by the pines

Definition

Obsessive-compulsive personality disorder (OCPD) is a type of personality disorder marked by rigidity, control, perfectionism, and an overconcern with work at the expense of close interpersonal relationships. Persons with this disorder often have trouble relaxing because they are preoccupied with details, rules, and productivity. They are often perceived by others as stubborn, stingy, self-righteous, and uncooperative.

The mental health professional’s handbook, the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (2000), which is also called DSM-IV-TR, groups obsessive-compulsive personality disorder together with the avoidant and dependent personality disorders in Cluster C. The disorders in this cluster are considered to have anxiety and fearfulness as common characteristics. The ICD-10, which is the European counterpart of DSM-IV-TR, refers to OCPD as “anankastic personality disorder.”

It is important to distinguish between OCPD and obsessive-compulsive disorder(OCD), which is an anxiety disorder characterized by the presence of intrusive or disturbing thoughts, impulses, images or ideas (obsessions), accompanied by repeated attempts to suppress these thoughts through the performance of irrational and ritualistic behaviors or mental acts (compulsions). It is unusual but possible, however, for a patient to suffer from both disorders, especially in extreme cases of hoarding behavior. In some reported cases of animal hoarding, the people involved appear to have symptoms of both OCD and OCPD.

Description

People suffering from OCPD have careful rules and procedures for conducting many aspects of their everyday lives. While their goal is to accomplish things in a careful, orderly manner, their desire for perfection and insistence on going “by the book” often overrides their ability to complete a task. For example, one patient with OCPD was so preoccupied with finding a mislaid shopping list that he took much more time searching for it than it would have taken him to rewrite the list from memory. This type of inflexibility typically extends to interpersonal relationships. People with OCPD are known for being highly controlling and bossy toward other people, especially subordinates. They will often insist that there is one and only one right way (their way) to fold laundry, cut grass, drive a car, or write a report. In addition, they are so insistent on following rules that they cannot allow for what most people would consider legitimate exceptions. Their attitudes toward their own superiors or supervisors depend on whether they respect these authorities. People with OCPD are often unusually courteous to superiors that they respect, but resistant to or contemptuous of those they do not respect.

While work environments may reward their conscientiousness and attention to detail, people with OCPD do not show much spontaneity or imagination. They may feel paralyzed when immediate action is necessary; they feel overwhelmed by trying to make decisions without concrete guidelines. They expect colleagues to stick to detailed rules and procedures, and often perform poorly in jobs that require flexibility and the ability to compromise. Even when people with OCPD are behind schedule, they are uncomfortable delegating work to others because the others may not do the job “properly.” People with OCPD often get so lost in the finer points of a task that they cannot see the larger picture; they are frequently described as “unable to see the forest for the trees.” They are often highly anxious in situations without clearly defined rules because such situations arouse their fears of making a mistake and being punished for it. An additional feature of this personality disorder is stinginess or miserliness, frequently combined with an inability to throw out worn-out or useless items. This characteristic has sometimes been described as “pack rat” behavior.

People diagnosed with OCPD come across to others as difficult and demanding. Their rigid expectations of others are also applied to themselves, however; they tend to be intolerant of their own shortcomings. Such persons feel bound to present a consistent facade of propriety and control. They feel uncomfortable with expressions of tender feelings and tend to avoid relatives or colleagues who are more emotionally expressive. This strict and ungenerous approach to life limits their ability to relax; they are seldom if ever able to release their needs for control. Even recreational activities frequently become another form of work. A person with OCPD, for example, may turn a tennis game into an opportunity to perfect his or her backhand rather than simply enjoying the exercise, the weather, or the companionship of the other players. Many OCPD sufferers bring office work along on vacations in order to avoid “wasting time,” and feel a sense of relief upon returning to the structure of their work environment. Not surprisingly, this combination of traits strains their interpersonal relationships and can lead to a lonely existence.

Causes and symptoms

Causes

No single specific cause of OCPD has been identified. Since the early days of Freudian psychoanalysis, however, faulty parenting has been viewed as a major factor in the development of personality disorders. Current studies have tended to support the importance of early life experiences, finding that healthy emotional development largely depends on two important variables: parental warmth and appropriate responsiveness to the child’s needs. When these qualities are present, the child feels secure and appropriately valued. By contrast, many people with personality disorders did not have parents who were emotionally warm toward them. Patients with OCPD often recall their parents as being emotionally withholding and either overprotective or overcontrolling. One researcher has noted that people with OCPD appear to have been punished by their parents for every transgression of a rule, no matter how minor, and rewarded for almost nothing. As a result, the child is unable to safely develop or express a sense of joy, spontaneity, or independent thought, and begins to develop the symptoms of OCPD as a strategy for avoiding punishment. Children with this type of upbringing are also likely to choke down the anger they feel toward their parents; they may be outwardly obedient and polite to authority figures, but at the same time treat younger children or those they regard as their inferiors harshly.

Genetic contributions to OCPD have not been well documented. Cultural influences may, however, play a part in the development of OCPD. That is, cultures that are highly authoritarian and rule-bound may encourage child-rearing practices that contribute to the development of OCPD. On the other hand, simply because a culture is comparatively strict or has a strong work ethic does not mean it is necessarily unhealthful. In Japanese societies, for example, excessive devotion to work, restricted emotional expression, and moral scrupulosity are highly valued characteristics that are rewarded within that culture. Similarly, certain religions and professions require exactness and careful attention to rules in their members; the military is one example. OCPD is not diagnosed in persons who are simply behaving in accordance with such outside expectations as military regulations or the rule of a religious order. Appropriate evaluation of persons from other cultures requires close examination in order to differentiate people who are merely following culturally prescribed patterns from people whose behaviors are excessive even by the standards of their own culture.

Symptoms

The symptoms of OCPD include a pervasive overconcern with mental, emotional, and behavioral control of the self and others. Excessive conscientiousness means that people with this disorder are generally poor problem-solvers and have trouble making decisions; as a result, they are frequently highly inefficient. Their need for control is easily upset by schedule changes or minor unexpected events. While many people have some of the following characteristics, a person who meets the DSMIV-TRcriteria for OCPD must display at least four of them:

• Preoccupation with details, rules, lists, order, organization, or schedules to the point at which the major goal of the activity is lost.
• Excessive concern for perfection in small details that interferes with the completion of projects.
• Dedication to work and productivity that shuts out friendships and leisure-time activities, when the long hours of work cannot be explained by financial necessity.
• Excessive moral rigidity and inflexibility in matters of ethics and values that cannot be accounted for by the standards of the person’s religion or culture.
• Hoarding things, or saving worn-out or useless objects even when they have no sentimental or likely monetary value.
• Insistence that tasks be completed according to one’s personal preferences.
• Stinginess with the self and others.
• Excessive rigidity and obstinacy.

Demographics

Obsessive-compulsive personality disorder is estimated to occur in about 1% of the population, although rates of 3%–10% are reported among psychiatric outpatients. The disorder is usually diagnosed in late adolescence or young adulthood. In the United States, OCPD occurs almost twice as often in men as in women. Some researchers attribute this disproportion to gender stereotyping, in that men have greater permission from general Western culture to act in stubborn, withholding, and controlling ways.

Diagnosis

It is relatively unusual for OCPD to be diagnosed as the patient’s primary reason for making an appointment with their doctor. In many cases the person with OCPD is unaware of the discomfort that his or her stubbornness and rigidity cause other people, precisely because these traits usually enable them to get their way with others. They are more likely to enter therapy because of such other issues as anxiety disorders, serious relationship difficulties, or stress-related medical problems. Diagnosis of OCPD depends on careful observation and appropriate assessment of the individual’s behavior; the person must not only give evidence of the attitudes and behaviors associated with OCPD, but these must be severe enough to interfere with their occupational and interpersonal functioning.

The differential diagnosis will include distinguishing between obsessive-compulsive disorder (OCD) and OCPD. A person who has obsessions and compulsions that they experience as alien and irrational is more likely to be suffering from OCD, whereas the person who feels perfectly comfortable with self-imposed systems of extensive rules and procedures for mopping the kitchen floor probably has OCPD. In addition, the thoughts and behaviors that are found in OCD are seldom relevant to real-life problems; by contrast, people with OCPD are preoccupied primarily with managing (however inefficiently) the various tasks they encounter in their daily lives.

Some features of OCPD may occur in other personality disorders. For example, a person with a narcissistic personality disorder may be preoccupied with perfection and be critical and stingy toward others; narcissists are usually generous with themselves, however, while people with OCPD are self-critical and reluctant to spend money even on themselves. Likewise, a person with schizoid personality disorder, who lacks a fundamental capacity for intimacy, may resemble someone with OCPD in being formal and detached in dealing with others. The difference here is that a person with OCPD, while awkward in emotional situations, is able to experience caring and may long for close relationships. Certain medical conditions may also mimic OCPD, but are distinct in that the onset of the symptoms is directly related to the illness. Certain behaviors related to substance abuse may also be mistaken for symptoms of OCPD, especially if the substance problem is unrecognized.

As described earlier, diagnosis may also be complicated by the fact that behaviors similar to OCPD may be normal variants within a given culture, occupation, or religion; however, in order to fulfill criteria for the personality disorder, the behaviors must be sufficiently severe as to impair the patient’s functioning.

Treatments

Psychotherapy

Psychotherapeutic approaches to the treatment of OCPD have found insight-oriented psychodynamic techniques and cognitive behavioral therapy to be helpful for many patients. This choice of effective approaches stands in contrast to the limitations of traditional forms of psychotherapy with most patients diagnosed with OCD. Learning to find satisfaction in life through close relationships and recreational outlets, instead of only through work-related activities, can greatly enrich the OCPD patient’s quality of life. Specific training in relaxation techniques may help patients diagnosed with OCPD who have the so-called “Type A” characteristics of competitiveness and time urgency as well as preoccupation with work.

It is difficult, however, for a psychotherapist to develop a therapeutic alliance with a person with OCPD. The patient comes into therapy with a powerful need to control the situation and the therapist; a reluctance to trust others; and a tendency to doubt or question almost everything about the therapy situation. The therapist must be alert to the patient’s defenses against genuine change and work to gain a level of commitment to the therapeutic process. Without this commitment, the therapist may be fooled into thinking that therapy has been successful when, in fact, the patient is simply being superficially compliant.

Medications

For many years, medications for OCPD and other personality disorders were thought to be ineffective since they did not affect the underlying causes of the disorder. More recent studies, however, indicate that treatment with specific drugs may be a useful adjunct (help) to psychotherapy. In particular, the medications known as selective serotonin reuptake inhibitors (SSRIs) appear to help the OCPD patient with his or her rigidity and compulsiveness, even when the patient did not show signs of pre-existing depression. Medication can also help the patient to think more clearly and make decisions better and faster without being so distracted by minor details. While symptom control may not “cure” the underlying personality disorder, medication does enable some OCPD patients to function with less distress.

Prognosis

Individuals with OCPD often experience a moderate level of professional success, but relationships with a spouse or children may be strained due to their combination of emotional detachment and controlling behaviors. In addition, people with OCPD often do not attain the level of professional achievement that might be predicted for their talents and abilities because their rigidity and stubbornness make them poor “team players” or supervisors. Although there are few large-scale outcome studies of treatments for OCPD, existing reports suggest that these patients do benefit from psychotherapy to help them understand the emotional issues underlying their controlling behaviors and to teach them how to relax. Since OCPD sufferers, unlike people with OCD, usually view their compulsive behaviors as voluntary, they are better able to consider change, especially as they come to fully recognize the personal and interpersonal costs of their disorder.

Prevention

Most theories attribute the development of OCPD to early life experiences, including a lack of parental warmth; parental overcontrol and rigidity, and few rewards for spontaneous emotional expression. Little work has been done, however, in identifying preventive strategies.

Definition

Obsessive-compulsive disorder (OCD) is currently classified as an anxiety disorder marked by the recurrence of intrusive or disturbing thoughts, impulses, images or ideas (obsessions) accompanied by repeated attempts to suppress these thoughts through the performance of certain irrational and ritualistic behaviors or mental acts (compulsions). The obsessions and compulsions take up large amounts of the patient’s time (an hour or longer every day) and usually cause significant emotional distress for the patient and difficulties in his or her relationships with others.

Some researchers have questioned whether OCD really belongs with the other anxiety disorders. They think that it should be grouped with the spectrum of such obsessive-compulsive disorders as Tourette’s syndrome, which are known to have biological causes.

OCD should not be confused with obsessive-compulsive personality disorder even though the two disorders have similar names. Obsessive-compulsive personality disorder is not characterized by the presence of obsessions and compulsions; rather, it is a lifelong pattern of insistence on control, orderliness, and perfection that begins no later than the early adult years. It is possible, however, for a person to have both disorders.

Description

Obsessive-compulsive disorder is a mental disorder with two components: obsessions, which consist of thoughts, impulses, or mental images; and compulsions, which are repetitive behaviors that the person feels driven to perform in response to the obsessions. In some cases, the compulsion may represent a strict rule that the patient must apply rigidly in every situation (tying one’s shoes a certain number of times, for example) in order to feel “right.” The exact content of obsessions varies from person to person, although certain themes are common. People with OCD experience their disturbing thoughts and images as intrusive and troublesome, but they recognize that their thoughts are products of their own minds. Obsessive thoughts are different from worries about such real-life problems as losing one’s job or bad grades in school. In addition, obsessive thoughts are not usually related to any real-life problems.

The most common types of obsessions in persons with OCD in Western countries are:

• fear of contamination (impurity, pollution, badness)
• doubts (worrying about whether one has omitted to do something)
• an intense need to have or put things in a particular order
• aggressive or frightening impulses
• recurrent sexual thoughts or images

It is important to understand that patients diagnosed with OCD do not perform their compulsions for pleasure or satisfaction. A compulsive behavior becomes linked to an obsessional thought because the behavior lowers the level of anxiety produced by the obsession(s).

The most common compulsions in Western countries are:

• washing/cleaning
• counting
• hoarding
• checking
• putting objects in a certain order
• repeated “confessing” or asking others for assurance
• repeated actions
• making lists

Although descriptions of patients with OCD have been reported since the fifteenth century in religious and psychiatric literature, the condition was widely assumed to be rare until very recently. Epidemiological research since 1980 has now identified OCD as the fourth most common psychiatric illness, after phobias, substance use disorders, and major depressive disorders. OCD is presently classified as a form of anxiety disorder, but current studies indicate that it results from a combination of psychological, neurobiological, genetic, and environmental causes.

Causes and symptoms

Causes

PSYCHOSOCIAL. In the early part of the century, Sigmund Freud theorized that OCD symptoms were caused by punitive, rigid toilet-training practices that led to internalized conflicts. Other theorists thought that OCD was influenced by such wider cultural attitudes as insistence on cleanliness and neatness, as well as by the attitudes and parenting style of the patient’s parents. Cross-cultural studies of OCD indicate that, while the incidence of OCD seems to be about the same in most countries around the world, the symptoms are often shaped by the patient’s culture of origin. For example, a patient from a Western country may have a contamination obsession that is focused on germs, whereas a patient from India may fear contamination by touching a person from a lower social caste.

Studies of families with OCD members indicate that the particular expression of OCD symptoms may be affected by the responses of other people. Families with a high tolerance for the symptoms are more likely to have members with more extreme or elaborate symptoms. Problems often occur when the OCD member’s obsessions and rituals begin to control the entire family.

BIOLOGICAL. There is considerable evidence that OCD has a biological component. Some researchers have noted that OCD is more common in patients who have suffered head trauma or have been diagnosed with Tourette’s syndrome. Recent studies using positron emission tomography(PET) scanning indicate that OCD patients have patterns of brain activity that differ from those of people without mental illness or with some other mental illness. Other studies using magnetic resonance imaging(MRI) found that patients diagnosed with OCD had significantly less white matter in their brains than did normal control subjects. This finding suggests that there is a widely distributed brain abnormality in OCD. Some researchers have reported abnormalities in the metabolism of serotonin, an important neurotransmitter, in patients diagnosed with OCD. Serotonin affects the efficiency of communication between the front part of the brain (the cortex) and structures that lie deeper in the brain known as the basal ganglia. Dysfunction in the serotonergic system occurs in certain other mental illnesses, including major depression. OCD appears to have a number of features in common with the so-called obsessive-compulsive spectrum disorders, which include Tourette’s syndrome; Sydenham’s chorea; eating disorders; trichotillomania; and delusional disorders.

There appear to be genetic factors involved in OCD. The families of persons who are diagnosed with the disorder have a greater risk of OCD and tic disorders than does the general population. Childhood-onset OCD appears to run in families more than adult-onset OCD, and is more likely to be associated with tic disorders. Twin studies indicate that monozygotic, or identical twins, are more likely to share the disorder than dizygotic, or fraternal twins. The concordance (match) rate between identical twins is not 100%, however, which suggests that the occurrence of OCD is affected by environmental as well as genetic factors. In addition, it is the general nature of OCD that seems to run in families rather than the specific symptoms; thus, one family member who is affected by the disorder may have a compulsion about washing and cleaning while another is a compulsive counter.

Large epidemiological studies have found a connection between streptococcal infections in childhood and the abrupt onset or worsening of OCD symptoms. The observation that there are two age-related peaks in the onset of the disorder increases the possibility that there is a common causal factor. Patients with childhood-onset OCD often have had one of two diseases caused by a group of bacteria called Group A beta-hemolytic streptococci (“strep” throat and Sydenham’s chorea) prior to the onset of the OCD symptoms. The disorders are sometimes referred to as pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, or PANDAS. It is thought that antibodies in the child’s blood cross-react with structures in the basal ganglia, producing or worsening the symptoms of OCD or tic disorders.

Symptoms

The symptoms of OCD should not be confused with the ability to focus on detail or to check one’s work that is sometimes labeled “compulsive” in everyday life. This type of attentiveness is an important factor in academic achievement and in doing well in fields that require close attention to detail, such as accounting or engineering. By contrast, the symptoms of OCD are serious enough to interfere with the person’s day-to-day functioning. Historical examples of OCD include a medieval Englishman named William of Oseney, who spent twelve hours per day reading religious books in order to be at peace with God; and Freud’s Rat Man, a patient who had repeated dreams of cursing Freud and covering him with dung. While the Rat Man was ashamed of these impulses and had no explanation for them, he could not control them.

More recent accounts of OCD symptoms include those of a young man who compulsively touched every electrical outlet as he passed, washed his hands several times an hour, and returned home repeatedly to check that the doors and windows were locked. Another account describes a firefighter who was worried that he had throat cancer. He spent three hours a day examining his throat in the mirror, feeling his lymph nodes, and asking his wife if his throat appeared normal.

Brief descriptions of the more common obsessions and compulsions follow.

CONTAMINATION. People with contamination obsessions are usually preoccupied with a fear of dirt or germs. They may avoid leaving home or allowing visitors to come inside in order to prevent contact with dirt or germs. Some people with contamination obsessions may wear gloves, coats, or even masks if they are forced to leave their house for some reason. Obsessions with contamination may also include abnormal fears of such environmental toxins as lead, asbestos, or radon.

Washing compulsions are commonly associated with contamination obsessions. For example, a person concerned about contamination from the outside may shower and launder all clothing immediately upon coming home. The compulsion may be triggered by direct contact with the feared object, but in many cases, even being in its general vicinity may stir up intense anxiety and a strong need to engage in a washing compulsion. One man who was afraid of contamination could not even take a short walk down the street without experiencing a compulsion to disinfect the soles of his shoes, launder all his clothing, and wash his hands until they were raw after he returned to his apartment.

Washing compulsions may not always be caused by a fear of germs. That is, a need for perfection or for symmetry may also lead to unnecessary washing. In such cases, the individual may be concerned about being “perfectly” clean, or feel that he cannot leave the shower until his left foot has been washed exactly as many times as his right foot. Other people with washing compulsions may be unable to tolerate feeling sweaty or otherwise not clean.

OBSESSIONAL DOUBTING. Obsessional doubting refers to the fear of having failed to perform some task adequately, and that dire consequences will follow as a result. Although the person may try to suppress the worrisome thoughts or images, he or she usually experiences a rising anxiety which then leads to a compulsion to check the task. For example, someone may worry about forgetting to lock the door or turn off the gas burner on the stove and spend hours checking these things before leaving home. In one instance, a man was unable to throw away old grocery bags because he feared he might have left something valuable inside one of them. Immediately after looking into an empty bag, he would again have the thought, “What if I missed something in there?” In many cases, no amount of checking is sufficient to dispel the maddening sense of doubt.

NEED FOR SYMMETRY. Persons suffering from an obsession about symmetry often report feeling acutely uncomfortable unless they perform certain tasks in a symmetrical or balanced manner. Thus, crossing one’s legs to the right must be followed by crossing legs to the left; scratching one side of the head must be followed by scratching the other; tapping the wall with a knuckle on the right hand must be followed by tapping with one on the left, etc. Sometimes the person may have a thought or idea associated with the compulsion, such as a fear that a loved one will be harmed if the action is not balanced, but often there is no clearly defined fear, only a strong sense of uneasiness.

AGGRESSIVE AND SEXUAL OBSESSIONS. Aggressive and sexual obsessions are often particularly horrifying to those who experience them. For some people, obsessive fears of committing a terrible act in the future compete with fears that they may already have done something awful in the past. Compulsions to constantly check and confess cause such individuals to admit to evildoing they had no part in, a phenomenon familiar to law enforcement following highly publicized crimes. These obsessions often involve violent or graphic imagery that is upsetting and disgusting to the person, such as rape, physical assault, or even murder. One case study concerned a young woman who constantly checked the news to reassure herself that she had not murdered anyone that day; she felt deeply upset by unsolved murder cases. A middle-aged man repeatedly confessed to having molested a woman at work, despite no evidence of such an action ever occurring in his workplace.

SYMPTOMS IN CHILDREN. Obsessions and compulsions in children are often focused on germs and fears of contamination. Other common obsessions include fears of harm coming to self or others; fears of causing harm to another person; obsessions about symmetry; and excessive moralization or religiosity. Childhood compulsions frequently include washing, repeating, checking, touching, counting, ordering and arranging. Younger children are less likely to have full-blown anxiety-producing obsessions, but they often report a sense of relief or strong satisfaction (a “just right” feeling) from completing certain ritualized behaviors. Since children are particularly skillful in disguising their OCD symptoms from adults, they may effectively hide their disorder from parents and teachers for years.

Unusual behaviors in children that may be signs of OCD include:

• Avoidance of scissors or other sharp objects. A child may be obsessed with fears of hurting herself or others.
• Chronic lateness or dawdling. The child may be per forming checking rituals (repeatedly making sure all her school supplies are in her bookbag, for example).
• Daydreaming or preoccupation. The child may be counting or performing balancing rituals mentally.
• Spending long periods of time in the bathroom. The child may have a handwashing compulsion.
• Schoolwork handed in late or papers with holes erased in them. The child may be repeatedly checking and cor recting her work.

For both children and adults, the symptoms of OCD wax and wane in severity; and the specific content of obsessions and compulsions may change over time. The disorder, however, very seldom goes away by itself without treatment. People with OCD in all age groups typically find that their symptoms worsen during major life changes or following highly stressful events.

Demographics

As noted above, OCD is a relatively common mental disorder, with about 2.3% of the population of the United States being diagnosed with the condition at some point in their lives. As of 2000, the annual social and economic costs of OCD in the United States are estimated at $9 billion. Although the disorder may begin at any age, the typical age of onset is late adolescence to young adulthood, with slightly more women than men being diagnosed with OCD. Interestingly, childhood OCD is more common in males, and the sex ratio does not favor females until adulthood. People with OCD appear to be less likely to marry than persons diagnosed with other types of mental disorders.

Diagnosis

OCD is a disorder that may not be diagnosed for years. People who suffer from its symptoms are often deeply ashamed, and go to great lengths to hide their ritualistic behaviors. The disorder may be diagnosed when family members get tired of the impact of the patient’s behaviors on their lives, and force the patient to consult a doctor. In other cases, the disorder may be self-reported. The patient may have come to resent the amount of time wasted by the compulsions; or he or she may have taken a screening questionnaire such as the brief screener available on the NIMH website (listed in the Resources section below).

The diagnosis of OCD may be complicated because of the number of other conditions that resemble it. For example, major depression may be associated with self-perceptions of being guilty, bad, or worthless that are excessive and unreasonable. Similarly, eating disorders often include bizarre thoughts about size and weight, ritualized eating habits, or the hoarding of food. Delusional disorders may entail unusual beliefs or behaviors, as do such other mental disorders as trichotillomania, hypochondriasis, the paraphilias, and substance use disorders. Thus, accurate diagnosis of OCD depends on the careful analysis of many variables to determine whether the apparent obsessions and compulsions might be better accounted for by some other disorder, or to the direct effects of a substance or a medical condition.

In addition, OCD may coexist with other mental disorders, most commonly depression. It has been estimated that about 34% of patients diagnosed with OCD are depressed at the time of diagnosis, and that 65% will develop depression at some point in their lives.

Definition

An obsession is an unwelcome, uncontrollable, and persistent idea, thought, image, or emotion that a person cannot help thinking even though it creates significant distress or anxiety.

Description

Obsessive ideas seem unnatural or alien to those who have them, but are nevertheless recognized as originating from the person’s own thoughts—they are not seen as delusions sent or controlled by an outside party.

Typical obsessions include fear of contamination as from doorknobs or handshakes, worry about leaving things in their proper order, persistent doubts about one’s responsible behavior, scary images involving violent acts, and images of sexual acts. People with obsessions may find themselves acting in compulsive ways in largely futile attempts to relieve the anxiety associated with their persistent, unpleasant thoughts. Others suffering from obsessions may try very hard to control or ignore them. It is important to note that legitimate worries about daily concerns—paying bills, studying for exams, keeping a job, interpersonal relationships—are not obsessions. Although they can occasionally be carried to obsessive lengths, these concerns can change with circumstances and, in most cases be controlled, with planning, effort, and action. Obsessions relate to problems that most people would consider far removed from normal, daily events and concerns.

Definition

Obesity is the condition of having an excessive accumulation of fat in the body, resulting in a body weight more than 20% above the average for height, age, sex, and body type, and in elevated risk of disability, illness, and death.

Description

The human body is composed of bone, muscle, specialized organ tissues, and fat. Together, all of these tissues comprise the total body mass, which is measured in pounds. Fat, or adipose tissue, is a combination of essential fat (an energy source for the normal physiologic function of cells and organs) and storage fat (a reserve supply of energy for future needs). When the amount of energy consumed as food exceeds the amount of energy expended in the normal maintenance of life processes and in physical activity, storage fat accumulates in excessive amounts. Essential fat is tucked in and around internal organs, and is an important building block of all cells in the body. Storage fat accumulates in the chest and abdomen, and, in much greater volume, under the skin.

Causes and symptoms

The human body was designed for life forty thousand years ago, when the ability to store energy in times of plenty meant the difference between life and death during famine. This protective mechanism is a source of trouble when food, in unlimited quantities, is readily available,. This is evident in the increasing prevalence of obesity in modern times, particularly in Western cultures. While obesity is just an exaggeration of a normal body, the storage of energy for future is properly classified as a health problem. This is because excessive amounts of storage fat may interfere with the normal physiology of the body. Obesity is directly related to the increasing prevalence of Type II diabetes in American society and for the appearance of Type II diabetes in children, previously a rarity. Because obesity promotes degenerative disease of joints and heart and blood vessels, it increases the need for some surgical procedures. At the same time, surgical complication rates are higher in obese patients. Obesity contributes to fatigue, high blood pressure, menstrual disorders, infertility, digestive complaints, low levels of physical fitness, and to the development of some cancers. The social costs of obesity that include decreased productivity, discrimination, depression, and low self-esteem, are less easily described and measured. Worldwide, obesity has reached epidemic proportions in the last thirty years, affecting both sexes and all ethnic, age, and socioeconomic groups. More than 50% of adults in the United States currently fall into overweight or obese classifications, and 22% of preschool children are classified as overweight. The increasing prevalence of obesity and diabetes in children and young adults heralds spiraling health care costs in the near future.

Because obesity reflects an imbalance between the amount of energy taken into the body in the form of food and the amount of energy expended in metabolism and physical activity, and because eating is an activity that involves choice and volition, obesity is classified by the Health Care Financing Administration (HCFA) as a “behavior” rather than as a disease. In recent years, following a pattern established in other behavioral problems such as alcoholism, researchers have attempted to establish a biologic basis for the development of obesity. They have succeeded in identifying many markers of the biochemical mechanisms that appear to be involved in feedback loops that control energy balance. However, much of the information is extrapolated from experimental work in rodents. Leptin, a hormone produced in fat cells is an example of such a marker. Leptin excited a great deal of hope as a potential treatment of obesity, but, as with many other laboratory discoveries, the hormone has proved far more complex and less easily understood in humans. Research to date indicates that obesity is the end product of numerous contributing factors, including genetics, hormonal influences, behavioral tendencies, medication effects, and the surrounding society. But the rapid and widespread increase in obesity in the last thirty years reflects changes in activity patterns and in eating habits, not a change in the human genetic pool or in physiology.

Diagnosis

There are two methods of diagnosing obesity. The first method is inspection—whereby an excessive amount of storage fat is usually noticeable upon visual inspection. The second method is inference of body fat content, obtained from body measurements such as weight or skinfold thickness, and comparison with charts of similar measurements in broad populations. The determination of obesity is based on the amount of variance from “normal,” a value that comes from statistics on death rates in people with similar measurements. Calculations such as the body mass index (BMI) use a height-weight relationship to calculate an individual’s ideal weight and personal risk of developing obesityrelated health problems. An individual with a BMI of25.9–29, for example, is considered overweight; a person with a BMI over 30 is classified as obese.

The problem with using weight as a measure of obesity is the fact that weight does not accurately represent body composition. A heavily-muscled football player may weigh far more than a sedentary man of similar height, but have significantly less body fat. Chronic dieters, who have lost significant muscle mass during periods of caloric deprivation, may look slim and weigh little, but have elevated body fat percentages. The most accurate means of estimating body fat content involves weighing a person two ways: First, the person is weighed under water. The difference between dry and underwater weight is calculated to obtain the volume of water displaced by the mass of the body. While this method is impractical, it has the advantage of determining body composition most accurately, and is the truest reflection of the actual percentage of body mass that is fat. Women whose body fat exceeds 30% of total body mass and men whose body fat exceeds 25% are generally considered obese.

The pattern of fat distribution on the body may indicate whether an individual has a predisposition to develop certain diseases or conditions that may accompany obesity. “Apple-shaped” individuals who store most of their weight around the waist and abdomen are at greater risk for cancer, heart disease, stroke, and diabetes than “pear-shaped” people, whose extra pounds settle primarily on their hips and thighs.

Treatment

Since obesity develops when intake of the food required to produce energy exceeds the amount of energy used in metabolism and in physical activity, the treatment of obesity must alter one or both aspects of the energy stream. The options are to decrease energy intake or to increase energy output, or both. However, the problem does not yield rapidly to either method. Storage fat is meant to protect its bearer from starvation when food is unavailable, and before fat is tapped for energy. In the face of decreased intake of food, the body breaks down muscle to construct the sugar it needs to feed the brain. Much of the early weight loss on a very low calorie diet represents loss of muscle tissue rather than loss of fat. Similarly, fat is not easy to access as fuel for exercise. A person of normal weight (according to one of the charts as described above) has enough body fat to fuel the muscles for days of continuous running, but will collapse long before burning any significant amount fat stored by the body.

When obesity develops in childhood, the total number of fat cells increases (hyperplastic obesity), whereas in adulthood, it is the total amount of fat in each cell that increases (hypertrophic obesity). Decreasing the amount of energy (food) consumed or increasing the amount of energy expended cannot change the number of fat cells already present. These actions can only reduce the amount of fat in each cell, and only if the process is slow and steady—as it was in reverse, when the excess fat accumulated. Prevention, as in so many problems, is far superior to any available treatment of obesity.

The strategy for weight loss in obese patients is first to change behavior; then, it is to decrease the expectation of rapid change. Behavioral treatment is goal-directed, process-oriented, and relies heavily on self-monitoring. Emphasis is on:

• Food intake: The potential energy provided by food is measured in calories, and the capacity of a certain type and amount of food to provide energy is called its caloric content. Keeping a food diary and developing a better understanding of the nutritional value and fat content of foods, changing grocery-shopping habits, paying attention to timing and appearance of meals, and slowing the speed of eating all help to modify food intake.
• Response to food: The body is capable of matching energy intake and output perfectly, but, in obese individuals, food intake is often unrelated from physiologic cues. Eating occurs for many reasons other than hunger. What psychological issues underlie the eating habits? Does stress cause binge eating? Is food seen as a reward? Recognition of psychological triggers is necessary for the development of alternate coping mechanisms that do not focus on food.
• Time usage: The body is suited for an ancient world in which physical activity was a necessity. In the modern world, physical activity must be a conscious choice. Making activity and exercise an integrated part of everyday life is a key to achieving and maintaining weight loss. Sedentary and overweight individuals have to reclaim slowly the endurance that is natural by managing their time to allow for gradual increases in both programmed and conscious lifestyle activity.

Definition

Zolpidem is classified as a hypnotic drug. These drugs help people sleep. In the United States, zolpidem is available as tablets under the brand name of Ambien.

Purpose

Zolpidem is a drug that is used to treat insomnia. Zolpidem is especially helpful for people who have trouble falling asleep. However, once individuals have fallen asleep, zolpidem also helps them continue to sleep restfully. Zolpidem should be used only for short periods, approximately seven to ten days. If sleeping pills are needed for a long period, an evaluation by a physician is recommended to determine if another medical condition is responsible for the insomnia.

Description

Although the way zolpidem helps people sleep is not entirely understood, it is believed to mimic a chemical in the brain called gamma-aminobutyric acid (GABA) that naturally helps to facilitate sleep. Zolpidem is a central nervous system depressant. This means that it slows down the nervous system. Unlike some sleeping pills, zolpidem does not interfere with the quality of sleep or usually leave the user feeling sedated in the morning. As a result, most people using zolpidem usually awake feeling refreshed in the morning.

Recommended dosage

The usual dose of zolpidem in adults is 5–10 mg. For healthy adults, 10 mg is commonly recommended. However, people taking other drugs that cause drowsiness, people who have severe health problems, especially liver disease, and older people (over age 65) should take a lower dose, usually 5 mg. Zolpidem should be taken immediately before bedtime and only if the person can count on getting seven or eight hours of uninterrupted sleep. It usually takes only about 30 minutes for the sleep-inducing actions of zolpidem to be felt. Unlike some sleeping pills, the sleep-facilitating effects appear to last six to eight hours.

If zolpidem is taken with a meal, it will take longer to work. For the fastest sleep onset, it should be taken on an empty stomach. The maximum dose for one day is 10 mg. People who miss a dose of zolpidem should skip the missed dose, and take the next dose at the regularly scheduled time. Under no circumstances should a person take more than 10 mg in one day. Zolpidem should be taken exactly as directed by the prescribing physician.

Precautions

Because zolpidem is used to help people fall asleep, it should not be used with other drugs (either over-thecounter, herbal, or prescription) that also cause drowsiness (for example, antihistamines or alcohol). Zolpidem should be used only with close physician supervision in people with liver disease and in the elderly, because these individuals are especially sensitive to the sedative properties of zolpidem. Zolpidem should not be used before driving, operating machinery, or performing activities that require mental alertness. People with a history of drug abuse, psychiatric disorders, or depression should be carefully monitored when using zolpidem since zolpidem may worsen symptoms of some psychiatric disorders.

If zolpidem is needed for more than seven to ten days, patients should be re-evaluated by a physician to determine if another disorder is causing their difficulty sleeping. When zolpidem or other sleeping pills are used every night for more than a few weeks, they begin to lose their effectiveness and/or people may become dependent upon them to fall asleep. Zolpidem can be habit-forming when taken over a long period. People using zolpidem should not stop taking the drug suddenly, but gradually reduce the dose over a few days before quitting, even if zolpidem has been used only a for short time.

Side effects

Some sleeping pills such as zolpidem can cause aggressiveness, agitation, hallucinations, and amnesia(memory problems), rapid, racing heartbeat, and chest pains. These side effects are rare, but the patient should call a physician immediately if they occur.

Side effects that occur in more than 5% of patients are headache, nausea, muscle aches, and drowsiness. Although drowsiness is desired when trying to fall asleep, a few people continue to be drowsy the next day. Daytime drowsiness may cause people, especially the elderly, to be less coordinated and more susceptible to falls. Other less common side effects are anxiety, confusion, dizziness, and stomach upset.

Interactions

Any drug that causes drowsiness may lead to substantially decreased mental alertness and impaired motor skills when taken with zolpidem. Some examples include alcohol, antidepressants such as imipramine or paroxetine, antipsychotics such as thioridazine, and antihistamines (commonly found in allergy and cold medications).

The effectiveness of zolpidem may be reduced if taken with rifampin, an antibiotic that is commonly used to treat tuberculosis infections.

Definition

Ziprasidone is a drug used to treat schizophrenia. It is available with a prescription under the brand name Geodan.

Purpose

Ziprasidone is in a class of drugs called antipsychotics. It is used to control symptoms of schizophrenia.

Description

The United States Food and Drug Administration approved ziprasidone for treatment of schizophrenia in 2001. Mental well-being is partially related to maintaining a balance between naturally occurring chemicals in the brain called neurotransmitters. Ziprasidone is thought to modify the actions of several neurotransmitters and in this way restore appropriate function to chemical systems in the brain that are out of balance in people with schizophrenia.

Recommended dosage

The dosage of ziprasidone varies widely from one individual to another. A common initially dosage is 20 mg of ziprasidone taken twice daily. The dosage is gradually increased until symptoms of schizophrenia subside. Dosages of up to 100 mg may be taken twice daily. Ziprasidone should be taken with food.

Precautions

Ziprasidone may alter the rhythm of the heart. Because of the risk of irregular heartbeats or even death, it should not be taken by people with a history of irregular or prolonged heart rhythms (long QT syndrome), those with heart failure, or individuals who have recently had a heart attack. People with a history of heart disease should discuss the risks and benefits of treatment with their doctor before starting ziprasidone. Ziprasidone may lower blood pressure to dangerously low levels, causing people to faint. It should not be taken by people who have slow heartbeats and those with low levels of potassium or magnesium in their blood.

Individuals with a history of seizure, even seizure brought on by drug or alcohol abuse, should use ziprasidone cautiously and with close physician supervision, because it may increase the tendency to have seizures.

Ziprasidone may increase body temperatures to dangerously high levels. People who exercise strenuously, those exposed to extreme heat, individuals taking drugs with anticholinergic effects (this includes many common antidepressants), and persons prone to dehydration, should use the drug cautiously and be alert to dehydration-related side effects. Elderly persons with increased risk of developing pneumonia should be carefully monitored while taking ziprasidone. Because there is a high incidence of suicide in all patients with psychotic illnesses, people using ziprasidone should be observed carefully for signs of suicidal behavior. Women who are pregnant or breast-feeding should not take ziprasidone.

Side effects

The most common reason that ziprasidone is stopped is due to development of a rash. Another common side effect is drowsiness. This side effect is usually worse when starting the drug and becomes less severe with continued use. People performing tasks that require mental alertness such as driving or operating machinery should refrain from doing so until they see how the drug affects them. Other side effects that may occur are abnormal, involuntary twitching (5%), and respiratory disorders (8%). Nausea, constipation, indigestion, and dizziness due to low blood pressure occur in more than 5% of people taking ziprasidone.

Other, less common, side effects are rapid heartbeats, low blood pressure, agitation, tremor, confusion, amnesia, dry mouth, increased salivation, joint pains, and abnormal vision.

The incidence of some adverse effects such as low blood pressure, anorexia, abnormal involuntary movements, sleepiness, tremor, cold symptoms, rash, abnormal vision, dry mouth or increased salivation appears to increase at higher dosages.

People taking ziprasidone should alert their health care provider immediately if they develop a rash or hives since this could indicate a potentially serious adverse reaction. Patients should also notify their health care provider immediately if they experience any abnormal involuntary muscle movements. People who think they may be experiencing any side effects from this or any other medication should talk to their physicians.

Interactions

Ziprasidone interacts with many other drugs. It is a good idea to review all medications being taken with a physician or pharmacist before starting this drug. Since ziprasidone may alter the rhythm of the heart, people who are also taking drugs such as quinidine, dofetilide, pimozide, sotalol, erythromycin, thioridazine, moxifloxacin, and sparfloxacin should not take it. These drugs may also affect properties of the heart and taken with ziprasidone increase the risk of irregular heart rhythms and other cardiac problems. Because ziprasidone causes sleepiness, it should be used sparingly and with care with other drugs that also have a tendency to make people drowsy such as antidepressants, antihistamines, some pain relievers, and alcohol. Ziprasidone may lower blood pressure to the point at which people feel dizzy or faint. People taking medication to regulate their blood pressure should have their blood pressure monitored and treatment modified as needed. Ziprasidone may also decrease the effects of drugs used to treat Parkinson’s disease such as levodopa.

Other drugs taken in combination with ziprasidone may alter the effects of ziprasidone. For example, drugs such as carbamazepine, used to treat seizures, increases liver metabolism and may cause ziprasidone to be less effective. Alternatively, drugs such as ketoconazole slow liver metabolism and may increase negative side effects associated with ziprasidone.

Definition

Zaleplon is classified as a hypnotic drug. These drugs help people sleep. Zaleplon is available in the United States as the brand name drug Sonata.

Purpose

Zaleplon is a drug that is used to treat short-term insomnia, and it can be habit-forming.

Description

The United States Food and Drug Administration approved Zaleplon in 1999 to treat short-term problems sleeping. Zaleplon is thought to act by mimicking a chemical in the brain that helps to facilitate sleep. It is different from other sleeping pills, because it begins to work almost immediately and its effects are rather short-lived (a few hours). These properties make it beneficial both for people who have troubling falling asleep at bedtime and for people who awaken in the middle of the night and have trouble falling back to sleep. Zaleplon may be taken in the middle of the night so long as the person can sleep at least four more hours before having to awaken.

Zaleplon is available as capsules. The drug is broken down by the liver. It is a controlled substance and can be habit-forming.

Recommended dosage

The usual dose of zaleplon for adults is 5–20 mg. For healthy adults, 10 mg is a common dosage. However, people over age 65, small adults with low body weight, and people with serious health problems (especially liver disease) should take a dose at the low end of this range (usually 5 mg). Zaleplon is taken immediately before bedtime. It usually takes only about 30 minutes for the sleep-inducing actions of zaleplon to be felt, and sleep-facilitating effects appear to last only a few hours. If zaleplon is taken with a meal, it will take longer to work. For the fastest sleep onset, it should be taken on an empty stomach. The maximum dose for one day is 20 mg. Under no circumstances should a person take more than 20 mg in one day.

Precautions

Zaleplon can be habit-forming and should be taken exactly as directed by a physician. A person who forgets a dose of zaleplon should skip the dose and take the next dose at the regularly scheduled time.

Because zaleplon is used to help people fall asleep, it should not be used with other drugs (over-the-counter or prescription) that also cause drowsiness. Zaleplon should be used only with close physician supervision in people with liver disease and in the elderly, because these individuals are especially sensitive to the sedative properties of zaleplon. Zaleplon should not be used before driving, operating machinery, or performing activities that require mental alertness. People with a history of drug abuse, psychiatric disorders, or depression should be carefully monitored when using zaleplon since zaleplon may worsen symptoms of some psychiatric disorders and can become a drug of abuse.

If zaleplon is needed for more than seven to ten days, patients should be re-evaluated by a physician to determine if another disorder is causing their difficulty sleeping. When zaleplon or other sleeping pills are used every night for more than a few weeks, they begin to lose their effectiveness and/or people may become dependent upon them to fall asleep. Zaleplon can be addictive. People using zaleplon should not stop taking the drug suddenly because withdrawal symptoms, including sleep disturbances, may occur even if zaleplon has been used only for a short time.

Side effects

Some sleeping pills such as zaleplon can cause aggressiveness, agitation, hallucinations, and amnesia (memory problems). A patient experiencing these side effects should call a physician immediately. A physician should also be called immediately if a person taking zaleplon develops a fast or irregular heartbeat, chest pains, skin rash, or itching.

The most common side effects of zaleplon are less serious and include dizziness, drowsiness, impaired coordination, upset stomach, nausea, headache, dry mouth, and muscle aches. Other side effects that may occur include: fever, amnesia, tremor, or eye pain. Many side effects appear worse at higher doses, so it is important to use the lowest dose that will induce sleep.

Interactions

Any drug that causes drowsiness may lead to substantially decreased mental alertness and impaired motor skills when taken with zaleplon. Some examples include alcohol, antidepressants such as imipramine or paroxetine, antipsychotics like thioridazine, and some antihistamines.

Because zaleplon is broken down by the liver, it may interact with other drugs broken down by the liver. For example, the drug rifampin, which is used to treat tuberculosis, may cause zaleplon to be less effective. Alternatively, cimetidine (Tagamet), a drug commonly used to treat heartburn, may cause people to be more sensitive to zaleplon.

Definition

Yoga is an ancient system of breathing practices, physical exercises and postures, and meditation intended to integrate the practitioner’s body, mind, and spirit. It originated in India several thousand years ago, and its principles were first written down by a scholar named Patanjali in the second century B.C. The word yoga comes from a Sanskrit word, yukti, and means “union” or “yoke.” The various physical and mental disciplines of yoga were seen as a method for individuals to attain union with the divine.

In the contemporary West, however, yoga is more often regarded as a beneficial form of physical exercise than as a philosophy or total way of life. As of 2002, more than six million people in the United States were practicing some form of yoga, with 1.7 million claiming to practice it regularly.

Purpose

Yoga has been recommended as an adjunct to psychotherapy and standard medical treatments for a number of reasons. Its integration of the mental, physical, and spiritual dimensions of human life is helpful to patients struggling with distorted cognitions or pain syndromes. The stretching, bending, and balancing involved in the asanas (physical postures that are part of a yoga practice) help to align the head and spinal column; stimulate the circulatory system, endocrine glands, and other organs; and keep muscles and joints strong and flexible. Yoga programs have been shown to reduce the risk of heart disease by lowering blood pressure and anxiety levels. The breath control exercises, known as pranayama, emphasize slow and deep abdominal breathing. They benefit the respiratory system, help to induce a sense of relaxation, and are useful in pain management. The meditation that is an integral part of classical yoga practice has been shown to strengthen the human immune system. Although Western medical researchers have been studying yoga only since the 1970s, clinical trials in the United States have demon strated its effectiveness in treating asthma, osteoarthritis, heart disease, stress-related illnesses, high blood pressure, anxiety, and mood disorders. Other reports indicate that yoga merits further research in the treatment of obsessive-compulsive disorder (OCD) and substance abuse. Studies done in Germany have focused on the psychological benefits of yoga. One clinical trial done in 1994 at the University of Wurzburg found that the volunteer subjects who had practiced yoga scored higher in life satisfaction, with lower levels of irritability and pychosomatic complaints, than the control group.

One of the advantages of yoga as a complementary therapy is its adaptability to patients with a wide variety of physical and psychiatric conditions. There are a number of different schools of yoga—over 40, according to one expert in the field—and even within a particular school or tradition, the asanas and breathing exercises can be tailored to the patient’s needs. One can find special yoga courses for children; for people over 50; for people with fibromyalgia, arthritis, or back problems; for cancer patients; and for people struggling with weight. Although most people who take up yoga attend classes, it is possible to learn the basic postures and breathing techniques at home from beginners’ manuals or videotapes. Patients who feel self-conscious about exercising in the presence of others may find yoga appealing for this reason. The American Yoga Association has produced a manual and videotape for beginners, as well as a book called The American Yoga Association’s Easy Does It Yoga for persons wih physical limitations. In addition, yoga does not require expensive equipment or special courts, tracks, or playing fields. An area of floor space about 6 ft by 8 ft, a so-called “sticky mat” to keep the feet from slipping, and loose clothing that allows the wearer to move freely are all that is needed.

Precautions

Patients with a history of heart disease, severe back injuries, inner ear problems or other difficulties with balance, or recent surgery should consult a physician before beginning yoga. Pregnant women are usually advised to modify their yoga practice during the first trimester.

People diagnosed with a dissociative disorder should not attempt advanced forms of pranayama (yogic breathing) without the supervision of an experienced teacher. Some yogic breathing exercises may trigger symptoms of derealization or depersonalization in these patients.

Yoga should not be practiced on a full stomach. It is best to wait at least two hours after a meal before beginning one’s yoga practice. In addition, while yoga can be practiced outdoors, it should not be done in direct sunlight.

One additional precaution is often necessary for Westerners. Yoga is not a competitive sport, and a “good” practice is defined as whatever one’s body and mind are capable of giving on a specific day. Westerners are, however, accustomed to pushing themselves hard, comparing their performances to those of others, and assuming that exercise is not beneficial unless it hurts— an attitude summed up in the phrase “no pain, no gain.” Yoga teaches a gentle and accepting attitude toward one’s body rather than a punishing or perfectionistic approach. A person should go into the stretches and poses gradually, not forcibly or violently. Stretching should not be done past the point of mild discomfort, which is normal for beginners; frank pain is a warning that the body is not properly aligned in the pose or that the joints are being overstressed. Most people beginning yoga will experience measurable progress in their strength and flexibility after a week or two of daily practice.

Description

There are six major branches of yoga: hatha, raja, karma, bhakti, jnana, and tantra yoga. Hatha yoga, the type most familiar to Westerners, will be discussed more fully in the following paragraph. Raja yoga is a spiritual path of self-renunciation and simplicity; karma yoga emphasizes selfless work as a service to others. Bhakti yoga is the path of cultivating an open heart and single-minded love of God. Jnana yoga is the sage or philosopher’s approach; it cultivates wisdom and discernment, and is considered the most difficult type of yoga. Tantra yoga emphasizes transcending the self through religious rituals, including sacred sexuality.

Hatha yoga is the best-known form of yoga in the West because it is often taught as a form of physical therapy. A typical hatha yoga practice consists of a sequence of asanas, or physical poses, designed to exercise all parts of the body in the course of the practice. The asanas incorporate three basic types of movement: forward bends, backward bends, and twists. Practitioners of hatha yoga have over 200 asanas to choose from in creating a sequence for practice. The postures have traditional Indian names, such as Eagle Pose, Half Moon Pose, or Mountain Pose. There are steps for entering and leaving the pose, and the student is taught to concentrate on proper form and alignment. The pose is held for a period of time (usually 10–20 seconds), during which the practitioner concentrates on breathing correctly. Mental focus and discipline is necessary in order to maintain one’s poise and balance in the asana. At the close of the practice, most students of yoga rest in a position that allows for a period of meditation. Most yoga practices take about an hour, although some are as short as 20 minutes.

There are a number of different styles of hatha yoga taught in the United States, the best known being Iyengar, Bikram, Kripalu, and ashtanga yoga. Iyengar yoga, which was developed by B.K.S. Iyengar, emphasizes attention to the details of a pose and the use of such props as blocks and belts to help students gain flexibility. Bikram yoga, taught on the West Coast by Bikram Choudhury, is practiced in heated rooms intended to make participants sweat freely as they warm and stretch their joints and muscles. Kripalu yoga, sometimes called the yoga of consciousness, emphasizes breathing exercises and the proper coordination of breath and movement. It also teaches awareness of one’s psychological and emotional reactions to the various poses and movements of the body. Ashtanga yoga, developed by K. Pattabhi Jois, is the basis of socalled power yoga. Ashtanga yoga is a physically demanding workout that is not suitable for beginners.

Definition

Wernicke-Korsakoff syndrome is a severe memory disorder usually associated with chronic excessive alcohol consumption, although the direct cause is a deficiency in the B vitamin thiamin.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), the professional handbook that aids clinicians in diagnosing patients’ mental disorders, refers to Korsakoff syndrome as alcohol-induced persisting amnestic disorder and includes it under the category of substance-induced persisting amnestic disorders.

Description

The disorder was first identified in the late nineteenth century. The first phase of the condition, called Wernicke’s encephalopathy, was described by German neurologist and psychiatrist Karl Wernicke in 1881. He noted three key symptoms in three patients—two with alcoholism and one who had swallowed sulfuric acid. These patients suffered from mental confusion, eye movement disorders, and ataxia (poor motor coordination). A few years later, S. S. Korsakoff, a Russian psychiatrist, began publishing reports describing a syndrome of anterograde amnesia—an inability to form new memories—and confabulation in individuals with severe alcoholism or certain medical illnesses. (Confabulation refers to the practice of filling in gaps in memory by fabrication.) By 1900, researchers and clinicians studying alcoholism recognized a connection between the two conditions. The typical syndrome begins with acute Wernicke’s encephalopathy, with Korsakoff syndrome emerging when the acute phase resolves. The symptoms of Wernicke’s encephalopathy appear suddenly. The most prominent symptom initially is mental confusion including memory problems. On examination, patients have difficulty moving their eyes to follow a visual stimulus due to paralysis of the muscles controlling eye movements. For instance, a patient may have trouble looking upward or to the side with one or both eyes. Problems maintaining balance while standing or walking, a condition known as ataxia, are frequently observed as well. If left untreated, most of these symptoms may resolve spontaneously, but the severe memory disorder characteristic of Korsakoff syndrome remains.

The typical person with Korsakoff syndrome appears fairly normal on first impression. Intelligence is intact, and individuals with the syndrome can carry on a conversation quite naturally. They are usually able to recall and talk about incidents that took place before the onset of the disorder and recognize family members and old friends without much difficulty. The ability to form new memories is nearly absent, however. In the course of conversation, people with Korsakoff syndrome may repeat comments or questions several times. They will fail to recognize people they met minutes before or greet a friend with excitement and surprise after a brief trip to another room. These are the characteristics of anterograde amnesia. Research shows that anterograde amnesia results from a failure of memory formation and storage. New information is processed normally, but almost immediately forgotten, never making it into the regions of the brain where memories of the past are stored. People with Korsakoff syndrome thus have no memories of events that happened after the onset of the illness. Many previously stored memories are still available, however, explaining why individuals with Korsakoff syndrome can usually remember the distant past quite well.

Causes and symptoms

Causes

Wernicke-Korsakoff syndrome is caused by thiamin deficiency. It is most commonly observed in people with alcoholism since heavy drinkers often eat poorly, and alcoholism interferes with absorption of nutrients from the digestive system. It can also occur in people who are malnourished for other reasons. Thiamin helps produce energy needed to make neurons function properly. Insufficient thiamin can lead to damage or death of neurons.

Thiamin deficiency damages regions of the brain, particularly the thalamus and the mammillary bodies. The thalamus is a structure deep within the brain that serves many important functions. It is often called the major relay station of the brain, and many neurons make connections in the thalamus. The mammillary bodies are part of the hypothalamus, located just below the thalamus. The mammillary bodies receive many neural connections from another part of the brain called the hippocampus, which appears to be the primary part of the brain involved in the formation of memories. Neurons in the mammillary bodies make connections with the thalamus, which in turn makes connections with the cortex of the brain, where long-term memories are stored. This may explain why damage to the mammillary bodies and thalamus can lead to anterograde amnesia. Memories formed in the hippocampus are never stored since connections between hippocampus and cortex are disrupted.

Eye movement disorders observed in the acute phase of the condition are probably due to damage to other nearby brain regions that make connections to the nerves controlling eye muscles. These nerves emerge from the brainstem located right below the thalamus and mammillary bodies. Nerves involved in balance also make connections with other nerves in the brainstem, but a separate part of the brain called the cerebellum may also contribute to ataxia. Reasons why some regions of the brain are selectively affected by thiamin deficiency are not yet fully understood, but selective vulnerability of certain neurotransmitters is suspected.

Symptoms

Mental confusion, eye movement disturbances, and ataxia are the primary symptoms of Wernicke’s encephalopathy—the first, acute stage of Wernicke-Korsakoff syndrome. At first glance, confusion and ataxia may resemble the effects of severe alcohol intoxication, but they persist after intoxication wears off. Some patients with Wernicke’s encephalopathy will recover completely without residual memory deficits, particularly if they are treated quickly with thiamin.

The chronic stage of Wernicke-Korsakoff syndrome, sometimes called Korsakoff psychosis, is distinguished by anterograde amnesia, and most untreated patients with Wernicke’s encephalopathy will develop this severe memory disorder, which prevents them from forming lasting memories of events or information encountered after the onset of the initial symptoms. Symptoms of Korsakoff syndrome may also develop spontaneously in many patients who never show signs of Wernicke’s encephalopathy. Once patients develop Korsakoff’s amnesia, recovery is unlikely.

Loss of memory for past events is called retrograde amnesia. Many people with Korsakoff syndrome have some retrograde amnesia in addition to anterograde amnesia, particularly for events that occurred shortly before the onset of illness, but most can recall the distant past without difficulty.

Immediate memory is not affected. For instance, an individual with Korsakoff syndrome could repeat a sentence or string of numbers immediately after hearing them, although this information would likely be forgotten within half a minute. Preservation of immediate memory allows individuals with Korsakoff syndrome to interact with others and respond to questions. Implicit memory is also preserved, so people with Korsakoff syndrome can learn new motor skills or develop conditioned reactions to stimuli. For example, individuals who play computer games can show improved performance each time they play, even if they cannot explicitly remember having played the game before.

Confabulation is another striking feature of Korsakoff syndrome, although it is not always observed. Confabulation refers to falsification of memory. The individual appears to be making up stories to cover up for inability to remember. Confabulation often seems to involve a confusion of the past and present. For example, if patients with Korsakoff syndrome are asked why they are in the hospital, they may say they just had a baby, are recovering from pneumonia, undergoing medical tests, or even applying for a job.

Patients with Wernicke-Korsakoff syndrome may also show signs of apathy and a lack of spontaneous behavior. Emotional expression may be lacking as well.

Interestingly, autopsies often reveal brain lesions characteristic of Wernicke-Koraskoff syndrome in alcoholic patients who showed general cognitive problems like those seen in dementia, but who never developed anterograde amnesia. These findings suggest that onset may be gradual in some patients.

Demographics

When diagnosis is based on postmortem findings, the estimated prevalence of Wernicke-Korsakoff syndrome is between 1 and 2% of the population. The classic presentation with acute onset of Wernicke’s encephalopathy is fairly rare, about 0.05% of all hospital admissions, although this does not account for patients who do not seek medical attention. Wernicke-Korsakoff syndrome usually follows many years of chronic alcoholism or malnutrition and is seldom seen among people under 20. Most patients are 40 years of age or older. The disorder is apparently more common in alcoholic individuals who are particularly vulnerable to malnutrition such as indigent or homeless people.

Diagnosis

Wernicke’s encephalopathy is diagnosed when patients seek medical attention and have the classic trio of signs: mental confusion, eye movement disorders, and ataxia. The diagnosis of Korsakoff syndrome is given when anterograde amnesia is present in an individual with a history of chronic, heavy drinking or malnutrition. When Korsakoff syndrome follows Wernicke’s encephalopathy, the entire Wernicke-Korsakoff syndrome diagnosis is appropriate. The diagnosis is supported by neuroimaging or autopsy findings showing degeneration of the thalamus and mammillary bodies and loss of brain volume in the area surrounding the fourth ventricle—a fluid-filled cavity near the brainstem.

Although DSM-IV-TR criteria for alcohol-induced persisting amnestic disorder apply to most people with Wernicke-Korsakoff syndrome, there are some differences between the two diagnoses. Despite research findings suggesting that severe amnesia is not a necessary symptom of Wernicke-Korsakoff syndrome, the DSM-IVTR requires the presence of either anterograde or retrograde amnesia for a diagnosis of alcohol-induced persisting amnestic disorder. One additional cognitive symptom is also required. Symptoms listed in the DSM-IV-TR include language disturbance (aphasia), inability to carry out motor activities (apraxia), inability to recognize objects (agnosia), or deficits in planning, initiation, organization and abstraction (executive functions). Individuals with Wernicke-Korsakoff syndrome frequently demonstrate problems with executive functions that contribute to the symptoms of confabulation and apathy. Aphasia, apraxia, and agnosia are not common signs of Wernicke-Korsakoff syndrome.

The DSM-IV-TR also requires that memory impairment must significantly impair a person’s ability to perform normal activities and functions, and it must represent a decline from a previous level of functioning. Amnesia cannot occur exclusively during states of delirium, alcohol intoxication, or withdrawal, or be exclusively associated with a dementia. Both of the these requirements are consistent with the usual presentation of Wernicke-Korsakoff syndrome.

Finally, the DSM-IV-TR requires evidence that amnesia is caused by use of alcohol. Such evidence can include an extensive history of heavy drinking; or physical examination or laboratory findings revealing other signs of heavy alcohol use, such as abnormal liver function tests. Despite this DSM-IV-TR requirement, Wernicke-Korsakoff’s syndrome can occur in the absence of heavy alcohol use. Emergence of the disorder in people without alcoholism is much less common today than it was in the past, however, since vitamins are now added to many foods. In practice, most people who show the hallmark symptoms of Wernicke-Korsakoff syndrome also qualify for the DSM-IV-TR diagnosis.

Treatments

Nutritional

Individuals with signs of Wernicke’s encephalopathy should be treated with thiamin immediately. In many cases, prompt administration of thiamin reverses the symptoms and prevents amnesia from developing. Thiamin can be administered intravenously or directly into the digestive system. Unfortunately, thiamin is less effective in the chronic phase of the condition. Based on autopsy findings suggesting the presence of Wernicke-Korsakoff syndrome in people with milder cognitive problems who do not show the classic signs of the disorder, researchers have examined the usefulness of thiamin treatment in people with alcohol dependence who are at risk of developing the syndrome. Results suggest that thiamin treatment improves performance on memory tests in this group, and that higher thiamin doses are associated with better performance. These findings suggest that thiamin treatment can help prevent Wernicke-Korsakoff syndrome in heavy drinkers.

Medication

Recent reports suggest that donepezil and rivastigmine, drugs used to treat Alzheimer’s disease, may improve memory in patients with Wernicke-Korsakoff syndrome. Both drugs prevent the breakdown of the neurotransmitter acetylcholine, which is important for the formation of memories. Patients treated with these drugs showed improvements on memory tests and were more able to recognize hospital staff and family members. Although improvements appear to be rather modest, these drugs may be useful for patients who do not respond to thiamin. Antidepressants that increase levels of serotonin may also be helpful, although the reasons why are not clear since these drugs are not effective with other memory disorders.

Conditioning

The fact that implicit memory is not affected by Wernicke-Korsakoff syndrome has led some researchers to explore the use of classical conditioning procedures in helping patients to remember specific people. In classical conditioning, animals and people learn to associate a stimulus with an outcome. The most famous example is the pairing of a ringing bell with food. Dogs naturally salivate when given food. In a famous experiment, Ivan Pavlov rang a bell immediately before serving food to dogs. After doing this repeatedly, Pavlov found that the dogs salivated upon hearing the bell ring even when the food was not presented. This form of learning does not rely on the hippocampus and cortex but appears to involve neurons in other parts of the brain. Patients with Wernicke-Korsakoff syndrome who are given specific rewards for correctly choosing a picture of a face that matches a face they have seen previously are more able to choose the correct face than those who do not receive the rewards. Although these individuals do not explicitly remember the face they saw previously, they are still able to make the correct choice. Training patients in this way could enable them to recognize familiar people and differentiate them from strangers.

Prognosis

The prognosis for full recovery from Wernicke-Korsakoff syndrome is poor. Once chronic Korsakoff’s amnesia ensues, approximately 80% of patients will never fully recover the ability to learn and remember new information. Because they cannot learn from experience, individuals with Wernicke-Korsakoff syndrome almost always require some form of custodial care. They are usually unable to work, although some can perform simple tasks they learned prior to onset of the condition if closely supervised.

Prevention

Wernicke-Korsakoff syndrome can be prevented with a nutritious diet containing sufficient thiamin. Because severe chronic alcoholism is the most common cause of thiamin deficiency, treatment of alcohol dependence is extremely important. In order to prevent Wernicke-Korsakoff syndrome among people who are unable to stop drinking or among particularly vulnerable individuals like homeless drinkers, some researchers and clinicians have advocated supplementing alcoholic beverages with thiamin.

Definition

Wide Range Achievement Test, 3rd ed. or WRAT-3 is a screening test that can be administered to determine if a more comprehensive achievement test is needed. Achievement tests refer to skills that individuals learn through direct instruction or intervention.

Purpose

The WRAT-3 measures basic skills in reading, arithmetic, and spelling. The test covers ages from five to 75 years old and takes approximately 30 minutes to administer.

Precautions

Although screening instruments may save time, these instruments can sometimes have misleading results. For instance, the scores may overestimate or underestimate a person’s skills or the test does not measure other important achievement abilities. To obtain a more indepth result of an examinee’s abilities, a more comprehensive achievement test must be administered. For example, the WRAT-3 has no assessment of fundamental skills such as reading comprehension, writing abilities, and applying mathematical concepts to real-life situations. Finally, psychometric testing requires a clinically trained examiner. Therefore, the test should only be administered and interpreted by a trained examiner.

Description

The WRAT-3 has two alternative testing forms (tan and blue). One form is administered with the second form available if needed. Both testing forms (both the tan and blue forms) can be administered. When this is done, a combined scored is obtained. Each testing form consists of one reading test, one arithmetic test, and one spelling test. The reading test is administered individually, but the other two tests may be given in groups of up to five people. The reading test consists of 15 letters and 42 individual words that the examinee is asked to name or pronounce. The spelling test consists of writing one’s name, 13 letters, and up to 40 words dictated to the examinee and used in a sentence. The spelling items increase with difficulty. Finally, the arithmetic test consists of two parts. Part I requires counting, reading number symbols, and solving simple arithmetic problems that are verbally presented to the examinee. Part II consists of using paper and a pencil to calculate up to 40 arithmetic problems within 15 minutes. These arithmetic problems are presented in a test booklet.

Results

Scoring consists of a 1 for a correct answer and a 0 for an incorrect answer. The raw scores are converted to standard scores. These are scores that allow the examiner to compare the individual’s score to other people who have taken the test. Additionally, by converting raw scores to standard scores the examiner has uniform scores and can more easily compare an individual’s performance on one test with the individual’s performance on another test. The average score for each test of the WRAT-3 is 100. An examiner can also obtain grade-equivalent scores, percentile ranks, and normal curve equivalents. A poor performance in any of the three areas assessed by this instrument can indicate the need for further testing.