强迫症治疗之一线照护的最佳实务


  August 24, 2009 — 8月1日的美国家庭医学杂志回顾了强迫症(obsessive-compulsive disorder,OCD)的第一线诊断和治疗建议。
  
  密西根大学医学院的Jill N. Fenske医师和Thomas L. Schwenk医师写道,OCD是一种神经精神异常,特征是反覆的苦恼想法,以及进行重复的行为或精神仪式来减轻焦虑。
  
  症状通常伴随有羞耻和秘密感,因为病患了解其想法和行为是过当的或不合理的。这个秘密,以及健康照护专业人士缺乏对OCD症状的认知,通常会造成延迟诊断与治疗。OCD一直被视为是难以治疗的,但实际上有许多有效的治疗方法。
  
  尽管OCD同时有压力和失能,它通常未被确认和治疗。一线照护医师应有能力确认OCD的各种表现,以及著魔和强迫表现的相关线索。难以治疗的OCD孩童和成人,应转诊给专家。
  
  各种类型的OCD与其典型特征如下:
  * 早发型OCD:这一型的特征是在青春期之前就证明有症状,抽动和其它精神疾病的频率比其它OCD亚型高。强迫的现象通常严重且频繁,在发生著魔之前即很明显。早发型OCD对于一线治疗的反应比其它亚型差,有强烈的家族倾向,一等亲的发生率达17%。
  * 囤积狂OCD:这一型的病患一般比其它OCD亚型较不为人知,对于心理治疗可能较无反应。症状通常是更严重的,整体退的程度较大,精神共病症的比率更高,特别是社交恐惧症。
  * 完美型OCD:这一型的主要表现是要求周遭事物都是「最佳的」、「确定的」、「可控制的」,导致需要反覆的某些动作来缓和不舒适的感觉。
  * 主要强迫型OCD:这一型占了四分之一的病患,常见的话题包括性、暴力与宗教。虽然没有公开的强迫表现,病患依旧有其仪式,可能是心灵面的,例如祈祷、计算、或背诵一些「好词(吉祥话)」。虽然这一亚型被视为对治疗较无反应,病患对药物和「曝露与回应预防」有反应。
  * 多虑型OCD:这一型的特征是宗教或道德的著魔,重点在病患对于信仰或宗教关系可能会有毁灭性。这种著魔可能包括亵渎的思想或聚焦在病患是否犯罪,伴随的强迫行为可能包括祷告、从牧师寻求信心、过度忏悔。
  * 抽动相关之OCD:这一型与早发型OCD有些相同,许多病患符合妥瑞氏症的判定准则。经常发生共病症,例如注意力不佳/过动异常、身体畸形性疾患/爱整形、拔毛癖、社交焦虑、和/或情绪异常。一般会发生囤积型)和身体型的强迫行为。此一亚型通常需要并用选择性血清素再吸收抑制剂(SSRI)以及非典型的抗精神病药物。
  
  加速恢复的重要开端,包括正确的诊断以及教育病患了解OCD的本质。当OCD症状引起病患功能不佳或明显的压力时即应加以治疗。虽然治疗很少可以治癒OCD病患,但是可以达到明显的症状缓解。治疗的合理目标是每天花不到1小时在那些强迫行为,使其对日常生活的影响最小。
  
  第一线治疗应包括认知行为治疗以及曝露与回应预防、或者使用SSRI药物,如citalopram、escitalopram、fluoxetine、fluvoxamine、paroxetine或sertraline进行治疗。医师应了解OCD所需的药物剂量通常会超过其它适应症的用药量,通常需要较长的治疗期间才有明显的治疗反应。
  
  对于抗拒治疗的OCD病患,可用的治疗选项包括加强一种SSRI和一种非典型抗精神病药物。因为OCD是一种慢性状况且复发率高,治疗中断一事应相当谨慎。OCD病患应被小心监测,以察觉可能的共病症,如忧郁和自杀意念。
  
  实务上的特殊关键临床建议,以及它们的证据等级如下:
  * 认知行为治疗包括曝露与回应预防是OCD治疗的一个有效方法(证据等级A)。
  * 建议使用于OCD的第一线药物、SSRIs是有效的(证据等级 A)。
  * 对于一些抗拒治疗OCD的病患,加强SSRI治疗与并用非典型抗精神病药物是有效的(证据等级B)。
  * 适当的SSRI治疗试验期间为8至12周,需要至少4至6周达到最大耐受剂量(证据等级C)。
  * 试图停用SSRIs之前,病患应服用这些药物至少1至2 年。为了帮助预防停用SSRIs时发生复发,医师应考虑曝露与回应预防之加强课程(证据等级C) 。
  * OCD病患应被监控其精神共病症与自杀风险(证据等级C)。
  
  研究作者结论表示,抗拒治疗OCD的病患应转诊给次专科医师。对于这些病患,有多种治疗方式,但是多数治疗的证据是根据小型的初步研究或专家意见。部份的住院型和居家型治疗机构适合严重的、抗拒治疗的OCD病患。
  
  回顾作者均宣告没有相关的财务关系。
  

Best Practices for Treating Obsessive-Compulsive Disorder in Primary Care Setting

By Laurie Barclay, MD
Medscape Medical News

August 24, 2009 — Recommendations for diagnosing and treating obsessive-compulsive disorder (OCD) in the primary care setting are reviewed in the August 1 issue of American Family Physician.

"...OCD is a neuropsychiatric disorder characterized by recurrent distressing thoughts and repetitive behaviors or mental rituals performed to reduce anxiety," write Jill N. Fenske, MD, and Thomas L. Schwenk, MD, from the University of Michigan Medical School in Ann Arbor.

"Symptoms are often accompanied by feelings of shame and secrecy because patients realize the thoughts and behaviors are excessive or unreasonable. This secrecy, along with a lack of recognition of OCD symptoms by health care professionals, often leads to a long delay in diagnosis and treatment. OCD has a reputation of being difficult to treat, but there are many effective treatments available."

Despite the considerable distress and disability accompanying OCD, it is often unrecognized and undertreated. Primary care physicians should be able to recognize various presentations of OCD as well as clues regarding the presence of obsessions or compulsions. Children with OCD and adults who are refractory to treatment should be referred to a specialist.

Various subtypes of OCD, and their typical presenting features, are as follows:

  • Early-onset OCD: This subtype typically manifests symptoms before puberty, with higher frequency of tics and other psychiatric comorbidities vs the other OCD subtypes. Compulsions, which are often severe and frequent, usually are evident before obsessions develop. Early-onset OCD is less responsive to first-line therapy than the other subtypes, and there is a strong familial predisposition, with incidence of 17% among first-degree relatives.
  • Hoarding OCD: Patients with this subtype usually have less insight vs other OCD subtypes and may be less responsive to psychological therapy. Symptoms are often more severe, with a greater degree of global impairment, and rates of psychiatric comorbidities are higher, especially for social phobia.
  • "Just right" OCD: In this subtype, the primary manifestation is a desire for circumstances or things to be "perfect," "certain," or "under control," resulting in a need to repeat certain actions to alleviate the uncomfortable feeling.
  • Primary obsessional OCD: This subtype occurs in one quarter of patients, with common themes including sex, violence, and religion. Although overt compulsions are absent, patients are not free from rituals, which may be mental, such as praying, counting, or reciting "good words." Although this subtype has been considered to be less responsive to treatment, patients do respond to medication and exposure and response prevention.
  • Scrupulosity OCD: This subtype, which is characterized by religious or moral obsessions, can be devastating for patients in whom faith or religious affiliation is important. The obsessions may involve blasphemous thoughts or focus on whether the patient has committed a sin, and the accompanying compulsions may include prayer, seeking reassurance from clergy, or excessive confession.
  • Tic-related OCD: This subtype overlaps significantly with early-onset OCD, and many patients meet criteria for Tourette's syndrome. Comorbid conditions often occur, such as, attention-deficit/hyperactivity disorder, body dysmorphic disorder, trichotillomania, social anxiety, and/or mood disorders. Hoarding and somatic obsessions typically occur. This subtype often requires combination treatment including a selective serotonin reuptake inhibitor (SSRI) and an atypical antipsychotic.

Important initial steps in facilitating recovery include correct diagnosis and educating the patient concerning the nature of OCD. Treatment is indicated when OCD symptoms cause impaired function or significant distress for the patient. Although treatment rarely cures the patient with OCD, significant symptomatic relief is achievable. Reasonable goals for treatment would be to spend less than 1 hour per day on obsessive-compulsive behaviors, causing minimal interference with daily activities.

First-line therapy should consist of cognitive behavioral therapy with exposure and response prevention, or pharmacotherapy with an SSRI, such as citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, or sertraline. Physicians should be aware that medication dosages required in OCD often exceed those needed for other indications, and there is also usually a longer duration of treatment needed before response becomes apparent.

For patients with OCD who are resistant to treatment, feasible options for therapy may include augmentation of an SSRI with an atypical antipsychotic. Because OCD is a chronic condition with a high rate of relapse, treatment should be discontinued only with caution. Patients with OCD should be carefully monitored to detect possible comorbid depression and suicidal ideation.

Specific key clinical recommendations for practice, and their accompanying level of evidence rating, are as follows:

  • Cognitive behavioral therapy including exposure and response prevention is an effective modality for OCD treatment (level of evidence, A).
  • Recommended first-line pharmacotherapy for OCD is SSRIs, which have been shown to be effective (level of evidence, A).
  • In some patients with treatment-resistant OCD, augmentation of SSRI therapy with atypical antipsychotic agents is effective (level of evidence, B).
  • Optimal duration for a trial of SSRI treatment is 8 to 12 weeks, with at least 4 to 6 weeks at the maximal tolerable dosage (level of evidence, C).
  • Before attempting discontinuation of SSRIs, patients should take these drugs for at least 1 to 2 years. To help prevent relapse when SSRIs are discontinued, the treating physician should consider exposure and response prevention "booster" sessions (level of evidence, C).
  • Patients with OCD should be monitored for psychiatric comorbidities and suicide risk (level of evidence, C).

"Patients with treatment-resistant OCD should be referred to a subspecialist," the study authors conclude. "There are a variety of treatment options for these patients, but the evidence for most therapies is based on small preliminary studies or expert opinion. Partial hospitalization and residential treatment facilities are options for patients with severe, treatment-resistant OCD."

The review authors have disclosed no relevant financial relationships.

Am Fam Physician. 2009;80:239-245.

    
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