Obsessive-compulsive disorders

Obsessive-compulsive disorder (OCD) until recently was considered to be a very rare disorder. However, newer epidemiological studies show OCD to be just as common as panic disorder, and two to three times as common as schizophrenia or bipolar disorder. 

OCD is a chronic psychiatric condition, often first emerging in childhood, and potentially lasting a lifetime. It results in considerable emotional suffering. Yet until recent times, few of those afflicted sought treatment. This is probably due to the common tendency for OCD patients to experience humiliation and shame over symptoms that they generally consider to be crazy or irrational and thus not to seek out professional help. 

Two-thirds of OCD patients are plagued by obsessions regarding dirtiness, contamination, and germs, with corresponding compulsions such as cleaning and hand washing. Another 20 percent primarily are worried about safety issues and engage 

Age of onset Although many cases of OCD begin in adolescence or early adulthood, about half begin in childhood. The incidence of OCD in children is 1 to 1.5 percent. 

Course Although some milder cases of OCD can be transient, most moderate-to-severe cases last for many years if xmtreated. 

The TCA clomipramine and the SSRls provide the foundation of the pharmacological treatment for OCD. Although pharmacotherapy is effective against many other Axis 1 disorders, most patients with OCD experience only a 35%-60% improvement in symptoms. In addition, medication responses may not be apparent until treatment has been administered for 10 weeks, and some patients will require higher doses than are typically used to treat depression. As in the treatment of depression, SSRls tend to be better tolerated than TCAs (clomipramine is the only effective TCA for OCD). 

Several augmentation strategies have been suggested. None has been associated with uniformly positive results in controlled trials, but possible effectiveness has been noted in selected patients. Augmentation strategies for OCD include the use of lithium, antipsy-chotics, clonazepam, or buspirone. 

As in other anxiety disorders, relatively few data are available on longer-term treatment of OCD. OCD is often a lifelong disorder with a waxing and waning course, for which many patients require prolonged pharmacotherapy. 

Although benzodiazepines, zolpidem, zaleplon, and eszopiclone are the mainstay of pharmacotherapy for insomnia, other sedating drugs, such as trazodone, diphenhydramine, or chloral hydrate, also may be used. Insomnia should first be addressed diagnostically, and in most cases, nonpharmacological interventions should be attempted before treatment with a hypnotic is instituted. Hypnotic agents should be administered in the lowest effective dose. Medications commonly prescribed for insomnia, along with their recom- 

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SSRIs are well tolerated. Adverse effects for compounds in this class include nervousness, tremor, dizziness, headache, insomnia, sexual dysfunction, nausea, and diarrhea. In addition, the tricycHc antidepressant clomipramine (33), which is a potent nonselective serotonin reuptake inhibitor, is approved for treatment of obsessive—compulsive disorder. 

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. 

Doxepin [1668-19-5] (38), unlike other commercially available tricyclics, has an oxygen atom in the bridge between the two aromatic rings. It is marketed as a cis—trans mixture (1 5) of isomers, both of which are active. This close relative of amitriptyline (33) has both sedative and anxiolytic properties associated with its antidepressant profile. Maprotiline [10262-69-8] (39) and amoxapine [14028-44-5] (40) are pharmacologically, although not chemically, similar to the tricycHc secondary amines. Clomipramine [303-49-1] (41) has similar pharmacological and antidepressant efficacy. However, clomipramine is approved by the U.S. FDA only for the treatment of obsessive—compulsive disorder. Representative brands of tricycHc antidepressants marketed in the United States are Hsted in Table 2. 

Antidepressants are small heterocyclic molecules entering the circulation after oral administration and passing the blood-brain barrier to bind at numerous specific sites in the brain. They are used for treatment of depression, panic disorders, generalized anxiety disorder, social phobia, obsessive compulsive disorder, and other psychiatric disorders and nonpsychiatric states. 

Obsessive-compulsive disorders Erythrocytes from patients with obsessive-compulsive disorder have significantly higher calpain activities than normal controls which could not be attributed to differences in memory function46... 

HT has been implicated in the etiology of numerous disease states, including depression, anxiety, social phobia, schizophrenia, obsessive compulsive disorders,... 

Antidepressant drugs are used to manage depressive episodes such as major depression or depression accompanied by anxiety. These drugs may be used in conjunction with psychotherapy in severe depression. The SSRIs also are used to treat obsessive-compulsive disorders. The uses of individual antidepressants are given in the Summary Drug Table Antidepressants. Treatment is usually continued for 9 months after recovery from the first major depressive episode. If the patient, at a later date, experiences another major depressive episode, treatment is continued for 5 years, and with a third episode, treatment is continued indefinitely. 

The enantiomerically pure 3-arylglutaric ester are precursors for the synthesis of (—)-paroxetine [10], a selective serotonin reuptake inhibitor used in the treatment of depression, obsessive compulsive disorder, and panic, and (i )-Baclofen [11], a GABAb receptor agonist, which is used cHnically in the treatment of spasticity (Chart 5.1). 

Extrapolation to other countries is not easy. Canada has a very different health-care system to the USA. A small-scale study involving 466 anxiety disorder patients in Quebec established a clear relationship between the severity of the disorder and utilization of health services (McCusker et al, 1997). Patients with obsessive-compulsive disorder were particularly likely to seek treatment. No information on dmg use was presented. 

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. 

Knapp M, Henderson J, Patel A (2000). Costs of obsessive-compulsive disorder a review. In Maj M, Sartorius N, Okasha A, Zohar J, eds, Obsessive Compulsive Disorder. Chichester John Wiley, 253—75. 

Rasmussen SA, Eisen JL, Pato MT (1993). Current issues in the pharmacologic management of obsessive compulsive disorder. J Clin Psychiatry 54 (suppl. 6), 4—9. 

Stein DJ, Roberts M, Hollander E, et al (1996). Quality of life and pharmaco-economic aspects of obsessive-compulsive disorder. A South African survey. SAfrMedJ86, 1579-85. 

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. 

Anxiety disorders, including panic disorder, obsessive-compulsive disorder, and social phobia... 

MCH Mean corpuscular hemoglobin OCD Obsessive-compulsive disorder... 

Rauch, S. and Jenike, M., Neurobiological models of obsessive-compulsive disorder. Psychosomatics 34(1), 20-32, 1993. 

Otto, M., Normal and abnormal information processing A neuropsychological perspective on obsessive compulsive disorder. Psychiatric Clinics of North America 15(4), 825-848, 1992. 

Carlsson, M.L. On the role of cortical glutamate in obsessive-compulsive disorder and attention-deficit hyperactivity disorder, two phenomenologically antithetical conditions. Acta Psychiatr. Scand. 102 401, 2000. 

Panic disorder Agoraphobia with panic disorder Agoraphobia without panic disorder Specific phobia Social phobia Generalised anxiety disorder Mild anxiety and depression disorder Obsessive compulsive disorder Acute stress disorder Post-traumatic stress disorder (PTSD) Adjustment disorder Panic disorder without agoraphobia Panic disorder with agoraphobia Agoraphobia Specific phobia Social phobia (also called social anxiety disorder) Generalised anxiety disorder Obsessive compulsive disorder Acute stress disorder Post-traumatic stress disorder (PTSD)... 

Prozac (Fluoxetine) Depression Obsessive-compulsive disorders Panic Post-traumatic stress disorder 2.9 1.0 1988 - US 1989 - UK Once daily... 

BDD is an obsessive-compulsive disorder that leads someone to have a preoccupation with what he or she perceives as a flaw in his or her appearance. Most frequently, the head and... 

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