Example Obsessive-Compulsive Disorder

a practicing forensic pathologist, was well respected in his field and was recognized within the professional community as a conscientious practitioner and scientist. Originally seen by a psychiatrist principally for compulsive symptoms that were increasingly interfering with his practice and social life, Ron decided to see a social worker about changing some of his behavior patterns. 

When discussing his childhood, Ron stated that he was an only child who was rewarded for keeping his room clean. He described his mother as a neat freak and his father as frequently absent from home. He always maintained a clean and tidy bedroom because he knew that neatness would 

Upon assessment it was evident to the social worker that Ron s symptoms were consistent with individuals who suffer from a type of anxiety disorder known as obsessive-compulsive disorder (OCD). The person who suffers from obsessive-compulsive disorder frequently has reoccurring obsessions (thoughts that interfere with action) and compulsions (behaviors that help ease current anxiety levels) that are related to the traumatic event. In OCD, the fourth most common psychiatric disorder in the United States, there appears to be a wide spectrum of symptoms (Cohen Steketee, 1998). These symptoms can range from mild to severe, yet if left untreated can impair an individual s previous level of functioning at work, school, or at home (De Silva Rachman, 1998). 

Anxiety An unpleasant state characterized by subjective feelings of worry, apprehension, (cognitive) difficulties concentrating, (behavioral) restlessness, irritability, insomnia, (somatic) sweat, shortness of breath, etc. Everyone experiences anxiety it only becomes pathological when the magnitude and/or duration exceed norma) limits (taking into account the preceding event). 

Clients can be exposed to uncertainty and are expected to address many problems that include health and wellness issues, finances, recent and multiple medical problems, or the death of loved ones. Defined simply, fear is the body s response to a real threat, and anxiety is an exaggerated response to something that is unrealistic or unknown. 

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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. 

Panic disorder is characterized by the occurrence of panic attacks that occur spontaneously and lead to persistent worry about subsequent attacks and/or behavioral changes intended to minimize the likelihood of further attacks. Sporadic panic attacks are not limited, however, to those with syndromal panic disorder as they do occur occasionally in normal individuals and in those with other syndromal psychiatric disorders. The hallmark of panic disorder is that the panic attacks occur without warning in an unpredictable variety of settings, whereas panic attacks associated with other disorders typically occur in response to a predictable stimulus. For example, a person with acrophobia might experience a panic attack when on a glass elevator. A patient with obsessive-compulsive disorder (OCD) with contamination fears may have a panic attack when confronted with the sight of refuse, and a combat veteran with post-traumatic stress disorder (PTSD) may experience a panic attack when a helicopter flies overhead or an automobile backfires. 

It is thought that this test for anxiety most closely resembles the behavior that accompanies a specific phobia. Because this burying behavior is consistent and does not decrease over time, it is also believed that this type of behavior resembles what is seen with obsessive-compulsive disorder. Benzodiazepines are an example of a drug that reduces both the avoidant and the burying behaviors in this test. 

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)... 

During all phases of treatment, education, supportive therapy, and, at times, more specific types of psychotherapy are essential for a satisfactory outcome. For example, interpersonal therapy can complement adequate maintenance antidepressant treatment, possibly diminishing the frequency of episodes (see the section Role of Psychosocial Therapies in Chapter 7), and cognitive-behavioral techniques in combination with antiobsessive agents (e.g., clomipramine) can improve the quality of life for patients with obsessive-compulsive disorder, minimizing time spent on disabling rituals (see the section Obsessive-Compulsive Disorder in Chapter 13). 

Some of the growth in antidepressant use may be related to the broad application of these agents for conditions other than major depression. For example, antidepressants have received FDA approvals for the treatment of panic disorder, generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD). In addition, antidepressants are commonly used to treat pain disorders such as neuropathic pain and the pain associated with fibromyalgia. Some antidepressants are used for treating premenstrual dysphoric disorder (PMDD), mitigating the vasomotor symptoms of menopause, and treating stress urinary incontinence. Thus, antidepressants have a broad... 

Perhaps the most commonly used example of the serotonin 2A strategy is the combination of an SSRI with trazodone. Clinicians have long recognized that trazodone will improve the agitation and insomnia often associated with SSRIs, allow high doses of the SSRI to be given, and consequently boost the efficacy of the SSRI not only in depression, but also in obsessive-compulsive disorder and other anxiety disorders. Thus, both types of bad math are in play here. 

By the 1990s antidepressants from the serotonin selective reuptake inhibitor (SSRI) class became recognized as preferred first-line treatments for anxiety disorder subtypes, ranging from obsessive-compulsive disorder, to panic disorder, and now to social phobia and posttraumatic stress disorder (Fig. 8—9). Not all antidepressants, however, are afficacious anxiolytics. For example, desipramine and bupropion seem to be of little help in several anxiety disorder subtypes. Documentation of efficacy... 

It is important to screen patients for co-occurring mental disorders, and their presence may become more apparent during the stabilization or maintenance phases of schizophrenia treatment. Examples include substance abuse disorders, depression, obsessive-compulsive disorder, and panic disorder. As co-occurring disorders will limit symptom and functional improvement and increase the risk of relapse, it is critical that they be appropriately treated. Pharmacological and nonpharmacological interventions specific for the co-occurring disorder should be implemented in combination with evidence-based treatment for schizophrenia. 

More narrow SNP scans were very successfully performed for candidate susceptibility loci. Examples of strong association exist for ischemic stroke, migraine, psoriasis, rheumatoid arthritis or Crohn s disease. The investigation of known loci by following the haplotype strategy has already been fruitful for brain-derived neurotrophic factor (BDNF) and obsessive compulsive disorder [13], for RET and Hirsch-spmng s disease [14], for apoHpoprotein E (APOE) and Alzheimer s disease [15], and for TAU and late-onset Parkinson s disease [16]. 

Selective serotonin norepinephrine reuptake inhibitors (SSNRIs) The newest group of medicines that have successfully been used to treat emotional and behavioral problems such as depression, panic disorder, obsessive-compulsive disorder (OCD), similar to their counterparts, the SSRIs. Some examples of the SSNRIs include Effexor, Serzone, and Remeron. 

Part II of the book outlines several mental-health diagnostic categories schizophrenia, mood disorders, depression, bipolar disorders, and specific anxiety disorders including generalized anxiety disorder and obsessive compulsive disorder. Each chapter provides a case example, consideration in diagnosis, and the interventions utilized. Medications used to treat these disorders and relevant psychosocial interventions are outlined. Each chapter emphasizes the need for accurate treatment planning and documentation and offers suggestions to facilitate this process. 

Indications Depression, obsessive compulsive disorder, enuresis, severe chronic pain, phobic disorders, bulimia, short-term treatment of duodenal or gastric ulcers Common drug examples ... 

Enhance serotonergic transmission through blocked reuptake at the synapse Indications Depression, panic and eating disorders, obsessive compulsion, premenstrual dysphoria, posttraumatic stress and bipolar disorders, alcohol dependence, premature ejaculation, diabetic neuropathy Common drug examples ... 

When a patient with OCD has impaired insight, the distinction between obsession and delusion becomes blurred. We would argue that such a patient is in fact delusional. The with poor insight specifier is therefore the OCD equivalent to the with psychotic features specifier applied to the mood disorders. There may in fact be a continuum of insight in patients with OCD that fluctuates over time. For example, patients with OCD may recognize that their preoccupation with an obsessional idea or compulsive ritual is excessive, yet they may remain insistent that the premise underlying their anxiety is entirely reasonable. 

Somatoform Disorders. Similarities also exist between OCD and certain somatoform disorders. For example, somatic obsessions occurring in OCD resemble hypochondriasis. These can usually be distinguished in that those with OCD have typically experienced other nonsomatic obsessions during the course of their illness and typically engage in classic compulsive behaviors to alleviate, albeit temporarily, their somatic concerns. 

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