Gender in obsessive-compulsive disorder and obsessive-compulsive spectrum disorders

Summary Background: There is increasing recognition that obsessive-compulsive disorder (OCD) and putative OCD spectrum disorders (OCSDs) are not homogenous entities. Gender may provide an important window onto the heterogeneity of these various disorders. Methods: A MEDLINE review of gender issues in OCD and putative OCD spectrum disorders (excluding eating disorders) was undertaken (1965–2000). These included demographic variables, clinical phenomenology, etiological factors, and treatment implications. Results: OCD differs from other anxiety disorders in having an approximately equal male:female gender ratio. OCSDs (e.g. body dysmorphic disorder) may have an equal gender ratio, may be more common in women (e.g. trichotillomania, hypochondriasis) or may be more common in men (e.g. Tourette's disorder). Etiological factors may differ across gender; an association between perinatal or early brain injury and OCD or Tourette's appears particularly important in males, while OCD and trichotillomania may also begin during pregnancy or shortly after childbirth with exacerbation of symptoms during menstruation. It is not clear that anti-androgens are effective in OCD, nor that gender predicts response to serotonin reuptake inhibitors in this disorder. Conclusion: There is a relative scarcity of literature addressing gender issues in OCD and putative OCSDs. That literature which does exist is not entirely conclusive, but raises a number of interesting questions for future research.     

The genetic basis of panic and phobic anxiety disorders

Panic disorder and phobic anxiety disorders are common disorders that are often chronic and disabling. Genetic epidemiologic studies have documented that these disorders are familial and moderately heritable. Linkage studies have implicated several chromosomal regions that may harbor susceptibility genes; however, candidate gene association studies have not established a role for any specific loci to date. Increasing evidence from family and genetic studies suggests that genes underlying these disorders overlap and transcend diagnostic boundaries. Heritable forms of anxious temperament, anxiety-related personality traits and neuroimaging assays of fear circuitry may represent intermediate phenotypes that predispose to panic and phobic disorders. The identification of specific susceptibility variants will likely require much larger sample sizes and the integration of insights from genetic analyses of animal models and intermediate phenotypes.     

强迫障碍患者的共病人格障碍

目的:探讨强迫障碍(obsessive-compulsive disorder,OCD)患者共病轴Ⅱ人格障碍的情况。方法:对44例符合美国精神障碍诊断统计手册4版(Diagnostic and Statistical Manual of Mental Disorders,Fourth Edition,DSM-IV)中OCD临床诊断标准的门诊和住院部患者,应用人格障碍诊断问卷4版(Per-sonality Diagnostic Questionnaire,PDQ+4)进行筛查。对筛查阳性者再用个性障碍晤谈手册(Personality Disorder Interview,PDI-IV)做半定式查询确定其中的人格障碍患者。结果:36名患者PDQ+4筛查阳性,阳性率为82%。36名阳性患者中有32名OCD患者同时符合人格障碍的诊断标准,共病率为73%(32/44),其中57%(25/44)的被试符合两种或两种以上人格障碍的诊断标准。共病率最高的3种人格障碍为C组的强迫型(64%)、回避型(57%)和A组的偏执型(21%)。结论:强迫障碍有较高的人格障碍共病率,其中共病率最高的为C组的强迫型和回避型。     

The temporal relationship between anxiety disorders and (hypo)mania: a retrospective examination of 63 panic, social phobic and obsessive-compulsive patients with comorbid bipolar disorder

BACKGROUND: The relationship between anxiety and depressive disorders has been conventionally limited to unipolar depression. Recent studies from both clinical and epidemiologic samples have revealed intriguing associations between anxiety and bipolar (mainly bipolar II) disorders. The present report examines the temporal sequence of hypomania to panic (PD), obsessive-compulsive (OCD) and social phobic (SP) disorders. METHODS: Specialty-trained clinicians retrospectively evaluated the foregoing relationships in 63 patients meeting the DSM-III-R diagnosis for PD, OCD and SP with lifetime comorbidity with bipolar disorders (87% bipolar II). Structured interviews were used. RESULTS: In nearly all cases, SP chronologically preceded hypomanic episodes and disappeared when the latter episodes supervened. By contrast, PD and OCD symptomatology, even when preceding hypomanic episodes, often persisted during such episodes; more provocatively, nearly a third of all onsets of panic attacks were during hypomania. LIMITATIONS: Assessing temporal relationships between hypomania and specific anxiety disorders on a retrospective basis is, at best, of unknown reliability. The related difficulty of ascertaining the extent to which past antidepressant treatment of anxiety disorders could explain the anxiety-bipolar II comorbidity represents another major limitation. CONCLUSIONS: Different temporal relationships characterized the occurrence of hypomania in individual anxiety disorder subtypes. Some anxiety disorders (notably SP, and to some extent OCD) seem to lie on a broad affective continuum of inhibitory restraint vs. disinhibited hypomania. By contrast, and more tentatively, PD in the context of bipolar disorder, might be a reflection of a dysphoric manic or mixed hypomanic symptomatology. The foregoing suggestions do not even begin to exhaust the realm of possibilities. The pattern of complex relationships among these disorders would certainly require better designed prospective observations.     

Internet-guided self-help with or without exposure therapy for phobic and panic disorders

BACKGROUND: As many sufferers from phobic and panic (phobia/panic) disorders cannot get to suitable therapists, routine aspects of therapy were delegated to internet-accessed computer-aided self-help with or without exposure instructions. METHODS: Phobia/panic referrals were randomised to computer-aided self-help via the internet at home in a 2:1 ratio either by self-exposure cognitive behaviour therapy (CBT) [FearFighter (FF), n = 45] or by minimal CBT without exposure [Managing Anxiety (MA), n = 23]. All had brief backup phone advice from a clinician concerning their computer guidance. RESULTS: On self-ratings and blinded assessor ratings, patients improved equally with each form of self-help over 10 treatment weeks but significantly more on 5 out of 10 measures by week 14 (1-month follow-up) when the self-help included self-exposure instructions than when it did not. In accord with this, standardised effect sizes (Cohen's d) indicated superiority of FF over MA on 5 measures by week 14. Satisfaction with treatment in all patients pooled correlated positively with improvement after treatment and at 1-month follow-up. CONCLUSIONS: At the end of treatment, computer-aided CBT self-help at home via the internet plus brief live helpline support was effective with or without exposure instructions, and at 1-month follow-up it was more effective on some measures if exposure instructions had been included. Analysis is needed of how non-exposure CBT produced its shorter-term effect.     

Clinical and psychological features distinguishing obsessive-compulsive and chronic tic disorders.

Medical and biogenetic research has suggested that obsessive-compulsive disorder and chronic (multiple) tic disorder may share a common etiology. This article reviews corresponding evidence for psychological similarities and differences between the two disorders. There are similarities in self-management strategies, psychological traits (both report high scores on different aspects of perfectionism) and in the ego-syntonic-ego-dystonic cycle of the impulsive-compulsive behavior. Situational cues likely to elicit or worsen the problem differ between the disorders as do associated emotions, comorbidity and background styles of action. In both disorders, cognitive factors, such as anticipations and appraisals of the problem, can play a role in onset and maintenance of the problem, and this raises the question as to whether cognitive or behavioral factors are best addressed in treatment. Psychological characteristics, such as lack of confidence, may contribute to apparent performance deficit. Psychological evaluation, particularly functional analysis, may aid in differential diagnosis between the two disorders, lead to improvement in treatment matching, and in understanding of the multidetermined etiology.     

Behavioural and emotional profiles of children and adolescents with disorders of arousal

Disorders of arousals are common sleep disorders characterized by complex motor behaviours that arise episodically out of slow‐wave sleep. Psychological distress has long been associated with disorders of arousal, but this link remains controversial, especially in children and adolescents. The aim of this multi‐centre study was to characterize behavioural and emotional problems in a sample of children/adolescents with disorders of arousal, and to explore their relationship with the severity of nocturnal episodes. The parents of 41 children/adolescents with a diagnosis of disorders of arousal (11.5 ± 3.3 years old, 61% males) and of a group of 41 age‐ and gender‐matched control participants filled in the Child Behavior Checklist, along with the Sleep Disturbance Scale for Children and the Paris Arousal Disorders Severity Scale. Multilevel t‐tests revealed significantly higher total scores and sub‐scores of the Child Behavior Checklist for the patient group compared with the control group. Thirty‐four percent of the patients obtained pathological total scores, and 12% of them borderline scores. The severity of emotional/behavioural problems in the patient group was positively correlated with the severity of the nocturnal episodes. Interestingly, children/adolescents with disorders of arousal also obtained higher excessive daytime sleepiness and insomnia symptoms sub‐scores at the Sleep Disturbance Scale for Children. These results confirmed the hypothesis that behavioural/emotional problems are surprisingly common in children/adolescents with disorders of arousal. Further studies are warranted to investigate the causal relationship between pathological manifestations, subtler sleep abnormalities, and diurnal emotional/behavioural problems in children/adolescents with disorders of arousal.     

Familial aggregation of schizophrenia-spectrum disorders and obsessive-compulsive associated disorders in schizophrenia probands with and without OCD.

A substantial proportion of schizophrenia patients also has obsessive-compulsive disorder (OCD). To further validate the clinical validity of a schizo-obsessive diagnostic entity, we assessed morbid risks for schizophrenia-spectrum disorders and OC-associated disorders in first-degree relatives of schizophrenia probands with and without OCD. Two groups of schizophrenia probands [with OCD (n = 57) and without OCD (n = 60)] and community-based controls (n = 50) were recruited. One hundred eighty two first-degree relatives of probands with OCD-schizophrenia, 210 relatives of non-OCD schizophrenia probands, and 165 relatives of community subjects were interviewed directly [59.3% (108/182), 51.9% (109/210), and 54.5% (90/165), respectively], using the Structured Clinical Interview for Axis-I DSM-IV Disorders and Axis II DSM-III-R Personality Disorders and the remaining relatives were interviewed indirectly, using the Family History Research Diagnostic Criteria. Relatives of OCD-schizophrenia probands had significantly higher morbid risks for OCD-schizophrenia (2.2% vs. 0%; P = 0.033) and OCPD (7.14% vs. 1.90%; P = 0.014), and a trend towards higher morbid risk for OCD (4.41% vs. 1.43%; P = 0.08) compared to relatives of non-OCD schizophrenia probands. When morbid risks for OCD, OCPD, and OCD-schizophrenia were pooled together, the significant between-group difference became robust (13.74% vs. 3.33%; P = 0.0002). In contrast, relatives of the two schizophrenia groups did not differ significantly in morbid risks for schizophrenia-spectrum disorders, mood disorders, or substance abuse disorders. A differential aggregation of OC-associated disorders in relatives of OCD-schizophrenia versus non-OCD schizophrenia probands, provides further support for the validity of a putative OCD-schizophrenia ("schizo-obsessive") diagnostic entity.     

Metacognitive interpersonal therapy in a case of obsessive-compulsive and avoidant personality disorders

Metacognitive interpersonal therapy (MIT) for personality disorders is aimed at both improving metacognition--the ability to understand mental statesand modulating problematic interpersonal representations while building new and adaptive ones. Attention to the therapeutic relationship is basic in MIT. Clinicians recognize any dysfunctional relationships with patients and work to achieve attunement to make the latter aware of their problematic interpersonal patterns. The authors illustrate here the case of a man suffering from obsessive-compulsive and avoidant personality disorders with dependent traits. He underwent combined individual and group therapies to (a) modulate his perfectionism, (b) prevent shifts towards avoiding responsibilities to protect himself from feared negative judgments, and (c) help him acknowledge suppressed desires. We show how treatment focused on the various dysfunctional personality aspects.     

New drug treatments for urinary incontinence

Urinary incontinence remains a common and distressing condition affecting many women and is known to have a significant effect on quality of life (QoL). Whilst conservative and behavioural therapy are important in the management of women with both stress incontinence and overactive bladder (OAB) ultimately many may benefit from pharmacological therapy. Antimuscarinic drugs are the commonly used agents in the treatment of OAB although often compliance and persistence are affected by adverse effects. Consequently many newer agents remain under investigation. In addition duloxetine has recently been introduced for the management of women with stress incontinence and may offer an alternative to surgery in selected cases.     

The effectiveness of evidence-based treatments for personality disorders when comparing treatment-as-usual and bona fide treatments

Objective

The purpose of Study 1 was to examine the relative efficacy of evidence-based treatments (EBTs) when compared to treatment-as-usual (TAU) for adults diagnosed with a personality disorder (PD). The purpose of Study 2 was to investigate the strength of the differences between bona fide psychotherapeutic treatments for PDs.

Method

Two separate computerized searches were conducted of: (a) studies that directly compared an EBT with a TAU for treatment of PDs, or (b) studies that compared at least two bona fide treatments for PDs. Meta-analytic methods were used to estimate the effectiveness of the treatments when compared to one another and to model how various confounding variables impacted the results of this comparative research.

Results

A total of 30 studies (Study 1; N = 1662) were included in the meta-analysis comparing EBTs to TAU. A total of 12 studies (Study 2; N = 723) were included in the meta-analysis comparing bona fide treatments. Study 1 found that EBTs were superior to TAU, although the TAU conditions were not comparable in many respects (e.g., not psychotherapy, lacking supervision, lacking training, etc.) to the EBT and there was significant heterogeneity in the effects. Study 2 found that some bona fide treatments were superior to others.     

New and emerging drug treatments for severe asthma

Asthma is a common chronic inflammatory condition of the airways affecting over 300 million people world‐wide. In 5%‐10% of cases, it is severe, with disproportionate healthcare resource utilization including costs associated with frequent exacerbations and the long‐term health effects of systemic steroids. Characterization of inflammatory pathways in severe asthma has led to the development of targeted biological and small molecule therapies which aim to achieve disease control while minimizing corticosteroid‐associated morbidity. Herein, we review currently licensed agents and those in development, and speculate how drug therapy for severe asthma might evolve and impact on clinical outcomes in the near future.     

利培酮合并氯丙咪嗪治疗难治性强迫症临床分析

目的比较利培酮合并氯丙咪嗪对难治性强迫症的临床疗效及不良反应。方法用前瞻性、随机单盲法,将28例难治性强迫症患者随机分为利培酮合并氯丙咪嗪组和氯丙咪嗪组（n=14）,疗程10周。在疗前,疗后2、4、6、8、10周末用Yale-Brown强迫量表（Y-BOCS）、汉密尔顿焦虑量表（HAMA）、汉密尔顿抑郁量表（HAMD）、副反应量表（TESS）和临床疗效评定标准评定疗效及不良反应。结果利培酮合并氯丙咪嗪组起效快,第2周末各分值与治疗前比较,差异有显著性（P＆lt;0.05）。两组从第4周末始各分值与治疗前比较,差异均有极显著性（P＆lt;0.01）。第4、6、8、10周两组间各分值比较,差异均有显著性（P＆lt;0.05）。利培酮合并氯丙咪嗪组总体疗效优于氯丙咪嗪组,两组有效率差异有显著性（P＆lt;0.05）,两组不良反应差异无显著性（P＆gt;0.05）。结论利培酮合并氯丙咪嗪治疗难治性强迫症较单用氯丙咪嗪好,且起效快,值得临床应用。     

A comparison of completers and noncompleters of exposure-based cognitive and behavioral treatment for phobic and anxiety disorders in youth

This article examined sociodemographic and clinical characteristics of child treatment completers and noncompleters who received exposure-based cognitive-behavioral treatment. A total of 137 children (46% girls) and their parents (predominantly Euro-American and Hispanic/Latino) participated in this study (106 completers, 31 noncompleters). The majority of noncompleters received an average of 5 sessions. Findings were generally consistent with past research in terms of lack of differences between completers and noncompleters. Results are discussed in the context of previous child attrition research and directions for future research.     

强迫症药物疗效与六个功能基因的分子遗传药理学研究

目的　探讨与5-羟色胺系统和多巴胺系统有关的6个基因(5-羟色胺2A受体基因、5-羟色胺转运体基因、多巴胺D2受体基因、多巴胺D4受体基因、儿茶酚胺氧位甲基转移酶基因、单胺氧化酶A基因)与强迫症药物疗效之间是否存在关联。方法　收集了113个强迫症核心家系,对强迫症患者给予5-羟色胺回吸收抑制剂治疗,采用Yale-Brown强迫量表在治疗8周前后进行评定,按Yale-Brown强迫量表评分分为有效组和无效组。采用限制性片段长度多态性和可变数串联重复序列多态性技术对有效组和无效组的强迫症家系在6个基因的7个位点上进行传递不平衡检测。结果　未发现6个基因与不同药效的强迫症家系之间存在关联,但发现有效组和无效组在5-羟色胺2A受体基因-1438G/A位点基因型频率存在差异,无效组有更多的纯合子(χ2=4.69,P=0.03)。结论　5-羟色胺2A受体基因可能和强迫症药物治疗效果有关。     

Decreased global field synchronization of multichannel frontal EEG measurements in obsessive-compulsive disorders

Global field synchronization (GFS) quantifies the synchronization level of brain oscillations. The GFS method has been introduced to measure functional synchronization of EEG data in the frequency domain. GFS also detects phase interactions between EEG signals acquired from all of the electrodes. If a considerable amount of local brain neurons has the same phase, these neurons appear to interact with each other. EEG data were received from 17 obsessive-compulsive disorder (OCD) patients and 17 healthy controls (HC). OCD effects on local and large-scale brain circuits were studied. Analysis of the GFS results showed significantly decreased values in the delta and full frequency bands. This research suggests that OCD causes synchronization disconnection in both the frontal and large-scale regions. This may be related to motivational, emotional and cognitive dysfunctions.