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Clinical Obsessive-Compulsive Disorders in Adults and Children

Richard Balon, MD

Wayne State University, Detroit, MI, USA

Edited by Robert Hudak and Darin D. Dougherty. New York, NY: Cambridge University Press; 2011; ISBN 978-0-5215-1569-6; pp 230; $90 (hardcover).

I remember one of my teachers during my medical school psychiatry rotation telling us obsessive-compulsive disorder (OCD) is probably the most serious of all mental disorders in terms of the combination of tremendous suffering, insight, and difficulty to treat it (he clearly meant among Axis I disorders). That was a long time ago. In spite of many developments in the field, I feel a bit similar to the way my teacher felt about this disorder. In all fairness, there have been some advances in the treatment of obsessive-compulsive disorders over the last few decades. We also have expanded our concept of OCD. At times, we also have questioned the classification of OCD as an anxiety disorder and proposed an entire category of disorders, with OCD being the anchor of this category. Thus, there have been some new developments, some clear, some a bit confusing.

It is useful, from time to time, to put together all developments in some area and review them to see where we are, what is new, and what is useful. That is what this book, Clinical Obsessive-Compulsive Disorders in Adults and Children, is focused on. As the authors say in the Preface, “the goal of this volume is to describe the current state of knowledge concerning the diagnosis and treatment of OCD and to describe how it is appropriately applied in a clinical setting” (p vii).

The book includes a Preface and 15 brief chapters. Chapter 1, “Introduction to obsessive-compulsive disorder,” is the usual introduction to a text focused on a disorder. It includes the history, diagnosis, epidemiology (I am not sure whether all would agree with the authors’ claim that OCD is one of the most common psychiatric disorders), symptoms and their dimensions, potential genetic and autoimmune causative factors, comorbidity of OCD with other mental disorders, a discussion of obsessive-compulsive personality disorder (OCPD) (the authors point out the driving force behind the respective pathologies of OCD and OCPD are different), course of OCD, insight into OCD, misdiagnosing OCD, and an interesting discussion of obsessions vs delusions. Chapter 2, “Neurobiology and neurocircuitry of obsessive-compulsive disorders and relevance to its surgical treatment,” is a useful discussion of 4 lesion procedures for OCD that are still in use—anterior capsulotomy, anterior cingulotomy, subcaudate tractotomy, and limbic leucotomy—including their outcomes and adverse effects. The chapter also includes a brief review of deep brain stimulation for OCD, the mechanism of action of neurosurgical procedures, and patient selection for these procedures (adequate trials of at least 3 selective serotonin reuptake inhibitors for at least 10 weeks and augmentation of previous drugs for 1 month with at least 2 of the following: lithium, clonazepam, buspirone, or a neuroleptic; all patients also must have had an adequate trial of behavioral therapy consisting of at least 20 hours of exposure and response prevention therapy). Chapter 3, “Selective serotonin reuptake inhibitors in the treatment of obsessive-compulsive disorder,” is a standard review of serotonergic antidepressants for OCD, including dosage guidelines and side-effect management. The following chapter, “Augmentation of serotonin reuptake inhibitors in the treatment of obsessive-compulsive disorder,” connects well with the chapter on using serotonergic antidepressants, discussing mostly augmentation with antipsychotics in adults and in children and adolescents, but also with other agents such as riluzole and buspirone. Interestingly, haloperidol and risperidone showed robust clinical efficacy compared with placebo, while augmentation with olanzapine and quetiapine in treatment-resistant OCD has been inconsistent.

Chapter 5, “Obsessive-compulsive disorder and comorbid mood disorders” is a bit poorly organized summary of comorbidity of OCD with major depression and bipolar disorders, including management issues. Chapter 6, “Obsessive-compulsive symptoms in schizophrenia: clinical characterization and treatment,” is a solid overview of OCD and schizophrenia, conditions that “share some demographic and clinical characteristics and pathophysiology,” including treatment of schizophrenia with obsessive-compulsive symptoms. The chapter also covers an interesting emerging topic: antipsychotic-induced obsessive-compulsive symptoms.

The next chapter, “Medication management of obsessive-compulsive disorder in children and adolescents,” returns to the treatment topic in a review of psychopharmacology of OCD in children and adolescents. Chapter 8, “Exposure and response prevention treatment for obsessive-compulsive disorder,” is a review of exposure and response prevention (ERP) in OCD, including the theoretical basis of ERP therapy, its comparison with cognitive-behavioral therapy (CBT) and medications, long-term effects of ERP, ERP in different OCD subtypes and in treatment-resistant and treatment-refractory OCD, and adjunct therapies to ERP in OCD. I liked the discussion of complications hindering ERP therapy, such as overvalued ideation, depression, comorbid disorders, personality, and disgust reaction with and without anxiety. Chapter 9, “Compulsive hoarding,” reviews the course, features, social and economic burden, and treatments (ERP, CBT, medications with mixed results) of a possible new entity within the obsessive-compulsive spectrum: compulsive hoarding. The following chapter, “Cognitive-behavioral therapy for children and adolescents with obsessive-compulsive disorder,” presents a nice review of CBT for children and adolescents and child-friendly CBT, with a detailed discussion of a specific program.

Chapter 11, “Community support and societal influences,” is a summary of issues such as support groups (professionally-assisted, peer-led, and online ones), family-to-family education programs, charitable and advocacy organizations, the school environment, and media (including commercial advertisement). The chapter also includes a list of resources for the organizations discussed. Chapter 12, “The family in the treatment of obsessive-compulsive disorder,” touches upon issues such as the role of the family in OCD, family quality of life, and family involvement in treatment. The following chapter, “Providing treatment for patients with obsessive-compulsive disorder,” reviews the treatment setting for OCD (outpatient, intensive outpatient, partial hospitalization, intensive residential, and inpatient hospital treatments) and then provides a useful list of intensive programs around the United States, Canada, the United Kingdom, India, Ireland, and Italy, with contact information. The last 2 chapters provide overviews of 2 other disorders of the obsessive-compulsive spectrum—body dysmorphic disorder and trichotillomania. Trichotillomania seems to be especially difficult to treat and specialists in this disorder are difficult to find. Medications—mostly serotonergic antidepressants—do not help much, if at all, and the long-term effects of habit reversal therapy (behavioral therapy designed to treat trichotillomania) are unclear.

This volume is what it intends to be, a comprehensive overview of the present status of our knowledge of OCD, obsessive-compulsive spectrum disorders, and their treatments. It provides a lot of useful theoretical and clinical information. The book has a few weaknesses. For example, comorbidity of OCD with anxiety disorders is not covered although the authors claim that comorbidity is the rule rather than the exception; there is also a surprising number of typographical errors. But those are not fatal and could be corrected if there is another edition of this book. Readers interested in OCD will definitely enjoy it; clinicians may find it useful.