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Obsessive-compulsive disorder (OCD) experienced in childhood or adolescence is often a chronic disorder with high subjective distress and impairment of family and social functioning. An early comprehensive intervention schedule can have a profound effect on outcome in later years. The clinical manifestations of OCD among children and adolescents do not seem to be inherently different from those of adult patients. In younger subjects, the clinical picture tends to be dominated by compulsions, and insight can be poor, with little recognition of the symptoms as a problem.There is often a shift in symptoms over time, with some symptoms being replaced by others, while in adults, the core obsessions and compulsions tend to be more stable. In addition to depression and anxiety disorders, the spectrum of comorbid psychopathology seen in pediatric OCD patients includes tic, disruptive behavior, and specific developmental disorders. The treatment of childhood and adolescent OCD relies on cognitive-behavioral techniques of psychotherapy and pharmacotherapeutic interventions similar to those recommended in adults. The efficacy of exposure and response prevention in pediatric OCD has been shown in numerous open studies, and four controlled trials. Pharmacotherapy relies on serotonergic medication, and all have been demonstrated to be significantly superior to placebo, as reported in a recently published meta-analysis. Current concerns with the use of SSRIs in children and adolescents were explored as regards OCD and anxiety disorders, and there is no evidence for an increase in suicide or related behaviors.
Bipolar disorder is commonly accompanied by substantial comorbidity, including high rates of anxiety disorders and also of substance and alcohol-use disorders. This chapter considers evidence-based pharmacotherapy for the three main clinical scenarios-episodes of bipolar depression, manic or mixed episodes, and the prevention of relapse. In new episodes of bipolar depression, the three approaches with the strongest evidence base at present are the use of quetiapine, lamotrigine, and the optimization of existing long-term treatments. The evidence for the use of conventional antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), in bipolar depression has weakened in recent years. Studies in bipolar disorder have for the most part employed valproate in the form of divalproex. A recentmeta-analysis identified four small randomized placebo-controlled trials of valproate in bipolar I or bipolar II depression. Strong evidence guides first-line choices for episodes of bipolar depression, manic or mixed episodes, and for relapse prevention.
Over the last 25 years, the perception of obsessive-compulsive disorder (OCD) has changed; where once it was seen as a rare refractory disorder, it is now viewed as a fairly prevalent, but treatable, medical condition responding to two main therapeutic strategies–serotonin reuptake inhibitors (SRIs) and cognitive-behavioral therapy (CBT). Given the emergence of new results with SRIs, more data on the role of augmentation strategies with second-generation antipsychotics, and recent genetic and neuroimaging findings with potential for advancing the understanding of the pathogenesis of OCD, it was thought appropriate to revisit OCD in order to identify key developments in this field and examine how they might be translated into the clinical arena. This consensus statement is the product of the International Anxiety Disorders Conference that took place in Cape Town in February 2006, and is referred to as the Cape Town Consensus (CTC).
In the Diagnostic and Statistical Manual of Mental Disorders (DSM) system, OCD has been classified as an anxiety disorder. However, in the International Classification of Diseases (ICD) system, OCD is separated from these conditions. This is consistent with several findings. OCD can begin before puberty, whereas other anxiety disorders, particularly generalized anxiety disorder (GAD), have a later age of onset. OCD is similarly prevalent in men and women, as opposed to depressive and anxiety disorders, which are more common in women. Pharmacologic challenges in some (but not all) studies show exacerbation of symptoms to 5-HT receptor agonists (eg, mCPP, sumatriptan), but not to other anxiogenic challenges such as yohimbine, sodium lactate, caffeine, CO2, cholecystokinin, and pentagastrin, which are known to elicit anxiety symptoms in anxiety disorders.
Background. Failure to resist chronic obsessive–compulsive symptoms may denote an altered state of cognitive control. We searched for the cerebral regions engaged in this dysfunction.
Method. Differences in brain regional activity were examined by event-related functional magnetic regional imaging (fMRI) in a group of adolescents or young adults (n=12) with childhood-onset obsessive–compulsive disorder (OCD), relative to healthy subjects. Subjects performed a conflict task involving the presentation of two consecutive and possibly conflicting prime and target numbers. Patients' image dataset was further analysed according to resistance or non-resistance to symptoms during the scans.
Results. Using volume correction based on a priori hypotheses, an exploratory analysis revealed that, within the prime-target repetition condition, the OCD subjects activated more than healthy subjects a subregion of the anterior cingulate gyrus and the left parietal lobe. Furthermore, compared with ‘resistant’ patients, the ‘non-resistant’ OCD subjects activated a bilateral network including the precuneus, pulvinar and paracentral lobules.
Conclusions. Higher regional activations suggest an abnormal amplification process in OCD subjects during the discrimination of repetitive visual stimuli. The regional distribution of functional changes may vary with the patients' ability to resist obsessions.
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