Written by: Emeritus Consultant Dr Chee Kuan Tsee
Edited by: Dr Low Tchern Kuang Lambert, Honorary Treasurer, on behalf of Singapore Psychiatric Association
Introduction
In holistic psychiatric practice we emphasize the importance of inter-relation, interaction and integration/dissociation between the individual and environment; between the body and mind; between the mental functions and neural circuits; and between the past and present life events and experiences. Mental disorders are therefore multi-factorial in causality and multidisciplinary in management.
Before discussing Obsessive Compulsive Disorder [OCD], it is worthwhile explaining what obsessional traits mean as such traits are normal when present.
Obsessional traits involve preoccupation with perfectionism. As a result of the want to be perfect, the individual lives in ambivalence and constant doubt about what he/she thinks, feels, does and whether he/she is making the correct choices or decisions. This process can be anxiety evoking and paralyzing. Once a solution is reached, he/she tends to follow a rigid routine and avoid or resist changes that would necessitate another round of decision making and adjustments which would be laborious and painful.
Theories on OCD causation
Based on psychoanalytic theories, unresolved conflict during the Anal Stage of Freud’s model of psychosexual development is a possible aetiological factor. There is ambivalence about what is right and wrong or good and bad during this stage.
Biological understanding based on organic aetiologies, neurochemistry and brain images indicate lesions in the basal ganglia [motor] with link to prefrontal cortex (DLPFC) [cognitive] forming loops.
OCD (Obsessive Compulsive Disorder) diagnosis
Diagnosis and treatment of OCD is often delayed and distorted because patients have difficulty expressing and explaining their symptoms or psychic experiences.
Often leading questions fulfilling diagnostic criteria, e.g. attempts to resist, have to be asked when the condition is suspected. However other differential diagnosis with similar phenomenology involving obsessive ruminations need to be ruled out. These conditions are mentioned below.
Psychopathology in OCD
It is more than just a check listing exercise.
The good clinician should enquire into the developmental, sequential and dynamic stages of symptoms as well as their specific contents.
There is a wise quote/saying attributed to various sources:
“Beware of your thoughts for they become words [heard or believed]
Beware of your words for they become actions/deeds
Beware of your actions/deeds for they become habits
Beware of your habits for they become your character
And your character becomes your destiny.”
Clinical OCD
Consists of two components:
- Obsessive symptoms – that which is said to be anxiogenic causing anxiety
i.e. involuntary, intrusive and recurrent thoughts or obsessive ruminations cause anxiety
[Obsessive ruminations may be in the form of images (visual), music/song, funny joke (auditory) and situation that is transient and not altogether unpleasant. However when persistent, these unwelcome negative impulses/urges (affective) become distressing.]
- Compulsive symptoms – that which is said to be anxiolytic relieving anxiety
Compulsive behavior includes both physical and mental rituals such as checking, washing, repetitive actions and speech, e.g. seeking of reassurance which is carried out repeatedly with accumulative elaboration till “satisfaction” to relieve tension/anxiety.
Third Aspect – associated with obsessive ruminations and contents
Primary (conscious) obsessive rumination may lead to hearing of one’s thought which can be indistinguishable from auditory hallucinations in the form of thought echo (echo de la pensee). This can subsequently lead to a secondary fixed belief indistinguishable from an overvalued or delusional idea which is perhaps understandable to the clinician.
“Obsessive rumination” in the unconscious mind [akin to many programs/apps open simultaneously in the background of a smart-phone or tablet, using up the memory of the device] might possibly give rise to hallucination, delusion and passivity experience [like intrusive or interrupting pop-ups in the monitor screen] that would be non-understandable and psychotic.
Complaints may appear to be “thought disordered” to the casual listener and patients may also act on or respond to the subjective contents of the “secondary” auditory hallucination or delusional idea, hence appearing to onlookers as non-understandable or psychotic.
Hence the need to carefully elicit psychopathology by paying attention to chronology of symptoms so as to distinguish obsessive ruminations seen in OCD from thought disorders seen in psychotic disorders.
Unconscious Anxiety [Freudian Theory]
It has been hypothesized that unconscious anxiety [central to mental psychopathology] may undergo complete conversion to physical or somatic symptoms leaving the individual to feel indifferent as in hysteria. On the other hand, the anxiety may be focused on specific objects or situations as in phobias. This anxiety can also be disguised as rituals, a form of “magical undoing” in obsessive compulsive disorders. When defence/coping mechanisms fail, the individual may experience free floating anxiety as seen in generalized anxiety disorder [GAD]
Anxiety may therefore be considered the “Mother of Psychopathology”:
It is frequently a precursor or trigger, reinforcing or exacerbating factor and associated or secondary symptom of many mental disorders e.g. early psychosis and early dementia.
Primary Obsessive Rumination
could be:
Aetiology of other [anxiety] mental disorders – the diagnoses of which depend on the manifestations of the dominant contents of the primary obsessive rumination
Mental disorders in individuals with obsessive ruminations could include:
Phobia – when content is about phobic object and situations such as dirt and death
Post Traumatic Stress Disorder – when content is about past experience, trauma and memory
Anorexia Nervosa – when content is about overweight and obesity
[In a predisposed individual, a personally desired or socially implanted thought regarding body size and shape might become an obsessive rumination which would develop into an overvalued idea (shared) with associated affect and precipitate into a delusional belief with preoccupied (akin to psychotic) behavior]
Hypochondriasis – when content is about physical/mental symptoms of no known causes
Dysmorphophobia – when content is about preoccupation with appearance of body parts
Schizophrenia – due to similarity of symptoms that may be associated or misdiagnosed.
Insomnia – due to obsessive rumination before sleep that keeps a person awake
Kleptomania– a controversial mental disorder in forensic practice might illustrate both components of situational obsessive impulse/urge that is anxiogenic and lead to compulsive commission of offence that is anxiolytic.)
Possibly other conditions such as autism and early stages of addictive behaviour.
Management and treatment
As OCD is considered an anxiety disorder, the treatment aims at relieving anxiety.
Since Obsessive Ruminations are anxiogenic, ideally and logically the thoughts/ruminations should be stopped or the anxiety generated relieved.
Compulsive Behaviours are anxiolytic at least in the early stage. Cognitive Behavioural Therapy (CBT) to overcome the compulsive behaviours therefore seems illogical. Besides, the targeted compulsive rituals often undergo change and elaboration.
Psychotherapy includes relaxation therapy, CBT at strategic stage and psychoanalytical therapy [Freudian and other developmental theories]
Physical treatments include pharmacotherapy, deep brain stimulation, brain surgery as a very last and controversial resort etc.
Benzodiazepines (GABA-ergic agonists) have been the mainstay of anxiolytics.
Common use of Selective Serotonin Reuptake Inhibitors (SSRIs) which are considered to be anti-impulsivity/compulsivity as well as anti-anxiety and anti-depressant have become the first line treatment nowadays.
Memantine, an antagonist of N-methyl-D-aspartate (NMDA) receptor of the Glutamatergic system has been empirically used for treatment resistant cases.
Ruminations and symptoms are worse when the mind is idle and unoccupied, hence importance of occupational therapy which helps the mind to focus and concentrate on tasks to distract and disrupt the neural circuitry of obsessive rumination and to build up productive neural circuits. Aversion therapy and Eye Movement Desensitization and Reprocessing (EMDR) may likewise work on similar principles.
Experience-based Cases on use of Zolpidem in OCD
Anecdotal (aka narrative), Empirical (based on observation and experiment and not on theory)
Heuristic (serving to discover; using trial and error) and Research Potential (Clinical Trial):
- A young lady diagnosed with schizophrenia and OCD was not responding well to anti-psychotic drug and SSRI.She was unstable, distressed and constantly crying because her brain/mind was in turmoil and bombarded with thoughts. She was also hearing a lot of noises/voices and has ideas of reference. She was unable to express and explain herself clearly. She consulted a doctor in Johor for poor sleep and was prescribed Zolpidem which not only helped her to sleep but also calmed her mind. This effect made her take Zolpidem even during the day, albeit feeling a little drowsy. She reported that: “Now I don’t think so much and don’t hear so much and feel better”. Her affect was well preserved.Based on the above information, Zolpidem was prescribed for another patient in her 30s.
- She has been diagnosed with schizophrenia, schizoaffective disorder, OCD, Bipolar disorder, polymorphic psychosis with multiple admissions despite anti-psychotics, anti-depressant and mood stabilizers. When “exacerbated” she displayed florid auditory hallucinations and delusional ideas of spiritual and grandiose nature and obsessive thoughts of harming her mother and killing herself even though she had denied being suicidal. It was difficult to follow her thoughts because she was rapid in her speech with mixed themes. In fact she had requested her own readmission each time.She was maintained precariously on anti-psychotics, SSRI, anti-anxiety drugs, mood stabilizer and Clozapine escalating to 500mg nocte. Her affect has always been well preserved and rapport with her has been good when in “remission.”After Zolpidem 6.25mg nocte was prescribed, she has improved, i.e. thinking less and hearing less auditory hallucinations, as well as becoming more stable and cheerful. Her distressed mother confirmed her progress. Her dose of Clozapine has been reduced by 100mg every two to three weeks and is now down to 100mg nocte. [Clozapine is known to aggravate OCD symptoms] She is however not quite symptom free yet.Two other schizophrenic patients, one with OCD symptoms also reported less obsessive rumination, decreased hearing of voices and less acting out.
- One male patient in his late forties has been treated for stress, anxiety, depression, irritability, insomnia for years without sustained progress. He has also been tried on ECT. Over the past few years he has not been regularly employed. He recently complained that his mind was full of thoughts and became agitated. He has always been compliant with his daily medications. Zolpidem 6.25mg nocte was added and his mind cleared considerably. He became calmer and cheerful, even jovial after a few days.
- A gentle lady in her 80s has been suffering from and treated for chronic anxiety state for decades. She complained of both physical and psychological anxiety symptoms. She has been maintaining fairly well on low doses of Lorazepam and Propranolol. However, lately she developed situational and anticipatory anxiety and also had difficulty eating her meals. She used to take about one hour finishing her meals but now the fear of choking occupies her mind and she takes about 4 hours to complete each meal. She was given Zolpidem half tab of 6.25mg, 30 minutes before meal time and after which was able to complete her meal in half the time. She was also advised to take small feeds each time. However there seemed to be new onset of “hallucinations”.
- Another woman in her 60s was diagnosed with schizophrenia and delusion of jealousy. Her husband did however admit to having an extra marital affair. She reported auditory hallucinations and symptoms of morbid jealousy and also possibly early dementia symptoms and spirit possession. She was likely to have been suffering from obsessive ruminations of past memory. However, Zolpidem appeared to have abolished her “psychotic” symptoms.
Based on these few anecdotal cases, Zolpidem seemed to ameliorate “obsessive rumination” which occurred in various mental disorders depending on the content of ruminations.
It is however still too early to form any definitive conclusion. More cases need to be collected with eventual proper clinical drug trials carried out to confirm this preliminary observation.
There is possible clinical research potential to carry this treatment out on:
OCD, Phobia, PTSD, Hypochondriasis, Dysmorphophobia, Anorexia Nervosa and Schizophrenia when presence of obsessive ruminations is evident or suspected.
Zolpidem is a GABA, A alpha-1 agonist similar to benzodiazepines in effects and side effects.
It is a hypnotic-sedative drug prescribed for insomnia and might perhaps work best in OCD.
However it may also have a special effect against obsessive ruminations.
PRINCIPLES OF PSYCHOPHARMACOTHERAPY
Approach to treatment is to restore normal neurotransmission affected by “synaptopathy” or “defective connectivity” The rationale is to augment what is deficient and to dampen what is excessive through use of drugs that are agonists or antagonists in the systems concerned.
In simplistic terms there are the GABA Inhibitory system and the Glutamate Excitatory system in the brain. They need to be in optimal balance for mental health.
To achieve an inhibitory state, relevant/specific agonist of the GABA-ergic system or relevant/specific antagonist of the Glutamatergic system or both at the same time could be employed. Similarly, to achieve an excitatory state, antagonist of the GABA-ergic system or agonist of the Glutamatergic system or both at the same time could be employed. Polypharmacy can be a way of enhancing and fine tuning for desired outcome.
Written by: Emeritus Consultant Dr Chee Kuan Tsee
Edited by: Dr Low Tchern Kuang Lambert, Honorary Treasurer, on behalf of Singapore Psychiatric Association