Anxiety is considered to be a normal reaction to a stressor. It may help someone to deal with a difficult situation by prompting them to cope with it. When anxiety becomes excessive, it may fall under the classification of an anxiety disorder.
Obsessive-compulsive disorder (OCD) is an anxiety disorder in which people have unwanted and repeated thoughts, feelings, ideas, sensations (obsessions), or behaviors that make them feel driven to do something (compulsions).
Often the person carries out the behaviors to get rid of the obsessive thoughts, but this only provides temporary relief. Not performing the obsessive rituals can cause great anxiety.
Causes, incidence, and risk factors
Obsessive-compulsive disorder (OCD) is more common than was once thought. Most people who develop it show symptoms by age 30.
There are several theories about the cause of OCD, but none have been confirmed. Some reports have linked OCD to head injury and infections. Several studies have shown that there are brain abnormalities in patients with OCD, but more research is needed.
About 20% of people with OCD have tics, which suggests the condition may be related to Tourette syndrome. However, this link is not clear.
Symptoms
- Obsessions or compulsions that are not due to medical illness or drug use
- Obsessions or compulsions that cause major distress or interfere with everyday life
There are many types of obsessions and compulsions. One example is an excessive fear of germs and the compulsion to repeatedly wash the hands to ward off infection.
The person usually recognizes that the behavior is excessive or unreasonable.
Signs and tests
Your own description of the behavior can help diagnose the disorder. A physical exam can rule out physical causes, and a psychiatric evaluation can rule out other mental disorders.
Questionnaires, such as the Yale-Brown Obsessive Compulsive Scale (YBOCS), can help diagnose OCD and track the progress of treatment.
Medication:
BENZODIAZEPINES (eg, alprazolam, lorazepam):
Benzodiazepines are believed to exert their anxiolytic effects through enhancement of the GABA-benzodiazepine receptor complex. Gamma-aminobutyric acid (GABA) is a major inhibitory neurotransmitter in the CNS that acts on specific receptor subtypes GABAA, the receptor involved in sedation and anxiolytic action, and GABAB. Benzodiazepines bind nonspecifically to GABAAreceptors, which may contribute to their anxiolytic effects.
There is evidence that tolerance develops to the sedative effects of benzodiazepines. Abrupt discontinuation should be avoided and a gradual dosage-tapering schedule should be employed after extended therapy. Withdrawal symptoms can appear following cessation of recommended doses after as little as one week of therapy.
SELECTIVE SEROTONIN REUPTAKE INHIBITORS:
There is evidence that tolerance develops to the sedative effects of benzodiazepines. Abrupt discontinuation should be avoided and a gradual dosage-tapering schedule should be employed after extended therapy. Withdrawal symptoms can appear following cessation of recommended doses after as little as one week of therapy.
SELECTIVE SEROTONIN REUPTAKE INHIBITORS:
Selective serotonin reuptake inhibitors (SSRIs) (eg,fluoxetine, sertraline) potentiate serotonergic activity by inhibiting neuronal reuptake of serotonin (5-HT). Increased serotonergic activity in the CNS reduces noradrenergic activity producing anxiolytic effects. SSRIs produce greater anxiolytic effects than agents that inhibit reuptake of both serotonin and norepinephrine. SSRIs are also shown to be an effective treatment for obsessive-compulsive disorder (OCD) with less potential for side effects than TCAs.
SSRIs have a low affinity for adrenergic and muscarinic receptors and have less sedative, anticholinergic, and cardiovascular effects than tricyclic antidepressants. Dosage tapering is preferred to abrupt discontinuation to avoid withdrawal symptoms. Concomitant administration of SSRIs with other serotonergic medications may cause serotonin syndrome.
SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITORS:
SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITORS:
Serotonin and norepinephrine reuptake inhibitors (SNRIs) (eg, duloxetine, venlafaxine) produce their anxiolytic effect by inhibiting neuronal reuptake of serotonin and norepinephrine. Like the SSRIs, SNRIs have a low affinity for adrenergic, histaminic, and muscarinic receptors and have similar side effect profiles to SSRIs.
TRICYCLIC ANTIDEPRESSANTS:
The anxiolytic effect of tricyclic antidepressants (TCAs) is not fully understood. Tricyclic antidepressants block neuronal reuptake of norepinephrine and serotonin. In general, secondary amine tricyclics (eg, nortriptyline) more selectively inhibit the reuptake of norepinephrine whereas tertiary amine tricyclics (eg, doxepin, clomipramine) inhibit both norepinephrine and serotonin. Tertiary amine tricyclics tend to be more sedating and have greater anticholinergic effects than secondary amine tricyclics. Tolerance to these effects may develop with continued use.
OTHER CLASSES:
OTHER CLASSES:
Azapirones (eg, buspirone) appear to exert their anxiolytic effects by increasing serotonergic activity through partial agonism of the receptor subtype 5-HT1A and weak antidopaminergic activity. There is a lack of cross tolerance between azapirones and benzodiazepines. Antihistamines (eg, hydroxyzine) are effective treatment alternatives for anxiety disorders, but only at doses that produce marked sedation.
Treatment
OCD is treated using medications and therapy.
The first medication usually considered is a type of antidepressant called a selective serotonin reuptake inhibitor (SSRI). These drugs include:
- Citalopram (Celexa)
- Fluoxetine (Prozac)
- Fluvoxamine (Luvox)
- Paroxetine (Paxil)
- Sertraline (Zoloft)
If an SSRI does not work, the doctor may prescribe an older type of antidepressant called a tricyclic antidepressant. Clomipramine is a TCA, and is the oldest medication for OCD. It usually works better than SSRI antidepressants in treating the condition, but it can have unpleasant side effects, including:
- Difficulty starting urination
- Drop in blood pressure when rising from a seated position
- Dry mouth
- Sleepiness
In some cases, an SSRI and clomipramine may be combined. Other medications, such as low-dose atypical antipsychotics (including risperidone, quetiapine, olanzapine, or ziprasidone) have been shown to be helpful. Benzodiazepines may offer some relief from anxiety, but they are generally used only with the more reliable treatments.
Cognitive behavioral therapy (CBT) has been shown to be the most effective type of psychotherapy for this disorder. The patient is exposed many times to a situation that triggers the obsessive thoughts, and learns gradually to tolerate the anxiety and resist the urge to perform the compulsion. Medication and CBT together are considered to be better than either treatment alone at reducing symptoms.
Psychotherapy can also be used to:
- Provide effective ways of reducing stress
- Reduce anxiety
- Resolve inner conflicts
Expectations (prognosis)
OCD is a long-term (chronic) illness with periods of severe symptoms followed by times of improvement. However, a completely symptom-free period is unusual. Most people improve with treatment.
Complications
Long-term complications of OCD have to do with the type of obsessions or compulsions. For example, constant handwashing can cause skin breakdown. However, OCD does not usually progress into another disease.
Calling your health care provider
Call for an appointment with your health care provider if your symptoms interfere with daily life, work, or relationships.
Prevention
There is no known prevention for this disorder.
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