Obsessive Compulsive Disorder

This book, in the words of its editor, Joseph Zohar, “celebrates 25 years of research in Obsessive Compulsive Disorder (OCD)” (p 327). It is written by an outstanding group of international experts (from the United States, UK, Israel, South Africa, the Netherlands, Italy, Spain, Canada) and published in the World Psychiatric Associations’ Current Science and Clinical Practice series. It is a thorough, comprehensive, well-written, state-of-the-art volume summarizing the current state of knowledge of this complex disorder. The book is divided into three sections. Section 1 focuses on assessment and treatment of this disorder, with chapters on pharmacotherapy, cognitive behavioral therapy (CBT), approaches to treatment resistance, and other therapeutic interventions (electroconvulsive therapy [ECT], transcranial magnetic stimulation [TMS], and deep brain stimulation [DBS]). Section 2, Clinical Spotlights, consists of two chapters: one on OCD subtypes and spectrum issues and one on pediatric OCD. Section 3, Research Spotlights, focuses on current and future research strategies in OCD; brain imaging, genetics, neurotransmitters, and endophenotypes are some of the topics addressed and discussed. Each chapter in this book includes a thorough review of the literature and provides the reader with a balanced and even-handed analysis of clinical and research data. Each chapter is accompanied by an impressive bibliography, allowing the curious reader to easily go to the original sources for further knowledge and clarification. This volume is worth reading in its entirety and will be of great interest to all clinicians. Alas, because of space limitations, I will only be able to touch on a few points in this brief review. Section 1 contains several well-written, informative, and clinically relevant chapters on diagnosis and treatment. I will briefly mention the chapter Approaches to Treatment Resistance for its significant clinical relevance given that 40% to 60% of OCD patients ultimately become treatment resistant. The chapter begins with a comprehensive discussion of terminological problems and definitions and introduces a number of operational criteria for the assessment of stages of treatment response. A very thorough analysis of both pharmacological and nonpharmacological strategies in resistant OCD follows. This chapter is very “user friendly,” and I found several sections particularly interesting: the use of infusion therapy, the effectiveness of CBT, the comparative efficacy of various antipsychotic agents, and the rationale for the use of glutamatergic agents. Another chapter in this section, Electroconvulsive Therapy, Transcranial Magnetic Stimulation and Deep Brain Stimulation in OCD, provides a very balanced description of these three interventions that have been used in refractory OCD. The authors, after careful review of all available data, conclude that studies so far have been inconclusive relative to the efficacy of either ECT or TMS. DBS, on the other hand, seems to be a promising approach for patients who remain disabled and treatment refractory, despite multiple other interventions. The authors capably discuss the five targets that have so far been used in DBS. They review all available data and provide a clear comparison of the five target sites, describing the similarities and differences in efficacy, mechanism of action, beneficial effects, and adverse events. The authors acknowledge that DBS is clearly a viable, effective neurosurgical treatment (albeit of last resort) for a group of seriously affected individuals. Section 2 (Clinical Spotlights), as I mentioned before, consists of two chapters: one chapter on subtypes and spectrum issues and one on pediatric OCD. I found the chapter on OC spectrum disorders (OCSDs) thought provoking and informative. Depending on the diagnostic methodology used, different psychiatric disorders could be included in this grouping. For instance, if we consider the core phenomenological features of OCSDs to be repetitive thoughts and behaviors, then OCSDs, according to the authors, should not even be placed in the anxiety disorders category—an interesting hypothesis needing further study. The chapter concludes with a very useful section on compulsive hoarding focused on what makes this disorder similar to and different from other OCSDs. The chapter on pediatric OCD provides a thorough review of the etiology of this disorder in children, including both genetic factors and nongenetic ones, such as adverse perinatal factors, pediatric autoimmune neuropsychiatric disorders associated with streptococcus, trauma/stress, and the family. The chapter presents a balanced summary of clinical features, comorbidities, and treatment options in children with OCD. It focuses on specific features that distinguish it from the disorder in adults. For instance, clinical features in children with OCD reflect conflicts that are developmentally specific to different age groups and therefore will vary somewhat with age; families frequently become deeply enmeshed when dealing with a child with OCD, often making treatment more difficult. On a more positive note, it appears that the outcome in childhood-onset OCD is generally better than in the adult population. In Section 3 of the book, the chapter on brain imaging provides a good review of neuroimaging findings in both adult and pediatric OCD and includes a wealth of new structural and functional data. It identifies areas of convergence and controversy and points to areas of future investigation. Let me briefly touch on a couple of findings from this chapter. We now know that patients with OCD have increased activation of the caudate nucleus and anterior orbital frontal cortex; this finding appears to be specific to OCD and not generalized to other anxiety disorders. There is also new evidence pointing to glutamate abnormalities playing a key role in the pathogenesis of this disorder. Many other findings are similarly described and discussed. I found the chapter Neurocognitive Angle: The Search for Endophenotypes elegant and instructive. The authors describe a hierarchical model of disease that may ultimately lead us to the discovery of specific genetic contributions to this disorder (a similar model is being successfully used in schizophrenia research.) The authors argue that the identification of endophenotypes (heritable predisposing risk factors) may be a necessary intermediate step in the complex journey of determining the heritability of any polygenetic disorder such as OCD. This chapter focuses on several putative cognitive endophenotypes that seem to be significant in OCD patients: cognitive inflexibility, impaired response inhibition, and impaired decision-making capacity. The study of these endophenotypes, using neuroimaging techniques, led to the identification of specific structural and functional changes in the brain of OCD patients. This emergent evidence for both cognitive and brain structure endophenotypic differences in OCD will, according to the authors, significantly assist us in the search for underlying genetic contributions. In conclusion, this entire volume is a trove of useful information for clinicians who are looking for up-to-date evidence-based therapeutic approaches for their OCD patients. Special kudos to Joseph Zohar, the editor of this book, for a wonderful job of putting together such a fabulous team and producing this excellent volume. Radu V. Saveanu, MD Professor and Vice Chair for Educational Affairs Department of Psychiatry and Behavioral Sciences Leonard M. Miller School of Medicine University of Miami, Florida DISCLOSURES The author declares no conflict of interest.

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