Scielo RSS <![CDATA[Brazilian Journal of Psychiatry]]> vol. 23 num. lang. en <![CDATA[SciELO Logo]]> <![CDATA[Apresentação]]> <![CDATA[<B>Epidemiologia e aspectos transculturais do transtorno obsessivo-compulsivo</B>]]> Epidemiological and phenomenological data are convergent and emphasize the similarities of obsessive-compulsive features among different cultures and geographic regions (North and South America, Europe, Africa, Asia). In the studies reviewed, obsessions and compulsions show to be very similar in their variety and content, regardless sociocultural differences and historical backgrounds. The influence of the culture was observed only circumstantially , for example, when shaping religious and sexual contents. The phenomenological homogeneity of obsessive-compulsive disorder, as a transhistorical and transcultural syndrome, suggests the existence of a setting of nuclear symptoms relatively independent of geographic, ethnic and cultural differences. The importance of biologic evolutionary and ethological studies is emphasized. <![CDATA[<B>Quadro clínico do transtorno obsessivo-compulsivo</B>]]> Obsessive-compulsive disorder is a very heterogeneous condition, not always easy to be identified. Obsessions are intrusive thoughts, impulses or images that cause anxiety or other emotional discomfort, whereas compulsions are repetitive behaviors or mental acts voluntarily performed to counterbalance or minimize the discomfort, or magically prevent any feared events. The most common symptoms are contamination, aggressive, somatic and sexual obsessions and washing, checking, repeating, counting and ordering compulsions. Patients usually have multiple symptoms simultaneously, which often change over time. Although the insight is typically preserved, it varies among patients and also fluctuates in the same patient in different ocasions. The main features are: exacerbated appraisal of risks, pathological doubts and incompleteness, as well as excessive sense of responsibility and guilt and thought/action fusion. As patients frequently feel ashamed of their symptoms, they can be reticent about them. Consequently, it usually takes time till they get adequate treatment. <![CDATA[<B>Curso clínico e prognóstico do transtorno obsessivo-compulsivo</B>]]> The long-term course and prognosis of obsessive-compulsive disorder (OCD) is insufficiently known. To identify predictors of OCD course, follow-up studies of patients with OCD were reviewed and their findings summarized. According to these studies, the following variables were correlated with poor outcome: early onset, severity of OCD symptoms, chronic course, poor social functioning at baseline, lifetime history of comorbid psychiatric and personality disorders, presence of parental Axis I psychiatric diagnosis, and delayed response to serotonin reuptake inhibitors in the beginning of the treatment. Due to the availability of new treatments, most patients with OCD can expect significant improvement, but not complete remission of the disorder. The reviewed follow-up studies support previous reports on the chronicity of OCD. <![CDATA[<B>Transtorno obsessivo-compulsivo</B>: <B>possíveis subtipos</B>]]> Several studies suggest that OCD is probably a heterogeneous disorder with several putative subtypes. Differences in treatment response, disease course, and clinical features are suggestive of the existence of subtypes with specific underlying pathophysiological substrates. Whether studying OCD from a phenomenological or genetic standpoint phenotypic characterization becomes crucial. This manuscript summarizes data that support the existence of a subgroup of OCD related to tics, a group with an early age onset; a possible subgroup related to rheumatic fever; and a group with poor insight. Validation of these putative subtypes may be possible with genetic family studies and will contribute to the development of more specific treatments. <![CDATA[<B>Comorbidade no transtorno obsessivo-compulsivo</B>]]> Epidemiological and clinical studies indicate that obsessive-compulsive disorder frequently occurs with comorbid disorders. Comorbidity with anxiety and mood disorders, substance abuse or dependence, somatoform, impulse control and tic disorders deserve special attention. In this paper a review of the concept, epidemiological findings, social and occupational functioning, and sequence of comorbid disorders in OCD is presented. <![CDATA[<B>Diagnóstico diferencial do transtorno obsessivo-compulsivo</B>]]> Obsessive-compulsive disorder (OCD) has clinical features that overlap in various degrees with many other mental disorders. As a result, the differential diagnosis sometimes can be difficult. This review briefly summarizes the phenomenologic similarities and differences between OCD and the following disorders: depression, phobias, hypochondriasis and body dysmorphic disorder, Tourette syndrome and tic disorder, obsessive-compulsive personality disorder, impulse control and eating disorders, generalized anxiety, panic and post-traumatic stress disorders, and delusional and schizophrenic disorders. The accurate diagnosis is essential for adequate treatment planning and management. <![CDATA[<B>Peculiaridades do transtorno obsessivo-compulsivo na infância e na adolescência</B>]]> Obsessive-compulsive disorder (OCD) has a bimodal age of onset and a range of treatment outcomes. Although most of the studies carried out so far have considered childhood and adult forms of OCD as the same disorder, more recent data have suggested that OCD children, as well as adults with an early onset of their obsessive-compulsive symptoms, may represent a distinct subgroup. This review briefly summarizes the most common clinical characteristics of the OCD presentation in children and adolescents, shows data reinforcing the idea that age of onset may be an important distinguishing feature and discusses the importance of a systematic assessment of age of onset for identifying more homogeneous subgroups of OCD patients. <![CDATA[<B>Aspectos neuropsicológicos do transtorno obsessivo-compulsivo</B>]]> Neuropsychology is contributing to elucidate the nature of brain dysfunction associated with obsessive-compulsive disorder (OCD). Neuropsychological studies of individuals with subclinical and clinical obsessive-compulsive symptoms are reviewed here. It was observed that OCD patients may display impaired "reality monitoring", memory for actions, non-verbal memory, visuo-spatial abilities, and executive functions. Some specific neuropsychological findings are associated with different clinical characteristics such as gender, duration of disease, severity of symptoms, and response to drug treatment. Comparative studies suggest that the neuropsychological dysfunction associated with OCD is significantly different from that seen in major depressive disorder or schizophrenia. However, many similarities were observed between patients with OCD and patients with social phobia, body dysmorphic disorder, and trichotillomania. Furthermore, studies suggest that certain neurochemical abnormalities may underlie particular neuropsychological dysfunctions found in OCD. Despite many heterogeneous results, the reviewed data seems to support the pathophysiological theory centered in the dysfunction of the fronto-striatal circuits in OCD. <![CDATA[<B>Transtorno obsessivo-compulsivo</B>: <B>aspectos neuroimunológicos</B>]]> This article discusses issues related to the hypotheses regarding the existence of immune mechanisms underlying the pathophysiology of a subgroup of patients with obsessive-compulsive disorder and/or Tourette's syndrome. Though developed from the studies on Sydenham's chorea, other concepts about the immune system regulation hypotheses still need further investigation. The proposition of PANDAS, the pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection, combined with the results obtained with plasma exchange procedure, which showed a remarkable improvement of the symptoms in children with obsessive-compulsive disorder and/or Tourette's syndrome, have given additional support to this model. <![CDATA[<B>Aspectos neuroquímicos</B>: <B>o papel da serotonina no TOC</B>]]> The therapeutic action of selective serotonin (5-HT) reuptake inhibitors (SSRIs) in obsessive-compulsive disorder (OCD) points to the role of 5-HT in this condition. Functional neuroimaging studies showed hyperactivity of the nucleus caudatum in OCD patients, which disappears following treatment with either SSRIs or cognitive behavior therapy. Pharmacological results indicate hypersensitivity of the 5-HT1D receptor subtype in OCD, similarly reversed by chronic administration of SSRIs. Neurochemical data show that these receptors are selectively concentrated in the striatum, and are localized in 5-HT terminals, where they inhibit 5-HT release by the nerve impulse. Since 5-HT reduces the activity of post-synaptic neurons in the striatum, it has been suggested that the hypersensitivity of 5-HT1D receptors contribute to the genesis of OCD symptoms. <![CDATA[<B>Aspectos genéticos do transtorno obsessivo-compulsivo</B>]]> Since the first descriptions of obsessive-compulsive disorder (OCD), genetic factors have been implicated in the etiology of the illness. Twin studies show a high concordance rate for monozygotic twins. Family studies found a higher risk for OCD among relatives of OCD patients. Segregation analysis studies suggest the possible role of a major effect gene in the etiology of OCD. Association studies using molecular techniques have been conducted to try to find a specific gene or polymorphism involved in OCD. This review outlines the evidence gathered to date, including the recent findings in the molecular genetics analysis. <![CDATA[<B>Aspectos neurorradiológicos do transtorno obsessivo-compulsivo</B>: <B>o papel dos gânglios da base</B>]]> Contemporary neuroanatomical models for obsessive-compulsive disorder (OCD) propose that abnormalities of specific cortico-subcortical circuits mediate the disorder's symptoms. This paper focuses on the basal ganglia, believed to play a critical role in the functioning of those brain circuits. Clinical and experimental studies investigating the presence of abnormalities of basal ganglia structures in OCD are reviewed, with particular emphasis on the neuroimaging literature. Despite controversies in the area, a considerable amount of data has accumulated suggesting that abnormalities of the caudate and putamen nuclei can be associated with OCD. These abnormalities may be particularly relevant to specific subtypes of the disorder, such as early-onset OCD. With the continuing sophistication of neuroimaging technologies, future studies may be able to further clarify the role of each basal ganglia component in the pathophysiology of the various clinical features of OCD. <![CDATA[<B>Processos cognitivos e seu tratamento no transtorno obsessivo-compulsivo</B>]]> This article summarized the main characteristics of cognitive and rational emotive therapies and reviews the main cognitive processes (essential beliefs, rules and schemas) and models in the treatment of obsessive-compulsive disorder. The main studies on treatment efficacy are also discussed. <![CDATA[<B>Tratamento farmacológico do transtorno obsessivo-compulsivo</B>]]> The pharmacotherapy for obsessive-compulsive disorder (OCD) has started with clomipramine, a potent non-selective serotonin reuptake inhibitor. Newer drugs that selectively inhibit serotonin reuptake (SSRIs) such as fluvoxamine, fluoxetine, paroxetine, and sertraline are also effective and well-tolerated by OCD patients, even in high doses. Efficacy of venlafaxine and citalopram for OCD are under investigation. Randomized controlled trials of OCD pharmacotherapy, as well as positive results found in open trials and case reports are reviewed in this paper. Potent selective serotonin reuptake inhibitors are the pharmacotherapy of choice for OCD. If one SSRI is ineffective, others may be beneficial. OCD is frequently a chronic condition that requires long-term treatment. <![CDATA[<B>Transtorno obsessivo-compulsivo resistente</B>: <B>conceito e estratégias de tratamento</B>]]> Despite the fact that majority of OCD patients responds to conventional treatments, about 40% remain symptomatic after appropriate trials with serotonin uptake inhibitors (SRIs) or behavioral therapy. A patient is considered treatment-resistant after failing to respond to three pharmacological trials with SRIs as well as to behavior therapy. When all somatic strategies have been tried, including augmentation with other medications, and the patient remains symptomatic, he or she is considered treatment refractory. The concepts of resistance and refractoriness are briefly revised, and the current augmentation strategies, as well as non-pharmacological approaches such as neurosurgery and transcranial magnetic stimulation, are addressed in this paper. Finally, issues of predictive response factors, pharmacogenetics, and the pathophysiology of resistant cases are suggested as targets for further researches. <![CDATA[<B>Principais efeitos colaterais das drogas antiobsessivas e seu manejo</B>]]> Selective serotonin reuptake inhibitors (SSRIs), clomipramine, and behavior therapy are the first line treatments for obsessive-compulsive (OCD) symptoms. One of the main reasons for treatment non-compliance and early discontinuation of medications by patients or premature change in prescriptions by clinicians are their side effects. Nausea, headache, insomnia, restlessness, sexual dysfunction, and tremors are common with SSRIs; hypotension, dry mouth, constipation, urinary retention, blurred vision, weight gain, sedation and cardiocirculatory problems, with clomipramine. The strategies and guidelines for these drugs' side effects management are here reviewed, based mainly in case reports and clinical experience. The clinician should be aware of the importance of addressing this issue, educating patients about the most frequent adverse reactions, and how to deal with them in order to prevent unwanted medication discontinuation, and enhance compliance with the treatment. <![CDATA[<B>Terapia comportamental do transtorno obsessivo-compulsivo</B>]]> Behavior therapy, an experimentally-based approach, has been able to successfully treat obsessive-compulsive disorder by means of graded exposure to feared stimuli and response prevention procedures. This article will present the main treatment features, emphasizing behavioral assessment, motivational interviewing techniques, session planning guidelines, and issues on rehabilitation. <![CDATA[<B>Relação família-paciente no transtorno obsessivo-compulsivo</B>]]> This article is based on the notion that obsessive-compulsive behaviors are perpetuated by negative reinforcement. The assessment of such contingencies inevitably leads to the examination of family's interactions, crucial for establishing the severity and prognosis of the disorder . The notion of family accommodation is analyzed as reinforcement contingencies that act upon family members and patients. Family members, often desperate and unaware of behavior practices provide inconsistent and intermittent consequences for the patient's behaviors. As a result, abnormal behaviors worsen, get chronic, and there's a general deterioration of the quality of life. It is suggested that, as a part of the routine, the clinician should evaluate systematically and carefully the family's interactions in order to plan and assess effectively his/her therapeutic interventions.