Compulsive Digital Gaming: An Emerging Mental Health Disorder in Children

Excessive digital gaming is emerging as a mental health disorder because youngsters are losing control of their lives by wasting their time by indulging in online multiplayer games. The popularity of the games can be gauged by the fact that India's online gaming market of US $360 million is expected to grow to $ 1 billion by 2021. Video gaming is an obsessive compulsive disorder. The players enjoy creating and building relationships with other online characters, which provides a virtual community feeling at the expense of one-to-one social interactions and real life bonding. In due course of time, the players are preoccupied or "hooked" to the games and display mood swings like irritability, restlessness, and aggressive behavior when they are denied the playing gadgets. Realizing the multifarious health hazards of digital gaming, WHO has recently classified it as a mental health disorder in the 11th revision of its International Classification of Diseases (ICD-11) so that it is accorded the state health benefits for its prevention and treatment. The technology is both a boon as well as a bane, the option is with us. It is important to avoid all obsessions or compulsions in life in order to follow the philosophy of "middle path".

Pedophilia-Themed Obsessive-Compulsive Disorder: Assessment, Differential Diagnosis, and Treatment with Exposure and Response Prevention

Fears of sexually harming children are fairly common among clients suffering from obsessive-compulsive disorder (OCD), yet these symptoms are largely unrecognized and frequently misdiagnosed by mental health professionals. Specifically, clients with pedophilia-themed OCD (P-OCD) experience excessive worries and distressing intrusive thoughts about being sexually attracted to, and sexually violating, children. Expressing these concerns may provoke misjudgments from uninformed mental health professionals that a client is presenting instead with pedophilic disorder. This misdiagnosis and subsequent improper interventions can then contribute to increased fear, anxiety, and in many cases, depression, in affected clients. Therefore, it is imperative that mental health professionals first possess a good understanding of this common manifestation of OCD. As such, in this article, we described obsessions and compulsions typical of P-OCD, in order to inform the reader of the distinctive differences between P-OCD and pedophilic disorder. Information about how to assess for P-OCD symptoms is then provided, followed by suggestions on how to tailor aspects of exposure and response prevention to treat this specific form of OCD.

Long-term efficacy of Internet-based cognitive behavior therapy for obsessive-compulsive disorder with or without booster: a randomized controlled trial

BACKGROUND

As relapse after completed cognitive behavior therapy (CBT) for obsessive-compulsive disorder (OCD) is common, many treatment protocols include booster programs to improve the long-term effects. However, the effects of booster programs are not well studied. In this study, we investigated the long-term efficacy of Internet-based CBT (ICBT) with therapist support for OCD with or without an Internet-based booster program.

METHOD

A total of 101 participants were included in the long-term follow-up analysis of ICBT. Of these, 93 were randomized to a booster program or no booster program. Outcome assessments were collected at 4, 7, 12 and 24 months after receiving ICBT.

RESULTS

The entire sample had sustained long-term effects from pre-treatment to all follow-up assessments, with large within-group effect sizes (Cohen's d = 1.58-2.09). The booster group had a significant mean reduction in OCD symptoms compared to the control condition from booster baseline (4 months) to 7 months, but not at 12 or 24 months. Participants in the booster group improved significantly in terms of general functioning at 7, 12 and 24 months, and had fewer relapses. Kaplan-Meier analysis also indicated a significantly slower relapse rate in the booster group.

CONCLUSIONS

The results suggest that ICBT has sustained long-term effects and that adding an Internet-based booster program can further improve long-term outcome and prevent relapse for some OCD patients.

Effectiveness of paroxetine in the treatment of obsessive–compulsive disorders

Clomipramine ushered in a new age of pharmacotherapy for obsessive-compulsive disorders, and it also facilitated our understanding of the biological aspects of obsessive-compulsive disorder, focusing on the serotonergic systems. The introduction of selective serotonin reuptake inhibitors has led to great progress in the pharmacological study of obsessive-compulsive disorder based on the serotonin hypothesis. Currently, selective serotonin reuptake inhibitors are positioned as a first-line drug of obsessive-compulsive disorder pharmacotherapy in the various guidelines and algorithms. Among six different selective serotonin reuptake inhibitors (paroxetine, sertraline, fluoxetine, fluvoxamine, citalopram, escitalopram) that are available worldwide, paroxetine has the broadest treatment spectrum and promises great benefits not only for obsessive-compulsive disorder patients, but also for those with comorbid depression and/or various kinds of anxiety disorders. This paper presents several clinical trials of paroxetine carried out, and discusses and reviews the therapeutic strategies for obsessive-compulsive disorder.

Exercise and physical activity in mental disorders: clinical and experimental evidence

Several epidemiological studies have shown that exercise (EX) and physical activity (PA) can prevent or delay the onset of different mental disorders, and have therapeutic benefits when used as sole or adjunct treatment in mental disorders. This review summarizes studies that used EX interventions in patients with anxiety, affective, eating, and substance use disorders, as well as schizophrenia and dementia/mild cognitive impairment. Despite several decades of clinical evidence with EX interventions, controlled studies are sparse in most disorder groups. Preliminary evidence suggests that PA/EX can induce improvements in physical, subjective and disorder-specific clinical outcomes. Potential mechanisms of action are discussed, as well as implications for psychiatric research and practice.

Combination of aripiprazole and ethanol attenuates marble-burying behavior in mice

Obsessive-Compulsive Disorder (OCD) is characterized by absurd, recurrent thoughts (obsessions) followed by certain stereotyped actions (compulsions). 5-Hydroxytryptamine (5-HT) abnormalities may be involved in OCD, and further, cause changes in serotonergic transmission that may have direct or indirect effects on the neuronal firing of other neuromodulators affecting thoughts, feelings and behaviors. Serotonin-related genes that are found in OCD include those coding for the 5-HT transporter (5-HTT) and receptors (5-HT(2A), 5-HT(2B), 5-HT(2C) and 5-HT(1B)) as well the 5-HT enzyme tryptophan hydroxylase. OCD can impair all areas of brain functioning and produce devastating effects on patients and their families. Marble-burying behavior of mice has been employed to study anxiety disorders, including the OCD. The aim of this study was to test the efficacy of aripiprazole and alcohol per se and in combination on marble-burying behavior of mice. A total of 114 male Swiss mice divided in 19 groups were studied. Aripiprazole (0.1 mg/kg, i.p.) per se as well as ethanol (0.1% w/v) per se did not show any anti-compulsive activity. But the combination comprising of ineffective doses of aripiprazole (0.1 mg/kg, i.p.) and ethanol (0.1% w/v) showed significant anti-compulsive activity as reflected by inhibition of marble-burying behavior.

Resisting the ritual

People with obsessive compulsive disorder are plagued with repetitive, intrusive thoughts. But with increasing access to cognitive behavioural therapy, treatment is more available.

[Classification of OCD in terms of response to behavior therapy, manner of onset, and course of symptoms]

Obsessive-compulsive disorder (OCD) is a heterogeneous disease in terms of manner of onset, dimension of symptoms, and responses to psychological or pharmacological treatments. This paper groups cases of OCD into "effective" and "ineffective" types, based on their responses to exposure and response prevention (ERP). In the next phase, cases in the "effective" category were further broken down into Type A, characterized as readily responding to ERP, and Type B, characterized as not readily responding to ERP. Factors associated with Type B include: 1) below-average intelligence, 2) co-morbidity of other mental disorders, 3) insufficient recognition of irrationality of OCD symptoms, 4) significant difficulties in daily life, 5) insufficient motivation to follow through with ERP, and 6) other personal problems. This paper discusses possible strategies for addressing these factors, and thereby increasing the potential effectiveness of ERP. Next, this paper describes the characteristics and treatment of obsessional slowness as a typical type for which ERP is ineffective. Finally, this paper examines the process of distinguishing between OCD and other mental disorders that do not respond to ERP in spite of showing OC symptoms.

[Obsessive-compulsive disorder]

Obsessive-compulsive disorder is a complex psychiatric disorder characterised by obsessions and/or compulsions. Obsessive-compulsive disorder has a relatively high prevalence and is a highly disabling disease. The disorder is associated with shame, which causes long delays in accessing treatment. Obsessive-compulsive disorder is caused by a complex interplay between genetic and environmental factors. Effective treatments exist in the form of either pharmacotherapy--clomipramine or selective serotonin reuptake inhibitors--or cognitive behaviour therapy.

Brief report: exposure and response prevention for obsessive compulsive disorder in a 12-year-old with autism

Obsessive Compulsive Disorder (OCD) involves exaggerated or excessive worry about threatening and non-threatening stimuli coupled with impairing rituals believed to reduce anxiety. Autism Spectrum Disorders (ASD) are characterized by impairment in social and communicative activities as well as restricted and repetitive behaviors. Approximately 2% of children with ASD are also diagnosed with OCD. Although there is extensive research demonstrating the effectiveness of behavioral interventions for pediatric OCD, little is known about how effective these treatments are for children who have a dual diagnosis of OCD and ASD. This report describes a 12-year-old male with Autism who was treated successfully with cognitive behavioral therapy with exposure and response prevention. This case study provides initial support that cognitive-behavioral therapy is effective in symptom reduction for children with comorbid autism and OCD.

Fast track randomized controlled trial to prevent externalizing psychiatric disorders: findings from grades 3 to 9

OBJECTIVE

This study tests the efficacy of the Fast Track Program in preventing antisocial behavior and psychiatric disorders among groups varying in initial risk.

METHOD

Schools within four sites (Durham, NC; Nashville, TN; Seattle, WA; and rural central Pennsylvania) were selected as high-risk institutions based on neighborhood crime and poverty levels. After screening 9,594 kindergarteners in these schools, 891 highest risk and moderate-risk children (69% male and 51% African American) were randomly assigned by matched sets of schools to intervention or control conditions. The 10-year intervention (begun in 1991 with three yearly cohorts) included parent behavior-management training, child social-cognitive skills training, reading tutoring, home visiting, mentoring, and a universal classroom curriculum. Outcomes included criterion counts and psychiatric diagnoses after grades 3, 6, and 9 for conduct disorder, oppositional defiant disorder, attention-deficit/hyperactivity disorder, any externalizing disorder, and self-reported antisocial behavior. Grade 9 outcomes were assessed between 2000 and 2003, depending upon cohort.

RESULTS

Significant interaction effects between intervention and initial risk level were found at each age but most strongly after grade 9. Assignment to intervention had a significant positive effect in lowering criterion count scores and diagnoses for conduct disorder, attention-deficit/hyperactivity disorder, and any externalizing disorder, and lowering antisocial behavior scores, but only among those at highest risk initially.

CONCLUSIONS

Prevention of serious antisocial behavior can be efficacious across sex, ethnicity, and urban/rural residence, but screening is essential.

Deep brain stimulation for treatment-refractory obsessive-compulsive disorder: the search for a valid target

Obsessive-compulsive disorder (OCD) is a common psychiatric disease that is marked by recurring, anxiety-provoking thoughts (obsessions) accompanied by repetitive and time-consuming behaviors (compulsions). Among the controversies in the OCD literature is the issue of the origin of the disease and whether brain changes observed with modern imaging techniques are the causes or results of OCD behaviors and thoughts. These issues remain unresolved; however, significant strides have been made in understanding the illness from both phenomenological and pathophysiological perspectives. The current staple of OCD management remains pharmacological in nature and often occurs in conjunction with cognitive behavioral therapy. Refractory cases, however, are occasionally referred for neurosurgical consultation, and several procedures have been examined. Success in the treatment of Parkinson's disease, the reversibility of the therapy, and a relatively safe side-effect profile have allowed deep brain stimulation (DBS) to be examined as an alternative treatment for some psychiatric conditions. Here we assess the possibility of applying DBS to the treatment of OCD. Morphological, functional metabolic, and volumetric data point to several brain regions that are important to the etiology and maintenance of OCD. Converging evidence from the genetics and neurocircuitry literature suggests that several subcortical structures play prominent roles in the disease. The functional modification of these structures could potentially provide symptom relief. Here, we review the ablative and DBS procedures for refractory OCD, and provide a research-driven hypothesis that highlights the ventromedial head of the caudate nucleus, and structures up- and downstream from it, as potential DBS targets for treatment-resistant disease. We hope that a research-driven approach, premised on converging evidence and previous experience, will lead to a safe and effective DBS procedure that will benefit patients who remain disabled despite presently available therapies.

Anxiety disorders and older women

Anxiety is a problem for millions of Americans. It poses special challenges for women as they grow into advanced age. This paper provides a general overview of anxiety disorders, including panic disorder, agoraphobia, specific phobia, social phobia, obsessive compulsive disorder, and generalized anxiety disorder. Etiology, assessment and treatment strategies are then addressed. Special focus is directed at biological and psychosocial issues as they relate to older women in the development, experience, treatment and prevention of anxiety disorders.

PANDAS: a new disease?

OBJECTIVE

To establish the diagnostic criteria for PANDAS and to analyze the existing evidence regarding its etiopathogenesis, treatment and prophylaxis.

SOURCES

Review of the scientific literature through a MEDLINE search carried out between 1989 and 2006.

SUMMARY OF THE FINDINGS

The diagnostic criteria for PANDAS were established nearly 10 years ago, but a lot of controversy still exists over the actual existence of this new pediatric disease. The name of this new disease, supposedly of poststreptococcal etiology, derives from an acronym that stands for pediatric autoimmune neuropsychiatric disease associated with streptococcal infection. Tics and obsessive-compulsive symptoms are the major clinical signs of the disease, which develop after streptococcal infections, probably through autoimmune mechanisms. Even though these neuropsychiatric symptoms are common in rheumatic chorea, whose etiology is also poststreptococcal, the classic choreiform movements and other symptoms of rheumatic fevers are absent in PANDAS. The use of antimicrobial and immunologic therapy has been investigated and considered feasible in some cases.

CONCLUSIONS

Further research is still necessary in order to answer the question posed in the title of this article. In the meantime, the identification of tic disorders and obsessive-compulsive disorders in children should include the possibility of PANDAS, seeking to provide evidence of previous streptococcal infection.

Escitalopram prevents relapse of obsessive-compulsive disorder

To examine the efficacy and tolerability of escitalopram in the prevention of relapse in patients with OCD, 468 patients with OCD were treated with open label escitalopram (10 mg or 20 mg) for 16 weeks, after which the 320 responders (Y-BOCS total score decrease > or =25%) were randomised to placebo or escitalopram (at the assigned dose) for 24 weeks double-blind treatment. The primary analysis (time to relapse) showed a significant advantage for escitalopram (p<0.001, log-rank test). The proportion of patients who relapsed was statistically significantly higher in the placebo group (52%) than in the escitalopram group (23%) (p<0.001, chi(2)-test). The risk of relapse was 2.74 times higher for placebo compared to escitalopram. Escitalopram was well tolerated and improvements in obsessive-compulsive symptoms reported during the open label period were sustained during the double-blind extension of treatment with active drug. These results demonstrate that escitalopram is effective for long-term treatment and relapse prevention in OCD.

Mechanisms of change in ERP treatment of compulsive hand washing: does primary threat make a difference?

The present study sought to examine patterns of habituation in exposure and response prevention (ERP) treatment of compulsive hand washing. Sub-clinical compulsive washers (n=27) with illness or non-illness primary threats were compared in order to detect potential differences in response to a single session of ERP. Changes in anxiety, disgust, and urge to wash were analyzed, and significant reductions in both anxiety and disgust were noted. Urge to wash significantly declined among washers primarily concerned with illness; among those concerned with non-illness threats, urge to wash did not significantly decline. Moreover, anxiety was found to decline when controlling for disgust and vice versa. Lastly, when both anxiety and disgust were entered into a model predicting changes in urge to wash, anxiety but not disgust predicted urge to wash for those with illness-related threats; for washers with non-illness threats, the findings were the reverse. Several clinical and theoretical implications are discussed.

Metacognitive therapy versus exposure and response prevention for pediatric obsessive-compulsive disorder. A case series with randomized allocation

BACKGROUND

Exposure with ritual prevention (ERP) is the psychotherapeutic treatment of choice for pediatric obsessive-compulsive disorder (OCD). In the present study, a new treatment rationale - metacognitive therapy (MCT) for children - was developed and evaluated.

METHODS

Ten children and adolescents with OCD were randomly assigned to either MCT or ERP therapy condition. Patients were assessed before and after treatment and at the 3-month and 2-year follow-up by means of symptom severity interviews. Depressive symptoms were also assessed. Manualized treatment involved up to 20 sessions on a weekly basis.

RESULTS

We found clinically and statistically significant improvements in symptom severity after treatment. At the 3-month and 2-year follow-up, the attained improvements during treatment were retained.

CONCLUSIONS

Despite some methodological limitations, results showed that MCT proved to be a promising psychotherapeutic alternative to the well-established ERP in the treatment of pediatric OCD. Further investigations into the efficacy of MCT are necessary to answer questions as to the working mechanisms underlying therapy for OCD.

A combined marble burying–locomotor activity test in mice: A practical screening test with sensitivity to different classes of anxiolytics and antidepressants

Over the last decades, the inhibition of spontaneous burying of glass marbles by mice has been used as an index of anxiolytic drug action in the so-called marble burying test. Indeed, acute administration of rapid-onset (e.g. diazepam) and slow-onset (e.g. fluoxetine) anxiolytics inhibit marble burying. However, non-anxiolytic compounds such as classical antipsychotics also reduce marble burying thus suggesting that the predictive validity of this procedure for anxiety may be limited. In the present study, after having selected a strain of mice (C57BL/6J) that showed spontaneous avoidance of glass marbles, we tried to improve the predictive validity of the marble burying test for anxiety by measuring locomotor activity during the marble burying test and--if needed--in control experiments by using a videotracking system. Twenty-four reference compounds were tested including anxiolytics, anxiogenics, antidepressants, antipsychotics and other classes. By comparing marble burying scores with locomotor measures, we found that, based on our criteria, most of the anxiolytics and antidepressants selectively inhibited marble burying in contrast to most of the other compounds (e.g. haloperidol, morphine). Two putative anxiolytics, i.e. the nociceptin orphanin FQ peptide receptor agonist Ro 64-6198 and the metabotropic glutamate 5 receptor antagonist 2-methyl-6-(phenylethynyl)pyridine, also showed a selective profile. We propose this modified procedure, requiring only a limited number of animals, as a valuable screening test for the detection of compounds having anxiolytic effects.

[Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). A report of two cases]

AIM

To critically review the past years of research on paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections in children and adolescents.

METHOD

Literature on PANDAS published from 1995 onward was systematically reviewed. The review focuses on definition and diagnostic consideration aetiological and therapeutical issues. To illustrate the clinical characteristic of PANDAS authors present two cases of children with a severe course of obsessive-compulsive disorder and Tourette's syndrome.

RESULTS

Post-streptococcal autoimmunity has been postulated as an aetiologic factor in the development of childhood-onset obsessive-compulsive disorder, tic disorders including Tourette's disorder. This hypothesis arose from a series of clinical observations including the documentation of obsessive-compulsive symptoms of children affected by Sydenham's chorea, a variant of rheumatic fever characterised by neurological dysfunction and also by concomitant investigations of childhood-onset OCD and Tourette's syndrome.

CONCLUSION

Results of these studies led to the identification of children whose clinical course is characterised by abrupt and dramatic symptom exacerbations which are temporally related to group A beta-hemolytic streptococcal infections. The identification of such a subgroup will allow for testing of the model of pathogenesis as well as development of novel treatment and prevention strategies. Future research are needed to explore the nature of PANDAS and their relationship with different psychiatric disorders in children and adolescents.

Changes in compulsion and anxiety symptoms with nicotine transdermal patches in non-smoking obsessive-compulsive disorder patients

OBJECTIVE

Some of the obsessive-compulsive disorder (OCD) symptoms can be elicited in rats by the administration of quinpirole (D2/D3 dopaminergic agonist). Nicotine administration blocked some aspect of checking behavior in that model. The main goal of this study was to determine if the clinical manifestations of OCD non smoking patients change with the administration of transdermal nicotine patches.

MATERIAL AND METHODS

Eleven patients were studied (6 female and 5 males), average age 29.7 +/- 5.5 years. All of them were OCD according to DSM-IV criteria. Clinical scorings were done with Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI). Nicotine (17.5 mg/day) or placebo transdermal patches were randomly administered for five continuous days.

RESULTS

Nicotine administration reduced the total Y-BOCS and the compulsive score of that scale, but did not reduce obsessions. Also anxiety was reduced as was shown by the BAI scores, when patients were on nicotine patches, no changes were observed in BDI.

CONCLUSIONS

The present results replicated the animal findings about reduction in compulsive behavior after nicotine administration. Also suggest that nicotine depending on the dysfunction of the different neurotransmitter systems may produce different behavior or cognitive effects, also that even nicotine showed some beneficial effect in OCD patients, the low rate of nicotine smoking in this type of patients, may show other mechanisms than may protect to smoke in some psychiatric patients.

Exposure and ritual prevention for obsessive-compulsive disorder: effects of intensive versus twice-weekly sessions

Exposure and ritual prevention (ERP) is the most effective treatment for obsessive-compulsive disorder (OCD), yet the intensive treatment schedule often described is not transportable to many settings. In the present study, the authors examined whether a twice-weekly (TW) ERP program reduced the effectiveness of intensive (IT) ERP. Forty OCD patients received 15 sessions of ERP: 20 received daily treatment over 3 weeks and 20 received twice weekly therapy over 8 weeks. Results indicated that both programs were effective. The effect of therapy schedule was moderate, with a trend toward more improvement in the intensive group at posttreatment. No differences were found at follow-up; some evidence of relapse was found with IT but not TW.

Physical self-regulation training for the management of temporomandibular disorders

AIMS

To evaluate the long-term effectiveness of a brief skills training program for the management of chronic facial muscle pain. This program of physical self-regulation (PSR) involved primarily training in breathing, postural relaxation, and proprioceptive re-education.

METHODS

Physical self-regulation training was presented by a dentist during two 50-minute sessions spaced at 3-week intervals and was compared to a standard dental care (SDC) program that included a flat-plane intraoral appliance and self-care instructions provided by a dentist. Participants (n = 44) were initially evaluated by a dentist experienced in the diagnosis and management of orofacial pain and were determined to have myofascial pain (Type 1a and 1b diagnoses per the Research Diagnostic Criteria) prior to random assignment to either the PSR or SDC conditions. Posttreatment evaluations 6 weeks and 26 weeks after treatment had begun were conducted by a dentist who was not aware of which treatment the participants received.

RESULTS

Initial results indicated that pain severity and life interference from pain were reduced in both groups (P < 0.001), while perception of control was increased (P < 0.001), as was incisal opening without pain (P < 0.05). At the 26-week follow-up, the PSR group reported less pain (P < 0.04) and greater incisal opening, both with (P < 0.04) and without (P < 0.01) pain, than the SDC group. There were also significant decreases (P < 0.05) in affective distress, somatization, obsessive-compulsive symptoms, tender point sensitivity, awareness of tooth contact, and sleep dysfunction for both groups over time.

CONCLUSION

The findings support the use of PSR for the short- and long-term management of muscle pain in the facial region. These results are discussed in terms of the potential mechanisms by which self-regulation treatment strategies are effective for the management of these pain disorders.

Thought action fusion: can it be corrected?

The goal of this study was to investigate whether or not a brief educational intervention delivered prior to engaging in an anxiety-provoking task (writing a sentence about hoping that a friend/relative was in a car accident) would be effective in offsetting anxiety in college students with a strong propensity to endorse statements of thought action fusion (TAF). As hypothesized, individuals receiving the educational intervention were less anxious than a placebo intervention control group at post task; they were also less likely to endorse statements of TAF after receiving the educational intervention. Also, those who chose to neutralize after writing the sentence (regardless of experimental group) were more likely to report feeling guiltier, more immoral and a greater sense of responsibility about writing the sentence prior to neutralizing than those who did not subsequently neutralize. These results are discussed in relation to the cognitive theory of obsessive-compulsive disorder and implications for prevention programs.

Group behavioral therapy of obsessive-compulsive disorder: seven vs. twelve-week outcomes

Previous research has demonstrated that individualized behavioral exposure and response prevention therapy is an effective treatment for Obsessive-Compulsive Disorder. In our prior preliminary report, 7-week group exposure and response prevention therapy was also found effective in reducing obsessions and compulsions. The present report describes a larger sample (N=113) of treatment seeking obsessive-compulsives who received group behavioral therapy. As before, group exposure and response prevention significantly improved ratings of obsessions, compulsions, and depression. These improvements were maintained at 3-month and long-term follow-up. A sub-sample of patients who received 12 weeks of treatment had outcomes at the end of the group and at follow-up that did not significantly differ from those who received 7 weeks of treatment. These results confirm the efficacy of a 7-week behavioral treatment program administered in a group format.

New developments in the treatment of obsessive-compulsive disorder

The treatment of obsessive-compulsive disorder (OCD) has changed dramatically in the last 10 years. Currently, the serotonin reuptake inhibitors (SRIs) and the serotonin selective reuptake inhibitors (SSRIs) are considered the "first choice" agents for pharmacologic treatment of OCD, although few head-to-head comparisons exist between any two specific agents. Strategies for nonresponders and partial responders to the SRI/SSRIs are reviewed. The only agents that have shown significant improvement as augmenting agents to an SRI/SSRI in systematic trials have been clonazepam and haloperidol. Predictors of response to pharmacotherapy have been limited, but several reports have found that an early age at onset of OCD has been associated with a poorer response to medications. Long-term maintenance medication may be necessary for some, although behavioral therapy may improve the need for extended pharmacotherapy. Cognitive behavioral therapy, specifically exposure with response prevention, still remains an effective and important component of treatment for many. One of the newest developments is the identification of a pediatric subtype of OCD characterized by prepubertal acute onset after group A beta-hemolytic streptococcal pharyngitis. Investigation trials with these children include immunomodulatory therapies and penicillin treatment and prophylaxis. If a unique subgroup of children with OCD can be identified, then novel treatments may prove effective and have a role in long-term prophylaxis.

Fluvoxamine in the treatment of obsessive-compulsive disorder and related conditions

The mainstay of the pharmacologic treatment of obsessive-compulsive disorder (OCD) is a 10- to 12-week trial of a potent serotonin reuptake inhibitor (SRI) at an adequate dose. Double-blind, placebo-controlled trials have established the anti-obsessive-compulsive (OC) efficacy of five different SRIs. One of the most thoroughly studied of these SRIs is fluvoxamine, the focus of this article. Fluvoxamine's pharmacologic and pharmacokinetic properties, its efficacy, and guidelines for its clinical use in OCD and related disorders are briefly reviewed. Potential drug-drug interactions are discussed and placed in clinical perspective. The management of common SRI-induced side effects is also addressed. Recent comparative studies suggest that fluvoxamine may be equivalent in efficacy to clomipramine, yet better tolerated. Fluvoxamine shows promise in the treatment of several so-called OC-spectrum disorders, but additional controlled trials are needed.

Combined Therapies in OCD

1. A supportive and therapeutic approach, including implementing "combined" therapies, has been important in achieving recovery of obsessive-compulsive disorder in a community setting. 2. Helping the patient maintain independence after professional community support has been discontinued was a primary objective of the initial treatment plan. 3. The combination of behavioral, cognitive, and pharmacological therapies has been successful in achieving ongoing maintenance of independence and desensitization to the anxiety and phobias within the patient's home environment and community and has prevented further hospitalizations.

The physiological threat of compulsive syndromes

Compulsive syndromes, especially obsessive-compulsive disorder, are much more common than previously believed. The behaviours that are a part of these syndromes can lead to physiologically threatening conditions whose medical consequences range from minor to fatal. It is crucial that not only mental health professionals, but all health professionals better understand the nature and consequences of compulsive disorders and their importance to general health.

Current issues in the pharmacologic management of obsessive compulsive disorder

In spite of significant advances in the development of behavioral and pharmacologic strategies for the treatment of obsessive compulsive disorder, little is known about the comparative efficacy and safety of those treatments. In addition, questions about the dose and duration in maintenance treatment remain unknown. This article reviews current issues in the pharmacologic management of patients with obsessive compulsive disorder.

[Early diagnosis of neurotic disorders using an automated system]

The authors distinguish a complex of informative criteria of early diagnosis of neurotic disorders employed in the screening algorithm. The efficacy of the algorithm was evaluated in 285 patients with neurosis and the diagnosis proved correct in 93-95.2% of cases. The automatized system of screening of neurotic disorders ensures improvements in exact diagnosis, saves time and expenditures.

A case of self-inflicted leucotomy

A suicide attempt with a gun resulted in left frontal lobe damage in a 19-year-old obsessive man. While intelligence did not suffer and no frontal lobe syndrome emerged, the patient's obsessive rituals were significantly reduced.

[Preventive psychotherapy for prevention of stealing]

In order to prevent patients from stealing, two categories of delinquents are to be taken into consideration: Those who suffer from somatic diseases and psychoses, e.g. prophyria, hypoglycemia, hebephrenia, schizophrenia, depression, mania or epileptic semiconscious states must be treated according to the basic sickness and by means of a supporting psychotherapy. In court exculpation should be recommended. Other people who fell the urge to steal are psychosocially disturbed. This may begin with lying, bad results at school and during professional or university training, and sometimes with running away from home. As soon as the family doctor observes these or similar phenomena, he should inform the parents, in order to start a preventive therapy of the family together with the prospective thief.

Lithium prophylaxis in recurrent affective disorders

Following the first reports of a prophylactic lithium action in recurrent affective disorders (Hartigan, 1963; Schou, 1963; Baastrup, 1964; Schou and Baastrup, 1966; Baastrup and Schou, 1967), a large number of research projects on this subject have been started. Prophylactic studies yield results slowly, and reports published to date are mainly of a preliminary nature. Some have been negative; the authors found little or no evidence of prophylactic lithium action (Fieve et al., 1968; Zall et al., 1968). Other observations seem to confirm the ability of lithium to prevent manic and depressive relapses (Achté et al., 1968; Blinder, 1968; Christodoulou, 1968; Dyson and Mendels, 1968; Gershon, 1968; Gottfries, 1968; Haastrup et al., 1968; Hofmann and Boleloucky-Bolen, 1968; Hullin et al., 1968; Kerry and Owen, 1968; Lauter, 1969; Levy, 1968; Melia, 1968; Sargant, 1968; Vaadal and Robak, 1968; Annell, 1969; Forssman and Wålinder, 1969; Fries, 1969; Uddenberg, 1969). The reports are based on samples which range from a few patients to about seventy. Few deal with systematic studies.