November 2009  << Back  

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Clinical Handbook of Obsessive-Compulsive Disorder and Related Problems

Richard Balon, MD

Wayne State University, Detroit, MI, USA

Edited by Jonathan S. Abramowitz, Dean McKay, and Steven Taylor; The Johns Hopkins University Press; Baltimore, Maryland; ISBN: 978-0-8018-8697-3; pp 343; $60.00 (hardcover).

I remember when one of my teachers in medical school stated that obsessive-compulsive disorder (OCD) is one of the most difficult mental disorders. He was correct, whether he was speaking in general or specific terms. The disorder is difficult to live with—whether you are a patient with OCD or are close to a patient with OCD—difficult to treat, and even difficult to classify. OCD traditionally has been classified as an anxiety disorder—or neurosis in the earlier classifications—although many felt that this was because it was not clear where to put it. Many also felt that OCD should be placed elsewhere within the classification system, either alone or with another group of similar disorders. The Preface to the Clinical Handbook of Obsessive-Compulsive Disorder and Related Problems suggests 2 approaches to classifying OCD and related disorders: (1) subtyping OCD, and (2) creating a spectrum of OCD and disorders with similar symptomatology. Subtyping has been suggested because OCD is heterogeneous and possibly composed of many different subtypes (p xi), and knowing them may help us better understand the disorder. Subtypes are defined by “differences among patterns of obsessive-compulsive symptoms” (p xii). Delineating the “spectrum” of obsessive-compulsive (OC) disorders groups disorders classified elsewhere that have similar symptomatology and respond to similar treatments. “Spectrum conditions are defined by some similarities to OCD” (p xii). The editors of this volume bring together a group of 40 authors to present the latest research on subtyping OCD and spectrum OC disorders in the hope that with a “more robust classification within OCD, it will become possible to validate theories and treatments empirically for these specific symptom presentations and better match each OCD patient to the most appropriate intervention” (p 3).

The book is divided into 2 parts: “Part I. Subtyping obsessive-compulsive disorder,” and “Part II. Problems related to obsessive-compulsive disorder” (basically OC spectrum).

Part I consists of 11 chapters. The first chapter, “Making sense of obsessive-compulsive disorder: Do subtypes exist?” discusses the core issue of whether or not to subtype this disorder. The authors conclude that although clinical observations and studies suggest that symptomatology-based subtypes of OCD exist, how to conceptualize them has not been resolved. The following 10 chapters review the possible subtypes: fears of contamination; compulsive checking; ordering, incompleteness, and arranging; unacceptable obsessional thoughts and covert rituals; compulsive hoarding; the PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) subgroup of OCD; OCD with poor insight; OCD and schizotypy; postpartum OCD; and scrupulosity. Each chapter “examines a particular clinical presentation of OCD that is often encountered in clinical practice” (p xiii) and “addresses the following aspects of each presentation: (a) symptomatology, (b) a review of the empirical support for the subtype(s), (c) a review of the etiological theories, and (d) treatment issues” (p xiii). Some chapters include clinical vignettes. The treatment discussions are usually fairly comprehensive and include psychological/behavioral treatments and pharmacotherapy. Each chapter ends with a summary and conclusion.

Part II includes 10 chapters. The first chapter discusses the empirical basis of the OC spectrum (eg, neurocircuitry and neurotransmitters in OCD; reward processing in OCD and OC spectrum disorders; action chunking in OCD and OC spectrum disorders). The remaining 9 chapters focus on “lumping with OCD a number of disorders from entirely different diagnostic categories” (p 173): eating disorders; trichotillomania; impulse-control disorders; autistic syndromes; nonparaphilic sexual disorders (including ego-dystonic compulsive masturbation; persistent, ego-dystonic promiscuity; compulsive cruising for sex; compulsive demands of unwanted sexual activity from a partner whose sexual drive is not hyposexual; compulsive fixation on an unobtainable partner; dependence for sexual arousal on pornography, drugs, and sexual accessories); Tourette syndrome and chronic tic disorders; body dysmorphic disorder; hypochondriasis; and obsessive-compulsive personality disorder (OCPD). The authors present good arguments for including these disorders in the OC disorders spectrum. Placing some of these disorders into this spectrum has been proposed for a long time and may not be surprising. Including some others—eg, eating disorders, hypochondriasis, or autistic syndromes—may be a bit more surprising but makes sense after reading this book. As argued in the text (p 174), we may need only a few broad constructs to account for how symptoms co-occur in large, population-wide samples. This empirical lumping also helps explain the comorbidity of various disorders (eg, mood and anxiety disorders). The discussions of disorders not usually thought of as part of this spectrum (eating disorders, hypochondriasis, autistic disorders) and OCPD are interesting. I was a bit surprised by the statement that “The egosyntonic nature of the symptoms and a lack of occupational impairment often contribute to a lack of motivation to seek treatment in individuals with OCPD” (p 328). My experience—with patients and even some of my colleagues—is that ego-syntonicity is the main contributor. However, I have seen some severe occupational impairment in otherwise intelligent OCPD persons. I would argue that beside ego-syntonicity, the lack of insight is the main component in the lack of motivation to seek treatment, as the authors also suggest.

This is an interesting and comprehensive volume. The more interesting part for me was Part II, with its focus on the OC disorders spectrum. The part focused on subtyping was a bit boring for me. I do not believe that it provides many clinically useful arguments for subtyping. Maybe the arguments presented are good enough for the specialists in treatment and research of OCD, but not for a general clinician. I also do not think one would change his/her clinical practice based on this text, yet. I would recommend this book to OCD researchers, but the rest of us should borrow it.