Biology 202
1999 Second Web Reports
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Obsessive-Compulsive Behavior and the Types of Treatments

Joseph Xiong

Could you imagine to constantly be thinking over and over about something, such as keeping your hands clean from germs? Now imagine yourself washing your hands repeatedly for an obscene amount of time because you want relief from these nagging thoughts. At the same time you realize, "Gosh, what am I doing?" These are the symptoms of an individual with Obsessive-Compulsive Behavior (OCB). OCB is an anxiety disorder which carries a person's ordinary concerns to an extreme. The disorder is characterized by a series of obsessions, which are reoccurring thoughts, or fears, that constantly persist throughout a single day and which inevitably drives an individual crazy (1). Compulsions are actions, or thoughts, that the individual performs to briefly relieve their obsessions (1). Two other characteristics of OCB are the recognition of these symptoms as being unreasonable and the consumption of time due to the routines (1), (4).

A basic fact is that OCB is non-discriminatory. OCB is thought to typically begin during adolescence, or early childhood. The symptoms are the same, but the child may not recognize the irrationality of these. In a survey conducted by Epidemiological Catchmen Area, it was found that approximately 1.5-2% of Americans suffer from OCB in a given year, and 2.5% have had symptoms sometime in their life. Amazingly, Canada, Puerto Rico, Germany, Korea, and New Zealand experience roughly the same percentage ratio (7), (11).

The specific cause of OCB is uncertain, but researchers have discovered through the use of Positron Emission Tomagraphy, that when individuals with OCB are compared to individuals without OCB the "orbital cortex, at the underside of the brain's frontal lobe," is overactive (9). The hypothesis is that there is a communication problem between the frontal lobe of the brain, which controls thought and decision, and the caudate nucleus, a part of the basal ganglia that acts as a relay station and control of movement (1), (11). Psychiatrist Jeffrey Schwartz at UCLA describes OCB as a "shake in the mind," because the disorder causes the individual to have abnormal thoughts (9). The overactive region activates, as Schwartz suggests, "a 'worry circuit' including the caudate nucleus, a part of the basal ganglia that helps in switching gears from one to another, the cingulate gyrus, which wrenches the gut with dread, and the thalamus, which processes the body's sensory inputs [to become] "locked in gear (9)." The major factor believed to be the cause are low levels of serotonin, a neural transmitter (1).

There are two kind of treatments available to help individuals with OCB. The first is simply medication, and the second is cognitive behavioral therapy (CBT) (11). The types of medication are based on the hypothesis, as described above, that the major cause may be a reduction in the levels of serotonin. Serotonin is synthesized in brain neurons and stored in vesicles (6). It has been found to be involved in the control of appetite, sleep, memory and learning, mood, behavior, muscle contraction, endocrine regulation, depression, and temperature regulation (6). Serotonin is released as a neurotransmitter and is either metabolized, diffused, or taken back into the pre-synaptic neuron through specific amine membrane transport systems (5), (6). Thus, for individuals who have OCB, an increase in serotonin is needed, and the most successful pharmaceutical drugs are serotonin reuptake inhibitors (SRIs). SRI's inhibit the uptake of serotonin back into the pre-synaptic neuron by "clogging" up the passages (5). In this manner, there is an increased amount of serotonin in the synaptic cleft between the pre-synaptic and post-synaptic neurons, and every once in a while, serotonin will be absorbed by the post-synaptic neuron (5).

Examples of SRI's are clomipramine (anafranil), fluoxetine (prozac), fluvoxamine (luvox), paroxetine (paxil), citalopram (celexa), and sertraline (zoloft) (2), (14). Researchers from the Dean Foundation for Health Research and Education have reported that clomipramine may be the most effective SRI (9). In general, these medications take two to three months to work in OCB patients, and the "symptoms rarely go away completely, but rather tend to 'fade' to the point that the patient can resume a normal life (10)." However, once the patient stops using the medication the symptoms reappear.

Cognitive-Behavioral Therapy (CBT) is a conceptual process in which the individual must have faith in his own rationalization skills. Rational refers to an individual's reasoning ability, and irrational relates to an automatic instinctive response to certain events. An example of an irrational response would be the belief that by touching a door knob one may contract AIDS. The rational side would point out that it is impossible to simply touch a door knob and get AIDS. In this case, CBT deals directly with the individual's choice in response to the obsession: "should I, or should I not touch the door knob." In examining the basis behind the therapy and disorder, the obsessions stem from the irrational, or primitive, part of the brain and not from the forebrain which is the rational portion. As Steven Phillips states, "as the primitive part of the brain is misfiring biologically, the reasonable neo-cortex is confused by the false alarms (12)." Thus, it is conceivable that the individual may realize that what he is doing is an unreasonable mannerism. The principle behind CBT is to help the patient decipher what is rational and what is irrational. The consequence would be to substitute the irrational form of thinking with the rational form (13).

A form of CBT is exposure and response prevention. Exposure refers to a deliberate, or voluntary confrontation of the feared object, or idea (8). The hypothesis is that after periods of exposure to the feared object, or idea, the individual may develop less fear for that particular object, or idea (14). Response prevention refers to the patient's willingness to refrain from acting out the ritual, or activity that he normally performs (8). Another important factor of CBT is cognitive therapy, which helps the individual reduce the amount of catastrophic and exaggerated thinking (8).

In considering a person suffering from OCB who loves to collect things, commonly labeled as a hoarder (3), a possible therapy would be to encourage the patient to first encounter his compulsion to collect so many items. In the treatment, two possible components are to analyze how many times a day the patient collect items, and how much he collects. The therapy could consist of helping the patient face his fear and to talk through it, then reduce the amount of times during the day that he is allowed to keep items and also the amount of things he may hold on to. This would go on for a few weeks, in which case as the patient progresses, the limits would be reduced. Other factors which may influence the patient would be to insist that the patient accepts the risk of losing an item, and to fight the anxiety to keep the item regardless of the discomfort level. As stated by Steven Phillips, "the more pain one is willing to endure the less it is experienced (12)."

In my analysis of the treatments available for OCB patients, I consider CBT as the most effective treatment. Although SRI's have proven to be successful, I am fascinated by the notion that there is an "I" function which is at work when a patient undergoes CBT. In considering the "I" function, it acts as a synthesizer of all the information made available, and then it decides what to do. The "I" function stems from the rational side and takes place of the irrational side. In this manner, the "I" function acts as the instinctive response and decisive response.

Although there is no cure for Obsessive-Compulsive Behavior, there are several treatments to help lessen the effects of OCB. The individuals who do use CBT as a form of therapy recognize a 50-80% decrease in the symptoms (14), and of the individuals who use SRI's, 70-80% respond to the effects (11). However, once the individual stops using SRI, the symptoms take over again. The best solution is to use both forms of treatment, or to use the SRI's as a quick start process, but then revert to using CBT as a later form of treatment. CBT is a fascinating treatment, because it allows humans to use the forebrain, which is the most highly developed portion of the brain. CBT is a conceptualizing exercise which pushes the OCB patient to understand both their irrational and rational sides. The process is extremely hard to swallow for the irrational side is automatic and involuntary, urging the patients to react to an event at will. However, if the person suffering from OCB practices this therapy extensively, though he may not be cured, life will become a lot easier.

References:

WWW Sources

1)OCB Foundations Page, some facts on OCD

2)OCB Foundations Page, treatments for OCD, shows 6 SRI drugs

3)OCB Information Site, What is OCD? and the different categories

4)OCB Information Site , OCD and criteria for OCD

5)OCB Information Site , Serotonin and how SRI's work

6)OCB Information Site, Serotonin: The NT for the 90's

7)National Mental Health Association, some facts on OCD

8)Neural Medical Page, Quick hints to types of treatments

9)Alliance for the Mentally Ill/Friends and Advocates of the Mentally Ill , "All About OCD" by Jeffrey Schwartz

10)Mental Health Infosource , articles on OCD

11)Mental Health Page , OCD information

12)OCB On Line Info. , "Speak of the Devil," article on CBT

13) OCB On Line Info. , article on CBT

14)Expert Concensus Guidleline Series , Good overview of CBT




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