Clinical Obsessive-Compulsive Disorders in Adults and Children

231 Pages·2011·3.42 MB·English

by  Robert Hudak MD

Clinical Obsessive-Compulsive
Disorders in Adults and
Children

Clinical Obsessive-Compulsive
Disorders in Adults and
Children
Edited by
Robert Hudak
UniversityofPittsburghSchoolofMedicine
and
Darin D. Dougherty
HarvardMedicalSchool
cambridge university press
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Clinicalobsessive-compulsivedisordersinadultsandchildren/edited
byRobertHudak,DarinD.Dougherty.
p. ; cm.
Includesbibliographicalreferencesandindex.
ISBN978-0-521-51569-6(hardback)
1. Obsessive-compulsivedisorder. I. Hudak,Robert,1966–
II. Dougherty,DarinD. III. Title.
[DNLM: 1. Obsessive-CompulsiveDisorder.WM176]
RC533.C6335 2011
616.850227–dc22
2010038772
ISBN978-0-521-51569-6Hardback
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beenmadetodisguisetheidentitiesoftheindividualsinvolved.Nevertheless,theauthors,editorsandpublisherscanmakeno
warrantiesthattheinformationcontainedhereinistotallyfreefromerror,notleastbecauseclinicalstandardsareconstantly
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Contents
Listofcontributors pagevi
Preface vii
1 Introductiontoobsessive-compulsive 9 Compulsivehoarding 122
disorder 1 ChristinaM.GilliamandDavidF.Tolin
RobertHudak
10 Cognitive-behavioraltherapyforchildrenand
2 Neurobiologyandneurocircuitryof adolescentswithobsessive-compulsive
obsessive-compulsivedisorderandrelevance disorder 138
toitssurgicaltreatment 20 AureenP.Wagner
DarinD.DoughertyandBenjaminD.Greenberg
11 Communitysupportandsocietal
3 Selectiveserotoninreuptakeinhibitorsinthe influences 152
treatmentofobsessive-compulsive ElaineDavis
disorder 30
12 Thefamilyinthetreatmentofobsessive-
SigniA.PageandRobertHudak
compulsivedisorder 172
4 Augmentationofserotoninreuptake AndreaAllenandStefanoPallanti
inhibitorsinthetreatmentof
13 Providingtreatmentforpatientswith
obsessive-compulsivedisorder 49
obsessive-compulsivedisorder 184
AndrewGoddardandYong-WookShin
TerriLaterza,KalieD.Pierce,andRobertHudak
5 Obsessive-compulsivedisorderandcomorbid
14 Bodydysmorphicdisorder 191
mooddisorders 61
KatharineA.Phillips
JonathanS.Abramowitz
15 Trichotillomaniaandotherimpulsecontrol
6 Obsessive-compulsivesymptomsin
disorders 207
schizophrenia:clinicalcharacterizationand
MichaelH.Bloch
treatment 71
MichaelPoyurovsky
7 Medicationmanagementof
obsessive-compulsivedisorderinchildren Index 216
andadolescents 92
AndrewR.Gilbert
8 Exposurewithresponsepreventiontreatment
forobsessive-compulsivedisorder 102
FugenNeziroglu,BethForhman,andSony
Khemlani-Patel
v
Contributors
AndreaAllen SonyKhemlani-Patel
MountSinaiSchoolofMedicine,NewYork,USA PsychiatryDepartment,NorthShoreUniversity
Hospital,GreatNeck,NY,USA
JonathanS.Abramowitz
DepartmentofPsychology,Universityof TerriLaterza
NorthCarolinaatChapelHill,ChapelHill, AdultOCDIntensiveOutpatientProgram,Western
NC,USA PsychiatricInstituteandClinic,Pittsburgh,PA,USA
MichaelH.Bloch FugenNeziroglu
YaleChildStudyCenter,NewHaven,CT,USA HofstraUniversity,Hempstead,NewYork,USA
ElaineDavis SigniA.Page
ObsessiveCompulsiveFoundationofWesternPA, UPMCMedicalEducationProgramPittsburgh,
Pittsburgh,PA,USA Pittsburgh,PA,USA
DarinD.Dougherty StefanoPallanti
HarvardMedicalSchoolandDepartmentof MountSinaiMedicalCentre,NewYork,USA
PsychiatryofMassachusettsGeneralHospital,Boston,
KatharineA.Phillips
MA,USA
ButlerHospitalandtheDepartmentofPsychiatryand
BethForhman HumanBehavior,AlpertMedicalSchoolofBrown
AdjunctFaculty,GraduateSchoolofSocialWork, University,Providence,RI,USA
AdelphiUniversity,GardenCity,NY,USA
KalieD.Pierce
AndrewR.Gilbert AdultOCDIntensiveOutpatientProgram,Western
DepartmentofPsychiatry,Universityof PsychiatricInstituteandClinic,Pittsburgh,PA,USA
PittsburghSchoolofMedicine,Pittsburgh,
MichaelPoyurovsky
PA,USA
RappaportFacultyofMedicine,Technion,Israel
ChristinaM.Gilliam InstituteofPsychiatry,Haifa,Israel
TheInstituteofLiving,Hartford,CT,USA
Yong-WookShin
AndrewGoddard ClinicalCognitiveNeuroscienceCenter,SNU-MRC,
IndianaUniversity,Indianapolis,IN,USA Seoul,Korea
BenjaminD.Greenberg DavidF.Tolin
ButlerHospital,WarrenAlpertMedicalSchoolof TheInstituteofLiving,HartfordandYaleUniversity
BrownUniversity,Providence,RI,USA SchoolofMedicine,NewHaven,CT,USA
RobertHudak AureenP.Wagner
UniversityofPittsburghSchoolofMedicine, TheOCDandAnxietyConsultancy,Rochester,
Pittsburgh,PA,USA NY,USA
vi
Preface
While obsessive-compulsive disorder (OCD) is one Comorbidity is the rule rather than the exception
of the most common psychiatric disorders, accurate inOCD.Therefore,multiplechaptersdealwithtreat-
diagnosis and treatment are still too often lacking. ment concerns in patients with comorbid disorders.
Past studies have suggested that 17.5 years elapse, on In Ch. 5, Abramovitz discusses OCD treatment in
average, between the onset of OCD symptoms and patients with comorbid mood disorders including
adequate diagnosis and treatment. Recently, greater a discussion of postpartum OCD, while in Ch. 6
attention is being paid to OCD in lay media outlets, Poyurovskycoverstheimportanttopicoftherelation-
which has resulted in a greater public awareness of ship between psychosis and OCD. Finally, Gilbert,in
OCD. Also, clinicians are receiving more training Ch.7,reviewsmedicationstrategiesinthetreatmentof
regarding the diagnosis and treatment of OCD than anotherspecialpopulation,childrenandadolescents.
in the past. Hopefully, these factors will shorten the Psychotherapyplaysacriticalroleintreatmentand
gap between symptom onset and adequate treatment. management, and Neziroglu and colleagues (Ch. 8)
However,evenwiththisgrowingknowledgebase,clini- discuss the principles behind exposure with response
cians are often required to seek out expert knowledge prevention therapy. Hoarding represents a specific
regarding OCD in order to optimize their diagnostic type of OCD symptoms requiring its own individual
and treatment strategies. While no textbook can be a therapies, and a review is provided by Gilliam and
substitute for individual teaching and supervision, a TolininCh.9.Psychotherapyinchildrenandadoles-
reviewofcontemporarydiagnosticandtreatmentstrat- cents can require different strategies than in adults,
egies should enhance the clinical acumen of readers andWagnerinCh.10providesdetailedclinicalinfor-
and help to ensure that readers provide their patients mation regarding the use of psychotherapy in this
withoptimalcare.Thegoalofthisvolumeistodescribe population.TheperceptionofOCDinthecommunity
thecurrentstateofknowledgeconcerningthediagnosis atlargecanhaveeffectsonaccesstoOCDtreatment.
andtreatmentofOCDandtodescribehowitisappro- This issue, as well as strategies to mitigate this prob-
priatelyappliedinaclinicaltreatmentsetting. lem,isreviewedbyDavisinCh.11.Familymembers
Theclinicalpresentation,theunderlyingetiology, are greatly affected by OCD and this issue almost
andpharmacotherapytreatmentofOCDarealladdre- always needs to be addressed in treatment. Allen and
ssedinthistext.Thefirstchaptercoversbasicinforma- Pallanti, in Ch. 12, provide an invaluable discussion
tion concerning OCD, including epidemiology and regardingtheinclusionoffamilyintreatment.Laterza,
phenomenology. Hudak also provides case examples Pierce,andHudakinCh.13reviewthedifferentlevels
to illustrate certain diagnostic challenges in OCD. of treatment (outpatient, day programs, residential
Dougherty and Greenberg discuss the latest findings programs,etc.)availabletoOCDpatients,andprovide
regardingtheneurobiologyofOCDinCh.2.Inaddi- case examples of how differing intensities of therapy
tion, they review surgical treatments for intractable impactsoutcome.
OCD. First-line medication treatments are reviewed Finally,OCDisoftenconsideredaspectrumdisor-
in Ch. 3, by Page and Hudak, while pharmacological der. Therefore, other putative spectrum disorders are
augmentationstrategiesaredescribedbyGoddardand reviewedinchaptersbyPhillips(Ch.14:bodydysmor-
ShininCh.4. phicdisorder)andBloch(Ch.15:trichotillomania).
vii

1
Chapter
Introduction to obsessive-compulsive
disorder
Robert Hudak
biological underpinnings became widely accepted.
History and diagnosis
Becauseoftheheterogeneousnatureofthesymptoms
Thereisprobablynootherpsychiatricillnessthathas of OCD, it is unlikely that a single factor will be
gonethroughamorefascinatingevolutioninitscon- identified as the biological origin for OCD.
ceptualization during contemporary times than Consequently,multipleavenuesofresearcharebeing
obsessive-compulsivedisorder(OCD).Justinthelast explored. Genetic, neuroanatomical, and infectious
30yearsthechangeintheperceptionandtreatmentof causesforOCDarethefocusofcurrentresearchand
OCD has been dramatic. In fact, this process is still theunderlyingcauseofOCDislikelymultifactorial.
ongoing as psychiatry increasingly moves towards a AsdefinedbytheDiagnosticandStatisticalManual
multidimensional model of OCD. This work-in- of Mental Disorders, 4th edition (DSM-IV; American
progress will be interesting to follow. At the turn of Psychiatric Association 1994), OCD has fairly
thetwentiethcentury,Freudwroteaboutobsessionsas straightforward criteria. The DSM simply asks that a
defensive psychological responses to unconscious personhaseitherobsessions(Box1.1)orcompulsions
impulses.He alsotalked about theunderlyingrole of (Box 1.2), that at some point during the disorder the
childhood sexual experiences. Pierre Janet first pro- personhasrecognizedthatthesymptomswereexces-
vided clinical descriptions of OCD in 1903 in Les siveorunreasonable,andthattheycausemarkeddis-
Obsessions et la Psychasthenie. As a result, through tress, are time consuming, or significantly interfere
most of the following decades, OCD was thought to with the patients functioning. The DSM-IV does
result from unresolved unconscious conflicts. For allow that the person can have poor insight (i.e., not
years, parents were thought to be the root cause recognize that the symptoms are unreasonable or
of this disorder through “excessively harsh toilet excessive).Becauseoftheintrusivenatureofanobses-
training”(Adams1973).Itisimportanttonote,how- sion,apersonmaydescribeitasanalienthought,oras
ever, that a disease model should not simply present a feeling as if the thought is not their thought.
a theory that on the surface appears to explain an However, the person will state that they know that
illness but should also predict a related treatment. thethoughtiscomingfromtheirownmind:justthat
Significantly,notreatmentbasedontheresolutionof it feels as if it is not. Careful interviewing by the
unconscious impulses was ever shown to work for practitioner should easily distinguish this from
OCD. thought insertion, a symptom of schizophrenia that
With psychoanalytic models clearly not valid in isnotseeninOCD.
explaining the pathology of OCD, cognitive models The differential diagnosis of OCDcan be difficult
were then explored. The cognitive models postulated enough that the illness has been termed chameleon-
thatindividualswithOCDmaypossessdysfunctional like(Attiullahetal.2000).Acontributingfactorinthis
beliefsincludingover-inflatedpersonalresponsibility, difficultyisthatobsessionscanfocusonvirtuallyany
overestimationofthreat,theneedtocontrolthoughts, thoughtcontent.WhileOCDissometimesportrayed
andperfectionism(Freestonetal.1996;Boucardetal. astheillnessinwhichpeoplehaveafearofgermsora
1999). Interestingly, it was not until the latter part of need to check things, the content of obsessions can
thetwentiethcenturythatamodelforOCDbasedon include virtually anything. It is the nature of the
ClinicalObsessive-CompulsiveDisordersinAdultsandChildren,ed.RobertHudakandDarinD.Dougherty.
PublishedbyCambridgeUniversityPress.Copyright©CambridgeUniversityPress2011.
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