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David Baxter

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New report to drive OCD diagnosis and treatment revolution
May 30, 2007

Leading international experts in obsessive compulsive disorder (OCD) have published a new consensus report aimed at providing analysis and guidance to drive improved diagnosis and management of OCD worldwide. Presented at The European Congress of Psychiatry, Madrid, 17-21 March 2007 and recently published in CNS Spectrums, the report has made a number of important recommendations including the separation of OCD from anxiety disorders to create its own category.

The Cape Town Consensus Group was brought together by the International College of Obsessive Compulsive Spectrum Disorders and funded by an unrestricted educational grant from Danish pharmaceutical company H. Lundbeck A/S in order to analyse the clinical and scientific evidence that exists in OCD.

"While understanding about OCD has improved greatly in the last 25 years, it still remains significantly under-diagnosed and consequently, patients aren't benefiting from the major advances in treatment," says Professor Joseph Zohar, a member of the consensus group and President of the International College of Obsessive Compulsive Spectrum Disorders (ICOCS). "It became increasingly clear that it was necessary to review the current approach to OCD, since substantial clinical and biological evidence distinguishes it from anxiety disorders. Recognition of this could lead to improvements in the diagnosis and management of this debilitating condition."

OCD affects between 2-3% of the general population and takes a great toll on sufferers and their friends and families, even if they only experience symptoms for a short time each day. Listed amongst the top 10 most debilitating illnesses by the World Health Organization (WHO) in terms of loss of income and decreased quality of life, OCD is associated with significant functional disability and economic costs. As well, up to two-thirds of individuals with OCD also suffer from depression at some point during their illness.

Current classification systems such as the Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV) and the International Classification of Diseases (ICD) differ in the classification of OCD and given the current development of the 5th edition of the DSM, the group felt it was important to weigh up the evidence to provide definitive guidance on the most appropriate classification and harmonise current guidelines.

The group's consensus is based on a review of the epidemiology, neurobiology, symptomatology and etiology of OCD. This analysis highlighted a number of areas that separate OCD from anxiety disorders including:

  • Its potential onset during puberty whereas other anxiety disorders have a later age of onset
  • Its equal prevalence amongst men and women as opposed to depressive and anxiety disorders which are more common in women
  • The difference in brain circuitry that mediates OCD compared to that involved in fear, stress-related or mood disorders
  • Its uniquely specific response to serotonin reuptake inhibitors, while noradrenergic medications (effective in anxiety and mood) are largely ineffective
  • The increasing evidence for treatment augmentation with second-generation antipsychotics, suggesting an important role of dopamine in OCD (which is not seen in other anxiety disorders)
  • Its lack of treatment response to benzodiazepines which can be affective in anxiety disorders
There are two treatments that have been proven to be effective against OCD. They include cognitive behavior therapy (CBT) and medication, primarily selective serotonin reuptake inhibitors (SSRIs). SSRIs have proven to be beneficial as it appears that potent effects on brain serotonin are necessary to produce improvement in OCD. The consensus group also highlights that growing evidence of the role of dopamine in OCD, pointing to the potential for the use of second generation antipsychotics within the treatment pathway.

Two potential methods were put forward by the group to categorise OCD, one placing OCD within a broad spectrum of affective spectrum disorders and another presenting OCD as a group of disorders lying midway between affective disorders and addiction disorders. Both recommendations recognize that there are actually a range of OCD subtypes which are currently classified within the umbrella of 'OCD'. These subtypes can be classified based on clinical symptoms (i.e. OCD combined with tics or hoarding), by treatment response and family studies.

Although reclassifying OCD as a distinct group of disorders may complicate the diagnostic process and fragment the concept of anxiety, the consensus group strongly recommends this approach as the proposed classification is a better fit with clinical evidence and may improve the management of OCD by moving towards treatment tailored to specific subtypes of OCD.

"Recognizing the complex and varied presentation of OCD will enable the tailoring of treatment according to the specific profile of the individual patient and therefore could contribute to better treatment outcomes," says Naomi Fineberg, Consultant Psychiatrist and Honorary Senior Lecturer, Imperial College London and the University of Hertfordshire. "OCD is a chronic condition requiring long-term treatment and if we can move towards management of OCD in this way we stand a much better chance of treatment success and relapse prevention to enable patients to better function in their everyday lives."

The Cape Town Consensus Group is a group of 14 leading experts with specific experience and long-term interested in OCD. The members of the group include: Joseph Zohar, MD, Israel; Eric Hollander, MD, USA; Dan J. Stein, MD, PhD, South Africa; Herman G.M. Westenberg, PhD, The Netherlands; David S. Baldwin, DM, FRCPsych, UK; Borwin Bandelow, MD, Germany; Donald W. Black, MD, USA; Pierre Blier, MD, PhD, Canada; Naomi A. Fineberg, MRCPsych, UK; Martine F. Flament, MD, PhD, Canada; Dan Geller, MD, USA; Sumant Khanna, MD, PhD, India; Juan J. Lopez-Ibor, MD, Spain; and Stefano Pallanti, MD, PhD, Italy.

Hollander E, Kim S, Khanna S, Pallanti S. Obsessive Compulsive Disorder and Obsessive Compulsive Spectrum Disorders: Diagnostic and Dimensional Issues. From Obsessive-Compulsive Spectrum to Obsessive-Compulsive Disorders. CNS Spectr. 12:2(Suppl 3):5-13 [Full text]

Eric Hollander E, Kim S, Zohar J. OCSDs in the Forthcoming DSM-V. CNS Spectr. 2007;12(5):320-323 [Full text]
 

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