Pathophysiology of Obsessive-Compulsive Disorder - Research Paper Example

Pathophysiology of Obsessive Compulsive Disorder (OCD)" Introduction The normal fear response to threatening stimuli comprises several components, including defensive behaviors, autonomic reflexes, arousal and alertness, corticosteroid secretion and negative emotions. In anxiety states, these reactions occur in an anticipatory manner, independent of external events. The distinction between a pathological and normal state of anxiety is not clear-cut but represents the point at which the symptoms interfere with normal productive activities influencing day-to-day activities (Katzang, 2009; Kaushik, 2011). Obsessive compulsive disorder is an anxiety disorder, a compulsive ritualistic behavior driven by irrational anxiety such as fear of contamination, thereby repeated washing of hands and cleaning or articles is performed by the patient. The treatment of such disorders generally involves an amalgamation of psychological approaches as well as drug treatment (Katzang, 2009; Kaushik, 2011). OCD (Obsessive Compulsive Disorder) is characterized by repetitive anxiety- provoking thoughts (obsession) or repetitive behaviors aimed at reducing anxiety (compulsions). If such thoughts or actions are prevented or interrupted, the patient becomes anxious. It is chronic, prevalent as well as disabling condition that persists throughout life, hampers normal life of an individual and those who are associated with the OCD patient (Katzang, 2009; Kaushik, 2011). The disease is a chronic condition and no absolute reason could be formulated till date. Noteworthy contribution of studies involving OCD highlight the perception of the phenomenology and pathophysiology of obsessive-compulsive disorder (OCD) prevalent both in children as well as adults, affecting 1-3% of the population (Torres et al, 2006). Epidemiological understanding about OCD suggests that OCD has emerged as the fourth most common mental disorder across the world irrespective of cultural differences. Considering the condition to be of paramount significance, World Health Organization (WHO, 2001) has graded OCD as one of the most debilitating disorders. An estimation carried out in 2000, enumerated OCD amongst the top 20 causes of illness related disability of individuals belonging to the age between 15 years and 44 years. In most of the cases, symptoms onset around the age of 10 years, prepuberty onset is observed in boys while in girls onset of symptoms usually occur during adolescence phase (Tukel et al, 2006). OCD patient displays significant distress that results in impaired psychosocial performances. Obsessions are recurring, invasive and upsetting beliefs, suggestions, illustrations, or recommendations that in most of the cases are inappropriate. In case of OCD these characteristics persist how-so-ever the individual tries to restrain, oppose or disregard them. Thus OCD is a condition that results due to recurring unnecessary thoughts and in order to exonerate such thoughts repetitive actions are being performed (Katzang, 2009; Kaushik, 2011). Studies reveal that family psychoeducation plays an imperative role in dealing with the mental illness cases. As OCD is reported to be one of the chief mental illnesses, emotional support, understanding of family members, problem-solving abilities could be handled in a cognitive manner, if the family understands the significance of the psychological influence on the OCD patient. Evidence involving such an approach highlight the success although barriers were observed in carrying out such pursuits but appropriate attitude, knowledge based practical and systemic obstacles to implementation leads to long term perspectives (Dixon et al, 2001). Signs and symptoms of the OCD process A variation is observed between the presence and absence of symptoms as well as on the intensity of the symptoms. The most prevalent symptom involves anxiety that occur with a thought of some mishap that may occur due to some ignorance or undone task. Symptoms are- Obsession- repeated inclination over undesirable thoughts, plan or preferences leads to obsessed behavior. The persistence of such thoughts creep into the normal thought generating apprehensions and anxiety. The contemplations could be sexual or violent or may be associated with ailments or contagion, a fear of becoming filthy or unhygienic, while driving a vehicle trying to put perfection, a panic or harm to self or dear ones especially partner. Such an instinct leads to compulsion in attitude. Compulsions- In order to overcome obsession, repeated tasks are performed by the OCD patient which may vary from same organization to rigidity, on the other hand some OCD cases display complicated behavior every time. Some of these acts include washing hands, clothes to seek perfection in deeds, wager to repeat things and make everything in a perfect order, praying, hoarding, counting the number of times an action has been performed (Barrett, 2008). These repeated actions are time consuming acts and hamper the routine life as well as affects the relationships. During the phase OCD patients may think that their behavior is not real or do not display surety about their acts or on the other hand they believe firmly on their anxiety and fear. According to Foa & Kozak (1995), 2.1% of OCD cases accounted chief obsessions only, while 1.7% displayed presence of compulsive behavior, on the other hand > 95% exhibit both obsessions and compulsions when examined with the Yale-Brown Obsessive Compulsive Symptom Checklist. Evidence reveal that OCD symptoms are similar in both adult and pediatric. According to Geller et al, (2003), obsessive behavior to cause harm and compulsive behavior of hoarding are displayed by children and adolescents as compared to adult OCD patients. Symptoms, however change with time from childhood to adulthood. According to Storch et al, (2008), a relationship exists between the intensity of approach and clinical distinctiveness, when the study was carried out with 78 children and adolescent cases of OCD. Their observation revealed that in around 45% of the OCD cases, the insight about the symptoms was poor and they displayed augmented OCD- associated mutilation. Anxiety behavior was followed by a feeling of shame and mortification. Such cases tend to conceal their characteristics of OCD, preventing early detection and treatment. Pathophysiology of OCD A thorough understanding of the pathophysiology of OCD is highly imperative to minimize the side-effects especially in children as well as enable the clinicians to monitor the response of medication being provided. The pathophysiology involves- Basal ganglia dysfunction- Basal ganglia encompass an assembly of nuclei in brain which are interrelated with cerebral cortex, thalamus and brainstem to carryout various functions including motor control, cognition, sentiments and learning ability. Any disturbance in these connectivity either due to injury or due to infection may result in altered behavioral functions leading to OCD. The symptoms of OCD occur due to dysfunction of the cortico-striato-thalamo-cortical circuitry. The reason could be postulated as enhanced glutamenergic signals from frontal cortex brings excitation in striatum which augments inhibitory GABA signal to GPi as well as substantia nigra (pars reticulata) (SNr), which is responsible for reducing the inhibitory output via GABA from GPi and SNr to thalamus, bringing thalamic excitatory glutamenergic output to frontal cortex. Thus a loop of positive feedback is created which is responsible for repetitive thoughts i.e. obsessions and actions i.e. compulsions. The two points responsible for enhanced glutamenergic signal from thalamus to the frontal cortex involves GPi/ SNr interaction with the thalamus as well as interface between striatum and GPe. In case of GPi/ SNr dysfunction, thalamus is not inhibited, thereby thalamus sends more glutamenergic signal (Saxena, 1998; Bloch 2011). On the other hand if the striatum becomes dysfunctional no GPe inhibition occurs, thereby inhibition on subthalamic nucleus occurs which diminishes the excitation of GPi/ SNr to display reduced inhibition of the thalamus, which is now capable of sending more glutamenergic signals. Evidence suggests that caudate nucleus is the probable site of such a dysfunction (Saxena, 2000). Neurotransmitter abnormalities- If the serotonin function is abnormal it results in abnormal pathophysiology of OCD patients irrespective of age. Studies reveal that serotonergic drugs are efficient in decreasing the symptoms of OCD. Serotonin reuptake inhibitors such as clomipramine is found to be highly effective in diminishing the symptoms of OCD in children, besides blocking serotonin reuptake the clomipramine also blocks histamine H2, as well as cholinergic and adrenergic receptors and display antidopaminergic characteristics. This provides support to the fact that serotonin has an imperative role in OCD (Kalra & Swedo, 2009). Neuroimmune dysfunction-Evidence suggests that some correlation between Sydenham cholera and OCD persists, also evidence support the correlation between rheumatic fever and childhood- onset of OCD; the correlation exists as both these bring dysfunction of cortico-striato-thalamo-cortical circuit (Kalra & Swedo, 2009). Evidence suggests that OCD exacerbation could be incited by a range of infections encompassing mycoplasma infection, influenza etc. GABHS (Group A β-hemolytic streptococci) autoresponse may provoke OCD symptoms, leading to the nomenclature of a new sub-group of children with OCD as PANDAS (pediatric autoimmune neuropsychiatric disorders). They also display psychiatric co-morbidities (Lewin , 2010; Kalra & Swedo, 2009). Complications due to pathophysiology of OCD- The complications associated with the pathophysiology of OCD involves behavioral changes, suicidal thoughts, substance abuse, other related anxiety disorders, alteration in mood, depression which is responsible to bring gloom and lack of self-worth, anorexia nervosa or eating disorders where a person may become either lean or obese, contact dermatitis may occur due to repeated washing of hands, trouble in learning, strained relationship with peer, partner, family etc and thereby affects the quality of life (Obsessive Compulsive Disorder). Management of OCD Diagnosis- behavioral problems of repeated thoughts may occur in children or adults and therefore one must seek medical help at an early onset of such condition. A physician may examine the patient and also ask frequent questions related to the behavior, habits and health as well as past medical history of any infection or disease. Based on the observations, medical reports and behavior patterns a doctor characterize the individual as an OCD patient. Treatment & Management- As OCD is a medical condition related with the mental illness, treatment of the condition involves an amalgamation of antidepressant medicines such as SSRIs as well as psychotherapy. Psychotherapy involves cognitive-behavioral therapy where the fake beliefs and thoughts are taken care, and individual is exposed to the reality which otherwise is the reason of fear. The kind of response given by the patient is recorded at first instance and gradually counseling is done where person is motivated to stay in the situation which is the cause of anxiety, it is a gradual process but it helps in generating self confidence in the OCD patients. Evidence suggesting the psychotherapy also highlight the fact that family psychotherapy, family atmosphere and co-operation of family members play an imperative role in overcoming the reason of worry and anxiety. Psychotherapy along with the medication provides benefit to the OCD patient to overcome obsession as well as compulsion (Psychotherapy for Obsessive-Compulsive Disorder). Summary Obsessive Compulsive Disorder is a kind of mental illness that is responsible for bringing obsession in thoughts and compulsion in deeds. Various evidence based research studies have shown that a systematic examination of the individual is most crucial component to diagnose the person with OCD. Repeated administration, communication, during the examination or post examination, the behavior displayed by the patient are a few characteristics that aid in accurate diagnosis of the OCD patient. The treatment with SSRIs must start as soon as the diagnosis of the OCD condition is confirmed. Besides clinical treatment, management of the OCD is also carried out with the cognitive- behavioral psychotherapy which is patient centered and if required a complete family psychotherapy is performed to maintain a congenial and co-operative family atmosphere. Constant monitoring of the patient over the interval enable physicians to keep a track about the flow of thoughts. References 1) Barrett PM, Farrell L, Pina AA, Peris TS, Piacentini J. (2008). Evidence-based psychosocial treatments for child and adolescent obsessive-compulsive disorder. Journal of Clinical Child and Adolescent Psychology, 237:131–155. 2) Bloch, M. H., Williams, K, and Pittenger, C. (2011). Glutamate abnormalities in obsessive compulsive disorder: Neurobiology, pathophysiology, and treatment. Pharmacology & Therapeutics journal, Vol. 132 Issue 3, p314-332 3) Compton, S. N., March, J. S., Brent, D., Albano, A. M., Weersing, R., Curry, J. (2004). 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