强迫障碍共病强迫型人格障碍的研究

目的:研究强迫型人格障碍(OCPD)在强迫障碍(OCD)中的共病情况,并研究OCD共病OCPD对OCD影响。方法:以69例门诊OCD患者为研究对象,采用DSM-Ⅳ轴Ⅱ障碍用临床定式检查(SCID-Ⅱ)研究强迫障碍患者的共病人格障碍(PD)情况,将研究对象分为2组:OCD共病OCPD组和OCD不共病OCPD组,对比研究2组间临床特征的不同。结果:79.7%强迫障碍患者合并有PD,C类中的OCPD和OCD共病率达43.5%。共病组较不共病组疾病严重程度更重,表现为发病年龄早、病程更长、强迫思维更严重。结论:OCPD和OCD关系密切,OCD共病OCPD是OCD严重程度的一个标志。     

Shared executive dysfunctions in unaffected relatives of patients with autism and obsessive-compulsive disorder.

BACKGROUND: Executive dysfunctions have been studied as a potential endophenotype associated with the genetic basis of autism. Given that recent findings from clinical and molecular genetic studies suggest that autism and obsessive-compulsive disorder (OCD) could share a common pattern of heritability, we assessed executive functions as a possible common cognitive endophenotype in unaffected family members of individuals with either autism or OCD. METHODS: Five tests assessing executive functions (Tower of London, verbal fluency, design fluency, trail making and association fluency) were proposed to 58 unaffected first-degree relatives (parents and siblings) of probands with autism and 64 unaffected first-degree relatives of OCD patients. Results were compared with those of 47 healthy controls matched for age, sex, and level of education. RESULTS: In the Tower of London test, both groups of unaffected relatives showed significantly lower scores and longer response times compared with controls. No differences were observed between autism and OCD relatives and healthy controls in the four other tasks (verbal fluency, design fluency, trail making test and association fluency). CONCLUSIONS: Our findings show the existence of executive dysfunction in the unaffected first-degree relatives of probands with OCD, similar to those observed in the relatives of patients with autism. These results support and extend previous cognitive studies on probands indicating executive dysfunctions in autism and OCD. Planning and working memory processes could thus represent a common cognitive endophenotype in autism and OCD that could help in the identification of genes conferring vulnerability to these disorders.     

Perinatal obsessive-compulsive disorder

A perinatal obsessive-compulsive disorder (OCD) is defined as an illness exhibiting first symptoms in the context of pregnancy and the postpartal period. There are no valid data up to date concerning the incidence of OCD, which might be of multifactorial origin, in this period in which females are highly vulnerable for psychiatric diseases. From a clinical point of view, obsessions and compulsions are mainly related to the well-being of the foetus or newborn baby. Differential diagnosis of perinatal OCD including pregnancy psychosis and post-partum depression is often difficult. Concerning treatment, non-pharmacological approaches should be preferred. Administration of SSRIs should be strongly restricted. However, there are no controlled therapy studies in patients with perinatal OCD. Furthermore, current knowledge about these patients is still limited. The aim of this review article is the presentation of phenomenology, pathogenesis, differential diagnosis and treatment of perinatal OCD. The mental situation of the female patients can be improved and stabilised if early diagnosis of a perinatal OCD leads to early initiation of an adequate therapy. This will then enable a good and stable mother-child relationship to develop.     

Lifetime-comorbidity of obsessive-compulsive disorder and subclinical obsessive-compulsive disorder in northern Germany

Objective Inspite of the worldwide relevance of obsessive-compulsive disorder (OCD), there is a substantial lack of data on comorbidity in OCD and subclinical OCD in the general population. Methods German versions of the DSM-IV adapted Composite International Diagnostic Interview were administered to a representative sample of 4075 persons aged 18–64 years, living in a northern German region. Results In both genders, high rates of comorbid depressive disorders were found in OCD and subclinical OCD, whereas somatoform pain disorder was only associated with OCD. In female subjects, OCD was additionally associated with social and specific phobias, alcohol, nicotine and sedative dependence, PTSD and atypical eating disorder. Conclusion Due to low comorbidity rates, subclinical OCD seems to represent an independent syndrome not restricted to the presence of other axis-I diagnoses. Comorbidity patterns show a disposition to anxiety and to depressive disorders in OCD and subclinical OCD. A broad association with obsessive-compulsive spectrum disorders could not be confirmed in our general population sample. Received: 24 July 2000 / Accepted: 16 May 2001     

双相障碍与强迫症的共病

概述

在双相障碍患者中强迫症状是常见的。因为双相障碍和强迫症的共病状态会令这两种障碍的临床治疗复杂化，所以确定这些共病的患者是很重要的。我们讨论了强迫症和双相障碍的共病，介绍了可能导致这种常见共病状态的发病机制，也讨论了该领域最新的研究进展，并提出一些管理这些患者的临床原则。

中文全文

本文全文中文版从2015年10月26日起在http://dx.doi.org/10.11919/j.issn.1002-0829.215009可供免费阅览下载 Previous studies have documented high rates of comorbidity of other psychiatric conditions among individuals with bipolar disorders (BD).[1] One study estimated that obsessive-compulsive disorders (OCD) accounted for 21% of all comorbidities in BD.[2] There is continuing debate about whether (a) these are two independent conditions that can co-occur or (b) OCD is a specific subtype of BD. Regardless of the interrelationship of the two conditions, the comorbid occurrence of these two types of symptoms can cause a clinical dilemma because selective serotonin reuptake inhibitors (SSRIs)-which are quite commonly used to treat OCD-increases the risk of precipitating manic symptoms.[3,4,5,6] The OCD symptoms that occur in individuals with BD often occur during the depressive episodes or during the intervals between episodes of depressive or manic symptoms.[7,8] This timing of OCD symptoms during BD is consistent with the cyclic nature of BD and suggests shared biological mechanisms between the two disorders. In support of this hypothesis, a study using Positron Emission Tomography (PET) found that in untreated persons with BD the serotonin-transporter binding potential in the insular and dorsal cingulate cortex was higher among BD patients with pathological obsessions and compulsions than among BD patients without such symptoms.[9] Moreover, a linkage study found that compared to OCD patients without comorbid BD, patients with comorbid OCD and BD were more likely to have a family history of mood disorders but less likely to have a family history of OCD.[10] However, another study found no significant difference in the rates of a positive family history of OCD between patients with OCD alone and those with comorbid OCD and BD.[11] Further support for the hypothesized common etiology comes from a preliminary molecular genetic study which found that hyperpolarization activated cyclic nucleotide-gated channel 4 (HCN4) is a common susceptible locus for both mood disorders and OCD, but further studies with larger sample sizes are needed to replicate this finding.[12] The presence of OCD in BD complicates the clinical presentation. Compared to patients with BD without comorbid OCD, those that have comorbid BD and OCD often have a more severe form of BD, have more prolonged episodes, are less adherent to medication, and are less responsive to medication. Recent studies about comorbid BD and OCD have reported the following: (a) Temporal relationship. Some studies suggest that OCD is an antecedent of BD,[10] but others report concurrent onset of OCD and BD.[13,14] (b) Course of disease. In 44% of patients with comorbid BD and OCD the episodes are cyclic.[15] The course of disease is more chronic among BD patients with OCD compared to those without comorbid OCD.[16,17] OCD is more commonly observed in patients with Type II BD, among whom the prevalence of OCD has been reported to be as high as 75%.[18] (c) Compulsive behaviors. The most commonly reported compulsions among patients with comorbid OCD and BD are compulsive sorting,[14,19,20,21] controlling or checking, [20] repeating behaviors,[13,22] excessive washing,[20] and counting.[19] Obsessive reassurance-seeking is also commonly reported in these patients.[23] In children and adolescents with BD, compulsive hoarding, impulsiveness,[24] and sorting[25] are more common. (d) Substance and alcohol abuse. A study found a higher prevalence of sedative, nicotine, alcohol, and caffeine use among individuals with comorbid OCD and BD compared to those with BD without OCD.[14] Similarly, compared to OCD patients without comorbid mood disorders, those with a comorbid mood disorder were more likely to have a substance abuse diagnosis (OR=3.18, 95%CI=1.81-5.58) or alcohol abuse diagnosis (OR=2.21, 95%CI=1.34-3.65).[11,13,26,27,28] (e) Suicidal behaviors. Compared to BD patients without OCD, a greater proportion of patients with both disorders had a lifetime history of suicidal ideation and suicide attempts.[2,11,13,29,30] The clinical management of comorbid OCD and BD requires first focusing on stabilizing the patient’s mood, which requires the combined use of multiple medications such as the use of lithium with anticonvulsants or atypical antipsychotic medications such as quetiapine;[31,32,33] adjunctive treatment with aripiprazole may be effective for the comorbid OCD symptoms.[4] In the case of OCD comorbid with type II BD, after full treatment of the mood symptoms with mood stabilizers the clinician can, while monitoring for potential drug interactions, cautiously try adjunctive treatment with antidepressants that are effective for both depressive symptoms and OCD symptoms and that have a low risk of inducing a full manic episode, including the selective serotonin reuptake inhibitors (SSRIs): fluoxetine, fluvoxamine, paroxetine, and sertraline.[32,35] In summary, BD comorbid with OCD may be etiologically distinct from either of the disorders. Clinicians should pay attention to its complex clinical manifestations and carefully consider the treatment principles outlined above.     

Pharmacotherapy of obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a chronic and often incapacitating disorder that is frequently complicated by mood and additional anxiety diagnoses. Although appropriate pharmacotherapy is often of great benefit, full remission is rare. Separate multi-center, placebo-controlled trials of clomipramine, paroxetine, fluoxetine, sertraline and fluvoxamine, respectively, have established the unparalleled efficacy and safety of the serotonin reuptake inhibitors (SRIs) in the treatment of OCD. Direct comparisons of SRIs suggest similar efficacy, but reduced tolerability for clomipramine in comparison to fluoxetine, fluvoxamine, sertraline and paroxetine in patients with OCD. Although 60-80% of OCD patients will respond to SRI treatment, partial symptom reduction (mean improvement, 25-40% from baseline) remains the rule. Controlled trials of adjuvant lithium, buspirone, thyroid hormone or clonazepam added to ongoing SRI therapy have failed to demonstrate substantial further antiobsessive effects. The presence of comorbid conditions, specific OCD symptom content and various other clinical features have been investigated as potential predictors of medication response in patients with OCD, but consistent factors have not yet been identified. Clinical experience and preliminary data does suggest that a lack of response to one or more SRIs does not preclude response to another SRI. An overview of the pharmacotherapy of OCD, including first-line medication(s) and the comparative efficacy and pharmacological features of the different SRIs will be presented in this review, as well as potential strategies for OCD patients who fail to respond to conventional pharmacotherapeutic interventions.     

Clomipramine in obsessive-compulsive disorder

The effects of clomipramine hydrochloride (CMI) versus placebo upon DSM-III-defined obsessive-compulsive disorder (OCD) were assessed in a 10-week double-blind multicenter trial and in a corresponding 1-year double-blind extension study. The NIMH global O-C scale, a 15-point ordinal severity scale, incorporating categorical features specific to OCD, was used to evaluate the severity of obsessive compulsive symptoms over the course of treatment, and a physician's rating of global therapeutic effect was used to assess overall change from baseline. In the core study, patients receiving placebo demonstrated minor and nonsystematic changes, whereas patients who received CMI had clinically and statistically significant reductions in the global severity of their disorder. Findings from the extension study were consistent with continuing efficacy for CMI, whereas corresponding data for patients receiving long-term placebo were difficult to interpret. Based upon shifts in categorical severity, symptoms for over half those patients who received CMI were rendered subclinical or within a range of normal functioning. In contast, less than 5% of patients receiving placebo had their symptoms reduced to a subclinical level. Generally, both treatments were well tolerated. Previous studies have indicated therapeutic potential for CMI in obsessive compulsive disorder. These findings confirm and extend previous observations.     

Guilt in obsessive-compulsive disorder

Despite the phenomenological and theoretical importance of guilt in obsessive-compulsive disorder, research in this area has been conducted primarily on normal populations and has produced contradictory results. This study had two aims. First, to compare the guilt of subjects with obsessive-compulsive disorder (n = 30) to the guilt of normal controls (n = 30); second, to examine the relationships among guilt, anxiety, depression, and obsessions in an obsessional and normal population. Obsessional subjects reported significantly more trait guilt, state guilt, and higher moral standards than normal controls. In both populations, trait guilt significantly predicted obsessional compulsive complaints, independent of anxiety and depression. The results are considered in relation to the literature on inflated perceived responsibility for threat; the specific nature of obsessional guilt is discussed.     

Assessment of obsessive-compulsive disorder

Self-report assessment devices of obsessive-compulsive symptoms are widely used by behavior therapists. In the present investigation, psychometric characteristics and concurrent, discriminant, and factorial validity of the Maudsley Obsessional Compulsive Inventory (MOCI) were studied in clinical samples. Test-retest reliability was high. The internal consistency was high for the total score and moderate for the subscales, checking and cleaning. The slowness and doubting subscales appeared to be less useful. The MOCI was found to reliably discriminate between obsessional patients on one hand and normals, patients with anorexia nervosa and anxiety disorders, on the other, but failed to discriminate obsessionals from depressives. Concurrent validity and factorial validity were satisfactory. The MOCI may be used to evaluate effects of treatment, but it is less sensitive than target ratings of obsessional problems.     

Organicity in obsessive-compulsive disorder

Though pharmacological and/or behavioral interventions have proven highly effective, 20 to 30% of the obsessive-compulsive disorder (OCD) population is treatment refractory. This study describes the OCD clinical profile that is correlated to organicity. Two groups of OCD patients were presented: an organic group and a control nonorganic group. The 9 organic patients exhibit an indifference to their illness, a lack of motivation, are nonanxious even during exposure exercises, are nondepressed, have rigid and concrete thinking, are treatment refractory, and have some type of organic impairment. The 10 nonorganic patients are also treatment refractory but do not exhibit the clinical profile correlated to the organic OCD patients. Furthermore, MRI results indicate that no organic impairment exists in this control group. All of these patients were tried on medication and behavior therapy to no avail. Reasons for lack of response in organic OCD patients, based on cerebral anatomical changes, are discussed.