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Transcript
Obsessive–compulsive disorder
Obsessive–compulsive disorder (OCD) is an anxiety disorder
characterized by involuntary intrusive thoughts and compulsive
behaviors. When a sufferer begins to acknowledge these intrusive
thoughts, the sufferer then develops anxiety based on the dread that
something bad has happened or will happen. The sufferer feels
compelled to voluntarily perform irrational, time-consuming physical
behaviors to diminish the anxiety.
Sufferers often try to keep their compulsive behaviors hidden from
others, often to avoid embarrassment, humiliation or to avoid being
seen as strikingly odd or different from others. If the condition is not
realized by an undiagnosed sufferer, they may scold themselves in
frustration as to why they are thinking or acting the way they are.
Although the acts of those who have OCD may appear paranoid and
come across to others as psychotic, this could not be farther from the
truth. An OCD sufferer is able to recognize their thoughts and
subsequent actions as irrational; they do not believe that they are in any
way more rational than anyone else, which is what makes the illness so
distressing, as the psychological self-awareness of the irrationality of
the disorder may be extremely painful. They are plagued by doubt and
uncertainty, hence the condition is also referred to as the "doubting
disease". The biggest challenge OCD sufferers face is learning to live
in doubt, without constant reassurance.
OCD is the fourth most common mental disorder and is diagnosed
nearly as often as the physiological ailments asthma and diabetes
1
mellitus.[1] In the United States, one in 50 adults has OCD.[2] 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.[3] 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) or some other condition.
Diagnostic criteria
To be diagnosed with OCD, a person must have obsessions and/or
compulsions, according to the DSM-IV-TR diagnostic criteria. The
Quick Reference to the diagnostic criteria from DSM-IV-TR (2000)[4]
states six characteristics of obsessions and compulsions:
Obsessions
1.
Recurrent and persistent thoughts, impulses, or images that are
experienced as intrusive and that cause marked anxiety or distress.
2.
The thoughts, impulses, or images are not simply excessive
worries about real-life problems.
3.
The person attempts to ignore or suppress such thoughts,
impulses, or images, or to neutralize them with some other thought or
action.
4.
The person recognizes that the obsessional thoughts, impulses, or
images are a product of his or her own mind, and are not based in
reality.
2
Compulsions
1.
Repetitive behaviors or mental acts that the person feels driven to
perform in response to an obsession, or according to rules that must be
applied rigidly.
2.
The behaviors or mental acts are aimed at preventing or reducing
distress or preventing some dreaded event or situation; however, these
behaviors or mental acts are not actually 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 his/her 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.[4] OCD often causes feelings similar to those of
depression.
Symptoms and prevalence
OCD does not have a higher affinity for a specific gender. It can begin
as early as the age of two, but most often begins in the late teens for
males and the early twenties for females. Current research primarily
supports a biological (genetic) cause in the development of OCD, along
with cognitive distortions and a distorted belief system, predominantly
during early childhood years. Children with biological prefrontal cortex
neurological disorders, predominantly ADHD, have demonstrated a
significantly higher risk for developing obsessive-compulsive
disorder.[5] Studies have placed the prevalence between one and three
3
percent, although the prevalence of clinically recognized OCD is much
lower, suggesting that many individuals with the disorder may not be
diagnosed.[6] The fact that many individuals do not seek treatment may
be due in part to stigma associated with OCD.
The typical OCD sufferer performs tasks (or compulsions) to seek
relief from obsession-related anxiety. 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 to ward off dire
consequences and to stop the stress from building up. Examples of
these tasks are repeatedly checking that one's parked car has been
locked before leaving it, turning lights on and off a set number of times
before exiting a room, repeatedly washing hands at regular intervals
throughout the day, touching objects a certain number of times before
leaving a room, or walking in a certain routine way.
Formal diagnosis may be performed by a psychologist, a psychiatrist or
psychoanalyst. OCD sufferers are aware that their thoughts and
behavior are not rational,[7] but they feel bound to comply with them to
fend off feelings of panic or dread. Although everyone may experience
unpleasant thoughts at one time or another, these are short-lived and
fade away in time.[8] For people with OCD, the thoughts are intrusive
and persistent, and can cause them great anxiety and distress.[9]
OCD without Overt compulsions
A major subtype of OCD is OCD without overt compulsions.[10] OCD
without overt compulsions is often referred to as "pure-O" by laymen
and sufferers of this disorder. The term is a bit of a misnomer,
4
however, because OCD without overt compulsions is no more "pure"
than any other form of OCD. Nonetheless, OCD without overt
compulsions represents a major subtype of OCD with some of the
estimates as high 50-60%.[11] Rather than engaging in observable rituals
and compulsions, the person with OCD without overt compulsions
engages in all manner of mental neutralizing behaviours (i.e. "covert"
compulsions).
Intrusive thoughts may involve violent obsessions about hurting others
or oneself.[12] They can include such thoughts as harming an innocent
child, jumping from a bridge, mountain or the top of a tall building,
urges to jump in front of a train or automobile, and urges to push
another in front of a train or automobile.[13] A survey of healthy college
students found that virtually all of them had intrusive thoughts from
time to time, including imagining or wishing harm upon a family
member or friend, impulses to attack or kill a small child, or animal, or
shout something rude or violent.[14]
The possibility that most patients suffering from intrusive thoughts will
ever act on those thoughts is low; patients who are experiencing intense
guilt, anxiety, shame, and anger over bad thoughts are different from
those who actually act on bad thoughts. The history of violent crime is
dominated by those who feel no guilt or remorse; the very fact that
someone is tormented by intrusive thoughts, and has never acted on
them before, is an excellent predictor that they won't act upon the
thoughts. According to Baer, a patient should be concerned that
intrusive thoughts are dangerous if the person doesn't feel upset by the
thoughts, rather finds them pleasurable; has ever acted on violent or
5
sexual thoughts or urges; hears voices or sees things that others don't
see; or feels uncontrollable irresistible anger.[15]
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", involving
"heterosexual or homosexual content" with persons of any age.[16] Like
other intrusive, unpleasant thoughts or images, most people have some
sexual thoughts at times, but people with OCD may attach significance
to the unwanted sexual thoughts, generating anxiety and distress. The
doubt that accompanies OCD leads to uncertainty regarding whether
one might act on the bad thoughts, resulting in self-criticism or
loathing.[16]
OCD with Overt Compulsions
Other major subtypes of OCD frequently revolve around washing or
checking; some sufferers may fear the presence of human body
secretions such as saliva, blood, semen, sweat, tears, vomit, or mucus,
or excretions such as urine or feces. Some OCD sufferers even fear that
the soap they are using is contaminated.[17] These anxiety-driven fears
often result in various compulsive cleaning behaviours, and may cause
a person to experience significant distress, which may make it difficult
for a person with OCD to tolerate a workplace, venture into public
locations, or conduct normal social relationships.
Symptoms related to performing tasks may include repeated hand
washing[18] or clearing of the throat; specific counting systems or
6
counting of steps; doing repetitive actions—more generally, this can
involve an obsession with numbers or types of numbers (e.g., odd
numbers). For example, when somebody suffering from OCD leaves
the house, they might tap the door knob 9 times and if they don't they
will go into distress, panic and even at certain times, they will pass out.
These obsessive behaviors can cause individuals to feel psychological
distress, because they are very concerned about having "made
mistakes" in the number of steps that they have taken, or the number of
stairs on a staircase. For some people with OCD, these obsessive
counting and re-counting tasks, along with the attendant anxiety and
fear, can take hours of each day, which can make 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.[19]
Related conditions
OCD is often confused with the separate condition obsessive–
compulsive personality disorder. The two are not the same condition,
however. OCD is ego dystonic, meaning that the disorder is
incompatible with the sufferer's self-concept. [20][21] Because disorders
that are ego dystonic go against an individual's perception of
his/herself, they tend to cause much distress. OCPD, on the other hand,
is ego syntonic—marked by the individual's acceptance that the
characteristics displayed as a result of this disorder are compatible with
his/her self-image. Ego syntonic disorders understandably cause no
distress. Persons suffering from OCD are often aware that their
7
behavior is not rational and are unhappy about their obsessions but
nevertheless feel compelled by them. Persons with OCPD are not
aware of anything abnormal about themselves; they will readily explain
why their actions are rational, and it is usually impossible to convince
them otherwise. Persons with OCD are ridden with anxiety; persons
who suffer from OCPD, by contrast, tend to derive pleasure from their
obsessions or compulsions.[22] This is a significant difference between
these disorders.
Equally frequently, these rationalizations do not apply to the overall
behavior, but to each instance individually; for example, a person
compulsively checking their front door may argue that the time taken
and stress caused by one more check of the front door is considerably
less than the time and stress associated with being robbed, and thus the
check is the better option. In practice, after that check, the individual is
still not sure, and it is still better in terms of time and stress to do one
more check, and this reasoning can continue as long as necessary.
Some OCD sufferers exhibit what is known as overvalued ideas. In
such cases, the person with OCD will truly be uncertain whether the
fears that cause them to perform their compulsions are irrational or not.
After some discussion, it is possible to convince the individual that
their fears may be unfounded. It may be more difficult to do ERP
therapy on such patients, because they may be, at least initially,
unwilling to cooperate. For this reason OCD has often been likened to
a disease of pathological doubt, in which the sufferer, while not usually
delusional, is often unable to realize fully what sorts of dreaded events
are reasonably possible and which are not. There are severe cases when
8
the sufferer has an unshakeable belief within the context of OCD which
is difficult to differentiate from psychosis.[23]
OCD is different from behaviors such as gambling addiction and
overeating. People with these disorders typically experience at least
some pleasure from their activity; OCD sufferers do not actively want
to perform their compulsive tasks, and experience no pleasure from
doing so. OCD is placed in the anxiety class of mental illness, but like
many chronic stress disorders it can lead to clinical depression over
time. The constant stress of the condition can cause sufferers to
develop a deadening of spirit, a numbing frustration, or sense of
hopelessness. OCD's effects on day-to-day life—particularly its
substantial consumption of time—can produce difficulties with work,
finances and relationships. There is no known cure for OCD as of yet,
but there are a number of successful treatment options available.
Related/Spectrum disorders
People with OCD may be diagnosed with other conditions, such as
generalized anxiety disorder, anorexia nervosa, social anxiety disorder,
bulimia nervosa, Tourette syndrome, Asperger syndrome, compulsive
skin picking, body dysmorphic disorder, trichotillomania, and (as
already mentioned) obsessive–compulsive personality disorder. There
is some research demonstrating a link between drug addiction and
OCD as well. Many who suffer from OCD also suffer from panic
attacks. There is a higher risk of drug addiction among those with any
anxiety disorder (possibly as a way of coping with the heightened
levels of anxiety), but drug addiction among OCD patients may serve
as a type of compulsive behavior and not just as a coping mechanism.
9
Depression is also extremely prevalent among sufferers of OCD. One
explanation for the high depression rate among OCD populations was
posited by Mineka, Watson, and Clark (1998), who explained that
people with OCD (or any other anxiety disorder) may feel depressed
because of an "out of control" type of feeling.[24]
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). The streptococcal antibodies become
involved in an autoimmune process. Though this idea is not set in
stone, if it does prove to be true, there is cause to believe that OCD can
to some very small extent be "caught" via exposure to strep throat (just
as one may catch a cold). However, if OCD is caused by bacteria, this
provides hope that antibiotics may eventually be used to treat or
prevent it.[25]
Causes
Psychological
Scientists studying obsessive–compulsive disorder 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.[26] Based on this reasoning,
10
treatment involved banishing the "evil" from the "possessed" person
through exorcism.[27] In the early 1910s, Sigmund Freud attributed
obsessive–compulsive behavior to unconscious conflicts which
manifested as symptoms.[27] 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".[28]
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 reemerges. Each time the behaviour occurs it is negatively reinforced
(see Reinforcement) 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).
11
Biological
There are many different theories about the cause of obsessive–
compulsive disorder. The majority of researchers believe that there is
some type of abnormality with the neurotransmitter serotonin, among
other possible psychological or biological abnormalities; however, it is
possible that this activity is the brain's response to OCD, and not its
cause.
Serotonin is thought to have a role in regulating anxiety, though it is
also thought to be involved in such processes as sleep and memory
function. In order to send chemical messages, serotonin must bind to
the receptor sites located on the neighboring nerve cell. It is
hypothesized that OCD sufferers may have blocked or damaged
receptor sites that prevent serotonin from functioning to its full
potential. This suggestion is supported by the fact 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.[29] For more about
this class of drugs, see the section about potential treatments for OCD.
The Stanford University School of Medicine OCD webpage states,
"Although the causes of the disorder still elude us, the recent
identification of children with OCD caused by an autoimmune
response to Group A streptococcal infection promises to bring
increased understanding of the disorder's pathogenesis."[30]
Recent research has revealed a possible genetic mutation that could
help to cause OCD. Researchers funded by the National Institutes of
12
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".[31] 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 possible genetic cause of OCD was discovered in August 2007
by scientists at Duke University Medical Center in North Carolina.
They genetically engineered mice that lacked a gene called SAPAP3.
This protein is highly expressed in the striatum, an area of the brain
linked to planning and the initiation of appropriate actions. The mice
spent three times as much time grooming themselves as ordinary mice,
to the point that their fur fell off.[32]
Using tools such as positron emission tomography (PET scans),
researchers have shown that those with OCD tend to have brain
activity[vague] that differs from those who do not have this disorder.[33] In
the book, Brain Lock[34], Jeffrey M. Schwartz suggests that OCD is
caused by the part of the brain[vague] 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
13
their own prior behavior—a process which induces anxiety in most
people, even those without OCD[citation needed].
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.[vague]
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 properly, and
therefore does not prevent this initial signal from recurring. This causes
the thalamus to become hyperactive and creates a virtually neverending 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.[29] 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 5HT2A and 5-HT2C in the OFC is believed to cause this inhibition. [35]
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
14
distinctive patterns in the brain structure of individuals with OCD and
their close family members. [36] 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.
Demographics and other statistics
In a 1980 study of 20,000 adults from New Haven, Baltimore, St.
Louis, Durham, and Los Angeles, the lifetime prevalence rate of OCD
for both sexes was recorded at 2.5 percent. Education also appears to
be a factor. The lifetime prevalence of OCD is lower for those who
have graduated high school than for those who have not (1.9 percent
versus 3.4 percent). However, in the case of college education, lifetime
prevalence is higher for those who graduate with a degree (3.1 percent)
than it is for those who have only some college background (2.4
percent). As far as age is concerned, the onset of OCD usually ranges
from the late teenage years until the mid-20s in both sexes, but the age
of onset tends to be slightly younger in males than in females.[37]
It has been alleged that sufferers are generally of above-average
intelligence, as the very nature of the disorder necessitates complicated
thinking patterns[38].
Treatment
15
According to the Expert Consensus Guidelines for the Treatment of
obsessive–compulsive disorder, behavioral therapy (BT), cognitive
therapy (CT), and medications are first-line treatments for OCD.
Psychodynamic psychotherapy may help in managing some aspects of
the disorder, but there are no controlled studies that demonstrate
effectiveness of psychoanalysis or dynamic psychotherapy in OCD.[39]
Behavioral therapy
The specific technique used in BT/CBT is called exposure and ritual
prevention (also known as "exposure and response prevention") or
ERP; this involves gradually learning to tolerate the anxiety associated
with not performing the ritual behavior. At first, for example, someone
might touch something only very mildly "contaminated" (such as a
tissue that has been touched by another tissue that has been touched by
the end of a toothpick that has touched a book that came from a
"contaminated" location, such as a school.) That is the "exposure". The
"ritual prevention" is not washing. Another example might be leaving
the house and checking the lock only once (exposure) without going
back and checking again (ritual prevention). The person fairly quickly
habituates to the anxiety-producing situation and discovers that their
anxiety level has dropped considerably; they can then progress to
touching something more "contaminated" or not checking the lock at
all—again, without performing the ritual behavior of washing or
checking.
Exposure ritual/response prevention has been demonstrated to be the
most effective treatment for OCD. It has generally been accepted that
psychotherapy, in combination with psychotropic medication, is more
16
effective than either option alone. However, more recent studies have
shown no difference in outcomes for those treated with the
combination of medicine and CBT versus CBT alone.[40]
Recently it has been reported simultaneous administration of DCycloserin (an antibiotic) substantially improves effectiveness of
Exposure and Response prevention.[41]
Medication
Medications as treatment include selective serotonin reuptake
inhibitors (SSRIs) such as paroxetine, sertraline, fluoxetine,
escitalopram, and fluvoxamine as well as the tricyclic antidepressants,
in particular clomipramine. SSRIs prevent excess serotonin from being
pumped back into the original neuron that released it. Instead, serotonin
can then bind to the receptor sites of nearby neurons and send chemical
messages or signals that can help regulate the excessive anxiety and
obsessive thoughts. In some treatment-resistant cases, a combination of
clomipramine and an SSRI has shown to be effective even when
neither drug on its own has been efficacious.
Benzodiazepines are also used in treatment. It's not uncommon to
administer this class of drugs during the "latency period" for SSRIs or
as synergistic adjunct long-term. Although widely prescribed,
benzodiazepines have not been demonstrated as an effective treatment
for OCD and may be habit-forming in those with a history of substance
abuse.[42]
17
Serotonergic antidepressants typically take longer to show benefit in
OCD than with most other disorders which they are used to treat, as it
is common for 2–3 months to elapse before any tangible improvement
is noticed. In addition to this, the treatment usually requires high doses.
Fluoxetine, for example, is usually prescribed in doses of 20 mg per
day for clinical depression, whereas with OCD the dose will often
range from 20 mg to 80 mg or higher, if necessary. In most cases
antidepressant therapy alone will only provide a partial reduction in
symptoms, even in cases that are not deemed treatment-resistant. Much
current research is devoted to the therapeutic potential of the agents
that effect the release of the neurotransmitter glutamate or the binding
to its receptors. These include riluzole, memantine, gabapentin and
lamotrigine.
Low doses of the newer atypical antipsychotics olanzapine, quetiapine,
ziprasidone and risperidone have also been found to be useful as
adjuncts in the treatment of OCD. The use of antipsychotics in OCD
must be undertaken carefully, however, since, although there is very
strong evidence that at low doses they are beneficial (most likely due to
their dopamine receptor antagonism), at high doses these same
antipsychotics have proven to cause dramatic obsessive–compulsive
symptoms even in those patients who do not normally have OCD[citation
needed]
. This can be due to the antagonism of 5-HT2A receptors
becoming very prominent at these doses and outweighing the benefits
of dopamine antagonism. However antidepressant mirtazapine which is
a 5-HT2A antagonist has shown to be of benefit to OCD patients[43].
Another point that must be noted with antipsychotic treatment is that
SSRIs inhibit the chief enzyme that is responsible for metabolising
18
antipsychotics—CYP2D6—so the dose will be effectively higher than
expected when these are combined with SSRIs. Also, it must be noted
that antipsychotic treatment should be considered as augmentation
treatment when SSRI treatment does not bring positive results.
Alternative drug treatments
The naturally occurring sugar inositol has been suggested as a
treatment for OCD[44], as it appears to modulate the actions of serotonin
and reverse desensitisation of neurotransmitter receptors. St John's
Wort has been claimed to be of benefit due to its (non-selective)
serotonin re-uptake inhibiting qualities[citations needed], although a doubleblind study using a flexible-dose schedule (600-1800 mg/day) found no
difference between St John's Wort and a placebo[45].
Nutrition deficiencies may also contribute to OCD and other mental
disorders. Vitamin and mineral supplements may aid in such disorders
and provide nutrients necessary for proper mental functioning[46].
Opioids may significantly reduce OCD symptoms, though their use is
not sanctioned for treatment due to physical dependence and long term
drug tolerance[citations needed]. Tramadol is an atypical opioid that appears
to provide the anti-OCD effects of an opiate and inhibit the re-uptake
of serotonin (in addition to norepinephrine)[47].
Tryptamine alkaloid psilocybin has been attempted as treatment[48].
There are reports that other hallucinogens such as LSD and peyote
have produced similar effects[citations needed]. It has been hypothesised that
this effect may be due to stimulation of 5-HT2A receptors and, less
19
significantly, 5-HT2C receptors; this causes an inhibitory effect on the
orbitofrontal cortex, an area of the brain in which hyperactivity has
been strongly associated with OCD[49].
Regular nicotine treatment may ameliorate symptoms of OCD,
although the pharmacodynamical mechanism by which this is achieved
is not yet known, and more detailed studies are needed to fully confirm
this hypothesis[50].
Psycho-surgery
For some, neither medication, support groups nor psychological
treatments are helpful in alleviating obsessive–compulsive symptoms.
These patients may choose to undergo psychosurgery as a last resort. In
this procedure, a surgical lesion is made in an area of the brain (the
cingulate cortex). In one study, 30% of participants benefited
significantly from this procedure.[9] Deep-brain stimulation and vagus
nerve stimulation are possible surgical options which do not require the
destruction of brain tissue, although their efficacy has not been
conclusively demonstrated.
In the US, psychosurgery for OCD is a treatment of last resort and will
not be performed until the patient has failed several attempts at
medication (at the full dosage) with augmentation, and many months of
intensive cognitive–behavioral therapy with exposure and
ritual/response prevention.[51] Likewise, in the UK, psychosurgery
cannot be performed unless a course of treatment from a suitably
qualified cognitive–behavioral therapist has been carried out.
20
Neuropsychiatry
Main article: Neuropsychiatry
OCD primarily involves the brain regions of the striatum, the
orbitofrontal cortex and the cingulate cortex. OCD involves several
different receptors, mostly H2, M4, NK1, NMDA, and non-NMDA
glutamate receptors.[citation needed] The receptors 5-HT1D, 5-HT2C, and the
μ opioid receptor exert a secondary effect. The H2, M4, NK1, and nonNMDA glutamate receptors are active in the striatum, whereas the
NMDA receptors are active in the cingulate cortex.
The activity of certain receptors is positively correlated to the severity
of OCD, whereas the activity of certain other receptors is negatively
correlated to the severity of OCD. Correlations where activity is
positively correlated to severity include the histamine receptor (H2); the
Muscarinic acetylcholine receptor(M4); the Tachykinin receptor (NK1);
and non-NMDA glutamate receptors. Correlations where activity is
negatively correlated to severity include the NMDA receptor (NMDA);
the Mu opioid receptor (μ opioid); and two types of 5-HT receptors (5HT1D and 5-HT2C) The central dysfunction of OCD may involve the
receptors nk1, non-NMDA glutamate receptors, and NMDA, whereas
the other receptors could simply exert secondary modulatory effects.
Pharmaceuticals that act directly on those core mechanisms are
aprepitant (nk1 antagonist), riluzole (glutamate release inhibitor), and
tautomycin (NMDA receptor sensitizer). Also, the anti-Alzheimer's
drug memantine is being studied by the OC Foundation in its efficacy
in reducing OCD symptoms due to it being an NMDA antagonist. One
21
case study published in The American Journal of Psychiatry suggests
that "memantine may be an option for treatment-resistant OCD, but
controlled studies are needed to substantiate this observation."[52] The
drugs that are popularly used to fight OCD lack full efficacy because
they do not act upon what are believed to be the core mechanisms.
Many trials are currently underway to investigate the efficacy of a
variety of agents that affect these 'core' neurotransmitters, particularly
glutamatergic agents.[3]
Notable cases

British poet, essayist, and lexicographer Samuel Johnson is an
example of a historical figure with a retrospective diagnosis of OCD.
He had elaborate rituals for crossing the thresholds of doorways,
repeatedly walked up and down staircases counting the steps, and had
compulsions regarding repetitive prayer which were most likely a form
of religious scrupulosity.[53][54][55]

American aviator and filmmaker Howard Hughes is known to
have suffered from OCD and it is believed that his mother may have
also been a sufferer. Friends of Hughes have mentioned his obsession
with minor flaws in clothing and he is reported to have had a great fear
of germs, common among OCD patients.[56] He did also suffer from
Social Anxiety Disorder (SAD) and Post-traumatic Stress Disorder
(PTSD) due to an aviation accident in which he was severely injured.
This resulted in him becoming reclusive later in life.

English footballer David Beckham has been outspoken regarding
his struggle with OCD. He has told media that he has to count all his
22
clothes, and that magazines have to lie in a straight line. No more than
three soda cans are allowed in his refrigerator, and if there are any
more at home they have to be placed in a cupboard. He has explained
that the reason he gets more tattoos is that he feels addicted to the pain
of the needle. In hotels, any books that are on a shelf must be placed in
the drawer. He has expressed a desire to get help for his problems.[57]
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Further reading
30