Click-click-click-click....click-click-click-click........click-click-click-click......you may be wondering what that noise is. This is the sound of a man who is afraid of something evil getting into his home. By locking and unlocking the deadbolt on the door and counting to four in three successive groups he believes that this ritual will keep him safe and he can not sleep at night until he has accomplished it. While this may sound utterly ridiculous to you and I, this fear and the alleviation of his fear by doing this ritual is very real to this man and to the many, many others that suffer from obsessive-compulsive disorder. This disorder can create such a problem for people that their whole lives are disrupted because of unwanted thoughts and actions. So what causes these thoughts to get out of control and how can someone control them? The answers may not be as easy as the questions.
"Obsessive-Compulsive disorder (OCD) is an anxiety disorder characterized by intrusive and distressing thoughts, urges and images as well as repetitive behaviors aimed at decreasing the discomfort caused by these obsessive thoughts (Swinson, 1998) ." Broken down, obsession is defined as thoughts that will not stop, while compulsions are the behaviors that the patient can't stop doing (Carlson, 2004). Just as the example in the beginning, of the man that could not stop thinking about the evil that could possibly get into his house (obsession) and also the pattern lock turning and counting (compulsion) which he could not stop himself from doing or his obsessive thoughts would take over. But is that really a problem if he is not hurting anyone? There are many famous people that had OCD and although they suffered from the disorder they contributed great things to our world. John Bunyan (author of Pilgrim's Progress), Therese of Lisieux (patron saint of France), Winston Churchill, Martin Luther and a name that has very recently become popular once again, Howard Hughes (Osborn, 1998). So this touches on one of the most important things that needs to be looked at with a disorder such as OCD. How well does the patient function with the disorder? Those that can adapt well to the disorder are healthier and have less of an onset of negative symptoms. Those that can not adapt become dysfunctional and the disorder consumes their lives ( Magnavita, 2004) these are the ones that need help in removing the troublesome thoughts. Clinically there are four qualities to diagnose whether the person will need help, the intrusiveness, recurrence, unwantedness and inappropriate nature of the thoughts. These four criteria separate the normal everyday thoughts and worries from those that classify as OCD thought (Osborn, 1998). To complicate it even more per an APA 2000 report "OCD is usually accompanied by other disorders such as other anxiety disorders, mood disorders, eating disorders and substance abuse disorders (Frost, 2002)."
On top of everything else there are also four different levels of OCD, counting, checking, cleaning, and avoidance (Carlson, 2004). While there may be four distinct clinical levels of OCD, most patients suffer from multiple symptoms, with women having a higher prevalence of the disorder than men (Swinton, 1998). Take for example the woman with a hypochondrial fear type of OCD, after some of her friends developed breast cancer she was sure that she was going to develop it also. Despite her husband, who was a physician, assuring her that she did not have breast cancer, she continuously checked herself for lumps and discharge that may indicate that breast cancer had developed and had him keep checking her also. Here she has the obsession of her developing breast cancer and the compulsive actions of checking for it. Eventually she starts checking her eight-year-old daughter also for discharge (compulsion is getting worse). Then she develops a second symptom of OCD, cleaning. She starts to continuously clean everything to keep the germs off of her family. Finally, a third symptom, counting, becomes prevalent as she gets progressively worse with her obsessive thoughts. She starts to pace the floor surfaces one at a time in a ritual to ward off illness from her family (Swinson, 1998).
A person that has OCD performs compulsive acts to ward off the obsessive thoughts, so why didn't the first compulsive act help this woman in alleviating her thoughts? There may be two answers to this, one it didn't really alleviate it so she looked for other things that may. However, more than likely the obsessive thoughts just kept getting worse to the point that she had to add more compulsive behavior to even out the worsening thoughts. Notice how the fear of the illness first started with her then moved to her daughter and then eventually to her whole family. Each time there was another fear added for another person an additional compulsive act was added to the previous one.
Besides just observing the behavior of an OCD sufferer, there is a battery of tests that will help point out if the person does indeed have OCD. The standard test that is used now is the Y-BOCS, it is a four part test that measures the severity and treatment results of OCD (Sammons, 2001). Some of the other tests can include the Maudsley Obsessive Compulsive Inventory (MOCI), Compulsive Activity Checklist (CAC), National Institute of Mental Health Global Obsessive Compulsive Scale (NIMHOCS) and also the Padua Inventory and Padua Inventory-revised (Sammons, 2001). These are just a few tests that can be used, another one that is popular for other disorders that may also be helpful is the Minnesota Multiphasic Personality Inventory (MMPI-2), this is a rather long questionnaire to gauge any emotional problems that they may have or to screen for disorders (Butcher, 2006).
OCD is thought to be a genetic disorder pointing to a physiological reason in the development of OCD. Researchers have been led to this conclusion due to the connection that OCD has with tic disorders. Both disorders share the same genotype, but it is not known why some people develop the tic disorder and some develop OCD (Carlson, 2004). However, this is not the only physical explanation there is for OCD as it can also be caused by damage to the brain after birth. Damage in the basal ganglia, cingulate gyrus and the prefrontal cortex seem to be linked to people developing OCD. Also contracting the B-hemolytic strain of strep can cause damages to these parts of the brain and can lead to the development of OCD when the bacteria is present in the body and flourishing (Carlson, 2004). More specifically OCD may be connected to the serotonin 5-HT receptor, but it is still being researched.
The connection of OCD and the 5-HT receptor came after the discovery that the tricyclic anti-depressant clomipramine reduced the symptoms of OCD sufferers compared to other tricyclics that were used (Sammons, 2001). These studies were not likely done at random but because depression sometimes accompanies the OCD symptoms in a person, just due to the distressing nature of the disorder and the control it has over a person life. The difference in the clomipramine, compared to other tricyclics is that it has an extra chlorine atom on its structure, this molecule causes it to have more of an effect on the reuptake of the serotonin at the 5-HT receptors compared to other neurotransmitters (Sammons, 2001). This is also why selective serotonin reuptake inhibitors (SSRI's) are also used in helping people deal with OCD.
The most popular, fluoxetine (Prozac) was the first SSRI antidepressant on the market (Schatzberg, 2001). A SSRI is a selective serotonin reuptake inhibitor, and just like its name says it prevents the reuptake of serotonin at either the pre- or post synaptic receptors causing serotonin to linger longer in the synaptic cleft, just like clomipramine. In the case of Prozac, it inhibits the serotonin reuptake at the 5-HT1 presynaptic receptor which is also the location of the origin of OCD, which is why it works with OCD as well as depression. But it is a slow acting drug as with the other SSRI's and it can take 4-6 weeks for the patent to see their symptoms alleviated (Julien, 2005). However, this can be a benefit also. Prozac has a half life of 2 to 3 days and metabolite has a half life of 6 to 10 days this creates a benefit in the administration of the drug in that it sometimes only needs to be given once a week. (Julien, 2005). This also has a bad side, if the patient needs to stop taking Prozac because it is not working, they need to have at least 5 weeks of no drug therapy before beginning a new treatment so that the drug can get out of their system completely (Julien, 2005). Of particular note, prozac is also used to help canines with obsessive compulsive disorder (Barondes, 2003), a canine that has OCD develops what is called Acral lick dermatitis. The dog is so obsessed with licking a certain part of its body that is can lick off all of the hair and the skin in that location (Carlson, 2004). Another drug that is used for OCD is a structural derivative of Prozac, it is known as fluvoxamine. It works the same way that fluoxetine does with more patient compliance and also fewer side effects (Julien, 2005).
Besides pharmacologically treating OCD, it can also be treated with psychodynamic therapy. This type of treatment has only been the subject of one known study in which the therapy has a 85% success rate in a group of 14 patients after a year of treatment (Magnavita, 2004). It has been found that the patients respond better to this treatment because they have more control and autonomy (Magnavita, 2004). Two other treatments seem to work also, exposure in vivo response prevention (ERP therapy) and also cognitive behavior therapy (Frost, 2002). Just like depression the best therapy for OCD would most likely be a combination of both counseling and pharmacological treatment.
For a disorder that was relatively unheard of prior to increased media coverage in the last 20 years, it is a very complicated. There are so many different types, levels, additional symptoms and additional disorders that go along with OCD that it is hard to look and say for sure that someone definitely has OCD without looking at the big picture. Oddly enough all of us have a little bit of OCD, maybe not to the point that it becomes a hindrance in your life or would be classified as a disorder but we perform rituals everyday without really thinking about them. Most notably is religious rituals that we constantly perform for protection. For those that OCD affects their life intently, there is hope as more research is being done into both phamacology and counseling that could help people alleviate these unwanted thoughts. In the end it is always how you cope with the curves that are thrown at you that determines how well you can adapt to life, even if you are constantly worried about it.
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