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Obsessive-compulsive disorder is characterized by anxious thoughts, images or inclinations (obsessions) and motivations (compulsions) to perform any actions that reduce this anxiety. The causes of development are unknown. The diagnosis is based on anamnestic information. Treatment consists in psychotherapy, drug therapy or, in severe cases, their combination. Obsessive-compulsive disorder occurs about the same frequency in men and women, it is observed in about 2% of the population.
According to DSM-IV, obsessive-compulsive disorder is a variant of an anxiety disorder characterized by obsessively repeated undesirable, unpleasant thoughts, images or impulses (obsessions) and / or repetitive actions that a person performs compulsorily and according to certain rules (compulsions). To establish the diagnosis is not necessarily the presence of both obsessions and compulsions. However, in most patients, they are combined, and only a small number of cases are observed separately from each other. The patient usually tries to actively suppress or neutralize the obsessions, convincing himself of their irrationality, avoiding provocative situations (if they exist) or realizing compulsions. In most cases, compulsions are performed to alleviate anxiety, but often they only increase anxiety, since they require considerable energy and time.
Pathogenesis of obsessive-compulsive disorder
Conditions that resemble obsessive-compulsive disorder, were first described more than 300 years ago. At each stage of the development of ideas about obsessive-compulsive disorder, they underwent changes under the influence of the intellectual and scientific climate of the era. In early theories, states like OCD were explained by perverted religious experiences. English authors of the XVIII - the end of the XVII century attributed obsessive blasphemous images to the influence of Satan. Even today, some patients with obsessions of conscientiousness "still consider themselves possessed by the devil and are trying to drive out evil forces. French authors of the nineteenth century, discussing the obsessions, emphasized the central role of doubt and indecisiveness. In 1837, the French doctor Esquirol used the term "folie du doute" ("disease of doubt") - to determine this group of symptoms. Later French authors, including Pierre Janet (Pierre Janet) in 1902, associated the development of obsessive states with a loss of will and a low mental energy.
For most of the XX century, psychoanalytic theories of obsessive-compulsive disorder dominated. According to them, obsessions and compulsions are some kind of protective mechanisms that are non-adaptive attempts to cope with the unresolved unconscious conflict that takes the beginning in the early stages of psychosexual development. Psychoanalysis offers a refined metaphor for mental activity, but it is not based on evidence obtained from brain research. These theories have lost appeal, since they did not lead to the development of effective and reproducible methods of treatment. Psychoanalysts focused on the symbolic meaning of obsession and compulsion, but did not pay enough attention to the form of symptoms-repetitive unpleasant for the patient senseless violent thoughts and actions. Meanwhile, the content of symptoms rather indicates what is most important for this patient or what scares him, but this does not explain why this patient developed obsessive-compulsive disorder. On the other hand, the content of some symptoms, for example, associated with cleansing or accumulation, can be explained by the activation of stereotyped action programs (for example, immature complex behavioral acts) realized by those areas of the brain that are involved in ROC.
Symptoms of obsessive-compulsive disorder
The dominant theme of obsessive thoughts can be causing harm, risk, danger of infection, doubt, damage or aggression. Usually patients with this disorder feel compelled to take repetitive, purposeful ritual actions to reduce their obsessions. For example, washing resists fear of pollution, checks - doubts, storage - thoughts of damage. Patients can avoid people who are aggressively attuned to their behavior caused by fears. Most rituals, such as washing hands or checking locks, are obvious, but some, for example an obsessive account, are not so noticeable.
To a certain extent, patients with obsessive-compulsive disorder understand that their obsessions are unreasonable and that their behavior aimed at reducing anxiety is excessive and inadequate. The preservation of criticism, even not to the full extent, allows us to differentiate obsessive-compulsive disorder from psychotic disorders, in which contact with reality is lost.
Because of embarrassment or stigmatization, patients with obsessive-compulsive disorder often hide their obsessions and rituals, which they can devote to several hours daily. Relations are often violated, school performance and quality of work may decrease. The secondary symptom is often depression.
Diagnosis of obsessive-compulsive disorder
Clinical diagnosis is based on the criteria for the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Exposure therapy and ritual prevention therapy are effective; its main element is to be in provoking situations or together with people who initiate obsessive thoughts and actions in the patient. After exposure, the patient refrains from performing rituals, allowing anxiety to increase, then to decrease as a result of addiction. Recovering occurs in a few years, especially in patients who use this approach after the end of the main course of treatment. However, not all patients are fully recovered.
Treatment of obsessive-compulsive disorder
Most experts believe that the best effect is achieved with a combination of psychotherapy and medication, especially in severe cases. Effective SSRIs and clomipramine (tricyclic antidepressant with a pronounced serotonergic effect). For most SSRIs, low doses (eg, fluoxetine 20 mg / day once, fluvoxamine 100 mg / day once, sertraline 50 mg / day once, paroxetine 40 mg / day once) are usually also effective, as are high doses.
In the past, obsessive-compulsive disorder was considered a condition resistant to treatment. Traditional methods of psychotherapy, based on psychoanalytic principles, rarely brought success. Disappointed and the results of the use of various drugs. However, in the 1980s, the situation changed due to the emergence of new methods of behavioral therapy and pharmacotherapy, the effectiveness of which was confirmed in large-scale studies. The most effective form of behavioral therapy in obsessive-compulsive disorder is the method of exposure and prevention reactions. The exposition consists in placing the patient in a situation that provokes discomfort associated with obsessions. At the same time, patients are given instructions on how to resist compulsive rituals - preventing a reaction.
The main tools for treating obsessive-compulsive disorder are currently clomipramine or selective serotonin reuptake inhibitors (SSRIs). Clomipramine, having a tricyclic nature, is an inhibitor of serotonin reuptake.
The modern era in the pharmacotherapy of obsessive-compulsive disorder began in the second half of the 60s with the observation that clomipramine, but not other tricyclic antidepressants (such as imipramine), is effective in obsessive-compulsive disorder. Clomipramine, a 3-chlorine analogue of tricyclic imipramine, inhibits the reuptake of serotonin 100 times more than the original substance. These distinctive clinical and pharmacological features of clomipramine allowed us to formulate a hypothesis about the role of serotonin in the pathogenesis of obsessive-compulsive disorder. The advantage of clomipramine over placebo and non-serotonergic antidepressants is confirmed by numerous studies with double-blind control. The effect of clomipramine in obsessive-compulsive disorder has been studied most thoroughly. Clomipramine was the first drug to be approved by the FDA for use in the United States for obsessive-compulsive disorder.