Obsessive Compulsive Disorder
From WikEd
Descriptions, Definitions and Characteristics
Obsessive-compulsive disorder (OCD) is a brain disorder, more specifically, an anxiety disorder. OCD is manifested in a variety of forms, but is most commonly characterized by a subject's obsessive drive to perform a particular task or set of tasks, compulsions commonly termed rituals. OCD should also be distinguished from the similarly named but very different obsessive-compulsive personality disorder. Obsessive-compulsive personality dissorder is defined as a personality characteristic rather than an anxiety disorder (Wikipedia, 2005).
The phrase "obsessive-compulsive" is often used in an offhand sense to describe someone who is meticulous or absorbed in a cause. Such casual references should not be confused with obsessive-compulsive disorder. It is also important to distinguish OCD from other types of anxiety, including the routine tension and stress that appear throughout life (Wikipedia, 2005).
Obsessions are thoughts and ideas that the sufferer cannot stop thinking about. Common OCD obsessions include fears of acquiring disease, getting hurt or causing harm to someone. Obsessions are typically automatic, frequent, distressing, and difficult to control or put an end to by themselves. A sufferer will almost always obsess over something which he or she is most afraid of. People with OCD who obsess over hurting themselves or others are actually less likely to do so than the average person (Wikipedia, 2005).
Compulsions refer to actions that the person performs, usually repeatedly, in an attempt to make the obsession go away. For an OCD sufferer who obsesses about germs or contamination, for example, these compulsions often involve repeated cleansing or meticulous avoidance of trash and mess. Most of the time the actions become so regular that it is not a noticeable problem. Common compulsions include excessive washing and cleaning; checking; hoarding; repetitive actions such as touching, counting, arranging and ordering; and other ritualistic behaviors that the person feels will lessen the chances of provoking an obsession. Compulsions can be observable, but they can also be mental rituals such as repeating words or phrases, or counting (Wikipedia, 2005).
The DSM-IV (Diagnostic and Statistical Manual of Disorders, Fourth Editions) classifies OCD as an anxiety disorder. OCD is characterized by distressing and intrusive thougths and repetitive actions that interfere with the individual’s daily functioning. The exact pathophysiologic process that underiles OCD has not been estabilshed. Research trials suggest that abnormalities in serotonin transmission in the central nervous system are central to OCD. These researchers strongly support by the use of specific serotonin reuptake inhibitors (SRI) in the treatment of OCD (Aronson, 2004).
Symptoms and Prevalence
Modern research has revealed that OCD is much more common than previously thought. An estimated 2-3% of the United States population is thought to have OCD or display OCD-like symptoms. Because of the condition's personal nature, and the lingering stigma that surrounds it, there may be many unaccounted-for OCD sufferers, and the above percentages could be even higher (Wikipedia, 2005).
The typical OCD sufferer performs tasks (or compulsions) to seek relief from obsessions. To others, these tasks may appear simple and unnecessary. But for the sufferer, such tasks can feel critically important, and must be performed in particular ways for fear of dire consequences and to stop the sufferers stress build up. Examples of these tasks include repeatedly checking that one's parked car has been locked before leaving it, turning lights on and off a set number of times before exiting a room, or repeatedly washing hands at regular intervals throughout the day (Wikipedia, 2005).
OCD rituals are often bound up with intricate detail. A smoker with OCD, for instance, may argue with him/herself that quitting cigarettes is possible only on the 13th or 27th of a month, and only when he or she has possession of four cigarettes at noon (Wikipedia, 2005).
Most OCD sufferers are aware that such thoughts and behavior are not rational, but feel bound to comply with them to fend off fears of panic or dread. Because sufferers are consciously aware of this irrationality but feel helpless to push it away, OCD is often regarded as one of the most frustrating of the major anxiety disorders (Wikipedia, 2005).
People who suffer from the separate and unrelated condition obsessive compulsive personality disorder are not aware of anything abnormal with them OCPD sufferers will readily explain why their actions are rational, and it is usually impossible to convince them otherwise. People who suffer with OCPD also tend to derive pleasure from their obsessions or compulsions. Those with OCD do not derive pleasure, they are ridden with anxiety - a significant difference between both these disorders. OCD is different from behaviors such as gambling addiction and overeating. People with these disorders typically experience at least some pleasure from their activity. OCD sufferers do not actively want to perform their compulsive tasks, and experience no tangible pleasure in doing so (Wikipedia, 2005).
Not all OCD sufferers engage in compulsive behavior. Recent years have seen increased diagnoses of Pure Obsessional OCD. This form of OCD is manifested entirely within the mind, and involves obsessive ruminations triggered by certain thoughts. These obsessive ruminations can be debilitating, often tying up a sufferer for hours at a time (Wikipedia, 2005).
OCD is placed in the anxiety class of mental illness, but like many chronic stress disorders it can lead to depression over time. The constant stress of the condition can cause sufferers to develop a deadening of spirit, a numbing frustration, or sense of hopelessness. OCD's effects on day-to-day life — particularly its substantial consumption of time — can produce difficulties with work, finances and relationships. Remarkably, some people still maintain successful careers and relationships as many do find they can hide or supress their OCD behaviour due to feeling unneccesarily ashamed of this debilitaiting disorder (Wikipedia, 2005).
Causes and Related Disorders
Recent research has revealed a possible genetic mutation that could be the cause of OCD. Researchers funded by the National Institutes of Health have found a mutation in the human serotonin transporter gene, hSERT, in unrelated families with OCD. This research has found that:
*Violence is rare among OCD sufferers, but the disorder is often
debilitating to the quality of life. Also, the psychological self-
awareness of the irrationality of the disorder can be painful. For
people with severe OCD, it may take several hours a day to carry out the
compulsive acts. To avoid perceived obsession triggers, they also often
avoid certain situations or places altogether.
*Sufferers are generally of above-average intelligence, as the very nature
of the disorder necessitates complicated thinking patterns.
*Some people with OCD also suffer from conditions such as Tourette
syndrome, compulsive skin picking, body dysmorphic disorder and
trichotillomania.
*Some cases are thought to be caused at least in part by childhood
streptococcal infections and are termed PANDAS (pediatric autoimmune
neuropsychiatric disorders associated with streptococcus). The
streptococcal antibodies become involved in an autoimmune process
(Wikipedia, 2005).
Treatment
OCD can be treated with behavioral therapy or cognitive therapy and with a variety of medications. According to the Expert Consensus Guidelines for the Treatment of Obsessive-Compulsive Disorder (Journal of Clinical Psychiatry, 1995, Vol. 54, supplement 4), the treatment of choice for most OCD is behavior therapy or cognitive behavior therapy. Medications can help make the treatment go faster and easier, but most experts regard behavior therapy as clearly the best choice. Medications generally do not produce as much symptom control as behavior therapy, and symptoms invariably return if the medication is ever stopped (Wikipedia, 2005).
The specific technique used in behavior therapy is called Exposure and Ritual Prevention (also known as Exposure and Response Prevention) or ERP. ERP involves gradually learning to tolerate the anxiety associated with not performing the ritual behavior. At first, for example, someone might touch something only very mildly "contaminated" (such as a tissue that has been touched by another tissue that has been touched by the end of a toothpick that has touched a book that came from a "contaminated" location, such as a school). That is the "exposure." The "ritual prevention" is not washing (Wikipedia, 2005).
Another example or ERP might be leaving the house and checking the lock only once (exposure) without going back and checking again (ritual prevention). The person fairly quickly habituates to the (formerly) anxiety-producing situation and discovers that their anxiety level has dropped considerably; they can then progress to touching something more "contaminated" or not checking the lock at all — again, without performing the ritual behavior of washing or checking (Wikipedia, 2005).
Medication treatments include selective serotonin reuptake inhibitors such as paroxetine (Paxil, Aropax), sertraline (Zoloft), fluoxetine (Prozac), and fluvoxamine (Luvox) as well as the tricyclic antidepressants, and in particular clomipramine (Anafranil). Some medications like Gabapentin have also been found to be useful in the treatment of OCD. Symptoms tend to return, however, once the drugs are discontinued (Wikipedia, 2005).
Recent research has found increasing evidence that opioids may significantly reduce OCD symptoms, though the addictive property of these drugs likely stands as an obstacle to their sanctioned approval for OCD treatment. Anecdotal reports suggest that some OCD sufferers have successfully self-medicated with opioids such as Ultram and Vicodin, though the off-label use of such painkillers is not encouraged, again because of their addictive qualities (Wikipedia, 2005).
Application in Classrooms and Similar Settings
Obsessive compulsive disorder in young people is common and under-recognized. Estimated prevalence rates in children and adolescents are about one percent. The distress to young people caused by the characteristic intrusive, unwanted, and often unpleasant thoughts or fears is often hidden, as children identify these symptoms as peculiar or embarrassing and keep them secret, sometimes for years. Likewise, compulsive behaviors such as washing or checking are usually perceived as unnecessary and often ridiculous, and children may go to great lengths to conceal them (Heyman, 1997).
The psychopathology of OCD in children is strikingly similar to that seen in the adult disorder. Many adults diagnosed with obsessive compulsive disorder report that their symptoms first began in childhood. Parents, teachers and primary care practitioners, as well as pediatricians and child psychiatrists, may well be familiar with the symptoms, and if children are asked directly they can often give lucid accounts of their problems, which are easily distinguished from ordinary childhood superstitions. In addition to causing acute distress and disruption to education and friendships, obsessive compulsive disorder in children can be highly disabling, associated with chronic psychiatric morbidity, as well as severe long term social impairment. Evidence exists that early detection and assertive treatments are important for minimizing the impairment experienced (Heyman, 1997).
Obsessive compulsive disorder in children has traditionally been classified as an anxiety disorder, and anxiety certainly is a core component. But for children to obtain optimum treatment both psychosocial and neurobiological aspects must be appreciated. Children with obsessive compulsive disorder will not all be equally responsive to treatment. One of the most important research drives is the need to understand and define the heterogeneity within the disorder, which in turn will doubtlessly provide pointers to the most appropriate treatments for different subtypes. For example, a group of children has been identified who acquire acute onset obsessive compulsive disorder related to an autoimmune response to streptococcal infection. It remains to be seen whether such subgroups have equivalent responsiveness to medication or behavioral intervention (Heyman, 1997).
To target treatment appropriately children with obsessive compulsive disorder need careful evaluation to rule out normal developmental variations, depression, and autistic disorders. A thorough assessment of symptom severity and consequent impairment is a good guide to the need for treatment; diagnostic instruments designed for use in children are widely used in specialist centers. If obsessive compulsive disorder is diagnosed, it is clear that most children will benefit from a trial of medication and many from medium to long term drug treatment. Likewise, most children warrant assessment for behavioral treatment, and many will respond favorably to a structured course of behavioral treatment based on exposure and response prevention. Children and adolescents with this disabling condition should not fail to get well validated and specific treatments, either because the disorder remains undetected or because of lack of expertise in delivering these treatments (Heyman, 1997).
Evidence of Effectiveness
Goodman (1999) wrote an article about obsessive compulsive disorder and the disorders diagnosis and treatment options. Goodman says that obsessive compulsive disorder is a chronic, disabling anxiety disorder that is characterized by recurrent obsessions and uncontrolled compulsions such as repetitive behavioral or mental acts that are performed in response to an obsession. OCD often occurs cormorbidly with a number of depressive and anxiety disorders. In addition, patients with OCD suffer significant personal and social morbidity and may have difficulty maintaining a job, finishing school, and developing relationships. The backbone of pharmacologic treatment for OCD is a 10 to 12 week trial with a selective serotonin reuptake inhibitor (SRI) in adequate doses. In most cases, treatment should be initiated with an SRI because of the superior safety, tolerability, and equivalent efficacy of this class of drugs compared with clomipramine. When dealing with patients who do not respond to the SRI, effective alternatives include switching to a different SRI, combining another medication or behavioral therapy with SRI therapy, considering novel or experimental drug treatments, or employing non-pharmacologic biological approaches, such as electroconvulsive therapy, neurosurgery, or repetitive transcranial magnetic stimulation. This article provides an update on the diagnosis and medical management of OCD and discusses guidelines for the use of SRIs and novel approaches for managing treatment-refractory patients.
Zitterl, Demal, Aigner, Lenz, Urban, Zapotoczky, and Aitterl-Eglseer (2000) completed a study on the naturalistic course of obsessive compulsive disorder and comorbid depression. Seventy-four patients who met the DSM-III-R criteria for obsessive compulsive disorder were studied in a perspective follow-up study in order to investigate course and prognosis of OCD with or without comorbid depressive symptomatology. Subjects were examined three times: at admission (baseline), 6 months later (follow-up 1), and 12 months after follow-up 1 (follow-up 2). At admission 72% of the OCD patients were assessed as depressive by the Hamilton Depression Scale score. Between admission and follow-up 1, all patients received behavior therapy and a serotonin reuptake inhibitor. Between follow-up 1 and follow-up 2 these same patients received different kinds of treatment in order to maximize therapeutic effects. The results obtained from the Yale-Brown Obsessive-Compulsive Scale showed that OCD patients who followed a good prognosis course, showed no significant depressive symptomatology at follow-up 2. These results imply that patients with a diagnosis of OCD may present depression at admission and/or follow-up 1. However if OCD symtomatology decreases longitudinally, depressive symptoms disappear too. The researchers assume that OCD is dominant over depression, and it seems that a comorbid depression does not have any major influence on the prognosis of OCD (Zitterl et al., 2000).
Obsessive compulsive (OCD) and delusional disorders (DD) have been recognized with increased frequency in recent years. Fear, Sharp and Healy (2000) studied obsessive compulsive disorder with delusions. This study reported illness-specific demography along with measures of symptom severity and tests to assess schizotypal ideation, dysfunctional attitudes, attributional and attention bias in 30 patients with OCD, 29 with DD, 16 with OCD with delusions (OC-DD) and a 30- subject control group (CG). Obsessional features appeared before delusions in the OC-DD group, suggesting that OCD was the primary pathology. Delusions were more likely in subjects obsessional about one rather than multiple themes. There was some support for proposals that depression and schizotypy may bring out delusions in OCD and some evidence for the utility of categorizing OCD according to the number of obsessions a subject has (Fear et al., 2000).
Eisen et al., (1999) completed a study on the patterns of remission and relapse in obsessive compulsive disorder. This was a two year prospective study that examined the course of illness in patients with obsessive compulsive disorder (OCD). Sixty-six patients with a primary diagnosis of OCD were followed prospectively for 2 years. Baseline information was collected on demographic characteristics and severity of OCD symptoms. Follow-up measures obtained at 3, 6, 12, and 24 months after baseline assessment included information on symptomatic and diagnostic status as well as behavioral and somatic treatments received.
Eisen et al., found that the probability of full remission from OCD over the 2 year period was 12%. The probability of partial remission was 47%. After achieving remission from OCD, the probability of relapse was 48%. No factors were identified that significantly predicted full or partial remission. The researchers found that using a serotonin reuptake inhibitor (SRI) did not increase the likelihood of full remission of OCD. The results of this study also suggest that behavior therapy may be under-utilized in treating OCD.
Pauls and Alsobrook (1999) compiled a study about the inheritance of obsessive compulsive disorder. The authors found that the influence of genetic factors had been suggested many times in the literature on OCD and that a number of studies had been conducted to determine if a subject could inherit OCD. The researchers stated that evidence for the influences of genetic factors has come from twin and family aggregation studies. Furthermore the authors suggest that drug-treatment and functional neuroimaging studies have added strength to the genetic investigations by emphasizing the neurobiologic aspects of OCD.
Critics and Their Rationale
The author of this web site has found no critics of obsessive compulsive disorder.
There is, however, significant disagreement about successful treatment strategies. Much of the anecdotal evidence (books about or by adults who now find their sysmptoms tolerable) supports a balance of behavioral modification, therapy, and drug treatments. However, there is continuing emphasis on drug therapy as the dominant or, too often, only form of treatment offered. Two examples that illustrate this need for the three-pronged approach to therapy and recover are: The Boy Who Couldn't Stop Washing : The Experience and Treatment of Obsessive-Compulsive Disorder by Judith L. Rapoport and Up and Down the Worry Hill : A Childrens Book about Obsessive-Compulsive Disorder and its Treatment by Aureen Pinto Wagner. There is also a slowly increasing recognition that full recovery is rarely possible and that many children and adults can lead rich and full lives with tolerable levels of symptoms.
Alternative Explanations Due to Diversity Considerations
The author of this web site has found no alternative explanations of obsessive compulsive disorder that deal with diversity considerations. No studies have been completed that specifically reference OCD and the disorders correlation with specific ethnicities.
According to Aronson (2004), the overall prevalence of OCD is equal in males and females.
Signed “life experiences�?, testimonies and stories
*Please feel free to add testimonies about OCD here.
This last year I had a student with OCD in my choir. She would become fixated on any negative event that had happened and then not be able to function for the rest of the day. My time was spend dealing with her negative reactions to these situations by trying to manage her behavior. Needless to say, I was not a very effective teacher when it came to teaching this student. –Chris Royer-
I think in many ways Type A personalities can be misdiagnosed as OCD. In many ways, the situations are similar. Most type A's have certain ways of doing things, and this can be misinterpreted as OCD. However, we as teachers need to be sensitive to this fact, and help our students the best way possible. S.Luxbacher
In response to the above testimony, I do believe that there is a fine line between Obsessive Compulsive behavior and Type-A personalities. I am very much a Type-A and have very strict ways of going about things. Something I specifically had trouble with was when teachers tried to force me to write papers in a certain manner. I always write out my essays on paper and continuously revise as I go on, and then I type it and do my final revision as I'm typing. Thus, I had a really hard time when teachers requested certain stages by a certain date because I could not just create a "rough draft." Whether it is OCD or just being Type-A, teachers need to be sensitive to the fact that students have certain routines, and there is no point in trying to change them if the student is successful using it.
My sister has been diagnosed with OCD, and before her teachers find out about it, they are generally less willing to help, less willing to spend exra time with her outside of school, and generally more suspicious of this student they find to be over-eager or overanxious. However, when teachers find out about her diagnosis, they are instantly supportive, helpful and understanding. I think teachers should seek to understand an entire situation before diagnosing it. As a teacher myself, I can think of a number of times I may have had an OCD student ask me for help or seem to come on too strong for whatever reason, but I dismissed them as being simply socially awkward and didn't have the patience or foresight to see the true reasons for their actions. --David Roth
References
Aronson, S.C. (2004). Obsessive Compulsive Disorder. Retrieved July 28, 2005
from http://www.eMedicine.com/
Eisen, J.L., Goodman, W.K., Keller, M.B., Warshaw, M.G., DeMarco, L.M., Luce,
D.D., & Rasmussen, S.A. (1999). Patterns of remission and relapse in
obsessive compulsive disorder: A 2 year prospective study. Journal of
Clinical Psychiatry, 60(5), 346-351.
Fear, C., Sharp, H., & Healy, D. (2000). Obsessive compulsive disorder with
delusions. Psychopathology, 33(2), 55-61.
Goodman, W.K. (1999). Obsessive compulsive disorder: Diagnosis and treatment.
Journal of Clinical Psychiatry, 60(18), 27-32.
Heyman, I. (1997). Children with obsessive compulsive disorder. Retrieved
July 27, 2005 from http://www.bmj.com/
Niner, Holly L. Mr. Worry : a story about OCD. Morton Grove, Ill. : Albert
Whitman & Co., 2004.
Sporting attractive art and a good story, this is an excellent resource to help explain OCD treatment to children, whether if it is for the diagnosed child or a family member or sibling.
Obsessive Compulsive Disorder. Retrieved July 27, 2005 from
http://www.wikipedia.org/
Pauls, D.L., & Alsobrook, J.P. (1999). The inheritance of obsessive compulsive
disorder. Child Adolescence Psychiatry Clinic, 8(3), 481-496.
Zitterl, W., Demal, U., Aigner, M., Lenz, G., Urban, C., Zapotoczky, H.G., &
Zitterl-Eglseer, K. (2000). Naturalistic course of obsessive compulsive
disorder and comorbid depression, Psychopathology 33(2), 75-80.
