Obsessive-compulsive disorder

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Classification according to ICD-10
F42 Obsessive-compulsive disorder
F42.0 predominantly obsessive-compulsive thoughts or compulsion to brood
F42.1 predominantly compulsive acts (compulsive rituals)
F42.2 Obsessive thoughts and actions, mixed
ICD-10 online (WHO version 2019)

The OCD or obsessive-compulsive disorder ( English obsessive-compulsive disorder or OCD ) is a mental disorder .

Sick people have an inner compulsion or urge to think or do certain things. Those affected usually defend themselves against this urge and experience it as exaggerated and senseless, but usually cannot deliberately counter it. The disorder brings significant burdens and impairments to everyday life.

Older names for obsessive-compulsive disorder are obsessive-compulsive disorder and anankastic neurosis . Obsessive-compulsive disorder must be distinguished from obsessive-compulsive personality disorder and from obsessive-compulsive symptoms in the context of other mental or neurological diseases.

Symptoms

The main symptoms of obsessive-compulsive disorder which are decisive for the diagnostic classification according to the ICD-10 are obsessive-compulsive thoughts or compulsive actions . Both symptoms are found in more than 90% of those affected. The wide range of possible symptoms is also typical, so that almost every person affected has their own individual symptom profile.

Obsessive thoughts

Obsessive thoughts are content- related thought disorders in the sense of obsessively pushing themselves over and over again, but thought content recognized as nonsensical. Some people also suffer from formal thought disorders, especially perseveration , circles of thought, restricted thinking or lack of thoughts . In severe cases, over-valued ideas also occur. As a rule, obsessions trigger defense rituals on a behavioral or cognitive level. Rarely occurring obsessive-compulsive thoughts without a backlash are also occasionally referred to in the Anglo-American region with the term "Pure-O" (English "pure obsessive").

Obsessive-compulsive thoughts can be divided into:

  • Obsessive ideas and fears (e.g., fear of not doing a job right, or fears that something bad might happen to the spouse)
  • Aggressive obsessions (fear of harming someone, doing sexually reprehensible things, offending someone, etc.)
  • Compulsion to brood (certain issues have to be thought over and over again. It is not possible to come to a decision or a solution)
  • Doubt (uncertainty, not having completed actions satisfactorily, misunderstanding, doing or failing to do something)
  • Compulsory counting ( arithmomania ) (certain things that appear in everyday life are counted)
  • Repetitions (certain thoughts must be ritualized and repeated)
  • Compulsions to deal with (with compulsive parts of the personality structure )

Obsessive-compulsive thoughts are therefore often about fearful thoughts and beliefs, harming yourself or another person (e.g. through contamination, through aggressive actions or through so-called "magical acts"), getting into an embarrassing situation, or by omitting to be indirectly responsible for a disaster or misfortune from actions or through one's own actions. Thoughts cannot be completed satisfactorily, so that they constantly impose themselves and have to be repeated without arriving at a real result.

Those affected often suffer from agonizing doubts. In 1838, Jean Esquirol gave obsessive-compulsive disorder the nickname "Maladie du doute" (English: "Disease of doubt"). In the German-speaking world, on the other hand, the term “obsession” coined by the Viennese psychiatrist Richard von Krafft-Ebing prevailed. Clinical experience also shows that people with obsessive-compulsive disorder overestimate the probability of negative events occurring. Frequently, those affected also show hypervigilance .

In a study by Salman Akhtar (1975), subjects were asked about obsessive-compulsive thoughts. The most frequently mentioned were:

  1. Dirt or contamination (human or animal excrement, dirt, dust, semen, menstrual blood, germs, infections)
  2. Violence and aggression (physical or verbal attack on yourself or others; accidents, misfortunes, war, disasters, death)
  3. Order (orderliness, striving for symmetry in the alignment of objects, etc.)
  4. Religion (existence of God, religious practices and rituals, beliefs, moral attitudes) or magic
  5. Sexuality (sexual acts in themselves or others, incestuous impulses, sexual performance)

Even if these are the most frequently mentioned contents of obsessive-compulsive thoughts, every topic is suitable as an obsessive-compulsive thought. The distinction between obsessive thoughts and normal thoughts therefore does not depend on the content of the thought, but on the way in which one thinks and how the thought is experienced by the person concerned.

Obsessive-compulsive thoughts can (as one example of many conceivable variants) be expressed in the case of aggressive obsessive-compulsive thoughts, in that a mother fears that she wants to poison her husband and children, or that a daughter fears that her mother will be thrown down the stairs.

The documentary How I learned to love numbers explains the phenomenon of obsessive-compulsive thoughts clearly from the perspective of a person concerned.

Compulsions

“Actions taken compulsively against or without the will. Trying to refrain from taking action creates massive internal tension and fear. ”Compulsive actions are stereotypes that have to be repeated over and over again. Most people know that their behavior is excessive and unreasonable and try to resist at first, but give up when fear overwhelms them. After that, they usually feel less anxious for a short period of time. Apart from this tension reduction, those affected do not feel any joy in performing the action themselves.

Some people develop the compulsive act into an obsessional ritual: The compulsive act is carried out in a way that is worked out in detail. Those affected have to go through the ritual every time in exactly the same way, according to certain rules that must be carefully observed. Failure to complete the act creates further fear and the ritual often has to be repeated from the beginning.

Examples:

  • Compulsory cleanliness : the compulsion to z. B. to constantly wash your hands
  • Control obligation: constant checking of hotplates, door locks, gas taps, ashtrays, important papers etc.
  • Compulsory order : the compulsion to always create symmetry, perfect order or a balance by precisely arranging things such as books, clothes or food according to precise rules
  • Forced to touch : the compulsion to touch certain things or not to touch them, for example to touch every street lamp
  • Verbal compulsions : expressions, sentences or melodies are repeated over and over again

diagnosis

According to ICD-10 and DSM-5

According to ICD-10 (code F42), the following conditions should be met for a diagnosis:

  1. The obsessive-compulsive thoughts or impulses to act must be recognized by the patient as his own.
  2. The patient still has to resist at least one obsessive thought or an obsession.
  3. The obsession or obsession must not be pleasurable in and of itself.
  4. The obsessive-compulsive symptoms must repeat themselves in a deeply uncomfortable manner.
  5. The symptoms must persist for at least 14 days on most days.

The American diagnostic system (the DSM ) differentiates between several levels, depending on the degree of insight into the obsessional problem. The currently valid 5th edition lists the disorder for the first time in a separate chapter under the extended generic term “Obsessive-compulsive disorder and related disorders”. Among the related disorders of activity are " body dysmorphic disorder ", " Compulsive hoarding ", " trichotillomania ", " Dermatillomanie " and similar disorders associated with psychotropic substances , drugs and other medical conditions.

Third-party rating scales (questionnaires for third-party assessment) can be used for more precise diagnosis, e.g. B .:

There are several self-assessment questionnaires:

  • Maudsley Obsessional Compulsive Inventory (MOC)
  • Leyton Obsessional Inventory (LOI) - also as a version for children
  • Hamburg Compulsory Inventory (HZI) - also in short form

In addition, it must be ruled out that the symptoms are not caused by another mental illness.

Differential diagnosis

  • Occasional panic attacks or mild phobic symptoms are compatible with the diagnosis. Although anxiety plays a major role in obsessive-compulsive disorder and is classified as so-called anxiety disorder according to American guidelines (or DSM 5), in German-speaking countries these do not count as anxiety disorders in the narrower sense.
  • Differentiation from schizophrenia : Eugen Bleuler used to postulate a connection between coercion and schizophrenia. Several recent studies suggest that there is no such direct link. Obsessive-compulsive patients do not have an increased risk of developing schizophrenia compared to the general population. However, compulsions also occur in the context of schizophrenia. In patients with schizophrenia, the presence of obsessive-compulsive symptoms appears to worsen the prognosis for quality of life and work ability.
  • Differentiation from obsessive-compulsive personality disorder : There is no demonstrable connection between symptomatic obsessive-compulsive disorder and an obsessive-compulsive personality disorder. While the obsessive-compulsive disorder in the context of the compulsive or anankastic personality disorder is perceived by the person concerned as " I-synton ", i.e. as compatible with his or her person, the symptomatic obsessive-compulsive disorder is perceived by the person concerned as " I-dystonic ", i.e. as a foreigner to me and to the person felt not belonging.
  • Obsessive-compulsive symptoms in tic disorder , Gilles-de-la-Tourette syndrome, and organic mental disorders are not diagnosed as obsessive-compulsive disorder, but rather viewed as part of the corresponding disorders. Likewise, tic symptoms in the context of obsessive-compulsive disorder do not necessarily lead to a diagnosis of Tourette's syndrome, since tic symptoms can also occur in the context of an obsessive-compulsive disorder.
  • Furthermore, stereotypes are to be distinguished in autism .
  • Purely obsessive-compulsive thoughts can also occur in connection with postpartum depression or postpartum psychosis. As a rule, the mother fears that she might harm the newborn.
  • The so-called obsessive- compulsive spectrum disorders are also to be distinguished from the pure obsessive-compulsive disorder . The concept of the “compulsory spectrum” has been discussed for several years, especially in the Anglo-Saxon academic community. It is postulated that certain diseases, which are mostly assigned to other categories in both the old DSM-IV and the ICD-10, can also be viewed as manifestations of a spectrum of obsessive-compulsive diseases due to their characteristics. These include, in particular: certain forms of hypochondria , body dysmorphic disorder , anorexia nervosa , depersonalization disorder , Tourette syndrome , trichotillomania , dermatillomania , hoarding ( animal hoarding , messie syndrome ) and pathological gambling. In some cases, these considerations have been incorporated into the new DSM-5 classification, which, with the generic term “Obsessive-compulsive disorder and related disorders”, combines several related disorders.

Comorbidities

As with other anxiety disorders, obsessive-compulsive disorder has often been seen to coexist with other mood and anxiety disorders. Obsessive-compulsive disorder most often occurs in combination with depression, panic disorder, and social phobia . Around 80 percent of those affected have depressive symptoms, but these do not always justify the diagnosis of "depression". A good third will suffer from depression at least once in their lives . Body dysmorphic disorder occurs in 12 percent of patients .

50 percent of those affected also have a personality disorder . The personality disorders that occur most frequently among the sick are the dependent and the self-insecure-avoidant . Comorbid compulsive personality disorder , on the other hand, is much less common. In general, obsessive-compulsive illnesses often exhibit problematic interaction patterns or personality traits.

Tic symptoms are also sometimes associated with obsessive-compulsive disorder. Depending on the type and severity of the obsessive-compulsive disorder, these can be assigned or diagnosed as a separate tic disorder or as Tourette's syndrome .

Compulsions in other diseases

The presence of obsessive-compulsive symptoms does not necessarily mean the presence of obsessive-compulsive disorder. Obsessive-compulsive thoughts and compulsive actions can occur independently of the classic obsessive-compulsive disorder as symptoms in the context of other neurological and psychiatric diseases. In the English-language scientific literature, this is referred to as “Obsessive Compulsive Symptoms” (OCS). This is the case, among other things, in the context of Tourette's syndrome , autism , traumatic brain injury , schizophrenia and neuropsychiatric syndromes such as PANS or PANDAS . In these cases, the obsessive-compulsive symptoms usually respond to treatment of the underlying disease that caused them.

Spread and course

Until the mid-1990s, obsessive-compulsive disorder was still relatively unknown in the population. This gave those affected the feeling of being isolated with the disease, which increased the risk of suicide and minimized the chance of seeking therapeutic treatment. Today it is assumed that around 2% of the population suffers from an OCD once in a lifetime ( lifetime prevalence ). In Germany, 3.8% of the adult population have an obsessive-compulsive disorder each year (one-year prevalence).

Because the population is little known about the disease, it is often not properly recognized and treated: it often takes seven to ten years before those affected can be treated effectively. There seem to be no gender differences in the frequency of affected individuals.

The disease usually begins in adolescence or early adulthood before the age of 30. On average, boys and men fall ill earlier than women. The disease usually progresses slowly and steadily worsens without effective therapy , two-thirds chronically, one third intermittent with acute deterioration under particular stress. The onset in childhood or early adulthood is more common in boys than girls. The earlier treatment is started, the better the prognosis. Treatment with psychotherapeutic methods or suitable medication can significantly improve the prognosis, even if complete freedom from symptoms is rarely achieved.

Separated or divorced people and the unemployed tend to be slightly over-represented among people with OCD. This is not surprising considering the difficulties the disorder can create in work and relationships.

The risk of worsening obsessive-compulsive symptoms during pregnancy and breastfeeding is 60–70%. Patients with obsessive-compulsive disorder also have an increased risk of postpartum depression .

causes

Until the 1960s, psychoanalytic explanatory models dominated the image of obsessive-compulsive disorder. After the development of behavioral theories of origin in the second half of the last century, the genetic and neurophysiological relationships have become the focus in recent years . The current state of research suggests that an individually different interaction of genetic predisposition and psychological causes (e.g. biographical factors or stress) is the reason for the development of an obsessive-compulsive disorder.

Psychological explanatory models

The different psychological research and work directions (e.g. psychoanalysis , behavior therapy ) have different explanations for the development and maintenance of obsessive-compulsive disorder.

Behavioral explanations

The two-factor theory of Mowrer explains the origin and maintenance of constraints and fears  - the emergence on the learning theory model of classical conditioning , maintaining on operant conditioning .

  • Classical conditioning: An originally neutral stimulus (neutral stimulus, NS for short), e.g. B. dirt, when coupled to an unconditioned stimulus (UCS) that is inherently fearful, becomes a vicarious trigger (CS) for the sensation of fear or aversion (CR). For example, one such unconditioned stimulus that naturally triggers the tension could be an emotional burden in the family.
  • Operant conditioning: As a result, compulsive actions (or obsessive thoughts) occur (R) in order to neutralize the fear or tension, which means to reduce it. If the anxiety is reduced, it acts as a negative reinforcement (C- /) of the compulsive actions (R), which means that they will occur more frequently in the future.

A cognitive-behavioral therapy theory proposed by Paul Salkovskis on the development of obsessive-compulsive disorder assumes that obsessive-compulsive disorder results from the negative evaluation of intrusive thoughts that occur from time to time in healthy people and their (subsequent) avoidance. The avoidance of the occurring thoughts can be done cognitively or at the behavioral level: Either an attempt is made to suppress the thoughts or to “neutralize” them through actions (e.g. if there is fear of contamination by washing hands). Both avoidance reactions, however, do not lead to the desired effects: The neutralization act only leads to relief in the short term, as the thoughts that triggered the behavior continue to impose themselves. Still, the person has learned that the act may provide relief, if only for a short time. The behavior is thus negatively reinforced (C- /). On the other hand, thought suppression has a paradoxical effect: through active suppression, thoughts are additionally reinforced ("rebound effect").

Cognitive psychology research identified several factors that make "normal" thoughts so disturbing to people with OCD:

  • Depressed Moods: A stronger depressed mood in these people leads to an increase in the number and strength of unwanted thoughts.
  • Strict code of conduct: Exceptionally high moral standards contribute to the fact that sexual and aggressive thoughts in particular are much less acceptable.
  • Dysfunctional Beliefs of Responsibility and Harm: Some people with obsessive-compulsive disorder believe that negative - in fact perfectly normal - thoughts that are bothersome to them could harm themselves or others.
  • Dysfunctional Beliefs and Thought Patterns : People with obsessive-compulsive disorder have mismatched ideas about how human thinking works, assuming they can control unpleasant thoughts .

Psychoanalytic explanations

Psychoanalysts believe that OCD develop if their own children , it begin to fear pulses and defense mechanisms used to reduce the resulting anxiety. The battle between id impulses and fear is fought on a conscious level. The id impulses usually appear as obsessive thoughts, the defense mechanisms as counter-thoughts or compulsive acts.

Sigmund Freud postulated that some children feel intense anger and shame in the so-called anal phase (around two years of age). These feelings fuel the struggle between id and ego and set the course for obsessive-compulsive disorder. In this phase of life, according to Freud, the children's psychosexual pleasure is tied to the excretory function, while at the same time the parents begin the toilet training and demand that the children delay anal satisfaction. If the toilet training starts too early or is too strict, it can provoke anger in the children and lead to the development of aggressive id impulses - antisocial impulses that keep pushing for expression. The children may stain their clothes all the more and become generally more destructive, sloppy, or stubborn. If the parents suppress this aggressiveness, the child may also develop feelings of shame and guilt, as well as feelings of being dirty. Against the aggressive impulses of the child, there is now a strong desire to control these impulses. This violent id-ego conflict can last a lifetime and eventually grow into obsessive-compulsive disorder.

Numerous ego psychologists turned away from Freud and attributed the aggressive impulses not to strict toilet training, but to an unsatisfied need to express oneself or to attempts to overcome feelings such as fear of vulnerability or insecurity. You agree with Freud, however, that people with OCD have strong aggressive impulses and a competing need for control over these impulses.

Biological explanatory models

Genetic factors

Numerous studies have since shown that obsessive-compulsive disorder is moderately hereditary or that certain genetic constellations make the disease more likely. This could contribute to a family-related increased occurrence of diseases from the compulsive spectrum. However, the relevant gene segments have not yet been identified with absolute certainty.

Neurobiological factors

Obsessive-compulsive disorder is associated with changes in brain metabolism. It has not been clarified whether these changes are causally related or a side effect of the obsessive-compulsive disorder.

  • Serotonin hypothesis : Various neurochemical studies and successes with serotonergic drugs indicate a connection between the serotonin metabolism of the brain and obsessive-compulsive disorder. The symptoms can be reduced by giving SSRIs. After stopping the medication, there is usually a relapse into the obsessive-compulsive symptoms.
  • Dopamine hypothesis : Especially in the obsessive-compulsive disorder of patients suffering from Tic syndromes or Gilles de la Tourette syndrome, dopamine or the dopaminergic transmitter system probably also plays an important role. There are indications that the transmitter disturbances are not the cause of the obsessive-compulsive disorder, but accompanying symptoms of "primary disturbances in the orbitofronto / zingulostriatalen projection system, which adapts the behavior to a changing external environment and internal emotional states and throws it back onto the monoaminergic nuclei of the midbrain".
  • Basal ganglia hypothesis : There are changes in certain brain regions, the basal ganglia ( cortex orbitofrontalis and in the caudate nucleus ). In positron emission computed tomographic studies, increased glucose turnover was found in the area of ​​the orbitofrontal cortex, the two caudate nuclei and the cingulate gyrus . At the same time, blood flow was reduced in these brain areas.

Immunological explanations

Stereotypical obsessive-compulsive symptoms and tics in connection with infectious or immunological factors in streptococcal infections in childhood ( PANDA syndrome ) or other pathogens (PANS / PITAND syndrome) led to immunological studies. There are indications of the effectiveness of immunomodulatory therapeutic approaches using plasmapheresis or iv immunoglobulins and a long-term improvement in the clinical picture through antibiotic prophylaxis . There are also findings that indicate an increased B-lymphocyte antigen D8 / 17. In addition, autoimmunological parameters, e.g. B. pathological autoantibodies detected. One study found an increased incidence of anti-basal ganglia antibodies in patients with compulsive movement disorders, comparable to Sydenham's chorea .

treatment

The current German S3 guideline on obsessive-compulsive disorder recommends offering patients with obsessive-compulsive disorder “disorder-specific cognitive behavioral therapy (CBT) including exposure and reaction management as the psychotherapy of first choice”. It also states that "drug therapy for obsessive-compulsive disorder should be combined with cognitive behavioral therapy with exposure and response management". Drug therapy alone without accompanying psychotherapy is only indicated if “cognitive behavioral therapy (CBT) is rejected or CBT cannot be performed due to the severity of the symptoms”. As well as if "CBT is not available due to long waiting times or insufficient resources or the willingness of the patient to get involved in further therapeutic measures (CBT) can be increased."

The main disadvantage of drug treatment for obsessive-compulsive disorder is that relapse rates after drug discontinuation are very high and can be up to 90 percent. However, around 20% of patients also have relapses after behavioral therapy. In severe forms, a combination of medication and exposure therapy is recommended. According to the currently valid guideline, patients with obsessive-compulsive disorder and a comorbid tic disorder should be treated “with an SSRI and, if necessary, with antipsychotics such as risperidone or haloperidol in the absence of a therapy response”. The deep brain stimulation only comes under critical benefit and risk assessment in severely affected patients with refractory obsessive-compulsive disorder in question.

With optimal therapy, a clear improvement of the symptoms and the course can be expected in most cases. However, a complete cure is rare. Symptoms are likely to worsen, especially if the medication is stopped abruptly and there is insufficient behavioral therapy .

psychotherapy

There are various psychotherapeutic procedures that can be used. These differ significantly in theory and methodology. The different strategies of the various forms of therapy are the subject of research and a far-reaching theoretical debate. The current German S3 guideline on obsessive-compulsive disorder names behavioral therapy methods as the first choice. Psychoanalytically based psychotherapy methods are also used to treat patients with obsessive-compulsive disorder. However, there is no evidence from randomized controlled trials for this procedure.

Behavior therapy

With behavior therapy , an effective psychotherapeutic treatment method is available. Early behavioral treatment should not be delayed because treatment at the onset of the disorder is more promising. For behavior therapy (VT), cognitive therapy (KT) and cognitive behavioral therapy (CBT), there were no differences in either effectiveness or practical implementation.

  • Confrontation with preventing reactions . In this now well-researched method, patients are repeatedly confronted with objects or situations that usually triggered anxiety, compulsive fears, and compulsions. The obsessive-compulsive patients should not perform any of the compulsive acts. Because this is very difficult for the client, the therapist may initially demonstrate the behavior as a model ( model learning ). While this treatment method used to be referred to as "reaction prevention", today it is usually referred to as "reaction management", because the reactions should not be completely prevented during the confrontation, only the avoidance reactions (see also exposure therapy ). Because it is almost impossible to observe mental (cognitive) avoidance, the patient should be instructed to deal with the content of the central issues of his fears and to get involved in the emotional quality of the situation ('emotional processing'). In this sense, it is only a matter of preventing avoidance behaviors from reacting while encouraging the emotional reaction. Confrontation and prevention of reactions is carried out both in individual and in group therapy. In 60 to 90% of the obsessive-compulsive patients who are treated with this procedure, an improvement occurs in the form of a reduction in compulsive acts and the subsequent fearful experiences. The success of the therapy can still be observed years later.
  • Habituation training : This technique is used for isolated obsessive thoughts. Clients are instructed to call themselves the obsessional thought or obsession and hold it present for a longer period of time. In another form, the patients confront the burdensome obsessive-compulsive thoughts by listening to repetitive voice recordings.
  • Association splitting is a model currently under development for those affected who suffer from obsessive thoughts that they can put into words. The method builds new neutral or positive connections in parallel to the negative, agonizing associations. As a result, alternative neural pathways (associations) are enlivened at the physiological level. The method can be used as a self-help technique. A systematic review showed significant effects on obsessive-compulsive thoughts and obsessive-compulsive symptoms overall compared to control conditions.

Psychodynamic procedures

In addition to behavioral therapy, psychodynamic therapies such as psychoanalysis are still used today . The aim of psychodynamic psychotherapy is to make inhibited impulses aware and to work through any conflict tensions as an unconscious staging on the basis of conflicts derived therefrom (e.g. between dependency and autonomy, subordination and rebellion, obedience and rebellion).

Treatment with medication

Medicinal substances from the field of psychotropic drugs are primarily used to treat obsessive-compulsive disorder. Often several drugs are combined and it can take some time for a patient to become effective.

Antidepressants

In several controlled studies, antidepressants that predominantly or selectively inhibit the reuptake of the messenger substance serotonin have been shown to be effective in the treatment of obsessive-compulsive disorder . B. Selective Serotonin Reuptake Inhibitors (SSRI), for example citalopram , escitalopram , fluoxetine , fluvoxamine , paroxetine , sertraline or the tricyclic antidepressant clomipramine ; Venlafaxine was also found effective in OCD in one study . In Germany, clomipramine, escitalopram, fluoxetine, fluvoxamine, paroxetine and sertraline are approved for the treatment of obsessive-compulsive disorder. Since there is no difference in effectiveness between the SSRIs and clomipramine, the SSRIs are the first choice because of their better tolerability. For the drug therapy of obsessive-compulsive disorder there are some special features: Usually higher doses are necessary than in the treatment of depression; Therapy is often only successful after a latency period of two to three months. Usually improvements of only 40–50% are achieved; Long-term maintenance drug therapy (at least 12–24 months) is required. If treatment is resistant, switching to another SSRI agent or clomipramine or venlafaxine can be attempted.

With drug therapy alone, a relapse can be expected in around 90% of cases after discontinuing the antidepressant. The medication should therefore be discontinued slowly and, if possible, only after behavioral therapy has been carried out in parallel. Drug therapy alone is indicated when suitable behavioral therapy is not available or requires a long waiting period, or when there is no motivation for behavioral therapy.

Neuroleptics

If there is no or inadequate response to SSRIs and clomipramine, and especially if tic disorders are present at the same time, additional therapy with the antipsychotics risperidone , haloperidol or, with some restrictions, quetiapine can be tried. During treatment with neuroleptics , side effects such as tiredness, drowsiness, impaired concentration and ability to react at the beginning of treatment, long-term increase in appetite and weight gain, hormonal disorders, very rarely and only in higher doses, agitation and motor involvement can occur. Some authors recommend neuroleptics especially if the obsessive- compulsive thoughts are of a magical nature , there is insufficient distance to the obsessive-compulsive content, or the obsessions seem bizarre. In a randomized clinical study at Columbia University in New York, however, doubts arose as part of the study design about the benefit of augmenting SSRIs with neuroleptics.

Other drugs

There is evidence that the active ingredient acetylcysteine , like other drugs that act on the glutaminergic synapses of the brain, can lead to an improvement in obsessive-compulsive symptoms. The same applies to some H1 antihistamines such as diphenhydramine and especially hydroxyzine , which is also a strong dopamine and serotonin 5-HT2 antagonist . In addition, there have been sporadic studies on various other active ingredients that have an effect on the serotonergic system (e.g. inositol ) and the acetylcholine receptors ( anticholinergics ).

In the course of observational studies, taking μ- opioids such as hydrocodone or tramadol showed a spontaneous reduction in obsessive-compulsive symptoms in otherwise treatment-resistant patients. However, there are no broad studies on this, and the reason and mode of action for the observed effect are still unclear. The use of opiates for obsessive-compulsive symptoms is therefore experimental and cross-indication (“off-label”); In addition, special precautionary measures must be taken if CYP2D6 inhibitors such as fluoxetine or paroxetine are taken at the same time , as the therapeutic range can be significantly reduced. Also have opiates considerable potential for addiction .

Surgical interventions

To treat severe treatment-resistant obsessive-compulsive disorder is the possibility of "deep brain stimulation" ( Deep Brain Stimulation ). Electrodes are permanently implanted in the brain, which conduct electrical impulses from a pacemaker implanted in the chest into areas of the brain that are decisive for the development of obsessive-compulsive symptoms. In the USA, this procedure has been approved by the FDA for the treatment of obsessive-compulsive disorder since 2009.

Supportive measures

In addition to the direct treatment of an obsessive-compulsive disorder, accompanying support measures, such as involving the closer social environment, can prove to be helpful. This can be done through family therapy , marriage counseling or social work measures . The following interventions are also of particular importance:

Psychoeducation : This is understood to mean the training and instruction of the sick or their relatives or caregivers in order to be able to deal better with the consequences of an obsessive-compulsive disorder. Understanding the causes and effects of the disease can have just as positive effects on the patient's care as they do on their social relationships. The risk of social stigmatization in the case of an obsessive-compulsive disorder can also be countered with psycho-educational methods.

Self-help : In view of the large treatment gap in the case of coercion, effective self-help is becoming increasingly important: Only 40% to 60% of those affected seek therapeutic help. The few effectiveness studies carried out so far speak for the benefit of self-help in the case of coercion. In a study by Tolin and colleagues, a self-help approach (exposure with prevention of reaction) was found to be effective, although the therapist-led intervention produced slightly better results. In all previous studies on self-help with coercion, at least a marginal direct contact with the therapist was provided, which limits the transferability of the results obtained to pure self-application. A number of self-help books are available in the German-speaking area (see literature). According to a meta-analysis published in 2019, a metacognitive self-help approach leads to a significant decrease in obsessive-compulsive symptoms compared to control conditions (effect size d = .40).

Obsessive Compulsive Disorder

Patients suffering from severe chronic obsessive-compulsive disorder, whose functional ability in professional and social life is impaired, have the opportunity to have their degree of severe disability assessed by an expert and to experience relief in various areas of life through the corresponding statutory protection regulations for the disabled. The degree of severe disability in severe obsessive-compulsive disorder can be up to 100.

Public individuals with obsessive-compulsive disorder

literature

Guidelines

Reference books

  • David Althaus, Nico Niedermeier, Svenja Niescken: Obsessive- compulsive disorder. When the addiction to security becomes a disease . Beck, Munich 2008, ISBN 978-3-406-57235-7 .
  • Lee Baer: The leprechaun in your head. The taming of obsessions . Huber, Bern 2003, ISBN 3-456-83962-6 .
  • Otto Benkert: Obsessive Compulsive Diseases. Causes - Symptoms - Therapies . Beck, Munich 2004, ISBN 3-406-41866-X .
  • Willi Ecker: The disease of doubt. Ways to Overcome Obsessions and Compulsions . CIP-Medien, Munich 1999, ISBN 3-932096-13-4 .
  • Susanne Fricke, Iver Hand: Understanding and coping with obsessive-compulsive disorder. Help for self-help . Balance, Bonn 2007, ISBN 978-3-86739-001-9 .
  • Terry Spencer Hesser: Tyrants in the head . Sauerländer, Mannheim 2001, ISBN 3-7941-4782-0 .
  • Nicolas Hoffmann, Birgit Hofmann: When constraints restrict life . Springer, Berlin 2017, ISBN 978-3-662-52849-5 .
  • Angelika Lakatos, Hans Reinecker: Cognitive behavior therapy for obsessive-compulsive disorder. A therapy manual . Hogrefe, Göttingen, 3rd edition. 2007, ISBN 978-3-8017-2064-3 .
  • Steffen Moritz: Successful against obsessive-compulsive disorder. Metacognitive training. Recognize and defuse thought traps. Springer, Heidelberg 2016, ISBN 978-3662487518 .
  • Lukas Nock: The clinical picture of obsessive-compulsive disorder from the perspective of clinical social work . Logos, Berlin 2008, ISBN 978-3-8325-2066-3 .
  • Carmen Oelkers, Martin Hautzinger, Miriam Bleibel: Obsessive-compulsive disorder. A cognitive-behavioral treatment manual. BeltzPVU, Weinheim / Basel 2007, ISBN 978-3-621-27521-7 .
  • Hans Reinecker: Compulsive Actions and Obsessive Thoughts . Hogrefe, Göttingen 2009, ISBN 978-3-8017-2055-1 .
  • Jeffrey M. Schwartz: Compulsions and How to Get Out of Them . Krüger, Frankfurt am Main 1997, ISBN 3-8105-1883-2 .
  • Frank Tallis : Obsessive Compulsive Disorder. A Cognitive and Neuropsychological Perspective. Chichester: Wiley 1995. ISBN 0-47195775-5
  • Christoph Wewetzer: Compulsions in children and adolescents . Hogrefe, Göttingen 2004, ISBN 3-8017-1739-9 .

Web links

Individual evidence

  1. ↑ a b S3 guideline obsessive-compulsive disorder. ( Memento from February 26, 2015 in the Internet Archive ) DGPPN , 2013 (distribution see p. 7, differential diagnosis p. 27).
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