Obsessional disorders in childhood and adolescence. Developmental, therapeutic and nosologic aspects.
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The error-related negativity (ERN or Ne) and positivity (Pe) are event-related potential components elicited during simple discrimination tasks after an error response. The ERN and Pe have a fronto-central scalp distribution and may be an indirect measure of anterior cingulate (AC) activity as it relates to performance monitoring. Brain imaging studies suggest that obsessive-compulsive disorder (OCD) is associated with exaggerated activity of the AC while electrophysiological studies have found an association between OCD and pronounced ERNs in adults. The present study explored the relation between obsessive-compulsive behaviors, the ERN, and the Pe in a sample of nonclinical 10-year-old children. It was found that more parent-reported obsessive-compulsive behaviors were associated with larger ERN and Pe components in the children. Results suggest unique contributions of the ERN and Pe in predicting obsessive-compulsive behaviors.
Precocious ego development is frequently mentioned in psychoanalytic theory as an important determinant of obsessive-compulsive neurosis. Writers such as Anna Freud suggest that an imbalance in the development of ego over drive may lead to obsessional neurosis. However, further examination of the psychoanalytic literature reveals that the nature of this supposed link is not clear. Explanations couched in economic language or in terms of an early hypersensitivity to stimulation are open to theoretical criticism or are unsatisfying. The author suggests that we focus on the effect of precocious ego development on developing object relations. It is suggested that precocity may lead to early disappointment in parental objects. The inter-relationships of disappointment with early identifications, premature sense of autonomy and anal problems are discussed. A case of an obsessive-compulsive adolescent girl is presented to illustrate the role of precocious ego development and superior intelligence in the formation of the symptoms.
Males with anxiety disorders appear to have increased mortality due to circulatory system disease, and Type A behavior is a risk factor for coronary heart disease (CHD). Thus, we determined Type A behavior in anxious patients. Fifty-seven DSM-III defined anxiety disorder patients completed the Jenkins Activity Survey (JAS) and Symptom Checklist-90-Revised (SCL-90-R). Significantly more male (92%) than female (52%) anxious patients had Type A behavior. Correlations between the JAS scales and SCL-90-R subscales were also different between male and female patients; in males, significant correlations were observed for SCL-90-R anxiety with both JAS Type A and JAS Hard-Driving and Competitive, and for SCL-90-R hostility with JAS Hard-Driving and Competitive. However, there were no consistent correlations between the JAS and the SCL-90-R subscales in females. A trend for fathers of anxious patients to have an increased prevalence of CHD was also observed. The increased incidence of Type A behavior in male, but not in female, anxious patients suggest a mechanism for increased mortality due to circulatory disease in male anxiety patients.
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BACKGROUND: Information regarding the long-term effectiveness of the combination of pharmacotherapy and cognitive-behavioral therapy (CBT) in the treatment of obsessive-compulsive disorder (OCD) is limited. Our study is the first to examine the long-term effectiveness of cognitive therapy (CT) and to compare long-term effectiveness of CT alone, exposure in vivo with response prevention (ERP) alone, and CBT (either CT or ERP) in combination with fluvoxamine in the treatment of OCD. METHOD: Of 122 outpatients with primary DSM-III-R-defined OCD originally enrolled in 2 randomized controlled trials, 102 patients (45 male/57 female; mean +/- SD age = 36.2 +/- 10.7 years; range, 19-64 years) were available to be assessed for the presence and severity of OCD and comorbid psychopathology at follow-up. Follow-up data were collected from November 1996 to June 1999. RESULTS: After 5 years, 54% of the participants no longer met the DSM-III-R criteria for OCD. Long-term outcome did not differ between the 3 treatment groups. At follow-up, treatment dropouts appeared to have more severe OCD complaints compared with treatment completers. Compared with patients receiving CT alone, significantly (p < .005) more patients receiving CBT with fluvoxamine used antidepressants 5 years later. CONCLUSIONS: This study demonstrates that at 5-year follow-up (1) prevalence of OCD had declined in all 3 treatment conditions, (2) the clinical benefits of all 3 treatment conditions were maintained, (3) OCD complaints were more severe for treatment dropouts than for treatment completers, and (4) about half of the patients initially treated with fluvoxamine continued antidepressant use.
Traditional scoring of sleep EEG in depressed patients shows abnormalities in sleep maintenance, sleep architecture, REM sleep, the distribution of slow wave and REM sleep during the night. Computerized analysis that comprises the period-amplitude analysis procedure and spectral analysis discloses changes in delta activity and distribution of delta activity. However, these methods of analysing EEG sleep are not able to distinguish the various concepts of depression: endogenous and non-endogenous depression, unipolar and bipolar depression, psychotic and non-psychotic depression. Polysomnographical data in patients with recurrent depression show alteration during remission suggesting trait-like abnormalities of sleep in depression illness. Shortened REM latency is not specific in depression. This sleep parameter is defined in many different ways explaining the heterogeneousness of study results and the failure of constituting a biological marker. Many sleep parameters are affected by several factors such as age, gender and severity. Several physiopathological hypotheses have been proposed to explain EEG sleep alterations. They refer either to circadian rhythms such as the two process model of Borbély, the phase advance hypothesis and the circadian amplitude hypothesis, or to neurotransmitter abnormalities such as the cholinergic hypothesis. None of them takes sufficient account of all the sleep abnormalities. Sleep abnormalities have also been described in other psychiatric disorders such as mania, panic and obsessional-compulsive disorders, generalized anxiety, phobias, post-traumatic stress disorder, eating disorders, borderline personality, schizophrenia and dementia. None of them have a particular sleep EEG profile which allows to differentiate between them. A concomitant episode of major depression cannot be uncovered by sleep recordings.
We are not suggesting that casting is appropriate for all patients with BPD, nor are we suggesting that patients need be casted for prolonged periods of time. In the 3 stated cases, the patients were desperate to have some behaviour modification introduced into their lives and welcomed the procedure. In all these cases, comorbidity existed. Because marked skin damage and open wounds often occur, other specialists with expertise in wound healing and joint mobility maintenance need to be involved. We were fortunate to have the services of a plastic surgeon with a special interest in psychiatric disorders. We believe that psychiatrists should be aware of this technique as a possible strategy to be used in very specific circumstances. It appears, in our short series of 3 cases, to have benefits in very specific cases. If it appears that casting may be helpful, our recommendations are as follows: 1. The behaviours should be thoroughly evaluated, and all alternative managements should be reviewed. 2. Reasonable rapport needs to be established between the patient and the major therapists so that compliance can be assured. 3. Other specialists should be consulted, such as plastic surgeons, who have the expertise to manage prolonged casting. 4. Along with casting, appropriate medications and psychotherapy must be in place for a balanced approach to management.
The aim of this article is to describe how we conceptualise in practical indications of individual psychotherapy in the frame of the consultation of a guidance center. We will not review the literature concerned with this subject. We shall start with the study of the following factors : parents, family, reality features (distance, time, money...). Then, we study the positive and negative features in the child. We explain first all we consider to be the main obstacles in the psychic structure of the child. Then we describe in detail the favorable elements to the psychotherapeutic work. We also recall cases who, without being impossible to treat, require a big experience from the therapist, because of complexity and demand. They are sometimes treated in our unit, according to the disponibility of the therapists. In conclusion, we indicate that the choice of psychotherapy depends not only from the sick child and his familial milieu, but also from the therapist who will involve himself in this type of treatment.
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The author examined 49 patients with schizophrenia taking the course of pseudoneurosis. It has been established that at advanced stages of pseudoneurosis the clinical picture is largely characterized by psychopathy-like changes of a varying structure--schizo-anancastic (n = 20), schizo-hysterical (n = 14) and of the "Verschrobenheit-type" (n = 15). Corresponding groups of patients were distinguished by characteristic pre-morbid manifestations, peculiarities of obsessions and the modus of adaptive behaviour, in particular by a peculiar adaptation to obsessive-phobic disturbances which correlated with psychopathy-like changes.
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