"My Face Is My Fate": biological and psychosocial approaches to the treatment of a woman with obsessions and delusions.
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Adult↗
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Obsessive compulsive disorder: a review of possible specific internal representations within a broader cognitive theory.
Obsessive Compulsive Disorder (OCD) is one of the most incapacitating of anxiety disorders, and is rated as a leading cause of disability by the World Health Organization (1996). Current cognitive models of OCD have focused on beliefs and management strategies involved in the development, maintenance, and exacerbation of OCD. However, despite evidence of their association to psychopathology, few researchers have applied the idea of underlying cognitive-affective structures, such as perceptions about the self and world, as operating in individuals with obsessive-compulsive thoughts and behaviors. This paper critically engages with current cognitive, developmental, and attachment research associated with views about the self and world. It is argued that consideration of such underlying cognitive-affective vulnerabilities may lead to a broader understanding of the development and maintenance of OCD. Consistent with previous theoretical work (e.g. ), we also argue that early experiences of parenting lead to the development of a dysfunctional self-structure and world-view relevant to OCD. Thus, this paper aims to extend the focus of current OCD research by exploring the possible role of a broader range of underlying vulnerability structures in the development and maintenance of OCD-related dysfunctional beliefs and symptoms.
Adult↗
'Compulsive' lever-pressing in rats is attenuated by the serotonin re-uptake inhibitors paroxetine and fluvoxamine but not by the tricyclic antidepressant desipramine or the anxiolytic diazepam.
Rats undergoing extinction of lever-pressing for food after the attenuation of an external feedback for this behavior, exhibit excessive lever-pressing unaccompanied by an attempt to collect a reward, which may be analogous to the excessive and unreasonable behavior seen in obsessive-compulsive disorder (OCD). Given that one of the most salient features of OCD is its selective response to treatment with serotonin re-uptake inhibitors (SRIs), the present study compared the effects of the SRIs paroxetine and fluvoxamine on compulsive lever-pressing, with those of the tricyclic antidepressant, desipramine, and the benzodiazepine, diazepam, which are not effective in the treatment of OCD. Paroxetine (1-15 mg/kg) and fluvoxamine (10-20 mg/kg) dose-dependently reduced the number of compulsive lever-presses and the number of lever-presses followed by an attempt to collect a reward; desipramine (5-15 mg/kg) dose-dependently reduced only the number of lever-presses followed by an attempt to collect a reward; diazepam (2-10 mg/kg) did not affect either type of lever-pressing, except for the highest dose (10 mg/kg), which almost completely abolished lever-press responding. When administered in an extinction session not preceded by signal attenuation, paroxetine, fluvoxamine and desipramine affected only the number of lever-presses followed by an attempt to collect a reward, whereas diazepam (4-8 mg/kg) decreased both types of lever-presses. The present findings strengthen the suggestion that compulsive lever-pressing may serve to model compulsive behavior in OCD, and lends the model predictive validity.
Animals↗
Tourette syndrome. Neuropsychological tests for obsessive-compulsive disorder and attention deficit hyperactivity disorder.
Recent evidence has suggested that the commonly observed comorbid behavioral disorders of Tourette syndrome, including attention deficit hyperactivity disorder and obsessive-compulsive disorder clearly have an impact on cognitive, educational, and psychosocial function. These behavioral features of Tourette syndrome can be more debilitating than the cardinal motor features of the disorder and they require careful clinical assessment so that appropriate treatment intervention can be offered to patients and their families. This article focuses on objective neuropsychological and behavioral assessment of obsessive-compulsive disorder and attention deficit hyperactivity disorder which have proven useful for both the clinical evaluation and treatment of obsessive-compulsive disorder and attention deficit hyperactivity disorder associated with Tourette syndrome and in the research setting. Instruments with proven psychometric reliability and validity for assessing obsessive-compulsive disorder and attention deficit hyperactivity disorder which also have been useful in Tourette syndrome populations are discussed. Objective and quantitative assessment of these comorbid behavioral conditions greatly enhance our ability to treat the full neurobehavioral spectrum of Tourette syndrome.
Attention Deficit Disorder with Hyperactivity↗
Treatment of obsessive-compulsive spectrum disorders with SSRIs.
BACKGROUND: Obsessive-compulsive spectrum disorders (OCSDs) are now recognised as distinct diagnostic entities related to obsessive-compulsive disorder (OCD). The features of OCSDs and OCD overlap in many respects including demographics, repetitive intrusive thoughts or behaviours, comorbidity, aetiology and preferential response to anti-obsessional drugs such as the selective serotonin reuptake inhibitors (SSRIs). METHOD: Literature was reviewed and preliminary data from various studies were re-examined to assess the relationship between compulsivity and impulsivity, and between OCD and OCSDs. RESULTS: OCSDs include both compulsive and impulsive disorders and these can be viewed as lying at opposite ends of the dimension of risk avoidance. Compulsiveness is associated with increased frontal lobe activity and increased serotonergic activity, while impulsiveness is associated with reduced activity of these variables. Neural circuits affected by serotonergic pathways have been identified and pharmacological challenge of OCSD patients with serotonin receptor agonists have supported the involvement of serotonergic processes. CONCLUSIONS: SSRIs such as fluvoxamine have established efficacy in OCD and preliminary studies indicate that they are also effective in OCSDs. The features of three specimen OCSDs--body dysmorphic disorder, pathological gambling and autism--and their treatment with SSRIs are reviewed.
Autistic Disorder↗
Subjective quality of life of patients with obsessive-compulsive disorder.
BACKGROUND: Obsessive-compulsive disorder (OCD) is the fourth most frequent diagnosis in psychiatry. Patients with OCD suffer from obsessive thinking and compulsive behavior, which impact their everyday life negatively. OBJECTIVE: Subjective quality of life (QoL) in patients with OCD was examined and compared to the general German population and to patients with schizophrenia. METHODS: Seventy-five patients, aged 21-72, with OCD (ICD 10 F42.0-F42.2) were recruited from the outpatient clinic for anxiety disorders at the Department of Psychiatry of the University of Leipzig. By means of the WHOQOL-BREF, QoL was assessed in patients with OCD in a representative sample of patients with schizophrenia and in a sample of the general population of Saxony/Germany. RESULTS: Compared with the general population, QoL in patients with OCDs was lower in all domains of the WHOQOL-BREF. Unexpectedly, QoL in patients with OCDs was lower in the domains "psychological well-being" and "social relationships" when compared with schizophrenia patients. CONCLUSIONS: OCD has a substantial adverse effect on patients' subjective QoL, which may be even greater than the adverse effect of schizophrenia. Therefore, it will be necessary to include interventions in the treatment of OCD aimed at improving residual deficits in psychosocial functioning and QoL.
Adolescent↗
Obsessive compulsive spectrum disorder.
A wide range of psychiatric and medical disorders have been hypothesized to be related to obsessive compulsive disorder (OCD) and thus, together, to form a family of disorders known as obsessive compulsive (or OCD) spectrum disorder. The grouping of these conditions is based on their phenomenological similarities with OCD (i.e., obsessive thinking and/or compulsive behaviors), as well as their having courses of illness, comorbidity and family history patterns, biological abnormalities, and treatment responses similar to OCD. Proposed OCD spectrum disorders have included body dysmorphic disorder, hypochondriasis, anorexia nervosa, trichotillomania, and some forms of delusional disorder, among others. However, conditions with impulsive features have also been hypothesized to belong to this family, including impulse control disorders in general, paraphilias and nonparaphilic sexual addictions, bulimia nervosa and binge eating disorder, and Tourette's disorder. We review the evidence supporting the grouping of these conditions into an OCD spectrum disorder family. We conclude that these disorders are different in some ways from OCD, but that they also have many similarities with OCD, and may therefore be related to one another and to OCD. In addition, we hypothesize that some of the differences among them may be explained in part by variation along a dimension of compulsivity versus impulsivity. Finally, because most of these conditions appear to be related to mood disorder, we hypothesize that the OCD spectrum disorder family may belong to the larger family of affective spectrum disorder.
Comorbidity↗
Ethical issues involved in the implementation of a differential reinforcement of inappropriate behaviour programme for the treatment of social isolation and ritualistic behaviour in an individual with intellectual disabilities.
The present case study describes an adult male with a 28-year history of institutional care underpinned by a moderate intellectual disability (ID), and ritualistic behaviour congruent with features of autism or obsessive-compulsive disorder. The subject's ID was recognized early in life and he was provided with a special educational placement at 6 years of age, although his increasingly disturbed behaviour had resulted in several psychiatric admissions by early adolescence, and by the age of 20, his presentation necessitated long-term secure psychiatric care. The present report describes the application and ethical issues pertaining to a differential reinforcement of inappropriate behaviour (DRI) programme for the reduction of ritualistic behaviour and social isolation, the latter being a direct consequence of the former, one year after the subject was admitted to a medium-secure assessment and treatment residential facility. The results suggest that, although the treatment was successful in targeting ritualization and reducing social isolation, ethical concerns extended to care staff concerns about the reinforcer adopted for the programme and the lack of informed consent from the subject. The former resulted in inconsistent application of the programme and its eventual termination. A follow-up assessment of the subject's extent of social isolation and ritualistic behaviour suggested a return to a pre-DRI level of morbidity. Limitations and suggestions for the future treatment of such cases are outlined.
Adult↗
An investigation of traumatic life events and obsessive-compulsive disorder.
Obsessive-compulsive disorder (OCD), like most other psychiatric disorders, is suspected of being influenced by an interaction between life events and genes, both with regard to onset and course of illness. To date, no specific genes have been identified as playing a frequent role, and only a relatively few empirical studies have assessed the association between stressful life events (SLEs) and OCD. The present study builds on past research by examining the potential contributions from traumatic life events (TLEs) on the severity and symptom features in 265 individuals with Structured Clinical Interview for DSM-IV (SCID)-diagnosed OCD. Of these participants 54% endorsed having experienced at least one TLE in their life time. The presence of one or more TLEs was associated with increased OCD symptom severity. This relationship remained significant despite controlling for key variables including age, OCD age-of-onset, comorbidity, and depressive symptoms. In addition, obsessions/checking and symmetry/ordering were two of four symptom factors that were specifically associated with the occurrence of TLEs. These results are generally supportive of a pathoplastic relationship between TLEs and OCD symptomatology and thus suggest the need for greater systematic consideration of life stresses in research focused on the nature and treatment of OCD.
Adult↗
Impulsivity and compulsivity in patients with trichotillomania or skin picking compared with patients with obsessive-compulsive disorder.
To compare impulsivity and compulsivity, we performed a case control study comparing a group of 20 patients with obsessive-compulsive disorder with a group of 20 patients with skin picking and/or trichotillomania (SP/T). The instruments used were Structured Clinical Interview for DSM-IV Axis I Diagnosis, Yale-Brown Obsessive-Compulsive Scale, Schalling Impulsivity Scale, and Hamilton Anxiety and Depression Inventories. A Multidimensional Impulsive-Compulsive Spectrum Assessment Instrument was designed for this particular study. The Yale-Brown Obsessive-Compulsive Scale scores were significantly higher in patients with obsessive-compulsive disorder, compared with patients with SP/T (F = 90.29; P < .001). The Hamilton Inventories and Schalling Impulsivity Scale revealed no significant intergroup differences. The Multidimensional Impulsive-Compulsive Spectrum Assessment Instrument allowed us to find 6 statistically significant differences between groups: the ability or inability to delay an impulse, quick response or action planning, feelings of pleasure or guilt during or after an act, ritualization, and whether the patient believes he/she has losses or benefits if prevented from acting. In conclusion, SP/T should deserve further attention about their classification in future versions of diagnostic manuals because, as in International Classification of Diseases, Tenth Revision, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition includes these disorders in the same chapter as pathological gambling, kleptomania, pyromania and others. Despite their resemblance to compulsions, their classification under the Obsessive-Compulsive Spectrum needs particular phenomenological and neurobiologic investigation.
Adolescent↗
Replication study supports evidence for linkage to 9p24 in obsessive-compulsive disorder.
Obsessive-compulsive disorder (OCD) is a severe psychiatric illness that is characterized by intrusive and senseless thoughts and impulses (obsessions) and by repetitive behaviors (compulsions). Family, twin, and segregation studies support the presence of both genetic and environmental susceptibility factors, and the only published genome scan for OCD identified a candidate region on 9p24 at marker D9S288 that met criteria for suggestive significance (Hanna et al. 2002). In an attempt to replicate this finding, we genotyped 50 pedigrees with OCD, using microsatellite markers spanning the 9p24 candidate region, and analyzed the data, using parametric and nonparametric linkage analyses under both a narrow phenotype model (DSM-IV OCD definite; 41 affected sib pairs) and a broad phenotype model (DSM-IV OCD definite and probable; 50 affected sib pairs). Similar to what was described by Hanna et al. (2002), our strongest findings came with the dominant parameters and the narrow phenotype model: the parametric signal peaked at marker D9S1792 with an HLOD of 2.26 ( alpha =0.59), and the nonparametric linkage signal (NPL) peaked at marker D9S1813 with an NPL of 2.52 (P=.006). These findings are striking in that D9S1813 and D9S1792 lie within 0.5 cM (<350 kb) of the original 9p24 linkage signal at D9S288; furthermore, pedigree-based association analyses also implicated the 9p24 candidate region by identifying two markers (D9S288 and GATA62F03) with modest evidence (P=.046 and .02, respectively) for association.
Chromosome Mapping↗
[Phenomenology of obsessions and compulsions. Experimental diagnosis of obsessive compulsive neurosis. I (author's transl)].
Obsessive-compulsive phenomena occur in 'normal,' neurotic and psychotic individuals. Operational definition, quantitative assessment, and diagnostic evaluation are still unsatisfactory, particularly with regard to differentiation of obsessive-compulsive phenomena (phenomenology), differentiation of trait and symptom factors, and evaluation of different obsessive-compulsive factors in the various kinds of neuroses. Our investigation of phenomenology differs from previous similar ones in basically two aspects: The newly developed obsessive-compulsive checklist covers the whole range of obsessions and compulsions, and questionnaire items of the checklist are operationally difined without reference to constructs from theories of personality or from psychopathology. Results include: Two-thirds of all patients suffer from combined obsessions and compulsions; factorial analysis reveals five symptom factors which are quite different from factor analytic results of previous studies; depression and phobias constitute a factor by themselves; checklist ratings and factor analytic results show the necessity for and basis of a new self-rating questionnaire to substitute for those currently in use. Implications of these results for future research in psychopathology as well as treatment evaluation are discussed.
Adult↗
Obsessions and compulsions in the community.
A total of 810 adults were examined by psychiatrists in the second stage of the Eastern Baltimore Mental Health Survey. A semistructured examination, the Standard Psychiatric Examination, was used. The relationships between obsessions and compulsions and personal characteristics, childhood behaviors, family history, and other psychopathology were evaluated. The estimated prevalence of obsessions and compulsions in this population was 1.5%. Cases were significantly more likely to report having had childhood fears, learning disabilities and a family history of alcoholism and suicidal behavior. There were significant positive relationships between scores on compulsive, borderline and histrionic personality disorder scales and the probability of obsessions and compulsions. These exploratory analyses in an epidemiologic sample may identify factors of etiologic importance in this condition.
Adolescent↗
Clinical and genetic relationships between autism-pervasive developmental disorder and Tourette syndrome: a study of 19 cases.
Children with autism or pervasive developmental disorder (PDD) and Tourette syndrome (TS) share a number of symptoms. Forty-one cases have been reported in which PDD patients subsequently developed TS. We term this PDD----TS. We describe an additional 16 such patients plus 3 families where a close relative of a TS proband had autism. There was a high frequency of alcoholism, drug abuse, obsessive-compulsive, and other behavior disorders in the relatives of these patients. This frequency was virtually identical to that observed in relatives of individuals with TS only. We suggest there is an intimate genetic, neuropathologic relatedness between some cases of PDD and TS. Many observations have led us to suggest that the genetic defect in TS may be a mutation of tryptophan oxygenase and that TS is inherited as a semidominant semirecessive trait, i.e., homozygosity for a common gene which shows some expression in the heterozygous state. We propose that some types of PDD are inherited in the same fashion and by the same gene. This would explain the similarity of symptoms, frequent evolution of PDD into TS, the apparent recessive inheritance of PDD despite no increase in consanguinity, the high frequency of behavior problems in the relatives of PDD----TS patients and the serotonin abnormalities.
Adolescent↗
Did Gustav Mahler have Sydenham's chorea?
Sydenham's chorea (SC), a major manifestation of acute rheumatic fever (RF), is characterized by chorea and other motor and non-motor features. Among the latter are behavioral symptoms, including obsessive-compulsive disorder. Although SC is typically a self-limited condition, up to 50% of patients may evolve with persistent chorea. There is evidence that Gustav Mahler had a movement disorder, but its nature remains undetermined. There are witnesses describing him as having facial dyskinesia and a gait disorder consistent with chorea. His conducting performance was notorious for obsessive attention to details of the staging and musical production. Mahler was diagnosed with a valvulopathy in 1907 and died of subacute bacterial endocarditis in 1911. It is possible that the composer suffered from RF in childhood with carditis and SC, which may left him with valvulopathy, obsessive-compulsive disorder, and persistent chorea.
Chorea↗
Quantitative EEG analysis during motor function and music perception in Tourette's syndrome.
Gilles de la Tourette's syndrome (TS) is a neurobehavioral disorder of childhood onset that is characterized by motor and vocal tics and associated behavioral disturbances including obsessive-compulsive symptoms. We performed 30 channel quantitative electroencephalograms (EEGs) on 13 Tourette patients and 26 controls and studied both resting and manumotor/music perception activation conditions. Resting EEGs did not show any differences between patients and controls, as known from the literature. However, during simple and complex hand movements, as well as music perception tasks, there were subtle differences predominantly in alpha frequency. They suggested reduced brain activation during motor tasks in frontal and central regions, and on music perception in temporal and parietal regions, respectively. These findings may add evidence to the functional neuroanatomy of Tourette syndrome, affecting more areas than disturbed motor circuits.
Adolescent↗
Citalopram, a selective serotonin reuptake inhibitor augments harmaline-induced tremor in rats.
Citalopram, a serotonin reuptake inhibitor (SSRI) is one of the widely used antidepressants. Apart from its antidepressant activity citalopram is also used for anxiety, panic disorders, obsessive-compulsive disorder and behavioral disturbances of dementia. Tremor is the second most common neurological adverse effect in patients receiving treatment with SSRIs. Use of these agents in depressed patients with essential tremor has not been studied. The present study was undertaken to investigate the effect of chronic citalopram treatment on harmaline-induced tremors in rats. Female Sprague-Dawley rats weighing 70+/-2 g were given citalopram in doses of 0, 10, 20 and 40 mg/kg by gavage for 2 weeks. On the 15th day, the rats were given harmaline (10 mg/kg, i.p.) 30 min after the last dose of citalopram. The latency of onset, intensity and duration of tremor and EMG were recorded. Serotonin (5HT) and 5-hydroxy indole acetic acid (5HIAA) were measured in brain stem. Citalopram dose dependently exacerbated the duration, intensity and amplitude of EMG of harmaline-induced tremor. A significant decrease in 5HT turnover (5HIAA/5HT ratio) in the brain stem was observed suggesting a possible role of serotoninergic impairment in citalopram-induced augmentation of harmaline-induced tremor. Clinical implications of these observations warrant further investigation.
Analysis of Variance↗
An adolescent male with multiple paraphilias successfully treated with fluoxetine.
Little is known about the psychiatric diagnosis and treatment of adolescents who sexually offend. We therefore describe an adolescent sex offender who met DSM-IV criteria for multiple paraphilias (except for the age criterion), bipolar type II disorder, and OCD, whose paraphilic urges and behaviors, depression, and violent obsessions responded to open label fluoxetine after failing to respond to long-term residential treatment. Although only a single and uncontrolled observation, this case suggests that some adolescent sex offenders may in fact have paraphilias, and that paraphilias in adolescents, like those in adults, may respond to serotonin reuptake inhibitors.
Adolescent↗