Introduction

Imagine your life dictated by repetitive behavior. To feel the need to turn on and off a light before going in to a room or wash your hands so much they bleed because of dryness. Obsessive-compulsive disorder (OCD) is characterized by unreasonable thoughts and fears. This term can be subdivided by two concepts; the core concept of fear and how it influences behavior. Fear, in the normal sense, is a vital response to danger but with people suffering OCD fear becomes common. By not achieving a behavior people who suffer from OCD build a sense of dread of an inevitable consequence that is outside their reach; and, to avoid such consequence they tend to do repetitive behaviors that are also known as compulsions. Some common themes of OCD may be an irrational fear of getting contaminated by germs and a compulsion that alleviates that fear would be to constantly wash hands. This often leads to repetitive and ritualistic behavior in order to find relief in their self-inflicted stressful situation.

This blog will look at the behavioral effects of said disease how it affects sleeping patterns and the big five personality traits. OCD will also look at the treatments to deceive besides cognitive behavioral therapy there is also from a collage of methods like drug therapy with the selective serotonin reuptake inhibitors or SSRI. Since it has been proven by many studies the most effective behavioral treatment for OCD is exposure and response prevention. This blog will also deal with surgical approaches to treating OCD and social observations that people with OCD have to struggle with like the following:

Causes of the disorder: cortico–striato–thalamo–cortical circuit, genes that affect serotonergic, dopaminergic and glutaminergic system, environmental factors

 In a study that evaluated two rodent models of OCD, a disruption of the dopaminergic system, more specifically a decrease in the dopamine signaling mediated by dopamine neurons reflected and supported the theory that OCD affects dopaminergic systems. In this experiment, investigators repeated injection of dopamine D2 agonist quinpirole and injection of the tricyclic antidepressant agent clomipramine in combination with a behavioral paradigm designed to

produce compulsive lever pressing. The results were then compared with their relative impact on the state of activity of the mesolimbic dopaminergic system in the ventral tegmental area. The clomipramine model did not caused an increase in compulsive level pressing. In contrast, quinpirole treated animals did in fact showed significant increases in compulsive level pressing. Therefore, it was concluded that VTA dopamine activity correlated with the behavioral responses in these models and confirmed other experiments that concluded that the disorder impacted the dopaminergic system.

Obsessive compulsive disorder is a multifactorial condition that, as demonstrated in twin studies, it’s related to polygenetic and environmental factors. It has been observed in neuroimaging studies with patients that have the condition that the cortico-striato-thalamo- cortical circuit or corticostriatal system plays a role in OCD. This circuit is part of one of the feedback loops between the basal ganglia and the motor cortex/ premotor cortex. In OCD, genes affecting the dopaminergic, serotonergic and glutaminergic systems as well as the interaction within them have been identified as causes of the disorder. Also, external circumstances like prenatal events, psychological and neurological trauma may modify the expression of risk genes and, hence, trigger the manifestation of obsessive–compulsive behaviors. Since the late 1980s, a rapid growth in the number of imaging studies of individuals with OCD and improve­ments in imaging technology and methods have led to considerable advancement in the understanding of the neural indicators of OCD pathophysiology. As said earlier, the corticostriatal system has been the prevailing model regarding the neural and pathophysiological foundations of OCD. It has been explained that the corticostriatal system performs an excitatory and inhibitory pathway. In healthy individuals, the excitatory pathway is modulated by the inhibitory function and based on convergent findings from animal and human research, the prevailing model postulates that a lower threshold for activation of this system results in excessive activity in the excitatory pathway over the inhibitory one. This leads to hyperactivation of the orbitofrontal–subcortical pathway. As a result, exaggerated concerns about danger, hygiene or harm may result in persistent conscious attention to the per­ceived threat (obsessions) and, subsequently, to compulsions aimed at neutralizing the perceived threat. The temporary relief that results from performing compul­sions leads to reinforcement and repetitive or ritualistic behavior when obsessions reappear.

Finally, it’s important to mention that some functional imaging stud­ies have found distinct neural correlates of specific OCD symptom dimensions. In other words, variations in neuronal systems may be partially different depending of the kind of symptom that the person has like washing, hoarding and checking.  

Types of OCD

OCD is a heterogeneous disorder with a number of subtypes of obsessive-compulsive problems, the most common subtype involving:

 Thoughts behaviors: Intrusive thoughts that is undirected and unproductive. This particular type dwells on a time consuming question like “what is the meaning of life?” Another type of thought could have sexual, disturbing and horrific undertones. It’s also noted that this type is repetitive and not voluntarily produced though they are least likely to act on the thought. The compulsion is avoidance of the trigger in order to prevent them from happening.

Checking: involves the compulsion to prevent damage. This tends to help make the person will “make sure” that certain disasters can be avoided like constantly checking house alarms or even the fear of losing important documents.

Contamination: The compulsion is the fear to clean or wash; this includes a fear to use public restrooms to the fear of contact; such as, touching other people. The ritual that accompanies the compulsion is in order to “feel” clean rather than to “be” clean.

 Hoarding: The inability to discard useless or worn out items. This particular type of OCD is the least responsive to treatment.

 It has been classified as an insider disorder by the American psychiatric Association diagnostic and statistical manual of mental disorders or DSM4. Inside the variety of anxiety disorders there are many forms such as panic attacks phobias and social anxiety.

Symptoms in a Nutshell

To better understand the stated symptomatology, Samantha Pena explains her daily life while struggling with OCD.

Social Implications

Aside from the psychopathology of OCD a study searched to explore and understand psychosocial aspects of the disease and to provide positive accounts of the condition and its treatment. This study accounted groups of self-diagnosed OCD and using the interpreted phenomenological analysis or IPA. This test consist of data study that came from a series of nine semi structured interviews carried out with individuals whose OCD diagnosis is not been measured by its severity. The age of the patients also varied in range from 22 to 53 years. The IPA is based on three key philosophical tenets phenomenology (or first person perspective), ideography and hermeneutics (text interpretation) bringing about a test that tests how people make sense of their major life experiences.  In other words to study actually focuses on a more humane division it moves on empathetic accounts questions and analyzes people's life experiences. This entails researchers producing an interpretive critical framework initially guided by the accounts produced from participants. After researchers interviewed each person preliminary things were produced from each transcript, which showed a pattern of super ordinate and subordinate themes. This study showed a more social aspect of the disease, identifying the subordinate theme as "wanting to be normal and to fit in" a social context and the subordinate theme of wanting therapy in order to achieve a better self. Other super-ordinate themes where how this condition has adversely affected their education careers and family and personal relationships leaving them with an overwhelming sense of personal failure. to better understand a person with OCD one has to see this as a type of barrier that worked against their fulfillment in developing meaningful relationships. One also has to understand that these individuals make tensions about their life's progress and compare against age-appropriate lifecycle goals they want to achieve normalcy but the condition's presence leaves them with resulting feelings of disappointment. These researchers also had the chance to accounts how people with OCD treats their condition and dealt with others who did not understand the drive to maintain OCD behaviors. In the end several participants felt that being able to locate the psychological causes of OCD help they make sense of it as an anxiety disorder.

This study also focused on the un-medicated way to treat obsessive-compulsive disorder is a cognitive behavioral therapy (CBT) which seeks to underlie dysfunctional beliefs and provides individual with an alternative explanation of anxiety origins pointing to the dysfunctional beliefs a person could have. In other words makes a person be more aware in order to challenge and replace cognitions in a systematic logical and empathetic way. It was concluded that 30% of the people who engage in CBT will not be helped by it because either they don’t engage in the therapy or they eventually drop out which does not improve their symptoms. A long term follow-up showed that CBT has a 55% success rate, showing that some treatment strategies are underdeveloped.

“How ‘Normal’ is ‘Abnormal’”; Big Five personality traits (extraversion, neuroticism, openness to experience, agreeableness, conscientiousness) and Narcissism

It has been subjected that abnormal personality can be molded as extremes of normal personality. The big five personality traits have been constantly used by psychologists describe the human psyche. These include:

This study also involved other traits such as narcissism and creativity which can be related to the big five. It is known that high end of extraversion and low and agreeableness are related to narcissism. Creativity, which is such an abstract concept, was measured using self-reported creativity and biographical inventory of creative behaviors. Interestingly, both openness and extraversion were related to self-reported creativeness in order to create novel and creative ideas this was turned over inclusiveness. Now there is a considerable body of empirical research the proposed a link between creativity and personality mood disorders leading to a genetic marker that brings creativity and psychotic traits as they come hand in hand. Obsessive-compulsive disorder exhibit neatness, order, cleanliness and perfectionism which contrasts completely with creative mindsets. This study also post narcissism as the other extreme of personality variants, since most narcissists would be characterized by grandiosity they would think of themselves as highly creative individuals. In this study there was a sample of 207 individuals that were recruited, the participants for each between 16 and 54 and came from diverse ethnic backgrounds. In order to attain creativity they use the biographical inventory of creative behaviors(BICB) that correlates self-rated creativity with divergent thinking. A self-rating would also provide a secondary measure creativity. The study concluded to be a positive car relationship between creativity and both openness and extroversion with the two accounting for approximately 26 to 31%. To contrast this data there was a correlation that shows that obsessive-compulsiveness is associated with introversion and neuroticism and it's not especially related to openness. It was also suggested that obsessive-compulsiveness is hard to measure by the big five questionnaire. Although, contrary to their hypothesis, obsessive-compulsiveness was positively related to everyday creative achievement. In other words this evidence suggests that ritualistic behaviors could possibly help promote creative behaviors. But to be more specific, the creative behavior of people with OCD are more likely to be associated with creativity in the areas of science and technology rather than in the arts. People who also suffer from OCD have been shown to have high levels of narcissism that is related to self-perception.

Pharmacotherapy

The primary pharmacotherapy treatment for OCD are serotonin reuptake inhibitors (SSRI's) which helped partially with the condition as it is shown improvements in 40 to 60% of OCD patients. A study showed the potential of cortical morphology based on individual structural covariance or ISC. This showed dysfunctional cortical maturation process as a biomarker that protects the clinical treatment response to SSRI based for current therapy success in patients suffering from OCD.



Brain morphology for OCD patients have reported just think of morphological or functional de-arrangements of multiple brain regions, such as the orbitofrontal cortex, anterior cingulate cortex, insula, inferior parietal lobule, precuneous, superior temporal cortex and lingual cortex which collectively constitute the pathopsychological brain circuit of OCD called the"cortico-striato-thalamo-cortical" loop. This study coordinated variations in brain morphological features including cortical surface area or CSA and thickness. This model seeks to understand how some people responded positively to SSRIs rather than others that didn't respond at all. This study recruited 56 medication for the OCD patients who met the diagnostic and statistical manual of mental disorders the fourth edition (DSM IV). Each of them was given a certified psychiatric scored test which measured obsessive-compulsiveness, depression and anxiety to measure the severity of their symptomatology. Using a whole brain anatomy three-dimensional McIntyre station prepared rapid gradient echo, they measured the structural covariance of cortical thickness at the individual level. Out of the data that was recruited they average and calculated the standard deviation of each result. The group was also subdivided into two portions; the nonresponsive group and the responsive group.

Surgical Methods for Treatment

Deep brain stimulation treatment: produced a global percentage of  Yale Brown obsessive compulsive scale(Y-BOCS) score reduction of 45.1% and a global percentage of responders of 60.0%. (Alonso, P. 2015).




Neurosurgery:

Although conventional behavioral and drug therapies are effective for treating most patients with obsessive-compulsive disorder (OCD), more than 10% of OCD patients remain incapacitated despite traditional ways to control it. In these cases neurosurgery plays a role in the treatment of the disorder. Deep brain stimulation (DBS) has been proposed as an alternative neurosurgery for severe treatment-resistant Obsessive-Compulsive Disorder (OCD), although with partially discrepant results probably related to differences in anatomical targeting and stimulation conditions. It’s an experimental neurosurgical treatment for OCD in which the brain is stimulated with electrical impulses. Deep brain stimulation is a technique that involves precise stimulation of particular parts of the brain through the implantation of removable electrodes. In a meta-analysis of treatment outcome and predictors of response, this alternative technique showed global percentage of Yale Brown obsessive compulsive scale (Y-BOC) reduction at 45.1% and global percentage of responders at 60.0%. Better response was associated with older age at OCD onset and presence of sexual/religious obsessions and compulsions. In this manner, DBS constitutes a valid alternative to lesional surgery for severe, therapy-refractory OCD patients. These results confirm that DBS appears to have an efficacy comparable to that reported for capsulotomy or cingulotomy that are going to be mentioned after this, ablative techniques after which 64% and 56% of patients respectively are rated as significantly improved. Studies analyzed, described these stimulation-related adverse effects as mild, transient and reversible after the adjustment of the stimulation. According to the results of this meta-analysis, the presence of sexual/religious obsessions and compulsions was associated with a significantly better response to DBS.

                                                                                

·         Cingulotomy: Study that combined anterior cingulotomy and DBS in Ventral capsule/ventral striatum. Combination did not yield superior outcomes. (Chang, W. 2013)

Cingulotomy is a form of psychosurgery introduced in 1948 as an alternative to lobotomy. Today it is mainly used in the treatment of depression and obsessive-compulsive disorder. It’s being hypothesized that the ventral capsule (VC), ventral striatum (VS), that make up the corticothalamic pathway and the cortex-striatum-thalamus-cortex (CSTC) loop and the anterior cingulate gyrus are parts of the obsessive compulsive disorder and depression circuits as mentioned earlier. In an experiment realized in 2013, investigators  assessed whether a combination of bilateral anterior cingulotomy and VC/VS deep brain stimulation (DBS) had an additive effect in patients with OCD and major depression because the targets of the two procedures are different and, therefore, may have additive effects. They analyzed the outcome of three patients with severe OCD resistant to traditional treatments that underwent combined bilateral anterior cingulotomy and VC/VS DBS procedures. The combination of the two therapies did not yield superior outcomes, as the clinical outcomes were comparable to those of previous reports for VC/VS DBS alone. Wide-area VC/VS DBS may be sufficient to control refractory OCD. Possible explanations states that a reason of this outcome may be because the inter-connections and relationships between the three different functional and anatomical circuits that are related to OCD and depression. Another reason may have been because of the extent of the stimulation.

·         Capsulotomy: When traditional methods to treat ocd fails, use of capsulotomy. Study that analyzed patients who had been treated with capsulotomy found that this method improve condition. Different scales used to diagnose ocd in study had significant differences. (Zhan, S. 2014)

Capsulotomy is a type of eye surgery in which an incision is made into the capsule of the crystalline lens of the eye. In modern operations for cataract, the lens capsule is usually not removed. For treatment-refractory OCD patients, bilateral anterior capsulotomy is a potential therapy. There has been shown in a study that bilateral capsulotomy is a precise therapy for refractory OCD, which can improve patients quality of life and restores their social function. In a review of all cases of capsulotomy previously reported in the literature, although there is no significant difference, indicate that anterior capsulotomy is more effective for the treatment of OCD than cingulotomy. But only very severe OCD cases should be chosen because of the risk of capsulotomy. DBS have fewer complications but it’s more expensive than capsulotomy due to the continuing costs of battery changes.

Non-Pharmacological Treatments (Cognitive-Behavioural Therapy)

Approaches to nonpharmacological treatments of patients with OCD include behavioral therapy that involves exposure to feared situations and the prevention of compulsive behavior and cognitive therapy in which maladaptive thoughts such as an exaggerated sense of risk, an enhanced sense of personal responsibility for events or excessive doubt are challenged. This last often is accompanied with family intervention. Cognitive-behavioral therapy (CBT) is considered the most effective. Several studies have  demonstrated the efficacy of CBT in OCD patients. The combination of CBT and pharmacotherapy is effective in reducing the symptoms of OCD, and may be superior to pharmacological or nonpharmacological therapy alone, especially in refractory cases where the patient is showing resistance of individual treatments.

CBT: Cognitive–behavioral therapy for obsessive–compulsive disorder

 Cognitive behavioral therapy has resulted in an OCD treatment protocol that is beneficial for individuals with this condition. Compared to traditional psychotherapy in which sessions are spent discussing the client’s problems, CBT treatment for OCD is shown to be more efficient. Both the client and the therapist take active roles in assessing the problem and in devising active steps towards alleviating the symptoms. In the UK, the National Institute for Health and Clinical Excellence’s guidelines on obsessive–compulsive disorder recommend cognitive–behavioral therapy, including exposure and response prevention, as an effective treatment for the disorder. A cognitive–behavioral model of OCD begins with the observation that intrusive thoughts, doubts or images are almost universal in the general population and their content is indistinguishable from that of clinical obsessions. An example is the urge to push someone onto a railway track. The difference between a normal intrusive thought and an obsessional thought lies both in the meaning that individuals with OCD attach to the occurrence or content of the intrusions and in their response to the thought or image. In CBT, a functional analysis is conducted and a hierarchy of the patient’s feared situations and thoughts is generated. Graded exposure follows, beginning with the stimuli that are the least anxiety-provoking, repeated self-exposure to feared stimuli will lead to extinction. Response prevention involves instructing the patient to resist the urge to carry out a particular compulsion and wait for the ensuing anxiety to subside.  Compulsions may be reduced gradually or patients instructed to delay their compulsive response for as long as possible. A patient unable to resist a compulsion to wash their hands would be asked to re-expose themselves to the feared stimuli – for example recontaminating themselves by touching a toilet seat and thus negating the effect of the compulsion.

Conclusion

Comparative analysis of therapies that is associated with the disease and a discussion of the alternative choice which would be the acceptance of OCD and associated symptoms in context of society.

As we have seen, multiple methods for the treatment of OCD exist. Traditional methods include pharmacological and nonpharmacological actions like Selective Serotonin Reuptake Inhibitors and Cognithive Behavioral Therapy respectively. When common treatments fail, neurosurgery takes place as alternative ways to relieve symptoms. Because of the cost, risks and uncertainty of these procedures, neurosurgeries must only be considered in severe cases of OCD and as mentioned, when common treatments are not effective. Due to outcomes in treatments with SSRI’s and CBT, the first one is considered to be more effective but a combination of both pharmacological and nonpharmacological options may also reduce symptoms. Further studies are required to evaluate which of the two, combination of medication and therapy or medication alone, are superior. In neurosurgeries, DBS is considered to be the one with fewer complications but the most expensive one in comparison to cingulotomy and capsulotomy. Combination of both cingulotomy and DBS as mentioned did not yield superior outcomes and the results are comparable or almost equal to DBS results. Between surgeries, it seems like capsulotomy is superior to cingulotomy but not to DBS. On the other hand, capsulotomy is a recommended procedure because of it low cost.

Mental disorders are highly stigmatized among society. People with conditions like OCD or others don’t feel comfortable speaking about it and in some cases they are resilient to seek treatment. Because of this, many people with OCD live their life without knowing that they have the condition and fear to feel unaccepted if they discuss their struggles. Because of this, many people lack the tools necessary to control their symptoms and fail to accept and consider this condition as part of their life. Studies have demonstrated that OCD can be in some part positive to individuals.  People who have the condition also tend to be more creative and skilled in the science field and other areas in their life. Although OCD is characterized to be time consuming, frustrating and a big anxious creator, some individuals with the disorder can gain a beneficial aspect out of it. People with different types of OCD can be very meticulous in their professional lives, more goal oriented, organized, perfectionists and because of their compulsions if possible that they develop some rituals that improve their physical health. In general, is necessary to increase awareness of mental disorders in a way that decreases the taboo of speaking about them and in this way make a society with a much more improved mental health.

Keywords: OCD, therapy, treatments, neurosurgeries, CBT, Intrapersonal, extrapersonal

References

Abudy, A., Juven-Wetzler, A., Zohar, J. (2011).Pharmacological Management of
Treatment-Resistant Obsessive-Compulsive Disorder. CNS Drugs,  25 (7): 585-596.

Alonso, P., Cuadras, D., Gabriels, L., Denys, D., Goodman, W., Grreenberg, B., Jimenez-Ponce, F., Khun, J., Lenartz, D., Mallet, L., Nuttin, B., Real. E., Segalas, C., Schuurman, R., Tezenas du Montzel, S., Menchon, J. (2015). Deep Brain Stimulation for ObsessiveCompulsive Disorder: A Meta-Analysis of Treatment Outcome and Predictors of Response. PLoS ONE 10(7).

Chang, W., Roh, D., Kim, C., Woo Chang, J. (2013). Combined bilateral anterior cingulotomy and ventral capsule/ventral striatum deep brain stimulation for refractory obsessive-compulsive disorder with major depression: Do combined procedures have a long-term benefit? Restorative Neurology and Neuroscience 31, 723–732.

Furnham, A., Hughes, D., & Marshall, E. (2013). Creativity, OCD, Narcissism and the Big Five. Thinking Skills and Creativity, 91-98.

Kohl, S., Ebbert, L., Sartorius, A., & Kuhn, J. (2015). A step forward in elucidating the mystery of OCD. Eur Arch Psychiatry Clin Neurosci European Archives of Psychiatry and Clinical Neuroscience, 735-736.

Murphy, H., & Perera-Delcourt, R. (2015.). ‘Learning to live with OCD is a little mantra I often repeat’: Understanding the lived experience of obsessive-compulsive disorder (OCD) in the contemporary therapeutic context. Psychology and Psychotherapy: Theory, Research and Practice, N/a-N/a.

Pauls, D., Abravomitch, A., Rauch, S., Geller, D. (2014). Obsessive–compulsive disorder: an integrative genetic and neurobiological perspective. Nature; Neuroscience, 15.

Rodgers, S., Ajdacic-Gross, V., Kawohl, W., Müller, M., Rössler, W., Hengartner, M., . . . Preisig, M. (2015). Comparing two basic subtypes in OCD across three large community samples: A pure compulsive versus a mixed obsessive–compulsive subtype. Eur Arch Psychiatry Clin Neurosci European Archives of Psychiatry and Clinical Neuroscience, 719-734.

Sesia, T., Bizup, B., Grace, A. (2013). Evaluation of animal models of obsessivecompulsive disorder: correlation with phasic dopamine neuron activity. International Journal of Neuropsychopharmacology, 16, 1295–1307.

Shen, J., & Shapiro, C. (2013). Obsessive–Compulsive Disorder and Sleep. Encyclopedia of Sleep, 272-274.

                                                                

Yun, J., Jang, J., Kim, S., Jung, W., & Kwon, J. (2015). Neural Correlates of Response to Pharmacotherapy in Obsessive-Compulsive Disorder: Individualized Cortical Morphology-Based Structural Covariance. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 126-133.

Zhan, S., Liu, W., Li, D., Pan, S., Pan, Y., Li, Y., Lin, G., Sun, B. (2014). Long-term follow-up of bilateral anterior capsulotomy in patients with refractory obsessive-compulsive disorder. Clinical Neurology and Neurosurgery 119, 91–95.

D. Veale. (2007). Cognitive–behavioural therapy for obsessive–compulsive disorder. Advances in Psychiatric Treatment, 13 (6).