Ocd and tics

Obsessive-Compulsive Disorder (OCD) | Chestnut Health Systems

What is OCD?

Obsessive-Compulsive Disorder (OCD) is a common, chronic and long-lasting disorder in which a person has uncontrollable, reoccurring thoughts (obsessions) and behaviors (compulsions) that he or she feels the urge to repeat over and over.

What are the signs and symptoms of OCD?

People with OCD may have symptoms of obsessions, compulsions, or both. These symptoms can interfere with all aspects of life, such as work, school, and personal relationships.

Obsessions are repeated thoughts, urges, or mental images that cause anxiety. Common symptoms include:

Fear of germs or contamination
Unwanted forbidden or taboo thoughts involving sex, religion, and harm

Aggressive thoughts towards others or self
Having things symmetrical or in a perfect order

Compulsions are repetitive behaviors that a person with OCD feels the urge to do in response to an obsessive thought. Common compulsions include:

Excessive cleaning and/or handwashing
Ordering and arranging things in a particular, precise way
Repeatedly checking on things, such as repeatedly checking to see if the door is locked or that the oven is off
Compulsive counting

Not all rituals or habits are compulsions. Everyone double checks things sometimes. But a person with OCD generally:

Can't control his or her thoughts or behaviors, even when those thoughts or behaviors are recognized as excessive
Spends at least 1 hour a day on these thoughts or behaviors
Doesn’t get pleasure when performing the behaviors or rituals, but may feel brief relief from the anxiety the thoughts cause
Experiences significant problems in their daily life due to these thoughts or behaviors

Some individuals with OCD also have a tic disorder. Motor tics are sudden, brief, repetitive movements, such as eye blinking and other eye movements, facial grimacing, shoulder shrugging, and head or shoulder jerking. Common vocal tics include repetitive throat-clearing, sniffing, or grunting sounds.

Symptoms may come and go, ease over time, or worsen. People with OCD may try to help themselves by avoiding situations that trigger their obsessions, or they may use alcohol or drugs to calm themselves. Although most adults with OCD recognize that what they are doing doesn’t make sense, some adults and most children may not realize that their behavior is out of the ordinary. Parents or teachers typically recognize OCD symptoms in children.

If you think you have OCD, talk to your doctor about your symptoms. If left untreated, OCD can interfere in all aspects of life.

What are the risk factors for OCD?

OCD is a common disorder that affects adults, adolescents, and children all over the world. Most people are diagnosed by about age 19, typically with an earlier age of onset in boys than in girls, but onset after age 35 does happen.

The causes of OCD are unknown, but risk factors include:

Genetics

Twin and family studies have shown that people with first-degree relatives (such as a parent, sibling, or child) who have OCD are at a higher risk for developing OCD themselves. The risk is higher if the first-degree relative developed OCD as a child or teen. Ongoing research continues to explore the connection between genetics and OCD and may help improve OCD diagnosis and treatment.

Brain Structure and Functioning

Imaging studies have shown differences in the frontal cortex and subcortical structures of the brain in patients with OCD. There appears to be a connection between the OCD symptoms and abnormalities in certain areas of the brain, but that connection is not clear. Research is still underway. Understanding the causes will help determine specific, personalized treatments to treat OCD.

Environment

People who have experienced abuse (physical or sexual) in childhood or other trauma are at an increased risk for developing OCD.

In some cases, children may develop OCD or symptoms following a streptococcal infection—this is called Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS). For more information, please read this fact sheet on PANDAS.

What types of treatments and therapies are available?

OCD is typically treated with medication, psychotherapy or a combination of the two. Although most patients with OCD respond to treatment, some patients continue to experience symptoms.

Sometimes people with OCD also have other mental disorders, such as anxiety, depression, and body dysmorphic disorder, a disorder in which someone mistakenly believes that a part of their body is abnormal. It is important to consider these other disorders when making decisions about treatment.

Medication

Serotonin reuptake inhibitors (SRIs) and selective serotonin reuptake inhibitors (SSRIs) are used to help reduce OCD symptoms. Examples of medications that have been proven effective in both adults and children with OCD include clomipramine, which is a member of an older class of “tricyclic” antidepressants, and several newer “selective serotonin reuptake inhibitors” (SSRIs), including:

fluoxetine
fluvoxamine
sertraline

SRIs often require higher daily doses in the treatment of OCD than of depression and may take 8 to 12 weeks to start working, but some patients experience more rapid improvement.

If symptoms do not improve with these types of medications, research shows that some patients may respond well to an antipsychotic medication (such as risperidone). Although research shows that an antipsychotic medication may be helpful in managing symptoms for people who have both OCD and a tic disorder, research on the effectiveness of antipsychotics to treat OCD is mixed.

If you are prescribed a medication, be sure you:

Talk with your doctor or a pharmacist to make sure you understand the risks and benefits of the medications you're taking.
Do not stop taking a medication without talking to your doctor first. Suddenly stopping a medication may lead to "rebound" or worsening of OCD symptoms. Other uncomfortable or potentially dangerous withdrawal effects are also possible.
Report any concerns about side effects to your doctor right away. You may need a change in the dose or a different medication.
Report serious side effects to the U. S. Food and Drug Administration (FDA) MedWatch Adverse Event Reporting program online at http://www.fda.gov/Safety/MedWatch or by phone at 1-800-332-1088. You or your doctor may send a report.

Other medications have been used to treat OCD, but more research is needed to show the benefit for these options. For basic information about these medications, you can visit the National Institute of Mental Health (NIMH) Mental Health Medications web page. For the most up-to-date information on medications, side effects, and warnings, visit the FDA website.

Psychotherapy

Psychotherapy can be an effective treatment for adults and children with OCD. Research shows that certain types of psychotherapy, including cognitive behavior therapy (CBT) and other related therapies (e.g., habit reversal training) can be as effective as medication for many individuals. Research also shows that a type of CBT called Exposure and Response Prevention (EX/RP) is effective in reducing compulsive behaviors in OCD, even in people who did not respond well to SRI medication. For many patients EX/RP is the add-on treatment of choice when SRIs or SSRIs medication does not effectively treat OCD symptoms.

Other Treatment Options

NIMH is supporting research into new treatment approaches for people whose OCD does not respond well to the usual therapies. These new approaches include combination and add-on (augmentation) treatments, as well as novel techniques such as deep brain stimulation (DBS). You can learn more about brain stimulation therapies on the NIMH website.

National Institute of Mental Health (2019). Obsessive-Compulsive Disorder. Retrieved June 10, 2019, from https://www.nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd/index.shtml.

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Obsessive-Compulsive Disorder and Tic Disorders

Home Treatments for Children Child, Adolescent, and Family Behavioral Health

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Overview

Children with obsessive-compulsive disorder (OCD) and tic disorders (sometimes called Tourette’s syndrome) have symptoms that can be disruptive and embarrassing, and even interfere with daily functioning. Duke’s behavioral health team has expertise and experience in successfully treating these disorders to improve your child’s and family’s quality of life.

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When to Seek Help for OCD and Tic Disorders

Content

Obsessive Compulsive Disorder
Obsessive-compulsive disorder (OCD) is characterized by unwanted, intrusive, distressing thoughts and compulsive behaviors. These thoughts or actions may be performed to neutralize obsessions or reduce distress/anxiety. OCD behaviors can begin appearing as early as age four but most often become noticeable around age seven or eight. Common obsessions include fears of germs or contamination or obsessions related to perfectionism. Common compulsions include excessive washing or cleaning, checking behaviors, and repeating or counting.

Tic Disorders
A child with a tic disorder has a strong urge to make a movement or sound and satisfies the urge by performing the tic. Some of the most common vocal tics are grunts, whistles, and repetition of certain words. Motor tics might include repetitive movements of the face, such as blinking, opening the mouth wide, or scrunching the nose. Your child may also have twitches in the arms or legs, or experience the urge to perform a sequence of movements. Tics are typically first noticed in early childhood, and many children outgrow them.

When to Seek Help
Children may outgrow these repetitive behaviors or fearful thoughts on their own, but if they persist or create disruption in your child’s life or family life, we can help. If you are concerned about your child’s behavior, talk to your primary care doctor. They may refer you to a behavioral health specialist who can offer solutions.

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Comprehensive Evaluation

Diagnosing Tic Disorders

Description

Our team will ask about the types of repetitive behaviors your child performs, how often they are occurring, how much time they consume, and how much distress or impairment they are causing for your child or your family.

Diagnosing OCD

Description

When assessing OCD, we will ask whether your child has obsessions or compulsive behaviors and whether these obsessions and/or compulsions are time-consuming, get in the way of important activities, or cause distress for you or your child.

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Treatments

Treatments Overview

After gathering information about your child's history and your goals for treatment, we tailor a plan that’s right for your family. It may include therapy, medication, or a combination of the two.

Habit Reversal Therapy for Tics

Description

Habit reversal therapy teaches your child to recognize the feeling or signal that happens just before they perform the tic. Our providers work with your child to choose a competing response to neutralize the tic urge. The urge will go away, but it takes focus and training to change the pattern of tics. For example, if your child repeatedly flaps their elbows up and down, the competing action might be to hold their elbows at their side until the urge goes away.

Cognitive Behavioral Therapy with Exposures for OCD

Description

Cognitive behavioral therapy exposes children to what they typically avoid. For example, if a child has a hand-washing compulsion, we ask the child to touch something that triggers the urge to wash and then have them not wash. They’ll learn that the anxious feeling usually fades. This therapy in combination with medications has proven to have the greatest success.

Medication

Description

Our psychiatrists work with your family to provide evidence-based medications for your child, when appropriate. We evaluate the risks of side effects versus the benefits of a particular medication and make a decision together about the best course of action for your child. We are skilled at managing and adjusting doses that will be most effective for your child.

Stress Management

Description

Stress, lack of sleep, and hunger may all trigger and worsen tics and OCD. Know that your own stress, anger, and frustration also can increase your child’s stress. We’ll help you and your child use stress management techniques to lessen the effects of stress on your family. If life circumstances cause a flare-up in your child’s behavior, we are happy to see your child to refresh strategies for coping with these disorders.

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Why Choose Duke

Content

A Team of Specialists Dedicated to Your Child
Our team of pediatric psychiatrists, psychologists, social workers, nurse practitioners, and nurses focuses on engaging you and your child in the therapy process. We understand that seeking help can be difficult, and our goal is to provide a safe environment for your family to learn new ways to reduce and manage the symptoms of OCD and tic disorders.

Families Are Involved at Clinic and at Home
Families get involved both at our clinic and with home “assignments” to support and reinforce what your child is learning during therapy. Parents receive guidance on how best to support their child’s progress in treatment.

Tailored Treatments for Your Child
Our specialists are sensitive to the strain these illnesses can cause in children who have serious or chronic physical illnesses. If your child’s OCD or tics become worse with the added stress of a physical illness, we can tailor treatment to address these concerns.

Research-Based Treatments
We have participated in national clinical trials that have defined techniques most likely to help children and families who are struggling with these disorders.

This page was medically reviewed on 10/03/2022 by

Christian F. Mauro, PhD | Child and Family Clinical Psychologist

Obsessive Compulsive Disorder, Tics and Tourette's Syndrome: Diagnosis and Treatment

Tics and Tourette's Syndrome. Typology, diagnosis

Tics are frequent, aimless, repetitive but non-rhythmic involuntary movements (muscle or motor tics) or involuntary, abrupt, frequently repeated sounds and/or words (vocal tics). Man can suppress them only by conscious effort and only for a short time. Tourette syndrome is diagnosed when both motor (motor) and vocal tics have been present for more than a year. nine0005

It used to be that tics were a rare disorder. However, according to modern research, 10-15% of schoolchildren have transient / isolated tics that occur during periods of emotional stress. Sometimes they appear during stress, sometimes after an infection, and can last for weeks, months, but not more than a year. Often parents don't recognize vocal tics as they can take the form of blowing their nose, sniffing, sniffing, coughing. In this case, the diagnosis is often made not by a psychiatrist or neurologist, but by a pediatrician, who excludes allergies or a runny nose. nine0005

Some experts believe that the antibodies produced by the body to fight streptococcal bacteria may cause tics or make them worse. However, most researchers believe that there is no evidence for such a link.

Chronic tics last more than 18 months and occur in 1% of children. Tourette's syndrome is diagnosed even less frequently. Tourette syndrome is often confused with ADHD or oppositional defiant disorder. As a rule, the first tics appear in patients aged 6-7 years, and 80% of the first tics are blinking. As the person gets older, the tics become more complex. Blinking can develop into tics that involve other muscles in the face and body. In some complex tics, people may shout obscenities or swear words (this symptom is called coprolalia). Although coprolalia is often associated with Tourette's, at least 85% of people with Tourette's do not have it. Complex tics may appear purposeful, such as when coprorally or copying another person's movements or words, but they are not intentional. Common associated disorders in Tourette syndrome are OCD and ADHD. nine0005

Tourette syndrome is usually cured by the age of 20-30 years. But in some people, it can remain for a long time or even persist in a severe form throughout life.

Thus, there are three types of tic disorder:

Transient tic disorder: children have motor and/or vocal tics for less than one year.
Persistent tic disorder (chronic tic disorder): children have motor or vocal tics (but not both) for more than one year. nine0020
Tourette syndrome: children have both motor and vocal tics for more than one year.

Tic Treatments

Behavioral Intervention (BELT)

BELT is a type of behavioral therapy. It may help some older children control their tics. PVLT includes:

Cognitive Behavioral Techniques (e.g. reverse skill training)
Tics Education Program
Relaxation training

Opposite skill training involves teaching children new behaviors to replace tics. For example, if the tic consists of a shrug, they may be taught to extend their arms until the urge to shrug passes. The educational program may include teaching children (and their parents) to identify situations in which tics occur or worsen.

Pharmacological treatment

Strong antipsychotic drugs such as haloperidol are often used in the medical treatment of tics. Such medicines must be used with extreme caution, as they have serious side effects. When taken, they can reduce symptoms by 30-40%, but do not relieve a person of tics forever. Doctors also recommend the use of new antipsychotics (ziprasidone). With a combination of ADHD and tics, clonidine or atomoxetine + clonidine therapy is effective. Antiepileptic drugs show good efficacy even at low doses, but Prozac and sertraline can worsen symptoms. nine0005

How to distinguish tics from stereotypes in autism?

One of the common symptoms in autism is stereotypy, that is, stereotyped repetitive aimless movements / actions that a person performs involuntarily (for example, shakes his hands, rotates in place, walks from side to side, utters certain sounds or words). How are they different from ticks? First, tics are very short, with a maximum duration of a few minutes. Stereotypes in autism have a completely different duration (they develop more slowly, they can take hours). In addition, unlike compulsive movements, they serve a specific purpose - self-soothing, relaxation - and bring pleasure to a person. While tics, on the contrary, cause discomfort, are accompanied by tension and unusual sensations: tickling, goosebumps. The specialist should be able to distinguish compulsive unconscious movements in tic disorder from self-stimulation (stimming) in ASD, since stereotypical autistic behavior does not respond to the treatment that tics respond to. However, it is important to remember that a person can have both autism and tic disorder, and their two types of symptoms. In this case, the doctor must choose an individual assistance program. nine0053

Obsessive-compulsive disorder

A significant role among mental illnesses is played by syndromes (complexes of symptoms), united in the group of obsessive-compulsive disorder (OCD), which received its name from the Latin terms obsessio and compulsio.

Obsession (lat. obsessio - taxation, siege, blockade).

Compulsions (lat. compello - I force). 1. Obsessive drives, a kind of obsessive phenomena (obsessions). Characterized by irresistible attraction that arises contrary to the mind, will, feelings. Often they are unacceptable to the patient, contrary to his moral and ethical properties. Unlike impulsive drives, compulsions are not realized. These drives are recognized by the patient as wrong and painfully experienced by them, especially since their very appearance, due to its incomprehensibility, often gives rise to a feeling of fear in the patient 2. The term compulsions is also used in a broader sense to refer to any obsessions in the motor sphere, including obsessive rituals. nine0005

In domestic psychiatry, obsessive states were understood as psychopathological phenomena, characterized by the fact that phenomena of a certain content repeatedly appear in the mind of the patient, accompanied by a painful feeling of compulsion [Zinoviev PM, 193I]. For N.s. characteristic involuntary, even against the will, the emergence of obsessions with clear consciousness. Although the obsessions are alien, extraneous in relation to the patient's psyche, the patient is not able to get rid of them. They are closely related to the emotional sphere, accompanied by depressive reactions, anxiety. Being symptomatic, according to S.L. Sukhanov [1912], "parasitic", they do not affect the course of intellectual activity in general, remain alien to thinking, do not lead to a decrease in its level, although they worsen the efficiency and productivity of the patient's mental activity. Throughout the course of the disease, a critical attitude is maintained towards obsessions. N.s. conditionally divided into obsessions in the intellectual-affective (phobia) and motor (compulsions) spheres, but most often several of their types are combined in the structure of the disease of obsessions. The isolation of obsessions that are abstract, affectively indifferent, indifferent in their content, for example, arrhythmomania, is rarely justified; An analysis of the psychogenesis of a neurosis often makes it possible to see a pronounced affective (depressive) background at the basis of the obsessive account. Along with elementary obsessions, the connection of which with psychogeny is obvious, there are “cryptogenic” ones, when the cause of painful experiences is hidden [Svyadoshch L.M., 1959]. N.s. are observed mainly in individuals with a psychasthenic character. This is where apprehensions are especially characteristic. In addition, N.S. occur within the framework of neurosis-like states with sluggish schizophrenia, endogenous depressions, epilepsy, the consequences of a traumatic brain injury, somatic diseases, mainly hypochondriacal-phobic or nosophobic syndrome. Some researchers distinguish the so-called. "Neurosis of obsessive-compulsive disorders", which is characterized by the predominance of obsessive states in the clinical picture - memories that reproduce a psychogenic-traumatic situation, thoughts, fears, actions. In genesis play a role: mental trauma; conditioned reflex stimuli that have become pathogenic due to their coincidence with others that previously caused a feeling of fear; situations that have become psychogenic due to the confrontation of opposing tendencies [Svyadoshch A. M., 1982]. It should be noted that these same authors emphasize that N.s.c. occurs with various character traits, but most often in psychasthenic personalities.

Currently, almost all obsessive-compulsive disorders are united in the International Classification of Diseases under the concept of "obsessive-compulsive disorder".

OKR concepts have undergone a fundamental reassessment over the past 15 years. During this time, the clinical and epidemiological significance of OCD has been completely revised. If it was previously thought that this is a rare condition observed in a small number of people, now it is known that OCD is common and causes a high percentage of morbidity, which requires the urgent attention of psychiatrists around the world. Parallel to this, our understanding of the etiology of OCD has broadened: the vaguely formulated psychoanalytic definition of the past two decades has been replaced by a neurochemical paradigm that explores the neurotransmitter disorders that underlie OCD. And most importantly, pharmacological interventions specifically targeting serotonergic neurotransmission have revolutionized the prospects for recovery for millions of OCD patients worldwide. nine0005

The discovery that intense serotonin reuptake inhibition (SSRI) was the key to effective treatment for OCD was the first step in a revolution and spurred clinical research that showed the efficacy of such selective inhibitors.

As described in ICD-10, the main features of OCD are repetitive intrusive (obsessive) thoughts and compulsive actions (rituals).

In a broad sense, the core of OCD is the syndrome of obsession, which is a condition with a predominance in the clinical picture of feelings, thoughts, fears, memories that arise in addition to the desire of patients, but with awareness of their pain and a critical attitude towards them. Despite the understanding of the unnaturalness, illogicality of obsessions and states, patients are powerless in their attempts to overcome them. Obsessional impulses or ideas are recognized as alien to the personality, but as if coming from within. Obsessions can be the performance of rituals designed to alleviate anxiety, such as washing hands to combat "pollution" and to prevent "infection". Attempts to drive away unwelcome thoughts or urges can lead to severe internal struggle, accompanied by intense anxiety. nine0005

Obsessions in the ICD-10 are included in the group of neurotic disorders.

The prevalence of OCD in the population is quite high. According to some data, it is determined by an indicator of 1.5% (meaning "fresh" cases of diseases) or 2-3%, if episodes of exacerbations observed throughout life are taken into account. Those suffering from obsessive-compulsive disorder make up 1% of all patients receiving treatment in psychiatric institutions. It is believed that men and women are affected approximately equally. nine0005

CLINICAL PICTURE

The problem of obsessive-compulsive disorders attracted the attention of clinicians as early as the beginning of the 17th century. They were first described by Platter in 1617. In 1621 E. Barton described an obsessive fear of death. Mentions of obsessions are found in the writings of F. Pinel (1829). I. Balinsky proposed the term "obsessive ideas", which took root in Russian psychiatric literature. In 1871, Westphal coined the term "agoraphobia" to refer to the fear of being in public places. M. Legrand de Sol [1875], analyzing the features of the dynamics of OCD in the form of "insanity of doubt with delusions of touch, points to a gradually becoming more complicated clinical picture - obsessive doubts are replaced by ridiculous fears of" touch "to surrounding objects, motor rituals join, the fulfillment of which is subject to the whole life sick. However, only at the turn of the XIX-XX centuries. researchers were able to more or less clearly describe the clinical picture and give syndromic characteristics of obsessive-compulsive disorders. The onset of the disease usually occurs in adolescence and adolescence. The maximum of clinically defined manifestations of obsessive-compulsive disorder is observed in the age range of 10-25 years. nine0005

Main clinical manifestations of OCD:

Obsessional thoughts - painful, arising against the will, but recognized by the patient as their own, ideas, beliefs, images, which in a stereotyped form forcibly invade the patient's consciousness and which he tries to resist in some way. It is this combination of an inner sense of compulsive urge and efforts to resist it that characterizes obsessional symptoms, but of the two, the degree of effort exerted is the more variable. Obsessive thoughts may take the form of single words, phrases, or lines of poetry; they are usually unpleasant to the sufferer and may be obscene, blasphemous, or even shocking. nine0005

Obsessional imagery is vivid scenes, often violent or disgusting, including, for example, sexual perversion.

Obsessional impulses are urges to do things that are usually destructive, dangerous or shameful; for example, jumping into the road in front of a moving car, injuring a child, or shouting obscene words while in society.

Obsessional rituals include both mental activities (eg, counting in a particular way, or repeating certain words) and repetitive but meaningless acts (eg, washing hands twenty or more times a day). Some of them have an understandable connection with the obsessive thoughts that preceded them, for example, repeated washing of hands - with thoughts of infection. Other rituals (for example, regularly laying out clothes in some complex system before putting them on) do not have such a connection. Some patients feel an irresistible urge to repeat such actions a certain number of times; if that fails, they are forced to start all over again. Patients are invariably aware that their rituals are illogical and usually try to hide them. Some fear that such symptoms are a sign of the onset of insanity. Both obsessive thoughts and rituals inevitably lead to problems in daily activities. nine0005

Obsessive rumination (“mental chewing gum”) is an internal debate in which arguments for and against even the simplest everyday actions are endlessly reconsidered. Some obsessive doubts relate to actions that may have been incorrectly performed or not completed, such as turning off the gas stove faucet or locking the door; others concern actions that could harm other people (for example, the possibility of driving past a cyclist in a car, knocking him down). Sometimes doubts are associated with a possible violation of religious prescriptions and rituals - “remorse of conscience”. nine0005

Compulsive actions - repetitive stereotypical actions, sometimes acquiring the character of protective rituals. The latter are aimed at preventing any objectively unlikely events that are dangerous for the patient or his relatives.

In addition to the above, in a number of obsessive-compulsive disorders, a number of well-defined symptom complexes stand out, and among them are obsessive doubts, contrasting obsessions, obsessive fears - phobias (from the Greek phobos).

nine0004 Obsessive thoughts and compulsive rituals may intensify in certain situations; for example, obsessive thoughts about harming other people often become more persistent in the kitchen or some other place where knives are kept.

Since patients often avoid such situations, there may be a superficial resemblance to the characteristic avoidance pattern found in phobic anxiety disorder. Anxiety is an important component of obsessive-compulsive disorders. Some rituals reduce anxiety, while after others it increases. Obsessions often develop as part of depression. In some patients, this appears to be a psychologically understandable reaction to obsessive-compulsive symptoms, but in other patients, recurrent episodes of depressive mood occur independently. nine0005

Obsessions (obsessions) are divided into figurative, or sensual, accompanied by the development of affect (often painful) and obsession of affectively neutral content.

Sensual obsessions include obsessive doubts, memories, ideas, drives, actions, fears, an obsessive feeling of antipathy, an obsessive fear of habitual actions.

Obsessive doubts - persistently arising contrary to logic and reason, uncertainty about the correctness of the actions being performed and committed. The content of doubts is different: obsessive everyday fears (whether the door is locked, whether windows or water taps are closed tightly enough, whether gas and electricity are turned off), doubts related to official activities (whether this or that document is written correctly, whether the addresses on business papers are mixed up , whether inaccurate figures are indicated, whether orders are correctly formulated or executed), etc. Despite repeated verification of the committed action, doubts, as a rule, do not disappear, causing psychological discomfort in the person suffering from this kind of obsession. nine0005

Obsessive memories include persistent, irresistible painful memories of any sad, unpleasant or shameful events for the patient, accompanied by a feeling of shame, remorse. They dominate the mind of the patient, despite the efforts and efforts not to think about them.

Obsessive inclinations - urges to commit one or another tough or extremely dangerous action, accompanied by a feeling of horror, fear, confusion with the inability to get rid of it. The patient is seized, for example, by the desire to throw himself under a passing train or push a loved one under it, to kill his wife or child in an extremely cruel way. At the same time, patients are painfully afraid that this or that action will be implemented. nine0005

Manifestations of obsessive ideas can be different. In some cases, this is a vivid "vision" of the results of obsessive drives, when patients imagine the result of a cruel act committed. In other cases, obsessive ideas, often referred to as mastering, appear in the form of implausible, sometimes absurd situations that patients take for real. An example of obsessive ideas is the patient's conviction that the buried relative was alive, and the patient painfully imagines and experiences the suffering of the deceased in the grave. At the height of obsessive ideas, the consciousness of their absurdity, implausibility disappears and, on the contrary, confidence in their reality appears. As a result, obsessions acquire the character of overvalued formations (dominant ideas that do not correspond to their true meaning), and sometimes delusions. nine0005

An obsessive feeling of antipathy (as well as obsessive blasphemous and blasphemous thoughts) - unjustified, driven away by the patient from himself antipathy towards a certain, often close person, cynical, unworthy thoughts and ideas in relation to respected people, in religious persons - in relation to saints or ministers churches.

Obsessive actions - actions performed against the wishes of patients, despite the efforts made to restrain them. Some of the obsessive actions burden the patients until they are realized, others are not noticed by the patients themselves. Obsessive actions are painful for patients, especially in those cases when they become the object of attention of others. nine0005

Obsessive fears, or phobias, include an obsessive and senseless fear of heights, large streets, open or confined spaces, large crowds of people, the fear of sudden death, the fear of falling ill with one or another incurable disease. Some patients may develop a wide variety of phobias, sometimes acquiring the character of fear of everything (panphobia). And finally, an obsessive fear of the emergence of fears (phobophobia) is possible.

Hypochondriacal phobias (nosophobia) - an obsessive fear of some serious illness. Most often, cardio-, stroke-, syphilo- and AIDS phobias are observed, as well as the fear of the development of malignant tumors. At the peak of anxiety, patients sometimes lose their critical attitude to their condition - they turn to doctors of the appropriate profile, require examination and treatment. The implementation of hypochondriacal phobias occurs both in connection with psycho- and somatogenic (general non-mental illnesses) provocations, and spontaneously. As a rule, hypochondriacal neurosis develops as a result, accompanied by frequent visits to doctors and unreasonable medication. nine0005

Specific (isolated) phobias - obsessive fears limited to a strictly defined situation - fear of heights, nausea, thunderstorms, pets, treatment at the dentist, etc. Since contact with situations that cause fear is accompanied by intense anxiety, the patients tend to avoid them.

Obsessive fears are often accompanied by the development of rituals - actions that have the meaning of "magic" spells that are performed, despite the critical attitude of the patient to obsession, in order to protect against one or another imaginary misfortune: before starting any important business, the patient must perform some that specific action to eliminate the possibility of failure. Rituals can, for example, be expressed in snapping fingers, playing a melody to the patient or repeating certain phrases, etc. In these cases, even relatives are not aware of the existence of such disorders. Rituals, combined with obsessions, are a fairly stable system that usually exists for many years and even decades. nine0005

Obsessions of affective-neutral content - obsessive sophistication, obsessive counting, recalling neutral events, terms, formulations, etc. Despite their neutral content, they burden the patient, interfere with his intellectual activity.

Contrasting obsessions ("aggressive obsessions") - blasphemous, blasphemous thoughts, fear of harming oneself and others. Psychopathological formations of this group refer mainly to figurative obsessions with pronounced affective saturation and ideas that take possession of the consciousness of patients. They are distinguished by a sense of alienation, the absolute lack of motivation of the content, as well as a close combination with obsessive drives and actions. Patients with contrasting obsessions and complain of an irresistible desire to add endings to the replicas they have just heard, giving an unpleasant or threatening meaning to what has been said, to repeat after those around them, but with a touch of irony or malice, phrases of religious content, to shout out cynical words that contradict their own attitudes and generally accepted morality. , they may experience fear of losing control of themselves and possibly committing dangerous or ridiculous actions, injuring themselves or their loved ones. In the latter cases, obsessions are often combined with object phobias (fear of sharp objects - knives, forks, axes, etc. ). The contrast group also partially includes obsessions of sexual content (obsessions of the type of forbidden ideas about perverted sexual acts, the objects of which are children, representatives of the same sex, animals). nine0005

Obsessions of pollution (mysophobia). This group of obsessions includes both the fear of pollution (earth, dust, urine, feces and other impurities), as well as the fear of penetration into the body of harmful and toxic substances (cement, fertilizers, toxic waste), small objects (glass fragments, needles, specific types of dust), microorganisms. In some cases, the fear of contamination can be limited, remain at the preclinical level for many years, manifesting itself only in some features of personal hygiene (frequent change of linen, repeated washing of hands) or in housekeeping (thorough handling of food, daily washing of floors). , "taboo" on pets). This kind of monophobia does not significantly affect the quality of life and is evaluated by others as habits (exaggerated cleanliness, excessive disgust). Clinically manifested variants of mysophobia belong to the group of severe obsessions. In these cases, gradually becoming more complex protective rituals come to the fore: avoiding sources of pollution and touching "unclean" objects, processing things that could get dirty, a certain sequence in the use of detergents and towels, which allows you to maintain "sterility" in the bathroom. Stay outside the apartment is also furnished with a series of protective measures: going out into the street in special clothing that covers the body as much as possible, special processing of wearable items upon returning home. In the later stages of the disease, patients, avoiding pollution, not only do not go out, but do not even leave their own room. In order to avoid contacts and contacts that are dangerous in terms of contamination, patients do not allow even their closest relatives to come near them. Mysophobia is also related to the fear of contracting a disease, which does not belong to the categories of hypochondriacal phobias, since it is not determined by fears that a person suffering from OCD has a particular disease. In the foreground is the fear of a threat from the outside: the fear of pathogenic bacteria entering the body. Hence the development of appropriate protective actions. nine0005

A special place in the series of obsessions is occupied by obsessive actions in the form of isolated, monosymptomatic movement disorders. Among them, especially in childhood, tics predominate, which, unlike organically conditioned involuntary movements, are much more complex motor acts that have lost their original meaning. Tics sometimes give the impression of exaggerated physiological movements. This is a kind of caricature of certain motor acts, natural gestures. Patients suffering from tics can shake their heads (as if checking whether the hat fits well), make hand movements (as if discarding interfering hair), blink their eyes (as if getting rid of a mote). Along with obsessive tics, pathological habitual actions (lip biting, gnashing of teeth, spitting, etc.) are often observed, which differ from obsessive actions proper in the absence of a subjectively painful sense of persistence and experience them as alien, painful. Neurotic states characterized only by obsessive tics usually have a favorable prognosis. Appearing most often in preschool and primary school age, tics usually subside by the end of puberty. However, such disorders can also be more persistent, persist for many years and only partially change in manifestations. nine0005

The course of obsessive-compulsive disorder.

Unfortunately, chronization must be indicated as the most characteristic trend in the OCD dynamics. Cases of episodic manifestations of the disease and complete recovery are relatively rare. However, in many patients, especially with the development and preservation of one type of manifestation (agoraphobia, obsessive counting, ritual handwashing, etc.), a long-term stabilization of the condition is possible. In these cases, there is a gradual (usually in the second half of life) mitigation of psychopathological symptoms and social readaptation. For example, patients who experienced fear of traveling on certain types of transport, or public speaking, cease to feel flawed and work along with healthy people. In mild forms of OCD, the disease usually proceeds favorably (on an outpatient basis). The reverse development of symptoms occurs after 1 year - 5 years from the moment of manifestation. nine0005

More severe and complex OCDs, such as phobias of infection, pollution, sharp objects, contrasting performances, multiple rituals, on the other hand, may become persistent, resistant to treatment, or show a tendency to recur with disorders that persist despite active therapy. Further negative dynamics of these conditions indicates a gradual complication of the clinical picture of the disease as a whole.

DIFFERENTIAL DIAGNOSIS

It is important to distinguish OCD from other disorders that involve compulsions and rituals. In some cases, obsessive-compulsive disorder must be differentiated from schizophrenia, especially when the obsessive thoughts are unusual in content (eg, mixed sexual and blasphemous themes) or the rituals are exceptionally eccentric. The development of a sluggish schizophrenic process cannot be ruled out with the growth of ritual formations, their persistence, the emergence of antagonistic tendencies in mental activity (inconsistency of thinking and actions), and the uniformity of emotional manifestations. Prolonged obsessional states of a complex structure must be distinguished from the manifestations of paroxysmal schizophrenia. Unlike neurotic obsessive states, they are usually accompanied by a sharply increasing anxiety, a significant expansion and systematization of the circle of obsessive associations, which acquire the character of obsessions of "special significance": previously indifferent objects, events, random remarks of others remind patients of the content of phobias, offensive thoughts and thereby acquire in their view a special, menacing significance. In such cases, it is necessary to consult a psychiatrist in order to exclude schizophrenia. It can also be difficult to differentiate between OCD and conditions with a predominance of generalized disorders, known as Gilles de la Tourette's syndrome. Tics in such cases are localized in the face, neck, upper and lower extremities and are accompanied by grimaces, opening the mouth, sticking out the tongue, and intense gesticulation. In these cases, this syndrome can be excluded by the coarseness of movement disorders characteristic of it and more complex in structure and more severe mental disorders. nine0005

Genetic factors

Speaking about hereditary predisposition to OCD, it should be noted that obsessive-compulsive disorders are found in approximately 5-7% of parents of patients with such disorders. Although this figure is low, it is higher than in the general population. While evidence for a hereditary predisposition to OCD is still uncertain, psychasthenic personality traits can be largely explained by genetic factors.

FORECAST

Approximately two-thirds of OCD patients improve within a year, more often by the end of this period. If the disease lasts more than a year, fluctuations are observed during its course - periods of exacerbations are interspersed with periods of improvement in health, lasting from several months to several years. The prognosis is worse if we are talking about a psychasthenic personality with severe symptoms of the disease, or if there are continuous stressful events in the patient's life. Severe cases can be extremely persistent; for example, a study of hospitalized patients with OCD found that three-quarters of them remained symptom-free 13 to 20 years later. nine0005

TREATMENT: BASIC METHODS AND APPROACHES

Despite the fact that OCD is a complex group of symptom complexes, the principles of treatment for them are the same. The most reliable and effective method of treating OCD is considered to be drug therapy, during which a strictly individual approach to each patient should be manifested, taking into account the characteristics of the manifestation of OCD, age, gender, and the presence of other diseases. In this regard, we must warn patients and their relatives against self-treatment. If any disorders similar to mental ones appear, it is necessary, first of all, to contact the specialists of the psycho-neurological dispensary at the place of residence or other psychiatric medical institutions to establish the correct diagnosis and prescribe competent adequate treatment. At the same time, it should be remembered that at present a visit to a psychiatrist does not threaten with any negative consequences - the infamous "accounting" was canceled more than 10 years ago and replaced by the concepts of consultative and medical care and dispensary observation. nine0005

When treating, it must be borne in mind that obsessive-compulsive disorders often have a fluctuating course with long periods of remission (improvement). The apparent suffering of the patient often seems to call for vigorous effective treatment, but the natural course of the condition must be kept in mind in order to avoid the typical error of over-intensive therapy. It is also important to consider that OCD is often accompanied by depression, the effective treatment of which often leads to an alleviation of obsessional symptoms. nine0005

Treatment of OCD begins with an explanation to the patient of the symptoms and, if necessary, with reassurance that they are the initial manifestation of insanity (a common concern for patients with obsessions). Those suffering from certain obsessions often involve other family members in their rituals, so relatives need to treat the patient firmly, but sympathetically, mitigating the symptoms as much as possible, and not aggravating it by excessive indulgence in the morbid fantasies of the patients. nine0005

Drug therapy

The following therapeutic approaches exist for the currently identified types of OCD. Of the pharmacological drugs for OCD, serotonergic antidepressants, anxiolytics (mainly benzodiazepine), beta-blockers (to stop autonomic manifestations), MAO inhibitors (reversible) and triazole benzodiazepines (alprazolam) are most often used. Anxiolytic drugs provide some short-term relief of symptoms, but should not be given for more than a few weeks at a time. If anxiolytic treatment is required for more than one to two months, small doses of tricyclic antidepressants or small antipsychotics sometimes help. The main link in the treatment regimen for OCD, overlapping with negative symptoms or ritualized obsessions, are atypical antipsychotics - risperidone, olanzapine, quetiapine, in combination with either SSRI antidepressants or other antidepressants - moclobemide, tianeptine, or with high-potency benzodiazepine derivatives ( alprazolam, clonazepam, bromazepam). nine0005

Any comorbid depressive disorder is treated with antidepressants at an adequate dose. There is evidence that one of the tricyclic antidepressants, clomipramine, has a specific effect on obsessive symptoms, but the results of a controlled clinical trial showed that the effect of this drug is insignificant and occurs only in patients with distinct depressive symptoms.

In cases where obsessive-phobic symptoms are observed within the framework of schizophrenia, intensive psychopharmacotherapy with proportional use of high doses of serotonergic antidepressants (fluoxetine, fluvoxamine, sertraline, paroxetine, citalopram) has the greatest effect. In some cases, it is advisable to connect traditional antipsychotics (small doses of haloperidol, trifluoperazine, fluanxol) and parenteral administration of benzodiazepine derivatives. nine0005

Psychotherapy

Behavioral psychotherapy

One of the main tasks of the specialist in the treatment of OCD is to establish fruitful cooperation with the patient. It is necessary to instill in the patient faith in the possibility of recovery, to overcome his prejudice against the "harm" caused by psychotropic drugs, to convey his conviction in the effectiveness of treatment, subject to the systematic observance of the prescribed prescriptions. The patient's faith in the possibility of healing must be supported in every possible way by the relatives of the OCD sufferer. If the patient has rituals, it must be remembered that improvement usually occurs when using a combination of the method of preventing a reaction with placing the patient in conditions that aggravate these rituals. Significant but not complete improvement can be expected in about two-thirds of patients with moderately heavy rituals. If, as a result of such treatment, the severity of rituals decreases, then, as a rule, the accompanying obsessive thoughts also recede. In panphobia, predominantly behavioral techniques are used to reduce sensitivity to phobic stimuli, supplemented by elements of emotionally supportive psychotherapy. In cases where ritualized phobias predominate, along with desensitization, behavioral training is actively used to help overcome avoidant behavior. Behavioral therapy is significantly less effective for obsessive thoughts that are not accompanied by rituals. Thought-stopping has been used by some experts for many years, but its specific effect has not been convincingly proven. nine0005

Social rehabilitation

We have already noted that obsessive-compulsive disorder has a fluctuating (fluctuating) course and over time the patient's condition may improve regardless of which particular methods of treatment were used. Until recovery, patients can benefit from supportive conversations that provide continued hope for recovery. Psychotherapy in the complex of treatment and rehabilitation measures for patients with OCD is aimed at both correcting avoidant behavior and reducing sensitivity to phobic situations (behavioral therapy), as well as family psychotherapy to correct behavioral disorders and improve family relationships. If marital problems aggravate the symptoms, joint interviews with the spouse are indicated. Patients with panphobia (at the stage of the active course of the disease), due to the intensity and pathological persistence of symptoms, need both medical and social and labor rehabilitation. In this regard, it is important to determine adequate terms of treatment - long-term (at least 2 months) therapy in a hospital with subsequent continuation of the course on an outpatient basis, as well as taking measures to restore social ties, professional skills, family relationships. Social rehabilitation is a set of programs for teaching OCD patients how to behave rationally both at home and in a hospital setting. Rehabilitation is aimed at teaching social skills to properly interact with other people, vocational training, as well as skills necessary in everyday life. Psychotherapy helps patients, especially those who experience a sense of their own inferiority, treat themselves better and correctly, master ways to solve everyday problems, and gain confidence in their strength.

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