online ML Comm 대한정신약물학회지 : 제 18 권제 6 호 2007 원저 한국형강박장애치료알고리듬 2007(IV): 공존질환이동반된경우 하태현 1 구민성 2 양종철 3 김원 4 김세주 5 권준수 6 김찬형 5 서울대학교의과대학분당서울대학교병원신경정신과학교실, 1 관동대학교의과대학정신과학교실, 2 전북대학교의과대학전북대학교병원정신과학교실, 3 인제대학교의과대학서울백병원정신과및스트레스연구소, 4 연세대학교의과대학정신과학교실, 행동과학연구소, 5 서울대학교의과대학정신과학교실 6 ABSTRACT Korean Treatment Algorithm for Obsessive-Compulsive Disorder 2007(IV): Comorbid Conditions Tae Hyon Ha, MD, 1 Min Sung Koo, MD, 2 Jong Chul Yang, MD, 3 Won Kim, MD, 4 Se Joo Kim, MD, 5 Jun Soo Kwon, MD, 6 Chan-Hyung Kim, MD 5 and Study Group for Korean Treatment Algorithm for Obsessive-Compulsive Disorder 2007 1 Department of Neuropsychiatry, Seoul National University Bundang Hospital, Bundang, 2 Department of Psychiatry, College of Medicine, Kwandong University, Goyang, 3 Department of Psychiatry, Chonbuk National University Hospital, Jeonju, 4 Department of Psychiatry and Stress Research Institude, College of Medicine, Inje University, Seoul, 5 Department of Psychiatry and Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, 6 Department of Psychiatry, Seoul National University College of Medicine, Seoul, Korea Objectives:Patients with obsessive-compulsive disorder (OCD) frequently exhibit complex clinical features, including comorbidity with other psychiatric disorders, which challenge diagnostic and therapeutic practice. This study presents a number of Korean experts ratings of the appropriateness of treatments for patients with comorbid OCD and other psychiatric disorders. Methods:The Korean Treatment Algorithm Project for Obsessive-Compulsive Disorder (KTAP-OCD 2007) developed a questionnaire that included questions about seven psychiatric comorbid conditions: major depressive disorder, bipolar disorder, panic or social anxiety disorder, schizophrenia, attention deficit hyperactive disorder (ADHD), oppositional/conduct/antisocial disorder, and Tourette disorder. Answers from 24 respondents were analyzed to assess first-line and second-line treatments for each comorbid condition. Results:Experts selected cognitive behavior therapy (CBT) in conjunction with medication as the treatment for comorbidity with major depressive disorder, anxiety disorders, ADHD, or Tourette disorder. They selected a selective serotonin reuptake inhibitor (SSRI) combined with atypical antipsychotics as the treatment of choice for patients with comorbid OCD and schizophrenia. When patients had comorbid OCD and bipolar disorder, 접수일자 :2007 년 7 월 24 일 / 심사완료 :2007 년 8 월 9 일이연구는대한정신약물학회의지원으로이루어졌음. 교신저자 : 김찬형, 135-720 서울강남구도곡동 146-92 연세대학교의과대학정신과학교실, 행동과학연구소전화 :(02) 2019-3340 전송 :(02) 3464-4304 E-mail:spr88@yumc.yonsei.ac.kr 414
하태현등 experts preferred adjunctive serotonin reuptake inhibitors to CBT. In all cases, experts were less likely to select clomipramine for second-line treatment. Conclusion:The findings from the KTAP-OCD 2007 survey on psychiatric comorbid conditions were generally consistent with foreign guidelines. However, more guidelines might be required for comorbidity with bipolar disorder and the use of clomipramine. (Korean J Psychopharmacol 2007;18(6):414-422) KEY WORDS:Obsessive-compulsive disorder Psychiatric comorbidity Korean treatment algorithm Pharmacotherapy Cognitive behavior therapy. 서론 강박장애는매우복잡한공존병리를지닌질환이다. Epidemiological Catchment Area 연구에의하면, 강박장애환자들의약 3분의 2가다른정신질환의일평생공존이환을지니며, 약 64% 에서 I축진단공존이환을, 36~75% 에서 II축진단공존이환을나타내는것으로알려져있다. 1,2) 공존질환을지닌환자들이그렇지않은강박장애환자들에비해도움을구하는비율이훨씬높다는사실을상기하면, 3) 임상환자군에서의공존질환은더욱흔히관찰되는치료적이슈임을짐작할수있다. 실제로외래환자들을대상으로한조사에의하면 92% 에서적어도한가지이상의 I축공존장애가관찰되었고, 물질관련장애와특정공포증을제외한나머지모든 I축장애가일반인구보다강박장애환자군에서높게나타났다. 4) 이결과는강박장애환자들에게서의공존질환평가의중요성을강조하는소견이라할수있는데, 일부공존질환의동반은강박장애의치료성과에영향을미칠수있기때문이다. 2) 강박장애에가장흔히동반되는질환은우울장애이다. 성인강박장애환자 100명을조사한 Rasmussen 과 Eisen 5) 은우울장애의평생유병율이 67% 에서관찰되며, 31% 는현재우울장애를지니고있음을보고하였다. 횡문화적으로는우울장애가평생유병율 12.4~60.3% 범위의비교적큰차이를나타내나, 6) 일반적으로기분장애가가장흔한공존질환이라는데에는이견이없어보인다. 우울장애는대부분이강박장애발병후오랜시점에서발생함으로써강박장애의고통에의한이차적인것으로생각되고있으나, 6,7) 동시에발생하는경우에는, 특히삽화성경과를보이는강박장애의경우에는양극성장애의 가능성을의심해보아야한다. 8) 우울장애가동반되는경우는불안, 우울, 강박증상의심각도가높고, 강박행동보다는강박사고가더많고, 범불안장애의공존이흔하며, 자살기도를포함한만성경과가많다. 8-10) 공존우울장애가강박장애의치료반응에미치는영향은일반적으로부정적인것으로간주된다. 행동치료에대한반응은우울장애가심할수록부정적이나, 6,11,12) 약물치료에대한반응은반드시그렇지는않아보인다. 13) 행동치료와약물치료의병합요법에대한반응은우울장애가부정적영향을미친다. 14) 양극성장애와강박장애의공존은아주최근에서야주목을받기시작하였고, 치료반응이나경과에미치는영향에관한문헌은거의없는실정이다. 강박장애외래환자의 15.7% 에서양극성장애를관찰한 Perugi 등 8) 은대부분이양극성 II형장애이며, 잠행성발병이나삽화성경과가많고, 강박증상의출현이우울삽화와병발하는경우가많음을보고하였다. 양극성장애와공존하는경우는대칭, 정확성, 정렬의증상이더많고, 우울장애와의공존에서범불안장애가흔한데반해, 사회공포증이더잦은것으로보인다. 9) 우울장애와양극성장애모두자살의위험을높인다. 9,15,16) 양극성장애와의공존에서가장중요하고어려운갈등적이슈는약물선택의전략에있다. 항강박약물의사용이조증또는경조증삽화를유발할수있기때문이다. 17-21) 통상불안장애와양극성장애의공존에서약물치료적우선순위는기분의안정에있다. 22) 불안장애는기분장애에뒤이어두번째로흔한공존질환이다. 세로토닌재흡수차단제의일반적항불안효과를고려하면, 불안장애와의공존에서약물학적치료전략의선택은큰어려움이없을것으로생각된다. 치료반응과관련하여특이한점은사회공포증또는외상후스트레스장애가공존하는경우이다. 사회공포증이동반된경 415
KTAP-OCD 2007(IV): 공존질환 우세로토닌재흡수차단제에대한반응이불량할수있고단가아민산화효소억제제가더도움이될수있음이보고된바있다. 23) 외상후스트레스장애와공존된경우는약물치료와행동치료모두에반응이좋지않다. 24-26) 정신분열병은 475 명의강박장애환자들을조사한 Eisen 과 Rasmussen 27) 에의하면약 4% 에서관찰되었다. 일반적으로강박장애자체가정신분열병의위험요인으로생각되지는않고있다. 28) 그러나정신분열병에서는강박장애또는강박증상이 1.1~59.6% 정도로다양하게보고되었고, 임상적으로는상당히저평가되고있다고지적된다. 29) 통상전형적항정신병약물들은치료효과가떨어지며, 28) 비전형항정신병약물들은정신분열병에서강박증상을유발한사례보고들 30,31) 과강박증상을감소시키는데효과적이었다는보고 32) 가혼재한다. 세로토닌재흡수차단제에반응하는환자군과그렇지않은환자군이존재할것으로추정되며, 이들을구분해낼수있는뚜렷한예측자가밝혀지지않은상태이나, 일반적으로는항강박치료제를추가하는방법이추천된다. 29) 주의력결핍과잉행동장애 (attention deficit hyperactive disorder) 의공존은소아청소년강박장애환아들의약 25% 에서관찰된다고보고되었다. 33) 주의력결핍과잉행동장애의공존은강박증상의표현형에는영향이없어보이나, 34) 정신사회적장해가더크다. 33-35) 또한이경우, 반항행동이많고행동억제가어려우며, 36) 틱장애, 반항장애, 품행장애, 양극성장애등외향형장애 (externalizing disorder) 의공존이높다. 33) 이들공존질환의치료효과에관한영향에관해서는문헌적정보가거의없다. 틱장애 (tic disorder) 는강박장애환자들의약 20% 에서, 그리고뚜렛장애 (Tourette disorder) 는 5~10% 에서평생유병율을보인다고알려졌다. 37) 통상틱장애가공존하는경우는강박증상의발병이이르고, 38,39) 강박사고에서는별차이가없으나만지거나두드리거나문지르거나눈을깜박이거나쳐다보아야하는종류의강박행동이더많다. 40,41) 틱장애의공존은강박증상의약물치료에대한반응을떨어뜨리며, 42,43) 행동치료에대한반응에는별영향을미치지않는것으로보인다. 43,44) 틱장애가공존할때항정신병약물첨부효과의이점은한이중맹위약대조연구에서밝혀져있다. 45) 국내에서는강박장애연구가부족하였고치료적합의에 416 관한논의는전무한실정이었다. 이에연구자들은대한정신약물학회의주관아래한국형강박장애약물치료지침서 (Korean Treatment Algorithm Project for Obsessive- Compulsive Disorder, KTAP-OCD 2007) 를개발하기로하였고전문가의의견을수렴하여조사하였다. 본논문에서는 KTAP-OCD 2007을제작하기위한설문조사중다양한정신과적공존질환이존재하는경우의치료적선택에대한조사결과를제시하고, 각경우의치료적지침을논하였다. 연구방법 KTAP-OCD 2007을개발하기위한설문지는미국의전문가합의지침 (Expert Consensus Guideline Series) 중에서강박장애의치료부분 46) 을근간으로하여몇가지외국지침을검토한후국내실정에적합한내용으로구성하였다. 평가척도는검토위원들의의견일치도를조사하기위해절대사용하지않는가장부적절한치료에해당하는 1점부터가장적절한치료 (treatment of choice) 인 9점에이르기까지 9점척도를사용하여각치료선택의적절성을평가하도록하였다. 치료의적절성에대한평가는 1~3 점, 4~6 점, 그리고 7~9 점의 3개범주로구분하였다. KTAP-OCD 2007을제작하기위한설문은 47개임상상황을아형, 약물반응, 치료력, 공존질환등에따라 82개의개별적인상황으로구분하여구성하였다. 이중정신과적공존질환이존재하는경우의치료의적절성을평가하는문항은모두 7개로서, 첫째, 주요우울증의공존, 둘째, 관해기양극성장애의공존, 셋째, 공황장애또는사회공포증의공존, 넷째, 정신분열병의공존, 다섯째, 주의력결핍과잉행동장애의공존, 여섯째, 반항장애, 품행장애, 반사회적장애의공존, 일곱째, 뚜렛장애의공존이었다. KTAP-OCD 2007 을제작하기위한검토위원회는강박장애에대한임상경험이나연구성과를토대로정신과전문의 34명을선정함으로써구성하였다. 검토위원들은대학병원소속이 24명, 종합병원소속이 4명, 정신과전문병원소속이 3명, 그리고개원의가 3명이었다. 총 34 명중설문에성실하게답한 24명 (70.6%) 은대학병원
하태현등 소속이 20명, 종합병원소속이 2명, 정신과전문병원소속이 1명, 그리고개원의가 1명이었다. 자료의분석은치료의적절성에대한 3개범주사이의분포차이를 χ 2 -검정을이용하여검증하였다. 그다음으로는평균과 95% 신뢰구간을계산하였다. 일차, 이차선택의등급은각문항의신뢰구간의가장낮은경계선에근거하여결정하여, 낮은경계선의점수가 6.5 이상인경우를일차선택치료로간주하였고, 3.5 이상이고 6.5 미만인경우는이차선택치료로간주하였다. 최우선치료 (treatment of choice) 는일차치료범주내의치료중검토위원의 50% 이상이 9점으로평가한항목으로하였다. 결과 1. 주요우울장애가공존하는경우인지행동치료와약물요법의병합치료가최우선치료로선택되었다. 약물의선택은선택적세로토닌재흡수차단제 (Selective Serotonin Reuptake Inhibitors, SSRI) 또는 SSRI 와벤조디아제핀의병용이선호되었다. 클로미프라민또는클로미프라민과벤조디아제핀의병용은이차선택치료로서선호되었다 ( 그림 1). 경하거나중등도의우울증상이동반된경우와심한우울증상이동반된경우의치료적선택은차이가없었다. 두경우에모두인지행동치료와세로토닌재흡수차단제 (Serotonin Reuptake Inhibitors, SRI) 의병합치료가가장선호되는치료였고, SRI 로치료를시작하는경우가다음으로선호되는치료였다. 다만, SRI 로시작하는치료의적절성은심한우울증상이동반된경우에서중 등도이하의우울증상이동반된경우보다약간높은점수를받았다. 인지행동치료로시작하는치료는이차전략으로선호되었다. 2. 관해상태의양극성장애가공존하는경우기분안정제와 SSRI 의병용치료, 그리고기분안정제와클로미프라민또는 SSRI 및인지행동치료의병합치료가가장선호되는일차치료전략이었다. 최우선치료는나타나지않았다. 기분안정제와인지행동치료의병합치료가그뒤를잇는선호도를나타내었고, 기분안정제와클로미프라민의병용치료가다음으로선호되는치료였다. 기분조절제를사용하지않는 SRI 치료는이차전략범주의하위점수를받았다 ( 그림 1). 3. 공황장애또는사회공포증이공존하는경우일차치료로선택된치료는최우선치료로선별된인지행동치료와약물요법의병합치료, 그리고 SSRI 단독치료, SSRI 와벤조디아제핀의병용요법순이었다. 이차전략으로선택된치료는클로미프라민과벤조디아제핀의병용치료, 단가아민산화효소억제제단독치료, 클로미프라민단독치료, 단가아민산화효소억제제와벤조디아제핀의병용치료순이었다 ( 그림 1). 4. 정신분열병이공존하는경우 SSRI 와비전형항정신병약물의병용치료가최우선치료로선호되었다. 약물치료에인지행동치료를병합하는경우가다음으로선택되었고, 클로미프라민과비전형항정신병약물의병용치료가그뒤를이었다. SSRI 또는클로미프라민의단독치료를이차선택범주의하위에해당하였다 ( 그림 1). Major depression 1. CBT+drugs 2. SSRI 3. SSRI+BZD 4. CMI 5. CMI+BZD 6. MAOI+BZD 7. MAOI Bipolar disorder 1. MS+SSRI 2. MS+SRI+CBT 3. MS+CBT 4. MS+CMI 5. SSRI or CMI Comorbid conditions Panic disorder or social phobia 1. CBT+drugs 2. SSRI 3. SSRI+BZD 4. CMI+BZD 5. MAOI 6. CMI 7. MAOI+BZD Schizophrenia 1. SSRI+AAP 2. CBT+drugs 3. CMI+AAP 4. SSRI 5. CMI Figure 1. Ratings of the appropriateness of the treatments for a patient with comorbid affective, anxiety or psychotic disorders. AAP: atypical antipsychotics, BZD:benzodiazepines, CBT:cognitive behavioral therapy, CMI:clomipramine, MAOI:monoamine oxidase inhibitors, MS:mood stabilizers, SRI:serotonin reuptake inhibitors, SSRI: selective serotonin reuptake inhibitors. Underlined are treatment of choices and bold characters mean first line treatment. 417
KTAP-OCD 2007(IV): 공존질환 5. 주의력결핍과잉행동장애가공존하는경우 인지행동치료와약물요법의병합치료가가장선호되는최우선치료였다. SSRI 와정신자극제를병용하는치료와 SSRI 단독치료가다음으로선택된일차선택치료였다. 클로미프라민과정신자극제의병용치료와클로미프라민단독치료는이차전략범주에해당하였다 ( 그림 2). 6. 반항장애, 품행장애, 또는반사회적장애가공존하는경우 SSRI 와인지행동치료및가족치료가가장선호되는일차선택치료였다. 다음으로 SSRI 와인지행동치료의병합치료가선택되었고, SSRI 단독치료가그뒤를이었다. 클로미프라민과인지행동치료및가족치료의병합치료는 SSRI 단독치료의다음순으로선택되었다. 클로미프라민과인지행동치료의병합치료, 인지행동치료와가족치료의병합치료, 클로미프라민단독치료, 인지행동치료단독은각각순서대로이차전략범주를이루었다 ( 그림 2). 7. 뚜렛증후군이공존하는경우 인지행동치료와약물요법의병합치료, 그리고 SSRI 와리스페리돈의병용요법이최우선치료로서동일한적절성점수를얻었다. 뒤이어 SSRI 단독요법과 SSRI 와전형적항정신병약물의병용요법이같은점수로서일차선 ADHD 1. CBT+drugs 2. SSRI+PS 3. SSRI 4. CMI+PS 5. CMI Comorbid conditions Oppositional, conduct or antisocial disorder 1. SSRI+CBT+FT 2. SSRI+CBT 3. SSRI 4. CMI+CBT+FT 5. CMI+CBT 6. CBT+FT 7. CMI 8. CBT Tourette disorder 1. CBT+drugs 2. SSRI+RSP 3. SSRI 4. SSRI+TAA 5. SSRI+others 6. SSRI+C or G 7. CMI+TAA 8. CMI 9. CMI+C or G Figure 2. Ratings of the appropriateness of the treatments for a patient with comorbid attention deficit hyperacitive disorder, oppositional, conduct, antisocial disorder, or Tourette disorder. ADHD:attention deficit hyperactive disorder, C:clonidine, CBT:cognitive behavioral therapy, CMI:clomipramine, FT:family therapy, G:guanfacin, PS:psychostimulants, RSP:risperidone, SSRI:selective serotonin reuptake inhibitors, TAA:typical antipsychotics. Underlined are treatment of choices and bold characters mean first line treatment. 택치료의범주를이루었다. SSRI 와클로니딘을포함한다른약물의병용요법, 그리고클로미프라민과리스페리돈의병용요법이그다음으로선호되었으며, 클로미프라민과전형적항정신병약물의병용치료, 클로미프라민단독치료, 클로미프라민과다른약물의병용치료등은이차선택치료범주의하위에해당하였다 ( 그림 2). 고찰 전반적으로국내전문가들은공존질환이있는경우에클로미프라민을선택하는순서가 SSRI 선택에비해큰차이를나타내며뒤떨어지는경향을뚜렷하게나타내었다. 그림 1과그림 2에서나타나듯이대부분의경우클로미프라민은이차선택범주로밀려있었다. 이는클로미프라민이 SSRI 에바로뒤이어선택되는경향을나타내는외국의전문가합의지침 46) 과가장분명한차이를나타내는소견이다. 아마도공존질환의경우에는내인성과부작용의위험을우선적으로고려하는임상치료의현실적측면이반영된것으로생각된다. 이러한차이를설명할수있는또다른가능성은외국의합의지침이발행된 1997년이후약 10년이지난시점에서 SSRI 에대한문헌적증거와임상적경험이더욱풍부하게축적되었다는점을들수있겠다. 우울장애가공존하는경우에는인지행동치료와약물요법의병합치료가일차선택치료로꼽혔으며, 이는최적의치료로서외국의합의지침결과와일치한다. 다만, 우울증상이심할때의일차적선택에서는차이를보였다. 국내전문가들은우울증상이심할때에도인지행동치료와약물요법의병합치료를가장우선적으로선택하였으나, 외국의합의지침은이경우 SRI 로치료를시작함을최우선으로제시하였다. 우울증상을동반한경우에는전통적인강박장애의인지행동치료인노출과반응방지법 (exposure and response prevention) 에대한반응이불량하다는증거 12,47) 는항우울제단독치료를우선적으로고려하게한다. 심한우울장애환자들은과잉반응을보이고공포상황에의노출중정상적으로발생하는탈감작을통한불안의감소가이루어지지않는다고생각되고있다. 6) 한편, 인지치료는우울장애에효과적인치료법이다. 48,49) 인지치료가강박증상에도효과적일지에관 418
하태현등 해서는아직문헌적증거가불충분하나, 우울장애에서의왜곡사고에대한인지적재구조화와같은요소는강박장애의인지행동치료에도동일하게적용되는요소이다. Abramowitz 6) 는전통적인노출과반응방지법에인지치료를부가하여중등도의우울장애를동반한강박장애환자를성공적으로치료한사례를제시한바있다. 더욱이인지치료는중등도이상의심한우울증상에도효과적인것으로알려졌다. 50,51) 따라서, 인지치료는강박장애가심한우울증상과공존하는경우한치료적선택으로서충분한가치가있다고생각된다. 외국에비해국내에서는표준적이거나구조화된노출및반응방지법보다는환자개인에게개별화된개인정신치료가더일반적인임상치료이다. 개별화된정신치료에서는환자의우울증상을다룰수있는인지치료적요소가개입될수있는여지가더많을것이며, 심한우울증상이공존하는경우에국내전문가들이병합치료를선호하는현상도이와같은맥락에서이해할수있겠다. 또한가지외국과의차이점은 SSRI 와벤조디아제핀의병용치료의순위가상대적으로높은데에있다. 강박장애의치료에클로나제팜을 SSRI에부가한효과를조사한이중맹연구에서는부정적인결과를보였지만, 52) 벤조디아제핀의효과를시사하는문헌자료도적지않다. 53-55) 또한, 일반적으로불안장애와우울장애의공존에서는벤조디아제핀의병용이빠른치료효과, 순응도향상등의효과를가져오므로, 56) 내인성의문제만없다면좋은선택이될수있다. 관해기양극성장애가공존하는경우의일차선택치료로서는기분조절제와 SSRI 의병용, 또는기분조절제와 SRI 및인지행동치료의병합치료가동일한점수로꼽혔다. 반면, 외국의합의지침에서최우선치료로지적된기분조절제에인지행동치료를부가하는치료는본조사에서이차선택으로우선순위가밀렸다. 국내전문가들은우울장애의공존에서인지행동치료에우선순위를주었던것에반해양극성장애의공존에서는약물치료에우선순위를준것으로보이며, 양극성장애에서의항우울제사용에대한저항감이낮은것으로생각된다. 일련의공존사례에서항우울제유발성 ( 경 ) 조증이거의모든환자들에게서발생하였고, 항우울제사용으로오히려강박증상이악화된상당비율이존재함을고려할때, 57) 그리고양극성장애환자의강박증상치료에 SRI 의효과가입 증되지않은현상태에서 SRI 의빠른선택은주의를요해야한다. 양극성장애에공존하는강박증상은 SRI 가아닌기분조절제나비전형항정신병약물에반응을보일수도있다. 57-59) 현재까지증거에기초한우선순위를정하기는어려우나, 두공존질환의임상적위계를고려하여안정적인기분경과에우선순위를둔선택이일반적이라생각된다. 향후더많은연구와조사가필요한부분이다. 공황장애나사회공포증이공존하는경우에는인지행동치료와약물요법의병합치료가최우선으로꼽혔고이는외국의합의지침과잘일치한다. SSRI 단독치료가뒤를잇는순서도역시외국과일치한다. 다만전술한바와같이, 국내전문가들은클로미프라민단독치료를덜선호하는경향이었다. 강박장애와불안장애의공존은인지행동치료의중요성이특히강조되는조합이며, 여기에는우울장애의공존에서와같이, 전통적노출및반응방지법을수정한개별적치료법의적용이필요하다. 60) 주의력결핍과잉행동장애가동반하는경우에는인지행동치료와약물요법의병합치료, 그리고 SSRI 와정신자극제의병용치료가순서대로일차선택치료로서선택되었고, 이는외국의합의지침과일치하는소견이다. 이공존에서도마찬가지로클로미프라민의선택은국내전문가들에게선호도가떨어졌다. 주의력결핍과잉행동장애의공존은파괴적행동장애 (disruptive behavior disorder) 의공존과관련된다. 33,36,61) 파괴적행동장애의공존은인지행동치료의효과를떨어뜨릴수있어, 62) 가족구성원들의참여와협조가요구된다. 61) 본조사결과에서도반항장애, 품행장애, 반사회적장애가공존할경우, 약물치료와인지행동치료및가족치료의병합치료가가장선호되는선택이었으며, 이는외국의합의지침과전적으로일치하는소견이다. 이공존에대한선택에서도역시클로미프라민은이차선택의범주에해당하였다. 뚜렛장애의공존에대해서는인지행동치료와약물치료의병합치료가가장선호되는일차선택치료였다. 틱장애또는뚜렛장애의공존은강박증상의약물치료반응에부정적영향을미치므로, 42,43) 인지행동치료적양식을초기치료에포함하여야한다. 외국의합의지침과차이를보이는부분은국내에서는 SSRI 와리스페리돈의병용치료가 SSRI 와전형적항정신병약물의병용치료보다우선적으로선택되었다는점이다. 이러한차이는틱장애 419
KTAP-OCD 2007(IV): 공존질환 또는뚜렛장애에대한리스페리돈의효과에관한연구가주로 2000년이후에이루어졌다는사실로써 63-65) 설명될수있을것이다. 기타공존상태와마찬가지로클로미프라민의선택은우선순위가낮았다. 본조사결과, 공존질환을동반한강박장애에서의국내전문가들의치료의적절성평가는외국의전문가의견과크게다르지않았으며, 최근의과학적증거를잘반영하고있다고판단된다. 다만, 국내전문가들은클로미프라민을선호하지않는경향이두드러지게나타나며, 양극성장애공존상태에서인지행동치료보다약물치료를선호하는경향이있다는점이주목할만한부분으로생각된다. 본연구의제한점으로는설문에응답한검토위원의수가충분치않았으며, 이들대부분이대학병원이나종합병원에서근무하는전문가들이었다는점을들수있다. 본조사결과가보다일반화되기위해서는더다양한임상환경에서의전문가들을대상으로한후속연구가필요할것이며, 이에앞서강박장애의평가와치료에관한임상적경험의확충과전문성확대가필요할것으로생각된다. 요약 본연구에서는강박장애의진단및치료에어려움을야기할수있는여러가지정신질환의공존상태에서의전문가들의약물치료선택을조사하고논의하였다. KTAP- OCD 2007은주요우울장애, 양극성장애, 공황또는사회불안장애, 정신분열병, 주의력결핍과잉행동장애, 반항 / 품행 / 반사회적장애, 그리고뚜렛장애의공존상태에서의치료적선택을질문하였고, 24명의응답을분석하였다. 주요우울장애, 불안장애, 주의력결핍과잉행동장애, 그리고뚜렛장애의공존에서는약물치료와인지행동치료의병합치료가최우선치료로꼽혔다. 정신분열병이공존하는경우에는비정형항정신병약물과 SSRI 의병용치료가최우선치료로꼽혔다. 국내전문가들은양극성장애가공존하는경우에인지행동치료에비해 SSRI 나클로미프라민의부가요법을선호하였다. 전반적으로클로미프라민은치료적선택의우선순위가떨어져이차치료의범주에해당하는경우가많았다. 이러한소견은기존의외국지침서와일반적으로일치하는경향이지만, 클로미 프라민의사용이덜선호된다는차이에주목할필요가있으며, 양극성장애의공존에서의세로토닌재흡수차단제의사용은향후더많은근거가마련될때까지주의를요하는소견으로생각된다. 중심단어 : 강박장애 공존질환 한국형치료알고리듬 약물치료 인지행동치료. 참고문헌 1) Attiullah N, Eisen JL, Rasmussen SA. Clinical features of obsessive-compulsive disorder. Psychiatr Clin North Am 2000; 23:469-491. 2) Kwon JS, Ha HT. Pharmacotherapy and the proposal of the integrative therapy model for treatment resistant obsessive-compulsive disorder. J Korean Neuropsychiatr Assoc 2003;42:302-313. 3) Torres AR, Prince MJ, Bebbington PE, Bhugra D, Brugha TS, Farrell M, et al. Obsessive-compulsive disorder: prevalence, comorbidity, impact, and help-seeking in the British National Psychiatric Morbidity Survey of 2000. Am J Psychiatry 2006;163: 1978-1985. 4) LaSalle VH, Cromer KR, Nelson KN, Kazuba D, Justement L, Murphy DL. Diagnostic interview assessed neuropsychiatric disorder comorbidity in 334 individuals with obsessive-compulsive disorder. Depress Anxiety 2004;19:163-173. 5) Rasmussen SA, Eisen JL. Clinical and epidemiologic findings of significance to neuropharmacologic trials in OCD. Psychopharmacol Bull 1988;24:466-470. 6) Abramowitz JS. Treatment of obsessive-compulsive disorder in patients who have comorbid major depression. J Clin Psychol 2004;60:1133-1141. 7) Welner A, Reich T, Robins E, Fishman R, Van Doren T. Obsessive-compulsive neurosis: record, follow-up, and family studies. I. Inpatient record study. Compr Psychiatry 1976;17:527-539. 8) Perugi G, Akiskal HS, Pfanner C, Presta S, Gemignani A, Milanfranchi A, et al. The clinical impact of bipolar and unipolar affective comorbidity on obsessive-compulsive disorder. J Affect Disord 1997;46:15-23. 9) Tukel R, Meteris H, Koyuncu A, Tecer A, Yazici O. The clinical impact of mood disorder comorbidity on obsessive-compulsive disorder. Eur Arch Psychiatry Clin Neurosci 2006;256:240-245. 10) Tukel R, Polat A, Ozdemir O, Aksut D, Turksoy N. Comorbid conditions in obsessive-compulsive disorder. Compr Psychiatry 2002;43:204-209. 11) Steketee G, Chambless DL, Tran GQ. Effects of axis I and II comorbidity on behavior therapy outcome for obsessive-compulsive disorder and agoraphobia. Compr Psychiatry 2001;42: 76-86. 12) Foa EB, Grayson JB, Steketee GS, Doppelt H G, Turner RM, Latimer PR. Success and failure in the behavioral treatment of obsessive-compulsives. J Consult Clin Psychol 1983;51:287-297. 13) den Boer JA. Psychopharmacology of comorbid obsessivecompulsive disorder and depression. J Clin Psychiatry 1997;58 (suppl 8):17-19. 14) Overbeek T, Schruers K, Vermetten E, Griez E. Comorbidity of obsessive-compulsive disorder and depression: prevalence, symptom severity, and treatment effect. J Clin Psychiatry 2002;63: 1106-1112. 15) Chen YW, Dilsaver SC. Comorbidity for obsessive-compulsive disorder in bipolar and unipolar disorders. Psychiatry Res 1995; 420
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