Apr 4, 2019 in Science

Obsessive-Compulsive Disorder

Explain the Disorder according to DSM-5

According to DSM-5, Obsessive-Compulsive Disorder (OCD) is characterized by obsessions and compulsions of various kinds. In particular, an individual can experience intrusive, distress-causing thoughts, images, ideas, or urges, which occur persistently and unwillingly. Such obsessions appear against free will. Therefore, a person tries to suppress, ignore, or somehow neutralize them, for example, through compulsive behaviors. In such a way, compulsions are defined in DSM-5 as repetitive movements aimed at fighting obsessions. Specifically, an individual can recurrently wash hands, order, check, pray, count, or whisper particular words. These actions are performed with the purpose of reducing anxiety or distress although in reality, there are no rational connections between the target and the means. In other words, such excessive behaviors or mental acts cannot prevent the thing, which is feared. Obsessions and compulsions occur recurrently during the day, constantly engage an individual, prevent him/her from performing necessary social activities, and often incapacitate. According to DSM-5, the symptoms of OCD are not caused by any medication or substance. 

Obsessive-Compulsive Disorder (OCD) is specified by the following dysfunctional beliefs: an inflated sense of responsibility, threat overestimation, perfectionism and intolerance of uncertainty, the excessive importance of thoughts and the need to control them. These dysfunctional beliefs may have a different degree of insight about their accuracy by different individuals. Thus, many have good or fair insight: they realize that such beliefs are definitely or probably not true. Some individuals have poor insight and believe that their obsessions are probably true. Finally, a few (nearly 4 %) have absent insight or delusional beliefs, and they are absolutely convinced that their dysfunctional beliefs are true. It is important to note that individuals can have a varied degree of insight through the course of the illness. Besides, about 30 % of patients with OCD have a tic disorder, especially males with onset of OCD at an early age. Their symptoms, comorbidity, course, and pattern of familial transmission are different.

Explain Genetic and Environmental Factors

Researchers believe that OCD can be triggered by a combination of various factors, including neurobiological, genetic, behavioral, cognitive, or environmental factors. There are possible temperamental risk factors for developing OCD, including greater internalizing symptoms, higher negative emotionality, and behavioral inhibition in childhood. To environmental risk factors belong past traumatic events, such as physical or sexual abuse, especially in childhood. Additionally, these factors can include different infectious agents and a post-infectious autoimmune syndrome. According to DSM-5, there are vivid genetic and physiological factors, to which belongs dysfunction in the orbitofrontal cortex, anterior cingulate cortex, and striatum. Genetic causes are proven by the fact that first-degree relatives of individuals with OCD are two times more likely to have the disorder and ten times so if they are relatives of individuals with onset of OCD in childhood or adolescence. Another evidence to indicate genetic risk factors is a concordance rate of 0.57 for monozygotic versus 0.22 for dizygotic twins. 

How Is It Diagnosed?

First of all, OCD is diagnosed by the presence of obsessions and compulsions. The examples of obsessions can be as follows: recurrent and persistent thoughts of contamination or threat, images of violent scenes, or an urge to stab somebody. It should be stressed that obsessions are unpleasant and involuntary; they cause negative experience and distress in individuals. As a result, an individual persistently attempts to suppress or neutralize them somehow, by other thoughts or repetitive actions. The latter are specified as compulsions, which are driven behaviors, such as washing, checking, counting, or repeating words. Individuals are urged to perform them against their will and usually apply some rigid rules that they attempt to follow. Obsessions are connected with compulsions by cause-and-effect relationship. To illustrate, an individual has an intrusive fear that the house will burn down because of the stove. To neutralize and control this obsession, he or she is constantly checking the stove with the hope that this repetitive action will prevent the house from burning down. Compulsions are neither pleasant nor connected to a dreaded event in reality, but they bring a sense of certain relief from anxiety. Another criterion according to which OCD is diagnosed is the amount of time spent by an individual on obsessions and compulsions. Clinically significant thoughts and recurrent actions take 1-3 hours a day or more, in contrast to the occasional intrusive thoughts or behaviors, which can happen in the life of any individual, such as checking the door. 

Although the content of intrusive thoughts and repetitive actions can be varied among individuals, there are common themes and dimensions across time and cultures. Here belong cleanings, symmetry, taboo thoughts, fear of harm, and hoarding objects. Individuals experience anxiety and panic attacks in situations, which trigger their obsessions and compulsions. As a result, they try to avoid particular people, places, or social interactions. Males are more likely to get OCD with early onset in childhood often combined with tic disorders. There are also gender differences in the content of symptoms with females having more frequently cleaning obsessions while men demonstrating disorder in the dimensions of forbidden thoughts and symmetry. 

 

What Is Different in the Brain?

Biological factors causing OCD are related to the differences in certain parts of the brain in the sufferers. Specifically, it is the circuit of the brain regulating aggression, sexuality, and bodily excretions. There are faults of information-processing from the front part of the brain called the orbitofrontal cortex to the deeper parts, namely the striatum and the thalamus as well as the caudate nucleus of the basal ganglia. The activation of this circuit in a normal individual helps appropriately address impulses with corresponding behaviors. In such a way, after one washes hands to eliminate germs, for instance, the impulse diminishes, and a person can engage quietly in other activities. In a brain struck by OCD, this particular circuit has difficulties in properly conveying information associated with impulses and their satisfaction, and an individual continues washing over and over again. Messages between nerve cells are passed by chemicals called neurotransmitters. Researchers have distinguished that the chemical in the brain called serotonin, which is a neurotransmitter, has abnormalities in the individuals with OCD. It is responsible for sending messages between brain cells and thus regulating anxiety, memory, or sleep. A key gene for making a serotonin transporter is the human serotonin transporter gene (hSERT), which has two mutations in the individuals with OCD. In consequence, hSERT works too fast and accumulates all serotonin in the neuron’s membrane, while no serotonin is left in the neuronal synapse for signaling. In other words, information-processing is inhibited in the brain with OCD because less serotonin is available for neuronal communication. 

What Treatments Are Available?

Researchers have demonstrated that OCD is a brain disorder triggered by incorrect information processing, more exactly, by communication problems between the deeper structures of the brain and its front part. In the past, there was no treatment for this illness, and it was considered untreatable. Nowadays, it is discovered that increasing the levels of serotonin can be favorable for communication between the corresponding parts of the brain and consequently alleviating OCD symptoms. Both treatment stages, the acute and maintenance ones, have the same components: therapy, medication, and education. The psychological tool, which helps patients resist OCD, is cognitive behavioral psychotherapy. It utilizes three techniques for treating the disorder. First, individuals with OCD are encouraged to deal actively with the objects and situations, which are actually the causes of their obsessions and compulsions. Second, it is necessary to keep from recurrent and persistent behaviors in response to intrusive thoughts and ideas. The third technique includes logical examination of the irrational assumptions and dysfunctional beliefs. Medication used for OCD treatment includes taking a selective serotonin reuptake inhibitor (SSRI) in the forms of fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), and paroxetine (Paxil) with the maximum benefit in 10 to 12 weeks. If this treatment is ineffective, it is possible to prescribe a nonselective serotonin reuptake inhibitor, for example, clomipramine (Anafranil). 

Importantly, education must be a part of the treatment of patients with OCD. They should learn, read about their disorder, communicate with others suffering from it, and regularly meet with a clinician. It is also necessary to develop a detailed treatment plan beginning with the first consultation with a therapist. In the acute stage of illness, patients should meet a medical professional every week to analyze their response to medication and therapy. After the course of treatment, it is advisable to have monthly check-ins for at least half a year. As for cognitive behavioral therapy, it can take at least a year. If a patient has two to four relapses after discontinuing treatment, he or she may need to take medication permanently. Finally, it is vital that family members of individuals with OCD are supportive and calm, expressing no critic or negative comments. They also must be informed about the disorder and cooperate with a clinician. 

Take a Stand – Is This Disorder Purely Genetic?

According to DSM-5, there is evidence that proves the genetic nature of OCD, especially in cases of disorder onset in childhood. At the same time, it would be ungrounded to define OCD as a purely genetic disorder. Indeed, one has to account for the fact that first-degree relatives of individuals with OCD have risk two times higher, and even ten times if these individuals have an early onset of the disorder. Moreover, the examination of monozygotic versus dizygotic twins has indicated that genetic factors in the course and onset of OCD play an important role. More evidence that supports the genetic view on the disorder under analysis is the prevalent early onset of the illness. Thus, in the U. S., the mean age at onset is 19.5 years, 25% of cases starting before 10 years. In contrast, the beginning of the disorder after 35 years does not usually occur. 

However, it is reasonable to recognize an immense impact of environmental factors, which can enlarge the risk, or, on the contrary, favorable social conditions can eliminate or lessen the risk of the disorder onset. Hence, researchers have developed psychological treatment called cognitive behavioral theory, which utilizes learning theory for constructing productive life experiences. Specifically, the psychological factors of OCD imply that certain individuals tend to interpret some thoughts with too much responsibility and consider them too significant. Researchers claim that some of the individuals with biological predisposition to OCD develop the disease while others do not and it depends on their learning experiences. So, it is possible to create favorable conditions and experiences in order to prevent the development of the disorder. Moreover, environmental factors such as parenting styles and stresses should be controlled to lower the risk.

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