[Paleopsych] SW: On Obsessive-Compulsive Disorder

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Medical Biology: On Obsessive-Compulsive Disorder

    The following points are made by Michael A. Jenike (New Engl. J. Med.
    2004 350:259):
    1) Consider the following case: A 33-year-old woman has a seven-year
    history of hand washing for two to six hours a day, as well as urges
    to check doors and stoves extensively before leaving her home. Her
    life is restricted, and her family members are upset about her
    2) The above description is that of a typical patient with an anxiety
    disorder called "obsessive-compulsive disorder" (OCD), which affects 2
    to 3 percent of the world's population.(1) The patient has a general
    sense that something terrible may occur if a particular ritual is not
    performed, and the failure to perform a ritual may lead immediately to
    severe anxiety or a very uncomfortable, nagging feeling of
    incompleteness. In addition to checking and washing rituals, patients
    with OCD often present with persistent intrusive thoughts, extreme
    slowness or thoroughness, or doubts that lead to reassurance-seeking
    rituals. Patients with OCD commonly seek care from physicians other
    than psychiatrists. For example, in one study, 20 percent of patients
    who visited a dermatology clinic had OCD, which had been previously
    diagnosed in only 3 percent.(2)
    3) The mean age at the onset of OCD ranges from 22 to 36 years, with
    the disorder developing in only 15 percent of patients older than 35
    years.(3) Men tend to have an earlier age at onset than women, but
    women eventually catch up, and roughly 50 percent of adults with OCD
    are women.(3) OCD is typically a chronic disorder with a waxing and
    waning course.(3) With effective treatment, the severity of symptoms
    can be reduced, but typically some symptoms remain.(3) On average,
    people with OCD see three to four doctors and spend more than nine
    years seeking treatment before they receive a correct diagnosis. It
    takes an average of 17 years from the onset of OCD to obtain
    appropriate treatment.
    4) OCD tends to be underdiagnosed and undertreated. Patients may be
    secretive or lack insight about their illness. Many health care
    providers are not familiar with the symptoms or are not trained in
    providing treatment. Some people may not have access to treatment, and
    sometimes insurance plans do not cover behavioral therapy, although
    the situation is improving. This lack of access or coverage is
    unfortunate, since earlier diagnosis and proper treatment can help
    patients to avoid the suffering associated with OCD and lessen the
    risks of related problems, such as depression, marital difficulties,
    and problems related to employment.(4)
    5) OCD may have a genetic basis.(5) Concordance for OCD is greater
    among pairs of monozygotic twins (80 to 87 percent) than among pairs
    of dizygotic twins (47 to 50 percent). The prevalence of OCD is
    increased among the first-degree relatives of patients with OCD, as
    compared with the relatives of control subjects, and the age at onset
    in the proband (the patient, the index case) is inversely related to
    the risk of OCD among the relatives.(5) There is evidence of a
    dominant or codominant mode of transmission of OCD.
    6) In rare cases, a brain insult such as encephalitis, a streptococcal
    infection (in children), striatal lesions (congenital or acquired), or
    head injury directly precedes the development of OCD. There is some
    evidence of a neurologic basis for OCD. For example, patients with OCD
    have significantly more gray matter and less white matter than normal
    controls, suggesting a possible developmental abnormality.
    Neuroimaging studies have documented consistent differences in
    regional brain activity between patients with OCD and control
    subjects, and the abnormal activity in patients with OCD shifts toward
    normal after either successful treatment with serotonin-reuptake
    inhibitors or effective behavioral therapy.
    References (abridged):
    1. Diagnostic and statistical manual of mental disorders, 4th ed.:
    DSM-IV. Washington, D.C.: American Psychiatric Association, 1994
    2. Fineberg NA, O'Doherty C, Rajagopal S, Reddy K, Banks A, Gale TM.
    How common is obsessive-compulsive disorder in a dermatology
    outpatient clinic? J Clin Psychiatry 2003;64:152-155
    3. Maj M, Sartorius N, Okasha A, Zohar J, eds. Obsessive-compulsive
    disorder. 2nd ed. Chichester, England: John Wiley, 2002
    4. The Expert Consensus Panel for Obsessive-Compulsive Disorder.
    Treatment of obsessive-compulsive disorder. J Clin Psychiatry
    1997;58:Suppl 4:2-72
    5. Pauls DL, Alsobrook JP II, Goodman W, Rasmussen S, Leckman JF. A
    family study of obsessive-compulsive disorder. Am J Psychiatry
    New Engl. J. Med. http://www.nejm.org

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