I will have lifelong obsessive-compulsive disorder



Obsessive-compulsive disorder are mental disorders in which the patient is forced to think and act that are perceived as distressing, but still have to be implemented. There is an insight, at least at times, that the obsessive thoughts or actions are exaggerated. The disturbance results in significant impairments in everyday life or stresses.

Classification according to ICD-10
F42 Obsessive-compulsive disorder
ICD-10 online (WHO version 2006)

Symptoms

The main symptoms of obsessive-compulsive disorder, which are also decisive for the diagnostic classification according to ICD-10, are obsessive-compulsive thoughts and / or compulsive actions; both symptoms are found in more than 90% of those affected.

Obsessive thoughts

"Obsessive-compulsive thoughts are obsessively imposed, but recognized as nonsensical." (Deister, 2001, p. 127f)

Obsessive-compulsive thoughts often appear in the form of:

  • obsessive-compulsive thoughts (e.g. repeated thoughts that the husband might die or constant doubt)
  • Obsessions (e.g. unauthorized sexual scenes)
  • Compulsory impulses (Urge to perform an action that can be trivial, socially shameful, disruptive or threatening)

Obsessive-compulsive thoughts are mostly about fearful thoughts and beliefs, such as harming, embarrassing, or causing harm to someone. But also trains of thought cannot be completed satisfactorily, so that they have to be constantly imposed and repeated without arriving at a real result.

In a study, subjects were asked about obsessive-compulsive thoughts (Akhtar et al., 1975).

  1. Dirt or contamination (human or other excrement, dirt, dust, semen, menstrual blood, germs, infections)
  2. Violence and aggression (physical or verbal attack on yourself or others; accidents, mishaps, war, disasters, death)
  3. Order (orderliness, striving for symmetry in the alignment of objects, etc.)
  4. Religion (existence of God, religious practices and rituals, beliefs, moral attitudes)
  5. Sexuality (sexual acts in themselves or others, incestuous impulses, sexual performance)

Compulsions

"Actions carried out compulsively against or without the will. Trying to refrain from the actions creates massive internal tension and fear." (Deister, 2001, p. 127f) Compulsive acts are stereotypes that have to be repeated over and over again. Most people know that their behavior is excessive and unreasonable and try to resist at first, but give up when fear overwhelms them. After that, they usually feel less anxious for a short period of time. Apart from this tension reduction, those affected do not feel any joy in performing the action themselves. Some people develop the compulsive act into an obsessional ritual: the compulsive act is carried out in a detailed manner. Those affected have to go through the ritual every time in exactly the same way, according to certain rules that must be carefully observed. Failure to complete the act creates further fear and the ritual often has to be repeated from the beginning.

Examples:

  • Compulsory cleanlinesssuch as compulsory washing
  • Compulsion to control = constant checking of certain things, such as stove tops, door locks, gas taps, ashtrays, important papers
  • Order = An attempt is always made to create symmetry, order or a balance in the environment, in which things such as books or food are perfectly organized according to strict rules.
  • Forced touch = Compulsion to touch things or not to touch them at the moment
  • Compulsory counting = all things that appear in everyday life are counted
  • verbal compulsions = Expressions, sentences or melodies are repeated over and over again

diagnosis

According to ICD-10, code F42, the following diagnostic guidelines apply:

  1. The obsessive-compulsive thoughts or impulses to act must be recognized by the patient as his own.
  2. The patient still has to resist at least one obsessive thought or one compulsive act.
  3. The obsession or obsession must not be pleasurable in and of itself.
  4. The obsessive-compulsive symptoms must repeat themselves in a deeply uncomfortable manner.
  5. The symptoms must persist for at least 14 days on most days.

Third-party rating scales can be used for more precise diagnosis, e.g. the Yale-Brown Obsessive-Compulsive Rating Scale (Y-BOCS) by Goodman et al. (1989).

Differential diagnosis

  • Occasional panic attacks or mild phobic symptoms are compatible with the diagnosis. Although anxiety also plays a role in obsessive-compulsive disorder, they are not an anxiety disorder in the strict sense.
  • Differentiation from schizophrenia: In the past, a connection between obsession and schizophrenia was often postulated. In fact, even according to more modern studies, transitions from obsessive-compulsive disorder to schizophrenia or the additional occurrence of obsessive-compulsive symptoms in schizophrenics are not uncommon. If so, the prognosis for schizophrenia is made worse by the coexistence of compulsions. However, not every psychosis-related or psychotic experience of obsessive-compulsive symptoms is already schizophrenia. Conversely, obsessive-compulsive symptoms in schizophrenics can in many cases plausibly be understood as counter-reactions against the threatening fragmentation of the self, that is, as a "defense mechanism".
  • Differentiation from obsessive-compulsive personality disorder: There is no demonstrable connection between symptomatic obsessive-compulsive disorder and an obsessive-compulsive personality disorder. While the obsessive-compulsive disorder in the context of the obsessive-compulsive / anankastic personality disorder is perceived by the person concerned as "I-synton", i.e. as compatible with his person, the symptomatic obsessive-compulsive disorder is perceived by the person concerned as "I-dystonic", i.e. as being a stranger to me and the person felt not belonging.
  • Obsessive-compulsive symptoms in tic disorder in Gilles-de-la-Tourette syndrome and in organic mental disorders Not diagnosed as obsessive-compulsive disorder, but viewed as part of the corresponding disorder patterns.
  • Furthermore, a distinction must be made between stereotypes in autism and Asperger's syndrome.
  • Purely obsessive-compulsive thoughts can also occur in connection with postpartum depression and / or postpartum psychosis. As a rule, the mother fears that she might harm the newborn.

Comorbidities

A comorbidity (= the common occurrence with another mental disorder) often exists with depression. Both disorders are associated with (reversible) changes in the brain metabolism, especially in the neurotransmitter system. Nevertheless, the symptoms can be clearly separated. More than 50% of the sick also show symptoms from other disorder groups.

Spread and course

Obsessive-compulsive disorder was still relatively unknown until the mid-1990s. This gave those affected the feeling of being "alone" with this disease, which increased the risk of suicide and minimized the chance of seeking therapeutic treatment. Today it is believed that around 2% of the population suffer from obsessive-compulsive disorder. Since the disease is little known in the population, it is often not properly recognized and treated: it often takes 7 to 10 years for those affected to receive targeted treatment.[1] Women seem to be affected just as often as men.

The disease usually begins in adolescence or early adulthood before the age of 30. On average, boys and men are more likely to get sick than women. The disease usually progresses slowly and then steadily worsens. Without effective therapy, two-thirds of the disease is chronic, and one-third is episodic with acute deterioration under particular stress.

At least for the untreated obsessive-compulsive disorder, it can be assumed that the course will usually become chronic, even if the intensity of the symptoms and the degree of impairment can fluctuate. Combined treatment with suitable medication and psychotherapeutic methods can often significantly improve the prognosis. But even if the available therapeutic options are exhausted, a complete and permanent remission of the obsessive-compulsive disorder is rather the rarity!

causes

There is no single cause. A combination of predisposition, cerebral metabolic disorders, and emotional causes are likely to be responsible for the development of an obsessive-compulsive disorder. There may be genetic reasons for obsessive-compulsive disorder [2].

Psychoanalytic explanatory models

Psychoanalysts believe that obsessive-compulsive disorder develops when children begin to fear their own id impulses and employ defense mechanisms to reduce the resulting anxiety. The battle between id impulses and fear is carried out on a conscious level. The id impulses usually appear as obsessive thoughts, the defense mechanisms as counter-thoughts or compulsive actions. Sigmund Freud believed that some children experience intense anger and shame in the anal phase (around 2 years of age). These feelings fuel the struggle between id and ego and set the course for obsessive-compulsive disorder. According to Freud, in this phase of life the children's psychosexual pleasure is tied to the excretory function, while at the same time the parents begin the toilet training and demand that the children delay anal satisfaction. If the toilet training starts too early or is too strict, it can provoke anger and development in the children more aggressive id impulses lead - anti-social impulses that repeatedly urge expression. The children may soil their clothes even more and become generally more destructive, sloppy, or stubborn. If the parents suppress this aggressiveness, the child may also develop feelings of shame and guilt, as well as feelings of being dirty. Against the aggressive impulses of the child, there is now a strong desire to control these impulses. This violent id-ego conflict can last a lifetime and eventually grow into obsessive-compulsive disorder.

A number of ego psychologists turned away from Freud and led the aggressive impulses back to an unsatisfied need to express oneself or to attempts to overcome feelings such as vulnerability or insecurity, rather than to strict toilet training. Yet even these theorists agreed with Freud that people with OCD have strong aggressive impulses and a competing need to control those impulses. (Comer, 2001)

Behavioral models

In the Behavior therapy The development of obsessive-compulsive symptoms is explained and explained even today using the learning-theoretical model and the terms of classical and operant conditioning. An originally neutral stimulus (dirt) is linked to a strong negative affect (fear, violent aversion) to become a proxy for this fear or aversion. As a result, compulsive actions occur to reduce anxiety. Due to the associated negative reinforcement, however, it is precisely the compulsive actions that are operant-conditioned. The model is practically identical to the one used for fears. This model mainly explains the formation and maintenance of Compulsions.

The cognitive-behavioral perspective as a further development of classical behavior therapy binds the Obsessive thoughts with a. A cognitive theory proposed by Salkovskis[3]Concerning the development of obsessive-compulsive disorder assumes that obsessive-compulsive disorder results from the negative evaluation of intrusive thoughts that occur from time to time even in healthy people and their (subsequent) avoidance. The avoidance of the occurring thoughts can be done cognitively or behaviorally: Either an attempt is made to suppress the thoughts or to “neutralize” them through actions (e.g. if there is fear of contamination by washing hands). Both avoidance reactions, however, do not lead to the desired effects: The neutralization act only leads to relief in the short term, as the thoughts that triggered the behavior continue to impose themselves. However, the person has learned that the act can provide relief, if only for a short time. The behavior is thus negatively reinforced. Thought suppression, on the other hand, has a paradoxical effect[4]: The thoughts are amplified by the active suppression.

The cognitive behavioral researchers identified several factors why "normal" thoughts are so distracting for people with obsessive-compulsive disorder:

  • Depressed mood: Greater depressed mood in these people leads to an increase in the number and strength of unwanted thoughts.
  • Strict code of conduct: extraordinarily high moral standards contribute to the fact that particularly sexual and aggressive thoughts are much less acceptable.
  • Dysfunctional beliefs of responsibility and harm: People with obsessive-compulsive disorder believe that their disturbing negative - perfectly normal - thoughts could harm themselves or others.
  • Dysfunctional beliefs and thought patterns: People with obsessive-compulsive disorder have mismatched ideas about how human thinking works, assuming they can have uncomfortable thoughts check.

Biological explanatory models

There are several biological explanations:

  • Serotonin hypothesis: Various neurochemical studies as well as the good results with serotonergic drugs indicate a connection between the serotonin metabolism in the brain and the occurrence of obsessive-compulsive disorders. Obviously it is a therapeutically and medically accessible phenomenon, but an accompanying phenomenon of a primary disturbance of the orbitofronto / zingulostriatal projection system, which is why the administration of medication is not really curative. Instead, symptoms relapse after stopping the medication.
  • Dopamine hypothesis: Especially in the obsessive-compulsive disorder in patients suffering from tic syndromes or Gilles de la Tourette syndrome, dopamine or the dopaminergic transmitter system probably also plays an important role. There are indications that the transmitter disturbances are not the cause of the obsessive-compulsive disorder, but a concomitant phenomenon of "primary disturbances in the orbitofronto / zingulostriatal projection system, which adapts the behavior to a changing external environment and internal emotional states and throws it back onto the monoaminergic nuclei of the midbrain" (Kapfhammer 2000 , P. 1233).
  • Basal ganglia hypothesis: There are functional disorders in certain brain regions, namely in the Orbital region and in Nuclei caudati (Part of the basal ganglia). These findings are supported by positron emission tomography (PET). In positron emission computed tomographic studies, an increased glucose turnover ("increased glucose utilization") was found in the area of ​​the orbitofrontal cortex, the two nuclei caudati and the cingulum. At the same time, the blood flow was reduced in this area of ​​the brain.

treatment

In the therapy of obsessive-compulsive disorder, combinations of an antidepressant with psychotherapy are sensible. Only the use of antidepressants or psychotherapy is far less effective than the combination of both.

psychotherapy

So far the psychoanalytic school achieve no noteworthy success in the therapy of obsessive-compulsive diseases. Psychodynamic aspects, however, occur precisely in obsessive-compulsive disorder as a result of sometimes violent transferences and countertransference, which can lead to a decisive obstacle to therapy if they are not recognized and addressed. It is therefore absolutely useful to have psychodynamic knowledge and experience in the treatment of obsessive-compulsive patients, even though their value compared to the behavioral and cognitive therapy elements is primarily to be seen in the diagnostic and differential diagnostic interactive area.

With the Behavior therapy An effective psychotherapeutic treatment method is now available. Early, effective behavioral therapy should not be delayed because treatment at the onset of the disorder is more promising.

Behavioral interventions: Rachman developed a method of confrontation and Irritation prevention. Clients are repeatedly confronted with objects or situations that normally aroused fear, compulsive apprehension, and compulsions, but should not engage in any of the behaviors they might feel compelled to do. Because this was very difficult for the clients, the therapists often demonstrated it as a model.The clients watched the therapists interact with the object without showing any compulsions. The therapists then encouraged the clients to behave in the same way (a form of participatory model learning). Confrontation and prevention of reactions were carried out in both individual and group therapy. In 60 to 90% of obsessive-compulsive patients treated with this procedure, an improvement occurs in the form of a reduction in compulsive acts and subsequent anxiety experiences. The success of the therapy can still be observed years later. This form of therapy is one of the most effective, but it does not help all patients, as one quarter does not improve (Comer, 2001).

cognitive behavioral interventions: Here, cognitive and behavioral techniques are combined.

  • Habituation training: Used individually when there are only obsessions. Clients are instructed to call themselves the obsessional thought or obsession and hold it present for a longer period of time. In another form, clients spend up to an hour once or twice a day listening to their own tape tapping their obsessions over and over again.
  • hidden reaction prevention: Used for numerous obsessions or compulsions. Clients learn to recognize, prevent, or distract themselves from any other obsessional thoughts or actions that arise during habituation training. In the course of the sessions, the frequency of obsessive thoughts and / or actions should decrease.

Cognitive behavioral therapy also questions obsessive-compulsive thoughts and uses the thought-stopping technique.

Treatment with antidepressants

Standard therapy for obsessive-compulsive disorder (especially in the acute phase) also includes long-term treatment with drugs that modulate the action of the messenger substances serotonin and noradrenaline in special brain regions (see above), e.g. serotonergic antidepressants SSRI (e.g. clomipramine, fluvoxamine, fluoxetine, sertraline) , Paroxetine) and tricyclic antidepressants. Today sertraline, fluoxetine and paroxetine are the first choice drugs.

Treatment with high doses of sertraline can also be achieved in patients who initially do not respond to SSRIs. The patients who did not respond to treatment with SSRIs were treated with 250–400 mg setralin / day. The normal dose is 50-200 mg. 40% of the patients showed an improvement in symptoms with tolerable side effects [5]

In treatment-resistant cases, clomipramine is used[6], Venlafaxine and / or fluvoxamine.

  • Studies of antidepressant treatment (SSRI): Greist et al. demonstrated the effectiveness of the SSRI sertraline for the long-term treatment of obsessive-compulsive disorder in a double-blind study [7]. Rasmussen et al. also proved the effectiveness of sertraline [8]. Chouinard et al. [9] J. Zohar and R. Judge demonstrated the effectiveness of paroxetine, which is comparable to that of clomipramine [10] The safety and effectiveness of fluoxetine in the long-term treatment of obsessive-compulsive disorder have not yet been confirmed by studies. However, it has been shown in short studies (less than 13 weeks of treatment) that fluoxetine reduces the symptoms of OCD [11]. Citalopram appears to be effective in controlling symptoms [12]. Koran et. al. believed that citalopram in combination with clomipramine was more effective in treating obsessive-compulsive disorder than clomipramine alone. However, their study was not a blind study. The authors plan to check their results with a double-blind study [13]

Treatment with neuroleptics

In the past, neuroleptics such as haloperidol were used with severe side effects. Today the better tolerated atypical neuroleptics are mainly used. These include risperidone, quetiapine, olanzapine and amisulpiride. In controlled studies, around half of the patients treated in this way responded. The obsessive-compulsive symptoms improved by 30-40%. Atypical neuroleptics are particularly recommended if the obsessive-compulsive thoughts are of a magical nature, there is insufficient distance from the obsessive-compulsive content, or the obsessions seem bizarre. [14].

Especially in severe cases, the combination of drug and behavioral therapy promises the greatest treatment success. In milder cases, behavior therapy is usually sufficient.

With optimal therapy, an improvement in the symptoms and the course can be expected in most cases. Complete cure is rarely achieved, but stable remission is almost always possible. However, a large number of obsessive-compulsive disorder patients must expect to take medication for life. Symptoms are likely to worsen, especially if the medication is stopped abruptly and if there is insufficient behavioral therapy.

Movies

  • "It couldn't be better" with Jack Nicholson
  • US crime series Monk. Adrian Monk is a private detective and bound by constraints, fears and rituals. But this illness helps him solve cases, as Monk pays attention to little things that no one else sees.

literature

  • A. Deister (2001): Obsessive-compulsive disorder. In: H.-J. Möller, G. Laux, A. Deister: Psychiatry and psychotherapy. 2. completely revised and exp. Edition. Thieme-Verlag, pp. 125-133
  • Akhtar, S., Wig, N.H., Verma, V.K., Pershod, D., & Verma, S.K. (1975). A phenomenological analysis of symptoms in obsessive-compulsive neurosis. Brit. J. Psychiat., 127, 324-348.
  • Christoph Wewetzer: Compulsions in Children and Adolescents. Hogrefe, Göttingen 2004, ISBN 3801717399
  • Comer, R. J. (Ed.) Clinical Psychology. Spektrum Verlag 2001
  • Dr. Nicolas Hoffmann & Birgit Hofmann, Exposure to fears and compulsions, practical handbook, Beltz Verlag PVU, Weinheim, Basel, Berlin 2004, ISBN 3-621-27535-5
  • Nicolas Hoffmann, When constraints constrict life, PAL Verlag Mannheim, 2004, ISBN 3-923614-37-3
  • S. Freud (1908): Character and anal eroticism. Collected Works, Vol. 7; Fischer-Verlag: 1966ff * W.K. Goodman, L.H. Price, S.A. Rasmussen et al. (1989): The Yale-Brown obsessive compulsive scale. I. Development, use, and reliability. Arch Gen Psychiatry 46: 1006-1011
  • Jeffrey M. Schwartz: Compulsions and How to Get Out of Them, Krüger, Frankfurt am Main 1997, ISBN 3-8105-1883-2
  • H.-P. Kapfhammer (2000): Obsessive-compulsive disorder. In: H.-J. Möller, G. Laux, H.-P. Kapfhammer: Psychiatry and Psychotherapy. Springer-Verlag, Berlin, Heidelberg, New York, pp. 1228-1246
  • Klaus Grawe:Neuropsychotherapy, Hofgrefe, Göttingen 2004, ISBN 3-8017-1804-2
  • Lee Baer: The leprechaun in your head. The taming of obsessions. Hans Huber Publishing House, Bern 2003, ISBN 3456839626
  • Otto Benkert: Obsessive-compulsive diseases. 2nd edition C.H. Beck, Munich 2004, ISBN 340641866x
  • Susanne Fricke, Iver Hand: Understanding and coping with obsessive-compulsive disorder - helping people to help themselves. BALANCE, Bonn 2007, ISBN 978-3-86739-001-9
  • Terry Spencer Hesser: Tyrants in the head. Sauerlander, 2001, ISBN 3794147820
  • Willi Ecker: The sickness of doubt. Ways to Overcome Obsessions and Compulsions. CIP media, 1999, ISBN 3932096134

swell

  1. http://idw-online.de/pages/de/news72008
  2. http://www.aerzteblatt-studieren.de/doc.asp?docId=106238
  3. Salkovskis, P.M., Ertle, A., & Kirk, J. (2000). Obsessive-compulsive disorder. In J. Margraf (Ed.), Behavioral Therapy Textbook. Berlin: Springer.
  4. Wegner, D.M., Schneier, D.J., Carter, S.R., & White, T.L. (1987). Paradoxical Effects of Thought Suppression. Journal of Personality and Social Psychology, 53, 5-13.
  5. J Clin Psychiatry 2006; 67, pp. 15-22
  6. O'Sullivan G, Noshirvani H, Marks I, Monteiro W, Lelliott P. Six-year follow-up after exposure and clomipramine therapy for obsessive compulsive disorder. J Clin Psychiatry 1991; 52: 150-5
  7. Int. Clin. Psychophramacol. 1995 Jun; 10 (2): S57-65
  8. Int Clin Psychopharmacol. 1997 Nov; 12 (6): 309-16
  9. Psychopharmacol Bull. 1990; 26 (3): 279-84
  10. http://bjp.rcpsych.org/cgi/content/abstract/169/4/468
  11. http://www.mentalhealth.com/drug/p30-p05.html
  12. http://www.medscape.com/viewarticle/441795 Citalopram Appears Safe, Effective In Refractory OCD
  13. Koran, Lorrin M .; Pallanti, Stefano; Paiva, Rogerio & Quercioli, Leonardo. Citalopram Plus Clomipramine for Refractory OCD. Paper presented at the Annual Meeting of the American Psychiatric Association, May 1999.
  14. http://www.zwaenge.ch/index/80/de/2/

Category: Mental Disorder