An Obsessive-compulsive disorder (OCD) - Literature review Example

?                                     Affiliation with more information about affiliation, research grants, conflict of interest and how to contact. Obsessive Compulsive Disorder An Obsessive-compulsive disorder (OCD) is a type of anxiety disorder which renders many people hopeless as they cannot control themselves from their obsessions. According to NCBI, “Obsessive-compulsive disorder is an anxiety disorder in which people have unwanted and repeated thoughts, feelings, ideas, sensations (obsessions), or behaviors that make them feel driven to do something (compulsions)” (Obsessive – Compulsive Disorder, 2008). People who have obsessive- compulsive disorder do the same things over and over again to make the thoughts go away and the repeated actions are called compulsion. Some of the examples of Obsessive-compulsive disorder are fear of germs, fear of going outside and even the fear of the unknown. The compulsion often include washing hands or clothes frequently, counting things over and over again, checking on things just to make sure that they are the same and cleaning things repeatedly. Obsessive-compulsive disorder, if untreated can take over a person’s life and render him/ her incapable of leading a normal life. The symptoms often begin in children or teenagers and of untreated can have a lasting impact on the person’s life. It is believed to be hereditary and tends to run in families. The treatment of Obsessive-compulsive disorder is often combined with medicine and therapy. Obsessive Compulsive disorder is a fairly common disorder, “With an estimated lifetime prevalence of 2.5 % in adults and 1 to 2 % in children and adolescents, OCD is a fairly common psychiatric disorder” (Obsessive – Compulsive Disorder, 2008). It was believed that OCD was a rare disorder before extensive research was done. “OCD was thought to be extremely rare in the community, as low as five per 1000 [1] or five per 10,000[2], hence the importance and prevalence of OCD had been underestimated for many decades” (Mohammadi et al. 2004). It was blindly believed in the olden days that OCB is not a common disorder. It is not necessarily related to stress or even a psychological conflict, but it is seen in all types of personality. It generally starts from preschool age to adulthood (before the age of 40). The symptoms of Obsessive Compulsive disorder can be seen in men and women at different stages. In regards to men, they commonly start having symptoms as teenagers whereas the symptoms are usually seen in women in their early 20’s. It is reported that 1/3 to one half of adults with Obsessive compulsive disorder started in childhood.             In Both Adults and children Obsessive Compulsive disorder plays a major in their lives. The Adult with OCD are able to comprehend the fact that their behavior is abnormal or even problematic whereas in the case of children they may not fully understand that their behaviors are not normal due to the undeveloped cognitive abilities.  In both adults and children with OCD experiences, they suffer distress when their compulsions cannot be completed. “OCD symptoms cause distress, take up time (more than an hour a day), or significantly interfere with the person's work, social life, or relationships. Most individuals with OCD recognize that their obsessions are coming from their own minds and are not just excessive worries about real problems” (Obsessive – Compulsive Disorder, 2008). It has also been found out those children with Obsessive Compulsive disorder have a low confidence level as compared to children without OCD. The anxiety level in Children with Obsessive compulsive disorder can be so great that they feel that a repetition is required to have comfortable feelings. Likewise this is also the same in adults, but adults are more aware of what is going on with their need to satisfy their uncomfortable feelings. As mentioned before the symptoms of OCD is developed from an early age and it is not uncommon. “It is generally estimated that up to one pre-adolescent child in two-hundred has OCD, although some studies suggest it could be as high as 3-4%” (OCD in Children, 2012).        Obsessive-compulsive disorder is a psychological disorder and there are three main risk factors for the development: Social, psychological and biological factors. Biological factors are genetic. The social factors are the factors which influences the person’s environment. The psychological include the personal experiences and emotional status of the individual. The causes of biological abnormalities are still unclear. Numerous studies have shown that there is abnormal brain functioning in individuals suffering from OCD. These studies have revealed that there over activity in the iambic system which is responsible for the overall emotional tone. This over activity what cause the physical sensations of anxiety, avoidance tendencies and tics. Individuals having abnormal functioning in the brain area like the limbic system, basal ganglia and cingulated gyrus may be vulnerable to feeling intensifies fear and developing patterns which results in obsessive compulsive disorder. In psychological factors, the behavior patterns are mainly based on learning processes and personal experiences. Many researches have suggested that in psychological factors, the thoughts of distress stem mainly from traumatic experiences, illness and even information from closed ones. In social factors, the bringing up of a child mainly affects the disorder. Theoretical Perspectives on OCD:        Rachman and De Silva (1978) were the first to observe that intrusive thoughts are indistinguishable from obsessional thoughts in their content during their studies on non-clinical subjects, which was later agreed by other researchers like Freeston, Ladouceur, Thibodeu & Gagnon (1991), Freeston, Ladouceur, Thibodeau & Gagnon (1992), Parkinson & Rachman (1981) and Salkovskis & Harrison (1984). These studies resulted in the behavioral theories for OCD. According to Salkovskis, Behavioral Theory of Obsessive Compulsive Disorder can be hypothesized as those “normal intrusive thoughts, images and impulses [which] become associated, through classical conditioning processes, with anxiety that has subsequently failed to extinguish" (Swinson et al. 1998, p. 34). Salkovskis further states that the failure to extinguish' occurs when sufferers develop escape and avoidance behaviors (e.g. obsessional washing) that prevent them from the extinction of the anxiety. Behavioral theory since was applied equally to different anxiety disorders such as specific phobia, agoraphobia, it necessitated an alternative approach to OCD. Treatment of OCD:                Recent studies have brought to light that normal compulsions are also common in non-clinical subjects and this paved way for the formulation of cognitive-behavioral theories for OCD. OCD, since is a chronic illness, it is treated most effectively with medications and psychotherapy. In some rare cases, medications and supportive psychotherapy become ineffective in treating a person with OCD. In those cases, other treatment options are provided, which are Psychiatric Hospitalization; Residential Treatment; Electroconvulsive Therapy (ECT); Trans-cranial magnetic stimulation; and Deep Brain Stimulation.        The medications usually considered in OCD are anti-anxiety medications and anti-depressants. Cognitive Behavioral therapy (CBT), a psychological approach to OCD, consists of Exposure and Response Prevention/ Ritual Prevention (ERP), which is accepted as the most effective type of psychotherapy for OCD. Studies have proved that the application of the medication along with supportive CBT has a positive effect on the treatment of patients with OCD. Psychotherapy for OCD:        Psychotherapy is a psychological way of helping people with mental disorders to have a self-knowledge about their illness and to aid them to develop strategies to cope with anxieties, stress, intrusive obsessional thoughts and compulsive behaviors. There many types of Psychotherapies. The most common among them are Cognitive Behavioral Therapy; Dialectical Behavior Therapy; Interpersonal Therapy; and Family-focused Therapy.        The psychotherapy used in the treatment of OCD consists of several techniques. These are Basic Cognitive Therapy Techniques, Systematic Desensitization, Exposure and Response Treatment, Modeling Treatment and Anxiety Management Therapy. It is vital in psychotherapy that the patient gets accustomed to the therapy and seeks re-assurance and trust from the doctor, which, otherwise, can promote patient dropouts from the treatment. Both individual and group treatments are found effective for the treatment for OCD. But individual sessions are applied in the cases of those individuals with social phobia. OCD is a chronic disorder; hence it may occur even after a successful therapy. Evidences based on extensive literature reviews indicate that some patients require long-term or intensive therapy of at least a year or 50 sessions. In simple cases, treatment for OCD, i.e., medications with supportive psychotherapy require about 12 to 20 weeks. i] Basic Cognitive Therapy Techniques: The cognitive therapy technique helps the patient to understand the reality of anxiety-inducing stimuli and obsessional thoughts and also to respond to them with new actions that are based on reasonable expectations. The usual primary step in this treatment by making the patient to record the occurrences of obsessional thoughts and associated events by keeping a daily diary. A patient with OCD will record repetitive thoughts. But these notes will contain obsessional thoughts as well as avoidance and neutralizing thoughts. Sometimes the obsessional thoughts itself can become neutralizing thought if there is voluntary effort from the patient who make himself think before the obsessional thoughts occur on their own.  These records, hence becomes challenging for the doctor who, therefore has to understood and differentiate between obsessional thoughts, neutralizing thoughts and avoidance thoughts. The doctor will also make the patient understand these thoughts, in most cases, is to record the words of repetitive thoughts and to expose the patient to the play-back of these words, in order to reduce their effect. The patients may also be given homework-assignments to help them change their compulsive behaviors and also to make them observe the occurrence of fears and obsessional thoughts triggered by them. Gradually, through self -observation, the patient will learn to acknowledge as well as to perceive the truth behind their obsessive thoughts and also to develop substituting methods, instead of compulsive behaviors, to cope with feared objects, situations and other stimuli. ii] Systematic Desensitization: This technique aims to break the link between obsession-inducing stimuli and compulsive behaviors by gradual exposure and confrontation of the patient to the anxiety inducing objects or situations. Relaxation technique, wherein the patient is gradually exposed to fearful stimuli, is a vital part of this technique. This technique requires the patient to make a list of anxiety inducing objects or situations, prioritizing them on the degree of fear. Then the patient is made to confront each item of the list, beginning with the least stressful of the object or the situation. iii] Exposure and Response Treatment: In ERP treatment the patient is purposefully exposed to those stimuli that are capable of evoking obsessional responses. The patient is repeatedly exposed to the feared subject, usually the most fearful stimulus first. It also prevents the patient from compulsive responses, which are avoidance and escape behaviors. This treatment differs from Desensitization Technique in that it does not involve gradual approach to the fearful stimuli. This therapy involves two techniques - Flooding and Graduated exposures. In Flooding the patient is exposed to the stimuli for a long duration, about 1 - 2 hours. In Graduated exposure the patient is exposed to the stimuli in varying durations and frequencies. In either case, the patient is made to realize that obsessional thoughts are irrelevant and then he is educated to tolerate the anxiety and to resist the urge to perform the compulsion. Several studies regarding psychotherapy for OCD point out that when ERP is combined with the standard cognitive approach, it can have positive effects on the treatment for OCD.    iv] Modeling Treatment: In this technique a live model or a videotaped situation similar to the patient's anxiety-evoking stimulus is used to educate the patient to behave in a reasonable expected behavior. v] Anxiety Management Therapy: In this therapy, which is sometimes used as an alternative to CBT, the patient is subjected to relaxation training, self-observation and exposure to anxiety and obsession evoking stimuli or situations. Here, the patient is not given retraining exercises and training for developing alternative compulsive behaviors.        Other psychotherapy techniques such as Emotion-based Psychotherapy (EBT), Psychodynamic Therapy or Talk therapy are used for the treatment for pediatric OCD. Many studies suggest that EBT is not effective and beneficial as CBT. But studies also indicate that the patient dropouts are found less in EBT than in CBT. Hence, these studies implicate that elements of EBT if incorporated in supportive CBT and medication treatments for OCD, it will be beneficial for the patients at the end of treatment.  Effects of Psychological Research and Psychosocial Interventions on OCD patients       Psychological research and psychosocial interventions have gained impetus momentum in the treatment of Obsessive Compulsive Behavior. This is attributed to the recognition of the significance of psychological processes in OCD, both as contributors to the anxiety-evoking obsessional and compulsive behaviors and also due to the negative psychological impact on the mental and social well-being of the sufferer of the OCD. Psychological and psychosocial interventions for OCD that are developed to address these needs of the sufferers of OCD are derived from various biological, psychological and social theories. The psychological and psychosocial interventions in the treatment of OCD aims to achieve the following outcomes: to decrease vulnerability; reduce the impact of stressful events, situations and other stimuli; decrease distress ; symptoms; improve the quality of life; reduce compulsive behaviors; improve reasonably expected minimize behaviors; improve communication and coping skills; and/or enhance treatment adherence. There are many psychological therapies and psychosocial intervention in practice such as adherence therapy; arts therapies; cognitive remediation; cognitive–behavioral therapy (CBT); counseling and supportive psychotherapy; family intervention; psychoanalysis and psychoanalytic/psychodynamic psychotherapy; psycho-education; and social skills training.        Cognitive-behavioral therapy (CBT) is the supportive psychotherapy used in the treatment of OCD. It was Albert Ellis who developed the first Cognitive Behavioral Therapy in the 1960s which he termed as Rational Emotive Behavior Therapy. The CBT practiced today for the treatment of various mental health disorders such as anxiety disorders, Obsessive Compulsive Disorder, Bulimia nervosa and post-traumatic stress disorder was developed by Aaron T Beck for the treatment of depression in the 1970's. CBT is defined as “a discrete psychological intervention wherein the patients establish links between their thoughts, feelings and action with respect to their current or past symptoms or actions; and the re-evaluation of their perceptions, beliefs or reasoning relate to the target symptoms" (Psychological Therapy and Psychosocial Interventions in the Treatment and Management of Schizophrenia, 2009). It also involves constant monitoring of the thoughts, feelings or behaviors by the patients with respect to the symptoms or recurrence of symptoms; promoting alternate ways of coping with the target symptom; reduction of stress; and improvement of functioning. This psychological intervention is based on the evidence that the intrusive thoughts that are responsible for the obsessions and compulsive behaviors of the sufferers of OCD can be recognized and altered using techniques that can change behavioral responses so that the urge to perform compulsive actions are reduced. CBT helps the patients to regain their control to reactions to stress and other stimuli as well as panic and helplessness that often accompanies the condition. Research in OCD: The Past and the Future:        Enormous studies have been conducted in the area of psychotherapy, assessment and treatment of Obsessive-Compulsive Disorder. OCD in adults and in children has also been subjected to research. Recent studies also show that both psychosocial and pharmacological treatments are beneficial in the reduction of anxiety symptoms of OCD, which is especially the case with elder adults. CBT has been the prevailing form of psychotherapy in these studies. But a firm conclusive data for endorsing CBT or a particular medication for use for the treatment of OCD is lacking.       In "Research Advances in Genetics and Genomics: Implications for Psychiatry", Insel and Collins (Martin, 2008) envisioned the possibility of discovering those genes responsible for the vulnerability to OCD, anorexia nervosa, depression and many other syndromes. This was made possible by the brain imaging techniques and genomic research.        With the creation of the blueprint of human genome, genome research for the psychiatric disorders was extensively conducted. Today, there have been vast developments in the genomic research of OCD, especially during the last decade. New OCD researches that measure brain activity with Magnetic Resonance Imaging (MRI) provide great scopes for the future as they have begun to reveal the distinctive patterns of people with OCD and their family members. These studies point out that the OCD patients as well as their relatives showed decrease of gray matter in brain regions due to suppression of responses and habits and that it is related to hereditary nature of OCD. The genes responsible for psychiatric disorders such as Alzheimer's disease, schizophrenia, bipolar disorder and anxiety disorders including OCD have been identified and their variations have also been measured. This will definitely help the researchers to create medicines and therapies that can help in the treatment of most of the psychological disorders, including OCD.         But the genetic and genomic study of OCD has some limitations. OCD is not a homogenous condition like other psychic disorders.  OCD, therefore, has to be divided in to sub-groups or phenotypes in order to understand its underlying etiological mechanisms. Miguel et al. in "Obsessive-compulsive disorder phenotypes: Implications for Genetic Studies" (Miguel et al. 2005) suggested strategies such as categorical approaches and dimensional approaches for identifying OCD phenotypes along with a more homogenous treatment to include etiologically related conditions. Since the genotype distribution of genes is varyingly different for different ethnic groups the findings of genetic studies of OCD of a particular group (for e.g. western population) cannot be replicated in other ethnic groups ( e.g. Asian population). Hence, large scale studies using large sample sizes are required to be performed in various populations in order to understand the genetic distribution of OCD and to develop specific medications and psychotherapies suitable for each subtype of OCD.          Reference List Martin, S. (2008). The Possible Future of OCD Treatment. About.com. Retrieved from http://www.netplaces.com/parenting-kids-with-ocd/the-promise-of-new-research/the-possible-future-of-ocd-treatment.htm Miguel et al. (2005). Obsessive - Compulsive Disorder Phenotypes: Implications for Genetic Studies. Pub Med.Gov. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15611786 Mohammadi et al. (2004). Prevalence of Obsessive – Compulsive Disorder in Iran. BMC Psychiatry. Retrieved from http://www.biomedcentral.com/1471-244X/4/2 Obsessive – Compulsive Disorder, (2008). H.O.P.E Counseling Services. Retrieved from http://www.hopecounselingservices.net/OCD.htm Obsessive – Compulsive Disorder, (2012). Medline Plus. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/000929.htm OCD in Children, (2012). Anxiety Care UK. Retrieved from http://www.anxietycare.org.uk/docs/ocdchild.asp Psychological Therapy and Psychosocial Interventions in the Treatment and Management of Schizophrenia, (2009). National Institute for Health and Clinical Excellence. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK11688/ Swinson et al. (1998). Obsessive – Compulsive Disorder: Theory, Research and Treatment. The Guilford Press. USA. Retrieved from http://books.google.co.in/books?id=a0EeWC7NlfgC&pg=PR6&dq=journal+articles+on+obsessive+compulsive+disorder&hl=en&sa=X&ei=0swNT5jNGsXOrQfLw9yQBA&ved=0CEIQ6AEwAg#v=onepage&q=journal%20articles%20on%20obsessive%20compulsive%20disorder&f=false Read More