KISEP Review Article J Korean Neuropsychiatr Assoc Vol 42, No 3 치료저항성강박장애의약물학적치료및통합적치료모형의제안 서울대학교의과대학정신과학교실 권준수 하태현 Pharmacotherapy and the Proposal of the Integrative Therapy Model for Treatment Resistant Obsessive-Compulsive Disorder Jun Soo Kwon, MD, PhD and Tae Hyon Ha, MD Department of Psychiatry, Seoul National University Medical College, Seoul, Korea There have been considerable advances in our understanding of the neurobiology and the treatment of obsessive-compulsive disorder (OCD). However, it seems that many patients with OCD are not met with proper treatment, and even the patients who receive sufficient therapy the response rate is not high. This paper reviews the pharmacological treatments of OCD with special focus on therapeutic options for treatment resistance cases. In treating a resistant case, the clinical characteristics including comorbid conditions of the patient should be reevaluated. Through until recently, there has been no standarized guideline to treat resistance cases and much is up to clinician s preference, but thoughtful selection and combination of drugs with optimized psychosocial approach may improve the response rate. We propose an integrative therapy model for treatment resistant OCD to emphasize the need for the expansion of treatment resources. Treatment resistant OCD deserves more clinical and socioeconomic attentions and needs further research for management. (J Korean Neuropsychiatr Assoc 2003;42(3):302-313) KEY WORDS:Obsessive-Compulsive Disorder Psychopharmacotherapy Treatment resistance Therapy model. 302 서 론 -
강박장애의약물학적치료의일반적지침 강박장애의일차선택치료제 Clomipramine Fluoxetine 303
Fluvoxamine Sertraline Paroxetine Citalopram - 각 SRI의비교 304
강박장애의유지치료 강박장애의치료반응과관련된요인 - - 305
강박장애의치료저항성 306
치료저항성강박장애의약물학적치료전략 Clomipramine 경구또는 clomipramine 정주투여 단가아민산화효소억제제 (MAOIs) - Clonazepam - Inositol Clonidine - 기타의약물들 307
SRI 병합요법 - 전형적항정신병약물의강화요법 Risperidone 강화요법 - - Olanzapine 강화요법 Clozapine Quetiapine 강화요법 Pindolol 강화요법 308
Tryptophan 강화요법 Buspirone, lithium, carbamazepine, trazodone, 갑상선호르몬강화요법 효과가기대되는새로운약물들 - - 신경외과적수술 강박장애의통합적치료모형 Treatment Start 1st Phase 2nd Phase 3rd Phase 0 week 12 week SRI Augmentation or Other drug 48 week Behavioral therapy Intensive CBT TMS or Psychosurgery Fig. 1. Flow chart of obsessive-compulsive disorder treatment. SRIselective serotonin reuptake inhibitor, CBTcognitive behavioral therapy, TMStranscranial magnetic stimulation 309
Genetic Developmental Environmenatal Prevention Brain Dysfunction Orbitofrontal gyrus Others related Augmentation or Other drug Thalamus Caudate OCD Loop SRI TMS or Psychosurgery Neuropsychological Dysfunctions Executive function Nonverbal memory Visuospatial Organization Clinical Symptoms and Syndrome Cognitive Training Home-based Software Obsessions Compulsions Comorbid Conditions CBT Other Psychosocial treatment Intensive CBT Functional Impairment Relational Problems Secondary Comorbidity Family Education Poor Quality of Life Self-help group Or OCD arganization 1st line treatments Strategies for Resistance Treatments In the future Fig. 2. Integrative treatment model for obsessive-compulsive disorder. OCDobsessive-compulsive disorder, SRIselective serotonin reuptake inhibitor, CBTcognitive behavioral therapy, TMStranscranial magnetic stimulation. 310
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