Kano Yukiko
Department of Child Neuropsychiatry, Graduate School of Medicine, The University of Tokyo.
Seishin Shinkeigaku Zasshi. 2013;115(9):990-6.
More than a half of patients with OCD are classified as early-onset. Early-onset OCD has been indicated to be associated with a greater OCD global severity and more frequently comorbid with tic disorders and other obsessive-compulsive (OC) spectrum disorders, compared with late-onset OCD. Early-onset OCD patients with severe impairment caused by both OC symptoms and comorbid OC spectrum disorders may be identified as being refractory. Tic disorders and autism spectrum disorder (ASD) are child and adolescent psychiatric disorders included in OC spectrum disorders. OCD comorbid with chronic tic disorders including Tourette syndrome (TS) is specified as tic-related OCD. Tic-related OCD is characterized by the high prevalence of early-onset and sensory phenomena including "just right" feeling. Self-injurious behaviors (SIB) such as head banging and body punching often occur in patients with TS. The patients' concern about SIB is likely to trigger them, suggesting that an impulse-control problem is a feature of TS. More than a half of patients with TS have OC symptoms. When OC symptoms in patients with TS were assessed with a dimensional approach, symmetry dimension symptoms were found most frequently over the lifetime. On the other hand, the severity of aggression dimension symptoms was the most stable during the course among all dimensions. Aggression dimension symptoms also exhibited a close relationship with impairment of global functioning and sensory phenomena. This tendency may be characteristic of tic-related OCD. It is sometimes difficult to differentiate between OC symptoms and restricted, repetitive behaviors which are core symptoms of ASD. Recently, ego-dystonia and insight are considered non-essential to diagnose OCD, whereas high-functioning and/or atypical ASD is recognized as being more prevalent than previously estimated. In this situation, attention to comorbidity of OCD and ASD is increasing, and the prevalence of OCD in children and adolescents with ASD was reported to be about 20%. One study on the impact of comorbid ASD in adults with OCD indicated that comorbid patients had higher scores for the Autism Questionnaire (AQ) subscales of attention switching and imagination but showed little difference in OC symptoms except for the predominance of compulsion compared to patients with pure OCD. "Just right" feeling and impulse-control problems were evident in OC patients comorbid with both ASD and TS. Out of five adults with TS who underwent deep brain stimulation (DBS) because of refractory tics, four had impulse-control problems including SIB, leading to very severe physical injuries in two patients. After DBS, tics and SIB improved in all patients; however, one patient experienced their re-aggravation. To improve understanding of and treatment/support for refractory OCD, OC spectrum disorders should also be considered.
超过一半的强迫症患者被归类为早发型。与晚发型强迫症相比，早发型强迫症被认为与更严重的强迫症整体严重程度相关，并且更频繁地与抽动障碍和其他强迫性（OC）谱系障碍共病。由OC症状和共病的OC谱系障碍导致严重损害的早发型强迫症患者可能被认定为难治性患者。抽动障碍和自闭症谱系障碍（ASD）是OC谱系障碍中包含的儿童和青少年精神障碍。与包括图雷特综合征（TS）在内的慢性抽动障碍共病的强迫症被指定为抽动相关强迫症。抽动相关强迫症的特征是早发型和感觉现象（包括“恰到好处”的感觉）的高患病率。诸如撞头和捶打身体等自我伤害行为（SIB）经常发生在TS患者中。患者对SIB的担忧很可能引发这些行为，这表明冲动控制问题是TS的一个特征。超过一半的TS患者有OC症状。当用维度方法评估TS患者的OC症状时，在一生中发现对称维度症状最为常见。另一方面，在所有维度中，攻击维度症状的严重程度在病程中最为稳定。攻击维度症状也与整体功能损害和感觉现象密切相关。这种趋势可能是抽动相关强迫症的特征。有时很难区分OC症状和ASD的核心症状——受限的重复行为。最近，自我矛盾和洞察力被认为对诊断强迫症并非必不可少，而高功能和/或非典型ASD被认为比之前估计的更为普遍。在这种情况下，对强迫症和ASD共病的关注日益增加，据报道，患有ASD的儿童和青少年中强迫症的患病率约为20%。一项关于共病ASD对成年强迫症患者影响的研究表明，共病患者在自闭症问卷（AQ）的注意力转换和想象力子量表上得分更高，但与单纯强迫症患者相比，除了强迫行为占主导外，OC症状几乎没有差异。“恰到好处”的感觉和冲动控制问题在同时患有ASD和TS的OC患者中很明显。在五名因难治性抽动而接受深部脑刺激（DBS）的成年TS患者中，有四名存在包括SIB在内的冲动控制问题，导致两名患者受到非常严重的身体伤害。DBS后，所有患者的抽动和SIB都有所改善；然而，一名患者出现了症状复发。为了更好地理解和治疗/支持难治性强迫症，还应考虑OC谱系障碍。
