El trastorno obsesivo compulsivo ( TOC ) es un trastorno mental en el que una persona tiene ciertos pensamientos repetidamente (llamados "obsesiones") o siente la necesidad de realizar ciertas rutinas repetidamente (llamadas "compulsiones") hasta un punto que genera angustia o deteriora el funcionamiento general . [1] [2] La persona es incapaz de controlar los pensamientos o las actividades por más de un corto período de tiempo. [1] Las compulsiones comunes incluyen lavarse las manos , contar cosas y verificar si una puerta está cerrada. [1] Estas actividades ocurren en tal grado que la vida diaria de la persona se ve afectada negativamente, [1]a menudo ocupa más de una hora al día. [2] La mayoría de los adultos se dan cuenta de que los comportamientos no tienen sentido. [1] La afección se asocia con tics , trastorno de ansiedad y un mayor riesgo de suicidio . [2] [3]
Desorden obsesivo compulsivo | |
---|---|
Algunas personas con TOC se lavan las manos con frecuencia y en exceso. | |
Especialidad | Psiquiatría |
Síntomas | Siente la necesidad de revisar las cosas repetidamente, realizar ciertas rutinas repetidamente , tener ciertos pensamientos repetidamente [1] |
Complicaciones | Tics , trastorno de ansiedad , suicidio [2] [3] |
Inicio habitual | Antes de los 35 años [1] [2] |
Causas | Desconocido [1] |
Factores de riesgo | Abuso infantil , estrés [2] |
Método de diagnóstico | Según los síntomas [2] |
Diagnóstico diferencial | Trastorno de ansiedad, trastorno depresivo mayor , trastornos alimentarios , trastorno de personalidad obsesivo-compulsivo [2] |
Tratamiento | Asesoramiento , inhibidores selectivos de la recaptación de serotonina , clomipramina [4] [5] |
Frecuencia | 2,3% [6] |
Se desconoce la causa. [1] Parece haber algunos componentes genéticos , y ambos gemelos idénticos se ven afectados con más frecuencia que los dos gemelos no idénticos. [2] Los factores de riesgo incluyen antecedentes de abuso infantil u otros eventos que inducen estrés . [2] Se ha documentado que algunos casos ocurren después de infecciones . [2] El diagnóstico se basa en los síntomas y requiere descartar otras causas médicas o relacionadas con las drogas. [2] Se pueden usar escalas de calificación como la Escala Obsesiva Compulsiva de Yale-Brown (Y-BOCS) para evaluar la gravedad. [7] Otros trastornos con síntomas similares incluyen trastorno de ansiedad, trastorno depresivo mayor , trastornos de la alimentación , trastornos de tic , y trastorno de la personalidad obsesivo-compulsivo . [2]
El tratamiento puede incluir psicoterapia , como terapia cognitivo-conductual (TCC) y antidepresivos , como inhibidores selectivos de la recaptación de serotonina (ISRS) o clomipramina . [4] [5] La TCC para el TOC implica una mayor exposición a los miedos y las obsesiones al tiempo que previene el comportamiento compulsivo que normalmente acompañaría a las obsesiones. [4] Contrariamente a esto, la terapia metacognitiva fomenta los comportamientos rituales para alterar la relación con los pensamientos que uno tiene sobre ellos. [8] Si bien la clomipramina parece funcionar tan bien como los ISRS, tiene mayores efectos secundarios y, por lo tanto, generalmente se reserva como un tratamiento de segunda línea. [4] Los antipsicóticos atípicos pueden ser útiles cuando se usan además de un ISRS en casos resistentes al tratamiento, pero también se relacionan con un mayor riesgo de efectos secundarios. [5] [9] Sin tratamiento, la afección suele durar décadas. [2]
El trastorno obsesivo compulsivo afecta aproximadamente al 2,3% de las personas en algún momento de sus vidas [6], mientras que las tasas durante un año determinado son de aproximadamente el 1,2%. [2] Es inusual que los síntomas comiencen después de los 35 años, y la mitad de las personas desarrollan problemas antes de los 20. [1] [2] Los hombres y las mujeres se ven afectados por igual [1] y el TOC se presenta en todo el mundo. [2] La frase obsesivo-compulsivo a veces se usa de manera informal sin relación con el TOC para describir a alguien como excesivamente meticuloso, perfeccionista , absorto o obsesionado de alguna manera. [10]
Signos y síntomas
El TOC puede presentarse con una amplia variedad de síntomas. Ciertos grupos de síntomas suelen presentarse juntos. A veces, estos grupos se ven como dimensiones o conglomerados que pueden reflejar un proceso subyacente. La herramienta de evaluación estándar para el TOC, la Escala Obsesiva Compulsiva de Yale-Brown (Y-BOCS), tiene 13 categorías predefinidas de síntomas. Estos síntomas encajan en tres a cinco grupos. [11] Una revisión metaanalítica de las estructuras de los síntomas encontró que una estructura de cuatro factores (agrupación) era la más confiable. Los grupos observados incluyeron un "factor de simetría", un "factor de pensamientos prohibidos", un "factor de limpieza" y un "factor de acaparamiento". El "factor de simetría" se correlacionó en gran medida con las obsesiones relacionadas con el orden, el conteo y la simetría, así como con las compulsiones repetidas. El "factor de pensamientos prohibidos" se correlacionó en gran medida con pensamientos intrusivos y angustiantes de naturaleza violenta, religiosa o sexual. El "factor de limpieza" se correlacionó en gran medida con las obsesiones por la contaminación y las compulsiones relacionadas con la limpieza. El "factor de acaparamiento" solo implicaba obsesiones y compulsiones relacionadas con el acaparamiento y se identificó como distinto de otros grupos de síntomas. [12]
Si bien el TOC se ha considerado un trastorno homogéneo desde una perspectiva neuropsicológica, muchos de los supuestos déficits neuropsicológicos pueden ser el resultado de trastornos comórbidos. Además, algunos subtipos se han asociado con la mejora del rendimiento en determinadas tareas, como el reconocimiento de patrones (subtipo de lavado) y la memoria de trabajo espacial (subtipo de pensamiento obsesivo). Los subgrupos también se han distinguido por los hallazgos de neuroimagen y la respuesta al tratamiento. Los estudios de neuroimagen sobre esto han sido muy pocos y los subtipos examinados han diferido demasiado para sacar conclusiones. Por otro lado, se ha estudiado la respuesta al tratamiento dependiente del subtipo, y el subtipo de acaparamiento ha respondido menos sistemáticamente al tratamiento. [13]
Obsesiones
Las obsesiones son pensamientos que se repiten y persisten a pesar de los esfuerzos por ignorarlos o confrontarlos. [14] Las personas con TOC realizan con frecuencia tareas, o compulsiones , para buscar alivio de la ansiedad relacionada con la obsesión. Dentro y entre los individuos, las obsesiones iniciales o los pensamientos intrusivos varían en su claridad y viveza. Una obsesión relativamente vaga podría implicar una sensación general de desorden o tensión acompañada de la creencia de que la vida no puede continuar con normalidad mientras persista el desequilibrio. Una obsesión más intensa podría ser la preocupación por el pensamiento o la imagen de un familiar cercano o amigo muriendo [15] [16] o intrusiones relacionadas con la " rectitud de la relación ". [17] Otras obsesiones se refieren a la posibilidad de que alguien o algo que no sea uno mismo —como Dios, el diablo o la enfermedad— dañe a la persona, a las personas o las cosas que le importan a la persona. Otras personas con TOC pueden experimentar la sensación de protuberancias invisibles que emanan de sus cuerpos o sentir que los objetos inanimados se animan. [18]
Algunas personas con TOC experimentan obsesiones sexuales que pueden incluir pensamientos o imágenes intrusivas de "besos, caricias, caricias, sexo oral , sexo anal , coito , incesto y violación " con "extraños, conocidos, padres, hijos, familiares, amigos, compañeros de trabajo. , animales y figuras religiosas ", y puede incluir" contenido heterosexual u homosexual "con personas de cualquier edad. [19] Al igual que con otros pensamientos o imágenes molestos y desagradables, algunos pensamientos sexuales inquietantes a veces son normales, pero las personas con TOC pueden otorgarles un significado extraordinario. Por ejemplo, los miedos obsesivos sobre la orientación sexual pueden parecerle a la persona con TOC, e incluso a quienes la rodean, como una crisis de identidad sexual . [20] [21] Además, la duda que acompaña al TOC conduce a la incertidumbre sobre si uno podría actuar sobre los pensamientos perturbadores, lo que resulta en autocrítica o autodesprecio. [19]
La mayoría de las personas con TOC comprenden que sus nociones no se corresponden con la realidad; sin embargo, sienten que deben actuar como si sus nociones fueran correctas. Por ejemplo, un individuo que se dedica al acaparamiento compulsivo podría inclinarse a tratar la materia inorgánica como si tuviera la sensibilidad o los derechos de los organismos vivos, mientras acepta que tal comportamiento es irracional en un nivel más intelectual. Existe un debate sobre si el acaparamiento debe considerarse junto con otros síntomas del TOC. [22]
El TOC a veces se manifiesta sin compulsiones manifiestas, que pueden denominarse TOC principalmente obsesivo. El TOC sin compulsiones manifiestas podría, según una estimación, caracterizar hasta el 50-60% de los casos de TOC. [23]
Compulsiones
Algunas personas con TOC realizan rituales compulsivos porque sienten inexplicablemente que deben hacerlo, mientras que otras actúan compulsivamente para mitigar la ansiedad que surge de los pensamientos obsesivos. La persona puede sentir que estas acciones de alguna manera evitarán que ocurra un evento temido o alejarán el evento de sus pensamientos. En cualquier caso, el razonamiento de la persona es tan idiosincrásico o distorsionado que resulta en una angustia significativa para la persona o para quienes la rodean. Pellizcarse la piel en exceso , tirarse del pelo , morderse las uñas y otros trastornos de comportamiento repetitivo centrados en el cuerpo se encuentran en el espectro obsesivo-compulsivo . [2] Algunas personas con TOC son conscientes de que sus comportamientos no son racionales, pero se sienten obligados a seguir adelante con ellos para defenderse de los sentimientos de pánico o pavor. [2] [24]
Algunas compulsiones comunes incluyen lavarse las manos, limpiar, revisar cosas (como cerraduras de puertas), repetir acciones (como encender y apagar interruptores), ordenar artículos de cierta manera y pedir tranquilidad. [25] Las compulsiones son diferentes de los tics (como tocar, golpear, frotar o parpadear) [26] y los movimientos estereotipados (como golpear la cabeza, mecer el cuerpo o morderse a sí mismo), que generalmente no son tan complejos y no son precipitados por obsesiones. [2] A veces puede ser difícil diferenciar entre compulsiones y tics complejos. [2] Aproximadamente del 10% al 40% de las personas con TOC también tienen un trastorno de tics de por vida. [27]
La gente confía en las compulsiones como un escape de sus pensamientos obsesivos; sin embargo, son conscientes de que el alivio es sólo temporal y que los pensamientos intrusivos regresarán pronto. Algunas personas usan compulsiones para evitar situaciones que puedan desencadenar sus obsesiones. Aunque algunas personas realizan acciones repetidamente, no necesariamente las realizan de forma compulsiva. Por ejemplo, las rutinas a la hora de dormir, el aprendizaje de una nueva habilidad y las prácticas religiosas no son compulsiones. El hecho de que los comportamientos sean compulsiones o simples hábitos depende del contexto en el que se llevan a cabo. Por ejemplo, se esperaría ordenar y ordenar libros durante ocho horas al día de alguien que trabaja en una biblioteca, pero parecería anormal en otras situaciones. En otras palabras, los hábitos tienden a aportar eficiencia a la vida, mientras que las compulsiones tienden a interrumpirla. [28]
Además de experimentar la ansiedad y el miedo que suelen acompañar al TOC, los pacientes pueden pasar horas realizando estas compulsiones todos los días. En tales situaciones, puede resultar difícil para la persona cumplir con sus roles laborales, familiares o sociales. En algunos casos, estos comportamientos también pueden causar síntomas físicos adversos. Por ejemplo, las personas que obsesivamente se lavan las manos con jabón antibacteriano y agua caliente pueden enrojecer y enrojecer la piel debido a la dermatitis . [29]
Las personas con TOC pueden usar racionalizaciones para explicar su comportamiento; sin embargo, estas racionalizaciones no se aplican al comportamiento general, sino a cada instancia individualmente. Por ejemplo, una persona que revisa compulsivamente la puerta de entrada puede argumentar que el tiempo que toma y el estrés causado por un control más es mucho menor que el tiempo y el estrés asociados con el robo, y por lo tanto, revisar es la mejor opción. En la práctica, después de esa verificación, la persona aún no está segura y considera que es mejor realizar una verificación más, y este razonamiento puede continuar durante el tiempo que sea necesario.
En la terapia cognitivo-conductual , a los pacientes con TOC se les pide que superen los pensamientos intrusivos sin caer en compulsiones. Se les enseña que los rituales mantienen el TOC fuerte, mientras que no realizarlos hace que el TOC se debilite. [30] Para las conductas repetitivas centradas en el cuerpo (BFRB), como la tricotilomanía , pellizcarse la piel y la onicofagia (morderse las uñas), se recomiendan intervenciones conductuales como el entrenamiento de inversión de hábitos [31] y el desacoplamiento [32] para el tratamiento de conductas compulsivas.
Visión
El DSM-V contiene tres especificadores para el nivel de conocimiento en TOC. La percepción buena o justa se caracteriza por el reconocimiento de que las creencias obsesivo-compulsivas son o pueden no ser ciertas. La falta de conocimiento se caracteriza por la creencia de que las creencias obsesivo-compulsivas probablemente sean ciertas. La ausencia de insight hace que las creencias obsesivo-compulsivas sean pensamientos delirantes y ocurre en aproximadamente el 4% de las personas con TOC. [33]
Ideas sobrevaloradas
Algunas personas con TOC exhiben lo que se conoce como ideas sobrevaloradas . En tales casos, la persona con TOC realmente no estará segura de si los miedos que la llevan a realizar sus compulsiones son irracionales. Después de alguna discusión, es posible convencer al individuo de que sus temores pueden ser infundados. Puede ser más difícil practicar la terapia ERP en estas personas porque es posible que no estén dispuestas a cooperar, al menos inicialmente. Hay casos graves en los que la persona tiene una creencia inquebrantable en el contexto del TOC que es difícil de diferenciar de los trastornos psicóticos . [34]
Rendimiento cognitivo
Aunque alguna vez se creyó que el TOC estaba asociado con una inteligencia superior a la media, este no parece ser necesariamente el caso. [35] Una revisión de 2013 informó que las personas con TOC a veces pueden tener déficits cognitivos leves pero de amplio alcance, más significativamente aquellos que afectan la memoria espacial y, en menor medida, la memoria verbal , la fluidez , la función ejecutiva y la velocidad de procesamiento, mientras que la atención auditiva no fue afectado significativamente. [36] Las personas con TOC muestran un impedimento en la formulación de una estrategia organizativa para codificar la información, el cambio de set y la inhibición motora y cognitiva. [37]
Se han asociado subtipos específicos de dimensiones de síntomas en el TOC con déficits cognitivos específicos. [38] Por ejemplo, los resultados de un metanálisis que compara los síntomas de lavado y verificación informaron que las lavadoras superaron a las damas en ocho de cada diez pruebas cognitivas. [39] La dimensión de los síntomas de la contaminación y la limpieza puede estar asociada con puntuaciones más altas en las pruebas de inhibición y memoria verbal. [40]
Niños
Aproximadamente entre el 1 y el 2% de los niños se ven afectados por el TOC. [41] Los síntomas del trastorno obsesivo-compulsivo tienden a desarrollarse con mayor frecuencia en niños de 10 a 14 años de edad, y los hombres presentan síntomas a una edad más temprana y en un nivel más grave que las mujeres. [42] En los niños, los síntomas se pueden agrupar en al menos cuatro tipos. [11]
Condiciones asociadas
Las personas con TOC pueden ser diagnosticadas con otras afecciones además de OCD o en lugar de ellas, como trastorno obsesivo compulsivo de la personalidad, trastorno depresivo mayor , trastorno bipolar , [43] trastorno de ansiedad generalizada , anorexia nerviosa , trastorno de ansiedad social , bulimia nerviosa. , Síndrome de Tourette , obsesión por la transformación , trastorno del espectro autista , trastorno por déficit de atención con hiperactividad , dermatilomanía (pellizcarse la piel compulsivamente), trastorno dismórfico corporal y tricotilomanía (arrancarse el cabello). Más del 50% de las personas con TOC experimentan tendencias suicidas y el 15% ha intentado suicidarse. [7] La depresión, la ansiedad y los intentos de suicidio previos aumentan el riesgo de futuros intentos de suicidio. [44]
También se ha descubierto que las personas con TOC se ven afectadas por el síndrome de la fase retrasada del sueño a una tasa sustancialmente más alta que el público en general. [45] Además, los síntomas graves del TOC se asocian constantemente con una mayor alteración del sueño. Se ha observado una reducción del tiempo total de sueño y de la eficiencia del sueño en personas con TOC, con retraso en el inicio y la desaparición del sueño y una mayor prevalencia del trastorno de la fase retrasada del sueño. [46]
Algunas investigaciones han demostrado un vínculo entre la adicción a las drogas y el TOC. Por ejemplo, existe un mayor riesgo de adicción a las drogas entre las personas con cualquier trastorno de ansiedad (posiblemente como una forma de lidiar con los niveles elevados de ansiedad), pero la adicción a las drogas entre las personas con TOC puede servir como un tipo de comportamiento compulsivo y no solo como mecanismo de afrontamiento. La depresión también es extremadamente frecuente entre las personas con TOC. Mineka, Watson y Clark (1998) propusieron una explicación para la alta tasa de depresión entre las poblaciones con TOC, quienes explicaron que las personas con TOC (o cualquier otro trastorno de ansiedad) pueden sentirse deprimidas debido a un tipo de sentimiento "fuera de control". [47]
Alguien que exhibe signos de TOC no necesariamente tiene TOC. Los comportamientos que presente como (o parecen ser) obsesivo o compulsivo también se pueden encontrar en una serie de otras condiciones, incluyendo obsesivo-compulsivo de la personalidad trastorno (OCPD), trastorno del espectro autista o trastornos en los que la perseveración es una característica posible ( ADHD , trastorno de estrés postraumático , trastornos corporales o problemas de hábitos), [48] o subclínicamente.
Algunas personas con TOC presentan características típicamente asociadas con el síndrome de Tourette, como compulsiones que pueden parecer tics motores; esto se ha denominado "TOC relacionado con tic" o "TOC Tourettic". [49] [50]
OCD se produce con frecuencia comorbidly tanto con trastorno bipolar y el trastorno depresivo mayor . Entre el 60 y el 80% de las personas con TOC experimentan un episodio depresivo mayor en su vida. Se han informado tasas de comorbilidad entre el 19 y el 90% debido a diferencias metodológicas. Entre el 9% y el 35% de las personas con trastorno bipolar también tienen TOC, en comparación con el 1-2% de la población general. Aproximadamente el 50% de las personas con TOC experimentan rasgos ciclotímicos o episodios hipomaníacos. El TOC también se asocia con trastornos de ansiedad. Se ha informado que la comorbilidad de por vida para el TOC es del 22% para la fobia específica , el 18% para el trastorno de ansiedad social , el 12% para el trastorno de pánico y el 30% para el trastorno de ansiedad generalizada . Se ha informado que la tasa de comorbilidad del TOC y el TDAH es tan alta como del 51%. [51]
Causas
Se desconoce la causa. [1] Se cree que influyen tanto los factores ambientales como los genéticos. Los factores de riesgo incluyen antecedentes de abuso infantil u otros eventos que inducen estrés . [2]
TOC inducido por fármacos
Muchos tipos diferentes de medicamentos pueden crear / inducir TOC puro en pacientes sin síntomas previos. Un nuevo capítulo sobre el TOC en el DSM-5 (2013) ahora incluye específicamente el TOC inducido por fármacos.
Se ha demostrado que los antipsicóticos atípicos ( antipsicóticos de segunda generación) como la olanzapina (Zyprexa) inducen TOC de novo en pacientes. [52] [53] [54] [55]
Genética
Parece haber algunos componentes genéticos con gemelos idénticos afectados con más frecuencia que con gemelos no idénticos. [2] Además, las personas con TOC tienen más probabilidades de tener familiares de primer grado que presenten los mismos trastornos que los controles emparejados. En los casos en los que el TOC se desarrolla durante la infancia, existe un vínculo familiar mucho más fuerte en el trastorno que en los casos en los que el TOC se desarrolla más tarde en la edad adulta. En general, los factores genéticos representan del 45 al 65% de la variabilidad de los síntomas del TOC en los niños diagnosticados con el trastorno. [56] Un estudio de 2007 encontró evidencia que apoya la posibilidad de un riesgo hereditario de TOC. [57]
Se ha encontrado una mutación en el gen transportador de serotonina humana hSERT en familias no relacionadas con TOC. [58]
Una revisión sistemática encontró que si bien ninguno de los alelos se asoció con el TOC en general, en los caucásicos el alelo L se asoció con el TOC. [59] Otro metanálisis observó un aumento del riesgo en aquellos con el alelo homocigótico S, pero encontró que el genotipo LS estaba inversamente asociado con el TOC. [60]
Un estudio de asociación de todo el genoma encontró que el TOC está vinculado con SNP cerca de BTBD3 y dos SNP en DLGAP1 en un análisis basado en trío, pero ningún SNP alcanzó significación cuando se analizó con datos de casos y controles. [61]
Un metanálisis encontró una asociación pequeña pero significativa entre un polimorfismo en SLC1A1 y OCD. [62]
La relación entre TOC y COMT ha sido inconsistente, con un metanálisis que reporta una asociación significativa, aunque solo en hombres, [63] y otro metanálisis que no reporta asociación. [64]
Los psicólogos evolucionistas han postulado que las versiones moderadas de la conducta compulsiva pueden haber tenido ventajas evolutivas. Ejemplos de ello serían el control constante y moderado de la higiene, el hogar o el medio ambiente en busca de enemigos. De manera similar, el acaparamiento puede haber tenido ventajas evolutivas. Desde este punto de vista, el TOC puede ser la "cola" estadística extrema de tales comportamientos, posiblemente el resultado de un gran número de genes predisponentes. [sesenta y cinco]
Autoinmune
Una hipótesis controvertida [66] es que algunos casos de TOC de inicio rápido en niños y adolescentes pueden ser causados por un síndrome relacionado con infecciones estreptocócicas del grupo A conocidas como trastornos neuropsiquiátricos autoinmunitarios pediátricos asociados con infecciones estreptocócicas ( PANDAS ). [66] Se presume que el TOC y los tics surgen en un subconjunto de niños como resultado de un proceso autoinmune posestreptocócico . [67] [68] [69] La hipótesis PANDAS no está confirmada ni respaldada por datos, y se han propuesto dos nuevas categorías: PANS (síndrome neuropsiquiátrico de aparición aguda pediátrica) y CANS (síndrome neuropsiquiátrico agudo infantil). [68] [69] Las hipótesis CANS / PANS incluyen diferentes mecanismos posibles subyacentes a las afecciones neuropsiquiátricas de inicio agudo, pero no excluyen las infecciones por GABHS como causa en un subconjunto de individuos. [68] [69] PANDAS, PANS y CANS son el foco de la investigación clínica y de laboratorio, pero aún no han sido probados. [67] [68] [69] Se debate si PANDAS es una entidad distinta que difiere de otros casos de tic o de TOC. [70] [71] [72] [73]
Una revisión de los estudios que examinan los ganglios basales anti- anticuerpos en el TOC encontró un mayor riesgo de tener anticuerpos anti-ganglios basales en aquellos con TOC frente a la población general. [74]
Mecanismos
Neuroimagen
La neuroimagen funcional durante la provocación de síntomas ha observado actividad anormal en la corteza orbitofrontal , corteza prefrontal dorsolateral izquierda , corteza premotora derecha , circunvolución temporal superior izquierda , globo pálido externo , hipocampo y uncus derecho . Se encontraron focos más débiles de actividad anormal en el caudado izquierdo , la corteza cingulada posterior y el lóbulo parietal superior . [75] Sin embargo, un metanálisis más antiguo de neuroimagen funcional en el TOC informó que el único hallazgo consistente de neuroimagen funcional fue un aumento de la actividad en la circunvolución orbitaria y la cabeza del núcleo caudado , mientras que las anomalías de activación del ACC eran demasiado inconsistentes. [76] Un metanálisis que comparó tareas afectivas y no efectivas observó diferencias con los controles en las regiones implicadas en la prominencia, el hábito, la conducta dirigida a objetivos, el pensamiento autorreferencial y el control cognitivo. Para las tareas no efectivas, se observó hiperactividad en la ínsula, ACC y cabeza del caudado / putamen , mientras que se observó hipoactividad en la corteza prefrontal medial (mPFC) y el caudado posterior. Se observó que las tareas afectivas se relacionan con una mayor activación en el precuneus y la corteza cingulada posterior (PCC), mientras que se encontró una disminución de la activación en el pálido , el tálamo anterior ventral y el caudado posterior. [77] La participación del bucle cortico-estriato-tálamo-cortical en el TOC, así como las altas tasas de comorbilidad entre el TOC y el TDAH, han llevado a algunos a establecer un vínculo en su mecanismo. Las similitudes observadas incluyen la disfunción de la corteza cingulada anterior y la corteza prefrontal , así como déficits compartidos en las funciones ejecutivas. [78] La participación de la corteza orbitofrontal y la corteza prefrontal dorsolateral en el TOC se comparte con el trastorno bipolar y puede explicar el alto grado de comorbilidad. [ cita requerida ] También se ha observado en el TOC una disminución de los volúmenes de la corteza prefrontal dorsolateral relacionada con la función ejecutiva. [79]
People with OCD evince increased grey matter volumes in bilateral lenticular nuclei, extending to the caudate nuclei, with decreased grey matter volumes in bilateral dorsal medial frontal/anterior cingulate gyri.[80][81] These findings contrast with those in people with other anxiety disorders, who evince decreased (rather than increased) grey matter volumes in bilateral lenticular/caudate nuclei, as well as decreased grey matter volumes in bilateral dorsal medial frontal/anterior cingulate gyri.[81] Increased white matter volume and decreased fractional anisotropy in anterior midline tracts has been observed in OCD, possibly indicating increased fiber crossings.[82]
Cognitive models
Generally two categories of models for OCD have been postulated, the first involving deficits in executive function, and the second involving deficits in modulatory control. The first category of executive dysfunction is based on the observed structural and functional abnormalities in the dlPFC, striatum and thalamus. The second category involving dysfunctional modulatory control primarily relies on observed functional and structural differences in the ACC, mPFC and OFC.[83][84]
One proposed model suggests that dysfunction in the OFC leads to improper valuation of behaviors and decreased behavioral control, while the observed alterations in amygdala activations leads to exaggerated fears and representations of negative stimuli.[85]
Because of the heterogeneity of OCD symptoms, studies differentiating various symptoms have been performed. Symptom-specific neuroimaging abnormalities include the hyperactivity of caudate and ACC in checking rituals, while finding increased activity of cortical and cerebellar regions in contamination-related symptoms. Neuroimaging differentiating content of intrusive thoughts has found differences between aggressive as opposed to taboo thoughts, finding increased connectivity of the amygdala, ventral striatum and ventromedial prefrontal cortex in aggressive symptoms while observing increased connectivity between the ventral striatum and insula in sexual/religious intrusive thoughts.[86]
Another model proposes that affective dysregulation links excessive reliance on habit-based action selection[87] with compulsions. This is supported by the observation that those with OCD demonstrate decreased activation of the ventral striatum when anticipating monetary reward, as well as increased functional connectivity between the VS and the OFC. Furthermore, those with OCD demonstrate reduced performance in Pavlovian fear-extinction tasks, hyperresponsiveness in the amygdala to fearful stimuli, and hyporesponsiveness in the amygdala when exposed to positively valanced stimuli. Stimulation of the nucleus accumbens has also been observed to effectively alleviate both obsessions and compulsions, supporting the role of affective dysregulation in generating both.[85]
Neurobiological
From the observation of the efficacy of antidepressants in OCD, a serotonin hypothesis of OCD has been formulated. Studies of peripheral markers of serotonin, as well as challenges with proserotonergic compounds have yielded inconsistent results, including evidence pointing towards basal hyperactivity of serotonergic systems.[88] Serotonin receptor and transporter binding studies have yielded conflicting results, including higher and lower serotonin receptor 5-HT2A and serotonin transporter binding potentials that were normalized by treatment with SSRIs. Despite inconsistencies in the types of abnormalities found, evidence points towards dysfunction of serotonergic systems in OCD.[89] Orbitofrontal cortex overactivity is attenuated in people who have successfully responded to SSRI medication, a result believed to be caused by increased stimulation of serotonin receptors 5-HT2A and 5-HT2C.[90]
A complex relationship between dopamine and OCD has been observed. Although antipsychotics, which act by antagonizing dopamine receptors may improve some cases of OCD, they frequently exacerbate others. Antipsychotics, in the low doses used to treat OCD, may actually increase the release of dopamine in the prefrontal cortex, through inhibiting autoreceptors. Further complicating things is the efficacy of amphetamines, decreased dopamine transporter activity observed in OCD,[91] and low levels of D2 binding in the striatum.[92] Furthermore, increased dopamine release in the nucleus accumbens after deep brain stimulation correlates with improvement in symptoms, pointing to reduced dopamine release in the striatum playing a role in generating symptoms.[93]
Abnormalities in glutamatergic neurotransmission have implicated in OCD. Findings such as increased cerebrospinal glutamate, less consistent abnormalities observed in neuroimaging studies and the efficacy of some glutamatergic drugs such as the glutamate-inhibiting riluzole have implicated glutamate in OCD.[92] OCD has been associated with reduced N-Acetylaspartic acid in the mPFC, which is thought to reflect neuron density or functionality, although the exact interpretation has not been established.[94]
Diagnóstico
Formal diagnosis may be performed by a psychologist, psychiatrist, clinical social worker, or other licensed mental health professional. To be diagnosed with OCD, a person must have obsessions, compulsions, or both, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM). The Quick Reference to the 2000 edition of the DSM states that several features characterize clinically significant obsessions and compulsions, and that such obsessions are recurrent and persistent thoughts, impulses or images that are experienced as intrusive and that cause marked anxiety or distress. These thoughts, impulses or images are of a degree or type that lies outside the normal range of worries about conventional problems.[95] A person may attempt to ignore or suppress such obsessions, or to neutralize them with some other thought or action, and will tend to recognize the obsessions as idiosyncratic or irrational.
Compulsions become clinically significant when a person feels driven to perform them in response to an obsession, or according to rules that must be applied rigidly, and when the person consequently feels or causes significant distress. Therefore, while many people who do not suffer from OCD may perform actions often associated with OCD (such as ordering items in a pantry by height), the distinction with clinically significant OCD lies in the fact that the person who suffers from OCD must perform these actions to avoid significant psychological distress. These behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these activities are not logically or practically connected to the issue, or they are excessive. In addition, at some point during the course of the disorder, the individual must realize that his or her obsessions or compulsions are unreasonable or excessive.
Moreover, the obsessions or compulsions must be time-consuming (taking up more than one hour per day) or cause impairment in social, occupational or scholastic functioning.[95] It is helpful to quantify the severity of symptoms and impairment before and during treatment for OCD. In addition to the person's estimate of the time spent each day harboring obsessive-compulsive thoughts or behaviors, concrete tools can be used to gauge the person's condition. This may be done with rating scales, such as the Yale–Brown Obsessive Compulsive Scale (Y-BOCS; expert rating)[96] or the obsessive-compulsive inventory (OCI-R; self-rating).[97] With measurements such as these, psychiatric consultation can be more appropriately determined because it has been standardized.[7]
OCD is sometimes placed in a group of disorders called the obsessive–compulsive spectrum.[98]
Differential diagnosis
OCD is often confused with the separate condition obsessive–compulsive personality disorder (OCPD). OCD is egodystonic, meaning that the disorder is incompatible with the sufferer's self-concept.[99][100] Because egodystonic disorders go against a person's self-concept, they tend to cause much distress. OCPD, on the other hand, is egosyntonic—marked by the person's acceptance that the characteristics and behaviours displayed as a result are compatible with their self-image, or are otherwise appropriate, correct or reasonable.
As a result, people with OCD are often aware that their behavior is not rational and are unhappy about their obsessions but nevertheless feel compelled by them.[101] By contrast, people with OCPD are not aware of anything abnormal; they will readily explain why their actions are rational. It is usually impossible to convince them otherwise, and they tend to derive pleasure from their obsessions or compulsions.[101]
Gestión
A form of psychotherapy called "cognitive behavioral therapy" (CBT) and psychotropic medications are first-line treatments for OCD.[1][102] Other forms of psychotherapy, such as psychodynamic and psychoanalysis may help in managing some aspects of the disorder, but in 2007 the American Psychiatric Association (APA) noted a lack of controlled studies showing their effectiveness "in dealing with the core symptoms of OCD".[103]
Therapy
The specific technique used in CBT is called exposure and response prevention (ERP), which involves teaching the person to deliberately come into contact with the situations that trigger the obsessive thoughts and fears ("exposure") without carrying out the usual compulsive acts associated with the obsession ("response prevention"), thus gradually learning to tolerate the discomfort and anxiety associated with not performing the ritualistic behavior. At first, for example, someone might touch something only very mildly "contaminated" (such as a tissue that has been touched by another tissue that has been touched by the end of a toothpick that has touched a book that came from a "contaminated" location, such as a school). That is the "exposure". The "ritual prevention" is not washing. Another example might be leaving the house and checking the lock only once (exposure) without going back and checking again (ritual prevention). The person fairly quickly habituates to the anxiety-producing situation and discovers that his or her anxiety level drops considerably; he or she can then progress to touching something more "contaminated" or not checking the lock at all—again, without performing the ritual behavior of washing or checking.[104]
ERP has a strong evidence base, and it is considered the most effective treatment for OCD.[104] However, this claim was doubted by some researchers in 2000, who criticized the quality of many studies.[105] A 2018 review found that self-help metacognitive training improved symptoms in OCD.[106] A 2007 Cochrane review also found that psychological interventions derived from CBT models were more effective than treatment as usual consisting of no treatment, waiting list or non-CBT interventions.[107] For body-focused repetitive behaviors (BFRB), behavioral interventions are recommended by reviews such as habit-reversal training[31] and decoupling.[32]
It has generally been accepted that psychotherapy in combination with psychiatric medication is more effective than either option alone.[108]
Medication
The medications most frequently used are the selective serotonin reuptake inhibitors (SSRIs).[4] Clomipramine, a medication belonging to the class of tricyclic antidepressants, appears to work as well as SSRIs but has a higher rate of side effects.[4]
SSRIs are a second-line treatment of adult obsessive compulsive disorder with mild functional impairment and as first-line treatment for those with moderate or severe impairment. In children, SSRIs can be considered as a second-line therapy in those with moderate to severe impairment, with close monitoring for psychiatric adverse effects.[102] SSRIs are efficacious in the treatment of OCD; people treated with SSRIs are about twice as likely to respond to treatment as are those treated with placebo.[109][110] Efficacy has been demonstrated both in short-term (6–24 weeks) treatment trials and in discontinuation trials with durations of 28–52 weeks.[111][112][113]
In 2006, the National Institute of Clinical and Health Excellence (NICE) guidelines recommended antipsychotics for OCD that does not improve with SSRI treatment.[5] For OCD there is tentative evidence for risperidone and insufficient evidence for olanzapine. Quetiapine is no better than placebo with regard to primary outcomes, but small effects were found in terms of YBOCS score. The efficacy of quetiapine and olanzapine are limited by an insufficient number of studies.[114] A 2014 review article found two studies that indicated that aripiprazole was "effective in the short-term" and found that "[t]here was a small effect-size for risperidone or anti-psychotics in general in the short-term"; however, the study authors found "no evidence for the effectiveness of quetiapine or olanzapine in comparison to placebo."[5] While quetiapine may be useful when used in addition to an SSRI in treatment-resistant OCD, these drugs are often poorly tolerated, and have metabolic side effects that limit their use. None of the atypical antipsychotics appear to be useful when used alone.[9] Another review reported that no evidence supports the use of first-generation antipsychotics in OCD.[115]
A guideline by the APA suggested that dextroamphetamine may be considered by itself after more well-supported treatments have been tried.[116]
Procedures
Electroconvulsive therapy (ECT) has been found to have effectiveness in some severe and refractory cases.[117]
Surgery may be used as a last resort in people who do not improve with other treatments. In this procedure, a surgical lesion is made in an area of the brain (the cingulate cortex). In one study, 30% of participants benefitted significantly from this procedure.[118] Deep-brain stimulation and vagus nerve stimulation are possible surgical options that do not require destruction of brain tissue. In the United States, the Food and Drug Administration approved deep-brain stimulation for the treatment of OCD under a humanitarian device exemption requiring that the procedure be performed only in a hospital with special qualifications to do so.[119]
In the United States, psychosurgery for OCD is a treatment of last resort and will not be performed until the person has failed several attempts at medication (at the full dosage) with augmentation, and many months of intensive cognitive–behavioral therapy with exposure and ritual/response prevention.[120] Likewise, in the United Kingdom, psychosurgery cannot be performed unless a course of treatment from a suitably qualified cognitive–behavioral therapist has been carried out.
Children
Therapeutic treatment may be effective in reducing ritual behaviors of OCD for children and adolescents.[121] Similar to the treatment of adults with OCD, CBT stands as an effective and validated first line of treatment of OCD in children.[122] Family involvement, in the form of behavioral observations and reports, is a key component to the success of such treatments.[123] Parental interventions also provide positive reinforcement for a child who exhibits appropriate behaviors as alternatives to compulsive responses. In a recent meta-analysis of evidenced-based treatment of OCD in children, family-focused individual CBT was labeled as "probably efficacious", establishing it as one of the leading psychosocial treatments for youth with OCD.[122] After one or two years of therapy, in which a child learns the nature of his or her obsession and acquires strategies for coping, that child may acquire a larger circle of friends, exhibit less shyness, and become less self-critical.[124]
Although the causes of OCD in younger age groups range from brain abnormalities to psychological preoccupations, life stress such as bullying and traumatic familial deaths may also contribute to childhood cases of OCD, and acknowledging these stressors can play a role in treating the disorder.[125]
Epidemiología
Obsessive–compulsive disorder affects about 2.3% of people at some point in their life,[6] with the yearly rate about 1.2%. OCD occurs worldwide.[2] It is unusual for symptoms to begin after the age of 35 and half of people develop problems before 20.[1][2] Males and females are affected about equally.[1]
Pronóstico
Quality of life is reduced across all domains in OCD. While psychological or pharmacological treatment can lead to a reduction of OCD symptoms and an increase in reported quality of life, symptoms may persist at moderate levels even following adequate treatment courses, and completely symptom-free periods are uncommon.[126][127] In pediatric OCD, around 40% still have the disorder in adulthood, and around 40% qualify for remission.[128]
Historia
In the 7th century AD, John Climacus records an instance of a young monk plagued by constant and overwhelming "temptations to blasphemy" consulting an older monk,[129]:212 who told him, "My son, I take upon myself all the sins which these temptations have led you, or may lead you, to commit. All I require of you is that for the future you pay no attention to them whatsoever."[129]:212 The Cloud of Unknowing, a Christian mystical text from the late 14th century, recommends dealing with recurring obsessions by first attempting to ignore them,[129]:213 and, if that fails, "cower under them like a poor wretch and a coward overcome in battle, and reckon it to be a waste of your time for you to strive any longer against them",[129]:213 a technique now known as "emotional flooding".[129]:213
From the 14th to the 16th century in Europe, it was believed that people who experienced blasphemous, sexual or other obsessive thoughts were possessed by the devil.[99][129]:213 Based on this reasoning, treatment involved banishing the "evil" from the "possessed" person through exorcism.[130][131] The vast majority of people who thought that they were possessed by the devil did not suffer from hallucinations or other "spectacular symptoms",[129]:213 but "complained of anxiety, religious fears, and evil thoughts."[129]:213 In 1584, a woman from Kent, England named Mrs. Davie, described by a justice of the peace as "a good wife",[129]:213 was nearly burned at the stake after she confessed that she experienced constant, unwanted urges to murder her family.[129]:213
The English term obsessive-compulsive arose as a translation of German Zwangsvorstellung ('obsession') used in the first conceptions of OCD by Carl Westphal. Westphal's description went on to influence Pierre Janet, who further documented features of OCD.[33] In the early 1910s, Sigmund Freud attributed obsessive–compulsive behavior to unconscious conflicts that manifest as symptoms.[130] Freud describes the clinical history of a typical case of "touching phobia" as starting in early childhood, when the person has a strong desire to touch an item. In response, the person develops an "external prohibition" against this type of touching. However, this "prohibition does not succeed in abolishing" the desire to touch; all it can do is repress the desire and "force it into the unconscious."[132] Freudian psychoanalysis remained the dominant treatment for OCD until the mid-1980s,[129]:210–211 even though medicinal and therapeutic treatments were known and available,[129]:210 because it was widely thought that these treatments would be detrimental to the effectiveness of the psychotherapy.[129]:210 In the mid-1980s, this approach changed[129]:210 and practitioners began treating OCD primarily with medicine and practical therapy rather than through psychoanalysis.[129]:210
Notable cases
John Bunyan (1628–1688), the author of The Pilgrim's Progress, displayed symptoms of OCD (which had not yet been named).[129]:53–54 During the most severe period of his condition, he would mutter the same phrase over and over again to himself while rocking back and forth.[129]:53–54 He later described his obsessions in his autobiography Grace Abounding to the Chief of Sinners,[129]:53–54 stating, "These things may seem ridiculous to others, even as ridiculous as they were in themselves, but to me they were the most tormenting cogitations."[129]:54 He wrote two pamphlets advising those suffering from similar anxieties.[129]:217–218 In one of them, he warns against indulging in compulsions:[129]:217–218 "Have care of putting off your trouble of spirit in the wrong way: by promising to reform yourself and lead a new life, by your performances or duties".[129]:218
British poet, essayist and lexicographer Samuel Johnson (1709–1784) also suffered from OCD.[129]:54–55 He had elaborate rituals for crossing the thresholds of doorways, and repeatedly walked up and down staircases counting the steps.[133][129]:55 He would touch every post on the street as he walked past,[129]:55 only step in the middles of paving stones,[129]:55 and repeatedly perform tasks as though they had not been done properly the first time.[129]:55
The American aviator and filmmaker Howard Hughes is known to have had OCD.[134] Friends of Hughes have also mentioned his obsession with minor flaws in clothing.[135] This was conveyed in The Aviator (2004), a film biography of Hughes.[136]
sociedad y Cultura
Art, entertainment and media
Movies and television shows may portray idealized or incomplete representations of disorders such as OCD. Compassionate and accurate literary and on-screen depictions may help counteract the potential stigma[137] associated with an OCD diagnosis, and lead to increased public awareness, understanding and sympathy for such disorders.[138]
- In the film As Good as It Gets (1997), actor Jack Nicholson portrays a man with OCD[139] who performs ritualistic behaviors that disrupt his life.[139]
- The film Matchstick Men (2003), directed by Ridley Scott, portrays a con man named Roy (Nicolas Cage) with OCD who opens and closes doors three times while counting aloud before he can walk through them.[140]
- In the television series Monk (2002–2009), the titular character Adrian Monk fears both human contact and dirt.[141][142]
- In Turtles All the Way Down (2017), a young adult novel by author John Green, teenage main character Aza Holmes struggles with OCD that manifests as a fear of the human microbiome. Throughout the story, Aza repeatedly opens an unhealed callus on her finger to drain out what she believes are pathogens. The novel is based on Green's own experiences with OCD. He explained that Turtles All the Way Down is intended to show how "most people with chronic mental illnesses also live long, fulfilling lives".[143]
- The British TV series Pure (2019) stars Charly Clive as a 24-year-old Marnie who is plagued by disturbing sexual thoughts, as a kind of primarily obsessional obsessive compulsive disorder.[144] The series is based on a book of the same name by Rose Cartwright.
Investigar
The naturally occurring sugar inositol has been suggested as a treatment for OCD.[145]
μ-Opioids, such as hydrocodone and tramadol, may improve OCD symptoms.[146] Administration of opiate treatment may be contraindicated in individuals concurrently taking CYP2D6 inhibitors such as fluoxetine and paroxetine.[147]
Much current research is devoted to the therapeutic potential of the agents that affect the release of the neurotransmitter glutamate or the binding to its receptors. These include riluzole,[148] memantine, gabapentin, N-acetylcysteine, topiramate and lamotrigine.[citation needed]
Otros animales
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enlaces externos
- Obsessive–compulsive disorder at Curlie
- National Institute Of Mental Health
- American Psychiatric Association
- APA Division 12 treatment page for obsessive-compulsive disorder
- Davis, Lennard J. (2008). Obsession: A History. University of Chicago Press. ISBN 978-0-226-13782-7.
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