Obsessive-compulsive disorder is a type of neurological disorder in which obsessive-compulsive symptoms are the main clinical correlate. It is characterized by the coexistence of conscious self-compulsions and counter-compulsions, which are strongly conflicting and cause anxiety and distress to the patient. The patient experiences that the ideas and impulses originate from the ego, but against his or her will, and that he or she needs to resist vigorously but cannot control them. The patient is also aware of the abnormality of the symptoms, but cannot get rid of them. Those with prolonged disease may show ritualistic actions as the main cause of mental distress, but social functioning is severely impaired.
The average age of onset of the disease is about 20 years, and the prevalence is similar in men and women.
Some patients are in remission within one year. Those who have had the disease for more than a year usually have a continuously fluctuating course that can last for several years. Patients with severe symptoms or with obsessive-compulsive personality traits and persistent exposure to a high number of life events have a poor prognosis.
I. Etiology and pathogenesis
1. Genetics There are few genetic studies on OCD, and the conclusions are not convincing.
2. Biochemistry There is a lot of evidence to support that patients with OCD have abnormalities in 5-HT function. Dopamine and cholinergic systems may also be involved in the pathogenesis of some patients with OCD.
3. Brain pathology Imaging studies have found that patients with OCD may have abnormalities in neural circuits involving the frontal lobes and basal ganglia of the brain. Sensory stimuli travel from the sensory organs to the cortex and then to the striatum, and if the sensory stimuli match the content of the information stored in the striatum, then a normal response to sensory input occurs; however, if the sensory input information originates in the anterior cingulate cortex, a part of the cortex that can elicit behavioral responses in the absence of appropriate sensory stimuli, then compulsive behavior occurs. This hypothesis is supported by neuroimaging and neuropharmacological studies.
4. Psychological theory The behaviorist theory considers OCD as a habitual response to a specific situation. Compulsive behaviors and compulsive ritual actions are considered to be a means of reducing anxiety, and because such actions only temporarily reduce anxiety, they lead to the occurrence of repetitive ritual behaviors.
In addition, life events and the individual’s personality traits (obsessive-compulsive personality) play a role in the development of the disorder.
II. Clinical manifestations
The disease starts slowly without any obvious cause. The basic symptoms are obsessive-compulsive ideas, obsessive-compulsive intentions, and obsessive-compulsive behavior. It can be mainly one kind of symptoms or several kinds of symptoms at the same time. Common manifestations are as follows.
(A) compulsive ideas
1, compulsive thinking The patient’s mind often repeatedly think of some words or phrases, and these words or sentences are often abhorrent to the patient. For example, a religious person, repeatedly think of some obscene or blasphemous words and phrases in the mind.
The patient repeatedly thinks about some common events, concepts or phenomena, and digs into the root of them, knowing that they have no real meaning, but cannot control themselves. For example, the patient repeatedly thinks, “Did the chicken or the egg come first?” “Why do people eat instead of grass?” .
The patient has doubts about the reliability of what he or she has done, and needs to check and check again and again. For example, whether the doors and windows are closed, whether the money and belongings are counted, etc. The patient himself can realize that things have been done, but he is just not sure.
4, compulsive association The patient’s mind appears an idea or see a sentence, then involuntarily associated with another idea or words, and most of them are opposing nature, at this time is called compulsive opposing thinking. For example, if you think of “peace”, you will immediately associate it with war, etc.
5, compulsive memories The patient’s consciousness involuntarily repeatedly presents the experienced things, can not get rid of, feel distressed.
6. Compulsive intention The patient feels a strong inner urge to do something against his or her will, but it usually does not turn into action, because the patient knows that this urge is irrational and absurd, so he or she can try to restrain it. But the inner impulse cannot be got rid of. For example, when you see an electric plug, you want to touch it, when you see the opposite sex, you want to hug it, etc.
(B) Compulsive actions and behaviors
1, compulsive examination Most of the measures taken to reduce the anxiety caused by compulsive suspicion. Often manifested as repeatedly check whether the doors, windows, gas is closed, whether the electric plug is unplugged, whether the account is wrong, etc., serious check dozens of times still do not feel at ease.
2.Forced washing Mostly from the fear of contamination of the compulsive concept of performance of repeated hand washing, laundry, disinfection of furniture, etc.. Often spend a lot of energy and time, know that it is not necessary, but can not control.
3, compulsive ritual actions are usually developed gradually to counteract the anxiety caused by certain compulsive ideas. For example, a student began to appear compulsive ideas will shake his head to fight, and it really works, but the good news is that shaking his head can not resist the compulsive ideas, so they add a hand tapping the table action, this method began to work, but the effectiveness gradually declined, so the patient added a foot stomping action to strengthen the role of the fight. Over time, the patient developed a complex ritualistic procedure: first shaking the head several times. The patient then taps the table several times and then stamps his foot …….
4, obsessive-compulsive questioning OCD patients often do not believe in themselves, in order to eliminate doubts or exhaustive thinking to bring their own anxiety, often repeatedly ask others (especially family members) to obtain explanations and reassurance.
5. Obsessive-compulsive slowness Clinically rare. These patients may deny having any compulsive ideas, and the slow motivation is to try to make everything they do perfect. Since the goal is perfection, precision, and symmetry, it often fails, thus increasing the time.
III. Diagnosis and differential diagnosis
(I) Diagnosis
1.Symptom criteria
(1) Meet the diagnostic criteria of neurosis with predominantly obsessive-compulsive symptoms, with at least one of the following.
(1) mainly compulsive thoughts, including compulsive ideas, memories or representations, compulsive oppositional ideas, exhaustive thinking, fear of losing self-control, etc.;
(2) Compulsive behavior (action), including repeated washing, checking, examining, or questioning, etc;
(3) Mixed forms of the above.
(2) The patient claims that the obsessive-compulsive symptoms originate from within him/herself and are not imposed by others or external influences.
(3) The compulsive symptoms appear repeatedly, and the patient considers them meaningless and feels unpleasant, even painful, so he tries to resist, but it does not work.
2.Severity criteria Social function is impaired.
3.Criteria of disease duration It has been at least 3 months since the symptom criteria were met.
4.Exclusion criteria Exclude compulsive symptoms secondary to other mental disorders; exclude compulsive symptoms secondary to organic brain diseases, especially basal ganglia lesions.
(B) Differential diagnosis
The diagnosis of a typical patient with OCD is not difficult. However, in some chronic patients, after failed attempts to get rid of obsessive-compulsive symptoms, they tend to develop behavioral patterns that are adapted to the pathological experience, and the need for treatment is not always urgent. Clinical differentiation is required from the following disorders.
1. schizophrenia Schizophrenia can present with obsessive-compulsive symptoms, but often without distress over them, without active restraint or desire to get rid of them, without treatment requirements, and with much absurd and bizarre symptom content and no self-awareness of the symptoms. Of course, the most important feature is that schizophrenic patients also have negative or positive symptoms of schizophrenia. A small number of patients with OCD may have symptoms of a bizarre nature, which can easily lead to clinical misdiagnosis. However, no matter how bizarre the content of the patient’s obsessive-compulsive ideas or how peculiar the compulsive behavior, the patient is still able to maintain the ability to reality check.
2, phobias and anxiety disorders Phobias, anxiety disorders and OCD all have anxiety manifestations, and identifying the primary symptoms is the key to differentiation. The object of phobia comes from objective reality; patients with obsessive-compulsive disorder with cleanliness can also have avoidance behaviors, but obsessive-compulsive ideas and behaviors often originate from the patient’s subjective experience, and their avoidance is related to obsessive suspicion and obsessive worry.
3, organic brain mental disorders organic lesions of the central nervous system, especially basal ganglia lesions, can appear obsessive-compulsive symptoms. Neurological history and signs and relevant auxiliary examination evidence can help to identify.
IV. Treatment
1.Psychotherapy The purpose is to have a normal and objective understanding of the patient’s personality characteristics and the disease, to have a correct and objective judgment of the real situation, to lose the mental baggage to reduce the sense of insecurity; to learn reasonable methods of coping, to enhance self-confidence, to reduce the sense of uncertainty; not to be overly ambitious, not too much excellence, to reduce the sense of imperfection. At the same time, we should educate their relatives and colleagues, neither condoning nor overdoing the patients, and encourage them to actively engage in useful cultural and sports activities, so that they can gradually be freed from the situation of compulsion. Behavioral therapy, cognitive therapy, and psychoanalytic therapy can all be used for OCD. Systematic desensitization can gradually reduce the number and duration of repetitive behaviors. Aversion therapy can be tried for those who do not respond to medication.
2.Medication The most commonly used. Antidepressants. Treatment time should not be shorter than 6 months, and some patients need long-term medication. For those with severe anxiety can be combined with benzodiazepines; for refractory OCD, valproate and other mood stabilizers or small doses of antipsychotic drugs, may achieve certain results.