Dimensional predictors of response to SRI pharmacotherapy in obsessive-compulsive disorder

Aripiprazole augmentation in 13 patients with refractory obsessive-compulsive disorder: a case series

OBJECTIVES

The primary treatment for obsessive-compulsive disorder (OCD) is selective serotonin reuptake inhibitors (SSRI). However, approximately a third of patients do not respond to SSRIs and remain chronically affected.

METHODS

Therefore, we added aripiprazole to SSRI therapy for 13 patients with treatment-refractory OCD (subjects who failed to respond to SSRI therapy for at least 2 months, and for an average of 508 days). Participants underwent at least 7 weeks of treatment with aripiprazole augmentation.

RESULTS

Patients were evaluated using the Y-BOCS and GAF scales. Aripiprazole (3-12 mg)/SSRI co-therapy significantly improved Y-BOCS and GAF scores. However, many patients needed to take antiparkinsonian drugs to control extrapyramidal symptoms.

CONCLUSIONS

These results suggest that aripiprazole augmentation of SSRI therapy may be effective for treatment-refractory OCD.

Glutamate abnormalities in obsessive compulsive disorder: neurobiology, pathophysiology, and treatment

Obsessive compulsive disorder is prevalent, disabling, incompletely understood, and often resistant to current therapies. Established treatments consist of specialized cognitive-behavioral psychotherapy and pharmacotherapy with medications targeting serotonergic and dopaminergic neurotransmission. However, remission is rare, and more than a quarter of OCD sufferers receive little or no benefit from these approaches, even when they are optimally delivered. New insights into the disorder, and new treatment strategies, are urgently needed. Recent evidence suggests that the ubiquitous excitatory neurotransmitter glutamate is dysregulated in OCD, and that this dysregulation may contribute to the pathophysiology of the disorder. Here we review the current state of this evidence, including neuroimaging studies, genetics, neurochemical investigations, and insights from animal models. Finally, we review recent findings from small clinical trials of glutamate-modulating medications in treatment-refractory OCD. The precise role of glutamate dysregulation in OCD remains unclear, and we lack blinded, well-controlled studies demonstrating therapeutic benefit from glutamate-modulating agents. Nevertheless, the evidence supporting some important perturbation of glutamate in the disorder is increasingly strong. This new perspective on the pathophysiology of OCD, which complements the older focus on monoaminergic neurotransmission, constitutes an important focus of current research and a promising area for the ongoing development of new therapeutics.

The involvement of distinct neural systems in patients with obsessive-compulsive disorder with autogenous and reactive obsessions

OBJECTIVE

To investigate the regional metabolite abnormalities and changes after treatment in patients with OCD with autogenous and reactive obsessions.

METHOD

We assessed right anterior cingulate cortex (ACC) and amygdala-hippocampal region (Am + Hpp) N-acetyl-aspartate (NAA), choline (Cho) and creatine (Cr) concentrations and NAA/Cr and Cho/Cr ratios using single-voxel proton magnetic resonance spectroscopy in 15 patients with autogenous obsessions (OCD-A), 15 patients with reactive obsessions (OCD-R) and 15 healthy controls (HC). Measurements were repeated after 16 weeks of fluoxetine treatment.

RESULTS

Baseline ACC NAA/Cr ratios of both OCD groups were significantly lower than HC. OCD-A group had significantly lower baseline NAA/Cr ratios in the Am + Hpp than other groups. These differences were more likely to be explained by higher Cr levels in ACC. We found no significant differences and changes for Cho levels and Cho/Cr ratios between groups and within groups. Significant increase in NAA/Cr ratios of OCD-A group found in the Am + Hpp was more likely to be explained by increased NAA levels. No significant changes were found in ACC NAA/Cr ratios.

CONCLUSION

While disturbed energy metabolism in ACC might reflect a common pathology in patients with OCD regardless of symptom dimension, alterations in mesiotemporal lobe are more likely for autogenous obsessions.

Evidence for successful implementation of exposure and response prevention in a naturalistic group format for pediatric OCD

BACKGROUND

Although exposure and response prevention (ERP) is an effective treatment for youth with obsessive-compulsive disorder (OCD), the majority of studies, randomized clinical trials of individual therapy, find variability in treatment response. We evaluated the potential role of individual differences in OCD presentation, comorbid disorders, age, and gender on treatment effects. Moreover, we examined these potential effects in a group format in a naturalistic, clinic-based sample of patients.

METHODS

Pediatric patients with a DSM-IV diagnosis of OCD (n=41) were treated with ERP in an intensive outpatient community-based program. OCD, mood, and anxiety symptom severity was measured at baseline, during treatment, and at discharge. Trajectories and predictors of treatment outcome were measured using linear growth models.

RESULTS

We found that group-based ERP was effective in reducing pediatric OCD symptom severity in a naturalistic treatment setting irrespective of age or gender. Furthermore, ERP was found to be effective at reducing depressive symptoms but not other anxiety symptoms. We also found inter-individual variability in the discharge levels of contamination, symmetry, and intrusive sexual thoughts and in the rate of severity reduction of intrusive sexual thoughts.

CONCLUSION

Group-based ERP is an effective treatment for children and adolescents with OCD. Several factors, including symptom dimensions and comorbid psychopathology, are associated with treatment response and outcome in this pediatric population.

Predictors of early adulthood quality of life in children with obsessive-compulsive disorder

OBJECTIVES

The goal of this study was to determine childhood clinical predictors of quality of life (QoL) in early adulthood in children with obsessive-compulsive disorder (OCD).

METHODS

A longitudinal cohort study was conducted with 36 (out of 62 eligible) children with OCD, interviewed once at childhood baseline (mean age 12.1 ± 2.1, range 8.0-15.8), and again in early adulthood after an average follow-up interval of 9 years. QoL was measured in adulthood with the longitudinal interval follow-up evaluation range of impaired functioning tool (LIFE-RIFT).

RESULTS

Forty-two percent of children experienced a remission of OCD symptoms by early adulthood. OCD appeared to most strongly impair the interpersonal relationships and work domains of QoL. QoL and severity of OCD and anxiety symptoms were significantly associated in early adulthood. Primary hoarding symptoms in childhood predicted poor QoL in adulthood. Increased symptoms in the forbidden thoughts dimension in both childhood and adulthood were associated with improved adulthood QoL.

CONCLUSIONS

Children for whom OCD symptoms remitted by adulthood showed no evidence of residual impairment in QoL, whereas children whose OCD symptoms failed to remit by adulthood showed at most mild impairment in QoL. Hoarding symptoms in childhood appear to portend not only the persistence of OCD symptoms but also poorer QoL in early adulthood.

Aripiprazole augmentation in 39 adolescents with medication-resistant obsessive-compulsive disorder

The aim of this study was to assess efficacy of aripiprazole augmentation of serotonin reuptake inhibitor (SRI) treatment in adolescents with obsessive-compulsive disorder (OCD) who did not respond to 2 initial trials with SRI monotherapy. A consecutive series of 39 adolescents (28 males and 11 females; age range, 12 to 18 years; mean age, 14.6 ± 1.2 years), with OCD diagnosed based on a clinical interview and according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria, were included. The mean final aripiprazole dosage was 12.2 ± 3.4 mg/d. At the endpoint, 27 patients (59.0%) had a Clinical Global Impression (CGI)-Improvement score 1 or 2 (very much or much improved) and a Clinical Global Impression-Severity (CGI-S) score 3 or below and were thus considered responders. The CGI-S improved from 6.0 ± 0.9 at the baseline (severely to extremely severely ill) to 3.5 ± 1.0 (mild to moderately ill) at the end of the follow-up (P < 0.0001), whereas the Children's Global Assessment Scale improved from 39.2 ± 5.8 to 49.8 ± 9.0 (P < 0.0001). Compared with nonresponders, responders were less impaired at the baseline in functional impairment (Children's Global Assessment Scale; P = 0.004) but not in clinical severity (CGI-S). Subtypes of OCD comorbidity and absence of insight did not affect clinical response. Mild transitory agitation (10.3%), mild sedation (10.3%), and sleep disorders (7.7%) were reported, but any of the patients discontinued medication because of adverse effects.In these severely impaired adolescents, aripiprazole augmentation of SRIs was well tolerated and effective in more than half of the patients.

The clinical utility of symptom dimensions in obsessive-compulsive disorder

Factor analyses in obsessive-compulsive disorder (OCD) have consistently identified several different symptom dimensions. Nevertheless the clinical utility of identifying such symptom dimensions remains somewhat unclear. On the basis of their principal symptoms, 343 OCD patients were divided into four symptom dimension subgroups; 1) contamination/washing, 2) hoarding, 3) symmetry/repeating and ordering, and 4) forbidden thoughts/checking. Clinical variables including 1-year treatment outcome were compared across these patient subgroups. Most patients (74%) could distinctively be categorized as falling into a particular symptom subgroup. The groups were differentially characterized by some demographic and clinical features. For instance, both the symmetry and hoarding groups were significantly associated with decreased global functioning and greater OCD severity. Moreover the hoarding group was significantly more likely than the others to show longer duration of illness, lower rate of marriage, poor insight, and poorer outcome. However, about a quarter of the participants could not be classified definitively into a particular group. Our findings provide partial support for the clinical utility of a simple measure of symptom dimensions in OCD. In clinical settings, however, the limitations of such a simple measure of predominant symptom dimensions should be borne in mind and further work on their validity and utility is needed.

Psychometric analysis of the Yale-Brown Obsessive-Compulsive Scale Second Edition Symptom Checklist

The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) was recently revised to address several clinical and conceptual issues. The resultant measure, named the Yale-Brown Obsessive-Compulsive Scale-Second Edition, consists of two primary scales: the Severity Scale and the Symptom Checklist. Although the Severity Scale has been the subject of a comprehensive psychometric analysis, no data have been reported on the psychometric properties of the Y-BOCS-II Symptom Checklist (Y-BOCS-II-SC). Accordingly, in the present study, clinician ratings on the Y-BOCS-II-SC for 130 patients with obsessive-compulsive disorder (OCD) were examined on a number of validity and reliability indices. Partially consistent with past factor analytic studies of the Y-BOCS Symptom Checklist, the Y-BOCS-II-SC yielded four factors representing symmetry/ordering, contamination/washing, hoarding, and sexual/religious/aggression dimensions; checking rituals cross-loaded with other dimensions. Generally, the Y-BOCS-II-SC dimensions were internally consistent and rated stably across raters and over a short interval. The Y-BOCS-II-SC symptom dimensions showed good convergence with self-reported obsessive-compulsive symptoms, and were at best moderately associated with divergent measures (e.g., OCD symptom severity, depressive symptoms, and symptoms of anxiety). Overall, the Y-BOCS-II-SC shows good psychometric properties; we highlight several domains in which the Y-BOCS-II-SC may have clinical and research utility, as well as several areas for future study.

Obsessive-compulsive disorder: a review of the diagnostic criteria and possible subtypes and dimensional specifiers for DSM-V

BACKGROUND

Since the publication of the DSM-IV in 1994, research on obsessive-compulsive disorder (OCD) has continued to expand. It is timely to reconsider the nosology of this disorder, assessing whether changes to diagnostic criteria as well as subtypes and specifiers may improve diagnostic validity and clinical utility.

METHODS

The existing criteria were evaluated. Key issues were identified. Electronic databases of PubMed, ScienceDirect, and PsycINFO were searched for relevant studies.

RESULTS

This review presents a number of options and preliminary recommendations to be considered for DSM-V. These include: (1) clarifying and simplifying the definition of obsessions and compulsions (criterion A); (2) possibly deleting the requirement that people recognize that their obsessions or compulsions are excessive or unreasonable (criterion B); (3) rethinking the clinical significance criterion (criterion C) and, in the interim, possibly adjusting what is considered "time-consuming" for OCD; (4) listing additional disorders to help with the differential diagnosis (criterion D); (5) rethinking the medical exclusion criterion (criterion E) and clarifying what is meant by a "general medical condition"; (6) revising the specifiers (i.e., clarifying that OCD can involve a range of insight, in addition to "poor insight," and adding "tic-related OCD"); and (7) highlighting in the DSM-V text important clinical features of OCD that are not currently mentioned in the criteria (e.g., the major symptom dimensions).

CONCLUSIONS

A number of changes to the existing diagnostic criteria for OCD are proposed. These proposed criteria may change as the DSM-V process progresses.

Symptom dimensions and subtypes of obsessive-compulsive disorder: a developmental perspective

In the absence of definitive etiological markers for obsessive-compulsive disorder (OCD% obsessive-compulsive (OC) symptom dimensions may offer a fruitful point of orientation. These dimensions can be understood as defining potentially overlapping clinical features that may be continuous with "normal" worries first evident in childhood. Although the understanding of the dimensional structure of OC symptoms is still imperfect, a recent large-scale meta-analysis has confirmed the presence of at least four separa ble symptom dimensions in children, as well as adults, with OCD. A dimensional approach does not exclude other methods to parse OCD. Thus far, a pediatric age of onset, the presence of other family members with OCD, and the individual's "tic-related" status appear to be potentially useful categorical distinctions. Although the OC symptom dimensions appear to be valid for all ages, it is unlikely that the underlying genetic vulnerability factors and neurobiological substrates for each of these symptom dimensions are the same across the course of development.

Symptom dimensions and subtypes of obsessive-compulsive disorder: a developmental perspective

In the absence of definitive etiological markers for obsessive-compulsive disorder (OCD% obsessive-compulsive (OC) symptom dimensions may offer a fruitful point of orientation. These dimensions can be understood as defining potentially overlapping clinical features that may be continuous with "normal" worries first evident in childhood. Although the understanding of the dimensional structure of OC symptoms is still imperfect, a recent large-scale meta-analysis has confirmed the presence of at least four separa ble symptom dimensions in children, as well as adults, with OCD. A dimensional approach does not exclude other methods to parse OCD. Thus far, a pediatric age of onset, the presence of other family members with OCD, and the individual's "tic-related" status appear to be potentially useful categorical distinctions. Although the OC symptom dimensions appear to be valid for all ages, it is unlikely that the underlying genetic vulnerability factors and neurobiological substrates for each of these symptom dimensions are the same across the course of development.