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Obsessive-Compulsive Disorder: New Insights

Obsessive-compulsive disorder (OCD) patients engage in bizarre rituals, usually involving cleanliness, order, checking for safety, hoarding or counting. One woman alphabetized the cans in her pantry and agonized over whether green beans should be filed under "g" or "b." Another, after constantly checking to see if she had turned off the iron, took it to work with her just to be sure. Sigmund Freud encountered patients with obsessive-compulsive disorder and theorized that they were trying to resolve submerged conflicts stemming from toilet training or punitive parenting. Doctors now know that the disorder is more common than once thought, occurring in all cultures and affecting two to three percent of persons in most countries. The unusual behavior apparently stems from biological malfunctions in the basal ganglia, a collection of cells at the base of the brain. It's now thought that OCD often has genetic roots; in some cases, it may also result from a bacterial or viral infection or by physical or emotional trauma. Obsessive-compulsive patients seldom respond to psychoanalysis but can get significant help with medications and behavioral or cognitive therapy. While the exact causes are still unknown, medications that help relieve the disorder, like many that help depression, all increase the level of serotonin available in the brain.

Haunted by a Thought or Action An obsession, as described by the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM IV), is a repeated, unwanted, intrusive thought, urge or image. This might be the fear of contamination or that something bad is going to happen or that something is lost or missing. Some believe they may have inadvertently hit a pedestrian. The person is fully aware that the thought is irrational; even though the feared event could happen, it probably won't. Nevertheless the thought can't be dismissed and is typically followed by a compulsive action to relieve anxiety. These rituals, such as washing hands hundreds of times a day or constantly checking door locks or appliance switches, eventually consume a good part of the person's daily routine and cause problems with family and friends. Some people with OCD have only obsessive thoughts; others have only compulsive actions. And there are many variations in how the thoughts and actions are manifested. Because they are ashamed and embarrassed, most individuals try to hide their symptoms often with considerable success. On average 17 years elapse between the first symptom and a diagnosis. For 70 percent of patients, symptoms start before age 30, often in childhood or adolescence. They may result from hormonal changes, emotional stress or physical trauma. Researchers believe that some cases of childhood OCD occur when the immune system responds to rheumatic fever or another infection by creating an inflammatory response in the brain. In such cases, the best treatment may be with penicillin. Brain scans of OCD patients using positron emission tomography (PET) reveal increased activity in the orbital cortex, responsible for sending out error or alert signals when something is not quite right. Abnormal activity also occurs in the caudate nucleus of the basal ganglia, an area responsible for processing such signals and switching them off once the condition has been remedied. With a malfunctioning caudate nucleus, the unclean or off center alert becomes perpetually engaged. As a result, one woman spent hours each day straightening the striped pattern on her bed clothes. When the proper medications are administered, brain activity returns to normal. A study at UCLA demonstrated that behavioral therapy also produced alterations in brain activity and a "much quieter" caudate nucleus.

Related Disorders Some researchers have studied disorders with similar symptoms, which they refer to as the obsessive-compulsive spectrum. These disorders include: pathological gambling, kleptomania, compulsive hair pulling, compulsive shopping, anorexia nervosa, binge eating, sexual compulsions and body dysmorphic disorder (a pathological preoccupation with a presumed defect in bodily appearance). These disorders also respond to medications which increase the serotonin available in the brain. One recent article in American Scientist theorized that disorders of the obsessive-compulsive spectrum may be caused by chemical imbalances resulting in deficiencies in the body's perception of rewards and contentment. A neurological disorder that responds to different types of medications but has many similarities to obsessive-compulsive disorder is Tourette's syndrome. Tourette's patients typically are plagued by a variety of tics and compulsive rituals such as counting, repeating magic words and a preoccupation with symmetry. Studies show that Tourette's syndrome and obsessive-compulsive disorder may involve similar brain circuits and similar abnormalities in the basal ganglia. And one type of obsessive-compulsive disorder appears to have genetic similarities to Tourette's syndrome. OCD is complex and multi-faceted, but advances are coming rapidly. In 1989 little could be done to treat OCD; today, doctors can choose from five medications: clomipramine, fluoxetine, fluvoxamine, sertraline and paroxetine. Medication does not totally erase symptoms, but a combination of drugs and either behavioral or cognitive therapy brings about significant improvement in about 90 percent of patients.

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Last modified: Tuesday, April 22, 2014

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