Obsessive Compulsive Disorder - Coursework Example

Obsessive-Compulsive Disorder 2007 Outline: A) Introduction: Incidence and prevalence B) General discussion criteria for diagnosis; 2. symptoms and subtypes, co-occurring disorders; 3. methods of assessment; 4. etiology; 5. treatment. C) Conclusion Foreword: Obsessive-compulsive disorder is recognized as a problem with a lifetime prevalence of 2-3% worldwide, affecting more than fifty million people in different countries. Yet little is known about the illness, its causes, and effective treatment. OCD is still largely under-recognized in clinical practice, while its economic costs are essential. This paper discusses what is known about the illness. Thesis: Obsessive-compulsive disorder is a prevalent lifetime disorder, causing the reduction in life quality and large economic costs, but being under-recognized and insufficiently studied. Obsessive-compulsive disorder is recognized as a problem with a lifetime prevalence of 2-3% worldwide, affecting more than fifty million people in different countries. The prevalence has not proved to be influenced by ethnicity, socioeconomic status, or educational achievement. OCD is more common than schizophrenia, and almost half as common as depression. Yet little is known about the illness, its causes, and effective treatment. OCD is still largely under-recognized in clinical practice, while its economic costs are essential. Obsessive-compulsive disorder emerges as early as age 4. In case it is not treated at once it may have profound impacts. Though males have shown to develop the disorder earlier than females, women have demonstrated lager predisposing to it, being especially at risk of developing OCD during pregnancy and the puerperium. On the other hand, the symptoms of the illness are more severe among men (Fineberg and Roberts, 2001; Thomsen, 2000; Heyman, et al, 2006; Freeman et al., 2007). Diagnostic criteria Both the American Psychiatric Associations Diagnostic and Statistical Manual, 4th edition (DSM-IV) and the World Health Organizations International Classification of Diseases, 10th revision (ICD-10) recognize obsessions and compulsions as the main symptoms of OCD. Obsessions are unwanted, repetitive, disturbing thoughts, images, ideas, or impulses running through the person’s mind over and over again. These are not merely excessive worries about real life problems. These thoughts, being generated by the individual, are distressing and egodystonic. The individual recognizes that the obsessional images, thoughts and impulses are a product of his own mind, but they make him feel nervous and afraid. Trying to avoid these feelings people with OCD start performing certain actions (rituals or compulsions) corresponding to the “rules” they have created for themselves. So compulsions are repetitive, time-consuming, stereotyped, anxiety-reducing rituals (behaviors or mental acts), driven in response to the obsessions and according to rules that must be implemented rigidly. The person with OCD resorts to these behaviors (hand washing, checking, ordering, etc.) or mental acts (praying, counting or repeating words silently) believing that they can prevent or reduce distress or prevent some dreaded event or situation. These rituals bring a short-term relaxation, but then the obsessive thoughts return and the individual repeats the rituals again. For all that, the compulsions are not pleasurable and do not mean the completion of any useful task. They may be not even linked to the underlying obsessions at all and are clearly excessive and time consuming. According to DSM-IV, other criteria of the OCD are: B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children. C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships. D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an Eating Disorder; hair pulling in the presence of Trichotillomania; concern with appearance in the presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence of a Substance Use Disorder; preoccupation with having a serious illness in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in the presence of Major Depressive Disorder). E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (DSM-IV, 1994, 456-7). The ICD-10 proposes more strict criteria. First of all, either obsessions or compulsions (or both) must be present on most days for a period of at least 2 weeks. The ICD-10 states that resistance towards the symptoms need not always be present or the patients with the chronic OCD may find that active resistance makes the symptoms worse. Further, all the features shared by obsessions and compulsions must be present: “acknowledged as originating in the mind of the patient; repetitive and unpleasant; at least one recognized as excessive or unreasonable; at least one must be unsuccessfully resisted (although resistance may be minimal in some cases); carrying out the obsessive thought or compulsive act is not intrinsically pleasurable” (ICD-10, 1992). Another difference between the classifications offered by the ICD-10 and DSM-IV is that the former conceptualizes OCD as a “stand-alone” disorder, placing it separately within the category of neurotic, stress-related and somatoform disorders, while the latter has prioritized anxiety as the major symptom and refers OCD to anxiety disorders, though OCD shares only several features with the other disorders of this group. Symptoms and subtypes, co-occurring disorders According to Naomi Fineberg and Ann Roberts (2001) most patients suffer a mixture of different obsessions and compulsions. However, surveys have showed that contamination fears (45%) are the most common obsession. Other frequently occurring obsessions are concern about doing harm to others, pathological doubts (42%), somatic obsessions (36%), and the need for symmetry (31%), with aggressive impulses (28%), repeated sexual imagery (26%) following them. 60% of the patients have got multiple obsessions. The most spread behavioral compulsions suffered by half of all the patients with OCD are those in the realm of repetitive checking (60%) or excessive washing and cleaning (50%), need to confess (36%), ordering/symmetry (31%) and hoarding (18%) following them. Covert counting (36%) is the major mental compulsive acts. Key themes, underlying the symptoms, are abnormal risk assessment, pathological doubt and incompleteness (p.6-7). Besides, other symptoms are fear of harm coming to self, religious obsessions, fear of behaving unacceptably or making a mistake; asking for reassurance, repeating words silently, ruminations, “neutralizing” thoughts. People may involve their family members into their compulsions (Heyman et al., 2006, 426). As a rule, patient do retain the insight into the absurdity of their symptoms, but it is not always so. The individuals with poor insight usually have more complex symptomathology and tend to be more severely ill (Fineberg and Roberts, 2001, p.6). It should be mentioned that mild forms of symptoms characteristic with OCD take place in every day life of many people, e.g. repetitive checking or superstitious behaviors. So they can be viewed as the criteria for OCD diagnosis only in case they are time-consuming and cause impairment and distress. Recurrent and intrusive thoughts, images and impulses are also common for other mental disorders (the preoccupation with body image in body dysmorphic disorder, fear in phobias, hair-pulling in trichotillomania, illness in hypochondriasis) (Fineberg and Roberts, 2001, p.6). Aggressive obsessions are also characteristic with other disorders, e.g. psycopathy. Moreover, it is necessary to keep in mind that people with OCD only worry that they might commit the offense but they do not perform it (Heyman et al., 2006, 426). It means that the diagnosis for OCD should only be made when other symptoms of the disorder are also present. As many other disorders, OCD may share comorbidity with a range of disorders from Axis I and II, depression being the major one (31% with current and 61% with lifetime state). Specific phobias, social phobia, eating disorders, alcohol abuse, panic disorders and Tourette’s syndrome are usual concurrent disorders. Studies have also indicated higher rates of suicidal behaviors (independent of concurrent depression) among OCD patient in comparison with patients suffering from other mental disorders. Tourette’s syndrome is often complicated by co-occurring OCD (35-50%). Though incidence of TC in OCD is much lower (only 5-7%), tics are reported in 20-30% of patients with OCD. Though obsessions and compulsions are also characteristic with schizophrenia, patients with OCD require separate treatment, while antipsychotic drugs are not only ineffective on their own, but may occasionally make the OCD worse. Dermatics from excessive cleaning rituals can be mixed with eczema or acne, or vice versa not understood by the specialist. People having OCD are frequent visitors to the genitourinary clinic, but OCD usually is not diagnosed there. These evidences demonstrate that the awareness of OCD must be raised among all the non-psychiatric health specialists that are likely to see the patients with OCD, these being dermatologist, general practitioner, oncologist, genitourinary specialist, neurologist, obstetrician, gynecologist (Fineberg and Roberts, 2001, p.8-11). Methods of assessment Patients with OCD suffer from shame and are afraid to be considered mad. For this reason, obsessive-compulsive disorder is a rather secretive condition. Besides, people may not perceive OCD as a problem. If you suspect OCD in somebody, you should put direct questions. The quickest way to screen the patient with OCD is to put six simple questions (Zohar-Fineberg obsessive compulsive screen): Do you wash or clean a lot? Do you check things a lot? Is there any thought that keeps bothering you that you would like to get rid of but cant? Do your daily activities take a long time to finish? Are you concerned about orderliness or symmetry? Do these problems trouble you? A face-to-face interview is an obligatory part of assessment. And as Goldsmith, Shapira and Goodman (2001) suggest, “well structured screening tools not only further define diagnosis, but determine the presence of additional psychiatric disorders from which the patient may suffer” (p.15). There are a number of ready interviews that may and should be used in assessment of OCD. The Structured Clinical Interview for DSM-IV (SCID-IV) is one of the most widely used screening tools for OCD. Its succinct, categorized questions allow completing a differential diagnosis of Axis I disorders. The SCID-IV has a large reliability, but it must be carried out by an appropriately trained specialists. Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) is very useful when the assessment of anxiety specific disorders or comorbid diagnosis is required. The ADIS-IV also becomes a highly reliable instrument in the hands of a trained professional. Once the diagnosis of OCD is set, the extent and severity of the symptoms must be determined, while it will show what treatment should be prescribed. For this one should use rating tools. Yale-Brown Obsessive Compulsive Scale is the most widely used tool for assessing symptom severity, translated in many languages and demonstrating “excellent interrater reliability and admirable test-retest reliability” (p.18). Y-BOCS measures not the number of symptoms, but the extent to which these symptoms affect the person’s life and provides possibility for monitoring change in symptoms. The modified patient-administered version of this tool has showed less reliability then the clinician-administered one in large-scale screening. The Screening Test for Obsessive-compulsive Problems (STOP) and the Florida Obsessive Compulsive Inventory (FOCI) are two pen-and-paper forms to be used in communities and clinics. The Maudsley Obsessional Compulsive Inventory (MOCI), a 30-item true-false test, was designed to differentiate between patients with OCD and nonpsychotic patients without OCD. It is brief and easy to administer but has some limitations. It allows assessing symptoms according to four groups: “checking”, “cleaning”, “slowness” and “doubting”, – but doesn’t cover hoarding and aggressive obsessions (p.18-9). The Leyton obsessional Inventory (LOI), used before the introduction of the Y-BOCS, may be useful in assessing obsessional thoughts (p.19). Etiology The etiology of obsessive-compulsive disorder is still not clear. There are many theories and all of them have found their proof to a certain degree. However, there are two main approaches to the problem: psychological or cognitive-behavioral and biological or biochemical. The supporters of the cognitive-behavioral approach believe that OCD is the response of the individual to the obsessive thoughts produced by his distorted cognition. The compulsive behaviors are seen as attempts to neutralize these thoughts, making things right again. Other researchers see the roots of the problem lying in the brain of an individual. Several models were created to explain how OCD works. Genetic model states that the disorder is caused by genes transmission, genetic mutation. The researchers say that a number of genes are involved into the process, predisposing a certain type of people to OCD, other undefined conditioned being met. The rate of concordance has been found to be higher for the identical twins, sharing common genetic material, than for fraternal twins. Besides, OCD in parents is a predictor of the disorder in children. Neuroanatomical model explains OCD by size and activity abnormalities in different brain structures. The researchers say that obsessive-compulsive behavior may originate in the fault in the cycle of thoughts in brain, over the miscommunication between the orbital-frontal cortex, caudate nucleus, and the thalamus. The OFC sends an initial “worry signal” to the thalamus, which sends it back to the OFC for interpretation. The caudate nucleus lies just between the OFC and thalamus, preventing the initial worry signal from being directed back to the thalamus after it has been received. This leads to the hyperactivity of the thalamus and creates a virtually never-ending feedback loop of worry thoughts, increasing anxiety in the OFC. Nuerochemical model looks for the causes of the disorder in the abnormality in the serotonin, dopamine, neuropeptides, and autoimmune system. For instance, serotonin is thought to play its part in regulating anxiety. The suggestion is supported by the fact that OCD patients treated by selective serotonin reuptake inhibitors (SSRIs) have shown improvements. On the other hand, the changes in the amount of serotonin may be not the cause but the consequence of the OCD. The supporters of neuroimmunology model suggest that the cause may lie, at least in part, in childhood streptococcal infections (strep throat) and PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcus). The research has shown that the antibodies created to fight strep throat damage the basal-ganglia (brain structure), which results in OCD symptoms (Valente, 2002, 127-8). As we can see, the etiology of obsessive-compulsive disorder is controversial and will be explained only in the future. Treatment OCD is usually treated with the Cognitive-Behavioral therapy and medications. Psychotherapy is implemented in some cases when the usual treatment doesn’t help, with positive results about 30%. CBT has proved to be very effective with patients of any age. The specific technique used in treatment of OCD is called Exposure and Response Prevention (ERP). The patients learn to tolerate the anxiety linked to ritual behaviors. It is done gradually. For instance the individual is taught to touch the object, that he can view as “contaminated” (exposure) and not to wash his hand after it (response prevention); or to check the lock only once without returning and checking again. When the person habituates to the proposed anxiety producing situation, the task is complicated. Parallel cognitive therapy helps to accustom to anxiety producing situations even faster, while the patients is made to look at them from a new point and realize that his fears were excessive and absurd. Drug therapy is usually prescribed in combination with CBT. Besides, SSRIs, mentioned above, that change the level of serotonin in brain, other medications are also used (these being lamotrigine (Lamictal), gabapentin (Neurontin), risperidone (Risperdal), atypical antipsychotics olanzapine (Zyprexa), etc). However, today SSRIs stay the most widely used drug treatment, having proved to be effective for people of all the ages. It is estimated that 40% of OCD patients don’t benefit from CBT and medications. These people may choose to undergo psychosurgery or additional treatment (Heyman et al, 2006, 428). Conclusion Further research is needed for OCD. There are a number of questions to be answered. These questions concern the classification of the disorder, its subtypes and comorbidity, causative factors, screening at earlier stages, and effective ways of treatment for patients of different ages and with various causes of OCD. References: American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th edn (American Psychiatric Association: Washington, DC, 1994). Goldsmith, Tody D., Shapira, Nathan A., and Goodman, Wayne K. (2001). Assessment of OCD. In Obsessive-Compulsive Disorder: A Practical Guide. Book by Naomi Fineberg, Donatella Marazziti, Dan J. Stein. Publisher: Martin Dunitz. London. Pp.15-21. Fineberg, Naomi, and Roberts, Ann (2001). Obsessive-compulsive disorder: a twenty-first century perspective. In Obsessive-Compulsive Disorder: A Practical Guide. Book by Naomi Fineberg, Donatella Marazziti, Dan J. Stein. Publisher: Martin Dunitz. London. Pp.1- 14. Freeman J.B., Choate-Summers M.L., Moore P.S., Garcia A.M., Sapyta J.J., Leonard H.L., Franklin M.E. (2007). Cognitive behavioral treatment for young children with obsessive-compulsive disorder. Biological Psychiatry, Vol.61 (3), 337-343. Heyman, I., Mataix-Cols, D., and Fineberg, N.A. (2006). 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