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"I couldn't do anything without rituals. They invaded every aspect of my life. Counting really bogged me down. I would wash my hair three times as opposed to once because three was a good luck number and one wasn't. It took me longer to read because I'd count the lines in a paragraph. When I set my alarm at night, I had to set it to a number that wouldn't add up to a 'bad' number."
Obsessive-compulsive disorderÂ (OCD) is aÂ mental disorderÂ characterized byÂ involuntary thoughts and fearsÂ that produceÂ anxiety, by repetitive behaviours or mental act that one feels compelled to do to reduce anxiety, or by combinations of such thoughts (obsessions) and behaviours (compulsions). People with OCD are unable to control these thoughts and rituals. Although most people know what they do is senseless, they still cannot ignore the thoughts because they scare something bad will befall them or their loved ones. Some people with OCD may develop complications that they become suicidal or depressed. Scholars generally agree that both psychological and biological factors play a role in causing the disorder, although the actual cause is still unknown. "In the United States, about 1 million children and teens, both boys and girls, have OCD. That's about 1 in every 200 children and teens. In some studies including adults, OCD was reported as commonly as 1 in 50 people."Â 1
OCD patient explaining his experience of having obsessions and compulsions http://www.siteceu.com/anxietyassess.html
Picture compares the difference between normal brain and OCD brain http://www.pharmacy-and-drugs.com/Mental_Health_and_Depression/Obsessive_compulsive_disorder.html
Exposure and response prevention (ERP)
ERP involves exposing you to the anxiety that is provoked by your obsessions and then preventing the use ofÂ rituals to reduce your anxiety.12 With increased exposure, the patient is getting fewer urges and the anxiety will be gradually subsided. After ongoing treatment, 50% to 80% of patients stop all compulsive behaviour. Exposure can be:
Actual,Â like touching doorknobs.
Mental,Â like mentally picturing yourself forgetting to shut the windows.
Once exposure has taken place, most people with OCD will feel the need to engage in compulsive behaviour in order to reduce the anxiety that the exposure has caused them.14 Nevertheless, CBT therapist will help you to prevent, or at least slow down, this compulsive response. Over time, there will be less anxiety when exposed to an unpleasant object or situation and the need for a compulsive response will become weaker.
To start with, your therapist will set targets for exposure that are easier to cope with. After that, he will move on to targets that are presently causing you considerable anxiety.
CBT counsellor will first conduct about 10 one-hour sessions for people with mild to moderate OCD. A more intensive course of CBT is required for moderate to severe OCD patients which lasts for more than 10 hours. However, this technique only applies to milder cases. For more severe symptoms, prescriptions of medications such as SSRIs are necessary.
Selective Serotonin Reuptake Inhibitors (SSRIs)
Some research suggests that abnormalities in neurotransmitter activity affect mood and behaviour. When neurotransmitters such as serotonin bind with receptors on an adjacent neuron, they carry the impulse to the next cell. But in someone with OCD, the cell that released the serotonin, also known as 5-hydroxytryptamine or 5-HT may reabsorb it too quickly. As a result, serotonin may not be enough to bind to the next cell and allow the nerve impulses to pass.
Antidepressants are used to help control the obsessions and compulsions of OCD because they may help increase levels of serotonin, which may be lacking when you have OCD. Antidepressants that have been specifically approved by the Food and Drug Administration to treat OCD include selective serotonin reuptake inhibitors(SSRIs) such as sertraline(Zoloft), paroxetine(Paxil), fluoxetine(Prozac), citalopram, andÂ fluvoxamineÂ as well as theÂ tricyclic antidepressants, especially clomipramine (Anafranil). With the exception of clonazepam, all effective anti-obsessional agents are antidepressants, but it is clear that their efficacy in OCD is not mediated via an antidepressant effect.19 This can be proven by antidepressant that lack potent serotonin reuptake inhibiting action is ineffective in OCD. SSRIs slow the process of reuptake of serotonin, increasing this neurotransmitter's presence in the synapse. By blocking reuptake, they allow serotonin to remain longer in receptor sites, improving the transmission of nerve impulses. Increased serotonin enhances neurotransmission - the sending of nerve impulses - and help regulate theÂ anxietyÂ and obsessive thoughts. In some treatment-resistant cases, a combination ofÂ clomipramineÂ and an SSRI has proven to be effective even when neither drug on its own has been efficacious.
Thus, the SSRIs work by allowing the body to make the best use of the reduced amounts of serotonin that it has at the time. In due course, the levels of natural serotonin will increase again, and the SSRI can then be reduced and removed from the prescription.
How SSRIs probably work
SSRIs prevent excessÂ serotoninÂ from being pumped back into the originalÂ neuronÂ that released it. They block the reuptake of serotonin, so the next time an impulse comes along, there is more transmitter, a stronger message is passed, and activity in that part of the brain is increased.
"Normal" nerve activity:
"Reduced" nerve activity e.g. as in OCD:Â
"Reduced" nerve activity but with recycling blocked, and increased messages passes:
It is crucial to remember that SSRI antidepressants probably mainly work by correcting the effect of having too little transmitter.
Selective serotonin-reuptake inhibitor (SSRI) antidepressants were almost twice as likely as placebo to confer modest improvement in symptoms of obsessive-compulsive disorder (OCD) among patients who responded to treatment in 17 short-term studies published from 1989 to 2004.14 SSRIs also have less side effects compared to other forms of antidepressants, less withdrawal symptoms, less danger if are taken overdose and overall are considered safer than other types of drugs.
Besides, another research on the SSRIs suggests that they are effective in treating OCD in adults, children and adolescents. About 60-70% of OCD sufferers benefit from medication treatment. Although SSRIs can effectively treat OCD in many patients, they are notoriously slow to work. It is typical to take SSRIs consistently for a period of 2-3 months before benefits may start to be seen. Some patients report feeling some improvement within days of starting an SSRI, but it may take 2-3 months before the levels build up in the system sufficiently to give the individual any noticeable relief.15 However, there were no significant differences among the SSRIs in terms of their effectiveness.
Picture shows the serotonin that is released are prevented to be reabsorbed by SSRI http://scienceblogs.com/neurotopia/2009/03/depression_post_4_the_serotoni.php
Ethical and Economic Implications
Serious questions have arisen as to SSRIs' safety and the way they are prescribed without patients being provided with full information, including the efficacy and potential side-effects of medication and the possible aetiologies of depression. These issues are particularly imperative in the care and treatment of youths, as there is evidence of increased suicidal thoughts and behaviours and other side effects in youth taking antidepressants. So SSRI antidepressants, except Prozac, are not approved by the FDA for use in people under 18.
Some studies have been carried out to assess the effects of SSRIs on normal subjects over periods of a few months or less. The effects are relatively selective, reducing self-reported negative affect (such as fear, hostility) while leaving positive affect (happiness, excitement) the same. That's why people who are healthy also use SSRIs to get these effects and to improve their personalities. Moreover, the growth in sales of SSRIs shows that more people, with mild depression, are using them. This is opposed to the actual aim where SSRIs are used to treat people with psychiatric problems and subsequently posed ethical issues among society.
Another problem with some of these drugs is their cost. The high cost of the SSRIs can be a big problem for someone with no insurance, or whose insurance doesn't cover drugs. At about $2 to $3 per pill, the pharmacy bill can be overwhelming.9 For patients with larger doses, these drugs can cost them up to $6 or $7 per day. When the patent expires on each of these drugs, other companies can make generic forms of each drug, and then the prices will fall.11 However, this will not happen for many years with the drugs now available.
Benefits and Risks
A major advantage of the SSRIs is that they are not so dangerous if someone takes an overdose. Patients with an over dosage who remain asymptomatic for several hours afterward are unlikely to need any further medical treatment. During the 10 years that SSRI antidepressants have been marketed, there have been remarkably few fatal overdoses reported in the literature or to the AAPCC or FDA involving ingestion only of an SSRI.Â 7Antidepressant drugs don't cause the addictions that one get with tranquilizers, alcohol or nicotine because we don't need to keep increasing the dose to get the same effect. Besides, the patient won't find himself craving for the SSRIs after he stop taking them. However, SSRIs may produce unpleasant withdrawal symptoms when they are stopped. But this does not involve a craving for the medication and is only temporary, and if the drug is tapered off rather than stopped suddenly, this can normally be avoided. Hence, it is not addiction. graph.jpg
The bar chart shows the number of cases of adverse drug reactions (SSRIs) concerning pregnant women in 2009 http://uniteforlife.files.wordpress.com/2009/03/graph.jpg
Also, the FDA warns that infants whose mothers took SSRIs while pregnant may be at an increased risk of persistent pulmonary hypertension. This risk is increased in women who take SSRIs at 20 weeks or later in pregnancy. This rare but serious lung problem occurs when a newborn's circulatory system doesn't adapt to breathing outside the womb.
Furthermore, SSRIs also believed to be frequently dampen sexual response. One study suggested that half of all people taking these medications may experience some sexual side effects. It's not uncommon for men taking these medications to have problems sustaining an erection. In addition to reducing interest in sex, SSRIs can make it difficult to become aroused, sustain arousal and reach orgasm, or unable to have an orgasm at all. If you experience any sexual problems while taking an SSRI, talk with your therapist. In some cases, sexual difficulties may stem from the underlying depression, not from the medication.
Clomipramine is a tricyclic antidepressant (TCA) that can be considered as an alternative to SSRIs to treat OCD. Compared to SSRIs, TCAs are used less commonly because they have more side effects compared to SSRIs. However, they will be used as second-line treatment by some authorities if treatment with SSRIs fail. There are few side effects of clomipramine, including
Increased appetite (which may lead to weight gain)
People with low blood pressure (hypotension) or cardiovascular disease are not suitable to take clomipramine. Therefore, a blood pressure test and an electrocardiogram (ECG) are recommended for the high risk group before any treatment can be commenced.
As with SSRIs, you will usually be recommended to take a 12-month course of clomipramine, after which your symptoms will be reviewed.14
Psychosurgery for obsessive compulsive disorder is normally regarded as a last resort treatment for severe OCD when other treatments have failed. Before surgery, a neurosurgeon uses magnetic resonance imaging to select a suitable site in the brain for surgery. During surgery, an electric current or ultrasonic radiation by the neurosurgeon to remove a small portion of the limbic system to 're-wire' the brain and resolve chronic mental health problems such as OCD fully, or at least partially. The limbic system is a structure in the brain that is responsible for some of the most important brain functions, such as higher emotions, memory and behaviour.14
Deep-brain stimulationÂ andÂ vagus nerve stimulationÂ are possible surgical options which do not involve the destruction of brain tissue. More than one third of all patients report dramatic improvements in their OCD after surgery.
Some of the common obsessions that people with OCD will have
I find that the information provided in website 9 http://www.healthyplace.com/depression/antidepressants/selective-serotonin-reuptake-inhibitors-ssris/menu-id-68/ is accurate and trustworthy. As it has mentioned, any medical advice provided on this site will only be given by medically trained and qualified professionals. Besides, author's or editor's details with credentials are given. The information on this site is regularly checked and updated to ensure the reliability and relevance of the information provided. The contents are also carefully reviewed by Health On the Net Foundation which is very reliable.
Moreover, http://ocd.about.com/od/treatment/a/Psychotherapy.htm has provided me useful information. The article was written by Owen Kelly, who has a Ph.D., M.Sc. and B.A. Hons, in Psychology with a specialization in behavioural neuroscience from Carleton University. He is a researcher at the University of Ottawa Institute of Mental Health Research as well as an adjunct research professor and lecturer in the Department of Psychology at Carleton University in Ottawa, Canada. Today, About.com is recognized as a top 15 content site and one of the largest producers of original content on the Web.20 Besides that, the information in this website is updated on 24 August 2010, so the content is up to date.