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| ICD9 = | ICDO = | OMIM = | MedlinePlus = | eMedicineSubj = med | eMedicineTopic = 1654 | MeshID = D009771 |Obsessive-compulsive disorder (OCD) is a psychiatric anxiety disorder most commonly characterized by a subject's obsessive, distressing, intrusive thoughts and related compulsions (tasks or "rituals") which attempt to neutralize the obsessions.The phrase "obsessive-compulsive" has worked its way into the wider English lexicon, and is often used in an offhand manner to describe someone who is meticulous or absorbed in a cause (see also "anal-retentive"). Such casual references should not be confused with obsessive-compulsive disorder; see clinomorphism. It is also important to distinguish OCD from other types of anxiety, including the routine tension and stress that appear throughout life. Although these signs are often present in OCD, a person who shows signs of infatuation or fixation with a subject/object, or displays traits such as perfectionism, does not necessarily have OCD, a specific and well-defined condition.To be diagnosed with Obsessive-compulsive disorder, one must have either obsessions or compulsions alone, or obsessions and compulsions, according to the DSM-IV-TR diagnostic criteria. The Quick Reference to the diagnostic criteria from DSM-IV-TR (2000) describes these obsessions and compulsions:Quick Reference to the Diagnostic Criteria from DSM-IV-TR. Arlington, VA: American Psychiatric Association, 2000.Obsessions are defined by:
# Recurrent and persistent thoughts, impulses, or images that are experienced at some time during the disturbance, as intrusive and inappropriate 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.
# 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 either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.
Causes and related disordersIt was the general belief in 14th, 15th, and 16th century Europe that those 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.Baer, L.; M. A. Jenike & W. E. Minichiello. Obsessive Compulsive Disorders: Theory and Management. Littleton, MA: PSG Publishing, 1986.Today the community of scientists studying obsessive-compulsive disorder has been split into two factions by a disagreement over the exact cause of the illness. On one side is a group who believe that obsessive-compulsive behavior is a psychological disorder. On the other side are scientists who believe that obsessive-compulsive behavior is caused by abnormalities in the brain. A majority of researchers now believe in this biological hypothesis of OCD.Stanford University School of Medicine OCD web page states that "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."
FreudIn 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 follows: p. 29.
Biological explanationsThere are many different theories about the cause of obsessive-compulsive disorder. The majority of researchers believe that there is some type of abnormality in 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. This neurotransmitter travels from one nerve cell to the next via synapses. 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.BBC Science and Nature: Human Body and Mind. Causes of OCD.
Symptoms and prevalence OCD is manifested in a variety of forms.Community 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 are unaccounted for clinically. 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 because many sufferers of OCD do not realize that what they are suffering from is OCD, mainly because the typical depiction of the disorder in the media and elsewhere only covers a few of the many symptoms of OCD.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: 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.Symptoms may include some, all, or perhaps none of the following:
Related disordersPeople with OCD may be diagnosed with other conditions, such as anorexia nervosa, social anxiety disorder, bulimia nervosa, Tourette syndrome, compulsive skin picking, body dysmorphic disorder, and trichotillomania. There is some research demonstrating a link between drug addiction and obsessive compulsive disorder as well. Many who suffer from OCD 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 obsessive compulsive 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.
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%.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.Antony, M. M.; F. Downie & R. P. Swinson. "Diagnostic Issues and Epidemiology in Obsessive-Compulsive Disorder". in Obsessive-Compulsive Disorder: Theory, Research, and Treatment, eds. M. M. Antony; S. Rachman; M. A. Richter & R. P. Swinson. New York: The Guilford Press, 1998, pp. 3-32. 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.Koran LM, Hanna GL, Hollander E, Nestadt G, Simpson HB; American Psychiatric Association. Am J Psychiatry 2007; 164(7 Suppl): 5-53. PMID 17849776.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 (formerly) 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.Medications as treatment include selective serotonin reuptake inhibitors (SSRIs) such as paroxetine (Seroxat, Paxil), sertraline (Zoloft), fluoxetine (Prozac), 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, the 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-compulsive 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 who don't 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 antagonsim. 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.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 a small number of anecdotal cases have emerged that have shown positive results. However there is so far little scientific evidence to support these claims.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.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.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 orbito-frontal 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 obsessive-compulsive disorder, 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. It should also be noted that there are anecdotal reports of OCD worsening when cigarettes are smoked.
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. Those correlations are as follows:Activity positively correlated to severity:
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