OCD治疗的几个问题(江西郭中孟)

Introduction




Obsessive-compulsive disorder (OCD) is a chronic, waxing and waning neuropsychiatric disorder characterised by obsessions and compulsions. Obsessions are recurrent and persistent thoughts, images, or impulses that are irrational, unwanted, excessive or inappropriate. They are intrusive and cause significant anxiety or distress. As they are unwanted, the individual attempts to ignore or resist such thoughts and neutralise them with some other thoughts or action. Although the obsessions are unwanted, they are recognised as a product of his or her mind and not imposed from without. Compulsions are repetitive behaviours or mental acts often performed in response to obsessions or according to rigid rules. They reduce the distress associated with obsessions. Compulsions are often performed to prevent some dreaded event although they are not connected realistically to what they are designed to prevent and are clearly excessive. The obsessions and compulsions can be extremely time consuming, often taking up many hours of a person's day leading to considerable distress and interference in functioning. Following are the common obsessions and compulsions reported by the patients.[1,2]
Diagnosis of OCD


A diagnosis of OCD is made if obsessions and/or compulsions are present and cause marked distress, are time consuming (more than 1 h per day), or significantly interfere with the person's routine social and/or occupational functioning.[3] Most patients with OCD have good insight in to their illness and perceive that obsessions and compulsions are unreasonable or excessive. However, DSM-IV field trial has demonstrated that nearly a third of OCD patients have poor insight.[4] To reflect the findings of the field trial, the DSM-IV added a new OCD specifier: 'with poor insight'. Insight may also vary across situations and times. For example, a person may recognise the unreasonableness or irrationality of contamination fears while discussing with the therapist in his office, but may exhibit poor insight when actually performing compulsions because of excessive anxiety. Insight could be poor in children with OCD because they may lack sufficient cognitive maturity to make this judgment. In essence, although good insight into symptoms is characteristic of OCD, a substantial minority of patients may also have somewhat poor insight. It is important to recognise this because many OCD patients with poor insight are often misdiagnosed as 'psychotic' and treated inappropriately with antipsychotic drugs.
Issues In The Pharmacological Treatment of Obsessive-Compulsive Disorder
S. B. Math; Y. C. Janardhan Reddy Int J Clin Pract. 2007;61(7):11701180
outline
Obsessions
பைடு நூலகம்



Fear of contamination (dirt, dust, sticky substances, etc.) or contracting an illness. Doubts about daily activities (e.g. whether the door is locked or not, whether the gas knob is turned off or not). Thoughts, images or urges related to sex (sexual thoughts and images about immediate family members), harm (urges to harm self or others e.g. fear of stabbing one's child) and religion (thoughts of blasphemy e.g. urges to abuse God). Need to arrange items in a particular order. Fear of getting an illness (e.g. AIDS, hepatitis, rabies etc.). Hoarding
Review Criteria


A MEDLINE search for all studies till December 2006 assessing the efficacy of pharmacotherapies in OCD was performed . Use the key words 'pharmacotherapy', 'drugs', 'SSRIs', 'treatment' and 'obsessive-compulsive disorder'. For obtaining data on augmentation strategies and refractory OCD, we used additional key words 'augmentation', 'adjunctive', 'refractory' and 'resistant'. In addition, the reference sections of major articles, and reviews were also screened. We employed the usual hierarchy of evidence to write the review. Systematic reviews and meta-analyses of randomised controlled studies (RCT) were considered the best evidence base followed by RCTs, open-label studies, case series and case reports. In addition, we also considered clinical guidelines and narrative reviews in writing this educational review.
Compulsions

Washing and cleaning (e.g. hands, utensils, clothes, floor etc.). Checking (e.g. door locks, electrical outlets, gas knobs etc.). Repetition (e.g. counting money, tracking accounts, rewriting, rereading etc.). Arranging and ordering things (books, clothes etc.). Hoarding of useless items (e.g. old newspapers, magazines, pens, bottles etc.). Mental rituals or compulsions (e.g. praying, counting, contrast thinking etc.). Compulsive reassurance-seeking from others regarding their doubts or confirming that they have not committed an inappropriate, or immoral act.