Obsessive Compulsive Disorder: A Clinical Update
1992; Elsevier BV; Volume: 67; Issue: 3 Linguagem: Inglês
10.1016/s0025-6196(12)60104-9
ISSN1942-5546
Autores Tópico(s)Eating Disorders and Behaviors
ResumoRecent epidemiologic studies have indicated that obsessive compulsive disorder is a fairly common psychiatric condition. In this article, obsessive compulsive disorder, its subtypes, and epidemiologic features are described. The common obsessions and compulsions are discussed, as are the comorbid conditions. Currently, etiologic hypotheses revolve around serotonergic and dopaminergic neurotransmitter systems. Management of patients with obsessive compulsive disorder involves education, pharmacotherapy, and behavior therapy, and recent advances in such treatments offer patients hope. Psychotherapy has not proved useful. In refractory cases, psychosurgical intervention remains an option. Recent epidemiologic studies have indicated that obsessive compulsive disorder is a fairly common psychiatric condition. In this article, obsessive compulsive disorder, its subtypes, and epidemiologic features are described. The common obsessions and compulsions are discussed, as are the comorbid conditions. Currently, etiologic hypotheses revolve around serotonergic and dopaminergic neurotransmitter systems. Management of patients with obsessive compulsive disorder involves education, pharmacotherapy, and behavior therapy, and recent advances in such treatments offer patients hope. Psychotherapy has not proved useful. In refractory cases, psychosurgical intervention remains an option. Obsessive compulsive disorder (OCD) is a common, potentially disabling anxiety disorder. Recently, public attention has been drawn to this condition by media presentations and informative books.1Marks IM Living With Fear: Understanding and Coping With Anxiety. McGraw-Hill International Book Company, New York1978Google Scholar, 2Greist JH Jefferson JW Marks IM Anxiety and Its Treatment: Help Is Available. American Psychiatric Press, Washington, DC1986Google Scholar, 3Rapoport JL The Boy Who Couldn't Stop Washing: The Experience & Treatment of Obsessive-Compulsive Disorder. EP Dutton, New York1989Google Scholar These communiqués have informed the public about the nature of OCD and the treatment of patients with this condition; thus, the self-referral rate of patients has increased. OCD has become more manageable because of recent advances in behavior therapy and psychopharmacotherapy. Herein, updated information on the description, epidemiologic features, and causes of OCD is presented. Comorbidity is discussed, as are the available treatment options. The combination of education, pharmacotherapy, and behavior therapy is emphasized. Psychosurgical intervention is described as a last-resort option. OCD has been described by many authors throughout the centuries. Freud's description of Rat Man4Freud S Three Case Histories. (Translated by P Rieff.). Macmillan Publishing Company, New York1973: 15-102Google Scholar addresses the psychodynamics and defense mechanisms of a patient with OCD. Recently, the Diagnostic and Statistical Manuals of Mental Disorders, published by the American Psychiatric Association, have included either OCD or obsessive compulsive neurosis in every edition. The revised third edition (DSM-III-R) categorizes OCD as a type of anxiety disorder.5American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders. Revised third edition. American Psychiatric Association, Washington, DC1987Google Scholar Thus, OCD is grouped with other conditions that have anxiety or phobia as a core symptom, including panic disorder with and without agoraphobia, agoraphobia without history of panic disorder, social phobia, simple phobia, posttraumatic stress disorder, generalized anxiety disorder, and anxiety disorder not otherwise specified. The criteria for OCD from the DSM-III-R are listed in Table 1. Patients with OCD suffer from obsessions—unwelcome ideas, thoughts, urges, or images that repeatedly intrude on their consciousness and seem to the patients, at least initially, to be senseless and unnecessary. Such patients recognize that their obsessions are a product of their own minds and not impositions from outside, such as is commonly observed in patients with psychosis. Compulsions, cognitive as well as physical, are activities performed ritualistically, usually in an attempt to decrease the anxiety caused by an obsession. Most adult patients realize that their obsessional thoughts and compulsive behavior are excessive or unreasonable. Some patients, however, “lose sight” of the excessiveness of their thoughts and behavior when their obsessions evolve into “overvalued ideas.” An overvalued idea may be a delusion in that patients believe that their obsession is reasonable and vital to their well-being or the well-being of others. A final element in the diagnosis of OCD based on the DSM-III-R is that the obsessions or compulsions cause considerable distress, are time-consuming, and therefore substantially interfere with the person's life. The DSM-III-R does not fully address the feared disasters, also known as catastrophic thinking, which are a component for some patients. In such patients, anxiety is generated by the anticipation of misfortune that they fear will occur if they confront a stimulus that results in an obsession and the compulsion is not performed. Sometimes, catastrophic thinking is identical to obsessional thinking, but often it differs, and clinicians must ask patients what they fear will occur, in detail, if a compulsion is not performed. For example, patients who wash their hands excessively because of an obsession with cleanliness may not say that their greatest fear is that they will transfer germs to their children, an outcome that would cause their children to become severely ill or die. Detailed knowledge of a patient's obsessions, compulsions, and catastrophic thinking is necessary for proper behavioral management.Table 1Diagnostic Criteria for Obsessive Compulsive Disorder, Based on Diagnostic and Statistical Manual of Mental Disorders (Revised Third Edition)From the American Psychiatric Association.5American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders. Revised third edition. American Psychiatric Association, Washington, DC1987Google Scholar By permission. A.Either obsessions or compulsions Obsessions:1.Recurrent and persistent ideas, thoughts, impulses, or images that are experienced, at least initially, as intrusive and senseless—for example, a parent's repeated impulses to kill a loved child or a religious person's recurrent blasphemous thoughts2.Person attempts to ignore or suppress such thoughts or impulses or to neutralize them with some other thought or action3.Person recognizes that the obsessions are the product of his or her own mind, not imposed from without (as in thought insertion)4.If another axis I disorder is present, the content of the obsession is unrelated to it—for example, the ideas, thoughts, impulses, or images are not about food in the presence of an eating disorder, about drugs in the presence of a psychoactive substance use disorder, or guilty thoughts in the presence of a major depressionCompulsions:1.Repetitive, purposeful, and intentional behaviors that are performed in response to an obsession, according to certain rules, or in a stereotyped fashion2.Behavior is designed to neutralize or to prevent discom- fort or some dreaded event or situation; however, either the activity is not connected in a realistic way with what it is designed to neutralize or prevent or it is clearly excessive3.Person recognizes that his or her behavior is excessive or unreasonable (this may not be true for young children; it may no longer be true for people whose obsessions have evolved into overvalued ideas)B.Obsessions or compulsions cause marked distress, are time-consuming (take more than an hour a day), or significantly interfere with the person's normal routine, functioning, usual social activities, or relationships with othersoccupational Open table in a new tab Numerous obsessions and compulsions associated with OCD are shown in Table 2, Table 3.6Rapoport JL The waking nightmare: an overview of obsessive compulsive disorder.J Clin Psychiatry. November 1990; 51: 25-28PubMed Google Scholar Frequently, patients withTable 2Common Obsessions Associated With Obsessive Compulsive DisorderFrom Rapoport.6Rapoport JL The waking nightmare: an overview of obsessive compulsive disorder.J Clin Psychiatry. November 1990; 51: 25-28PubMed Google Scholar By permission of Physicians Postgraduate Press, Inc. Disgusted response to bodily wasteConcern over dirt or germsFear of harm to self or othersConcern over toxic chemicalsConcern about becoming illConcern that others will become ill“Forbidden” sexual thoughtsFear of embarrassing actsSomatic obsessionsFear of losing thingsNeed for symmetry or exactnessNeed to know or rememberNeed to say or apologizeNeed to countNeed to check Open table in a new tab Table 3Common Compulsions Associated With Obsessive Compulsive DisorderFrom Rapoport.6Rapoport JL The waking nightmare: an overview of obsessive compulsive disorder.J Clin Psychiatry. November 1990; 51: 25-28PubMed Google Scholar By permission of Physicians Postgraduate Press, Inc. Cleaning or washing ritualsChecking on health statusAvoidance or cleaning ritualsSeeking reassurance about healthDistractions or “undoing” ritualsAvoiding public settingsChecking specific to obsessional contentHoarding ritualsArranging ritualsAsking repetitive questionsMaking repetitive statements or apologiesCounting ritualsChecking rituals Open table in a new tab OCD are categorized on the basis of the rituals they perform. Stern and Cobb7Stern RS Cobb JP Phenomenology of obsessive-compulsive neurosis.Br J Psychiatry. 1978; 132: 233-239Google Scholar surveyed 45 patients with OCD to determine the frequency of occurrence of obsessive compulsive symptoms. (Some patients had more than one compulsion; therefore, percentages total more than 100%.) The following were the most common rituals. (1) Cleaning (51% of patients), caused by a fear of contamination by dirt, germs, urine, feces, chemicals, or any other repugnant substance. (2) Repeating (40%), which occurs when patients repeat a ritual a certain number of times to prevent a catastrophe. Frequently, such patients have “magic numbers” that dictate the number of times the compulsion must be repeated to ensure safety. (3) Completing compulsions (11%), a type of repeating ritual in which patients believe that a behavior must be completed in an exact and often complicated fashion in order for the task to prevent some unrealistically feared consequence. (4) Checking (38%), which is a compulsive seeking of reassurance that a task has been done correctly by visually, physically, or verbally checking repeatedly. Commonly, patients need to be sure that a door is locked, the stove is off, the appliances are unplugged, or the windows are shut before retiring or leaving the dwelling. Checking is far beyond what is necessary to ensure that the task has been done correctly. Verbal checking entails asking others for reassurance. (5) Meticulous behavior (9%), which prompts patients to ensure that all things are in the proper place and order. (6) Avoiding (51%), a practice of attempting to prevent contact with stimuli that cause obsessive compulsive behavior. Successful avoidance may prevent patients from experiencing obsessions or compulsions but frequently prevents them from fulfilling occupational, scholastic, or social obligations. (7) Hoarding (percentage undetermined), an uncommon ritual in which patients collect unneeded things and spend considerable time sorting and organizing this material.8Greenberg D Witztum E Levy A Hoarding as a psychiatric symptom.J Clin Psychiatry. 1990; 51: 417-421PubMed Google Scholar Sometimes, huge quantities of materials are collected and facilities are procured to store them. Relatives' attempts to discard the “hoard” cause anxiety for patients. Cognitive rituals and obsessional slowness are two additional compulsions. Cognitive rituals are mental activities performed by patients to decrease anxiety. The main difference between an obsessive thought and a cognitive ritual is that an obsession usually increases anxiety, and a cognitive ritual is done in an attempt to decrease anxiety.9Greist JH Jefferson JW Marks IM Anxiety and Its Treatment: Help Is Available. American Psychiatric Press, Washington, DC1986: 36-38Google Scholar Obsessional slowness is an uncommon problem in which patients require extraordinary periods to complete simple tasks. Patients will frequently stop and start the task. They claim to be doing mental checking activities or cognitive rituals while performing the task. Psychiatrists are frequently asked what the chances are that a patient with OCD will act on an obsession. Because obsessions frequently involve impulses to harm others or are gory, filthy, profane, or otherwise horrifying, it is understandable that patients, care givers, and family members might seek predictions about the behavior of the patient. Greist and associates10Greist JH Jefferson JW Marks IM Anxiety and Its Treatment: Help Is Available. American Psychiatric Press, Washington, DC1986: 55-66Google Scholar noted that people with obsessions that involve harming others rarely enact such obsessions. In their study, patients acted on their urges in only 2 of 400 instances, and 1 of these patients had a psychosis. The risk of a patient with uncomplicated OCD acting harmfully is extremely low. Family members of persons with OCD also become involved in the compulsive behavior. A spouse may assist in checking behaviors before leaving the home “just to get it over with so we can get out of the house,” or a relative may repeatedly assure a patient that a feared disaster has not occurred so that compulsive behavior can be averted. These involvements cause family or marital discord because patients with OCD are only temporarily reassured. Unless recognized, this discord can inhibit progress in behavior therapy or compliance with medications. In addition, secondary gain issues may perpetuate the obsessive compulsive sessions. OCD was once thought to be an unusual psychiatric condition with a prevalence of approximately 5 cases in 1,000 persons.11Rüden E Ein Beitrag zur Frage der Zwangskrankheit, insbesondere ihrer hereditären Beziehungen.Arch Psychiatr Nervenkr. 1953; 191: 14-54Crossref Scopus (104) Google Scholar Recent studies such as the Epidemiologic Catchment Area Program have shown that the lifetime prevalence rate of OCD is 3.0%, the 6-month prevalence is 1.6%, and the annual incidence for all ages is 0.69 per 100 years of risk.12Bland RC Newman SC Orn H Period prevalence of psychiatric disorders in Edmonton.Acta Psychiatr Scand Suppl. 1988; 338: 33-42Crossref PubMed Scopus (187) Google Scholar, 13Bland RC Orn H Newman SC Lifetime prevalence of psychiatric disorders in Edmonton.Acta Psychiatr Scand Suppl. 1988; 338: 24-32Crossref PubMed Scopus (304) Google Scholar, 14Eaton WW Kramer M Anthony JC Dryman A Shapiro S Locke BZ The incidence of specific DIS/DSM-III mental disorders: data from the NIMH Epidemiologic Catchment Area Program.Acta Psychiatr Scand. 1989; 79: 163-178Crossref PubMed Scopus (306) Google Scholar, 15Rasmussen SA Eisen JL Epidemiology of obsessive compulsive disorder.J Clin Psychiatry. February 1990; 51: 10-13PubMed Google Scholar Possible causes for previous underestimation of prevalence and incidence figures include the following: (1) most patients with anxiety disorders are treated by non-mental-health professionals, (2) patients with OCD may come to care givers with nonobsessional symptoms, (3) OCD commonly coexists with other psychiatric conditions, and (4) patients with OCD are secretive about their condition; thus, it may not be addressed by mental-health professionals and researchers.15Rasmussen SA Eisen JL Epidemiology of obsessive compulsive disorder.J Clin Psychiatry. February 1990; 51: 10-13PubMed Google Scholar The mean age at onset of OCD is 19.8 ± 9.6 years.15Rasmussen SA Eisen JL Epidemiology of obsessive compulsive disorder.J Clin Psychiatry. February 1990; 51: 10-13PubMed Google Scholar, 16Rasmussen SA Tsuang MT Clinical characteristics and family history in DSM-III obsessive-compulsive disorder.Am J Psychiatry. 1986; 143: 317-322Crossref PubMed Scopus (544) Google Scholar The condition develops at a mean age of 17.5 years in male patients and a mean age of 20.8 years in female patients.17Flament MF Rapoport JL Murphy DL Berg CJ Lake CR Biochemical changes during clomipramine treatment of childhood obsessive-compulsive disorder.Arch Gen Psychiatry. 1987; 44: 219-225Crossref PubMed Scopus (144) Google Scholar Although a female preponderance exists for some anxiety disorders, the gender ratio for OCD is approximately 1:1.18Marks IM Fears, Phobias, and Rituals: Panic, Anxiety, and Their Disorders. Oxford University Press, New York1987: 423-453Google Scholar In a review by Marks,18Marks IM Fears, Phobias, and Rituals: Panic, Anxiety, and Their Disorders. Oxford University Press, New York1987: 423-453Google Scholar patients waited 8 to 12 years before obtaining care. Because of recent media presentations on this condition, patients may seek treatment sooner. OCD seems to be familial. Between 21 and 25% of family members of probands with OCD also have this condition, and an additional 17% have some type of related symptoms.15Rasmussen SA Eisen JL Epidemiology of obsessive compulsive disorder.J Clin Psychiatry. February 1990; 51: 10-13PubMed Google Scholar A review of studies of monozygotic twins by Rasmussen and Tsuang19Rasmussen SA Tsuang MT The epidemiology of obsessive compulsive disorder.J Clin Psychiatry. 1984; 45: 450-457PubMed Google Scholar revealed a 63% concordant rate for obsessive compulsive symptoms. The fact that the rate was not 100% may indicate that environmental factors play a role in the pathogenesis. Sociocultural factors among the epidemiologic features of OCD have been difficult to interpret. OCD has been encountered in many countries in addition to western ones; therefore, it may be a universal phenomenon. Social class of patients with OCD varies greatly.18Marks IM Fears, Phobias, and Rituals: Panic, Anxiety, and Their Disorders. Oxford University Press, New York1987: 423-453Google Scholar Some studies show a tendency for OCD to be associated with above-average social class and intelligence, but bias has been difficult to eliminate from such studies. Conditions associated with OCD are listed in Table 4.Table 4Comorbid Conditions Associated With Obsessive Compulsive Disorder DepressionTourette's syndromeOther anxiety disordersAnorexia nervosaObsessive compulsive personality disorderTrichotillomaniaBody dysmorphic disorderSchizophrenia Open table in a new tab Depression frequently complicates OCD. As many as 80% of patients with OCD have dysphoric moods and 75% have current or past major depressive episodes.20Rasmussen SA Tsuang MT Epidemiology and clinical features of obsessive-compulsive disorder.in: Jenike MA Baer L Mmichiello WE Obsessive-Compulsive Disorders: Theory and Management. PSG Publishing Company, Littleton, Massachusetts1986: 23-44Google Scholar, 21Black DW Noyes Jr, R Comorbidity and obsessive-compulsive disorder.in: Maser JD Cloninger CR Comorbidity of Mood and Anxiety Disorders. American Psychiatric Press, Washington, DC1990: 305-316Google Scholar Many patients seek treatment because of depression, not obsessive compulsive symptoms. Conversely, depression is complicated by such symptoms in 23 to 28% of patients.21Black DW Noyes Jr, R Comorbidity and obsessive-compulsive disorder.in: Maser JD Cloninger CR Comorbidity of Mood and Anxiety Disorders. American Psychiatric Press, Washington, DC1990: 305-316Google Scholar The determination of which came first, depression or OCD, can be difficult, but attempting to distinguish whether depression or OCD is the primary illness is important. Usually, temporal relationships between the two symptom complexes must be determined. If OCD occurs first, presumably the anxiety disorder is the primary illness, and vice versa. Tourette's disorder is typified by motor and vocal tics that occur several times during a day, almost every day, or intermittently throughout a 1-year period or more. The anatomic site, number, frequency, complexity, and severity of the tics change over time. The onset is usually before age 21 years.5American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders. Revised third edition. American Psychiatric Association, Washington, DC1987Google Scholar OCD and Tourette's disorder have many commonalities including increased familial risk of OCD in probands with Tourette's syndrome and similar longitudinal histories of chronicity and age at onset. Of patients with Tourette's disease, 90% have obsessive compulsive symptoms.21Black DW Noyes Jr, R Comorbidity and obsessive-compulsive disorder.in: Maser JD Cloninger CR Comorbidity of Mood and Anxiety Disorders. American Psychiatric Press, Washington, DC1990: 305-316Google Scholar Pitman and colleagues22Pitman RK Green RC Jenike MA Mesulam MM Clinical comparison of Tourette's disorder and obsessive-compulsive disorder.Am J Psychiatry. 1987; 144: 1166-1171PubMed Google Scholar showed that 10 of 16 patients with Tourette's disorder (62.5%) also met criteria for OCD. In some patients, this syndrome evolves into conditions in which obsessive compulsive symptoms predominate.23Goodman WK McDougle CJ Price LH Riddle MA Pauls DL Leckman JF Beyond the serotonin hypothesis: a role for dopamine in some forms of obsessive compulsive disorder?.J Clin Psychiatry. August 1990; 51: 36-43PubMed Google Scholar Dopamine antagonists are the drug of choice for managing patients with Tourette's disorder, whereas patients with OCD are treated with serotonin uptake inhibitors (as subsequently discussed). OCD is classified with the anxiety disorders because of an association with anxiety and phobias. Symptoms of phobia have been found in 40 to 80.2% of patients with obsessive behavior.21Black DW Noyes Jr, R Comorbidity and obsessive-compulsive disorder.in: Maser JD Cloninger CR Comorbidity of Mood and Anxiety Disorders. American Psychiatric Press, Washington, DC1990: 305-316Google Scholar Mellman and Uhde24Mellman TA Uhde TW Obsessive-compulsive symptoms in panic disorder.Am J Psychiatry. 1987; 144: 1573-1576PubMed Google Scholar found that 27% of patients with panic disorder also had obsessive compulsive symptoms. Many mental-health workers have noted similarities between anorexia nervosa and OCD. In anorexia nervosa, patients have an intense fear of gaining weight or of becoming fat, even when they are underweight. They also are disturbed with the weight, size, or shape of their body. Anorexia nervosa predominantly affects women. Kasvikis and co-workers25Kasvikis YG Tsakiris F Marks IM Basoglu M Noshirvani HF Past history of anorexia nervosa in women with obsessive-compulsive disorder.Int J Eating Disorders. 1986; 5: 10691075Crossref Scopus (68) Google Scholar studied a series of 280 patients with OCD and found that 10.6% of the women had a history consistent with anorexia nervosa. Recent studies have shown similar but not identical results of positron emission tomography in patients with OCD and anorexia nervosa.26Baxter Jr, LR Schwartz JM Guze BH Bergman K Szuba MP PET imaging in obsessive compulsive disorder with and without depression.J Clin Psychiatry. April 1990; 51: 61-69PubMed Google Scholar, 27Wiesel FA Positron emission tomography in psychiatry.Psychiatr Dev. 1989; 7: 19-47PubMed Google Scholar, 28Herholz K Krieg JC Emrich HM Pawlik G Beil C Pirke KM Pahl JJ Wagner R Wienhard K Ploog D Heiss W-D Regional cerebral glucose metabolism in anorexia nervosa measured by positron emission tomography.Biol Psychiatry. 1987; 22: 43-51Abstract Full Text PDF PubMed Scopus (79) Google Scholar With both illnesses, the caudate nucleus demonstrates increased metabolic activity although differences exist in the frontal lobe findings. Whether obsessive compulsive personality disorder and OCD are related is controversial. Psychoanalytic theorists believe that obsessive compulsive personality disorder and OCD are on a continuum. In fact, similar defense mechanisms are found in these conditions. Several studies have shown that obsessive compulsive personality disorder is overrepresented among persons with OCD.20Rasmussen SA Tsuang MT Epidemiology and clinical features of obsessive-compulsive disorder.in: Jenike MA Baer L Mmichiello WE Obsessive-Compulsive Disorders: Theory and Management. PSG Publishing Company, Littleton, Massachusetts1986: 23-44Google Scholar, 29Rosenberg CM Personality and obsessional neurosis.Br J Psychiatry. 1967; 113: 471-477Crossref PubMed Scopus (23) Google Scholar, 30Black A The natural history of obsessional neurosis.in: Beech HR Obsessional States. Methuen & Company, London1974: 19-54Google Scholar, 31Kringlen E Obsessional neurotics: a long-term follow-up.Br J Psychiatry. 1965; 111: 709-722Crossref PubMed Scopus (188) Google Scholar, 32Widiger TA Frances AJ Personality disorders.in: Talbott JA Hales RE Yudofsky SC The American Psychiatric Press Textbook of Psychiatry. American Psychiatric Press, Washington, DC1988: 621-648Google Scholar, 33Pollak JM Obsessive-compulsive personality: a review.Psychol Bull. 1979; 86: 225-241Crossref PubMed Scopus (86) Google Scholar, 34Swedo SE Leonard HL Rapoport JL Lenane MC Goldberger EL Cheslow DL A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling).N Engl J Med. 1989; 321: 497-501Crossref PubMed Scopus (416) Google Scholar, 35Hollander E Liebowitz MR Winchel R Klumker A Klein DF Treatment of body-dysmorphic disorder with serotonin reuptake blockers.Am J Psychiatry. 1989; 146: 768-770PubMed Google Scholar, 36Fenton WS McGlashan TH The prognostic significance of obsessive-compulsive symptoms in schizophrenia.Am J Psychiatry. 1986; 143: 437-441PubMed Google Scholar Other studies, however, suggest that OCD is not related to obsessive compulsive personality disorder.21Black DW Noyes Jr, R Comorbidity and obsessive-compulsive disorder.in: Maser JD Cloninger CR Comorbidity of Mood and Anxiety Disorders. American Psychiatric Press, Washington, DC1990: 305-316Google Scholar, 32Widiger TA Frances AJ Personality disorders.in: Talbott JA Hales RE Yudofsky SC The American Psychiatric Press Textbook of Psychiatry. American Psychiatric Press, Washington, DC1988: 621-648Google Scholar, 33Pollak JM Obsessive-compulsive personality: a review.Psychol Bull. 1979; 86: 225-241Crossref PubMed Scopus (86) Google Scholar Trichotillomania is thought to be associated with OCD. Patients with trichotillomania have an irresistible urge to pull out their hair; this behavior results in noticeable loss of hair. Tension occurs before the patient pulls out the hair, and relief of tension or gratification results from the actual hair-pulling activity. Trichotillomania is similar to OCD in that grooming behaviors are extreme. Patients with trichotillomania have responded to the antiob-sessional drug clomipramine hydrochloride.34Swedo SE Leonard HL Rapoport JL Lenane MC Goldberger EL Cheslow DL A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling).N Engl J Med. 1989; 321: 497-501Crossref PubMed Scopus (416) Google Scholar Body dysmorphic disorder is also thought to be related to OCD. Patients with this disease are preoccupied with some imagined defect or malformation.5American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders. Revised third edition. American Psychiatric Association, Washington, DC1987Google Scholar The belief in the defect is not delusional but leads patients to become preoccupied (obsessed) with the perceived malformation. Case reports describe fluoxetine as effective in managing this condition.35Hollander E Liebowitz MR Winchel R Klumker A Klein DF Treatment of body-dysmorphic disorder with serotonin reuptake blockers.Am J Psychiatry. 1989; 146: 768-770PubMed Google Scholar Even though similar treatment for trichotillomania and body dysmorphic disorder leads to improvement, these conditions may not be related. Although some investigators have noted an association between obsessive compulsive and schizophrenic symptoms, longitudinal studies have not found an increased frequency of schizophrenia in either patients with OCD or their relatives.21Black DW Noyes Jr, R Comorbidity and obsessive-compulsive disorder.in: Maser JD Cloninger CR Comorbidity of Mood and Anxiety Disorders. American Psychiatric Press, Washington, DC1990: 305-316Google Scholar Fenton and McGlashan36Fenton WS McGlashan TH The prognostic significance of obsessive-compulsive symptoms in schizophrenia.Am J Psychiatry. 1986; 143: 437-441PubMed Google Scholar found that 13% of 163 patients with chronic schizophrenia exhibited prominent obsessive compulsive symptoms. Thus, the overlap between OCD and schizophrenia is undirectional. Psychodynamic and behavioral theories have been developed in attempts to explain the cause of OCD; however, among psychiatrists, biologic theories predominate. A complex, interrelated series of hypotheses are being explored. All these hypotheses focus on the inhibitory neurotransmitter serotonin because serotonin uptake inhibitors (clomipramine, fluoxetine, and fluvoxamine) have proved sup
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