Obsessivecompulsive Disorder

Obsessive-compulsive disorder (OCD) is characterized by intrusive thoughts or images (obsessions) and by repetitive and stereotypic acts (compulsions). In DSM-IV it is made clear that compulsions can be either behaviours or mental acts. Despite the face validity of the clinical distinction between obsessions (which may increase anxiety) and compulsions (which serve to decrease anxiety), factor analyses have increasingly provided evidence for the construct validity of a four-factor model of OCD, including contamination concerns aggressive/checking symptoms, symmetry/ordering concerns and hoarding [18,19].

OCD has a prevalence of around 2%, and some studies have suggested that it is one of the most disabling of all the medical disorders [2]. Studies have demonstrated a remarkably long gap (up to 17 years) between diagnosis and appropriate treatment [20]. Thus, an immediate focus for those interested in preventing the chronicity and morbidity of OCD is the importance of early diagnosis and treatment. Working with consumer advocacy groups and the media may play an important role in increasing awareness, decreasing stigma, and so contributing to earlier and more appropriate intervention [21].

To optimize early detection of OCD, it is particularly important to recognize the group of patients with early onset OCD [22]. Childhood onset OCD patients are more likely to be male and to have comorbid tics. Normal childhood rituals need, however, to be differentiated from pathological OCD symptoms. Fortunately, there is good evidence that many of these patients respond to standard OCD treatments, including pharmacotherapy with the SSRIs [23].

A proportion of childhood-onset cases of OCD can be characterized as having paediatric neuropsychiatric disorders associated with streptococcus (PANDAS). These cases are thought to involve auto-immune responses after infection with this bacterium [24]. This research suggests the possibility that early diagnosis and treatment of streptococcal infection might reduce the incidence of OCD. Nevertheless, the extent to which autoimmune mechanisms account for OCD cases as a whole remains unknown, and such work has not yet been undertaken. An early trial of penicillin prophylaxis in subjects with PANDAS did not prove effective in preventing subsequent OCD symptoms [25]. Penicillin did not, however, effectively prevent streptococcal infection, suggesting that trials with other antibiotics are warranted.

It is theoretically possible that individual and family interventions with high-risk individuals might be useful in enhancing early detection and prevention of OCD. It remains unclear to what extent OCD is caused by genetic versus environmental influences. Nevertheless, it is potentially possible to target individuals at high risk (for example, those with parental OCD), or to target times of higher risk (for example, pregnancy and puerperium [26]). Although it is possible that medication could be used in patients at high risk for OCD, an immediate question is whether cognitive-behavioural therapy (CBT) might not have a role in such cases.

Ultimately, particular neurobiological markers (e.g. abnormal functional brain activity, the presence of particular genetic variants) may prove crucial in targeting individuals at risk for developing OCD. Certainly, there is already evidence that particular variants in the serotonin transporter protein (5-HTTP) gene are associated with high risk for OCD [27]. Nevertheless, at present work on functional imaging and genetic variants in OCD remains primarily within the realm of research.

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