Erklärungs-Modelle für die Zwangserkrankung (syn= Zwangsstörung)
Bei zusammenfassender Betrachtung weiss man über die Ätiologie, als die eigentliche Verursachung der Zwangsphänomene noch sehr wenig. Deshalb sollen im folgenden auch nur stichpunktartig einzelne (Teil-)Erkenntnisse der verschiedenen Forschungsrichtungen und Schulen aufgeführt werden.
Zwänge und „Zwangsstörung“ in der Psychoanalyse
In psychoanalytischen Konzepten (Freud 1908) spielte anfänglich eine gestörte Triebdynamik eine entscheidende Rolle für die Entwicklung der zwanghaften Persönlichkeitsstruktur und der Zwangs-Symptome. Die „anale Trias“: Ordnungsliebe, Sparsamkeit und Eigensinn wurde entdeckt. Die Zwangs-Symptome erschienen als Audruck der kompromisshaften Lösungsversuch eines Konfliktes aus der „analen“ Entwicklungsphase, in denen zugleich die symbolische Trieberfüllung, als auch die Trieb- und Angstabwehr zum Ausdruck kommt. Das Symptom zeigt zugleich „Befriedigungs-“ und „Strafcharakter“. Inhaltlich geht es um den Konflikt zwischen unkontrollierten sexuellen und aggressiven Triebimpulsen einerseits und einer stark ausgeprägten Gewissensinstanz andererseits, die diese Handlungen verbietet. Spätere psychoanalytische Schulen haben die Triebdynamik für die Erklärung der Zwangs-Symptome nicht mehr in dieser Weise bemüht, sondern stattdessen auf innere Konflikte im Bereich „Autonomie und Selbstkontrolle“ fokussiert.
Zwänge und „Zwangsstörung“ in der Verhaltenstherapie
In der Verhaltenstherapie erklärte und erklärt man auch heute noch die Entstehung von Zwangs-Symptomen über das lerntheoretische Modell und die Begriffe des klassischen und operanten Konditionierens. Ein ursprünglich neutraler Stimulus (Schmutz) wird durch Kopplung an einen starken negativen Affekt (Angst, heftige Abneigung) zu einem stellvertretenden Auslöser eben dieser Angst oder Abneigung. Als Folge treten Zwangs-Handlungen auf, um die Angst zu reduzieren. Durch die damit verbundenen negative Verstärkung werden aber gerade die Zwangshandlungen operant konditioniert. Das Modell ist praktisch identisch mit dem für Ängste verwendeten (s. dort).
Neuere Modelle betonen inzwischen die Bedeutung von kognitiven Bewertungsprozessen für die Entstehung und Entwicklung von Zwangs-Gedanken und Zwangs-Handlungen.
Neuropsychologische, -chemische und -anatomische Studien haben eine Reihe von Erkenntnissen zutage gefördert, die helfen, Zwangs-Phänomene besser zu verstehen und zu behandeln. So kann das „pathologische Zweifeln“ (= krankhaftes Zweifeln) von Zwangs-Kranken vermutlich einer Dysfunktionalität des kortikostriatalen Systems“ zugeordnet werden (vgl. Tallis 1997).
Serotonin-Hypothese
Verschiedene neurochemische Untersuchungen sowie die guten Erfolge mit serotonergen Medikamenten verweisen auf einen Zusammnenhang zwischen dem Serotonin-Stoffwechsel im Hirn und dem Auftreten von Zwangsstörungen. Offenbar handelt es sich allerdings um ein zwar therapeutisch-medikamentös zugängliches, aber um ein Begleitphänomen einer primären Störung des orbitofronto/zingulostriatalen Projektionssystems, weshalb die Medikamentengabe nícht wirklich heilend ist. Stattdessen kommt es nach Absetzen der Medikation zu einem Rückfall in die Symptomatik.
Dopamin-Hypothese
Vor allem bei den Zwangsstörungen der an Tic-Syndromen oder am Gilles-de-la-Tourette-Syndromerkrankten Patienten spielt wahrscheinlich auch das Dopamin bzw. das dopaminerge Transmitter-System eine bedeutsame Rolle. Es gibt Hinweise, dass die Transmitterstörungen nicht Ursache der Zwangserkrankung, sondern Begleiterscheinung von „primären Störungen im orbitofronto/zingulostriatalen Projektionssystem, welches das Verhalten an eine sich verändernde äussere Umwelt und innere emitionale Zustände anpasst und auf die monoaminergen Kerne des Mittelhirns zurückwirft“ (Kapfhammer 2000, S. 1233)
Basalganglien-Hypothese
Volk (2001) beschreibt die erweiterte Basalganglienhypothese wie folgt:
„Eine sensorische Information (z.B. Verschmutzung), wird in den Basalganglien erkannt. Die Basalganglien reduzieren daraufhin ihre inhibitorische Kontrolle auf den Thalamus, wodurch es zu einer Aktivierung von Nervenbahnen, die zum Kortex laufen, kommt, und dann über die Induktion eines kortikal motorischen Impulses das entsprechende Verhaltensmuster aktiviert wird, welches zur Beseitigung der Verschmutzung (z.B. Hände waschen) führt.
Dieser Funktionskreis kann jedoch auch ohne sensorischen Input aktiviert werden, nämlich über das Cingulum und den orbitofrontalen Kortex, wobei dieses Sognal aufgrund der intern regulierten Motivationslage induziert wird. So könnten bei der Annahme einer Überaktivität des Cingulums bzw. des orbitofrontalen Kortex ohne sensorischen Input beständige Aktivierungen (Zwangshandlungen) dieses Funktionskreises auftreten. Analog zu Zwangshandlungen kann dieser Ablauf auch für Kognitionen nachgezeichnet werden (siehe auch: Lesch 1991).“ (S. 99)
Die Basalganglienhypothese wird durch PET-Studien gestützt:
PET-Studien
In Positronen-Emissions-Computertomographischen Studien fand sich sowohl im Bereich des orbitofrontalen Kortex, der beiden nuclei caudati sowie des Cingulums ein erhöhter Glucoseumsatz („erhöhte Glucoseutilisation“). Gleichzeitig war in diesem Hirnarealen die Durchblutung reduziert
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