SUMMARY - important
UNDERSTANDING OCD
OFF-LABEL MEDICATIONS USED FOR OCD
READING MATERIAL LINKS
STUDIES SEEKING PATIENTS
REFERENCES
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S = serotonin
D = dopamine
NE = norepinephrine

SUMMARY

There are many ways to fight OCD. There are self help books for milder problems. There is medication and one-on-one therapy for more serious problems. There is a long list of antidepressants to try. If you have a phobia or intolerance for medication you can try exposure and response prevention behavior therapy (E/RP). You can work on reducing the stress in your life. You can learn to recognize when OCD exaggerates the need for caution, or sets unrealistic standards. The more tools you use, the better your odds. There are an estimated 2.5% of the US population will have OCD during their lifetime. If you need something to show your doctor, it's best to take something written by an MD or PhD. (See the Reading Material Links)

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UNDERSTANDING OCD

What is OCD?

OCD is an acronym that stands for obsessive compulsive disorder. It is characterized by obsessions (persistent thoughts that cause anxiety) and/or compulsions (rituals that temporarily reduce anxiety.) They come in different degrees, from annoying to devastating. If the compulsions take at least an hour a day or the symptoms significantly interfere with school, work or relationships, it's probably serious enough to be called OCD. At worst obsessive fears can prevent you from doing normal activities and compulsions can take hours a day. This can lead to losing your job, getting divorced, becoming a recluse or considering suicide. It is an anxiety disorder.

What are some common symptoms? :

Obsessions:

Compulsions:

What causes OCD?

I first got OCD around 1977. I would get better for awhile, then get worse again, then get better etc. This seems to be typical. Here is something I learned over the years. Serotonin (S), dopamine (D), and norepinephrine (NE) are natural chemicals in the brain that must be balanced for good mental health. OCD seems to be caused by an imbalance in these chemicals. 1 And a small study of OCD patients showed they had a significantly higher CNS glutamate levels than the normal controls. 2 Glutamate is associated with overstimulation and anxiety. There are no good or evil neurotransmitters. Too much or too little of any of them relative to the others can cause mental health problems. Adequate levels of all and proper balance between them is everything.

Genetic predisposition (this is fundamental)

Environmental stress (effects level and balance of neurotransmitters)
Learned behavior.
Genetic predisposition is fundamental. Everyone with a high stress level or a strep infection doesn't develop OCD.

Stress is important also. I was never bothered by OCD until I went through a very stressful time in my life. If one identical twin has OCD that doesn't mean that the other one does. So something in the environment must make the difference.

I don't think we learn compulsions from anyone else. My compulsions weren't the result of observing or reading about other people with OCD. Some compulsions seem to be an exaggeration of normal caution, like washing and checking. Other compulsions seem to come out of nowhere, like counting and touching.

I do think we learn to depend on compulsions and avoiding things to control our anxiety. Even when medication improves the chemical imbalance, the compulsions and phobias don't leave suddenly or completely. I do think that culture effects what you obsess about. Nobody was obsessing about germs 300 years ago. If OCD is giving you a bad time, watching a horror movie doesn't help.

When we learn self-critical attitudes we over respond to them. If our parents set high standards, our misperception sets them even higher. If your job requires an attitude of extreme caution or double checking, this makes OCD worse. Religion is supposed to teach right from wrong, but being overly cautious can lead to scrupulosity.

Summary of the causes.

Which treatments are most likely to help?

Don't expect medication alone to be a 100% cure. Even when the chemical imbalance improves, the compulsions and phobias can remain. You might still need ERP. And don't expect ERP therapy alone to be a 100% cure. In my opinion the more serious the imbalance is or the lower neurotransmitter levels are, the less effective ERP will be. Medication and ERP work best together.

Which medications are approved by the FDA for treating OCD?

Brand Name Generic Name Comments
Anafranil clomipramine SRI
Floxyfral, Luvox fluvoxamine SSRI
Aropax, Paxil, Seroxat paroxetine SSRI
Lovan, Prozac fluoxetene SSRI
Lustral, Zoloft sertraline SSRI

What is an SSRI?

This is an acronym that stands for "selective serotonin reuptake inhibitors". They are antidepressants that raise S levels in the brain. In OCD, S is usually too low relative too NE. It's important that these two neurotransmitters be balanced. These medications should help with anxiety and depression as well as obsessions and compulsions. While an SSRI alone helps most people with OCD, it doesn't help all of them.

Just my opinion: Since S down regulates NE receptors. And since SSRIs have a D component. They help bring low D and high NE into balance. I haven't been able to find any references one way or the other, but I think that OCD is partly caused by too much dopamine-beta-hydroxylase, the enzyme that converts D to NE. And that even when D is high enough to cause Tourette's with OCD, NE is even higher. And maybe too much monoamineoxidase makes all the monoamine neurotransmitters (S, NE, D and GABA) lower than average as well. So there might be several underlying problems: (1) serotonin being especially low and/or (2) an imbalance between D and NE and/or (3) all the neurotransmitters being lower than average leading to up regulated receptors. Fortunately for most people with OCD an SSRI alone is all they need. But unfortunately there seems to be several sub types with different underlying chemistry that don't respond to an SSRI alone. Helping them can be a challenging puzzle.

NE and OCD

NE was 20% higher in the cerebrospinal fluid of a group of OCD patients than it was in a group of controls. 4 And NE reuptake inhibitors alone, such as desipramine, do not improve OCD symptoms. 5 But this doesn't mean that OCD patients can't have low NE side effects from taking an SSRI.

D and OCD

Sometimes not enough D is a problem. Antipsychotics (they block D) alone generally make OCD symptoms worse. 6 And a low dose of diphenhydramine (a very anticholinergic medication) alone caused significant improvement in a group of OCD patients. 7 And the SSRIs do more than just raise S. Some of the SSRIs have a strong D component (Anafranil is very anticholinergic), while sertraline is a mild dopamine reuptake inhibitor and Prozac and Paroxetine are mildly anticholinergic. 8 Some people need a strong D component and others can only tolerate a mild one. Anticholinergic medication promotes the action of D. Low dopamine seems to be especially bad for obsessions. And people with Parkinson's who are not on medication (low in dopamine) seem to have a lot of OCD symptoms.

But too much D can make OCD worse. Hyper-dopaminergic mutant mice have symptoms of both OCD and Tourette's. 9 And people who have OCD with Tourette's respond to an SSRI plus antipsychotic medication. And patients who don't respond to an SSRI alone often respond to the combination of an SSRI and an antipsychotic. 10 People taking Parkinson's medication (which results in high dopamine) also seem to have lot of OCD symptoms.

What can cause the chemical imbalance?

Genetic predisposition, strep infections can damage the brain, stress can lower S and raise dopamine-beta-hydroxylase (the enzyme that converts D to NE) 11 and street drugs.

What about benzodiazepines?

BZs especially when combined with an antidepressant are mainstays in the treatment of anxiety disorders. 12

Which receptors are involved?

According to the Wikipedia article on OCD, stimulating histamine, acetylcholine, subtance P or glutamate receptors can make it worse and blocking them can make it better. And stimulating serotonin or Mu opiod receptors can make it better. And the partial effectiveness of various medications results from not addressing all of the receptors involved.13

OFF LABEL MEDICATIONS USED FOR OCD

Other antidepressants that are sometimes used

Medications that are sometimes added to an antidepressant All doctors can prescribe medication for OCD. Psychologists can not prescribe medication, but if they specialize in BT (behavior therapy) or CBT (cognitive behavior therapy) they can do ERP (exposure and response prevention) behavior therapy.

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READING MATERIAL LINKS

General Reading

Self Help Books

Helps with milder problems. For more serious problems, medication with one-on-one therapy is best.

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STUDIES SEEKING PATIENTS