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Obsessive-compulsive personality disorder

Introduction
Cause
Examine
Diagnosis

Introduction

Introduction Obsessive-compulsive disorder, referred to as obsessive-compulsive disorder, is a type of neurological disorder characterized by repeated obsessions. The concept of obsession is a thought, representation or intention that repeatedly enters the field of patient consciousness in a rigid form. These thoughts, representations, or intentions are of no practical significance, unnecessary or superfluous to the patient; the patient realizes that these are his own thoughts, and he wants to get rid of it, but he is powerless and therefore very distressed. Forced action is a repetitive stereotype or ritual action that is the result of a patient's succumbing to a forced mind to reduce inner anxiety.

Cause

Cause

(1) Causes of the disease

In the past, most of the disease was thought to stem from mental factors and personality defects. In the past 20 years, genetic and biochemical research, especially the widespread use of drugs, has shown a significant effect, suggesting that the disease has its biological basis.

1. Genetic factors family survey showed that the risk of anxiety disorder among the first-degree relatives of the obsessive-compulsive proband was significantly higher than that of the control group. If the person with obsessive-compulsive symptoms but did not meet the diagnostic criteria was included, the patient groups parents The risk of obsessive-compulsive symptoms (15.6%) was significantly higher than that of the control group (2.9%). Twin studies have shown that the same rate of twins is higher than that of twins. It suggests that the occurrence of obsessive-compulsive disorder may have a certain genetic predisposition.

2. Biochemical changes Some people think that 5-HT energy system may be related to the onset of obsessive-compulsive disorder. Drugs with 5-HT reuptake retardation, such as selective 5-HT reuptake inhibitor (SSRI), can be effective for obsessive-compulsive disorder. Some scholars have found that patients with obsessive-compulsive disorder have elevated serum prolactin or cortisol, and its role in the development of obsessive-compulsive disorder is still unclear.

3. Anatomical and physiological disconnection of the frontal lobe and striatum is effective for refractory obsessive-compulsive disorder, presumably related to dysfunction of basal ganglia.

Psychology

(1) The psychodynamic theory of the Freudian school: The psychological mechanisms of the formation of obsessive-compulsive symptoms include: fixation, regression, isolation, release, reaction formation, and replacement of impermissible sexual and aggression impulses. This defense mechanism is unconscious and therefore not perceived by the patient. (2) The learning theory of the behaviorist school: The behaviorist school believes that first, the patient causes anxiety due to a special situation. In order to alleviate anxiety, the patient produces an avoidance response, which is manifested as a forced ritual action. Some neutral stimuli such as thoughts and imaginations (such as language, words, representations, and thoughts) are accompanied by initial stimuli, which can further form a higher level of conditioning, which generalizes anxiety and ultimately leads to the formation of obsessive concepts.

(two) pathogenesis

1. The results of the family survey showed that the risk of anxiety disorder in the first-degree relatives of patients with obsessive-compulsive disorder was significantly higher than that of the first-degree relatives of the control group, but their risk of obsessive-compulsive disorder was not higher than that of the control group. If patients with first-degree relatives who had obsessive-compulsive symptoms but did not meet the diagnostic criteria for obsessive-compulsive disorder were included, the risk of parental obsessive-compulsive symptoms in the patient group (15.6%) was significantly higher than that of the control group (2.9%) ( Black et al., 1992). This compulsive feature has a higher prevalence in monozygotic twins than in twin twins (Carey and Gottesman, 1981). These results suggest that certain qualities of compulsive behavior are heritable. Other reports indicate that obsessive-compulsive disorder can coexist with schizophrenia, depression, panic disorder, phobia, eating disorders, autism, and hyperactive slang syndrome.

2. Clomipramine, fluoxetine, fluvoxamine, paroxetine, sertraline, etc. have drugs that inhibit 5-HT reuptake, and have obsessive-compulsive symptoms. Good results; and other tricyclic antidepressants that inhibit 5-HT reuptake, such as amitriptyline, imipramine, and imipramine, have poor therapeutic effects on obsessive-compulsive disorder. The reduction of obsessive-compulsive symptoms is often accompanied by a decrease in platelet 5-HT content and cerebrospinal fluid 5-hydroxyindoleacetic acid (5-HIAA) content. Pre-treatment platelet 5-HT and cerebrospinal fluid in patients with higher basal levels of 5-HIAA were better with clomipramine. Oral administration of a selective 5-HT agonist, methyl-chlorophenyl-piperazine (mCPP), can temporarily increase obsessive-compulsive symptoms. These all suggest that the increased function of the serotonin (5-HT) system is associated with the onset of obsessive-compulsive disorder.

3. Some clinical evidence suggests that the onset of obsessive-compulsive disorder may be associated with selective basal ganglia dysfunction. For example, in the hyperactive slang syndrome, which is closely related to basal ganglia dysfunction, 15% to 18% of patients have obsessive-compulsive symptoms, which is much higher than the prevalence of obsessive-compulsive disorder in general residents (2%); head trauma, rheumatoid dance Symptoms, after Economo encephalitis, the basal ganglia is damaged and the patient has obsessive-compulsive symptoms; brain CT examination shows that some patients with obsessive-compulsive disorder have a reduced volume of bilateral caudate nucleus (Luxenberg et al., 1988); positron emission brain scans have been found In patients with obsessive-compulsive disorder, the bilateral caudate nucleus and the lateral metabolic potential of the frontal cortex are elevated (Baxter et al., 1987); patients with good results with 5-HT reuptake inhibitory or behavioral therapy have caudate nucleus, frontal lobe and Excessive activity of cingulate gyrus decreased (Baxter et al., 1992; Perani et al., 1995). Patients with active behavioral therapy also observed a significant decrease in synergistic activity between the detour and the caudate nucleus, suggesting that the dysfunctional brain circuit was severed (Schwartz et al., 1996). It has been suggested that the severity of the obsessive-compulsive concept is associated with the frontal and basal ganglia activities, and the accompanying anxiety reflects the hippocampus and cingulate cortex activity (McGuire et al., 1994), Brita et al. (1996), functional magnetic resonance imaging. Imaging (fMRI) showed that the behavioral-induced OCD symptoms in real-time showed a significant increase in the relative blood flow of the caudate nucleus, cingulate gyrus, and frontal cortex compared to resting state. Based on this type of research, the hypothesis is that the obsessive-compulsive disorder is caused by the dysfunction of the plaque-edge-basal ganglia. Resection of the frontal lobe and striatum is used to treat refractory obsessive-compulsive disorder and to reduce symptoms (Kettle and Marks, 1986), supporting this theory.

4. The Freudian school regards obsessive-compulsive disorder as a further development of the pathological compulsive character. Because the defense mechanism can't handle the anxiety of compulsive personality formation, it produces obsessive-compulsive symptoms. The psychological mechanisms of compulsive symptoms include: fixation, regression, isolation, release, reaction formation, and replacement of impermissible sexual and aggression impulses. This defense mechanism is unconscious and therefore not perceived by the patient.

The behaviorist school uses a two-stage learning theory to explain the mechanisms by which obsessive-compulsive symptoms occur and persist. In the first phase, anxiety is caused by a particular situation through classical conditioning. In order to alleviate anxiety, the patient develops an escape or avoidance response, which is manifested as a forced ritual movement. If the anxiety is alleviated by means of ritual actions or avoidance reactions, in the second stage, such compulsive behaviors are repeated and continued through operational conditioning. Neutral stimuli such as language, words, representations, and thoughts are accompanied by initial stimuli, which can further form a higher level of conditioning and generalize anxiety.

Examine

an examination

Obsessive-compulsive disorder is characterized by persistent, imposed, unwanted thinking and uncontrollable thinking. Compulsive thinking is often about polluting, hurting yourself or others, disasters, blasphemy, violence, sex or other painful topics. These thoughts are the patient's own, not inserted by the outside world (such as the "thinking insertion" of schizophrenia. This kind of thinking also includes the imagination or scene in the brain, which makes the patient very painful and can lead to Extremely upset.

The basic symptoms of the disease are obsession and compulsion. More than 90% of patients have both obsessive and compulsive behaviors; but according to Of et al. (1995), 28% of patients are mainly obsessive-compulsive, 20% are mainly forced, and 50% are very protruding. The patient has a certain degree of self-awareness about the obsessive-compulsive symptoms, knowing that such thinking or behavior is unreasonable or unnecessary, and trying to control is not successful. About 5% of patients do not think that their concept and behavior are unreasonable when they first get sick, and there is no treatment requirement, which is called obsessive-compulsive obsessive-compulsive disorder.

Obsession concept

Refers to the thoughts, appearances, emotions or intentions that repeatedly enter the field of patient consciousness. These are of no practical significance to the patient, and are unnecessary or redundant. The patient can also clearly realize that this is not right, and know that these are his own psychological activities, and he wants to get rid of it, but he is powerless and therefore very distressed.

(1) Obsessional thoughts: Some words, discourses, ideas or beliefs repeatedly enter the field of patient consciousness, interfere with the normal thinking process, knowing that it is not right and can not be controlled, can not get rid of, can have the following forms of expression.

1 Forced suspicion: The patient repeatedly doubts the correctness of his words and deeds; knowing that it is unnecessary, but can not get rid of it. For example, when you go out, you suspect that the gas is closed; although it has been checked once, twice, three times... still not assured. Another example is whether the file is signed with its own name, whether it is wrong, whether the number of pages is correct, and so on. At the same time of suspicion, often accompanied by anxiety and anxiety, it prompts patients to repeatedly check their behavior, can not terminate, very painful.

2 Compulsive and exhaustive thinking: The patient has some questions or natural phenomena in daily life, and he has to think about it in detail. He knows that there is no practical meaning, but it is not necessary, but he cannot control himself. For example, thinking over and over again: Why is rice white, millet is yellow? And coal is black? Why are leaves green, not other colors? Sometimes they can't stop, so they can't eat, sleep, sleep, and can't be relieved. Some patients show that they are endlessly arguing with their own minds.

3 Forced association: When a patient sees a sentence or a word, or a concept appears in his mind, he or she can't help but think of another idea or phrase. If Lenovos concept or statement is contrary to its original meaning, such as unity, it immediately associates with split; seeing the sky... immediately associates with underground... and so on, calling compulsive opposition (or compulsive opposition). thinking). Because the emergence of the concept of opposites violates the subjective will of the patient, the patient is often distressed.

4 Forced representation: refers to the repeated visual experience (representation) in the mind, often with a disgusting nature, can not get rid of.

5 Forced recall: The patient's experience of the incident has been repeatedly presented in his mind, unable to get rid of, and feel distressed.

(2) Forced emotions: manifested as unnecessarily worried or disgusting with certain things, knowing that it is unnecessary or unreasonable, and that they cannot get rid of themselves. For example, worry that you will offend a colleague or boss, worry about the people around you, and worry that you will be irrational, fearing that you are contaminated with poison or bacteria. If you see a hospital, a mortuary, or someone, you immediately have a strong sense of disgust or fear, knowing it is unreasonable, but you can't control it, so you try to avoid it, called obsessional phobia.

(3) Forced intention: The patient repeatedly experiences and wants to make a strong inner impulse to act or act contrary to his or her wishes. It is absurd and impossible for patients to know that it is impossible to try to control themselves not to do it, but they cannot get rid of this inner impulse. For example, there is an inner impulse to jump down the window of a tall building; looking at his beloved wife, what kind of intentions would be like to kill her. Although this kind of inner impulse was very strong at the time, it was never put into action.

2. Forced behavior refers to recurring, rigid ritual movements that are unreasonable but have to be done. Often responsive to the anxiety caused by obsessive-compulsive attitudes, but these behaviors do not give a pleasant feeling, with forced examinations and forced cleansing (especially hand washing) most common. Patients often see that they can prevent certain objectively unlikely events and consider them to be harmful to patients, often secondary to forced suspicion.

(1) Forced examination: It is the measure taken by the patient to alleviate the anxiety caused by compulsive suspicion. If you repeatedly check the doors, windows, gas and water pipes when you go out, check the contents of the file repeatedly when you send the documents to see if you have written the wrong words.

(2) Forced cleaning: The patient always has dirty clothes in the hands or clothes. In order to eliminate the fear of contamination by dirt, odor or bacteria, he often washes his hands, bathes or washes clothes. Some patients not only wash themselves repeatedly, but also those who want to live with him, such as spouses, children, parents, etc. must also be thoroughly cleaned according to his requirements.

(3) Forced inquiry: OCD patients often do not believe in themselves. In order to eliminate doubts or to worry about the anxiety of patients, it is often repeated to ask others to give explanations or guarantees. Some patients can express themselves in their own minds, asking themselves and answering them repeatedly to enhance their self-confidence.

(4) Compulsive ritual action: When a patient produces a strong, persistent, uncontrollable forced impulse or desire to perform certain actions, often leading to anxiety and extreme uneasiness, it can be temporarily relieved by performing specific ritual actions. This kind of uneasiness. This ritual action is usually associated with forced thinking. For example, the patient thinks that "my hand is dirty", which in turn stimulates repeated hand washing. Other patients repeatedly imagine that electricity and gas can cause fires, thus triggering repeated inspections of power supplies, electrical appliances, outlets, and gas switches. Most common forced ritual movements are cleaning or inspection. Other ritual actions, including going out, must go two steps forward and then step back, before going out; otherwise the patient feels intense nervousness. Before taking a seat, you must first touch your seat with your finger to sit down; this action may be symbolic in eliminating the concept of obsession. Compulsive counting, counting stairs, counting panes or doing things have a specific and stereotypical order. These movements are repeated, others seem unreasonable or ridiculous, and have no practical meaning in themselves, but the patient has completed the ritual movement just to reduce or prevent the tension caused by obsession or avoid anxiety.

Some patients only count in their own mind, or repeat certain sentences to relieve anxiety, is a mental compulsion. This symptom is not uncommon and is often overlooked. Although ritual actions are intended to alleviate anxiety or restlessness, this reduction in anxiety is usually short-lived. Some patients will think it necessary to repeat this ritual many times. Because many obsessive-compulsive patients have more than one type of forced thinking and related ritual movements, many of the time will be occupied by these ritual actions. In addition, obsessive-compulsive disorder can lead to avoidance of some things or situations (such as dirt, leaving home to avoid locking the door), thus affecting life. The symptoms of obsessive-compulsive disorder are dominant, unhelpful, and annoying to patients, families, friends, and colleagues.

(5) Compulsive slowness can cause slow action due to ritual movements; for example, repeated inspections of electrical appliances and gas at the time of going out, so that patients can not go out late, even when they get on the train, they have to go back to their homes for inspection, which often makes them impossible to be on time. Go to work. But it may also be original. For example, whenever a patient reads a book, his eyes often stop at a certain word in a certain line, and the following contents cannot be read smoothly. This phenomenon may stem from the fact that the patient is not sure whether he has seen or understood the line of words and is therefore stagnant. These patients often do not feel anxious.

The above-mentioned obsessive-compulsive symptoms often make the patient entangled in some unrealistic concepts and behaviors, hindering normal work and life, and making patients feel distressed.

The pre-morbid personality of patients with obsessive-compulsive disorder is often characterized by coercion. This personality trait will be described in the Personality Disorders chapter. There are two main manifestations of this disease:

First, forced thinking is the main clinical symptom, including compulsive concept, forced recall, forced appearance, forced suspicion, compulsive opposition, forced obsessive thinking, compulsive fear and so on.

Second, forced movements are the main clinical symptoms, such as forced washing, forced checkup, forced inquiry, and forced ritualization.

Characteristics of obsessive symptoms:

His thoughts and actions belong to himself; at least one of his forced thinking and movements is still vainly resisted by the patient, and at the same time, he is accompanied by obvious anxiety because of the unsuccessful resistance; repeated thoughts, appearances or impulses make the patient very unhappy. These symptoms can make patients feel troubled by the fact that they are entangled in meaningless behaviors and behaviors that hinder normal work and life. Obsessive-compulsive patients have a pre-existing personality with compulsive characteristics.

According to the typical obsessive-compulsive symptoms, the patient recognizes that the obsessive-compulsive symptoms originate from oneself, rather than being imposed or influenced by others, recurring, meaningless, knowingly not correct, and unable to get rid of, disturbing their daily life and learning. And work, very anxious, distressed, trying to eliminate or confront, or urgently require treatment, the general diagnosis is not difficult. However, in chronic cases, after trying to get rid of the obsessive-compulsive symptoms, patients form a behavior that adapts to their pathological psychology, no longer feel distressed about their obsessive-compulsive symptoms, and instead insist on retaining their pathological behavior and no longer require treatment. About 5% of patients do not think that their concept and behavior are unreasonable, and there is no treatment requirement, which is called obsessive-compulsive disorder.

According to ICD-10, forced thinking or behavior (or both) makes the patient feel painful, life is affected, is the patient's own thinking or impulse, and at the same time, at least one kind of thinking or action must not be resisted, think or do these The ritual movement is unpleasant, reluctantly repeating forced thinking or ritual movements. Most of the time, symptoms exist for more than 3 months, at least 2 weeks, can be diagnosed as obsessive-compulsive disorder.

Diagnosis

Differential diagnosis

Differential diagnosis of obsessive-compulsive personality disorder:

1. Forced thinking of schizophrenia obsessive-compulsive disorder is sometimes mistaken for illusion of schizophrenia. However, patients with obsessive-compulsive disorder often have self-knowledge and believe that this forced thinking is unrealistic. They often feel painful and anxiety because they cannot avoid it. However, patients with schizophrenia may have obsessive-compulsive symptoms in the early stage, and their obsessive-compulsive symptoms lack obvious psychology. The incentive has the characteristics of bizarre content, variable form and incomprehensibility. Moreover, patients often do not feel distressed, without obvious anxiety, and have no strong desire for self-control and desire for treatment, and their self-knowledge is incomplete. And the emergence of obsessive-compulsive symptoms in patients with schizophrenia It is only a part of the symptoms of schizophrenia, and may be accompanied by other symptoms of schizophrenia, which can be used as a basis for identification. In patients with chronic obsessive-compulsive disorder, short-term psychotic symptoms may occur, but they may recover soon. It is not considered that schizophrenia has developed at this time. A small number of cases of schizophrenia can coexist with obsessive-compulsive disorder, and the next two diagnoses should be made.

2. Depressive depression patients may have obsessive-compulsive symptoms, often expressed as excessive thinking or thinking about specific thoughts. However, these thoughts of depressive disorder are not as meaningless as obsessive-compulsive disorder, and depression, which is usually accompanied by obsessive-compulsive symptoms, is still dominated by depressed mood disorders. People with obsessive-compulsive disorder are also often associated with depression. It should be analyzed from the pathogenesis process to analyze whether the main clinical symptoms are obsessive-compulsive symptoms or depression; whether the obsessive-compulsive symptoms are primary or secondary to depression. The obsessive-compulsive symptoms of depression patients can be eliminated with the disappearance of depression; and the depression of patients with obsessive-compulsive disorder can also be improved by the reduction of obsessive-compulsive symptoms. Two types of symptoms exist independently and should be diagnosed in the next two cases.

3. The core symptom of phobia phobia is fear of a special environment or object. The object of fear comes from objective reality, with obvious avoidance behavior, without obsessive attitude; while forced thinking and behavior are derived from the subjective experience of the patient; Its avoidance behavior is related to forced suspicion and forced fear. Both diseases can also exist at the same time.

4. Brain organic diseases Central nervous system organic diseases, especially basal ganglia lesions can also appear obsessive-compulsive symptoms. Identification based on medical history and physical signs.

5. Excessive repetitive behaviors with intrinsic pleasure, such as gambling, drinking or smoking, cannot be considered compulsive. The behavior of forced behavior is an unpleasant repetition.

6. Obsessive-compulsive disorder, in addition to comorbidity with schizophrenia and depression, can also be associated with hyperactive slang syndrome, tic disorder, panic disorder, simple phobia and social phobia, eating disorder, autism, etc. presence. All should be diagnosed according to the diagnostic criteria.

The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) is useful for understanding the characteristics of the symptoms, establishing a good doctor-patient relationship, and designing a behavioral treatment plan.

Obsessive-compulsive disorder is characterized by persistent, imposed, unwanted thinking and uncontrollable thinking. Compulsive thinking is often about polluting, hurting yourself or others, disasters, blasphemy, violence, sex or other painful topics. These thoughts are the patient's own, not inserted by the outside world (such as the "thinking insertion" of schizophrenia). This kind of thinking also includes imaginations or situations in the brain that make the patient very painful and can cause extreme anxiety.