Obsessive-Compulsive Disorder

Contemporary Issues in Treatment

Wayne K. Goodman, Matthew V. Rudorfer, Jack D. Maser

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781317200222
• Edition: 1
• Topic: Psychologie
• Subtopic: Abnormale Psychologie

Obsessive-compulsive disorder is now recognized to be a serious and chronic illness affecting more than 2% of the population. While the last decade of the twentieth century witnessed many advances on both the pharmacological and the behavioral fronts, fewer than 50% of cases benefitted significantly from treatments available at the time. In this volume, originally published in 2000, leading authorities offer a comprehensive, cutting-edge overview of etiology, diagnosis, assessment, and the latest cognitive-behavioral, biological, and combined approaches to intervention. A special focus is treatment-resistant illness.

Obsessive-Compulsive Disorder: Contemporary Issues in Treatment will be an indispensable resource for all professionals who seek better solutions to the often seemingly intractable problems of their OCD clients.

I

CLINICAL SUBTYPES AND SPECTRUM

1

Spectrum, Boundary, and Subtyping Issues: Implications Obsessive-Compulsive Disorder

Eric Hollander
Cheryl M. Wong

Mount Sinai School of Medicine

Obsessive-compulsive disorder (OCD) and its relation to other related disorders has only recently become the focus of extensive investigations. Obsessive-compulsive (OC) spectrum disorders may conceivably affect up to 10% of the U.S. population (Hollander & Wong, 1995b). Our newly emerging knowledge raises many questions about research directions. In this chapter we define and elucidate the OCD spectrum, focus on the treatment-resistant population, and describe the future research initiatives that need to be undertaken.

DEFINITIONS OF THE OCD SPECTRUM

OC spectrum disorders share many features with OCD (Hollander, 1993a, 1993b; Hollander & Wong, 1995b). These include overlap in:

1. Symptom profile: characterized by intrusive obsessive thoughts or repetitive behaviors.

2. Associated features: demographics, family history, comorbidity, clinical course.

3. Neurobiology: assessed by pharmacological challenge studies, imaging, immune factors.

4. Response to selective antiobsessional behavioral therapies and pharmacotherapies.

5. Etiology: genetics, environmental factors.

OC-related disorders include many distinct psychiatric categories, which are discussed later in this chapter.

It is important to note, however, that often these spectrum disorders coexist in the same patient, thereby making accurate diagnoses even more important. Many of these patients with comorbid spectrum disorders are often labeled as treatment-resistant when they do not respond to conventional treatments that are targeted to a narrow diagnostic category. There-fore, knowledge of a broader spectrum of diagnostic entities that are often associated and interrelated would lead to more tailored treatments, and hopefully improved response rates.

Symptom Profile and Phenomenology

OCD is characterized by either obsessions (recurrent and persistent ideas, thoughts, or images) or compulsions (repetitive behaviors performed according to certain rules or in a stereotyped fashion; American Psychiatric Association, 1994). In addition, these obsessions or compulsions cause marked distress or significantly interfere with the patient’s function. Symptomatically, both compulsivity and impulsivity have in common the inability to inhibit or delay repetitive behaviors. The difference between the two lies in the driving foci. In compulsivity, it is the need to decrease the discomfort associated with rituals, and in impulsivity, it is the need for the maximization of pleasure. It should also be noted, however, that not all compulsions reduce anxiety. In more impulsive patients, there is also an additional component of the rituals being pleasurable, albeit with associated guilt after the behavior is carried out. In individuals with OC-related disorders, features of both compulsivity and impulsivity may be observed. Clearly, compulsivity and impulsivity are not mutually exclusive, and individuals may have one set of behaviors driven by the need to reduce anxiety, and another set of behaviors driven to obtain pleasure. This could be due to differential dysregulation of serotonin (5-HT) pathways in different brain areas in these patients, but more research needs to investigate this possibility.

In the first subset or cluster of the OC spectrum disorders, there is a marked preoccupation with bodily appearance or sensations, with associated behaviors performed to decrease anxiety brought on by these preoccupations. Examples within this cluster include body dysmorphic disorder (BDD), hypochondriasis (Hollander 1993a, 1993b), and eating disorders such as anorexia nervosa (Thiel, Broocks, & Ohlmeier, 1995). This group of patients may have a fixity of beliefs, contributing to the treatment resistance in BDD, hypochondriasis, and anorexia nervosa.

The second cluster of OC spectrum disorders includes impulsive-style disorders. These include impulse control disorders (McElroy, Harrison, Keck, & Hudson, 1995) such as pathological gambling (DeCaria & Hollander, 1993; Hollander & Wong, 1995a), compulsive buying (McElroy, Keck, & Phillips, 1995; McElroy, Keck, Pope, Smith, & Strakowski, 1994; Wong & Hollander, 1996), sexual compulsions (Anthony & Hollander, 1993; Coleman, 1987; Hollander & Wong, 1995a), trichotillomania (Stein et al., 1995; Winchel, 1992) and self-injurious behavior (Favazza, 1992). There is no clear functional significance of impulsive behavior with regard to anxiety regulation (either increased or decreased), but the functional impact of the behaviors centers on pleasure regulation. The largest obstacle to treating these patients often is keeping them engaged in therapy. Insufficient or inadequate treatment secondary to poor follow-up would often lead to a resurgence of symptoms and illness relapse.

The third large cluster of OC spectrum disorders includes neurological disorders with compulsive features. Patients with OCD have a higher incidence of tics and other neurological soft signs (Aronowitz et al., 1994; Baer, 1994; Denckla, 1989; Hollander, Schiffman, et al., 1990; Holzer et al., 1994; Nicolini, Wessbecker, Meija, & Sanchez de Carmona, 1993; Pauls, Alsobrook, Goodman, Rasmussen, & Leckman, 1995). The neurological cluster involves little obsessional content and mostly manifests motoric, repetitive symptomatology. It resembles the “just-so” symmetrical subtype discussed later. We found (Hollander, Schiffman, et al., 1990) that in our OCD participants compared to controls, all of whom were medication-free during the study period, soft signs correlated with severity of obsessions. There were was also a correlation between abnormality of visual memory and recognition on neuropsychological testing and total soft signs. We also found (Aronowitz et al., 1994) that OCD patients performed significantly more poorly than normal controls on visuospatial, visuoperceptual, and visual discrimination tasks, as well as set shifting, sequencing, and tracking tasks. These findings were especially prominant in male patients.

Disorders in this category include autism, which affects social, communicative, and imaginative development, with a compulsive core characterized by stereotypic movements, craving for sameness, and narrow repetitive interests (McDougle, Kresch, et al., 1995; Wong & Hollander, 1996); Asperger’s disorder, which involves less severe speech disturbance than autism, but still affects social development with associated stereo-typies and narrow repetitive interests (Hjort, 1994); Tourette’s syndrome, which comprises multiple motor and vocal tics with associated obsessions and compulsions (Miguel et al., 1995; Swedo & Leonard, 1994); and Sydenham’s chorea, which occurs secondary to rheumatic fever and involves the basal ganglia with associated repetitive involuntary movements and anxiety (Swedo, Rapoport, et al., 1989; Swedo & Leonard, 1994). Swedo, Rapoport, et al. (1989) studied 23 children and adolescents with Sydenham’s chorea and 14 with rheumatic fever but without chorea. They found that the Sydenham’s patients had significantly more obsessive thoughts and compulsive behaviors and significantly greater interference from these behaviors. Three of these patients also met criteria for OCD. However, out of the initial 39 Sydenham’s patients and 21 controls, 16 patients with Sydenham’s and 7 control patients were lost to follow-up. The participants were asked to fill out a self-report questionnaire that they received by mail. If an individual reported more than 10 obsessional symptoms, he or she was interviewed by telephone with a structured diagnostic interview. Only a subgroup of low-scoring patients were interviewed by telephone. Therefore, given the high drop-out rate and lack of a comprehensive diagnostic and psychiatric evaluation, larger, well-controlled studies with better diagnostic procedures are needed.

Associated Features

Although OCD can start as early as age 2, there is also an increased incidence in the teenage and early adult years (American Psychiatric Association, 1994; A. Black, 1974). Likewise, the OC-related disorders tend to have an age of onset in adolescence or the early 20s (Hollander, 1993a, 1993b; Hollander & Wong, 1995b). There is a higher incidence of positive family history of OCD, other OC spectrum disorders, and mood disorders (Degonda, Wyss, & Angst, 1993; McElroy, Harrison, et al., 1995; Okasha, Saad, Khalil, Dawla, & Yehia, 1994; Pauls et al., 1995). Pauls et al. (1995) undertook an extensive and thorough study that looked at 100 probands with OCD and all available first-degree relatives. The participants were interviewed directly by structured interviews and the Yale Brown Obses-sive Compulsive Scale (Goodman, Price, & Rasmussen, 1989), and best estimate diagnoses were assigned. The validities for OCD and Tourette’s and chronic tics were excellent (kappas = 0.97 and 0.98, respectively). Comparison with first-degree relatives of 33 psychiatrically unaffected participants was also carried out. They found that the rate of OCD was significantly higher in probands with OCD (10.3%) than in comparison participants (1.9%). In addition, the rate of tics was also significantly greater among the family members of probands (4.6%) than among the comparison group (1.0%). The relatives of female probands with OCD were more likely to have tics, and the relatives of probands with early onset were at higher risk for both OCD and tics. There is also often comorbidity with other OC-related disorders. In kleptomania, McElroy et al. (1991) reported that all 20 kleptomaniac patients had a lifetime diagnoses of major mood disorders, 16 had a lifetime history of anxiety disorders, and 12 had lifetime diagnoses of eating disorders. A high morbid risk of major mood disorders was found in first-degree relatives. However, this study had a small sample size and larger future studies are needed. Ego-dystonic features are more common in the later onset OCD cases compared to earlier onset cases. There seems to be a chronic course in most of the cases. Although there is no reported male or female preponderance in adult OCD (A. Black, 1974), the spectrum disorders may differ with respect to gender. Women tend to be overrepresented in studies of BDD (Hollander & Wong, 1995a), compulsive buying (McElroy, Keck, & Phillips, 1995; McElroy et al., 1994), and kleptomania (McElroy et al., 1991). Men seem to predominate in pathological gambling (DeCaria & Hollander, 1993; Rosenthal, 1992) and hypochondriasis (Warwick, 1995). It is not clear whether the differences are due to endocrine, neuroanatomical, or social and cultural factors. It should also be noted that in the subtypes of childhood-onset and tic-related OCD, up to 75% of the cases are male (Hollingsworth, Tanguay, Grossman, & Pabst, 1980).

Neurobiology

Serotonin Function. Neurobiological models of OCD and related disorders stress the role of 5-HT in pathophysiological mechanisms. In some studies of OCD, pharmacological challenge with oral m-chlorophenyl-piperazine (m-CPP), a partial serotonergic agonist, produced increased severity of OC symptoms in a subgroup of OCD patients studied (Hollander, DeCaria, et al., 1992; Zohar, Muellar, Insel, Zohar-Kadouch, & Murphy, 1987). Hollander, DeCaria, et al. (1992) found that following m-CPP, but not after fenfluramine or placebo, 55% of OCD patients experienced an exacerbation of OC symptoms. Prolactin response was also blunted in OCD patients, and patients with greater behavioral response to m-CPP had smaller prolactin responses. These results were consistent with the findings reported by Zohar et al. (1987). To contrast with the impulsive end of the spectrum, borderline personality-disordered patients with impulsive features were also studied using m-CPP (Hollander, Stein, et al., 1994). Instead of obsessional symptoms, disinhibition or depersonaliza-tion—core symptoms of borderline personality disorder—were instead produced. In addition, male patients had higher cortisol levels and marginally blunted prolactin responses after receiving m-CPP. These are preliminary findings that have to be supported by future studies involving larger sample sizes.

Patients with OCD (Hollander, DeCaria, et al., 1992), Tourette’s syndrome, and anorexia nervosa showed blunted prolactin response to m-CPP challenge. On the other hand, impulsive disorders such as borderli...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Original Title Page
• Original Copyright Page
• Table of Contents
• List of Contributors
• Preface
• Part I. Clinical Subtypes and Spectrum
• Part II. Pathophysiology and Etiology
• Part III. Assessment
• Part IV. Cognitive-Behavioral Treatments
• Part V. Drug and other Somatic Treatments
• Part VI. Combined Treatment
• Part VII. Mechanisms of Action
• About the Editors
• Author Index
• Subject Index