Compulsions common

SSRIs are widely used for treatment of depression, as well as, for example, panic disorders and obsessive—compulsive disorder. These dmgs are well recognized as clinically effective antidepressants having an improved side-effect profile as compared to the TCAs and irreversible MAO inhibitors. Indeed, these dmgs lack the anticholinergic, cardiovascular, and sedative effects characteristic of TCAs. Their main adverse effects include nervousness /anxiety, nausea, diarrhea or constipation, insomnia, tremor, dizziness, headache, and sexual dysfunction. The most commonly prescribed SSRIs for depression are fluoxetine (31), fluvoxamine (32), sertraline (52), citalopram (53), and paroxetine (54). SSRIs together represent about one-fifth of total worldwide antidepressant unit sales. 

The anxiety disorders are common and surprisingly disabling conditions. Studies on the health economics of generalized anxiety disorder, panic disorder, social anxiety disorders and obsessive compulsive disorder document the cost to the individual and to society. Attention has focused on the major psychiatric disorders such as depression, schizophrenia and the dementias. Studies suggest that many anxiety disorders are of early onset and too often chronic they are quite common and impose a heavy burden on society. More studies will be needed to discern the fine grain in the survey material and to identify more precisely the location and type of societal costs. These factors will vary from country to country, from district to district, between men and women and between various age groups. 

Pharmacologically, a principal point relates to the cost-effectiveness of the newer indications for SSRIs in the less common disorders such as obsessive—compulsive disorder and social phobia. These conditions do place a disproportionate burden on health-care systems, and clinical trials of the newer indications are convincing. However, no cost-effectiveness study has yet been petformed to assess this, and prescribing will continue to be based on individual clinical need. 

Initially, most prominent effect is elated mood, although depression may occur hypervigilance and anxiety that may progress to panic with high doses or chronic use, may see impairment of judgment, violence to others or self, paranoia or psychosis with delusions and hallucinations (hallucinations are generally tactile or auditory, rarely visual) an increase in motor activity is common compulsive or stereotyped behavior (e.g., skin picking) may be seen severe intoxication may result in a self-limited delirium... 

The development of mild forms of anxiety and neuroveg-etative and/or cognitive responses to stress may represent an adaptive evolutionary step against environmentally (external) or self-triggered (internal) threats, but maladaptive reactions have also emerged in human evolution. Thus, anxiety disorders are maladaptive conditions in which disproportionate responses to stress, or even self-evoked responses, are displayed. Anxiety disorders are one of the most frequent psychiatric illnesses, and have a lifetime prevalence of 15- 20% [1, 89]. The most common presentations are generalized anxiety disorder, with a lifetime prevalence rate of close to 5% [1, 89] social anxiety disorder, with very variable lifetime prevalence rates ranging from 2 to 14% [90] panic disorder, with rates from 2 to 4% [1,89] and post-traumatic stress disorder (PTSD), with a prevalence rate close to 8%. Specific phobias, acute stress and obsessive-compulsive behavior are other clinical presentations of anxiety disorders. 

Common side effects of dopamine agonists are nausea, confusion, hallucinations, lightheadedness, lower-extremity edema, postural hypotension, sedation, and vivid dreams. Less common are compulsive behaviors, psychosis, and sleep attacks. Hallucinations and delusions can be managed using a stepwise approach (Table 55-4). When added to L-dopa, dopamine agonists may worsen dyskinesias. 

The most common obsessions faced by patients with OCD involve fears of contamination. This fear may focus on germs and infectious diseases, household chemicals, environmental pollutants, or bodily wastes. These contamination obsessions most often result in washing compulsions but may also produce compulsive visits to health care providers. Obsessional doubts (e.g., Did I remember to. .. ) are typically associated with checking compulsions. Another common obsession, need for symmetry and exacmess, leads to compulsive arranging, ordering, or counting. Obsessions may also be aggressive, somatic, or sexual in content. 

Appropriate management of AN also requires the early detection and treatment of any comorbid psychiatric disorders. The most common comorbid conditions associated with AN are major depressive disorder (MDD), obsessive-compulsive disorder (OCD), and substance use disorders. At the time of presentation, over 50% of AN patients also fulfill criteria for MDD however, accurate diagnosis of depression in these patients is complicated by the fact that prolonged starvation often produces a mood disturbance and neurovegetative symptoms identical to MDD. If MDD appears to be comorbid with AN at the time of presentation, there is debate as to whether it is more prudent to withhold treatment of the depression until weight restoration has been initiated. If the depression persists despite refeeding, then treatment of the depression is likely warranted. 

Other Hypersomnias. Narcolepsy is not the only hypersomnia, but it is by far the most common. Primary hypersomnia shares sleep attacks and excessive daytime sleepiness with narcolepsy but does not feature cataplexy or REM-associated abnormalities. Another rare hypersomnia is Kleine-Levin syndrome (KLS), which most often occurs in teenage boys. KLS consists of intermittent bouts of hypersomnia and bizarre behaviors including compulsive eating and sexual inappropriateness. Distinguishing these hypersomnias from narcolepsy may help clarify the patient s prognosis, but the treatment alternatives are very similar. 

The full complement of anxiety syndromes including panic, generalized anxiety, obsessive-compulsiveness, and post-traumatic stress disorder can arise in the after-math of TBI. In fact, anxiety may be the most common neuropsychiatric complication of TBI. Anxiety appears to be most likely to arise when the injury occurs to the right side of the brain. The treatment alternatives for post-TBl anxiety parallel those used when treating anxiety disorders and include serotonin-boosting antidepressants, buspirone (Buspar), and the benzodiazepines (see Table 12.1). 

Obsessive-compulsive, tic, and movement disorders in childhood and adolescence are now recognized as relatively common neuropsychiatric disorders, varying in severity, duration of symptom exacerbations, and degree of disability. In some children, the symptoms of these disorders are distinct and easily defined, whereas others display ever-changing combinations of obsessions, compulsions, abnormal motor movements, and tics that may be a mix of transient, chronic, simple, complex, vocal, or motor tics. 

Can antidepressants such as tricyclics or buproprion augment the effect of stimulants on nondepressed children with ADHD Randomized controlled trials have yet to address this question. Nonetheless, such combinations are common in clinical practice. One case report showed leukopenia in a child treated with a combination of MPH and tricyclics for 4 months, although the doses were not specified (Burke et ah, 1995). Another case report indicated that obsessive-compulsive symptoms developed secondary to the combination of MPH and tricyclics (Pataki et ah, 1993). On a cautionary note, MPH has been found to interact with guanethidine to produce paradoxical hypotension. Patients on monoamine oxidose (MAO) inhibitors are likely to develop hypertensive crises if given a stimulant. 

Borcherding, B.G., Keysor, C.S., Rapoport, J.L., Elia, J., and Amass, J. (1990) Motor/vocal tics and compulsive behaviors on stimulant drugs is there a common vulnerability Psychiatry Res 33 83-94. 

The neurotransmitter serotonin (5-hydroxytryptamine [5-HT]) is widely distributed in the CNS, subsuming a variety of functions including drive satiety, mood, aggression, anxiety, and compulsive and impulsive behaviors. It may be an important neurotransmitter in psychiatric symptoms commonly associated with PTSD such as aggression, obsessive/intrusive thoughts, alcohol and substance abuse, and suicidal behavior (Friedman, 1990). Suicidal behavior is known to be associated with both childhood maltreatment and low 5-HT functioning (Van der Kolk et ah, 1991 Benkelfat,... 

Most bulimic patients (60%-80%) have a lifetime history of depression (Braun et ah, 1994). They have problems with interpersonal relationships, self-concept, and impulsive behavior and show high levels of anxiety and compulsivity. Chemical dependency is not unusual in this disorder, alcohol abuse being the most common. Bulimics will abuse amphetamines to reduce their appetite and lose weight (Braun et ah, 1994). 

The most common type of OCD is an obsession with contamination that leads to compulsions for cleaning the environment and washing any areas of the body, like the hands or face, that might become contaminated. A person with this kind of OCD often has the compulsion to wash his or her hands over and over again, even if the skin becomes chapped, red, and bleeding. 

Comorbid anxiety and depressive features are common in clinical practice, and DSM-IV has included mixed anxiety-depression in its appendix of conditions needing nosological refinement. The presence of comorbid anxiety has prognostic implications. For example, prospective studies of patients with depression have found that the co-occurrence of panic attacks was correlated with a poor outcome (Coryell et al. 1988 van Valkenburg et al. 1984). Some evidence suggests that such patients do better with MAOls. Likewise, patients with depression and obsessive-compulsive disorder may be more resistant to treatment, even with SSRls (Hollander et al. 1991)... 

Obsessive-compulsive disorder (OCD] is usually chronic, often debilitating, and much more common than previously believed. Not long ago, OCD was widely viewed as untreatable. The 1980s witnessed renewed optimism about the prognosis of OCD as new, more effective forms of pharmacotherapy (i.e., potent serotonin reuptake inhibitors [SRIs]] and behavior therapy (i.e., exposure/response prevention) were introduced and tested. Despite these advances, a substantial number of patients with OCD... 

The association with Gilles de la Tourette s disorder is particularly important. Although only a few OCD patients have tics, the prevalence is much higher than in the general population. Conversely, obsessive-compulsive symptoms are common in Tourette s patients. Thus, there is a clear association between Tourette s disorder and OCD. Tourette s is familial, and most likely genetically transmitted ( 157). Less is known about the heritability of OCD, but there is some suggestion that it is, at least in part, genetically determined (158, 159 and 160). 

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