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OCDAna Domingo Viana

Ana Domingo Viana

ContentsCLINICAL CHARACTERISTICS OF OCD........................................................................3

DIAGNOSTIC CRITERIA....................................................................................................................................3

CLASSIFICATION AND DIAGNOSIS OF OCD...............................................................5

LABELLING......................................................................................................................................................5

RELIABILITY.....................................................................................................................................................5

VALIDITY.........................................................................................................................................................7

CULTURAL RELATIVISM...................................................................................................................................7

MORE ISSUES..................................................................................................................................................7

BIOLOGICAL EXPLANATIONS OF OCD.......................................................................9

GENES.............................................................................................................................................................9

NEUROANATOMICAL FACTORS......................................................................................................................9

BIOCHEMICAL FACTORS – serotonin............................................................................................................11

PSYCHOLOGICAL EXPLANATIONS OF OCD..............................................................13

PSYCHODYNAMIC.........................................................................................................................................13

BEHAVIOURAL..............................................................................................................................................13

COGNITIVE....................................................................................................................................................14

PSYCHOLOGICAL THERAPIES OF OCD.....................................................................15

ERP (EXPOSURE AND RESPONSE PREVENTION)............................................................................................15

COGNITIVE....................................................................................................................................................16

BIOLOGICAL THERAPIES FOR OCD..........................................................................17

DRUGS – BIOCHEMICAL................................................................................................................................17

NEUROANATOMICAL – PSYCHOSURGERY....................................................................................................18

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Ana Domingo Viana

CLINICAL CHARACTERISTICS OF OCD

Obsessions are recurrent thought processes which are unpleasant and cause anxiety and distressed. They are believed as uncontrollable.

Compulsions are actions you have to do or the thought will come true. They are the behaviours that you can see. The patient has self-awareness that the behaviour is irrational but can’t stop so it causes anxiety levels to rise. They are aware that the thoughts come from themselves and not an external force.

DIAGNOSTIC CRITERIA DSM-IV-TR ICD-10

A. The Person Exhibits Either Obsessions or Compulsions or both

Obsessions are indicated by the following:

o The person has recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress

o The thoughts, impulses, or images are not simply excessive worries about real-life problemso The person attempts to ignore or suppress such thoughts, impulses, or images or to neutralize them with

some other thought or actiono The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her

own mind (not imposed from without as in thought insertion)

Compulsions are indicated by the following:

o The person has repetitive behaviours (eg, hand washing, ordering, checking) or mental acts (eg, praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly

o The behaviours or mental acts are aimed at preventing some dreaded event or situation; however, these behaviours or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.

B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. (Note: this does not apply to children.)

C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person's normal routine, occupational/academic functioning, or usual social activities or relationships.

Y-Bocs

It is a one to one interview between the patient and the clinician. The interviewer has a checklist of symptoms and the patient has to choose the three most prominent or disturbing symptoms.

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Checklist:

Obsessions Compulsionso Aggressive obsessionso Contamination obsessionso Sexual obsessionso Hoarding/savingo Religiouso Need for symmetry or exactnesso Somtic obsessions (body appearance)o Miscellaneous...etc

o Cleaning/washingo Checkingo Repeating ritualso Countingo Ordering/arrangingo Hoarding/collectingo Mental rituals other than checking/countingo Miscellaneous...etc

Evidence and example: YOU WOULD NEVER NEED A CASE STUDY LIKE THIS

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CLASSIFICATION AND DIAGNOSIS OF OCD

LABELLINGAO1

People are marked with the label that they have OCD so they internalise the label and this behaviour becomes more frequent (self-fulfilling prophecy), even when the behaviour ends or is treated they would still be classified as OCD sufferer.

Causes stigmatisation and marginalisation in society because for example, in job applications, this information has to be displayed so they might struggle to get work and be self-sufficient.

AO2

Effectiveness:

People are missing out on effective treatment and we want them to seek this treatment because it works – Thoren et al (1980) found that clomipramine (a SSRI) was significantly superior to placebo in reducing obsessional symptoms.

Evidence:

Kessler and Zhao (1999) found that 40% of OCD sufferers came forward for treatment because if they have this label attached they won’t be able to find a job later on so they don’t go to the doctor if they know they have OCD symptoms.

Validity of evidence:

How do we know that 40% of sufferers come forward for treatments if we don’t know how many people have OCD? There might also be an alternative explanation for these results such as the fear of treatment and control.

RELIABILITYAO1

Reliability is the consistency of the diagnosis. Something can be reliable but not valid but it cannot be valid and not reliable.

Inter-rater reliability – different doctors diagnose different disorders. Inter rater reliability would be when different doctors diagnose the same disorder.

There are problems with co-morbidity which is an overlap between two disorders, in this case OCD and depression.

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AO2

Effectiveness:

To check for reliability:

o Inter-rater reliability – more than one doctor diagnosing the same patient.o Split-half technique – looking at the first half of the test and compare it to the second half, if the same

results are found there is internal reliability and if the half’s are different there is a problem with the measuring tool.

o Test-retest – test again.

Problems with test-retest:

Patients may perform differently between the tests if the retest is too long after because people may ‘improve’ i.e. They might have started to challenge their irrational thoughts after having been told in the first test they have OCD and started to do self-therapy because the nature of having done the first test people may analyse their own behaviour.

If you test-retest too soon after the test patients might be subject to demand characteristics, if they remembered what they put in the first test they might put the same thing (which would explain Kim et al’s* results). The law of parsimony would explain this suggesting that if you have done one thing once you are likely to do the same thing when presented with the same situation because humans are naturally lazy and will do what requires less cognitive effort.

Evidence:

Woody et al (1995) assessed 54 patients with OCD using the Y-Bocs scale and he found inter-observer reliability suggesting Y-Bocs are a reliable way to assess the strength and severity of OCD. THIS EVIDENCE WOULD PROBABLY BE BEST AS AO1 TO ILLUSTRATE RELIABILITY OF OCD DIAGNOSIS. HOWEVER, test-retest results after an average of 48 days was lower than desirable.

*Kim et al (1990) found good test-retest reliability over the short term.

Brown et al carried out two interviews on 1400 patients with a gap of two weeks between interviews and found that the inter-rater reliability was excellent. The most likely explanation of this was that the compulsions provided a clear behavioural indication of the presence of OCD. There were however, some sources of unreliability, the main one being the differences in the symptoms reported by patients in the two interviews.

Steinberg et al compared DSM IV and ICD 10 in their diagnosis of OCD, they found large differences between the two suggesting there are problems with the consistency of diagnosis. When using DSM-IV, 95% of patients were diagnosed with OCD but when using ICD 10 only 46% of the same patients were diagnosed with OCD.

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VALIDITY AO1

Validity refers to whether the test is measuring what it intends to measuring, whether it is really OCD.

The validity of diagnosis is whether the classification reflects the true nature of the condition as something that is real and distinct from other disorders.

Discriminant validity – refers to the ability to distinguish between OCD and other conditions.

There are problems with co-morbidity which is an overlap between two disorders, in this case OCD and depression.

AO2

Checking for validity:

o Ask experts – list of characteristics. Jeffrey Schaler – we have to be careful to make sure mental illness does not equal social control.

We need to reduce social desirability biases and any false information, so there is a need for accurate information from patients.

To reduce demand characteristics:

o Interview close friends and family members.o Considering the fact that patients may not have an awareness of the severity of the behaviour.

Evidence:

Rosenfield et al found that patients diagnosed with OCD had higher Y-Bocs scores than patients with other anxiety disorders and normal control groups; therefore there is a distinction between OCD and other disorders. AGAIN THIS WOULD PROBABLY BE BETTER AS AO1 TO ILLUSTRATE VALIDITY OF OCD. Woody found poor discriminations between depression and measures of OCD and Y-Bocs.

CULTURAL RELATIVISMAO1

The incidence of OCD tends to be the same in every culture (2-3%).

Symptoms are shaped by the patient’s culture of origin. For example in India they may fear contamination by touching somebody of a lower caste. This may lead to problems with the diagnosis and classification of OCD because the symptoms checklists may be culturally biased.

MORE ISSUESAO1

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Shahady found that General Practitioners don’t normally recognise OCD due to the co-morbidity between OCD and other disorders such as depression, alcohol or eating disorders. Only a minority of cases receive timely treatment.

Hollander found that in average an individual waits 17 years before getting the correct treatment.

Hollander and colleagues conducted a retrospective postal survey of 2,607 members of an American based OCD charity. Seven hundred and one individuals (26.9%) responded, of whom 82% were patients: 63% of the patients reported a delay in seeking treatment; 34% were unaware that their illness represented a recognized disorder; 13% were too embarrassed or afraid to seek help; 9% believed treatments were unavailable; 4% were unable to leave their homes or travel due to their OCD and 3% were concerned about the side effects of medication.

AO2

Effectiveness:

The WHO ranked OCD within the twenty leading causes of medical disability. Given the substantial socioeconomic costs associated with untreated OCD, estimated in one American study, 6% pf the total cost associated with mental illness. People might not be able to work properly, lose jobs.. so don’t contribute to the economy.

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BIOLOGICAL EXPLANATIONS OF OCD

GENESAO1

Billet et al (1998) reviewed 14 published twin studies and found that of 80MZ twin pairs, 54 were concordant for OCD (67.5%) and that out of 29DZ only 9 were concordant for OCD (31%).

Exactly how genetic factors contribute to OCD is unknown, but it is thought they affect brain structure impacting on the individual’s ability to perform mental tasks. The fact that MZ twins have a higher concordance rate means there might be genetic influence as they are genetically identical COMPARED TO DZ TWINS WHO ONLY SHARE 50% OF GENES. AO2 – MZ twins are more likely to have similar environments so treated more similarly.

A gene called sapap3 is a gene placed in the striatum – that controls processes such as planning and initiating an appropriate action. Feng et al (2007) found that mice lacking this gene had high anxiety levels and spent excessive amounts of time grooming (cleaning) to the extent of pulling their own fur. When given sapap3 protein, the abnormal behaviour disappeared. AO2 – animal study so cannot extrapolate findings to humans, there isn’t any solid evidence for the influence of genes on OCD.

Brain structure might the proximate cause and we are looking for the ultimate cause.

AO2

Value:

Implication of genetic approach can lead to seeking extreme solutions such as castration, selective breeding and the abortion of women that are thought to carry the OCD gene. MORAL IMPLICATIONS. HOW BAD IS OCD AND WOULD IT JUSTIFY THIS? COULD ALSO JUST LEAD TO IDENTIFICATION SO PEOPLE CAN GET HELP QUICKER

Effectiveness:

You cannot separate the genes from the environment so you never know if what is causing the behaviour is the genes or the environment.

If OCD turns out to be biological, due to brain structure or biochemistry it is something you are born with which has to appear in the genetic code which would reduce the explanation back to genes. (unless it is pre-natal factors!). If it is genetic the blame is placed on the parent not on the patient itself which then can result in even more stress which is a symptom of OCD and increase OCD.

NEUROANATOMICAL FACTORSAO1

The basal ganglia contains: the caudate nucleus, putament (SPELLING)and global pallidus.

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Rapoport et al (1995) found that surgery which disconnects the basal ganglia from the frontal cortex can reduce symptoms in severe OCD. The OFC is the part of the brain that becomes aware if something goes wrong.

The OFC sees dirt so processes what it is and sends signals to the thalamus passing through the caudate nucleus which regulates the signals. The thalamus then receives ‘worry’ message and thinks ‘I must deal with the problem’ sending strong signals back to the OFC through the caudate nucleus. The caudate nucleus normally acts suppressing the original ‘worry’ message but in OCD the caudate nucleus is thought to be damaged so cannot stop the OFC signals increasing compulsive behaviour and anxiety. This explains both obsessions and compulsions by OCD sufferers. This has been supported by SSRI medication which increases the stimulation of serotonin receptors in the OFC and thereby to inhibit the over activity.

Sees dirt! Must ask for help! Must calm the situation must deal with the problem!

OFC CAUDATE NUCLEUS THALAMUS

AO2

Evidence:

Rapoport studied patients that had Rheumatic fever which is a chronic disease of the heart. He found that 20% of patients also develop Sydenham's chorea, as an autoimmune response to the basal ganglia. He conducted a survey on 23 Sydenham’s chorea patients and 14 patients who had rheumatic fever but not Sydenham’s chorea. In double blind technique studies he found that scores for obsessional symptoms were higher among those with Sydenham’s chorea. He found that three chorea patients but no rheumatic fever patients med the diagnosis for full-fledged OCD. This suggests that OCD might be a cause of dysfunction in the basal ganglia. (the IV is whether there is basal ganglia damage or not).

Max et al found that basal ganglia damage from head injury leads to OCD. Surgery that disconnects the basal ganglia from frontal cortex reduces OCD symptoms.

Menzies et al looked at 31 people suffering OCD, 31 closely related to them and 31 not related at all. They measured their ability to stop repetitive behaviour. It was found that OCD patients and their healthy relatives had lower amounts of grey matter compared to the control group, in particular in the OFC and the right frontal regions of the brain. These parts of the brain are known to have regulatory role and so makes sense for them to be involved in OCD

Validity of evidence:

Rapoport - Natural experiment – may have many extraneous variables so cannot state a direct relationship between IV and DV. It is a small sample so might not be able to generalise to the further population and all the participants are from the USA so might have some environmental-cultural factors affecting the results.

Although it is a natural experiment it is a well controlled ones because everybody had Rheumatic fever and some developed naturally Sydenham’s chorea and those were the ones that developed OCD.

Menzies et al – you are studying people that already have OCD so you don’t know if the basal ganglia and frontal cortex is what causes OCD or if it is a result of the OCD. Is it the cause or the effect?

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There is unreliability of using brain scans as patients may have already taken some drugs that alter brain structure (not only for OCD but maybe for depression due to their co-morbidity) so you don’t know what caused the OCD.

BIOCHEMICAL FACTORS – serotoninAO1

OCD has been linked to reduced levels of serotonin in the brain. Serotonin moves from one cell to the next absorbed by serotonin receptors. In OCD it is thought that the serotonin receptors are blocked, not allowing serotonin to enter the cell.

Evidence:

Leonard

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CMI

DMI

CMI

DMI

Ana Domingo Viana

CROSSOVER STUDY COMPARING DMI AND CMI 1

CMI – drug that increases serotonin

DMI – anti-depressant drug

CMI is more effective in reducing OCD symptoms while increasing serotonin. DMI that doesn’t affect serotonin shows a slight change which CMI shows significant change. This is a very clear experiment that Serotonin affects OCD.

Baxter compared fluoxetine with in vivo exposure plus response prevention (behavioural therapy) and found that improvement in OCD produced by both treatments was associated with the same changes in the brain function, namely reduced activity in the right caudate nucleus.

Effectiveness:

Treatment aetiology fallacy – just because a particular drug provides relief from symptoms does not mean that a lack of the drug is the underlying cause of the disorder. Aspirin can remove the pain of a headache but headaches are not caused by a lack of aspirin in the nervous system.

Learning must cause brain changes because chemistry occurs which might decrease levels of serotonin so if you are given serotonin OCD would decrease but it wasn’t the ultimate cause of OCD just an effect.

GENERAL AO2

Reductionism: reduces all the explanation to genes, ignoring nature which allows simple treatments which allows an easy understanding and testing with controlled IV and DV.

Deterministic: the sufferer doesn’t have control of the situation with a lack of free will.

Locher and Stein (2001) suggest that there are some interesting gender issues raised by the differential rates of OCD and associated mental disorders. In males it appears that early brain injury may be associated with OCD whereas in females, OCD often appear after childbirth and pregnancy which suggests that OCD may have different triggers in men and women.

IMPLICATIONS FOR TREATMENT

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PSYCHOLOGICAL EXPLANATIONS OF OCD

PSYCHODYNAMICAO1

OCD is to do with problems in the anal stage of psychosexual development according to Freud between 18 months and 3 years which is a concern with control and order. (Ie. Parents not toilet training kids properly by for example over-punishing).

The child then becomes angry and represses his feelings because he can’t direct it to his parents because they are in a position of power over him so the anger is pushed away to the unconscious mind. This repressed thoughts need to escape provoking anxiety. There is an attempt to displace these thoughts. If these thoughts are seen in consciousness they seem alien and frightening (obsessions) so they manage the anxiety by carrying out the compulsions.

AO2

Evidence:

Freud (1909) studied the ‘Rat man’ who had obsessive fears about harm coming to his fiancée and her father by rats. The man tried to stop his obsessions by engaging in compulsive acts for example jumping into the path of a carriage to remove a rock he thought was in his way. Freud said there were two reasons for the obsessions. That they were a result of conflicting thoughts about her fiancée and her father (loving the father but also wishing him dead to inherit the money) or that they are a result of childhood conflicts.

Effectiveness:

Salzman suggests that taking a psychodynamic approach leads to psychoanalysis therapy which can have a negative effect on OCD recovery because it requires lots of thinking.

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BEHAVIOURALAO1

Dual process model (Mowrer). There is a fear of stimuli that is acquired through a process of classical conditioning. The fear is then maintained through operant conditioning. This approach can’t explain the cognitions (obsessions) because it only centres on behaviour.

The source becomes aversive through association with a negative event (for example a child being told off for eating food off the floor) he associates dirty things with anxiety.

UCS UCR told off anxiety

UCS + NS UCR told off + dirt anxiety

CS CR dirt anxiety

This is an avoidance behaviour (avoiding dirt by cleaning) that makes you feel better which is a negative reinforcement; the washing removes the bad feeling so is likely to be repeated.

AO2

Evidence:

Conditioning – Tracy et al suggests that Mowrer’s theory can predict that OCD patients are predisposed to rapid conditioning. On a study there were two groups, the OCD like group and the normal group, arranged according to their responses on an OCD checklist, they were exposed to dust in an eye-blink task and found that the OCD like people were more rapidly conditioned.

Compulsive behaviour – Rachman and Hogdon thought that if the compulsive acts relieve the anxiety associated with obsessional thoughts, blocking this acts should cause a rise in anxiety. They did studies that made participants carry out ‘prohibited’ activities (such as touching something dirty) that would cause an increase in anxiety and an urge to carry out their safety rituals. Patients were allowed to carry the compulsive act which noted reduction in anxiety. If the patients were asked to delay the compulsion the anxiety levels were found to persist.

COGNITIVEAO1

Rachman and Hodgson (1980) say that we all have intrusive thoughts but that we are able to dismiss them or distract ourselves from them. In OCD when you try to stop the thoughts they become more intrusive. This is more likely when you are stressed or depressed as you lose the ability to control your thoughts.

The thoughts can be stressful which in turn creates anxiety and more inability to control intrusive thoughts. To stop the thoughts becoming real the individual engages in safety rituals (such as cleaning).

AO2

Evidence:

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Bouchard et al says that people with OCD appear to have different patterns of thinking, such as believing that they can and should have total control over their world. People react to their obsessions and anxieties with maladaptive thought patterns. Clark found that people with OCD do have more intrusive thoughts than ‘normal’ and that people with OCD report trying to do things that will neutralise unwanted thoughts (Freeson et al)

NEED MORE AO2 HERE. YOU COULD GET ASKED TO DISCUSS PSYCHOLOGICAL EXPLANATIONS OF OCD

PSYCHOLOGICAL THERAPIES OF OCDALL THERAPIES:

To evaluate therapies we have to look at how appropriate it is (suitable) INCLUDE COMMENTS ON THIS IN YOUR AO2 and how effective (successful) they are. A therapy is an intent to reduce suffering and restore normality. The chosen therapy should have a likely chance of success.

ERP (EXPOSURE AND RESPONSE PREVENTION)AO1

It is a behavioural approach. It aims to reduce the compulsions. Meyer (1966).

Patients are exposed to objects or situations that would arise anxiety in them and they are encouraged to stop doing their safety rituals (like touching something dirty and not washing their hands). Relaxation techniques are taught to help deal with the fear. Other techniques are also taught such as verbal persuasion, continuous monitoring and the encouragement of other alternative behaviours.

The therapist provides the client with a model of how to behave (like in social learning theory) they are provided with a model that does the appropriate action and are encouraged to try and copy the behaviour. Client’s family is invited in and the client is given ‘homework’ to apply to real life situations.

This therapy aims to break the previous association, made by classical conditioning, between dirt and anxiety making a new association where dirt doesn’t provide any negative effect.

Meyer found that it involves 90 minute sessions up to 15-20 sessions over 3 weeks.

AO2

Effectiveness:

Between 55 and 85% of OCD clients improve significantly and the effects are long lasting. When ritual behaviour reduces, cognitions appear to reduce as well. This treatment is not appropriate for people with

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obsessions but not obvious behavioural and controllable compulsions, for example somebody that counts the letters in a sentence.

This therapy is normally combined with cognitive therapy because the cognitions (obsessions) have to be dealt with too.

These therapies take less time and have no side effect. Baxter showed that PET scans showed improvement in brain functioning (e.g. Decrease in thalamus activity) and they claim that their research demonstrates that ERP has biological effects.

Evidence:

Rachman et al (1970) showed the reduced compulsive cleaning behaviour of a man. When treated for his compulsive cleaning the client showed a steady decline in both the total time he spent washing and the number of times he washed daily.

Sapolskis and Kirk (1997) reported moderate success and suggested that complete removal of symptoms occurred in half of the sufferers (can the other half lead a normal life? Can that count as effective?) and that it was common for clients to drop out.

Meyer (1966) in his original study found that out of 15 patients, only 2 had relapse at a 5-year follow up. He found that effectiveness of ERP was increased in controlled environments. (that would require time and money which might mean that it is not appropriate for everybody). He did a controlled study in a hospital were staff were trained to reduce the opportunities of engaging in rituals. In the short term, stopping the OCD was unpleasant. The fact that it involves so long sessions (90 minute sessions up to 15-20 sessions over 3 weeks) makes the appropriateness be doubted as people have to be very committed, have a lot of free time and be willing to engage in the therapy.

Foa et al found that refusement to engage in therapy is a problem.

COGNITIVEAO1

Cognitive therapies work to challenge the irrational thoughts that underlie the obsessions and compulsions. Therapists provide information to educate clients about their misinterpretations of intrusive thoughts and about the futility neutralising acts. They challenge inappropriate thoughts by testing the reality of the client’s negative expectations. Need to actually need to do the behaviour to see that nothing bad will happen (which includes behavioural aspects). They challenge the inappropriate thoughts by literally shouting ‘stop’ each time and channelling the thoughts to something else.

REBT – Ellis. Reduce OCD by giving up beliefs that things have to be the way they want or that it is perfect. Encouraged to test fears and see that if the compulsions are not performed nothing bad will happen. ERP is most effective to challenge obsessions and compulsions. AO2 – more argumentative – less centred on clients sensitiveness and their wants - Challenging client-centred therapies.

AO2

Effectiveness:

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Van Oppen et al – cognitions alone don’t work as much as ERP but is most effective when combined. They don’t have side effects.

Rational-emotive therapy is especially effective with clients who feel guilty because of their own perceived inadequacies and who impose high demands on themselves.

Only appropriate for people who are very committed and can cope with the challenge therapy because it can cause clients to be distressed.

Evidence:

There is evidence for a need for cognitive therapy. Newmark found that anxious patients are more likely to have irrational beliefs. 65% of anxious patients and 2% of “normal’s” want to be liked.

DON’T FORGET THE KIND OF AO2 THAT WE LOOKED AT LAST YEAR WHEN WE DID TREATMENTS FOR PSYCHOPATHOLOGY

BIOLOGICAL THERAPIES FOR OCD

DRUGS – BIOCHEMICALAO1

SSRI – increase serotonin by blocking the reabsorbtion or reuptake. There is a problem with receptor sites so SSRI come in and block the reuptake. So the SSRI’s are more likely to be absorbed by the receptors if it is left in the synaptic gap. In OCD there are few receptor sites working.

Tricyciclics – they are the same as SSRI but also increase noradrenalin. They are only used when SSRI’s don’t work. AO2 – they have more side effects like hallucinations, nausea, insomnia, negative effects on heart and circulatory system. Pato notes that they are most effective for people that also have depression.

AO2

Effectiveness:

Koran found that studies are only up to 3 months so it is difficult to assess the long term effects of the drug. Pato found that the long-term effects of tryciclics were short-lived where withdrawal from the drug led to 90% relapse rate, much higher than that found with ERP.

Treatment gains are modest and symptoms return if drugs are discontinued. Barr et al also found that it is also not clear whether drugs work specifically for OCD or on its associated depression.

Breggin found that given there are problems with classification and diagnosis of OCD maybe it is more damaging than helpful giving a drug rather than a behavioural therapy.

Evidence:

Dolkberg compared placebo to SSRI and found that 50-70% of patients taking SSRI reported some reduction in symptoms when only 5% of people taking placebo reported reduction in symptoms.

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Leonard showed that tyciclics (DMI) are useful in reducing OCD symptoms but only over 13 weeks.

Schwartz found that behavioural therapy has the same effects as drugs in the brain (can also use Baxter). People doing behavioural therapy (ERP) compared to drugs had the same effect in the caudate nucleus therefore it suggests that ERP is the same but without the side effects.

NEUROANATOMICAL – PSYCHOSURGERYAO1

Brain structure – basal ganglia

Alter the connections in the brain by burning away small portions of tissue.

- Capsulotomy Lessions (cuts) that cause permanent damage.- Cingulotomy

Capsulotomy: removes the capsum (part of limbic system) involved with emotion and anxiety.

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Cingulotomy: removes the link between the orbitofrontal cortex and caudate nucleus (part of basal ganglia)

Stimulation

- Vagus nerve stimulation

They put an electro in the neck that sends electric pulses through the left vagus nerve attached to the brain, this is the part of the brain that carries messages from the brain to the body’s major organs like the heart, lungs and intestines and is linked to the part of the brain involved in mood regulation, sleep... and it Sends impulses every 5 minutes for 30 seconds to this part of the brain. (Involves wires that are permanently attached)

- Transcranial magnetic stimulation

New treatment. It is a specific stimulation to a part of the brain, lasting between 30 to 60 minutes and not requiring anaesthesia. An electric coil is held against the forehead near an area of the brain thought to hold mood regulation, then, short electromagnetic pulses are administrated. The person normally feels a slight knocking or tapping on their head as the pulses are administrated, they don’t know which part of the brain is best to stimulate.

AO2

Effectiveness:

Cingulotomy: controlled study involving 44 patients diagnosed with OCD, 32% met the criteria for having responded to the therapy, 14% did partially. Only about 1000 procedures have been performed for OCD patients, but none resulting in death. However, the haemorrhage rate is 0.3% and other adverse effects include seizures and hydrocephalus.

Capsulotomy: historically, response rates range between 48% and 78%. A recent study using gamma capsulotomy indicates a 27% response rate for patients receiving a single bilateral lesion and a 2% response rate in patients receiving two pairs of bilateral lesions. Currently no deaths have been reported but adverse effects include headaches, confusion...

You can’t measure the placebo effect with brain surgery so you don’t know if what you’re removing is really what caused the abnormal behaviour, or OCD. Taking away part of the brain could also result in taking away the ability to perform other functions.

Evidence:

Cingulotomy: There is a follow up study by Nyman who found that there were short term changes in personality like apathy and de-motivation and in the follow up they found that recovery took place over time and personality was normal again.

Mary Lou Zimmerman had OCD all her life. She was operated with capsulotomy and cingulotomy and afterwards she couldn’t walk, stand, eat or go to the toilet by herself. ISSUES – informed consent – she was told there was a 70% chance of success and a 30% chance of unchanged behaviour but that there was no

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chance of harm so she might not have know what she was agreeing to. Also, her state of mind before the operation was desperate and anxious so she couldn’t give fully informed consent.

Magnetic stimulation: Greenberg found that out of 12 patients after a 20 minute stimulation there was a reduction of OCD symptoms up to 8 hours. Other studies have found even less reduction time. Early success can be due to the placebo effect which is the reduction in symptoms just because the patient knows that it has had something done to it.

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