Obsessive-Compulsive Neurosis (OCD) is a type of neurological disorder in which obsessive-compulsive ideas and compulsive behaviors are the main clinical phases. The clinical features of OCD are self-induced and the patient is aware that the obsessive-compulsive ideas, intentions and behaviors are unnecessary, but the patient cannot control them. It is difficult to generalize the various forms of OCD.
Data from epidemiological surveys of neurological disorders in 12 regions of China (1982) show that the prevalence of OCD is 0.3 per 1,000. Overseas data show that the estimated prevalence in the general population is 0.5 per 1,000. The age of onset is mostly between 16 and 30 years. The prevalence is similar in men and women, with the majority of brain workers.
There is no corresponding name for this disease in Chinese medicine, and there is no specific discussion in the literature over the ages. However, as stated in the Nei Jing, “The liver is the official of the general, and it is the source of the thoughts.” “The gall bladder is the official of the middle and righteous, and makes decisions.” The pathology of this disease is related to planning and decision making, so the treatise of the Nei Jing reveals the pathology of this disease and is of great significance in guiding clinical treatment.
Etiology and pathology
I. Western medical etiology
1, genetic factors The disease has a certain tendency to run in families. As a genetic characteristic of the red blood cell (ABO) blood type, research associated with OCD found that OCD has a higher incidence of type A and a lower incidence of type O.
2. Psychosocial factors As a predisposing factor, in normal people occasionally have obsessive-compulsive ideas, but they do not persist. Only under the influence of psychological and social factors are reinforced to persist, such as changes in the work environment, major responsibilities, overly demanding, difficult situations, fear of accidents or family discord, sexual difficulties, tension caused by pregnancy and childbirth, coupled with the patient’s cautiousness, indecisiveness, indecision, lack of self-confidence and anxiety, and promote compulsive symptoms.
3, biochemical factors pentraxin (5-HT) nerve function is reduced, with increased pentraxin neurotransmitter drugs, can treat OCD.
4, organic factors Clinically, patients with sleeping encephalitis, temporal lobe contusion, epilepsy can be seen obsessive-compulsive symptoms. And surgical treatment shows that removal of the limbic white matter of the caudal nerve bundle is effective in improving obsessive-compulsive symptoms, suggesting that it is related to the function of the above mentioned sites.
In addition, personality traits play an important role in the pathogenesis of the disease, as these patients tend to be stodgy, well-organized, and overly serious.
Chinese medicine etiology and pathogenesis
According to Chinese medicine, the occurrence of this disease is closely related to emotional factors or physical weakness. The liver is the master of planning, and the gall bladder is the master of deciding, and most of the diseased organs involve the liver and gall bladder. This disease occurs mostly in timid people who are injured by emotion and will, resulting in dereliction of the duties of the liver and gallbladder, loss of harmony between qi and blood, and changes of qi, fire, phlegm, stasis and deficiency.
Clinical manifestations
I. Compulsive ideas
(a) Obsessive Doubt: It refers to the inability to feel at ease about what has been done. It is common to repeatedly doubt the lock of the door that has been locked, or worry whether the envelope that has been glued many times is stuck, whether stamps are affixed, etc., or repeatedly count the banknotes thinking that they are not clearly counted, repeatedly check the topics done thinking that there are mistakes, repeatedly doubt whether the dosage prescribed by the doctor is appropriate and whether it will delay The doctor’s prescription is not the right dosage, whether it will delay the disease, etc. The doctor’s prescriptions are not the right dosage, will delay the disease, and so on.
(2) Obsessive Reminiscence: For past events and experiences, the patient repeatedly recalls them, knowing that it is meaningless and unnecessary to recall them, but cannot get rid of them and cannot get rid of them, such as recalling what they have said in the past and whether it is appropriate, or regretting what they have said in the past and recalling them repeatedly.
(3) Obsessive Ruminations: Pondering over meaningless questions such as “Why is the Earth named Earth?”, “Why are people male and female? Why is my sister older than me” and endlessly pondering over these questions.
(4) Obsessive Contradictory Ideas: The patient’s mind often thinks of opposing ideas. For example, if you see the slogan “harmony” written on the wall, you immediately think of “contradiction”; if you see “happy”, you think of “sad ” and so on the opposite concept.
(E) Aggressivity obsessive besetment: fear of hurting oneself or hurting others, fear of using or even seeing knives, fear of using tea sets, fear of poisoning oneself inside; fear of saying insulting words, fear of doing embarrassing things, fear of accidentally hurting others.
(vi) Contamination compulsion (Obsessive of contamination): concern or aversion to body excretions or secretions (such as urine and faeces, snot, saliva), fear of dirt, bacteria, excessive concern about environmental pollutants, household items, animals, sticky things, fear of contamination to make others sick.
(vii) Sexual obsessive (Sexual obsessive): prohibited and possibly abnormal thoughts about sex, uncontrollable sexual imagination or sexual impulses, content involving homosexuality or incest, or the urge to point to the sexual behavior of others, such as the fear of contact or penetration of one’s sexual organs with the sexual organs of the adjacent pedestrian (can occur in both men and women) … … Fear of saying something unethical.
II. Compulsive intentions and actions
(a) Obsessive Intention (Obsessive Intention): It refers to the opposite will when the patient does something. For example, when a lawyer goes to court, he can’t help but want to say something against his client, but he knows he can’t say it. Therefore, it causes fear and anxiety, so it avoids going to court as a defense lawyer. Another example is a young woman who wants to fall down the stairs when she holds her child, which is against her own will and makes her very distressed.
(B) Obsessive Washings: The patient is always worried about not washing his hands and getting infectious diseases.
(C) Obsessive Counting (Obsessive Count): This is an uncontrollable desire to count. If you see a roadside tree, you start counting, and whenever you make a mistake, you have to start counting again, otherwise you feel irritable and difficult to restrain.
(4) Shopping addiction (spending speech): It refers to the desire to buy things when you see them, and it is often put into action without control, such as buying many useless things and keeping them at home, and the more they are piled up, the more you cannot handle them.
(E) Obsessive Rituals: The patient always needs to do a fixed procedure to feel at ease, otherwise he or she will be anxious. For example, a student always has to stop when entering the threshold of the classroom, followed by standing upright, before entering the classroom, only then the heart will be comfortable. One day, he ran into the classroom because of the time constraint, and after sitting down, he felt like he was on pins and needles, so he went out of the classroom on the pretext of going to the bathroom, and then repeated the above actions before entering the classroom.
Among the above symptoms, obsessive-compulsive thoughts are the most common, and obsessive-compulsive behaviors are mostly compliance behaviors to reduce the anxiety caused by obsessive-compulsive thoughts. Patients may experience that the compulsion comes from the self and realize that the compulsion is abnormal, but they cannot stop. Patients with prolonged illness may exhibit predominantly ritualized actions with reduced mental distress, but social functioning is impaired at this time. Patients with OCD are often accompanied by depression, anxiety, and other neurotic symptoms, but all secondary to obsessive-compulsive symptoms.
[Diagnosis and Differential Diagnosis
I. Diagnostic points
(a) Western medicine diagnosis points
The diagnosis is generally not difficult for those who have typical obsessive-compulsive symptoms as the core and urgently require treatment. However, in chronic cases, after the patient has failed to fight against the obsessive-compulsive symptoms, he or she is prone to form behaviors that adapt to the pathological experience, and the request for treatment is not very urgent at this time.
(B) Chinese medicine diagnosis points
Identify the location of the disease: The location of the disease mainly involves the liver, gallbladder, heart and other internal organs. In the liver and gallbladder, the heart and mind are often manifested as palpitations and insomnia.
Identify the nature of the disease: there are deficiencies and realities in this disease. The deficiencies are mostly due to deficiency of Yin and Blood and loss of nourishment of the heart and mind; the realities are mostly due to Qi stagnation, fire and heat, phlegm and blood stasis disturbing the Qi flow of the liver and gallbladder and dereliction of duty.
II. Differential diagnosis
Since obsessive-compulsive symptoms can appear in a variety of psychiatric disorders, clinically they need to be distinguished from the following diseases.
(a) Phobia and anxiety disorders Phobia, anxiety disorders and OCD can all have anxiety symptoms. The object of phobias comes from external 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 inner subjective experience, and their avoidance is related to obsessive suspicion and obsessive worry.
(B) Depression 20% of patients with depression can be accompanied by obsessive-compulsive symptoms, and sometimes obsessive-compulsive symptoms can mask depressive symptoms. However, patients with depression tend to have milder obsessive-compulsive symptoms, and most patients do not have an active desire to fight obsessions. In contrast, patients with OCD can also have depressive moods, and the distinction is mainly to identify which symptoms are primary.
(iii) Schizophrenia Schizophrenia can present with obsessive-compulsive symptoms, but often without a corresponding experience of distress, a desire to actively restrain or get rid of them, or an active request for treatment, and the content of obsessive-compulsive symptoms is mostly absurd and bizarre, without self-awareness. Psychiatric examination may reveal symptoms of schizophrenia. It is worth noting that certain antipsychotic drugs can induce obsessive-compulsive disorder and need to be differentiated.
(iv) Organic brain psychiatric disorders The diagnosis of patients with late onset should be cautious and attention should be paid to exclude organic lesions of the central nervous system, especially basal ganglia lesions, which can present with obsessive-compulsive symptoms. At this point, the identification is mainly based on the presence or absence of neurological signs and relevant auxiliary examinations such as cranial CT or magnetic resonance MRI.
Treatment
I. Treatment principles
Western medicine treatment is a combination of drug therapy and psychotherapy.
Chinese medicine treatment is guided by evidence-based treatment, treating the liver and gallbladder and adapting to the symptoms. In particular, it is important to identify the nature of the disease: qi, fire, phlegm, stasis and deficiency, so as not to lose bias.
Western medical treatment
(A) Drug treatment
At present, the main clinical use of tricyclic drugs, clomipramine (clomipramine) is the most commonly used. Usage: The daily dosage is 150mg~300mg, divided into 2 doses. Generally 2~3 weeks to start to show effect,
Gradually increase the dosage from small dose to therapeutic amount in about 10 days. If the maintenance treatment is ineffective for 4-6 weeks, consider changing the medication or combining with other drugs, and the treatment time is generally not shorter than 3-6 months. Selective pentraxin reuptake inhibitors (SSRIs) class of fluoxetine, paroxetine dose are 40 to 200 mg/day, fluvoxamine, sertraline, citalopram and escitalopram for the treatment of obsessive-compulsive disorder, also to larger doses are generally more than double the treatment of depression. Their efficacy is better than tricyclics and they have fewer side effects. In addition, if OCD is accompanied by anxiety can be appropriately combined with benzodiazepines, such as alprazolam; for refractory OCD, the combination of phenytoin sodium, carbamazepine or lithium salts and other mood stabilizers, may achieve some efficacy.
(B) Psychotherapy
Interpretive psychotherapy is mainly used. The purpose of psychotherapy is to improve the patient’s objective understanding of his or her personality defects and the disease he or she is suffering from, to reduce the patient’s mental burden and anxiety caused by the disease, to make the patient realize that the course of the disease is mostly prolonged, to throw away the mental baggage to reduce the sense of insecurity; to learn reasonable ways to cope with the disease, and to improve confidence in overcoming the disease. It is also possible to raise family members’ awareness of the disease and to work together with patients to help them cure the disease.
Behavioral and cognitive therapies can all be used for OCD. Both systematic desensitization therapy and aversion therapy can be used in behavioral therapy, such as the former by gradually reducing the number and duration of the patient’s repetitive behaviors. The latter is used clinically to treat obsessive-compulsive ideas by bouncing the arm.
Other therapies are: Morita therapy, diversionary psychotherapy, cognitive apprehension method, and biofeedback therapy.
Chinese medicine treatment
(a) Identification and treatment
1.Biliary depression and phlegm disturbance
Symptoms Depressed mood, fearful and suspicious, easily frightened and dreamy, dizziness and dullness, fantasy, chest tightness and bitterness, greasy tongue coating and slippery pulse.
Treatment Clear heat, resolve phlegm, warm bile and calm the mind.
Radicals: Warming the Gallbladder Soup (Three Causes and One Disease Formula) plus and minus Radix Panaxiae, Yun Ling, Chen Pi, Glycyrrhiza glabra, Citrus aurantium, Bamboo Roo, Shenglong Teeth, Yuan Zhi, Shi Calamus. In case of phlegm-heat, add Bile South Star and Huang Lian; in case of blood stasis, add Tao Ren.
2.Qi depression and blood stasis
Symptoms: depression, suspiciousness, restlessness, nightmares, pain in both sides of the body, increasing with anger, belching and acidity, petechiae on the tongue, stringiness of the pulse.
Treatment Diversify the liver and gallbladder, regulate qi and activate blood.
Prescription: Free and Easy San (Taiping Huimin Hodong Bureau Formula) plus or minus
Radix Bupleurum, Radix Paeoniae Alba, Radix Angelicae Sinensis, Rhizoma Atractylodes Macrocephalae, Rhizoma Atractylodis Macrocephalae, Poria, Malva, Citrus Aurantium, Lycopodium, Peppermint, Acorus Calamus. For depression, add Acacia Bark and Yu Jin; for blood stasis, add Peach kernel and Safflower; for heat, add Gardenia and Dan Pi.
3.Damp heat in liver and gallbladder
Symptoms Emotional agitation, irritability, thinking and thinking, constant association, mood and anger, red face and bitter mouth, distension and fullness of the ribs, red tongue and string pulse.
Treatment: Clearing the liver, tonifying the gallbladder, dipping fire and calming the mind.
Radix gentian and liver diarrhea Tang (Collective Explanation of Medical Formulae) plus or minus
Gentiana, Chai Hu, Dan Pi, Gardenia, Angelica, Yu Jin, Scutellaria, Mouton. In case of yin deficiency, add Sha Shen, Mai Dong, Sheng Di, Fructus Lycii; in case of phlegm-heat, add Sheng Tie Lu Drink and Bile Nan Xing.
4.Stasis of blood blocking the orifice
Symptoms: Suspicious and worrying, incessant association, sallow complexion, skin with nail fault, or accumulation of obstruction, amenorrhea, petechiae on the tongue, sunken and astringent pulse.
Treatment To invigorate blood circulation, resolve blood stasis, open the orifices and clear the channels.
Radix Rejuvenating the Blood and Opening the Organs of the Nostrils: Red peony, Chuanxiong, peach kernel, safflower, leeches, calamus, musk, ginger, jujube, green onion and yellow wine. For obstruction in the intestine, add San Ling, Curcuma longa and Turmeric.
5.Deficiency fire disturbing the mind
Symptoms Palpitations, insomnia and dreaminess, nervousness, chest tightness, irritability of the five hearts, dry throat and mouth, night sweating, red tongue with little fluid, thin pulse.
Treatment Nourish Yin and clear heat, nourish the heart and calm the mind.
Formula Tian Wang Tonic Heart Dan (Secret Anatomy of Health) plus or minus
Shengdi, Wuweizi, Angelica sinensis, Tianmendong, MaiMenDong, Phellodendron, Sour date palm, Ginseng, XuanShen, DanShen, Poria, YuanZhi, Radix Platycodon. Add calamus and dragon’s tooth for mental disorders; add yujin for qi depression.
(B) Acupuncture treatment
1. Body acupuncture: take the corresponding points according to the disease. ① emotional instability, irritability, insomnia, take Yanglingquan, Taichong, Sanyinjiao, etc.; ② emotional depression, boredom, paranoia, take the branch gou, period, Spleen Yu, etc.; ③ mental instability, thoughtfulness, timidity, take Nei Guan, Shen Men, etc.; ④ emotional instability, irritability, irritability, panic, take Kidney Yu, Tai Xi, Sanyinjiao, etc.
2.Auricular acupuncture: take acupuncture points: Shenmen, sympathetic, heart, liver, kidney, subcortical. Select 2 to 3 points each time and needle daily or every other day, or bury the ear acupuncture points, or use Wang Bu Liuxing seed acupuncture points to apply pressure.
Prevention, conditioning and prognosis]
Attention to mental health, efforts to learn positive methods and techniques to deal with various kinds of stress, enhance self-confidence, do not avoid difficulties, and develop the psychological quality of courage to withstand hardship and setbacks, is the key to prevention and care.
Some patients with obsessive-compulsive disorder can be remitted within a year. For those who have been ill for more than a year, the course of the disease is usually continuously fluctuating and can last for several years or even a lifetime. Others exhibit intermittent episodes that can last six months to two years before going into full remission, with relapse possible only with sudden stressful events. The prognosis is better for those with a short course, significant environmental factors, better life circumstances, better social adjustment, and less prominent obsessive-compulsive personality traits; the prognosis is worse for those with obsessive-compulsive personality traits and more continuous encounters with life events.