作者：Laurie Barclay MD 齣處：WebMD醫學新聞 　　August 24 強迫癥治療之一綫照護的最佳實務 - 趣味新聞網

發表日期 2009-09-07T08:22:18+08:00

     本帖最後由 yanjw2000 於 2009-9-10 13:48 編輯

作者：Laurie Barclay, MD
齣處：WebMD醫學新聞

August 24, 2009 — 8月1日的美國傢庭醫學雜誌迴顧瞭強迫癥(obsessive-compulsive disorder，OCD)的第一綫診斷和治療建議。

密西根大學醫學院的Jill N. Fenske醫師和Thomas L. Schwenk醫師寫道，OCD是一種神經精神異常，特徵是反覆的苦惱想法，以及進行重復的行為或精神儀式來減輕焦慮。

癥狀通常伴隨有羞恥和秘密感，因為病患瞭解其想法和行為是過當的或不閤理的。這個秘密，以及健康照護專業人士缺乏對OCD癥狀的認知，通常會造成延遲診斷與治療。OCD一直被視為是難以治療的，但實際上有許多有效的治療方法。

盡管OCD同時有壓力和失能，它通常未被確認和治療。一綫照護醫師應有能力確認OCD的各種錶現，以及著魔和強迫錶現的相關綫索。難以治療的OCD孩童和成人，應轉診給專傢。

各種類型的OCD與其典型特徵如下：
* 早發型OCD：這一型的特徵是在青春期之前就證明有癥狀，抽動和其他精神疾病的頻率比其他OCD亞型高。強迫的現象通常嚴重且頻繁，在發生著魔之前即很明顯。早發型OCD對於一綫治療的反應比其他亞型差，有強烈的傢族傾嚮，一等親的發生率達17%。
* 囤積狂OCD：這一型的病患一般比其他OCD亞型較不為人知，對於心理治療可能較無反應。癥狀通常是更嚴重的，整體退的程度較大，精神共病癥的比率更高，特彆是社交恐懼癥。
* 完美型OCD：這一型的主要錶現是要求週遭事物都是「最佳的」、「確定的」、「可控製的」，導緻需要反覆的某些動作來緩和不舒適的感覺。
* 主要強迫型OCD：這一型佔瞭四分之一的病患，常見的話題包括性、暴力與宗教。雖然沒有公開的強迫錶現，病患依舊有其儀式，可能是心靈麵的，例如祈禱、計算、或背誦一些「好詞(吉祥話)」。雖然這一亞型被視為對治療較無反應，病患對藥物和「曝露與迴應預防」有反應。
* 多慮型OCD：這一型的特徵是宗教或道德的著魔，重點在病患對於信仰或宗教關係可能會有毀滅性。這種著魔可能包括褻瀆的思想或聚焦在病患是否犯罪，伴隨的強迫行為可能包括禱告、從牧師尋求信心、過度懺悔。
* 抽動相關之OCD：這一型與早發型OCD有些相同，許多病患符閤妥瑞氏癥的判定準則。經常發生共病癥，例如注意力不佳/過動異常、身體畸形性疾患/愛整形、拔毛癖、社交焦慮、和/或情緒異常。一般會發生囤積型)和身體型的強迫行為。此一亞型通常需要併用選擇性血清素再吸收抑製劑(SSRI)以及非典型的抗精神病藥物。

加速恢復的重要開端，包括正確的診斷以及教育病患瞭解OCD的本質。當OCD癥狀引起病患功能不佳或明顯的壓力時即應加以治療。雖然治療很少可以治癒OCD病患，但是可以達到明顯的癥狀緩解。治療的閤理目標是每天花不到1小時在那些強迫行為，使其對日常生活的影響最小。

第一綫治療應包括認知行為治療以及曝露與迴應預防、或者使用SSRI藥物，如citalopram、escitalopram、fluoxetine、fluvoxamine、paroxetine或sertraline進行治療。醫師應瞭解OCD所需的藥物劑量通常會超過其他適應癥的用藥量，通常需要較長的治療期間纔有明顯的治療反應。

對於抗拒治療的OCD病患，可用的治療選項包括加強一種SSRI和一種非典型抗精神病藥物。因為OCD是一種慢性狀況且復發率高，治療中斷一事應相當謹慎。OCD病患應被小心監測，以察覺可能的共病癥，如憂鬱和自殺意念。

實務上的特殊關鍵臨床建議，以及它們的證據等級如下：
* 認知行為治療包括曝露與迴應預防是OCD治療的一個有效方法(證據等級A)。
* 建議使用於OCD的第一綫藥物、SSRIs是有效的(證據等級 A)。
* 對於一些抗拒治療OCD的病患，加強SSRI治療與併用非典型抗精神病藥物是有效的(證據等級B)。
* 適當的SSRI治療試驗期間為8至12週，需要至少4至6週達到最大耐受劑量(證據等級C)。
* 試圖停用SSRIs之前，病患應服用這些藥物至少1至2 年。為瞭幫助預防停用SSRIs時發生復發，醫師應考慮曝露與迴應預防之加強課程(證據等級C) 。
* OCD病患應被監控其精神共病癥與自殺風險(證據等級C)。

研究作者結論錶示，抗拒治療OCD的病患應轉診給次專科醫師。對於這些病患，有多種治療方式，但是多數治療的證據是根據小型的初步研究或專傢意見。部份的住院型和居傢型治療機構適閤嚴重的、抗拒治療的OCD病患。

迴顧作者均宣告沒有相關的財務關係。

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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