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OCD floats free of anxiety
217
Lectures Monday, 19 October 1992
OCD floats free of anxiety
Montgomery, S.A. St. Mary's Hospital, London, UK Key words: Obsessive compulsive disorder; Depression; Separate classification
The diagnostic status of obsessive compulsive disorder (OCD) has been confused by its misleading categorisation under the anxiety disorders in DSM III and DSM IIIR. Anxiety symptoms undoubtedly feature prominently in OCD a s indeed they do in schizophrenia and many other disorders. Diagnostic categorisation based on anxiety symptoms alone is insufficient and needs validation. Historically the European approach has been to perceive a separation between OCD and anxiety disorders, an approach which the American diagnostic system has tended to override. Diagnostic categorisations of psychiatric illness can be validated by such criteria as observed differences in psychopathology, sex distribution; course of illness, response to treatment and stability of diagnosis. There is little evidence to support the inclusion of OCD among the anxiety disorders and much to support the perception of OCD as a separate nosological entity. OCD differs from anxiety disorders in the sex distribution of the illness which is approximately equal in OCD whereas in anxiety and depression disorders there is a preponderance of women. OCD is also a more stable diagnosis over time than the anxiety disorders which tends to develop into other illnesses, in particular depression. The best evidence for the diagnostic separation of OCD has come from treatment studies which have pointed to an underlying serotonergic mechanism in the disorder. Response to treatment is seen only with potent serotonergic drugs such as clomipramine, fluvoxamine, sertraline, and fluoxetine, but not with other antidepressants which lack direct potent effects on serotonin reuptake (Fineberg et al 1992). If the depressive symptoms in OCD represented depressive illness response to treatment with a range of antidepressants would be expected. This is not the case. The depressive symptoms also have a selective response to serotonin reuptake inhibitors and do not improve in response to treatment with non-serotonergic drugs (Goodman et al 1990). The depressive symptoms respond in parallel with the OCD symptoms and seem to be integral to the OCD rather than representing a secondary depressive illness. This would also explain the rapid increase in depression which accompanies the rapid resurgence of OCD symptoms when patients are switched double-blind from clomipramine to placebo in crossover or discontinuation studies. Psychic and somatic symptoms of anxiety are also frequent in OCD but their presence does not justify the categorisation of OCD as an anxiety disorder. The anxiety symptoms in OCD respond differently from the response seen in anxiety disorders, and respond to antiobsessional drugs at the same rate as the obsessional symptoms. Drugs conventionally thought to have anxiolytic effects have been investigated in OCD, albeit less thoroughly than the antidepressants, and significant effects have not been reported. Benzodiazepines, monoamine oxidase inhibitors, and neuroleptics have all been tested with discouraging results. The serotonin reuptake inhibitors have some differential advantage in treating the anxiety symptoms associated with depression (Montgomery 1991) but the therapeutic benefit in OCD cannot be attributed to this effect since if this were the mechanism of their antiobsessional effect one would expect conventional anxiolytics to be effective as well. Failure to differentiate between the depressive symptoms which frequently accompany OCD and symptoms of major depression has been a source of diagnostic confusion. The presence of depressive symptoms, whether or not they satisfy diagnostic criteria for major depression, does not affect the response of the OCD to antiobsessional drugs. Furthermore the
218 depressive symptoms themselves respond at the same rate and to the same drugs as the obsessional symptoms, the response is quite different from what would be expected if these symptoms were the manifestations of a comorbid but separate depression. The evidence is compelling that the depressive symptoms are integral to the OCD. This argues for the primacy of the OCD in an individual who is apparently suffering from comorbid OCD and depression rather than representing a separate disorder. In other words a hierarchical principe should be recognised that places OCD above depression and similarly above anxiety disorders. An individual may have depressive symptoms and anxiety symptoms but if OCD is present a diagnosis of a depressive or anxiety disorder cannot be substained; the diagnostic criteria for OCD should take precedence. Based on the data from the treatment studies it seems reasonable to conclude that OCD should be removed from the anxiety disorders where it has been uneasily housed in the DSMIII system. OCD should once again be recognised as a separate disorder in line with the older European tradition. In placing OCD within a classificatory system it should be recognised that OCD is the more important disorder and should clearly be placed above depression in a diagnostic hierarchy. The presence of associated neurological disorder and dysfunction suggests that OCD or part of OCD might be placed in a diagnostic hierarchy in or near the organic brain disorders. A more precise positioning in relation to the organic disorders depends very largely on further studies, currently in progress, which are aimed at clarifying the neurological deficits and their influence on long term outcome in treatment studies. References Fineberg, N.A., Bullock, T., Montgomery D.B. and Montgomery S.A., 1992, Serotonin reuptake inhibitors are the treatment of choice in OCD. Int. Clin. Psychopharmacol. 7. Goodman, W.K., Price, L.H., Delgado, P.L., Palumbo, J., Krystal, J.H., Nagy, L.M., Rasmussen, S.A., Heninger, G.R. and Chamey, D.S., 1990, Specificity of serotonin reuptake inhibitors in the treatment of obsessive compulsive disorder: comparison of fluvoxamine and desipramine. Archives of General Psychiatry 47, 577-585. Montgomery, S.A., 1991, Clinical significance of 5-HT uptake inhibitors. Human Psychopharmacology 6, $3-$7.
Abstract not received.
Lectures Monday, 19 October 1992
OCD floats free of anxiety
Montgomery, S.A. St. Mary's Hospital, London, UK Key words: Obsessive compulsive disorder; Depression; Separate classification
The diagnostic status of obsessive compulsive disorder (OCD) has been confused by its misleading categorisation under the anxiety disorders in DSM III and DSM IIIR. Anxiety symptoms undoubtedly feature prominently in OCD a s indeed they do in schizophrenia and many other disorders. Diagnostic categorisation based on anxiety symptoms alone is insufficient and needs validation. Historically the European approach has been to perceive a separation between OCD and anxiety disorders, an approach which the American diagnostic system has tended to override. Diagnostic categorisations of psychiatric illness can be validated by such criteria as observed differences in psychopathology, sex distribution; course of illness, response to treatment and stability of diagnosis. There is little evidence to support the inclusion of OCD among the anxiety disorders and much to support the perception of OCD as a separate nosological entity. OCD differs from anxiety disorders in the sex distribution of the illness which is approximately equal in OCD whereas in anxiety and depression disorders there is a preponderance of women. OCD is also a more stable diagnosis over time than the anxiety disorders which tends to develop into other illnesses, in particular depression. The best evidence for the diagnostic separation of OCD has come from treatment studies which have pointed to an underlying serotonergic mechanism in the disorder. Response to treatment is seen only with potent serotonergic drugs such as clomipramine, fluvoxamine, sertraline, and fluoxetine, but not with other antidepressants which lack direct potent effects on serotonin reuptake (Fineberg et al 1992). If the depressive symptoms in OCD represented depressive illness response to treatment with a range of antidepressants would be expected. This is not the case. The depressive symptoms also have a selective response to serotonin reuptake inhibitors and do not improve in response to treatment with non-serotonergic drugs (Goodman et al 1990). The depressive symptoms respond in parallel with the OCD symptoms and seem to be integral to the OCD rather than representing a secondary depressive illness. This would also explain the rapid increase in depression which accompanies the rapid resurgence of OCD symptoms when patients are switched double-blind from clomipramine to placebo in crossover or discontinuation studies. Psychic and somatic symptoms of anxiety are also frequent in OCD but their presence does not justify the categorisation of OCD as an anxiety disorder. The anxiety symptoms in OCD respond differently from the response seen in anxiety disorders, and respond to antiobsessional drugs at the same rate as the obsessional symptoms. Drugs conventionally thought to have anxiolytic effects have been investigated in OCD, albeit less thoroughly than the antidepressants, and significant effects have not been reported. Benzodiazepines, monoamine oxidase inhibitors, and neuroleptics have all been tested with discouraging results. The serotonin reuptake inhibitors have some differential advantage in treating the anxiety symptoms associated with depression (Montgomery 1991) but the therapeutic benefit in OCD cannot be attributed to this effect since if this were the mechanism of their antiobsessional effect one would expect conventional anxiolytics to be effective as well. Failure to differentiate between the depressive symptoms which frequently accompany OCD and symptoms of major depression has been a source of diagnostic confusion. The presence of depressive symptoms, whether or not they satisfy diagnostic criteria for major depression, does not affect the response of the OCD to antiobsessional drugs. Furthermore the
218 depressive symptoms themselves respond at the same rate and to the same drugs as the obsessional symptoms, the response is quite different from what would be expected if these symptoms were the manifestations of a comorbid but separate depression. The evidence is compelling that the depressive symptoms are integral to the OCD. This argues for the primacy of the OCD in an individual who is apparently suffering from comorbid OCD and depression rather than representing a separate disorder. In other words a hierarchical principe should be recognised that places OCD above depression and similarly above anxiety disorders. An individual may have depressive symptoms and anxiety symptoms but if OCD is present a diagnosis of a depressive or anxiety disorder cannot be substained; the diagnostic criteria for OCD should take precedence. Based on the data from the treatment studies it seems reasonable to conclude that OCD should be removed from the anxiety disorders where it has been uneasily housed in the DSMIII system. OCD should once again be recognised as a separate disorder in line with the older European tradition. In placing OCD within a classificatory system it should be recognised that OCD is the more important disorder and should clearly be placed above depression in a diagnostic hierarchy. The presence of associated neurological disorder and dysfunction suggests that OCD or part of OCD might be placed in a diagnostic hierarchy in or near the organic brain disorders. A more precise positioning in relation to the organic disorders depends very largely on further studies, currently in progress, which are aimed at clarifying the neurological deficits and their influence on long term outcome in treatment studies. References Fineberg, N.A., Bullock, T., Montgomery D.B. and Montgomery S.A., 1992, Serotonin reuptake inhibitors are the treatment of choice in OCD. Int. Clin. Psychopharmacol. 7. Goodman, W.K., Price, L.H., Delgado, P.L., Palumbo, J., Krystal, J.H., Nagy, L.M., Rasmussen, S.A., Heninger, G.R. and Chamey, D.S., 1990, Specificity of serotonin reuptake inhibitors in the treatment of obsessive compulsive disorder: comparison of fluvoxamine and desipramine. Archives of General Psychiatry 47, 577-585. Montgomery, S.A., 1991, Clinical significance of 5-HT uptake inhibitors. Human Psychopharmacology 6, $3-$7.
Abstract not received.