An update on the efficacy of psychological therapies in the treatment of obsessive-compulsive disorder in adults

Psychologists' Diagnostic Accuracy and Treatment Recommendations for Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a debilitating condition prevalent in up to 2.3% of the population, yet obsessive-compulsive symptoms are commonly misidentified by mental health professionals, adversely impacting treatment recommendations. This study examined OCD misidentification rates across two different types of obsessions, the influence of misidentification on treatment recommendation, and attitudes associated with clinicians' decisions surrounding the diagnosis of OCD and treatment recommendations in a sample of 110 licensed psychologists. Results showed that over one-third (35.0%) of participants incorrectly diagnosed two vignettes, representing symptoms of sexual orientation OCD (SO-OCD) and symmetry. Of those who correctly diagnosed the vignettes, about half of participants (symmetry = 55.4%; SO-OCD = 47.1%) recommended exposure and response prevention (ERP) as the primary treatment choice. Participants who endorsed greater client empowerment were more likely to misdiagnose the SO-OCD vignette (t(108) = 2.97, p = 0.004). Less experience with evidence-based practice and negative attitudes toward evidence-based practice were associated with the choice of treatment other than ERP (t(71) = -2.98, p = 0.004 and t(72) = 3.40, p < 0.001, respectively). Elevated OCD misdiagnosis and its adverse impact on treatment recommendations, as well as knowledge of factors contributing to misdiagnosis and mistreatment, imply the need for greater education and training.

Exposure and response prevention versus stress management training for adults and adolescents with obsessive compulsive disorder: A randomized clinical trial

OBJECTIVE

Though exposure and response prevention (ERP) is a well-proven treatment for OCD across the lifespan, prior RCTs have not studied adolescent and adult patients with the same ERP protocol relative to an active comparator that controls for non-specific effects of treatment. This approach assesses differences in the effect of OCD-specific exposures in affected adolescents and adults and in response to ERP compared to a stress-management control therapy (SMT).

METHODS

This assessor-blinded, parallel, 2-arm, randomized, ambulatory clinical superiority trial randomized adolescents (aged 12-18) and adults (24-46) with OCD (N = 126) to 12 weekly sessions of ERP or SMT. OCD severity was measured before, during and after treatment using the child or adult version of the Yale-Brown Obsessive Compulsive Scale (C/Y-BOCS), depending on participant age. We predicted that ERP would produce greater improvement in OCD symptoms than SMT and that there would be no significant post-treatment differences across age groups.

RESULTS

ERP (n = 63) produced significantly greater improvements on C/Y-BOCS scores at post-treatment than SMT (n = 63) (Effect size = -0.72, CI = -0.52 to -0.91, p < .001). ERP also produced more treatment responders (ERP = 86%, SMT = 32%; χ2 = 46.37, p < .001) and remitters than SMT (ERP = 39%, SMT = 7%; χ2 = 16.14, p < .001). Finally, there were no statistically significant post-treatment differences in C/Y-BOCS scores between adolescents and adults assigned to ERP.

CONCLUSION

A single ERP protocol is superior to SMT in treating both adolescents and adults with OCD. OCD-specific therapy is necessary across the lifespan for optimal outcomes in this highly disabling disorder, though non-specific treatments like SMT are still all-too-commonly provided.

Things that make you go Hmm: Myths and misconceptions within cognitive-behavioral treatment of obsessive-compulsive disorder

The past four decades have yielded a robust body of evidence supporting the efficacy and effectiveness of cognitive-behavioral therapy (CBT) as a gold-standard treatment for obsessive-compulsive disorder (OCD) across the lifespan. Exposure and response prevention (E/RP) has been identified as a key component of this approach. Despite robust research support for CBT with E/RP, several myths and misconceptions continue to proliferate in both research and practice settings. Such myths and misconceptions are concerning, as they lack empirical basis, may hinder widespread dissemination and implementation of CBT for OCD, and run contrary to the practice of evidence-based psychological medicine. Focusing on the importance of promoting evidence-based practice and generative clinical science, the present review article synthesizes relevant research within the field of treatments for OCD to address the following myths / misconceptions: (a) uncertainty exists concerning the evidence base supporting CBT for OCD, (b) E/RP attrition and dropout rates are unacceptably high due to excessive risk and perceived patient intolerability, and (c) alternative treatments for OCD need to be expeditiously developed due to major limitations of E/RP. Recommendations for future research and clinical dissemination and implementation to further advance a generative clinical science of OCD treatment are discussed.

The effect of exposure and response prevention therapy on obsessive-compulsive disorder: A systematic review and meta-analysis

This meta-analysis mainly examined the effect size of exposure and response prevention (ERP) for obsessive-compulsive disorder (OCD) when compared with different control conditions, and the difference in the efficacy of different variants of ERP in the treatment of OCD. Thirty studies were included, involving 39 randomized controlled trials with 1793 participants, from 30 studies up to January 18, 2022. Hedge's g was calculated using random-effects models. The results showed that ERP had a definite effect on OCD (g = 0.37), and its effect was significant when the control condition was placebo (g = 0.97) or drug (g = 0.59). However, ERP did not show statistical differences with other therapies in improving OCD (g = -0.07). In addition, we found that both therapist and self-controlled exposure (at the same time as the therapist controls, self-control is exercised after the therapy session) and total response prevention can better improve OCD symptoms. In addition, compared with the control group, ERP reduced depression (g = 0.15) and anxiety symptoms (g = 0.23) in patients with OCD. Meta-regression results showed that the longer the length of sessions, the better the treatment effect (t = 2.41, p = 0.022).

On the automatic detection of enacted compulsive hand washing using commercially available wearable devices

BACKGROUND

Compulsive hand washing is one of the most frequent compulsions and includes highly ritualized, repetitive hand motions. Developing an algorithm that can automatically detect compulsive washing with off-the-shelf wearable devices is a first step toward developing more sophisticated sensor-based assessments and micro-interventions that might ultimately supplement cognitive behavioral therapy for obsessive-compulsive disorder (OCD).

OBJECTIVE

The main objective was to establish whether enacted compulsive hand washing can be distinguished from routine hand washing. This distinction will inform future research on the development of an algorithm that can automatically detect compulsive hand washing.

METHOD

Twenty-one participants were trained individually to wash their hands according to 1 of 5 scripted hand-washing procedures that were based on descriptions of pathological compulsive washes and additionally to wash their hands as they usually would, while wearing a smartwatch. Washes were video recorded to obtain validation data. To generate a baseline model, we opted to extract well-known features only (mean and variance of each sensor axis). We tested four classification models: linear support vector machine (SVM), SVM with radial basis functions, random forest (RF), and naive Bayes (NB). Leave-one-subject-out cross-validation was applied to gather F1, specificity, and sensitivity scores.

RESULTS

The best-performing parameters were a classification window duration of 10 s, with a mean-variance feature set calculated from quaternions, rate of turn, and magnetic flux measurements. The detection performance varied with the particular enacted compulsive hand wash (F1 range: 0.65-0.87). Overall, enacted compulsive and routine hand washing could be distinguished with an F1 score of 79% (user independent), a sensitivity of 84%, and a specificity of 30%.

CONCLUSIONS

Our analysis of the sensor data demonstrates that enacted compulsive hand washing could be distinguished from routine hand washing with acceptable sensitivity. However, specificity was low. This study is a starting point for a series of follow-ups, including the application in individuals diagnosed with OCD.

Resting-state functional connectivity of the amygdala subregions in unmedicated patients with obsessive-compulsive disorder before and after cognitive behavioural therapy

BACKGROUND

Cognitive behavioural therapy (CBT) is considered an effective first-line treatment for obsessive-compulsive disorder (OCD). However, the neural basis of CBT for OCD has not yet been elucidated. The role of the amygdala in OCD and its functional coupling with the cerebral cortex have received increasing attention, and may provide new understanding of the neural basis of CBT for OCD.

METHODS

We acquired baseline resting-state functional MRI (fMRI) scans from 45 unmedicated patients with OCD and 40 healthy controls; we then acquired another wave of resting-state fMRI scans from the patients with OCD after 12 weeks of CBT. We performed seed-based resting-state functional connectivity analyses of the amygdala subregions to examine changes in patients with OCD as a result of CBT.

RESULTS

Compared to healthy controls, patients with OCD showed significantly increased resting-state functional connectivity at baseline between the left basolateral amygdala and the right middle frontal gyrus, and between the superficial amygdala and the right cuneus. In patients with OCD who responded to CBT, we found decreased resting-state functional connectivity after CBT between the amygdala subregions and the visual association cortices and increased resting-state functional connectivity between the amygdala subregions and the right inferior parietal lobe. Furthermore, these changes in resting-state functional connectivity were positively associated with changes in scores on the compulsion or obsession subscales of the Yale-Brown Obsessive-Compulsive Scale.

LIMITATIONS

Because of the lack of a second scan for healthy controls after 12 weeks, our results may have been confounded by other variables.

CONCLUSION

Our findings yield insights into the pathophysiology of OCD; they also reveal the potential neural changes elicited by CBT, and thus have implications for guiding effective treatment strategies with CBT for OCD.

The Emergence of a Stereotypic Movement During Intensive Short-Term Dynamic Psychotherapy in a Patient with Obsessive Compulsive Disorder: A Case Report

No previous research has investigated the emergence of stereotypic movements in patients during psychotherapeutic sessions, nor have such movements been mentioned in the numerous articles on Habib Davanloo's technique of intensive short-term dynamic psychotherapy. In this article, we present two clinical vignettes from early intensive short-term dynamic psychotherapy sessions, using Davanloo's technique, with a patient who was observed to have an emerging stereotypic movement. These vignettes, extracted from the videotaped sessions using audiovisual technology, concern a young woman who is known to have treatment-resistant obsessive-compulsive disorder. By presenting this case report, we aim to highlight the possibility of the occurrence of such a movement in response to specific interventions, and propose its clinical significance. We interpret this movement as being a tension-releasing mechanism that manifests in response to the therapist's exploration of the patient's emotions. We propose that the purpose of this stereotypic movement is to defend against the patient's actual experience of her repressed feelings. Clinical outcome of this case suggests that psychodynamic psychotherapy could be an effective intervention for patients with treatment-resistant obsessive-compulsive disorder.

Patient adherence to cognitive behavioural therapy for obsessive-compulsive disorder: A systematic review and meta-analysis

Whilst cognitive behavioural therapy (CBT) is the treatment of choice for obsessive-compulsive disorder (OCD), around half of the participants do not experience remission following treatment. As yet, there is no comprehensive systematic review of the extent to which patient non-adherence presents a challenge to the overall benefit of CBT for OCD. The aim of this systematic review and meta-analysis was to identify the magnitude, moderators and reasons for poor patient adherence to CBT for OCD in terms of: (1) treatment refusal, (2) treatment dropout, (3) session attendance/module completion, and (4) between-session CBT task adherence. Sociodemographic and clinical variables, treatment and study design characteristics were examined as moderators of adherence. The systematic search identified 123 studies including 5627 participants taking part in CBT or control conditions. A pooled rate of 15.6% of eligible patients refused CBT and a further 15.9% of treatment starters dropped out from treatment. Group CBT had significantly lower dropout rates than individually-delivered CBT. No other significant moderators were found. Most studies reported moderate to good adherence to between-session CBT tasks, which had a significant medium to large association with post-treatment OCD symptom reduction. Recommendations for enhanced measurement and reporting of patient adherence to CBT for OCD are made along with clinical implications of findings.

New-wave behavioral therapies in obsessive-compulsive disorder: Moving toward integrated behavioral therapies

New-wave behavioral therapies in obsessive-compulsive disorders (OCDs) comprise of third-wave therapies and newer cognitive therapies (CTs). This review covers outcome studies published in English until December 2017. A total of forty articles on mindfulness-based CT, metacognitive therapy, acceptance and commitment therapy, and danger ideation reduction therapy in the form of single-case studies, case series, open-label trials, two-group comparison studies, and randomized controlled studies were included. Results show that studies on these therapies are limited in number. Methodological limitations including lack of active control groups, randomized controlled trials, small sample sizes, and short follow-up periods were also noted. However, the available literature demonstrates the feasibility and utility of these therapies in addressing the issues unresolved by exposure and response prevention (ERP) and cognitive behavior therapy (CBT). These therapies were often combined with traditional ERP and CBT based on the profile and response of the client; hence, it is unclear whether they can be used as standalone therapies in the larger segment of the OCD population. Supplementary use of these strategies alongside established therapies could provide better utilization of resources. In view of the need for such integration, further research is warranted. The use of sound methodologies and establishing the mechanism of action of these therapies would assist in choosing the techniques for integration.

Mindfulness-based exposure and response prevention for obsessive compulsive disorder: Findings from a pilot randomised controlled trial

BACKGROUND

Only about half of people with obsessive compulsive disorder (OCD) show clinically significant improvement following the recommended therapy, exposure and response prevention (ERP), partly due to poor therapy acceptability. A mindfulness-based approach to ERP (MB-ERP) has the potential to improve acceptability and outcomes.

METHODS

This was an internal pilot randomised controlled trial (RCT) of group MB-ERP compared to group ERP. 37 participants meeting DSM-IV OCD criteria were randomly allocated to MB-ERP or ERP.

RESULTS

Both groups improved in OCD symptom severity. However, MB-ERP did not lead to clinically important improvements in OCD symptom severity at post-intervention compared to ERP - the minimum clinically important difference was not contained in the 95% confidence intervals. There were negligible between-group differences in engagement and MB-ERP did not appear to have broader benefits compared to ERP on depression, wellbeing or OCD-related beliefs. Conversely, MB-ERP led to medium/medium-large improvements in mindfulness compared to ERP.

CONCLUSIONS

MB-ERP is unlikely to lead to clinically meaningful improvements in OCD symptom severity compared to ERP alone. We underline the importance of adhering to treatment guidelines recommending ERP for OCD. Insufficient attention may have been given to mindfulness practice/discussion in MB-ERP and further research is recommended to explore this possibility.

Responsibility/Threat Overestimation Moderates the Relationship Between Contamination-Based Disgust and Obsessive-Compulsive Concerns About Sexual Orientation

Disgust has been shown to perform a "disease-avoidance" function in contamination fears. However, no studies have examined the relevance of disgust to obsessive-compulsive (OC) concerns about sexual orientation (e.g., fear of one's sexual orientation transforming against one's will, and compulsive avoidance of same-sex and/or gay or lesbian individuals to prevent that from happening). Therefore, we investigated whether the specific domain of contamination-based disgust (i.e., evoked by the perceived threat of transmission of essences between individuals) predicted OC concerns about sexual orientation, and whether this effect was moderated/amplified by obsessive beliefs, in evaluation of a "sexual orientation transformation-avoidance" function. We recruited 283 self-identified heterosexual college students (152 females, 131 males; mean age = 20.88 years, SD = 3.19) who completed three measures assessing disgust, obsessive beliefs, and OC concerns about sexual orientation. Results showed that contamination-based disgust (β = .17), responsibility/threat overestimation beliefs (β = .15), and their interaction (β = .17) each uniquely predicted OC concerns about sexual orientation, ts = 2.22, 2.50, and 2.90, ps < .05. Post hoc probing indicated that high contamination-based disgust accompanied by strong responsibility/threat overestimation beliefs predicted more severe OC concerns about sexual orientation, β = .48, t = 3.24, p < .001. The present study, therefore, provided preliminary evidence for a "sexual orientation transformation-avoidance" process underlying OC concerns about sexual orientation in heterosexual college students, which is facilitated by contamination-based disgust, and exacerbated by responsibility/threat overestimation beliefs. Treatment for OC concerns about sexual orientation should target such beliefs.

Using bivariate latent basis growth curve analysis to better understand treatment outcome in youth with anorexia nervosa

OBJECTIVE

This study explored the relation between eating-related obsessionality and weight restoration utilizing bivariate latent basis growth curve modelling. Eating-related obsessionality is a moderator of treatment outcome for adolescents with anorexia nervosa (AN). This study examined the degree to which the rate of change in eating-related obsessionality was associated with the rate of change in weight over time in family-based treatment (FBT) and individual therapy for AN.

METHOD

Data were drawn from a 2-site randomized controlled trial that compared FBT and adolescent focused therapy for AN. Bivariate latent basis growth curves were used to examine the differences of the relations between trajectories of body weight and symptoms associated with eating and weight obsessionality.

RESULTS

In the FBT group, the slope of eating-related obsessionality scores and the slope of weight were significantly (negatively) correlated. This finding indicates that a decrease in overall eating-relating obsessionality is significantly associated with an increase in weight for individuals who received FBT. However, there was no relation between change in obsessionality scores and change in weight in the adolescent focused therapy group.

DISCUSSION

Results suggest that FBT has a specific impact on both weight gain and obsessive compulsive behaviour that is distinct from individual therapy.

Psychosocial interventions for internalizing disorders in youth and adults with ASD

Internalizing disorders are common in individuals with ASD. Psychosocial interventions targeting these disorders in the ASD population have burgeoned in the last decade. Cognitive-behavioural therapy, modified for ASD, is the most frequently investigated model, although other interventions, including behaviour therapy, third-wave interventions, models targeting transdiagnostic constructs, and alternative interventions and treatment delivery methods are now emerging. This review provides a summary of the efficacy of these interventions in treating internalizing disorders in youth and adults with ASD. The barriers to accessing these treatments, which are experienced by many individuals with ASD and their families, as well as future research directions, are also discussed.

Effectiveness of Cognitive Behavioral Therapy for Individuals with Autism Spectrum Disorders and Comorbid Obsessive-Compulsive Disorder: A Review of the Research

Autism spectrum disorders (ASD) and obsessive-compulsive disorder (OCD) are highly comorbid, precipitating an urgent need to identify evidence-based practices that might be used to address this comorbidity exclusively. The aim of this study was to conduct a review of intervention research and clinical reports to examine the use of cognitive behavioral therapy (CBT) with individuals who have comorbid ASD and OCD. Based on the pre-determined review inclusion criteria, 11 studies were included in the review: three randomized control trials (RCT), one case controlled study, two single subject experimental designs, and five case studies. These studies offer promising data on the use of CBT interventions for individuals with ASD and comorbid OCD as well as for individuals with OCD and comorbid ASD when standard CBT protocol is enhanced with modifications such as parental involvement, increased use of visuals, personalized treatment metaphors, self-monitoring, positive reinforcement, and use of clear language and instructions. Limitations and implications for future research and practice are discussed.

Obsessive–compulsive disorder in young people

Obsessive–compulsive disorder (OCD) is one of the most debilitating psychiatric conditions in young people. In DSM-5 it is no longer characterised as an anxiety disorder, but instead is part of a group of ‘obsessive–compulsive and related disorders'. In the past 10 years, cognitive—behavioural therapy (CBT) has become well established as the first-choice treatment. This article explains some of the elements of CBT and describes new directions in research which might improve interventions.

A randomized controlled study of brief family-based intervention in obsessive compulsive disorder

BACKGROUND

Cognitive behaviour therapy (CBT) for Obsessive Compulsive Disorder (OCD) is therapist-intensive and prolonged making it less accessible to patients, particularly in resource-constrained situations. We examined the efficacy of a brief psychotherapeutic intervention as an adjunct to serotonin reuptake inhibitors (SRIs) in OCD.

METHOD

We randomized 64 adult OCD patients stabilized on SRIs to either the 6-session brief family-based intervention (BFBI; n = 30) that included psychoeducation, exposure and response prevention and family intervention or to a control arm of relaxation exercises (RE). Assessments were conducted at baseline and at 1- and 3- months post-intervention. Primary outcome measure was response to treatment defined as ≥ 35% reduction in the Yale-Brown Obsessive Compulsive Scale total score relative to baseline score plus a Clinical Global Impression- Improvement rating of very much improved or much improved. Family accommodation and expressed emotions were also assessed.

RESULTS

At 3- month follow-up, the BFBI group responded better than the RE group (53% vs. 12%, p < 0.001). Illness severity, family accommodation and expressed emotion declined significantly over time in the BFBI group compared to the RE group. The BFBI (OR = 13.17, p < 0.001) and baseline illness severity (OR = 0.746, p < 0.011) predicted treatment response.

LIMITATIONS

Sample size was small and follow-up duration was short. Control group had less time with the therapist although number of sessions was identical in both the groups.

CONCLUSION

Briefer intervention is effective in treating OCD. Briefer and inclusive format of intervention has important implications for clinical practice in resource-constrained circumstances.

Does patient reluctance towards exposure and psychologists' attitudes about evidence based practice influence treatment recommendations for panic disorder? An experimental investigation

This study examined the effects of patient reluctance towards exposure on practitioners' subsequent treatment recommendations. Participants (N=236) were doctoral level psychologists who received a vignette of a patient with panic disorder, which either did (experimental group) or did not (control group) mention patient reluctance towards exposure. Evidence Based Practice (EBP) attitudes were also assessed and taken into account. A significant main effect of reluctance, averaged across all levels of EBP attitudes, and theoretical orientations was obtained (OR=2.85, 95% CI=[1.51, 5.39], p=0.001, RR=1.46), with controls 1.46 times more likely to recommend exposure. A significant main effect of EBP attitudes was also obtained (p<0.001). The odds of recommending exposure increased by 11% with each increase of positive EBP attitudes, across both levels of patient reluctance and theoretical orientation.

An Integrative Approach to Treatment-Resistant Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a debilitating psychiatric disorder that often runs a chronic unremitting course. Treatment outcomes can be unsatisfactory despite the availability of various somatic and psychological therapies. Psychodynamic psychotherapy in combination with cognitive behavioral therapy (CBT) with exposure and response prevention (ERP) could help patients with treatment-resistant OCD achieve better outcomes. An integrative approach can help patients gain insight, strengthen the therapeutic alliance, improve treatment adherence, and provide symptomatic relief when other treatments seem insufficient or have failed. We describe the treatment process of a person with treatment-resistant OCD who received pharmacotherapy, concurrent CBT/ERP, and a brief course of psychodynamic psychotherapy. Case formulations from cognitive behavioral and psychodynamic perspectives are presented. The authors discuss the advantages of doing a psychodynamic assessment and formulation in treatment refractory cases and the wisdom of integrating psychotherapy interventions for OCD, as well as the unique clinical features of cases that warrant a multimodal treatment approach.

“Winter Is Coming!”—Treatment of Obsessive-Compulsive Disorder Imagery After Viewing the Television Series Game of Thrones

This article presents the detailed case of a 27-year-old man who began to suffer from intrusive imagery after watching a brutal scene in the TV series Game of Thrones. The content of the intrusive imagery included images of people with enucleated eyes and was initially accompanied by anxiety about sharp objects. The patient’s mental distress was assessed by the Yale-Brown Obsessive Compulsive Scale and the Impact of Event Scale—Revised, and the patient was diagnosed with obsessive-compulsive disorder (OCD). Eye movement desensitization and reprocessing (EMDR) therapy was provided to treat related distressing memories and the intrusive imagery. As treatment progressed, more complex and layered aspects of the symptom presentation became evident, and EMDR was integrated with other treatments. These included psychodynamic psychotherapy to address his complicated relationship with his father, exposure and response prevention (ERP) therapy to reduce avoidance of sharp objects, and cognitive therapy (CT) for aggressive violent thoughts toward others. The article identifies the various clinical decision points and discusses theoretical conceptualizations and related factors. This clinical case report provides additional support for the body of knowledge on the relationship between traumatic events and imagery in OCD. Therefore, trauma-focused treatments, such as EMDR therapy, which concentrates specifically on those experiences, might be especially effective.

Cognitive-behavioural therapy for obsessive-compulsive disorder co-occurring with psychosis: Systematic review of evidence

AIM

To review available evidence on the use of cognitive behavioural therapy (CBT) for treating obsessive compulsive disorder co-occurring with psychosis.

METHODS

In this paper we present a detailed and comprehensive review of the current literature focusing on CBT treatment of obsessive compulsive disorder (OCD) co-occurring with schizophrenia or schizoaffective disorder. We identified relevant literature published between 2001 and May 2016 through MEDLINE/PubMed search using as search string (“obsessive compulsive disorders” or “obsessive compulsive symptoms”) and (“schizophrenia” or “schizoaffective disorder” or “psychosis”) and (“cognitive behavioural therapy”). Other citations of interest were further identified from references reported in the accessed articles. The search was limited to studies written in English and carried out in adult patients. A total of 9 studies, 8 case reports and 1 case series, were found.

RESULTS

The reviewed evidence indicates that CBT is: (1) safe, i.e., does not worsen psychotic symptoms; (2) well accepted, with a discontinuation rate quite similar to that reported for patients with OCD without psychosis comorbidity; (3) effective, with a symptom reduction quite similar to that reported for patients with OCD without psychosis and for SRIs treatment of OCD co-occurring with psychosis; and (4) effective in patients with OCD induced by second-generation antipsychotic as well as in patients with OCD not induced by second-generation antipsychotic. Alcohol/substance use disorder comorbidity and OCD onset preceding that of SCH/SA was predictors of poor outcome. These results are derived only by additional studies with adequate sample size.

CONCLUSION

Our results support the use of CBT for OCD in patients with psychosis.

The putative catalytic role of higher serotonin bioavailability in the clinical response to exposure and response prevention in obsessive-compulsive disorder

Objective:

Exposure and response prevention (ERP) is effective to treat obsessive-compulsive disorder (OCD), but the lack of tolerance to the aversion nature of exposure techniques results in a high drop-out rate. There have been reports of a generic stress endurance effect of serotonin (5-HT) in the central nervous system (CNS) which might be explained by suppression of defensive fixed action patterns. Previous studies have proposed that higher baseline 5-HT concentration and slow decrease in concentration during drug treatment of OCD were predictors of good clinical response to 5-HT reuptake inhibitors. The objective of this study was to investigate whether pre-treatment platelet rich plasma (PRP) 5-HT concentration is associated with latency of treatment response and final response to an ERP protocol for obsessive-compulsive disorder (OCD).

Methods:

Thirty adult and treatment-free OCD patients were included in an 8-week, 16-session ERP protocol. 5-HT concentration was determined at baseline and after treatment. Patients with a reduction ≥30% on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) at the end of ERP were defined as responders.

Results:

A positive correlation between baseline 5-HT concentration and reduction of symptoms on the Y-BOCS was observed after 4 weeks. Baseline 5-HT concentration was not correlated with clinical response after 8 weeks of ERP, possibly due to the similar though delayed clinical response of patients with lower (compared to those with higher) baseline 5-HT concentration. Patients with higher 5-HT baseline concentration also showed more improvement in depressive symptoms with treatment.

Conclusion:

The present results partially support the hypothesis of a stress endurance effect of 5-HT in OCD patients. According to the literature, fast onset responders possibly have more or larger 5-HT containing neurons, higher endogenous 5-HT synthesis or lower monoamine oxidase activity; all these hypotheses remain to be investigated.

Predictors of response to cognitive behaviour therapy for obsessive-compulsive disorder

Response to psychological treatment for Obsessive-Compulsive Disorder (OCD) varies, and dropout and relapse rates remain troubling. However, while studies examining symptom reductions are favourable, outcomes are less encouraging when outcome is defined in terms of clinically significant change. Moreover, there is little understanding of what predicts treatment outcome. This study examined demographic, symptomatic and cognitive predictors of outcome in 79 participants undertaking individualised cognitive-behavioural therapy for OCD. After investigating differences between treatment completers and non-completers, we examined treatment response as defined by post-treatment symptom severity and clinically reliable change, as well as predictors of treatment response. Completers were less likely to present with co-morbidity. The treatment was highly efficacious irrespective of whether completer or intention-to-treat analysis was undertaken, with 58% of treatment completers considered “recovered” at post-treatment. Lower pre-treatment levels of OCD symptoms and greater perfectionism/intolerance of uncertainty were the best unique predictors of OCD severity outcomes at post-treatment. Changes in obsessional beliefs were associated with symptomatic change, although only perfectionism/intolerance of uncertainty was a significant unique predictor of post-treatment change. Recovery status was predicted only by pre-treatment OCD severity. In helping to identify those at risk for poorer outcomes, such research can lead to the development of more effective interventions.

The effectiveness of psychodynamic psychotherapies: An update

This paper provides a comprehensive review of outcome studies and meta-analyses of effectiveness studies of psychodynamic therapy (PDT) for the major categories of mental disorders. Comparisons with inactive controls (waitlist, treatment as usual and placebo) generally but by no means invariably show PDT to be effective for depression, some anxiety disorders, eating disorders and somatic disorders. There is little evidence to support its implementation for post-traumatic stress disorder, obsessive-compulsive disorder, bulimia nervosa, cocaine dependence or psychosis. The strongest current evidence base supports relatively long-term psychodynamic treatment of some personality disorders, particularly borderline personality disorder. Comparisons with active treatments rarely identify PDT as superior to control interventions and studies are generally not appropriately designed to provide tests of statistical equivalence. Studies that demonstrate inferiority of PDT to alternatives exist, but are small in number and often questionable in design. Reviews of the field appear to be subject to allegiance effects. The present review recommends abandoning the inherently conservative strategy of comparing heterogeneous "families" of therapies for heterogeneous diagnostic groups. Instead, it advocates using the opportunities provided by bioscience and computational psychiatry to creatively explore and assess the value of protocol-directed combinations of specific treatment components to address the key problems of individual patients.

The prediction of treatment outcomes by early maladaptive schemas and schema modes in obsessive-compulsive disorder

BACKGROUND

Higher levels of early maladaptive schemas (EMS) and schema modes according to schematherapy by Jeffrey Young are present in obsessive-compulsive disorder (OCD) compared to healthy controls. This study examines the relationship of EMS and schema modes to OC symptom severity and the predictive value of EMS and schema modes on treatment outcome in inpatients receiving Cognitive-Behavioral Therapy (CBT) with Exposure and Response Prevention (ERP). The main assumption was a negative association between the EMS of the domain 'disconnection' and dysfunctional coping and parent schema modes and the treatment outcome.

METHODS

EMS, schema modes, depression and traumatic childhood experiences were measured in 70 patients with OCD. To analyze the predictors, two regression analyses were conducted considering multiple variables, such as depression, as covariates.

RESULTS

Regression analyses demonstrated that higher scores on the EMS named failure and emotional inhibition and depressive symptom severity at pretreatment were significantly related to poor outcome and explained a high percentage of the variance in OC symptoms at posttreatment. No influence on the treatment outcome was observed for schema modes, other EMS or other covariates.

CONCLUSIONS

The results support the approach to extend the CBT with ERP treatment with therapeutic elements focusing on maladaptive schemas, particularly in non-responders.

CBT for OCD: habituation or cognitive shift?

Cognitive Behavioural Therapy (CBT) including Exposure and Response Prevention (ERP) is recommended by NICE as the psychological treatment of choice for obsessive compulsive disorder (OCD). Twenty-five percent of OCD patients refuse ERP, and many psychologists advocate formulation-driven cognitive therapy, including ERP, as opposed to ERP alone. However, a recent meta-analysis suggested there is insufficient evidence to suggest ERP is improved by cognitive methods. This paper proposes to contribute to this debate by providing a detailed description of the treatment of a patient with intrusive cognitions of a sexual nature, who was treated successfully using behavioural experiments designed to test cognitions, rather than ERP. This is, arguably, the way in which most cognitive behavioural therapists would work with someone with OCD. However, this approach is not reflected in the literature at present. The authors report the patient's feedback that therapeutic change was brought about through cognitive shift, as a result of the formulation-driven behavioural experiments.

Clinical practice: Obsessive-compulsive disorder

A 19-year-old man is brought to his primary physician by his father, who explains that his son washes his hands a hundred times a day, will not touch anything that has been touched by someone else without scrubbing it first, and has a fear of germs that has left him isolated in his bedroom, unable to eat, and wishing he were dead. Although the father reports that his son has always been finicky, this problem started approximately 2 years ago and has gradually become completely disabling. How should this patient be evaluated and treated?

Study protocol for a randomised controlled trial of internet-based cognitive-behavioural therapy for obsessive-compulsive disorder

BACKGROUND

Obsessive-Compulsive Disorder (OCD) is a common chronic psychiatric disorder that constitutes a leading cause of disability. Although Cognitive-Behaviour Therapy (CBT) has been shown to be an effective treatment for OCD, this specialised treatment is unavailable to many due to access issues and the social stigma associated with seeing a mental health specialist. Internet-based psychological treatments have shown to provide effective, accessible and affordable treatment for a range of anxiety disorders, and two Randomised Controlled Trials (RCTs) have demonstrated the efficacy and acceptability of internet-based CBT (iCBT) for OCD, as compared to waitlist or supportive therapy. Although these initial findings are promising, they do not isolate the specific effect of iCBT. This paper details the study protocol for the first randomised control trial evaluating the efficacy of therapist-assisted iCBT for OCD, as compared to a matched control intervention; internet-based therapist-assisted progressive relaxation training (iPRT). It will aim to examine whether therapist-assisted iCBT is an acceptable and efficacious treatment, and to examine how effectiveness is influenced by patient characteristics.

METHOD/DESIGN

A randomised controlled trial using repeated measures with two arms (intervention and matched control) will be used to evaluate the efficacy and acceptability of iCBT for OCD. The RCT will randomise 212 Australian adults with a primary diagnosis of OCD into either the active intervention or control condition, for 12 weeks duration. Outcomes for participants in both study arms will be assessed at baseline and post-intervention. Participants in iCBT will be further assessed at six month follow-up, while participants in the control condition will be crossed over to receive the iCBT intervention and reassessed at post-intervention and six month follow-up. The primary outcome will be clinically significant change in obsessive-compulsive symptom scores.

DISCUSSION

This will be the first known therapist assisted internet-based trial of a comprehensive CBT treatment for OCD as compared to a matched control intervention. Demonstrating the efficacy of an internet-based treatment for OCD will allow the development of models of care for broad-based access to an evidence-based but complex treatment.

Moving Perspectives on Patient Competence: A Naturalistic Case Study in Psychiatry

Patient competence, defined as the ability to reason, appreciate, understand, and express a choice is rarely discussed in patients with obsessive compulsive disorder (OCD), and coercive measures are seldom used. Nevertheless, a psychiatrist of psychologist may doubt whether OCD patients who refuse treatment understand their disease and the consequences of not being treated, which could result in tension between respecting the patient's autonomy and beneficence. The purpose of this article is to develop a notion of competence that is grounded in clinical practice and corresponds with the experiences of patients with obsessions and/or compulsions. We present a naturalistic case study giving both the patient's and the therapist's perspective based on in-depth interviews and a narrative analysis. The case study shows that competence is not merely an assessment by a therapist, but also a co-constructed reality shaped by the experiences and stories of patient and therapist. The patient, a medical student, initially told her story in a restitution narrative, focusing on cognitive rationality. Reconstructing the history of her disease, her story changed into a quest narrative where there was room for emotions, values and moral learning. This fitted well with the therapist's approach, who used motivational interventions with a view to appealing to the patient's responsibility to deal with her condition. We conclude that in practice both the patient and therapist used a quest narrative, approaching competence as the potential for practical reasoning to incorporate values and emotions.

When more is less: doubt, repetition, memory, metamemory, and compulsive checking in OCD

Memory and metamemory phenomena associated with obsessive-compulsive disorder (OCD) have received much attention in literature dedicated to a better understanding of the doubt and repetition associated with obsessions and compulsions. Following previous work on repeated checking among nonclinical participants, we asked participants to repeatedly turn on, turn off and check a real kitchen stove (n = 30 compulsive checkers diagnosed with OCD and n = 30 non-clinical undergraduates), or a real kitchen faucet (n = 30 non-clinical undergraduates) in a standardized, ritualized manner, in two connected experiments. Results indicated that following repeated relevant checking, both clinical and nonclinical participants reported significantly reduced memory confidence, vividness and detail; those who completed repeated irrelevant checking did not. The effects of repeated checking on memory accuracy were also explored. Results are discussed in terms of cognitive-behavioural formulations of OCD and in terms of the effects of repetition on memory and metamemory in association with checking behaviour.

Emerging drugs to treat obsessive-compulsive disorder

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a chronic and disabling neuropsychiatric disorder with a lifetime prevalence of approximately 1 - 2% and a rate of treatment resistance of 40%. Other disorders have been related to OCD and have been grouped together in a separate DSM-5 chapter, hypothesizing the existence of an 'OC spectrum', showing a paradigm shift in the conceptualization of the disorder.

AREAS COVERED

A review of the most important and recent neurobiological findings that sustain the hypothesis of a more sophisticated model of the disorder is provided, together with a brief overview of the most relevant pharmacological animal models of OCD and its first-line treatments. Current research goals, new compounds tested and the rationale behind the development of these new pharmacologic agents are then explained and reviewed.

EXPERT OPINION

In the past years, no effective novel compounds have emerged for the treatment of OCD, even if many efforts has been made in the study of its neurobiological underpinnings. Relevant changes in the conceptualization of the disorder, suggested by interesting new neurobiological evidences, may result helpful in the development of new treatments.

Commonly asked questions in the treatment of obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a common and often a highly disabling condition that was considered untreatable before the 1960s. The advent of serotonin reuptake inhibitors and exposure and response prevention revolutionized the treatment of OCD. Although they are still the first line treatments for OCD, new treatments like augmentation strategies, brain stimulation techniques, psychosurgery, newer forms of psychotherapy (like cognitive therapy, acceptance and commitment therapy) have been added to the armamentarium. With the available treatment strategies, many patients can achieve at least partial remission of symptoms. Nevertheless, the plethora of information gives rise to many questions on their application for practicing clinicians. We provide evidence-based responses to these questions and suggest a broad guideline for treatment of OCD.