Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by obsessions that cause marked anxiety or distress and/or by compulsions that serve to neutralize anxiety. Symptoms may be mild but merely annoying or may disable a person throughout a lifetime.

Obsessions are persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress. The most common obsessions are repeated thoughts about contamination (that is, becoming contaminated by germs or by shaking hands); repeated doubts (wondering whether one has performed some act, such as having left a door unlocked or a coffee pot brewing on the stove); a need to have things in a particular order; aggressive or horrific impulses (which the person might never act on); or sexual imagery that is inappropriate or frightening.

Compulsions are repetitive behaviors (hand washing, checking) or mental acts (praying, counting, repeating words silently). The goal of compulsions is to prevent or reduce anxiety or distress. The person feels driven to perform the compulsion to reduce the distress caused by the obsessive thought.

Many people may consider themselves to be compulsive because they hold themselves to a high standard of performance and are perfectionist and highly organized in work and recreational activities. This type of compulsiveness often is an attribute that contributes to a person's self-esteem and success.

People who have been clinically diagnosed with OCD suffer from obsessive and compulsive behaviors that are extreme enough to interfere with their everyday lives. The obsessions and compulsions these people experience can ruin their lives.

Incidence of OCD

For a long time, mental health professionals considered OCD to be a rare condition. That may be because OCD often has gone unrecognized. Many people who suffer from OCD are ashamed of their irrational behaviors and try to keep their problem a secret. But in recent years, as science has confirmed that OCD is a potentially severe anxiety disorder, more people have begun to seek treatment.

OCD, in fact, affects more than 2.3% of the U.S. population between the ages of 18-54, according to the National Institute of Mental Health (NIMH). According to the Mayo Clinic, an estimated 3.3 million Americans have obsessive-compulsive disorder. That makes OCD more common than schizophrenia, bipolar disorder, or panic disorder. In addition, OCD is an "equal opportunity" illness, striking people of all ages, gender, and ethnic groups.

OCD's impact on society is enormous. In 1990, in the United States alone, OCD resulted in social and economic losses of more than $8.4 billion--nearly 6% of the nation's total mental health bill of $148 billion (National Institute of Mental Health (NIMH) www.nimh.nih.gov/anxiety/ocdfacts.cfm).

What Causes OCD?

Psychiatrists once thought that OCD was caused by traumatic past events in a person's life. A person with OCD, for example, might have learned as a child to overemphasize cleanliness or to develop a belief that certain thoughts were dangerous or unacceptable.

Now a growing body of research indicates that biological factors and/or cognitive processes may cause or contribute to the disorder. Many OCD patients, for example, respond well to medications that alter brain chemistry. Tendencies to develop OCD may be inherited: the condition has been known to run in families. And there is evidence that OCD involves abnormalities in brain chemistry.

To identify biological factors that may be relevant in onset or development of OCD, NIMH researchers used a device called a positron emission tomography (PET) scanner to study brains of OCD patients.

The investigators found that OCD patients exhibit brain activity that differs from that of people who do not suffer from mental illness, or who have mental problems other than OCD. Researchers found that OCD patients exhibited abnormal neurochemical activity in brain regions known to play a role in certain neurological disorders.

Other recent studies using magnetic resonance imaging (MRI) technology found that subjects with OCD had significantly less white brain matter than normal control subjects did.

Even if there is a biological basis for OCD, that doesn't mean that a person's environment, beliefs, and attitudes are not also linked to the disease. In addition, people with OCD may process information differently from those who do not have the illness.

How OCD is ManifestED

Traditionally, OCD was thought to show up during teenage years or in early adulthood. But new research indicates that some children develop the illness as early as preschool. In fact, a third of all OCD cases may begin in childhood.

The essential features of obsessive-compulsive disorder are recurrent obsessions or compulsions that are severe enough to be time-consuming (taking more than 1 hour a day) or that cause marked distress or significant impairment. Usually at some point during the course of the disorder, the person recognizes that the obsessions or compulsions are excessive or unreasonable, but is powerless to change behavior without intervention.

OCD is sometimes accompanied by other psychological problems, including depression, eating disorders, substance abuse disorder, personality disorder, attention deficit disorder, or another of the anxiety disorders. These coexisting conditions can make OCD difficult to diagnose and treat.

In addition, symptoms of OCD may be seen in conjunction with other neurological disorders. People with Tourette's syndrome, for example, may have an increased rate of OCD. Scientists now are investigating a hypothesis that a genetic relationship exists between OCD and such "tic" disorders, which are characterized by involuntary movements and vocalizations.

Other illnesses that may be linked to OCD are trichotillomania (a repeated urge to pull out scalp hair, eyelashes, eyebrows, or other body hair); body dysmorphic disorder (excessive preoccupation with imaginary or exaggerated defects in appearance); and hypochondriasis (fear of having a serious disease, even though nothing is wrong with a person). In addition, NIMH researchers are looking at the possible link of OCD to some autoimmune diseases in which infection-fighting cells, or antibodies, turn against the body in an attempt to destroy it.

Most people with OCD know that their obsessions are unrealistic, but they may sometimes be uncertain about the validity of their fears or even believe that their fears are founded. In almost all cases, OCD victims struggle to banish their unwanted obsessive thoughts and to stop themselves from engaging in compulsive behaviors.

Many people seem to be able to keep their OCD symptoms under control at work or school, but resistance may weaken and then the condition can become so severe that compulsive rituals take over victims' lives, making it impossible for them to function normally.

People with OCD often try to hide the condition from friends and co-workers because they are ashamed of and confused by their seemingly senseless behaviors. Such feelings of inadequacy prevent many people from seeking treatment for the condition. This is regrettable because science has developed many medications that can help people with OCD.

Pharmacological TreatmeNT

Many persons with OCD benefit from pharmacological treatment. Others may be helped by medication in conjunction with behavioral therapy. Others begin with medication to gain control over symptoms and then switch to therapy.

In recent years several clinical trials have found that a number of drugs can affect the neurotransmitter serotonin and significantly decrease symptoms of OCD. The tricyclic antidepressant clomipramine (Anafranil) was the first of such serotonin reuptake inhibitors (SRIs) specifically approved to treat OCD.

Clomipramine was followed by other SRIs known as "selective serotonin reuptake inhibitors" (SSRIs). Those approved by the U.S. Food and Drug Administration to treat OCD include fluoxetine (Prozac), fluvoxamine (Luvoc), and paroxetine (Paxil). Several clinical trials suggest that OCD patients may be helped by sertraline (Zoloft). It can take as long as 10-12 weeks to feel the beneficial effect of high dose SSRI treatment. This can be a point of frustration for the patient, but with time, SSRIs have been shown to help patients with obsessive-compulsive behaviors overcome them.

Such medications have helped, to some degree, in more than three quarters of patients who took them. In less than half of patients, the medications helped with a partial reduction in symptoms. Unfortunately, about only 10-15% of the patients have a full remission of their symptoms, making the disease chronic in nature.

If patients do not respond to a medication or they develop side effects, doctors may try another SRI. Often, if medications are discontinued, 85% of the patients relapse within 2 months. If a medication works to alleviate symptoms, doctors may lower the dosage, but most patients take OCD medications indefinitely (see more information at the Mental Health Channel, www.mentalhealthchannel.net/ocd/index.shtml ).

PsychotheraPY

Most OCD patients have not responded well to traditional psychotherapy, the goal of which is to help people to gain insight into their problems. But one behavioral therapy that has worked for many people with OCD is called "exposure and response prevention." In this approach, the patient deliberately confronts a feared object or idea. The therapist then encourages the patient to refrain from ritualizing to obtain relief. A compulsive hand washer, for example, may be asked to touch an object believed to be "contaminated," and may then be urged to avoid washing for several hours, until the anxiety has decreased.

Most OCD patients who have completed behavioral therapy have reported a lessening of symptoms. Usually these patients are highly motivated and have a positive attitude about treatment. What's more, the therapy appears to have long-lasting effects. Compulsive rituals have been shown to improve 70-80% in patients that accept and comply with therapies such as exposure in vivo and response prevention (Perse 1988). Another study found that incorporating relapse-prevention components in a treatment program--including follow-up sessions after intensive therapy--contributed to maintenance of improvement (Hiss 1994). One study done in France, where 2-3% of the population is affected by the disorder, acknowledged that response and prevention therapy benefits 70% of the patients (Legeron 1989). Group treatment using exposure and response prevention for obsessive-compulsive disorders was found to be as effective in a 7-week program as in a 12-week program (Himle 2001).

Another type of psychological treatment, cognitive-behavioral therapy, may also help some people with OCD. This form of therapy attempts to change beliefs and thinking patterns of people with OCD. More studies are needed to evaluate the effects of cognitive-behavioral therapy.

Many people may believe religious beliefs shouldn't have a part in psychiatry, but according to Dr. Gangdev of the Community Mental Health Service in the Tokoroa Hospital of New Zealand, strong religious beliefs may play a role in treating psychiatric disorders. Gangdev treated a woman with doubt obsessions in a single session using a positive religious affirmation. This form of treatment is called cognitive restructuring and thought-stopping. Stated Gangdev, "although unusual in standard clinical practice, rapid resolution of obsessions is possible." The woman remained well for 5 months, but was lost to follow-up (Gangdev 1998).

Other TherapiES

Scientists are investigating the potential of neurosurgery, a new approach to treating OCD. In the few centers where neurosurgery has been performed, the treatment has been recommended only for people who have failed to respond to conventional medications or psychotherapy (Nemeth 1998).

There have been several published anecdotal reports of the successful use of electroconvulsive therapy (ECT) in OCD patients (Wohlfahrt 1996). Most often, however, benefits of ECT have been short-lived (Khanna 1988). The treatment generally is restricted to people with treatment-resistant OCD accompanied by severe depression (Maletzky 1994; Schott 1992).

Natural TreatmenTS

Some naturopathic physicians have reported success in treating OCD with a variety of natural therapies.

Certain herbs and supplements act directly on the nervous system, promoting relaxation and feelings of tranquillity. Others may relax tense muscles, ease stress-related headaches, soothe stomachs upset by stress, and encourage restful sleep.

L-Theanine
L-Theanine is an amino acid derived from green tea. Theanine readily crosses the blood-brain barrier of humans and exerts subtle changes in biochemistry. An increase in alpha waves has been documented. One of the things that theanine changes is GABA, a brain chemical known for its calming effect. Theanine increases GABA. Theanine also increases levels of dopamine, another brain chemical with mood-enhancing effects. Theanine reduces stress which is directly connected to the intensity of OCD episodes (Kakuda et al. 2000).

Inositol
Inositol (myo-inositol) is required for proper formation of cell membranes, where it functions as phosphatidylinositol. It affects nerve transmission and helps in transporting fats within the body and also facilitates the action of many methylating agents. Inositol is important in reproduction, embryogenesis, and neural tube defects. It also stimulates the production of lung surfactant, which is extremely important in the newborn. Inositol has been recognized in the past for its combined effect with choline as part of lecithin. Having a lowered or altered production of inositol has been associated with adult onset diabetes, multiple sclerosis, premature retinopathy, fatty liver, chronic renal failure, depression, panic disorders, and OCD.

In a 1997 report entitled "Controlled Trials of Inositol in Psychiatry" published in the Journal of the European College of Neuropsychopharmacology, Levine reported the effects of inositol on many disorders in which it had been studied. Inositol is reported to reverse desensitization of serotonin receptors; this is important because serotonin reuptake inhibitors are known to benefit obsessive-compulsive disorders. Thirteen patients in a double-blind controlled crossover trial were each given 18 grams a day or a placebo for 6 weeks. Researchers found that inositol significantly reduced scores of obsessive-compulsive symptoms compared to placebo (Levine 1997).

Tryptophan
Tryptophan is an essential amino acid found in cheeses, peanuts, milk, and meat sources. Tryptophan is the only precursor to the neurotransmitter serotonin. Serotonin helps induce sleep and tranquility and helps to fight depression. Vitamin B6 is necessary for the synthesis of tryptophan into serotonin.

Patients that have treatment-resistant OCD may benefit from sequential administration of tryptophan to increase levels of serotonin. In one study, OCD patients who were resistant to SRIs were given the beta-adrenergic antagonist pindolol, which led to an improvement in depressive symptoms but did not alter the OCD symptomatology. Tryptophan was then added to the administration of pindolol, producing a significant improvement after 4 weeks, and even more improvement at 6 weeks (36% decrease of the Yale-Brown Obsessive Compulsive Score). The improvement was maintained with treatment prolongation (Blier 1996). Another study done in Italy, however, showed no improvement in OCD with the administration of tryptophan (Smeraldi 1996).

In another controlled study, Huwig-Poppe used a tryptophan depletion test on OCD and normal healthy subjects to evaluate the effect serotonin has on sleep patterns. He found that depletion of tryptophan led to more noticeable disturbances in the continuity of sleep in the OCD patients than in the healthy subjects, indicating there was an increase in wake time and a decrease in the total sleep time for the OCD patients. In both groups there was a decrease of total sleep time. The results led to the conclusion that there is an important role of the serotonergic system for sleep maintenance and the phasic aspects of REM sleep (Huwig-Poppe 1999).

Other TherapiES

Exercise
Canadian researchers report that regular exercise may help many people who suffer from psychiatric disorders, including phobias and OCD. Researchers Gregg A. Tkachuk and Garry L. Martin of the Department of Psychology at the University of Manitoba in Winnipeg examined studies of anxiety disorder and exercise dating back to 1981. They found that strength training, running, walking, and other forms of aerobic exercise help to alleviate mild to moderate depression and may also help to treat other mental disorders including anxiety and substance abuse.

SUMMARY

Research indicates that biological factors and/or cognitive processes may cause or contribute to OCD. OCD sufferers, therefore, respond well to medications that alter brain chemistry. Some natural therapies that act directly on the central nervous system may lessen the symptoms of OCD or the precipitating anxiety (see the Anxiety and Stress protocol for more information on anxiety disorders).

1. L-theanine has a calming effect and may help decrease symptoms of anxiety, 200 mg, twice a day.
2. Inositol (myo-inositol) may reverse desensitization of serotonin receptors leading to improvement of OCD symptoms. For OCD and panic disorders, 4 grams in 3 divided doses a day is recommended.
3. Tryptophan may help increase levels of the neurotransmitter serotonin. Two grams should be given in the evening on an empty stomach.

For more informatiON

Contact the National Mental Health Association, (800) 969-6642.

Product availabiliTY

L-theanine and inositol are available from the Life Extension Foundation by calling (800) 544-4440 or by ordering online. Ask the Foundation to provide you with a list of knowledgeable physicians in your area who will prescribe clomipramine and other drugs to treat OCD.