CASE STUDY

Obsessive–compulsive disorder (OCD) is a mental disorder characterized by intrusive thoughts that produce anxiety, by repetitive behaviors aimed at reducing anxiety, or by combinations of such thoughts (obsessions) and behaviors (compulsions). The symptoms of this anxiety disorder range from repetitive hand-washing and extensive hoarding to preoccupation with sexual, religious, or aggressive impulses. These symptoms can be alienating and time-consuming, and often cause severe emotional and economic loss. Although the acts of those who have OCD may appear paranoid and come across to others as psychotic , OCD sufferers often recognize their thoughts and subsequent actions as irrational, and they may become further distressed by this realization.

OCD is the fourth most common mental disorder and is diagnosed nearly as often as asthma and diabetes mellitus. In the United States, one in 50 adults has OCD. The phrase "obsessive-compulsive" has become part of the English lexicon, and is often used in an informal or caricatured manner to describe someone who is meticulous, perfectionistic, absorbed in a cause, or otherwise fixated on something or someone. Although these signs are often present in OCD, a person who exhibits them does not necessarily have OCD, and may instead have obsessive–compulsive personality disorder (OCPD), an autism spectrum disorder or some other condition.

Symptoms

Obsessions

The typical OCD sufferer performs tasks, or compulsions, to seek relief from obsession-related anxiety. Within and among individuals, the initial obsessions, or intrusive thoughts, can vary in their clarity and vividness. A relatively vague obsession could involve a general sense of disarray or tension, accompanied by a belief that life cannot proceed as normal while the imbalance remains. Among the more articulable obsessions one may have is a preoccupation with the idea of violently hurting others or oneself. A survey of healthy college students found that virtually all of them had these types of thoughts from time to time.Like these students, OCD sufferers generally do not enact or even enjoy these violent thoughts. On the contrary, they are pathologically disturbed by these ideas—and by the sense that they could inexplicably possess them. Other obsessions concern the possibility that someone or something other than oneself—such as God, the Devil, or disease—will harm either the sufferer or the people or things that the sufferer cares about. Some people dread entire concepts, fearing their materialization by causes that may seem implausible or indiscriminate to others. For example, a generalized fear of contamination might entail not only wariness of bodily secretions or excretions, but also apprehension toward household chemicals, radioactivity , newsprint, pets, or even soap

Sexual obsessions may involve intrusive thoughts or images of "kissing, touching, fondling, oral sex, anal sex, intercourse, and rape" with "strangers, acquaintances, parents, children, family members, friends, coworkers, animals and religious figures", and can include "heterosexual or homosexual content" with persons of any age. As with other intrusive, unpleasant thoughts or images, most people have some disquieting sexual thoughts at times, but people with OCD may attach extraordinary significance to the thoughts. For example, obsessive fears about sexual orientation can appear to the sufferer, and even to those around them, as a crisis of sexual identity. The doubt that accompanies OCD leads to uncertainty regarding whether one might act on the troubling thoughts, resulting in self-criticism or loathing.

Some people with OCD may sense that the physical world is qualified by certain immaterial conditions. They might intuit invisible protrusions from their bodies, or could feel that inanimate objects are ensouled. These people tend not to profess religious or metaphysical convictions, such as a belief in animism, through which such notions are derived; even a child with OCD might find these notions ultimately silly. However, regardless of how these ideas actually correspond with the external world, they can underpin the OCD sufferer's conception of the most practical or proper way for them to understand and face that world. For example, an individual who engages in compulsive hoarding might be inclined to treat inorganic matter as if it had the sentience or rights of living organisms, but such an individual might see no need or way to rationalize their hoarding on behalf of the items they collect.

Compulsions

While some with OCD perform compulsive rituals because they inexplicably feel they must, others act compulsively so as to mitigate the anxiety that stems from their obsessive thoughts. The sufferer might regard these actions as the conditions set forth by an ominous obsession, or might frame them as a more direct route to eliminating the obsessions from the mind. In either case, the sufferer's reasoning is idiosyncratic or distorted to a maladaptive level. Compulsions include counting specific things (such as footsteps) or in specific ways (for instance, by intervals of two) and doing other repetitive actions, often with atypical sensitivity to numbers or patterns. People might repeatedly wash their hands or clear their throats; repeatedly check that their parked cars have been locked before leaving them; turn lights on and off, or touch objects, a certain number of times before exiting a room; or walk in a certain routine way.

For some people with OCD, these tasks, along with the attendant anxiety and fear, can take hours of each day, making it hard for the person to fulfill their work, family, or social roles. In some cases, these behaviors can also cause adverse physical symptoms: people who obsessively wash their hands with antibacterial soap and hot water (to remove germs) can make their skin red and raw with dermatitis. To others, these tasks may appear odd and unnecessary. But for the sufferer, such tasks can feel critically important, and must be performed in particular ways. OCD sufferers are aware that their thoughts and behavior are not rational, but they feel bound to comply with them in order to fend off feelings of panic or dread.

OCD without overt compulsions

OCD sometimes manifests without overt compulsions. Informally nicknamed "Pure-O", OCD without overt compulsions could, by one estimate, characterize as many as 50 percent to 60 percent of OCD cases. Rather than engaging in observable compulsions, the person with this subtype might perform more covert, mental rituals, or might feel driven to avoid the situations in which particular thoughts seem likely to intrude. As a result of this avoidance, people can struggle to fulfill both public and private roles, even if they place great value on these roles and even if they had fulfilled the roles successfully in the past. Moreover, a sufferer's avoidance can confuse others who do not know its origin or intended purpose, as it did in the case of a man whose wife began to wonder why he would not hold their infant child.

Causes

Psychological

Scholars generally agree that both psychological and biological factors play a role in causing the disorder, although they differ in their degree of emphasis upon either type of factor.

From the 14th to the 16th century in Europe, it was believed that people who experienced blasphemous, sexual, or other obsessive thoughts were possessed by the Devil. Based on this reasoning, treatment involved banishing the "evil" from the "possessed" person through exorcism. In the early 1910s, Sigmund Freud attributed obsessive–compulsive behavior to unconscious conflicts which manifested as symptoms. Freud describes the clinical history of a typical case of "touching phobia" as starting in early childhood, when the person has a strong desire to touch an item. In response, the person develops an "external prohibition" against this type of touching. However, this "prohibition does not succeed in abolishing" the desire to touch; all it can do is repress the desire and "force it into the unconscious".

The cognitive–behavioral model suggests that compulsive behaviour is carried out to remove anxiety-provoking intrusive thoughts. Unfortunately this only brings about temporary relief as the thought re-emerges. Each time the behaviour occurs it is negatively reinforced by the relief from anxiety, thereby explaining why the dysfunctional activity increases and generalises (extends to other, related stimuli) over a period of time. For example, after touching a door-knob a person might have the thought that they may develop a disease as a result of contamination. They then experience anxiety, which is relieved when they wash their hands. This might be followed by the thought "but did I wash them properly?" causing an increase in anxiety once more, the hand-washing once again rewarded by the removal of anxiety (albeit briefly) and the cycle being repeated when thoughts of contamination re-occur. The distressing thoughts might then spread to fear of contamination from e.g. a chair (someone might have touched the chair after touching the door handle).

Biological

OCD has been linked to abnormalities with the neurotransmitter serotonin, although it could be either a cause or an effect of these abnormalities. Serotonin is thought to have a role in regulating anxiety. In order to send chemical messages from one neuron to another, serotonin must bind to the receptor sites located on the neighboring nerve cell. It is hypothesized that the serotonin receptors of OCD sufferers may be relatively understimulated. This suggestion is consistent with the observation that many OCD patients benefit from the use of selective serotonin reuptake inhibitors (SSRIs), a class of antidepressant medications that allow for more serotonin to be readily available to other nerve cells

Recent research has revealed a possible genetic mutation that could help to cause 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. Moreover, in his study of identical twins, Rasmussen (1994) produced data that supported the idea that there is a "heritable factor for neurotic anxiety".In addition, he noted that environmental factors also play a role in how these anxiety symptoms are expressed. However, various studies on this topic are still being conducted and the presence of a genetic link is not yet definitely established.

Another section of the brain, the striatum, was implicated in 2007 by scientists at Duke University Medical Center in the US. They genetically engineered a striatal abnormality in mice. This area of the brain is linked to planning and the initiation of appropriate actions. The mice spent thrice the amount of time grooming themselves as ordinary mice, to the point that their fur fell off.

Using tools such as positron emission tomography (PET scans), researchers have shown that those with OCD tend to have brain activity that differs from those who do not have this disorder.In the book, Brain Lock, Jeffrey M. Schwartz suggests that OCD is caused by the part of the brain that is responsible for translating complex intentions (e.g., "I will pick up this cup") into fundamental actions (e.g., "move arm forward, rotate hand 15 degrees, etc.") failing correctly to communicate the chemical message that an action has been completed. This is perceived as a feeling of doubt and incompleteness, which then leads the individual to attempt consciously to deconstruct their own prior behavior—a process which induces anxiety in most people, even those without OCD

It has been theorized that a miscommunication between the orbitofrontal cortex, the caudate nucleus, and the thalamus may be a factor in the explanation of OCD. The orbitofrontal cortex (OFC) is the first part of the brain to notice whether or not something is wrong. When the OFC notices that something is wrong, it sends an initial "worry signal" to the thalamus. When the thalamus receives this signal, it in turn sends signals back to the OFC to interpret the worrying event. The caudate nucleus lies between the OFC and the thalamus and prevents the initial worry signal from being sent back to the thalamus after it has already been received. However, it is suggested that in those with OCD, the caudate nucleus does not function normally, and therefore does not prevent this initial signal from recurring. This causes the thalamus to become hyperactive and creates a virtually never-ending loop of worry signals being sent back and forth between the OFC and the thalamus. The OFC responds by increasing anxiety and engaging in compulsive behaviors in an attempt to relieve this apprehension. This overactivity of the OFC is shown to be attenuated in patients who have successfully responded to SSRI medication. The increased stimulation of the serotonin receptors 5-HT2A and 5-HT2C in the OFC is believed to cause this inhibition.

Some research has discovered an association between a type of size abnormality in different brain structures and the predisposition to develop OCD. Through the use of magnetic resonance imaging (MRI), researchers at Cambridge's Brain Mapping Unit were able to discover distinctive patterns in the brain structure of individuals with OCD and their close family members. This is the first instance in which it has been demonstrated that those with a familial risk of developing OCD have anatomical differences when compared with ordinary individuals. The discovery of these structural differences in the area of the brain associated with stopping motor response may ultimately aid researchers who seek to determine which genes contribute to the development of OCD.

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 Streptococcal infections).

Formal diagnosis may be performed by a psychologist, a psychiatrist or psychoanalyst . To be diagnosed with OCD, a person must have obsessions, compulsions, or both, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM). The Quick Reference to the 2000 edition of the DSM suggests that several features characterize clinically significant obsessions and compulsions. Such obsessions, the DSM says, are recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and that cause marked anxiety or distress. These thoughts, impulses, or images are of a degree or type that lies outside the normal range of worries about conventional problems. A person may attempt to ignore or suppress such obsessions, or to neutralize them with some other thought or action, and will tend to recognize the obsessions as idiosyncratic or irrational.

Compulsions are defined as repetitive behaviors or mental acts that a person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly. These behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these activities are not logically or practically connected to the issue, or they are excessive. In addition to these criteria, at some point during the course of the disorder, the individual must realize that their obsessions or compulsions are unreasonable or excessive. Moreover, the obsessions or compulsions must be time-consuming (taking up more than one hour per day), cause distress, or cause impairment in social, occupational, or school functioning

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