCD for both sexes was recorded at 2.5 percent.

Education also appears to be a factor. The lifetime prevalence of OCD is lower for those who have graduated high school than for those who have not (1.9 percent versus 3.4 percent). However, in the case of college education, lifetime prevalence is higher for those who graduate with a degree (3.1 percent) than it is for those who have only some college background (2.4 percent). As far as age is concerned, the onset of OCD usually ranges from the late teenage years until the mid-20s in both sexes, but the age of onset tends to be slightly younger in males than in females.

Violence is very rare among OCD sufferers, but the disorder is often debilitating to their quality of life. Also, the psychological self-awareness of the irrationality of the disorder can be painful. For people with severe OCD, it may take several hours a day to carry out the compulsive acts. To avoid perceived obsession triggers, they also often avoid certain situations or places altogether.

It has been alleged that sufferers are generally of above-average intelligence, as the very nature of the disorder necessitates complicated thinking patterns.

Treatment

According to the Expert Consensus Guidelines for the Treatment of obsessive-compulsive disorder, behavioral therapy (BT), cognitive therapy (CT), medications, or any combination of the three, are first-line treatments for OCD. Psychodynamic psychotherapy may help in managing some aspects of the disorder, but there are no controlled studies that demonstrate effectiveness of psychoanalysis or dynamic psychotherapy in OCD.

Behavioral and family therapy

The specific technique used in BT/CBT is called exposure and ritual prevention (also known as "exposure and response prevention") or ERP; this involves gradually learning to tolerate the anxiety associated with not performing the ritual behavior. At first, for example, someone might touch something only very mildly "contaminated" (such as a tissue that has been touched by another tissue that has been touched by the end of a toothpick that has touched a book that came from a "contaminated" location, such as a school.) That is the "exposure." The "ritual prevention" is not washing. Another example might be leaving the house and checking the lock only once (exposure) without going back and checking again (ritual prevention). The person fairly quickly habituates to the anxiety-producing situation and discovers that their anxiety level has dropped considerably; they can then progress to touching something more "contaminated" or not checking the lock at all—again, without performing the ritual behavior of washing or checking.

This has been demonstrated to be the most effective treatment for OCD. In the U.K. psycho-surgery cannot be performed unless a course of treatment from a suitably qualified cognitive-behavioural therapist has been carried out. cognitive self-therapy and behavior modification to develop new patterns of response to their obsessions.

Medication

Medications as treatment include selective serotonin reuptake inhibitors (SSRIs) such as paroxetine (Seroxat, Paxil, Xetanor, ParoMerck, Rexetin), sertraline (Zoloft, Stimuloton), fluoxetine (Prozac, Bioxetin), escitalopram (Lexapro), and fluvoxamine (Luvox) as well as the tricyclic antidepressants, in particular clomipramine (Anafranil). SSRIs prevent excess serotonin from being pumped back into the original neuron that released it. Instead, serotonin can then bind to the receptor sites of nearby neurons and send chemical messages or signals that can help regulate the excessive anxiety and obsessive thoughts. In some treatment-resistant cases, a combination of clomipramine and an SSRI has shown to be effective even when neither drug on its own has been efficacious. Serotonergic antidepressants typically take longer to show benefit in OCD than with most other disorders which they are used to treat, as it is common for 2–3 months to elapse before any tangible improvement is noticed. In addition to this, the treatment usually requires high doses. Fluoxetine, for example, is usually prescribed in doses of 20 mg per day for clinical depression, whereas with OCD the dose will often range from 20 mg to 80 mg or higher, if necessary. In most cases antidepressant therapy alone will only provide a partial reduction in symptoms, even in cases that are not deemed treatment-resistant. 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. The use of antipsychotics in OCD must be undertaken carefully, however, since, although there is very strong evidence that at low doses they are beneficial (most likely due to their dopamine receptor antagonism), at high doses these same antipsychotics have proven to cause dramatic obsessive-compulsive symptoms even in those patients who do not normally have OCD. This is most likely due to the antagonism of 5-HT2A receptors becoming very prominent at these doses and outweighing the benefits of dopamine antagonism. Another point that must be noted with antipsychotic treatment is that SSRIs inhibit the chief enzyme that is responsible for metabolising antipsychotics — CYP2D6 — so the dose will be effectively higher than expected when these are combined with SSRIs. Also, it must be noted that antipsychotic treatment should be considered as augmentation treatment when SSRI treatment does not bring positive results. Thus, according to the Obsessive Compulsive Foundation, the antipsychotic treatment that is not added into SSRI treatment can cause on-set OCD symptoms.

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 desensitisation of the neurotransmitter's receptors.

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.

Recent research has found increasing evidence that opioids may significantly reduce OCD symptoms, though the addictive property of these drugs likely stands as an obstacle to their sanctioned approval for OCD treatment. Anecdotal reports suggest that some OCD sufferers have successfully self-medicated with opioids such as Ultram and Vicodin, though the off-label use of such painkillers is not widely accepted, again because of their addictive qualities. Tramadol is an atypical opioid that may be a viable option as it has a low potential for abuse and addiction, mild side effects, and shows signs of rapid efficacy in OCD. Tramadol not only provides the anti-OCD effects of an opiate, but also inhibits the re-uptake of serotonin (in addition to norepinephrine). This may provide additional benefits, but should not be taken in combination with antidepressant medication unless under careful medical supervision due to potential serotonin syndrome.

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

Research has generally shown that psychotherapy, in combination with psychotropic medication, is more effective than either option alone.

Recent studies at the University of Arizona using the tryptamine alkaloid psilocybin have shown promising results. There are reports that other hallucinogens such as LSD and peyote have produced similar benefits. It has been hypothesised that this effect may be due to stimulation of 5-HT2A receptors and, less importantly, 5-HT2C receptors. This causes, among many other effects, an inhibitory effect on the orbitofrontal cortex, an area of the brain in which hyperactivity has been strongly associated with OCD.

Emerging evidence has suggested that regular nicotine treatment may be helpful in improving symptoms of OCD, although the pharmacodynamical mechanism by which this improvement is achieved is not yet known, and more detailed studies are needed to fully confirm this hypothesis. Anecdotal reports suggest OCD can worsen when cigarettes are smoked.

Extreme cases of OCD

Psychosurgery and Transcranial magnetic stimulation

For some, neither medication, support groups nor psychological treatments are helpful 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% of participants benefited significantly from this procedure. 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.

Neuropsychiatry

Pharmaceuticals that act directly on those core mechanisms are aprepitant (nk1 antagonist), riluzole (glutamate release inhibitor), and tautomycin (NMDA receptor sensitizer). Also, 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." The drugs that are popularly used to fight OCD lack full efficacy because they do not act upon what are believed to be the core mechanisms.

In popular culture

The movie, As Good As It Get features a somewhat realistic portrayal by Jack Nicholson of a man with Obsessive Compulsive Disorder[1] Melvin,,,,, who is diagnosed with OCD and displays some of its key features such as:

References

ISBN links support NWE through referral fees

• Health Informaton for the Whole Family Retrieved January 3, 2009.
• Landsman, Karen and Kathleen M. Rupertus, and Cherry Pedrick. Loving Someone with OCD New Harbinger Publications 2005 ISBN 9781572243293
• Lucile Packard Children's Hospital at Stanford Retrieved January 5, 2009

Further reading

• My Worktime Routine, ISBN 1-59-113901-5, by David Vince.
• Brain Lock: Free Yourself from Obsessive-Compulsive Behavior, ISBN 0-06-098711-1, by Jeffrey M. Schwartz.
• Treatment of the Obsessive Personality, ISBN 0-87668-881-4, by Leon Salzman
• Freedom From Obsessive Compulsive Disorder: A Personalized Recovery Program for Living with Uncertainty'' (2003), ISBN 1-58542-246-0, by Jonathan Grayson.
• Just Another Day, ISBN 1-59-113901-5, by Shadi Srour.
• The Treatment of Obsessions, ISBN 0-19-851537-5, by Stanley Rachman.
• The Mind and the Brain: Neuroplasticity and the Power of Mental Force, ISBN 0-06-098847-9, by Jeffrey M. Schwartz, Sharon Begley.
• The Imp of the Mind: Exploring the Silent Epidemic of Obsessive Bad Thoughts, ISBN 0-452-28307-8, by Lee Baer.
• Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2000), ISBN 0-19-514092-3, by Fred Penzel.
• What you can change... and what you can't, ISBN 0-449-90971-9, by Martin E.P. Seligmann, chap. "obsessions"
• Tormenting Thoughts and Secret Rituals: The Hidden Epidemic of Obsessive-Compulsive Disorder, ISBN 0-440-50847-9, by Ian Osborn.
• The Art of Meditation ISBN 81-7992-164-6 by David A. Cooper, Jaico Publishing House
• Overcoming Obsessive Compulsive Disorder: A self-help guide using Cognitive Behavioural Techniques (2005) ISBN 1-84119-936-2 by David Veale and Rob Willson

External Links

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