Current issues in the treatment of OC-spectrum conditions

N-Acetylcysteine in the Treatment of Pediatric Tourette Syndrome: Randomized, Double-Blind, Placebo-Controlled Add-On Trial

BACKGROUND

Current pharmacological treatments for Tourette Syndrome (TS), such as antipsychotic agents and α-2 agonists, are moderately effective in the treatment of tics, but have substantial side effects that limit their use. N-acetylcysteine (NAC) modulates glutamatergic systems, and has been used safely as an antioxidant agent with minimal side effects for decades. NAC has been increasingly studied for the treatment of other obsessive-compulsive spectrum disorders. We aim to examine the efficacy of NAC for the treatment of pediatric TS in a double-blind, placebo-controlled, add-on study.

METHODS

Thirty-one children and adolescents 8-17 years of age with TS were randomly assigned to receive NAC or matching placebo for 12 weeks. Our primary outcome was change in severity of tics as measured by the Yale Global Tic Severity Scale (YGTSS), Total tic score. Secondary measures assessed comorbid obsessive-compulsive disorder (OCD), depression, anxiety, and attention-deficit/hyperactivity disorder (ADHD). Linear mixed models in SAS were used to examine differences between NAC and placebo.

RESULTS

Of 31 randomized subjects, 14 were assigned to placebo (two females; 11.5 + 2.8 years) and 17 to active NAC (five females; 12.4 + 1.4 years) treatment. No significant difference between NAC and placebo was found in reducing tic severity or any secondary outcomes.

CONCLUSIONS

We found no evidence for efficacy of NAC in treating tic symptoms. Our findings stand in contrast to studies suggesting benefits of NAC in the treatment of other obsessive-compulsive spectrum disorders in adults, including OCD and trichotillomania, but are similar to a recent placebo-controlled trial of pediatric trichotillomania that found no benefit of NAC.

Shame in the obsessive compulsive related disorders: a conceptual review

BACKGROUND

Theoretical and anecdotal support for the role of shame in obsessive compulsive related disorders (OCRDs) is prominent. Developing our understanding of shame׳s role in OCRDs is important to building knowledge about this new diagnostic category. This review aims to consolidate our understanding of shame in each OCRD, through summarizing existing clinical, conceptual, and empirical work.

METHODS

We provide an overview of shame, its measurement considerations, and a full review of 110 articles addressing shame in OCRDs.

RESULTS

General shame and shame about having a mental illness are the broadest types of shame relevant to OCRDs; symptom-based shame and body shame may be more specific to OCRDs. In OCD, violent, sexual, or blasphemous obsessions may trigger symptom-based shame. In trichotillomania (TTM) and skin picking (SP), symptom-based shame may be related to pulling, picking, and post-pulling/picking behaviors. In hoarding disorder, symptom-based shame may accompany beliefs about being defective due to living with clutter. Body shame appears inherent to body dysmorphic disorder, while in TTM and SP it may arise as a secondary response to damage resulting from body focused repetitive behaviors.

LIMITATIONS

Much of the current knowledge on shame in OCRDs comes from anecdotal, case, and conceptual work. Empirical studies do not always assess specific types of shame, instead assessing shame as a general construct.

CONCLUSIONS

Shame is closely related to OCRDs. Clinical and research recommendations drawing from the literature are provided.