In two case reports, we describe typical obsessive-compulsive disorders with overlapping diagnoses.
The characteristic defensive operations of the ego consist in isolation of affect, intellectualization, reaction formation, undoing, and displacement. The great variety of these defense mechanisms results in the diverse symptoms in obsessive-compulsive disorder. Different psychodynamic interpretations (Freud, Gabbard, Mentzos) are described. One of the most fundamental problems and threatening feelings of obsessive-compulsive persons is to get out of control.
New access to the syndrome shows neurobiological investigations. There seems to be a relevant dysfunction of cortico-striato-thalamo-cortical loops. This is connected with a dysbalance of different neuromodulators and neurotransmitters. It can be characterized by hyperactivity. Biochemically, hyperactivity in this loop is related to dopamine and glutamate.
We put these neurobiological findings into a neuropsychodynamic context. One of the main defense mechanisms is displacement, the shift from thought to action—the latter replaces the former. The compulsive action is experienced as dystonic to the own self.
If the direct loop is strong, excitation takes over inhibition with the subsequent abnormally strong initiation of behavior and movement. This leaves no room for the spontaneous thoughts as they are generated on the cortical level—they simply displaced by the movements. As the subcortical generation of movements takes over and is no longer in balance with the cortical generation of internally oriented cognition including self-relatedness, the initiated movement is experienced as dystonic rather than syntonic to the self. Hence, the neuropsychodynamic conceptualization is well compatible with the neurobiological findings and may even further specify it on a functional level.
For neuropsychodynamic therapy we see here a window which may allow new therapeutic strategies which are able to influence the abovementioned balance in a positive way.
KeywordsObsessive-compulsive behavior with overlapping diagnoses Characteristic defensive operations Dysfunction of cortico-striato-thalamo-cortical loops Dysbalance of different neuromodulators and neurotransmitters A window for new neuropsychodynamic therapeutic strategies
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