Rumination disorder

Obsessive-Compulsive Disorder Patients with obsessive-compulsive disorder complain of anxiety-producing intrusive thoughts and/or perform repetitive, anxiety-reducing rituals. A combination of behavior therapy and drug therapy is generally beneficial in this relatively common disorder. Behavior therapy consists of exposing patients to anxiety-provoking situations and helping them avoid ritualistic responses. Drug therapy appears to work by blocking serotonin reuptake in the brain. Obsessive-compulsive disorder has aroused the curiosity of medical investigators since before the turn of the century. According to the revised Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R),(1) "the essential feature of this disorder is recurrent obsessions or compulsions sufficiently severe to cause marked distress, be time-consuming, or significantly interfere with the person's normal routines, occupational functioning, or usual social activities or relationships with others." The diagnostic criteria for obsessive-compulsive disorder are presented in Table 1.

Obsessions are repetitive, unwanted, intrusive thoughts or impulses that arouse considerable anxiety in an individual, even though the individual recognizes that these thoughts and impulses are irrational or senseless. Compulsions, which usually follow obsessions, are repetitive, ritualistic mental or stereotypic behaviors that an individual feels compelled to perform in order to reduce the anxiety aroused by associated obsessions. Common obsessions and corresponding compulsions are listed in Table 2.

Recent epidemiologic studies document a lifetime prevalence rate for obsessive-compulsive disorder of about 2.5 percent and one-month and six-month prevalence rates of 1.3 percent and 1.5 percent, respectively.(2,3) Thus, obsessive-compulsive disorder is almost three times more common than schizophrenia. Most patients present with both obsessions and compulsions, but about 15 percent have pure obsessional disorder. Obsessive-compulsive disorder tends to be more common in early adolescence and in the third decade of life. Onset after age 35 is rare.

The symptoms of obsessive-compulsive disorder commonly wax and wane, but complete remission is unusual. The disorder is often accompanied by considerable psychosocial disability, usually in proportion to the severity of the symptoms. Frequently, patients with mild obsessive-compulsive disorder can continue to function, despite the interference and distress caused by the disorder.

Illustrative Case

A 20-year-old woman presented at her family physician's office with the complaint that her four-year-old daughter had "lumps" in her neck. Similar visits during the preceding year had resulted in the diagnosis of "well child." Each time that her daughter was found to be healthy, the mother had expressed considerable gratitude and exhibited reduced anxiety.

After reviewing the history and determining that the child was indeed well, the physician and the mother discussed her concerns about the child's health. With some reluctance (she was embarrassed by her unrealistic level of concern), the mother explained that she feared her daughter might "catch" cancer. As a result, she did not allow the child to play with other children if they had a family history of cancer. She also fed the child "natural foods" and gave her vitamin E daily.

The mother also worried that she herself might inadvertently "infect" the child. After shopping for groceries, she often spent several hours washing the food before allowing her family to eat what she had purchased. Recently, fearing contamination by cancer-causing germs, she had begun selecting food items from the back shelves in the supermarket. Although the mother was concerned about her daughter, not herself, she washed her own hands 40 to 60 times a day because she was worried that she might carry contaminated substances home from her part-time job as a clerk. As a result, she had developed a chronic hand dermatitis.

When questioned about the extra time involved in these activities, the mother estimated that she was preoccupied with unrealistic worries for four to six hours a day and that she spent at least three more hours each day performing rituals intended to reduce the anxiety associated with her obsessions. When asked about the consequences of these behaviors, the woman tearfully explained that her marriage was falling apart and that she felt tremendously guilty about "putting my daughter and husband through this hell."

Etiologic Factors

The cause of obsessive-compulsive disorder is unknown, although various etiologic theories have been proposed. Psychodynamic speculation has focused on unconscious aggressive impulses (represented in the obsessions), which are counteracted by elaborate "undoing" rituals. Behavioral or social learning theories generally describe the onset of conditioned anxiety, usually centered on the fear of harm to self or loved ones, followed by trial-and-error generalization of anxiety-reducing rituals and avoidance behaviors to new situations. Family therapists, less concerned with the intrapsychic origin of obsessions, emphasize the role of the symptom in dysfunctional family patterns.

Recent neurobiologic evidence suggests that obsessive-compulsive disorder may be caused by a defect in serotonergic input to higher cortical centers. This defect, it has been proposed, results in an inability to manage the typical worries of everyday life.

Positron emission tomography in drugfree patients with obsessive-compulsive disorder demonstrates abnormalities in the caudate nuclei and orbital gyri that are not present in normal control subjects. These abnormalities return toward normal after symptomatically successful drug therapy with the weak serotonin reuptake blocker, trazodone (Desyrel).(4) Clomipramine (Anafranil), fluvoxamine and, perhaps, fluoxetine (Prozac), which are all potent serotonin reuptake blockers, have been effective in some patients with obsessive-compulsive disorder.

Abnormal markers for platelet serotonin, alterations in the metabolism of serotonin in the central nervous system and various neuroendocrine abnormalities also have been found in patients with obsessive-compulsive disorder. These abnormalities were not found in normal control subjects or psychiatric patients with other disorders.(5,6)

While the neurobiologic and behavioral theories are supported by limited empiric data, all of these theoretic positions are best viewed as descriptions rather than causal explanations of obsessive-compulsive disorder.

Differential Diagnosis and Evaluation

Obsessive-compulsive disorder is usually easy to diagnose, based on the characteristic pattern of senseless obsessions and corresponding mental or behavioral rituals. Frequently, the physician can arrive at a preliminary diagnosis by asking the patient one or two appropriate questions, such as "Do you worry a lot about certain things?" or "Do you ever check that the lights are off or the doors are locked even when you already know they are?"

It is important to remember, however, that many patients are extremely embarrassed by their symptoms because they themselves view the symptoms as exaggerated and senseless and because the obsessions often have aggressive or sexual themes. Consequently, the diagnosis of obsessive-compulsive disorder may require a high index of suspicion, especially when the presenting complaint involves anxiety, excessive worry about medical problems, or physical complaints such as chronic hand dermatitis.

Although they may have been treated with anxiolytics or insight-oriented psychotherapy, many patients with obsessive-compulsive disorder have not received an appropriate diagnosis. An accurate diagnosis, along with an explanation of the disorder and its treatment, is frequently a great relief for these patients.

Differentiating obsessive-compulsive disorder from major depression, other anxiety disorders and the psychotic disorders, particularly schizophrenia, depends on the mental content of the obsessions. The patient's subjective reaction to the obsessions and compulsions is also important in the differential diagnosis.

As many as one-third of patients with obsessive-compulsive disorder develop secondary major depression. Secondary and primary depression differ in the sequence of symptoms: secondary depression follows the onset of obsessive-compulsive disorder, which is then considered the primary disorder. Obsessive symptoms developing in the context of primary major depression, besides differing in the timing of symptom onset, are characterized more by rumination on depressive themes (guilt, self-doubt, low self-esteem or suicidal thoughts) than by anxiety. As a rule, such themes are not considered senseless by the depressed person, and they are not followed by anxiety-reducing rituals.

Among the anxiety disorders, the phobic disorders are perhaps most similar to obsessive-compulsive disorder. Phobias are usually limited to one or sometimes a few situations, are less senseless than the obsessions seen in obsessive-compulsive disorder, and usually involve avoidance of the feared situation, rather than ritualization, as the means of reducing anxiety. Post-traumatic stress disorder, which shares intrusive ideas and avoidance rituals with obsessive-compulsive disorder, differs from the latter in that the symptoms are clearly related to a preceding traumatic event.

The psychotic disorders share an interesting and sometimes difficult diagnostic boundary with obsessive-compulsive disorder. This is especially so when a patient's obsessions become ego-syntonic and overvalued (i.e., when the patient "almost" believes them to be true). Such obsessions can be falsely labeled as delusional beliefs (without a foundation in reality and without skepticism on the part of the patient), and they may appear similar to the delusions seen in schizophrenia. Careful questioning can usually clarify the distinction between obsessions and delusions, especially when the historical development of the symptom is considered. The diagnosis of schizophrenia is also suggested by the presence of other features of the disorder, such as auditory hallucinations or loose associations, which are rarely, if ever, seen in straightforward obsessive-compulsive disorder.

While many personality styles are represented among patients with obsessive-compulsive disorder, avoidant and dependent personalities are the most common. Obsessive-compulsive personality disorder, although overrepresented among individuals with obsessive-compulsive disorder, is not a risk factor per se for obsessive-compulsive disorder. The prognosis for individuals with schizotypal personality disorder who develop obsessive-compulsive disorder is poorer than average, perhaps because of a common predisposition to schizophrenia.(7) In obsessive-compulsive disorder, as in other psychiatric disturbances, patients with severe personality disorders may have difficulty cooperating with treatment.

Symptoms reminiscent of obsessive-compulsive disorder have been associated with various neuropsychiatric illnesses, such as postconcussion syndromes, encephalitis and central nervous system mass lesions. Toxic psychoses, whether metabolic or caused by drug ingestion or withdrawal, may also manifest with obsessional symptoms. However, in psychiatry, as in family medicine, uncommon presentations are more often manifestations of common disorders than rare illnesses, and the majority of obsessional outpatients have obsessive-compulsive disorder rather than other disorders.

The diagnosis of obsessive-compulsive disorder, as implied above, rests almost entirely on careful history taking. Since many patients receive drug therapy, routine laboratory studies are an acceptable, if not required, initial adjunct to diagnosis. Thyroid function tests, including thyroid-stimulating hormone, may identify the occasional obsessively depressed hypothyroid patient. There is no indication for routine head scans using computed tomographic scanning or magnetic resonance imaging or for electroencephalographic evaluations. In most cases, neuropsychiatric and psychologic tests are not useful in establishing the diagnosis.

Therapy

BEHAVIOR THERAPY

There is little evidence that psychodynamic psychotherapy is effective in patients with obsessive-compulsive disorder. On the contrary, the symptoms of many patients with the disorder fail to resolve with insight-oriented psychotherapy. While psychotherapy may be useful for other problems in patients with obsessive-compulsive disorder, it cannot be recommended as a primary treatment for obsessive-compulsive disorder itself.

Behavior therapy, on the other hand, is of proven benefit in obsessive-compulsive disorder.(8) Improvement of symptoms has been shown to persist over time, with a parallel improvement in depressive symptoms and overall functioning in family and work settings. Treatment consists of exposure and response prevention, directed primarily toward the patient's compulsions, since it is more difficult to gain access to a patient's obsessions. For example, a man with cleaning compulsions stemming from an obsessional fear of germ contamination would, with his permission, be exposed gradually to specific objects that he feels are contaminated. "Homework," mandating exposure to these objects and the elimination of avoidance behavior and other rituals, is almost always prescribed and may be the only treatment required in many cases. In the patient in the illustrative case, homework might consists, in part, of eliminating, delaying or reducing the time the patient spends washing her hands.

In general, 30 to 45 minutes of exposure to a specific feared situation or object is sufficient for the patient's anxiety to attenuate during a single session. Repeated exposure is almost always necessary, but with encouragement, most patients readily move up the stimulus hierarchy toward more difficult exposure situations. Further behavior therapy may be needed as new obsessions or compulsions periodically appear.

Flooding, or confronting the patient with the most feared stimulus first, can be effective and may be worth a try when the disorder is mild and the patient desires rapid improvement. Patients with primary obsessional symptoms sometimes respond to though stopping techniques or their reverse, satiation (a form of mental exposure therapy).(9) Marks(8) and Goldstein and Foa(9) present more detailed discussions of the various techniques used in behavior therapy. Interestingly, some patients have been able to treat themselves behaviorally with the assistance of a self-help manual.(10)

Behavior therapy is generally considered the treatment of first choice, because it has been shown to be at least as effective as psychopharmacologic interventions in reducing the symptoms of obsessive-compulsive disorder.(11) However, as many as 15 percent of patients refuse behavior therapy, and another 10 percent are unable to comply with the suggested regimen for exposure and response prevention. A number of patients simply do not improve, despite a high level of compliance. A few patients also have severe depressive symptoms that warrant drug therapy. These facts, as well as the occasional unavailability of behavior therapy and its time-consuming nature, make drug therapy an attractive option for many patients.

DRUG THERAPY

Given the chronic nature and associated disability of severe obsessive-compulsive disorder, it is not surprising that there have been anecdotal reports of treatment success for most classes of psychopharmacologic medications.(8) The empiric literature, however, does not support the use of neuroleptics, stimulants or anticonvulsants in the treatment of obsessive-compulsive disorder, except in the case of concomitant schizotypal personality disorder, where low-dose neuroleptics may be helpful.(12)

Benzodiazepine anxiolytics, while capable of ameliorating generalized anxiety disorder, do not affect obsessions or compulsions and should be used sparingly, if at all, in the treatment of obsessive-compulsive disorder. Benzodiazepines also may reduce the effectiveness of behavior therapy because of state-dependent learning (i.e., what is learned in the drugged state does not transfer well to the nondrugged state). Preliminary data suggest that buspirone (BuSpar), a nonbenzodiazepine anxiolytic that is effective in generalized anxiety disorder, is not beneficial in obsessive-compulsive disorder.(13)

The empiric literature also fails to support the use of standard tricyclic antidepressants, such as imipramine (Janimine, Tipramine, Tofranil) or nortriptyline (Aventyl, Pamelor), or monoamine oxidase inhibitors, such as phenelzine (Nardil) or tranylcypromine (Parnate), in patients with obsessive-compulsive disorder. Although lithium (Eskalith, Lithane, Lithobid) is not effective in obsessive-compulsive disorder, it may be used to augment clomipramine, fluvoxamine or fluoxetine therapy.

Fortunately for patients with obsessive-compulsive disorder, effective psychopharmacologic agents are becoming available. More than ten placebo-controlled, double-blind trials(8,11) have shown clomipramine to be beneficial in the treatment of obsessive-compulsive disorder. Although most patients experience only a 30 percent reduction in obsessions and compulsions, the improvement in psychosocial function is often far greater. The level of symptom relief is roughly comparable to that obtained with behavior therapy. A few patients experience complete resolution of symptoms. In most cases, patients derive more benefit from behavior therapy following successful drug treatment.

Since clomipramine is a chloro-substituted modification of imipramine, the two drugs have similar side effect profiles, including anticholinergic effects (dry mouth, constipation), antihistaminic effects (sedation) and a-adrenergic-blocking effects (orthostatic hypotension). However, orgasmic dysfunction, which may occur in as many as 90 percent of men and women taking clomipramine, is less common in patients taking imipramine.(14)

Clomipramine is likely to become generally available in the United States in mid-1990. It is currently available via experimental protocols from CIBA-Geigy directly and through various university centers engaged in blinded trials of the use of clomipramine in obsessive-compulsive disorder.

Two other medications, fluvoxamine and fluoxetine, may also be useful in patients with obsessive-compulsive disorder. Fluvoxamine, a novel serotonin reuptake blocker unrelated to standard antidepressants,(15) may be approved for the treatment of obsessive-compulsive disorder within the next two years. Fluvoxamine is generally well tolerated by most patients, although it may produce gastrointestinal side effects and hyperarousal. However, fewer than 10 percent of patients with obsessive-compulsive disorder discontinue fluvoxamine therapy because of side effects.(16)

Fluoxetine, another serotonin reuptake blocker recently marketed in the United States as an antidepressant, may be effective in obsessive-compulsive disorder when administered in higher doses than those commonly used in the treatment of depression.(17) Unfortunately, many patients are unable to tolerate high doses of this drug because of hyperarousal, anorexia or other gastrointestinal side effects.

Unlike clomipramine, fluvoxamine and fluoxetine are essentially devoid of anticholinergic and antihistaminic side effects and do not adversely affect blood pressure or cardiac conduction. Because of their side effect profiles, both fluvoxamine and fluoxetine are probably safer than other agents under conditions of overdosage.

Role of the Family Physician

As in many psychiatric disorders, most patients with obsessive-compulsive disorder will be seen and treated by primary care physicians rather than by psychiatrists. Because obsessive-compulsive disorder is more common than was previously recognized and because effective treatments are now available, it is important for family physicians to have a high index of suspicion for the diagnosis.

Once the diagnosis is made, it is entirely appropriate for the interested family physician to direct a course of behavior therapy as well as a trial of fluoxetine or one of the other new agents when they are released by the Food and Drug Administration. Patients who do not respond readily to standard treatments or who have complicating medical or psychiatric conditions should be referred at the time of diagnosis. Family physicians who are uncertain about the diagnosis or who would prefer to delegate treatment should refer patients to a psychiatrist interested in the behavioral and biologic treatment of anxiety disorders.

Information about referral sources, including psychiatrists currently authorized to administer clomipramine or fluvoxamine, is available through the Obsessive-Compulsive Disorder Foundation (P.O. Box 9573, New Haven, CT 06535) or the Phobia Society of America (P.O. Box 42514, Washington, DC 20015). The former group is useful as a resource for the patient with obsessive-compulsive disorder and for the relatives of an affected person; the latter group serves a similar function for patients with phobias and related anxiety disorders, including obsessive-compulsive disorder. For family physicians interested in learning more about anxiety disorders, the Phobia Society of America presents excellent combined professional and lay continuing education programs.

TABLE 1

Diagnostic Criteria for Obsessive-Compulsive Disorder A. Either obsessions or compulsions:

Obsessions: (1), (2), (3), and (4):

(1) recurrent and persistent ideas, thoughts, impulses, or images that are

experienced, at least initially, as intrusive and senseless, e.g., a parent's

having repeated impulses to kill a loved child, a religious person's having

recurrent blasphemous thoughts

(2) the person attempts to ignore or suppress such thoughts or impulses or

to neutralize them with some other thought or action

(3) the person recognizes that the obsessions are the product of his or her

own mind, not imposed from without (as in though insertion)

(4) if another Axis I [psychiatric] disorder is present, the content of the

obsession is unrelated to it, e.g., the ideas, thoughts, impulses, or

images are not about food in the presence of an Eating Disorder, about

drugs in the presence of a Psychoactive Substance Use Disorder, or

guilty thoughts in the presence of a Major Depression

Compulsions: (1), (2), and (3):

(1) repetitive, purposeful, and intentional behaviors that are performed in

response to an obsession, or according to certain rules or in a

stereotyped fashion

(2) the behavior is designed to neutralize or to prevent discomfort or some

dreaded event or situation; however, either the activity is not connected

in a realistic way with what it is designed to neutralize or prevent, or it is

clearly excessive

(3) the person recognizes that his or her behavior is excessive or

unreasonable (this may not be true for young children; it may no longer

be true for people whose obsessions have evolved into overvalued ideas) B. The obsessions or compulsions cause marked distress, are time-consuming

(take more than an hour a day), or significantly interfere with the person's

normal routine, occupational functioning, or usual social activities or

relationships with others.

TABLE 2

Common Obsessions and Compulsions

TABLE 3

Partial Differential Diagnosis of Obsessive-Compulsive Disorder Depressive disorders

Major depression Anxiety disorders

Generalized anxiety disorder

Simple phobia

Social phobia

Panic disorder

Post-traumatic stress disorder Psychotic disorders

Delusional disorder

Schizophrenia Personality disorders

Obsessive-compulsive personality disorder

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