Introduction
OCD is a rather familiar term than a disease nowadays. Many films and social media posts use this term widely. Characters with OCD grab attention in the theatres. Medically OCD (Obsessive–compulsive disorder) is a mental disorder characterized by absurd, recurrent and uncontrollable thoughts (obsessions) that produce anxiety, which are followed by repetitive behaviours (compulsions) aimed at reducing anxiety. OCD may be looked upon as a condition in which the affected person frequently experiences irresistible urges to perform repetitive rituals (compulsions). OCD may be defined as the irruption in the mind of uncontrollable, ego dystonic and recurrent thoughts, impulses or images. In OCD, repetitive rituals serve to counteract the anxiety precipitated by obsessions. The OCD patients realize the irrational nature of thoughts and rituals but feel helpless and hopeless about controlling them. Obsessive-Compulsive disorder can impair all areas of brain functioning and produce devastating effects on patients and their families. In modern psychoanalysis, obsessive-compulsive disorder is described as a portrayal of ambivalence, with confusion of thoughts and actions that are paradoxically manifested by rigidity and abnormal behaviours. It may provoke aggressive or sexual actions that might produce shame, weakness, or loss of pride. The thoughts and behaviours associated with OCD are viewed as senseless, and ego-dystonic, means they stand contradictory to the individual’s motives, goals, identity, and self-perception thereby creating significant subjective distress. The excessive nature of the compulsion, however, creates its own distress and it appears that the individual may be caught up in a kind of negative reinforcement loop. The obsessive-compulsive spectrum disorders are Tourette’s disorder, Body dysmorphic disorder, Hypochondriasis, Pathological jealousy, Trichotillomania, Skin picking, Nail biting, Compulsive buying, Kleptomania, Pathological gambling, Nonparaphilic sexual disorders, Obsessive compulsive personality disorder. OCD is an anxiety disorder featuring intrusive and troubling thoughts, which are perceived as the products of one’s own mind unlike schizophrenia. The Patient affected by OCD feels compelled to carry out certain stereotyped behaviors, although he recognizes that his behavior is at times irrational. Entire brain functioning is disturbed in patients suffering from OCD, thereby producing devastating effects at the work-place as well as at homes of the patients. OCD is a complicated disorder. Selective serotonin reuptake inhibitors (SSRIs) and to some extent tricyclic antidepressants form the main stay in the symptomatic treatment of OCD. Most of the OCD cases are incurable. Therefore, there is a great challenge in the management of OCD.
Signs & symptoms
The OCD is clinically manifested by a wide range of symptoms. The most common types of obsessions are related to contamination, pathological doubts, somatic dysfunctions, need for symmetry, aggression and hyper sexual drive. The classical forms of compulsions include checking, washing, counting, need to ask, precision and hoarding. In OCD, senseless, repetitive rituals (such as counting, washing etc.) serve to counteract the anxiety precipitated by obsessive thoughts.
- Repetitive and unwanted actions which are senseless in the scenario
- Recurrent obsessions and/or compulsions (e.g., doubting, checking, washing) that are time consuming than normal.
- Aggression and irrational thoughts & beliefs
Causes
The exact cause of OCD is not still known. But genetic and hereditary factors play a role in the development of the disorder. The neuro-chemical changes in the brain like abnormality in the neurotransmitter serotonin is also responsible for the changes.OCD patients may have blocked or damaged receptor sites preventing serotonin from functioning to full potential. Possible genetic mutation in the human serotonin transporter gene leads to this condition in some people.
Pathophysiology
The brain regions impaired in OCD includes dorsolateral prefrontal cortex (DLPC), anterior cingulate cortex (ACC), basal ganglia, orbito-frontal cortex (OFC), striatum, amygdala, thalamus and brainstem.
1.Dorsolateral prefrontal cortex (DLPC)
It is the most important cortex part for cognitive functions in human beings like in working memory and adaptation to changes in the environment. DLPC plays a crucial role in focusing attention on specific stimuli and in decision-making. Lesions of DLPC impair the successful performance of goal-directed behaviours.
- Anterior cingulate cortex (ACC)
ACC is involved in a variety of cognitive processes such as attention, motivation, reward, error detection, working memory, problem solving and action–plan. There are two major regions within ACC viz. a dorsal region, known as the cognitive region, and a ventral or affective region. The cognitive region is a part of attentional network and is closely connected with the DLPC, premotor, and parietal cortices whereas, the affective region is linked to the amygdala, nucleus accumbens, hypothalamus, anterior insula, hippocampus and OFC and sends projections to the neuro-vegetative, viscero-motor and endocrine systems. Excessive activation of ACC has been reported in patients presenting psychiatric disturbances such as phobias, OCD and mood disorders. Moreover, electrophysiological studies have demonstrated its particular role in error detection processes.
- Basal ganglia-thalamo-cortical circuits
Basal ganglia integrate the various inputs arriving from the cortex and uses this information for selecting certain motor and/or cognitive programs. The point of entry of information to the basal ganglia is through striatum, which receives converging information from the limbic and associative cortices. It then sends projections to the output structures, i.e., the globus pallidus pars internalis (Gpi) and the substantia nigra pars reticulata (SNr), through two pathways: one direct and the other indirect. The indirect pathway successively involves the globus pallidus pars externalis (Gpe) and the subthalamic nucleus (STN). In addition, the cortex sends direct inputs to the STN and the connections between the Gpe and Gpi.These two pathways seem to play opposite roles in controlling cortical activity. Activation of the direct loop facilitates the triggering of programs at the cortical level through a double inhibition. On the other hand, the indirect loop blocks the activation of thalamic relay by increasing the activity of the Gpi, a GABA-ergic inhibitory structure. Dopamine of nigral origin seems to facilitate the direct pathway through D1 receptors and plays an inhibitory role on the indirect pathway through D2 receptors. The pathological activation of segregated closed loop circuits involving cortex-basal ganglia–thalamus–cortex pathways would produce reverberating activity and result in a persistent discharge of the innate programs characteristic of OCD. The clinical manifestations of neuronal disorders of the basal ganglia can be viewed as a disruption of information processing at the cortical level due to the loss of the focusing action of subcortical inputs.
- Orbito-frontal cortex (OFC)
The OFC is a large brain region, which has been viewed as the highest integration center for emotional processing. By analogy with the Dorsolateral prefrontal cortex (DLPC), which is the prefrontal area for parietal lobe, the OFC can be regarded as the prefrontal area for the temporal lobe. The OFC seems to play a role in situations where the subject has to make rapid alterations in behaviour to accommodate the environmental changes. Several lines of evidence suggested that OFC played a crucial role in the decision-making process based on rewards. Patients with orbitofrontal damage experience great difficulties in decision-making. They also tend to take risks, whether profitable or not. The underactivity of these regions could probably explain the spatial memory deficits and visual memory deficits observed in OCD patients. The repetitive rituals (compulsions) and aggressive behaviour, which is predominant in OCD patients is probably due to serotonin depletion.
- Striatum
The striatum is known to be formed by two types of information-processing modules: the striasomes and the matrisomes. The striasomes receive information from the limbic structures such as amygdala, OFC & ACC. In turn, they send projections to the dopaminergic neurons of the substantia nigra. These anatomical findings suggest that the striasomes could also play a role in the emotional modulation of cortical information. The matrisomes receive information from the lateral parts of the premotor and prefrontal cortices, which are involved in the anticipation behavior and planning. The cholinergic inter-neurons of the striatum, viz. tonically active neurons (TANS), may be playing a particular role in integrating the information flowing through the striasomes and matrisomes.
The limbic part of the striatum (ventral striatum) under the control of the dopaminergic afferents might be involved in reward–driven learning processes. On the other hand, the dorsal striatum seems to be involved in the procedural learning of behavioural routines that are performed almost without conscious effort. In particular, in the context of procedural learning, the disruption of the “readiness” and “release” functions ascribed to the striatum might support some aspects of OCD pathophysiology. However, the striatum could also play a part in other processes potentially disrupted in OCD, such as emotional modulation of information and representation of the expected consequences of action. On the other hand, the performance of repetitive behaviours in OCD patients might have a positive effect on the reduction of anxiety, a process that can be assimilated to some form of reward.
- Amygdala
The amygdala and its various outputs might play a major role in mediating the clinical signs and symptoms of fear and anxiety. Amygdala also appears to play an important role in the expressions of emotion and motivation, probably through its connections with the OFC, ACC and ventral striatum. A dysfunction of this structure, as suggested by some neuroimaging studies in OCD patients, might mediate the non-specific anxiety experienced relative to obsessive thoughts.
- Thalamus
The diencephalic position of the thalamus in the brain explains why it receives large cortical inputs. It participates in emotional expression, cognitive functions and working memory. Thalamic dysfunction has been associated with deficits in executive functions like planning, goal directed behaviour, attention, and working memory.
The repetitive rituals (compulsions) and aggressive behaviour, which is predominant in OCD patients is probably due to serotonin depletion.
- PET Scans show people with OCD have different brain activity from others
- Another theory says that miscommunication between the orbital frontal cortex, the caudate nucleus and the thalamus
- Caudate nucleus doesn’t function properly and causes thalamus to become hyperactive and sends never-ending worry signals between OFC and thalamus OFC responds by increasing anxiety
Diagnosis
- Psychological and psychiatric evaluation.
- Physical examination
Treatments
The two main treatments for OCD are psychotherapy and medications. Often, treatment is most effective with a combination of these.
Pharmacological treatments
The serotonin reuptake inhibitors (SRIs) are consistently effective in patients of Obsessive-compulsive disorder.
Antidepressant drugs viz. fluvoxamine, fluoxetine, paroxetine, sertraline and citalopram have also been found useful in management of OCD.
The atypical antipsychotics such as risperidone act on refractory OCD.
It is done in chronic, severely distressing forms of OCD where conventional treatments are ineffective. Anterior cingulotomy was the most widely used neurosurgical procedure applied in the treatment of anxiety refractory OCD. Two surgical techniques have been used: radiofrequency thermolesion or thermocapsulotomy and the newer radiosurgical or gamma knife capsulotomy techniques
Psychological treatments
Psychological treatments based on cognition-behavioural therapy (CBT) are effective in the treatment of OCD, alone or in combination with SSRIs.
Prognosis
However, OCD remains a chronic illness, with symptoms that may wax and wane during the life of the patient. Roughly 15% of patients can show a progressive worsening of symptoms or deterioration in functioning over time. Approximately 5% of patients have a complete remission of symptoms between episodes of exacerbation.
Complications
- Excessive time spent engaging in ritualistic behaviours.
- Health issues, such as contact dermatitis from frequent hand-washing.
- Difficulty attending work, school or social activities.
- Troubled relationships.
- Overall poor quality of life.
- Suicidal thoughts and behaviour.
Disease & Ayurveda
Mental disorders in Ayurveda comes under the heading unmada which is classified into many types, mostly according to the symptoms. Ayurveda also classifies persons according to psychological traits in the name of Sattwa into deva, aarsha, gaandharva etc. But it is important to understand unmada is a pathological condition where Sattwa is physiological and individually different behaviour patterns only. OCD can be classified into Unmaada where Vaata Pitta and Kapha doshas show their vitiated signs.
Nidana
Consuming food items which are opposite in potency
Insulting god, teachers and noble people in society
Sudden fear and sudden happiness
Unwholesome and unfamiliar physical and mental activities
Purvaaroopa
Not mentioned
Samprapti
Due to the causative factors, the vitiated doshas move irregularly all over the body and cause imbalance in circulation & metabolism. These vitiated doshas when affect hrudaya(seat of all emotions and vitality) and the manovahasrotas(channels carrying psychic impulses), they develop diseases of the mind.
Lakshana
Faulty intellect, believes, and thoughts
Delusion and confusion
Impatience
Unsteadiness of eyes & emotions
Irrelevant speech
Sensation of vacant mind
Divisions
Nija
Agantu
Prognosis
Yaapya
Chikithsa
Treatment of unmada mostly depends upon the signs and symptoms. A person with OCD can have effective Ayurveda treatment and the quality of life can be improved. When thepatient may not be knowing, cleaning the body by expelling out the metabolic waste accumulated in it can enhance proper metabolism. When the metabolism is normal, the brain functions and thereby behaviour of the person get better.
Samana
Takradhaara
Udwartanam
Abhyangam
Moordhapichu
Brumhanam
Sodhana
Snehapanam
Swedanam
Vamanam
Virechanam
Nasya-dhoomapaanam
Snehavasti
Kashayavasti
Commonly used medicines
Mridweekadi kashayam
Brahmeedrakshadi kashayam
Drakshadi kashayam
Brahmarasayanam
Chyavanaprasam
Kallyanaka ghrutam
Saaraswata ghrutam
Brands available
AVS Kottakal
AVP Coimbatore
Vaidyaratnam oushadhasala
SNA oushadhasala
Home remedies
Obsessive-compulsive disorder is a chronic condition, which means it may always be part of the life. While OCD needs treatment by a professional, some things done at home can help get better prognosis:
- Practice the techniques and skills advised by the mental health professional to help manage symptoms, and practice them regularly.
- Take the medications as directed.
- Learn about OCD and stick to treatment plan
- Stay focused on goals.
- Join a support group like reaching out to others facing similar challenges can help.
- Find healthy outlets such as hobbies and recreational activities. Exercise regularly, eat a healthy diet and get adequate sleep.
- Learn relaxation and stress management with the help of meditation, yog or massaging techniques
- Stick with your regular activities like school, work etc.
Diet
- To be avoided
Heavy meals and difficult to digest foods – cause indigestion.
Junk foods- cause disturbance in digestion and reduces the bioavailability of the medicine
Carbonated drinks – makes the stomach more acidic and disturbed digestion
Refrigerated and frozen foods – causes weak and sluggish digestion by weakening agni (digestive fire)
Curd – causes vidaaha and thereby many other diseases
- To be added
Light meals and easily digestible foods
Green gram, soups, buttermilk boiled with turmeric, ginger and curry leaves
Freshly cooked and warm food processed with cumin seeds, ginger, black pepper, ajwain etc
Behaviour:
Better to avoid exposure to excessive sunlight wind rain or dust.
Avoid lifting heavy weights and other vigorous physical activities.
Maintain a regular food and sleep schedule.
Avoid bath in cold water immediately after exercise. Allow body to be in normal temperature.
Yoga
Stretching exercises, meditation for relaxation and following a specific Yogacharya with yoga asanas like suryanamaskara, pavanamuktasana, vajrasana, etc are recommended for improving circulation and digestion.
Regular exercise helps improve bioavailability of the medicine and food ingested and leads to positive health.
Yoga can maintain harmony within and with surroundings.
Suryanamaskara
Pavanamuktasana
Vajrasana
All the exercises and physical exertions must be decided and done under the supervision of a medical expert only.
Research articles