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Obsessive-compulsive disorder
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Obsessive-compulsive disorder (OCD) is a mental disorder most commonly characterized by intrusive, repetitive thoughts resulting in compulsive behaviors and mental acts that the person feels driven to perform, according to rules that must be applied rigidly, aimed at reducing anxiety by preventing some dreaded event or by resolving a more nebulous sense of tension. However, the likelihood that a dreaded event will occur, or the causal relationship between the performance of compulsions and the reduction of this likelihood, tends to be imagined or exaggerated.
OCD is the fourth most common mental disorder and is nearly as common as asthma and diabetes mellitus.
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Obsessive-compulsive disorder (OCD) is a mental disorder most commonly characterized by intrusive, repetitive thoughts resulting in compulsive behaviors and mental acts that the person feels driven to perform, according to rules that must be applied rigidly, aimed at reducing anxiety by preventing some dreaded event or by resolving a more nebulous sense of tension. However, the likelihood that a dreaded event will occur, or the causal relationship between the performance of compulsions and the reduction of this likelihood, tends to be imagined or exaggerated.
OCD is the fourth most common mental disorder and is nearly as common as asthma and diabetes mellitus. In the United States, one in 50 adults has OCD. In severe cases, it affects a person's ability to function in everyday activities. The disorder often has a serious impact on the sufferer's (and their family's) 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.
The phrase "obsessive-compulsive" has become part of the English lexicon, and is often used in an informal or caricatured manner to describe someone who is meticulous, perfectionistic, absorbed in a cause, or otherwise fixated on something or someone. Although these signs are often present in OCD, a person who exhibits them does not necessarily have OCD, and may instead have obsessive-compulsive personality disorder (OCPD) or some other condition.
Diagnostic criteria
To be diagnosed with OCD, a person must have obsessions and/or compulsions, according to the DSM-IV-TR diagnostic criteria. The Quick Reference to the diagnostic criteria from DSM-IV-TR (2000) states six characteristics of obsessions and compulsions:
Obsessions
- Recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and that cause marked anxiety or distress.
- The thoughts, impulses, or images are not simply excessive worries about real-life problems.
- The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action.
- The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind, and are not based in reality.
Compulsions
- 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 or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts are not actually connected to the issue, or they are excessive.
In addition to these criteria, at some point during the course of the disorder, the individual must realize that his/her obsessions or compulsions are unreasonable or excessive. Moreover, the obsessions or compulsions must be time-consuming (taking up more than one hour per day), cause distress, or cause impairment in social, occupational, or school functioning. OCD often causes feelings similar to those of depression.
Symptoms and prevalence
OCD manifests in a variety of forms. Studies have placed the prevalence between one and three percent, although the prevalence of clinically recognized OCD is much lower, suggesting that many individuals with the disorder may not be diagnosed. The fact that many individuals do not seek treatment may be due in part to stigma associated with OCD. Another reason for not seeking treatment is that many sufferers of OCD do not realize that they have the condition.
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 to stop the stress from building up. 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, repeatedly washing hands at regular intervals throughout the day, touching objects a certain number of times before leaving a room, or walking in a certain routine way. Physical symptoms may include those brought on from anxieties and unwanted thoughts, as well as tics or Parkinson's disease-like symptoms: rigidity, tremor, jerking arm movements, or involuntary movements of the limbs.
Formal diagnosis may be performed by a psychologist, a psychiatrist or psychoanalyst. OCD sufferers are aware that their thoughts and behavior are not rational, but they feel bound to comply with them to fend off feelings of panic or dread. Although everyone may experience unpleasant thoughts at one time or another, these are short-lived and fade away in time. For people with OCD, the thoughts are intrusive and persistent, and can cause them great anxiety and distress.
Intrusive thoughts are unwelcome, involuntary thoughts, images or unpleasant ideas that may become obsessions, are upsetting or distressing, and can be difficult to be free of and manage. As with other forms of OCD, the awareness of the irrationality of these thoughts can be frustrating as the individual wishes to stop them but cannot. Intrusive thoughts, urges, and images are of inappropriate things at inappropriate times, usually falling into three categories: inappropriate aggressive thoughts, inappropriate sexual thoughts, and blasphemous religious thoughts. Most people experience these thoughts; when they are associated with OCD or depression, they may become paralyzing, anxiety-provoking, and persistent. Many people experience the type of unpleasant or unwanted thoughts that people with more troubling intrusive thoughts have, but most people are able to dismiss these thoughts. When intrusive thoughts co-occur with OCD, patients are less capable of ignoring the unpleasant thoughts and may pay undue attention to them, causing the thoughts to become more frequent and distressing.
The common underlying theme to the diverse intrusive thoughts is summarised by Bruce et al with the example, "What if I were to snap, lose control of myself, and do something totally uncharacteristic of me--perhaps even without my knowing it--that results in harm to myself or someone else?"
OCD without Overt compulsions
A major subtype of OCD is OCD without overt compulsions. OCD without overt compulsions is often referred to as "pure-O" by laymen and sufferers of this disorder. The term is a bit of a misnomer, however, since OCD without overt compulsions is no more "pure" than any other form of OCD. Nonetheless, OCD without overt compulsions represents a major subtype of OCD with some of the estimates as high 50-60%. Rather than engaging in observable rituals and compulsions, the person with OCD without overt compulsions engages in all manner of mental neutralizing behaviours (i.e. "covert" compulsions).
Intrusive thoughts may involve violent obsessions about hurting others or oneself. They can include such thoughts as harming an innocent child, jumping from a bridge, mountain or the top of a tall building, urges to jump in front of a train or automobile, and urges to push another in front of a train or automobile. A survey of healthy college students found that virtually all of them had intrusive thoughts from time to time, including imagining or wishing harm upon a family member or friend, impulses to attack or kill a small child, or animal, or shout something rude or violent.
The possibility that most patients suffering from intrusive thoughts will ever act on those thoughts is low; patients who are experiencing intense guilt, anxiety, shame, and anger over bad thoughts are different from those who actually act on bad thoughts. The history of violent crime is dominated by those who feel no guilt or remorse; the very fact that someone is tormented by intrusive thoughts, and has never acted on them before, is an excellent predictor that they won't act upon the thoughts. According to Baer, a patient should be concerned that intrusive thoughts are dangerous if the person doesn't feel upset by the thoughts, rather finds them pleasurable; has ever acted on violent or sexual thoughts or urges; hears voices or sees things that others don't see; or feels uncontrollable irresistible anger.
Sexual obsessions may involve intrusive thoughts or images of "kissing, hugging a lot, touching, fondling, oral sex, anal sex, intercourse, and rape" with "strangers, acquaintances, parents, children, family members, friends, coworkers, animals and religious figures", involving "heterosexual or homosexual content" with persons of any age. Like other intrusive, unpleasant thoughts or images, most people have some inappropriate sexual thoughts at times, but people with OCD may attach significance to the unwanted sexual thoughts, generating anxiety and distress. The doubt that accompanies OCD leads to uncertainty regarding whether one might act on the bad thoughts, resulting in self-criticism or loathing.
OCD with Overt Compulsions
Other major subtypes of OCD frequently revolve around washing or checking; some sufferers may fear the presence of human body secretions such as saliva, blood, semen, sweat, tears, vomit, or mucus, or excretions such as urine or feces. Some OCD sufferers even fear that the soap they are using is contaminated. These anxiety-driven fears often result in various compulsive cleaning behaviours, and may cause a person to experience significant distress, which may make it difficult for a person with OCD to tolerate a workplace, venture into public locations, or conduct normal social relationships.
Symptoms related to performing tasks may include repeated hand washing or clearing of the throat; specific counting systems or counting of steps; doing repetitive actions—more generally, this can involve an obsession with numbers or types of numbers (e.g., odd numbers). For example, when somebody suffering from OCD leaves the house, they might tap the door knob 9 times and if they don't they will go into distress, panic and even at certain times, they will pass out. These obsessive behaviors can cause individuals to feel psychological distress, because they are very concerned about having "made mistakes" in the number of steps that they have taken, or the number of stairs on a staircase. For some people with OCD, these obsessive counting and re-counting tasks, along with the attendant anxiety and fear, can take hours of each day, which can make it hard for the person to fulfill their work, family, or social roles. In some cases, these behaviors can also cause adverse physical symptoms: people who obsessively wash their hands with antibacterial soap and hot water (to remove germs) can make their skin red and raw with dermatitis.
Related conditions
OCD is often confused with the separate condition obsessive-compulsive personality disorder. The two are not the same condition, however. OCD is ego dystonic, meaning that the disorder is incompatible with the sufferer's self-concept. Because disorders that are ego dystonic go against an individual's perception of his/herself, they tend to cause much distress. OCPD, on the other hand, is ego syntonic—marked by the individual's acceptance that the characteristics displayed as a result of this disorder are compatible with his/her self-image. Ego syntonic disorders understandably cause no distress. Persons suffering from OCD are often aware that their behavior is not rational and are unhappy about their obsessions but nevertheless feel compelled by them. Persons with OCPD are not aware of anything abnormal about themselves; they will readily explain why their actions are rational, and it is usually impossible to convince them otherwise. Persons with OCD are ridden with anxiety; persons who suffer from OCPD, by contrast, tend to derive pleasure from their obsessions or compulsions. This is a significant difference between these disorders.
Equally frequently, these rationalizations do not apply to the overall behavior, but to each instance individually; for example, a person compulsively checking their front door may argue that the time taken and stress caused by one more check of the front door is considerably less than the time and stress associated with being robbed, and thus the check is the better option. In practice, after that check, the individual is still not sure, and it is still better in terms of time and stress to do one more check, and this reasoning can continue as long as necessary.
Some OCD sufferers exhibit what is known as overvalued ideas. In such cases, the person with OCD will truly be uncertain whether the fears that cause them 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. There are severe cases when the sufferer has an unshakeable belief within the context of OCD which is difficult to differentiate from psychosis.
OCD is different from behaviors such as gambling addiction and 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 placed in the anxiety class of mental illness, but like many chronic stress disorders it can lead to clinical depression over time. The constant stress of the condition can cause sufferers to develop a deadening of spirit, a numbing frustration, or sense of hopelessness. OCD's effects on day-to-day life—particularly its substantial consumption of time—can produce difficulties with work, finances and relationships. There is no known cure for OCD as of yet, but there are a number of successful treatment options available.
Related/Spectrum disorders
People with OCD may be diagnosed with other conditions, such as generalized anxiety disorder, anorexia nervosa, social anxiety disorder, bulimia nervosa, Tourette syndrome, Asperger syndrome, compulsive skin picking, body dysmorphic disorder, trichotillomania, and (as already mentioned) obsessive-compulsive personality disorder. There is some research demonstrating a link between drug addiction and OCD as well. Many who suffer from OCD also suffer from panic attacks. There is a higher risk of drug addiction among those with any anxiety disorder (possibly as a way of coping with the heightened levels of anxiety), but drug addiction among OCD patients may serve as a type of compulsive behavior and not just as a coping mechanism. Depression is also extremely prevalent among sufferers of OCD. One explanation for the high depression rate among OCD populations was posited by Mineka, Watson, and Clark (1998), who explained that people with OCD (or any other anxiety disorder) may feel depressed because of an "out of control" type of feeling.
Some cases are thought to be caused at least in part by childhood streptococcal infections and are termed PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections). The streptococcal antibodies become involved in an autoimmune process. Though this idea is not set in stone, if it does prove to be true, there is cause to believe that OCD can to some very small extent be "caught" via exposure to strep throat (just as one may catch a cold). However, if OCD is caused by bacteria, this provides hope that antibiotics may eventually be used to treat or prevent it.
Causes
Psychological
Scientists studying obsessive-compulsive disorder generally agree that both psychological and biological factors play a role in causing the disorder, although they differ in their degree of emphasis upon either type of factor.
From the 14th to the 16th century in Europe, it was believed that people who experienced blasphemous, sexual, or other obsessive thoughts were possessed by the Devil. Based on this reasoning, treatment involved banishing the "evil" from the "possessed" person through exorcism.
In the early 1910s, Sigmund Freud attributed obsessive-compulsive behavior to unconscious conflicts which manifested as symptoms. Freud describes the clinical history of a typical case of "touching phobia" as starting in early childhood, when the person has a strong desire to touch an item. In response, the person develops an "external prohibition" against this type of touching. However, this "prohibition does not succeed in abolishing" the desire to touch; all it can do is repress the desire and "force it into the unconscious".
The cognitive-behavioral model suggests that compulsive behaviour is carried out to remove anxiety-provoking intrusive thoughts. Unfortunately this only brings about temporary relief as the thought re-emerges. Each time the behaviour occurs it is negatively reinforced (see Reinforcement) by the relief from anxiety, thereby explaining why the dysfunctional activity increases and generalises (extends to other, related stimuli) over a period of time. For example, after touching a door-knob a person might have the thought that they may develop a disease as a result of contamination. They then experience anxiety, which is relieved when they wash their hands. This might be followed by the thought "but did I wash them properly?" causing an increase in anxiety once more, the hand-washing once again rewarded by the removal of anxiety (albeit briefly) and the cycle being repeated when thoughts of contamination re-occur. The distressing thoughts might then spread to fear of contamination from e.g. a chair (someone might have touched the chair after touching the door handle).
Biological
There are many different theories about the cause of obsessive-compulsive disorder. The majority of researchers believe that there is some type of abnormality with the neurotransmitter serotonin, among other possible psychological or biological abnormalities; however, it is possible that this activity is the brain's response to OCD, and not its cause. Serotonin is thought to have a role in regulating anxiety, though it is also thought to be involved in such processes as sleep and memory function. In order to send chemical messages, serotonin must bind to the receptor sites located on the neighboring nerve cell. It is hypothesized that OCD sufferers may have blocked or damaged receptor sites that prevent serotonin from functioning to its full potential. This suggestion is supported by the fact that many OCD patients benefit from the use of selective serotonin reuptake inhibitors (SSRIs)—a class of antidepressant medications that allow for more serotonin to be readily available to other nerve cells. For more about this class of drugs, see the section about potential treatments for OCD.
The Stanford University School of Medicine OCD webpage states, "Although the causes of the disorder still elude us, the recent identification of children with OCD caused by an autoimmune response to Group A streptococcal infection promises to bring increased understanding of the disorder's pathogenesis."
Recent research has revealed a possible genetic mutation that could help to cause OCD. Researchers funded by the National Institutes of Health have found a mutation in the human serotonin transporter gene, hSERT, in unrelated families with OCD. Moreover, in his study of identical twins, Rasmussen (1994) produced data that supported the idea that there is a "heritable factor for neurotic anxiety". In addition, he noted that environmental factors also play a role in how these anxiety symptoms are expressed. However, various studies on this topic are still being conducted and the presence of a genetic link is not yet definitely established.
Another possible genetic cause of OCD was discovered in August 2007 by scientists at Duke University Medical Center in North Carolina. They genetically engineered mice that lacked a gene called SAPAP3. This protein is highly expressed in the striatum, an area of the brain linked to planning and the initiation of appropriate actions. The mice spent three times as much time grooming themselves as ordinary mice, to the point that their fur fell off.
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. A popular explanation for OCD is that offered in the book Brain Lock by Jeffrey Schwartz, which suggests that OCD is caused by the part of the brain that is responsible for translating complex intentions (e.g., "I will pick up this cup") into fundamental actions (e.g., "move arm forward, rotate hand 15 degrees, etc.") failing to correctly communicate the chemical message that an action has been completed. This is perceived as a feeling of doubt and incompleteness, which then leads the individual to attempt to consciously deconstruct their own prior behavior—a process which induces anxiety in most people, even those without OCD .
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. The increased stimulation of the serotonin receptors 5-HT2A and 5-HT2C in the OFC is believed to cause this inhibition.
Some research has discovered an association between a type of size abnormality in different brain structures and the predisposition to develop OCD. Through the use of magnetic resonance imaging (MRI), researchers at Cambridge's Brain Mapping Unit were able to discover distinctive patterns in the brain structure of individuals with OCD and their close family members. This is the first instance in which it has been demonstrated that those with a familial risk of developing OCD have anatomical differences when compared with ordinary individuals. 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.
In some patients, the consumption of caffeine may make OCD symptoms worse.
Demographics and other statistics
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.
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), and medications 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 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.
Exposure ritual/response prevention has been demonstrated to be the most effective treatment for OCD. It has generally been accepted that psychotherapy, in combination with psychotropic medication, is more effective than either option alone. However, more recent studies have shown no difference in outcomes for those treated with the combination of medicine and CBT versus CBT alone.
Recently it has been reported simultaneous administration of D-Cycloserin (an antibiotic) substantially improves effectiveness of Exposure and Response prevention.
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.
Benzodiazepines are also used in treatment. It's not uncommon to administer this class of drugs during the "latency period" for SSRIs or as synergistic adjunct long-term. Although widely prescribed, benzodiazepines have not been demonstrated as an effective treatment for OCD and may be habit-forming in those with a history of substance abuse.
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. Much current research is devoted to the therapeutic potential of the agents that effect the release of the neurotransmitter glutamate or the binding to its receptors. These include riluzole, memantine, gabapentin (Neurontin) and lamotrigine (Lamictal).
Low doses of the newer atypical antipsychotics olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone 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 can be due to the antagonism of 5-HT2A receptors becoming very prominent at these doses and outweighing the benefits of dopamine antagonism. However antidepressant mirtazapine which is a 5-HT2A antagonist has shown to be of benefit to OCD patients. 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.
Alternative drug treatments
The naturally occurring sugar inositol has been suggested as a treatment for OCD, as it appears to modulate the actions of serotonin and reverse desensitisation of neurotransmitter receptors. St John's Wort has been claimed to be of benefit due to its (non-selective) serotonin re-uptake inhibiting qualities, although a double-blind study using a flexible-dose schedule (600-1800 mg/day) found no difference between St John's Wort and a placebo.
Nutrition deficiencies may also contribute to OCD and other mental disorders. Vitamin and mineral supplements may aid in such disorders and provide nutrients necessary for proper mental functioning.
Opioids may significantly reduce OCD symptoms, though their use is not sanctioned for treatment due to physical dependence and long term drug tolerance. Tramadol is an atypical opioid that appears to provide the anti-OCD effects of an opiate and inhibit the re-uptake of serotonin (in addition to norepinephrine).
Tryptamine alkaloid psilocybin has been attempted as treatment. There are reports that other hallucinogens such as LSD and peyote have produced similar effects. It has been hypothesised that this effect may be due to stimulation of 5-HT2A receptors and, less significantly, 5-HT2C receptors; this causes an inhibitory effect on the orbitofrontal cortex, an area of the brain in which hyperactivity has been strongly associated with OCD.
Regular nicotine treatment may ameliorate symptoms of OCD, although the pharmacodynamical mechanism by which this is achieved is not yet known, and more detailed studies are needed to fully confirm this hypothesis.
Psycho-surgery
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.
In the US, psychosurgery for OCD is a treatment of last resort and will not be performed until the patient has failed several attempts at medication (at the full dosage) with augmentation, and many months of intensive cognitive-behavioral therapy with exposure and ritual/response prevention. Likewise, in the UK, psychosurgery cannot be performed unless a course of treatment from a suitably qualified cognitive-behavioural therapist has been carried out.
Neuropsychiatry
OCD primarily involves the brain regions of the striatum, the orbitofrontal cortex and the cingulate cortex. OCD involves several different receptors, mostly H2, M4, NK1, NMDA, and non-NMDA glutamate receptors. The receptors 5-HT1D, 5-HT2C, and the µ opioid receptor exert a secondary effect. The H2, M4, NK1, and non-NMDA glutamate receptors are active in the striatum, whereas the NMDA receptors are active in the cingulate cortex.
The activity of certain receptors is positively correlated to the severity of OCD, whereas the activity of certain other receptors is negatively correlated to the severity of OCD. Correlations where activity is positively correlated to severity include the histamine receptor (H2); the Muscarinic acetylcholine receptor(M4); the Tachykinin receptor (NK1); and non-NMDA glutamate receptors. Correlations where activity is negatively correlated to severity include the NMDA receptor (NMDA); the Mu opioid receptor (µ opioid); and two types of 5-HT receptors (5-HT1D and 5-HT2C)
The central dysfunction of OCD may involve the receptors nk1, non-NMDA glutamate receptors, and NMDA, whereas the other receptors could simply exert secondary modulatory effects.
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. Many trials are currently underway to investigate the efficacy of a variety of agents that affect these 'core' neurotransmitters, particularly glutamatergic agents.
Notable cases
- British poet, essayist, and lexicographer Samuel Johnson is an example of a historical figure with a retrospective diagnosis of OCD. He had elaborate rituals for crossing the thresholds of doorways, repeatedly walked up and down staircases counting the steps, and had compulsions regarding repetitive prayer which were most likely a form of religious scrupulosity.
- American aviator and filmmaker Howard Hughes is known to have suffered from OCD and it is believed that his mother may have also been a sufferer. Friends of Hughes have mentioned his obsession with minor flaws in clothing and he is reported to have had a great fear of germs, common among OCD patients. He did also suffer from Social Anxiety Disorder (SAD) and Post-traumatic Stress Disorder (PTSD) due to an aviation accident in which he was severely injured. This resulted in him becoming reclusive later in life.
- English footballer David Beckham has been outspoken regarding his struggle with OCD. He has told media that he has to count all his clothes, and that magazines have to lie in a straight line. No more than three soda cans are allowed in his refrigerator, and if there are any more at home they have to be placed in a cupboard. He has explained that the reason he gets more tattoos is that he feels addicted to the pain of the needle. In hotels, any books that are on a shelf must be placed in the drawer. He has expressed a desire to get help for his problems.
See also
Further reading
- My Worktime Routine, ISBN 1-59-113901-5, by David Vince.******The Boy Who Finally Stopped Washing: OCD From Both Sides of the Couch (2008) by 3LIAS MARTINEZ
External links
- , at BrainPhysics OCD Resource, developed by the OC and Spectrum Disorders Association
- , by Dr. Steven Phillipson
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