Obsessive-compulsive disorder
A woman visits her dermatologist, complaining of extremely dry
skin and seldom feeling clean. She showers for two hours every day.
A lawyer insists on making coffee several times each day. His
colleagues do not realize that he lives in fear that the coffee will be
poisoned, and he feels compelled to pour most of it down the drain. The lawyer
is so obsessed with these thoughts that he spends 12 hours a day at work -- four
of them worrying about contaminated coffee.
A man cannot bear to throw anything away. Junk mail, old
newspapers, empty milk cartons all "could contain something valuable that might
be useful someday." If he throws things away, "something terrible will happen."
He hoards so much clutter that he can no longer walk through his house.
Insisting that nothing be thrown away, he moves to another house where he
continues to hoard.
A 10 year old girl keeps apologizing for "disturbing" her class.
She feels that she is too restless and is clearing her throat too loudly. Her
teachers are puzzled and over time become annoyed at her repeated apologies
since they did not notice any sounds or movements. She is also preoccupied with
"being good all the time".
These people suffer obsessive-compulsive disorder (OCD). The
National Institute of Mental Health estimates that more than 2 percent of the
U.S. population, or nearly one out of every 40 people, will suffer from OCD at
some point in their lives. The disorder is two to three times more common than
schizophrenia and bipolar disorder.
What is Obsessive-compulsive disorder?
Obsessions are intrusive, irrational thoughts
-- unwanted ideas or impulses that repeatedly well up in a person's mind. Again
and again, the person experiences disturbing thoughts, such as "My hands must be
contaminated; I must wash them"; "I may have left the gas stove on"; "I am going
to injure my child." On one level, the sufferer knows these obsessive thoughts
are irrational. But on another level, he or she fears these thoughts might be
true. Trying to avoid such thoughts creates great anxiety.
Compulsions are repetitive rituals such as
handwashing, counting, checking, hoarding, or arranging. An individual repeats
these actions, perhaps feeling momentary relief, but without feeling
satisfaction or a sense of completion. People with OCD feel they must perform
these compulsive rituals or something bad will happen.
Most people at one time or another experience obsessive thoughts
or compulsive behaviors. Obsessive-compulsive disorder occurs when an individual
experiences obsessions and compulsions for more than an hour each day, in a way
that interferes with his or her life.
OCD is often described as "a disease of doubt." Sufferers
experience "pathological doubt" because they are unable to distinguish between
what is possible, what is probable, and what is unlikely to happen.
Who gets OCD?
People from all walks of life can get OCD. It strikes people of
all social and ethnic groups and both males and females. Symptoms typically
begin during childhood, the teenage years or young adulthood.
What causes OCD?
A large body of scientific evidence suggests that OCD results
from a chemical imbalance in the brain. For years, mental health professionals
incorrectly assumed OCD resulted from bad parenting or personality defects. This
theory has been disproven over the last 20 years. OCD symptoms are not relieved
by psychoanalysis or other forms of "talk therapy," but there is evidence that
behavior therapy can be effective, alone or in combination with medication.
People with OCD can often say "why" they have obsessive thoughts or why they
behave compulsively. But the thoughts and the behavior continue.
People whose brains are injured sometimes develop OCD, which
suggests it is a physical condition. If a placebo is given to people who are
depressed or who experience panic attacks, 40 percent will say they feel better.
If a placebo is given to people who experience obsessive-compulsive disorder,
only about two percent say they feel better. This also suggests a physical
condition.
Clinical researchers have implicated certain brain regions in
OCD. They have discovered a strong link between OCD and a brain chemical called
serotonin. Serotonin is a neurotransmitter that helps nerve cells
communicate.
Scientists have also observed that people with OCD have
increased metabolism in the basal ganglia and the frontal lobes of the brain.
This, scientists believe, causes repetitive movements, rigid thinking, and lack
of spontaneity. Successful treatment with medication or behavior therapy
produces a decrease in the over activity of this brain circuitry. People with
OCD often have high levels of the hormone vasopressin.
In layperson's terms, something in the brain is stuck, like a
broken record. Judith Rapoport, M.D., describes it in her book, The Boy Who
Couldn't Stop Washing, as "grooming behaviors gone wild."
How do people with OCD typically react to their
disorder?
People with OCD generally attempt to hide their problem rather
than seek help. Often they are remarkably successful in concealing their
obsessive-compulsive symptoms from friends and co-workers. An unfortunate
consequence of this secrecy is that people with OCD generally do not receive
professional help until years after the onset of their disease. By that time,
the obsessive-compulsive rituals may be deeply ingrained and very difficult to
change. How long does OCD last?
OCD will not go away by itself, so it is important to seek
treatment. Although symptoms may become less severe from time to time, OCD is a
chronic disease. Fortunately, effective treatments are available that make life
with OCD much easier to manage.
Is age a factor in OCD?
OCD usually starts at an early age, often before adolescence. It
may be mistaken at first for autism, pervasive developmental disorder, or
Tourette's syndrome, a disorder that may include obsessive doubting and
compulsive touching as symptoms.
Like depression, OCD tends to worsen as the person grows older,
if left untreated. Scientists hope, however, that when the OCD is treated while
the person is still young, the symptoms will not get worse with time.
What are other examples of behaviors typical of people
who suffer from OCD?
People who do the following may have OCD:
repeatedly check things, perhaps dozens of times, before feeling
secure enough to go to sleep or leave the house. Is the stove off? Is the door
locked? Is the alarm set?
fear they will harm others. Example: A man's car hits a pothole
on a city street and he fears it was actually a body.
feel dirty and contaminated. Example: A woman is fearful of
touching her baby because she might contaminate the child.
constantly arrange and order things. Example: A child can't go
to sleep unless he lines up all his shoes correctly.
are excessively concerned with body imperfections -- insist on
numerous plastic surgeries, or spend many, many hours a day
body-building.
are ruled by numbers, believing that certain numbers represent
good and others represent evil.
are excessively concerned with sin or
blasphemy.
Is OCD commonly recognized by
professionals?
Not nearly commonly enough. OCD is often misdiagnosed, and it is
often underdiagnosed. Many people have dual disorders of OCD and schizophrenia,
or OCD and bipolar disorder, but the OCD component is not diagnosed or treated.
In children, parents often are aware of some anxiety or depression but not of
the underlying OCD. Researchers believe OCD, anxiety disorders, Tourette's, and
eating disorders such as anorexia and bulimia can be triggered by some of the
same chemical malfunctioning of the brain.
Is heredity a factor in OCD?
Yes. Heredity appears to be a strong factor. If you have OCD,
there's a 25-percent chance that one of your immediate family members will have
it. It definitely seems to run in families. Can OCD be effectively treated?
Yes, with medication and behavior therapy. Both affect brain
chemistry, which in turn affects behavior. Medication can regulate serotonin,
reducing obsessive thoughts and compulsive behaviors.
Anafranil (clomipramine): A tricyclic
antidepressant, Anafranil has been shown to be effective in treating
obsessions and compulsions. The most commonly reported side effects of this
medication are dry mouth, constipation, nausea, increased appetite, weight gain,
sleepiness, fatigue, tremor, dizziness, nervousness, sweating, visual changes,
and sexual dysfunction. There is also a risk of seizures, thought to be
dose-related. People with a history of seizures should not take this medication.
Anafranil should also not be taken at the same time as a monoamine oxidase
inhibitor (MAOI).
Many of the antidepressant medications known as selective
serotonin reuptake inhibitors (SSRIs) have also proven effective in treating
the symptoms associated with OCD. The SSRIs most commonly prescribed for OCD are
Luvox (fluvoxamine), Paxil (paroxetine), Prozac (fluoxetine), and Zoloft
(sertraline).
Luvox (fluvoxamine): Common side effects of this
medication include dry mouth, constipation, nausea, sleepiness, insomnia,
nervousness, dizziness, headache, agitation, weakness, and delayed
ejaculation.
Paxil (paroxetine): Side effects most associated with
this medication include dry mouth, constipation, nausea, decreased appetite,
sleepiness, insomnia, tremor, dizziness, nervousness, weakness, sweating, and
sexual dysfunction.
Prozac (fluoxetine): Dry mouth, nausea, diarrhea,
sleepiness, insomnia, tremor, nervousness, headache, weakness, sweating, rash,
and sexual dysfunction are among the more common side effects associated with
this drug.
Zoloft (sertraline): Among the side effects most commonly
reported while taking Zoloft are dry mouth, nausea, diarrhea, constipation,
sleepiness, insomnia, tremor, dizziness, agitation, sweating, and sexual
dysfunction.
Celexa (Citalopram) Side effects may include dry mouth,
nausea, or drowsiness .
SSRIs should never be taken at the same time as
MAOIs.
How log should an individual take medication before
judging its effectiveness?
Some physicians make the mistake of prescribing a medication for
only three or four weeks. That really isn't long enough. Medication should be
tried consistently for 10 to 12 weeks before its effectiveness can be
judged.
What is behavior therapy, and can it effectively relieve
symptoms of OCD?
Behavior therapy is not traditional psychotherapy. It is
"exposure and response prevention," and it is effective for many people with
OCD. Consumers are deliberately exposed to a feared object or idea, either
directly or by imagination, and are then discouraged or prevented from carrying
out the usual compulsive response. For example, a compulsive hand-washer may be
urged to touch an object he or she believes is contaminated and denied the
opportunity to wash for several hours. When the treatment works well, the
consumer gradually experiences less anxiety from the obsessive thoughts and
becomes able to refrain from the compulsive actions for extended periods of
time.
Several studies suggest that medication and behavior therapy are
equally effective in alleviating symptoms of OCD. About half of the consumers
with this disorder improve substantially with behavior therapy; the rest improve
moderately.
Will OCD symptoms go away completely with medication and
behavior therapy?
Response to treatment varies from person to person. Most people
treated with effective medications find their symptoms reduced by about 40
percent to 50 percent. That can often be enough to change their lives, to
transform them into functioning individuals. A few consumers find that neither treatment produces significant
change, and a small number of people are fortunate to go into total remission
when treated with effective medication and/or behavior therapy.
Reviewed by Judith Rapoport, MD May
2003
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