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Obsessive–Compulsive Disorder (OCD)

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Introduction

Obsessive–compulsive disorder (OCD) is a mental disorder where people feel the need to check things repeatedly, perform certain routines repeatedly, or have certain thoughts repeatedly. People are unable to control either the thoughts or the activities. Common activities include hand washing, counting of things, and checking to see if a door is locked. Some may have difficulty throwing things out. These activities occur to such a degree that the person's daily life is negatively affected. Often they take up more than an hour a day. Most adults realize that the behaviors do not make sense. The condition is associated with tics, anxiety disorder, and an increased risk of suicide. The cause is unknown.

Rating scales such as the Yale–Brown Obsessive Compulsive Scale can be used to assess the severity. Other disorders with similar symptoms include anxiety disorder, major depressive disorder, eating disorders, tic disorders, and obsessive–compulsive personality disorder.

Treatment for OCD involves the use of behavioral therapy and sometimes selective serotonin reuptake inhibitors (SSRIs). The type of behavior therapy used involves increasing exposure to what causes the problems while not allowing the repetitive behavior to occur. While clomipramine appears to work as well as SSRIs it has greater side effects. Atypical antipsychotics may be useful when used in addition to an SSRI in treatment-resistant cases but are also associated with an increased risk of side effects. Without treatment, the condition often lasts decades.

Obsessive–compulsive disorder affects about 2.3% of people at some point in their life. Rates during a given year are about 1.2% and it occurs worldwide. It is unusual for symptoms to begin after the age of thirty-five and half of people develop problems before twenty. Males and females are affected about equally. In English the phrase obsessive–compulsive is often used in an informal manner unrelated to OCD to describe someone who is excessively meticulous, perfectionistic, absorbed, or otherwise fixated.

Obsessions are thoughts that recur and persist despite efforts to ignore or confront them. People with OCD frequently perform tasks, or compulsions, to seek relief from obsession-related anxiety. Within and among individuals, the initial obsessions, or intrusive thoughts, vary in their clarity and vividness. A relatively vague obsession could involve a general sense of disarray or tension accompanied by a belief that life cannot proceed as normal while the imbalance remains. A more intense obsession could be a preoccupation with the thought or image of someone close to them dying or intrusions related to "relationship rightness." Other obsessions concern the possibility that someone or something other than oneself—such as God, the Devil, or disease—will harm either the person with OCD or the people or things that the person cares about. Other individuals with OCD may experience the sensation of invisible protrusions emanating from their bodies, or have the feeling that inanimate objects are ensouled.

Some people with OCD experience sexual obsessions that may involve intrusive thoughts or images of "kissing, touching, fondling, oral sex, anal sex, intercourse, incest and rape" with "strangers, acquaintances, parents, children, family members, friends, coworkers, animals and religious figures", and can include "heterosexual or homosexual content" with persons of any age. As with other intrusive, unpleasant thoughts or images, most "normal" people have some disquieting sexual thoughts at times, but people with OCD may attach extraordinary significance to the thoughts. For example, obsessive fears about sexual orientation can appear to the person with OCD, and even to those around them, as a crisis of sexual identity. Furthermore, the doubt that accompanies OCD leads to uncertainty regarding whether one might act on the troubling thoughts, resulting in self-criticism or self-loathing.

People with OCD understand that their notions do not correspond with reality; however, they feel that they must act as though their notions are correct. For example, an individual who engages in compulsive hoarding might be inclined to treat inorganic matter as if it had the sentience or rights of living organisms, while accepting that such behavior is irrational on a more intellectual level.

Primarily obsessional

OCD sometimes manifests without overt compulsions. Nicknamed "Pure-O", or referred to as Primarily Obsessional OCD, OCD without overt compulsions could, by one estimate, characterize as many as 50 percent to 60 percent of OCD cases. Primarily obsessional OCD has been called one of the most distressing and challenging forms of OCD. People with this form of OCD have distressing and unwanted thoughts emerging frequently, and these thoughts typically center on a fear that one may do something totally uncharacteristic of oneself, possibly something potentially fatal to oneself or others. The thoughts may likely be of an aggressive or sexual nature.

Rather than engaging in observable compulsions, the person with this subtype might perform more covert, mental rituals, or might feel driven to avoid the situations in which particular thoughts seem likely to intrude. As a result of this avoidance, people can struggle to fulfill both public and private roles, even if they place great value on these roles and even if they had fulfilled the roles successfully in the past. Moreover, the individual's avoidance can confuse others who do not know its origin or intended purpose, as it did in the case of a man whose wife began to wonder why he would not hold their infant child. The covert mental rituals can take up a great deal of a person's time during the day.

Compulsions

Dermatillomania

Some people with OCD perform compulsive rituals because they inexplicably feel they have to, others act compulsively so as to mitigate the anxiety that stems from particular obsessive thoughts. The person might feel that these actions somehow either will prevent a dreaded event from occurring, or will push the event from their thoughts. In any case, the individual's reasoning is so idiosyncratic or distorted that it results in significant distress for the individual with OCD or for those around them. Excessive skin picking (i.e., dermatillomania) or hair plucking (i.e., trichotillomania) and nail biting (i.e., onychophagia) are all on the obsessive–compulsive spectrum. Individuals with OCD 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.

Some common compulsions include counting specific things (such as footsteps) or in specific ways (for instance, by intervals of two), and doing other repetitive actions, often with atypical sensitivity to numbers or patterns. People might repeatedly wash their hands or clear their throats, make sure certain items are in a straight line, repeatedly check that their parked cars have been locked before leaving them, constantly organize in a certain way, turn lights on and off, keep doors closed at all times, touch objects a certain number of times before exiting a room, walk in a certain way, like only stepping on a certain color of tile, or have a routine for using stairs, such as always finishing a flight on the same foot.

The compulsions of OCD must be distinguished from tics; movements of other movement disorders such as chorea, dystonia, myoclonus; movements exhibited in stereotypic movement disorder or some autistic people; and the movements of seizure activity. There may exist a notable rate of comorbidity between OCD and tic-related disorders.

People rely on compulsions as an escape from their obsessive thoughts; however, they are aware that the relief is only temporary, that the intrusive thoughts will soon return. Some people use compulsions to avoid situations that may trigger their obsessions. Although some people do certain things over and over again, they do not necessarily perform these actions compulsively. For example, bedtime routines, learning a new skill, and religious practices are not compulsions. Whether or not behaviors are compulsions or mere habit depends on the context in which the behaviors are performed. For example, arranging and ordering DVDs for eight hours a day would be expected of one who works in a video store, but would seem abnormal in other situations. In other words, habits tend to bring efficiency to one's life, while compulsions tend to disrupt it.

In addition to the anxiety and fear that typically accompanies OCD, sufferers may spend hours performing such compulsions every day. In such situations, it can be hard for the person to fulfill their work, family, or social roles. In some cases, these behaviors can also cause adverse physical symptoms. For example, people who obsessively wash their hands with antibacterial soap and hot water can make their skin red and raw with dermatitis.

People with OCD can use rationalizations to explain their behavior; however, these rationalizations do not apply to the overall behavior but to each instance individually. For example, a person compulsively checking the front door may argue that the time taken and stress caused by one more check of the front door is much less than the time and stress associated with being robbed, and thus checking is the better option. In practice, after that check, the person is still not sure and deems it is still better to perform one more check, and this reasoning can continue as long as necessary.

Overvalued ideas

Some people with OCD 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 people because they may be unwilling to cooperate, at least initially. There are severe cases in which the person has an unshakeable belief in the context of OCD that is difficult to differentiate from psychotic disorders.

Cognitive performance

A 2013 meta-analysis confirmed people with OCD to have mild but wide-ranging cognitive deficits; significantly regarding spatial memory, to a lesser extent with verbal memory, fluency, executive function and processing speed, while auditory attention was not significantly affected. People with OCD show impairment in formulating an organizational strategy for coding information, set-shifting, motor and cognitive inhibition.

Associated conditions

People with OCD may be diagnosed with other conditions, as well or instead of OCD, such as the aforementioned obsessive–compulsive personality disorder, major depressive disorder, bipolar disorder, generalized anxiety disorder, anorexia nervosa, social anxiety disorder, bulimia nervosa, Tourette syndrome, Asperger syndrome, attention deficit hyperactivity disorder, dermatillomania (compulsive skin picking), body dysmorphic disorder, and trichotillomania (hair pulling). In 2009 it was reported that depression among those with OCD is particularly alarming because their risk of suicide is high; more than 50 percent of people experience suicidal tendencies, and 15 percent have attempted suicide. Individuals with OCD have also been found to be affected by delayed sleep phase syndrome at a substantially higher rate than the general public. Moreover, severe OCD symptoms are consistently associated with greater sleep disturbance. Reduced total sleep time and sleep efficiency have been observed in people with OCD, with delayed sleep onset and offset and an increased prevalence of delayed sleep phase disorder.

Behaviorally, there is some research demonstrating a link between drug addiction and the disorder as well. For example, 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 people with OCD may serve as a type of compulsive behavior and not just as a coping mechanism. Depression is also extremely prevalent among people with 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.

Someone exhibiting OCD signs does not necessarily have OCD. Behaviors that present as (or seem to be) obsessive or compulsive can also be found in a number of other conditions as well, including obsessive–compulsive personality disorder (OCPD), autism, disorders where perseveration is a possible feature (ADHD, PTSD, bodily disorders or habit problems), or sub-clinically.

Some with OCD present with features typically associated with Tourette's syndrome, such as compulsions that may appear to resemble motor tics; this has been termed "tic-related OCD" or "Tourettic OCD".

There is tentative evidence that OCD may be associated with above-average intelligence or at least a small increase in intelligence.

Causes

Although the cause is unknown. Both environmental and genetic factors are believed to play a role. Risk factors include a history of child abuse or other stress-inducing event.

Other causes include:

  • Some cases have been documented to occur following infections.
  • Genetics: There appear to be some genetic components with identical twins more often affected than non-identical twins. Further, individuals with OCD are more likely to have first-degree family members exhibiting the same disorders than do matched controls. In cases where OCD develops during childhood, there is a much stronger familial link in the disorder than cases in which OCD develops later in adulthood. In general, genetic factors account for 45–65% of the variability in OCD symptoms in children diagnosed with the disorder. Recent evidence supports the possibility of a heritable predisposition for neurological development favoring OCD. A mutation has been found in the human serotonin transporter gene, hSERT, in unrelated families with OCD. Per evolutionary psychology moderate versions of compulsive behavior may have had evolutionary advantages. Examples would be moderate constant checking of hygiene, the hearth, or the environment for enemies. Similarly, hoarding may have had evolutionary advantages. In this view OCD may be the extreme statistical "tail" of such behaviors possibly due to a high amount of predisposing genes.
  • Infection: Rapid onset of OCD in children and adolescents may be caused by a syndrome connected to Group A streptococcal infections (PANDAS).
  • The diagnosis is based on the symptoms and requires ruling out other drug related or medical causes.

 Mechanisms

Brain scans of people with OCD have shown that they have different patterns of brain activity than people without OCD and that different functioning of circuitry within a certain part of the brain, the striatum, may cause the disorder. Differences in other parts of the brain and neurotransmitter dysregulation, especially serotonin and dopamine, may also contribute to OCD. Independent studies have consistently found unusual dopamine and serotonin activity in various regions of the brain in people with OCD. These can be defined as dopaminergic hyperfunction in the prefrontal cortex (mesocortical dopamine pathway) and serotonergic hypofunction in the basal ganglia. Glutamate dysregulation has also been the subject of recent research, although its role in the disorder's etiology is not yet clear. Glutamate is known to act as a cotransmitter with dopamine in dopamine pathways that project out of the ventral tegmental area.

People with OCD evince increased grey matter volumes in bilateral lenticular nuclei, extending to the caudate nuclei, with decreased grey matter volumes in bilateral dorsal medial frontal/anterior cingulate gyri. These findings contrast with those in people with other anxiety disorders, who evince decreased (rather than increased) grey matter volumes in bilateral lenticular / caudate nuclei, while also decreased grey matter volumes in bilateral dorsal medial frontal/anterior cingulate gyri. Orbitofrontal cortex overactivity is attenuated in people who have successfully responded to SSRI medication, a result believed to be caused by increased stimulation of serotonin receptors 5-HT2A and 5-HT2C. The striatum, linked to planning and the initiation of appropriate actions, has also been implicated; mice genetically engineered with a striatal abnormality exhibit OCD-like behavior, grooming themselves three times as frequently as ordinary mice.

Diagnosis

Cleaning is not an OCD activity per se; thoughts, impulses, or images about a topic like cleaning must be of a degree or type that lies outside the normal range of worries about conventional problems.

Formal diagnosis may be performed by a psychologist, psychiatrist, clinical social worker, or other licensed mental health professional. To be diagnosed with OCD, a person must have obsessions, compulsions, or both, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM). The Quick Reference to the 2000 edition of the DSM states that several features characterize clinically significant obsessions and compulsions. Such obsessions, the DSM says, are recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and that cause marked anxiety or distress. These thoughts, impulses, or images are of a degree or type that lies outside the normal range of worries about conventional problems. A person may attempt to ignore or suppress such obsessions, or to neutralize them with some other thought or action, and will tend to recognize the obsessions as idiosyncratic or irrational.

Compulsions become clinically significant when a person feels driven to perform them in response to an obsession, or according to rules that must be applied rigidly, and when the person consequently feels or causes significant distress. Therefore, while many people who do not suffer from OCD may perform actions often associated with OCD (such as ordering items in a pantry by height), the distinction with clinically significant OCD lies in the fact that the person who suffers from OCD must perform these actions, otherwise they will experience significant psychological distress. These behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these activities are not logically or practically connected to the issue, or they are excessive. In addition, at some point during the course of the disorder, the individual must realize that their obsessions or compulsions are unreasonable or excessive.

Moreover, the obsessions or compulsions must be time-consuming (taking up more than one hour per day) or cause impairment in social, occupational, or scholastic functioning. It is helpful to quantify the severity of symptoms and impairment before and during treatment for OCD. In addition to the peron's estimate of the time spent each day harboring obsessive-compulsive thoughts or behaviors, concrete tools can be used to gauge the people’s condition. This may be done with rating scales, such as the Yale–Brown Obsessive Compulsive Scale (Y-BOCS). With measurements like these, psychiatric consultation can be more appropriately determined because it has been standardized.

OCD is sometimes placed in a group of disorders called the obsessive–compulsive spectrum.

Differential diagnosis

OCD is often confused with the separate condition obsessive–compulsive personality disorder (OCPD). OCD is egodystonic, meaning that the disorder is incompatible with the sufferer's self-concept. Because ego dystonic disorders go against a person's self-concept, they tend to cause much distress. OCPD, on the other hand, is egosyntonic—marked by the person's acceptance that the characteristics and behaviours displayed as a result are compatible with their self-image, or are otherwise appropriate, correct or reasonable.

As a result, people with OCD are often aware that their behavior is not rational, are unhappy about their obsessions but nevertheless feel compelled by them. By contrast people with OCPD are not aware of anything abnormal; they will readily explain why their actions are rational, it is usually impossible to convince them otherwise, and they tend to derive pleasure from their obsessions or compulsions.

Management

Behavioral therapy (BT), cognitive behavioral therapy (CBT), and medications are first-line treatments for OCD. Psychodynamic psychotherapy may help in managing some aspects of the disorder. The American Psychiatric Association notes a lack of controlled demonstrations that psychoanalysis or dynamic psychotherapy is effective "in dealing with the core symptoms of OCD." The fact that many individuals do not seek treatment may be due in part to stigma associated with OCD.

Therapy

One exposure and ritual prevention activity would be to check the lock only once, and then leave. The specific technique used in BT/CBT is called exposure and ritual prevention which involves teaching the person to deliberately come into contact with the situations that trigger the obsessive thoughts and fears ("exposure"), without carrying out the usual compulsive acts associated with the obsession ("response prevention"), thus gradually learning to tolerate the discomfort and anxiety associated with not performing the ritualistic 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 drops 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 (ERP) has a strong evidence base, and it is considered the most effective treatment for OCD. However, this claim has been doubted by some researchers who criticize the quality of many studies.

It has generally been accepted that psychotherapy, in combination with psychiatric 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.

Medication

The medications most frequently used are the selective serotonin reuptake inhibitors (SSRIs), of which the most commonly used for treating OCD are fluoxetine, sertraline, paroxetine and fluvoxamine. Clomipramine, a medication belonging to the class of tricyclic antidepressants appears to work as well as SSRIs but has a higher rate of side effects.

SSRIs are a second line treatment of adult obsessive compulsive disorder (OCD) with mild functional impairment and as first line treatment for those with moderate or severe impairment. In children, SSRIs can be considered as a second line therapy in those with moderate-to-severe impairment, with close monitoring for psychiatric adverse effects. SSRIs are efficacious in the treatment of OCD; people treated with SSRIs are about twice as likely to respond to treatment as those treated with placebo. Efficacy has been demonstrated both in short-term (6–24 weeks) treatment trials and in discontinuation trials with durations of 28–52 weeks. Generally, the dosages of SSRIs that have proven to be effective for the treatment of OCD are higher than the usual dosages recommended for the treatment of depression. Thus, while the recommended daily dose of sertraline for treating depression is in most cases 50 mg per day, the dosage for the treatment of OCD can be as high as 150 or 200 mg per day.

Procedures

Electroconvulsive therapy (ECT) has been found to have effectiveness in some severe and refractory cases.

Surgery may be used as a last resort in people who do not improve with other treatments. In this procedure, a surgical lesion is made in an area of the brain (the cingulate cortex). In one study, 30% of participants benefited significantly from this procedure. Deep-brain stimulation and vagus nerve stimulation are possible surgical options that do not require destruction of brain tissue

Children

Therapeutic treatment may be effective in reducing ritual behaviors of OCD for children and adolescents. Similar to the treatment of adults with OCD, CBT stands as an effective and validated first line of treatment of OCD in children. Family involvement, in the form of behavioral observations and reports, is a key component to the success of such treatments. In a Parental intervention also provides positive reinforcement for a child who exhibits appropriate behaviors as alternatives to compulsive responses. In a recent meta-analysis of evidenced-based treatment of OCD in children, family-focused individual CBT was labeled as "probably efficacious", establishing it as one of the leading psychosocial treatments for youth with OCD. After one or two years of therapy, in which a child learns the nature of his or her obsession and acquires strategies for coping, that child may acquire a larger circle of friends, exhibit less shyness, and become less self-critical.

Although the causes of OCD in younger age groups range from brain abnormalities to psychological preoccupations, life stress such as bullying and traumatic familial deaths may also contribute to childhood cases of OCD, and acknowledging these stressors can play a role in treating the disorder.

Obsessive–compulsive disorder affects about 2.3% of people at some point in their life. Rates during a given year are about 1.2% and it occurs worldwide. It is unusual for symptoms to begin after the age of thirty five and half of people develop problems before twenty. Males and females are affected about equally.

Prognosis

Psychological interventions such as behavioral therapy and cognitive-behavioral therapy as well as medication can lead to a reduction of OCD symptoms for a number of people. However, symptoms may persist at moderate levels even following adequate treatment courses, and completely symptom-free periods are uncommon.

Research

The naturally occurring sugar inositol has been suggested as a treatment for OCD.

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.

μ-Opioids, such as hydrocodone and tramadol, may improve OCD symptoms. Administration of opiate treatment may be contraindicated in individuals concurrently taking CYP2D6 inhibitors such as fluoxetine and paroxetine.

Much current research is devoted to the therapeutic potential of the agents that affect the release of the neurotransmitter glutamate or the binding to its receptors. These include riluzole, memantine, gabapentin, N-acetylcysteine, topiramate and lamotrigine.

References

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