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Clinical Obsessive-Compulsive Disorders in Adults and Children

Shaw, Jon A. MD

The Journal of Nervous and Mental Disease: January 2012 - Volume 200 - Issue 1 - p 103
doi: 10.1097/NMD.0b013e31823fb044
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Division of Child and Adolescent Psychiatry Miller School of Medicine University of Miami Miami, FL

The editors, Robert Hudak and Darin D. Dougherty, have good credentials and are well-experienced clinicians who clearly state the concerns that motivated them to undertake this review of a very complex mental disorder. They note that past studies have suggested that, frequently, there is a 17- to 18-year lapse between the onset of obsessive-compulsive disorder (OCD) symptoms and appropriate diagnosis and treatment. Their stated intent is to “describe the current state of knowledge concerning the diagnosis and treatment of OCD” and “to enhance the clinical acumen of readers and to help ensure that readers provide their patients with optimal care”. With this intent in mind, they have brought together a number of mental health professionals to contribute their specific expertise to elucidate the various facets and dimensions of OCD and the OCD spectrum disorders.

Various authors discuss the diversity of clinical presentations, epidemiology, neurobiology, comorbidity, the role of family and community influences, and the spectrum of psychopharmacological and psychotherapeutic interventions for OCD. They have not limited themselves specifically to OCD per se but recognize that there is a spectrum of OCD disorders such as body dysmorphia and compulsive behaviors such as tricholomania and hoarding. The “Introduction to OCD,” written by one of the editors, Robert Hudak, MD, provides a brief overview and focuses on the phenomenology of OCD and briefly introduces other topics that will be discussed more fully in later chapters such as comorbidity, genetic and autoimmune causative factors, neurobiology, and the spectrum of behavioral and psychopharmacological intervention strategies. Dr. Hudak rightfully addresses the important role of “mental compulsion,” which has often been ignored in the literature (i.e., such rituals as praying and counting) and notes that approximately 10% of OCD patients have mental rituals as their primary compulsion.

In concert with the emerging interest in neuroscience, Doctors Darin D. Dougherty and Benjamin Greenberg in their brief but excellent chapter, “Neurobiology and Neurocircuitry of Obsessive-Compulsive disorder and Relevance to its Surgical Treatment,” review the neurobiology of OCD and the role of deep brain stimulation and surgical treatment for OCD.

Issues of comorbidity are delineated in the chapters “Comorbidity Mood Disorder in OCD” and “Obsessive-Compulsive Symptoms in Schizophrenia: Clinical Characteristics and Treatment.” One of the most difficult diagnostic problems is being able to discriminate between a delusion and an obsessional thought pattern. Dr. Poyurovsky, in a well-written discourse, guides us through the phenomenological and diagnostic labyrinth and discusses the intricacies of the “schizo-obsessive subgroup of schizophrenia.” Other chapters on body dysmorphia and hoarding are well presented. The chapter on trichotillomania and impulse control disorders is a little brief and is limited to a discussion of trichotillomania. The reviewer wishes that they had given more attention to other impulse control disorders that seem to have a compulsive edge such as gambling, kleptomania, eating, and others, although one could surmise that they are not ego-dystonic and, in that sense, may not be considered true compulsions.

Several chapters focus on the role of medications in the treatment of OCD (i.e., “Selective Serotonin Reuptake Inhibitors in the Treatment of Obsessive Compulsive Disorder,” “Medication Management of Obsessive Compulsive Disorder in Children and Adolescents,” and “Augmentation of Serotonin Reuptake Inhibitors in the Treatment of Obsessive-Compulsive Disorder”). Each chapter provides its own separate venue through which to understand the complexity of the role of medication in the treatment of OCD and its limitations. There is a brief but adequate discussion of the early developmental course of OCD in children and adolescents and the role of assessment instruments such as the Children’s Yale-Brown Obsessive Compulsive Scale. Particularly instructive is the discussion focused on the selection of specific medications, dosing guidelines, and a protocol for titration and the management of adverse effects associated with the selective serotonin reuptake inhibitors and augmentation strategies. The contributions of the National Institute on Mental Health–funded Pediatric OCD Treatment Study are well presented and discussed, specifically noting that the combined treatment with sertraline and cognitive behavioral therapy is superior to sertraline alone, thus clearly indicating the limitation of medication management. Other selective serotonin reuptake inhibitors seem to have equal efficacy.

The important role of behavioral interventions is presented in two chapters: “Exposure and Response Treatment for Obsessive-Compulsive Disorder” and “Cognitive Behavioral Therapy for Children and Adolescents.” The chapters present a comprehensive portrait of current behavioral strategies and efficacy studies, briefly introduce the “Relational Frame Theory,” and note as well the emerging evidence that behavioral interventions may facilitate neurobiological and neurotransmitter alterations in the brain comparable with psychopharmacological interventions; clearly, however, more research is desired.

A final chapter entitled “Providing Treatment for Patients with Obsessive Compulsive Disorder” attempts to synthesize and provide an overview of treatment strategies relevant at different levels of care to include outpatient treatment, partial hospitalization, inpatient treatment, and more intensive residential programs. It is suggested that Exposure Response Prevention (ERP) is the first line of treatment and that ERP plus medication is reserved for individuals with more moderate and severe symptoms. The editors provide a list of “Intensive Treatment Programs” available nationally for individuals with more refractory OCD, a resource alone that would make the text a worthwhile purchase.

As with any such endeavor, the authors vary in the skill and knowledge that they bring to this enterprise. With so many contributors, 15 in number, there is some redundancy, but repetition serves the interest of the reader because they may selectively read the various chapters. Nevertheless, the overall quality of the text is excellent: it represents the state of the art and is worthy on the bookshelf of any who would like to be familiar with the current understanding of OCD, OCD spectrum disorders, and their treatment.

Jon A. Shaw, MD

Division of Child and Adolescent Psychiatry

Miller School of Medicine

University of Miami

Miami, FL

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DISCLOSURE

The author has nothing to disclose.

© 2012 Lippincott Williams & Wilkins, Inc.