Department of Psychiatry, University of California, San Francisco.
Department of Psychiatry and Yale Child Study Center, Yale University School of Medicine, New Haven, Connecticut.
JAMA. 2017 Apr 4;317(13):1358-1367. doi: 10.1001/jama.2017.2200.
Obsessive-compulsive disorder (OCD) is a neuropsychiatric disorder associated with significant impairment and a lifetime prevalence of 1% to 3%; however, it is often missed in primary care settings and frequently undertreated.
To review the most current data regarding screening, diagnosis, and treatment options for OCD.
We searched PubMed, EMBASE, and PsycINFO to identify randomized controlled trials (RCTs), meta-analyses, and systematic reviews that addressed screening and diagnostic and treatment approaches for OCD among adults (≥18 years), published between January 1, 2011, and September 30, 2016. We subsequently searched references of retrieved articles for additional reports. Meta-analyses and systematic reviews were prioritized; case series and reports were included only for interventions for which RCTs were not available.
Among 792 unique articles identified, 27 (11 RCTs, 11 systematic reviews or meta-analyses, and 5 reviews/guidelines) were selected for this review. The diagnosis of OCD was revised for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, which addresses OCD separately from anxiety disorders and contains specifiers to delineate the presence of tics and degree of insight. Treatment advances include increasing evidence to support the efficacy of online-based dissemination of cognitive behavioral therapies, which have demonstrated clinically significant decreases in OCD symptoms when conducted by trained therapists. Current evidence continues to support the use of selective serotonin reuptake inhibitors as first-line pharmacologic interventions for OCD; however, more recent data support the adjunctive use of neuroleptics, deep-brain stimulation, and neurosurgical ablation for treatment-resistant OCD. Preliminary data suggest safety of other agents (eg, riluzole, ketamine, memantine, N-acetylcysteine, lamotrigine, celecoxib, ondansetron) either in combination with selective serotonin reuptake inhibitors or as monotherapy in the treatment of OCD, although their efficacy has not yet been established.
The dissemination of computer-based cognitive behavioral therapy and improved evidence supporting it represent a major advancement in treatment of OCD. Although cognitive behavioral therapy with or without selective serotonin reuptake inhibitors remains a preferred initial treatment strategy, increasing evidence that supports the safety and efficacy of neuroleptics and neuromodulatory approaches in treatment-resistant cases provides alternatives for patients whose condition does not respond to first-line interventions.
强迫症（OCD）是一种神经精神疾病，与显著的损伤和 1%至 3%的终身患病率有关；然而，它在初级保健环境中经常被忽视，并且经常治疗不足。
回顾 OCD 的最新筛查、诊断和治疗选择的数据。
我们搜索了 PubMed、EMBASE 和 PsycINFO，以确定 2011 年 1 月 1 日至 2016 年 9 月 30 日期间发表的针对成年人（≥18 岁）OCD 的筛查、诊断和治疗方法的随机对照试验（RCT）、荟萃分析和系统评价。随后，我们为其他报告搜索了检索文章的参考文献。优先考虑荟萃分析和系统评价；仅纳入了 RCT 不可用的干预措施的病例系列和报告。
在 792 篇独特的文章中，有 27 篇（11 项 RCT、11 项系统评价或荟萃分析、5 项综述/指南）被选为本次综述。OCD 的诊断已根据《精神疾病诊断与统计手册》第五版进行修订，该版将 OCD 与焦虑症分开，并包含专门用于描绘抽搐存在和洞察力程度的特征。治疗进展包括越来越多的证据支持在线传播认知行为疗法的有效性，当由经过培训的治疗师进行时，这种疗法已证明 OCD 症状有临床显著下降。目前的证据继续支持选择性 5-羟色胺再摄取抑制剂作为 OCD 的一线药物干预措施；然而，最近的数据支持将神经阻滞剂、深部脑刺激和神经外科消融术用于治疗难治性 OCD。初步数据表明，其他药物（如利鲁唑、氯胺酮、美金刚、N-乙酰半胱氨酸、拉莫三嗪、塞来昔布、昂丹司琼）联合选择性 5-羟色胺再摄取抑制剂或作为 OCD 的单一疗法的安全性，尽管其疗效尚未确定。
计算机化认知行为疗法的传播和对其的支持是 OCD 治疗的重大进展。虽然认知行为疗法加或不加选择性 5-羟色胺再摄取抑制剂仍然是首选的初始治疗策略，但越来越多的证据支持神经阻滞剂和神经调节方法在治疗抵抗病例中的安全性和有效性，为那些对一线干预措施没有反应的患者提供了替代方案。
