Obsessive-compulsive disorder (OCD) is an illness that affects thoughts and actions but is believed to be rooted in a chemical imbalance of the brain. OCD is classified as an anxiety disorder. This puzzling illness is characterized by recurrent and disturbing thoughts (called obsessions) and/or repetitive, ritualized behaviors that the person feels driven to perform (called compulsions). Obsessions can also take the form of intrusive images or unwanted impulses.

Common types of obsessions include concerns with contamination (e.g., fear of dirt germs, or illness), safety/harm (e.g., being responsible for a fire), unwanted acts of aggression (e.g., unwanted impulse to harm a loved one), unacceptable sexual or religious thoughts (e.g., sacrilegious images of Christ), and the need for symmetry or exactness.

Common compulsions include excessive cleaning (e.g., ritualized hand washing), checking, ordering and arranging rituals, counting, repeating routine activities (e.g., going in/out of a doorway), and hoarding (e.g., collecting useless items). While most compulsions are observable behaviors (e.g., hand washing), some are performed as unobservable mental rituals (e.g., silent recitation of nonsense words to vanquish a horrific image

The majority of patients have both obsessions and compulsions, but a minority have obsessions alone (about 20%) or compulsions alone (about 10%). The person with OCD usually tries to actively dismiss the obsessions or neutralize them by engaging in compulsions or avoiding situations that trigger the obsessions. In most cases, compulsions serve to alleviate anxiety. However, it is not uncommon for the compulsions themselves to engender anxiety, especially when they become very demanding.

A hallmark of OCD is that the person recognizes that his/her thoughts or behaviors are senseless or excessive. However, the drive can be so powerful that the person caves in to the compulsion even though he/she knows it makes no sense. One woman spent hours each evening sifting through the household trash to ensure that nothing valuable was being discarded. When asked what she was looking for, she chuckled and said, "I have no idea, I don't own anything valuable." Some people who have had OCD for a long time may stop resisting their compulsive drives because they feel it's just easier to give in to them. Most OCD sufferers have multiple types of obsessions and compulsions.

Course of OCD

OCD can be relentless. If untreated,  OCD is usually chronic and follows a waxing a waning course. That is, symptoms may get somewhat better for months or even years, only to get worse again before returning to a lower level of severity. Only about 5% - 10 % of OCD sufferers enjoy a spontaneous remission in which all symptoms of OCD go away for good. Another 5% - 10% experience progressive deterioration in their symptoms. Stress can make OCD worse, but trying to eliminate all stress is unlikely to quell OCD. In fact, it is better for most people with OCD to keep busy. Idleness can be the breeding ground for increased obsessional thinking. Changes in the severity of OCD may be related to fluctuations in the body's internal chemical environment. Women with OCD often report that their symptoms become more severe during the week before their menstrual period. Presumably, this is related to the natural ebb and flow of hormones that regulate the menstrual cycle. Diet has not been shown to influence OCD.

In the majority of cases, the onset of OCD is not associated with an apparent external precipitant. On the other hand, recent research suggests that some cases of OCD in childhood may be preceded by an upper respiratory infection with Group A Beta-hemolytic streptococcus or commonly known as "Strep Throat." In some cases, OCD first appears after childbirth, a condition called post-partum OCD.

Treatment

OCD is a type of anxiety disorder, the most common of all the mental disorders. Many people misunderstand these disorders and think people should be able to overcome the symptoms by sheer willpower. But, the symptoms can't be willed or wished away. There are treatments, developed through research, that work well for these disorders.

Anxiety disorders are treated in two ways - with medication and with therapy. Sometimes only one treatment is used or both treatments are combined. If you have an anxiety disorder, talk with your doctor about what will work best for you.

A number of drugs used for treating depression, called antidepressants, have been found to help with anxiety disorders as well. Monoamine oxidase inhibitors (MAOIs) are used, along with the newer selective serotonin reuptake inhibitors (SSRIs). Other medicines include anti-anxiety drugs called benzodiazepines and beta-blockers.

Treatment with therapy includes cognitive-behavioral therapy (CBT) and behavioral therapy. In CBT, the goal is to change how a person thinks about, and then reacts to, a situation that makes them anxious or fearful. In behavioral therapy, the focus is on changing how a person reacts to a situation. CBT or behavioral therapy most often lasts for 12 weeks. It can be group or individual therapy. A special type of behavior therapy, called exposure and response prevention, is often used with OCD.

Gammaknife  Radiosurgery

Obsessive-compulsive disorder is a common mental disorder, notorious for its chronicity and intractability.  While SRIs or CBT alone are often effective in the treatment of OCD, many patients have an inadequate or partial response.  Stereotactic lesions within the anterior limb of the internal capsule have been shown to provide symptomatic relief in such refractory cases.  

To be considered treatment-resistant, the OCD needs to have been unsuccessfully treated with pharmaceutical agents e.g. at least two SRIs. Treatment-resistant OCD is typically defined as having failed adequate trials of a selective SRI (SSRI), e.g., fluoxetine, a trial of the SRI clomipramine, and CBT.   Up to 5% of the total population with OCD seeking care has severe, treatment-resistant illness. These patients, who experience tremendous suffering and functional impairment, have few treatment alternatives. New innovative approaches to treatment are needed for these severely ill patients.

Options for the treatment of severely refractory OCD include Stereotactic neurosurgical procedures. Stereotactic procedures are precise methods used to lesion or remove brain tissues utilizing a three-dimensional coordinate plane for location and identification.

The Gamma KnifeŽ Anterior Capsulotomy allows noninvasive cerebral surgery to be performed in one session and with extreme precision, sparing tissues adjacent to the target. The lesions in the brain are formed by concentrating cross-fired gamma irradiated beams at the target in the anterior limb of the internal capsule.

Gamma KnifeŽ surgery represents a major advance in brain surgery, and in the last two decades has changed the landscape within the field of neurosurgery. Its development has enhanced neurosurgical treatments offered to patients with OCD by providing a safe, accurate and reliable treatment option. Gamma KnifeŽ enables patients to undergo a non-invasive form of brain surgery without surgical risks, a long hospital stay or subsequent rehabilitation.

Gamma KnifeŽ surgery is unique in that no surgical incision is made to expose the inside of the brain, thereby reducing the risk of surgical complications and eliminating the side effects and dangers of general anesthesia. The "blades" of the Gamma KnifeŽ are the beams of gamma radiation programmed to target the lesion at the point where they intersect. In a single treatment session, 201 beams of gamma radiation focus precisely on the lesion. The exposure is brief and only the tissue being treated receives a significant radiation dose, while the surrounding tissue remains unharmed. With the Gamma KnifeŽ, a surgical incision is not required; the attendant risks of open neurosurgical procedures (hemorrhage, infection, cerebrospinal fluid leakage, etc.) are therefore avoided. Patients experience little discomfort. The absence of an incision eliminates the risk of hemorrhage and infection. Hospitalization is short, typically an overnight stay or an outpatient surgical procedure. Patients can immediately resume their previous activities.

Patients with OCD benefit from lesions comprising the anterior limb of the internal capsules. The effect was attributed to the potential interruption of pathways interconnecting the frontal lobe and the thalamus .Postoperative magnetic resonance imaging (MRI) verification and lesion identification is essential for the further analysis and treatment optimization and can eventually provide insights into the mechanisms involved.

 

OCD cannot be prevented. However, early diagnosis and treatment can help reduce the time a person spends suffering from the condition.