An Integrative Approach to Treatment-Resistant Obsessive-Compulsive Disorder

Cognitive deficits and clinical symptoms in patients with treatment-refractory obsessive-compulsive disorder: The role of slowness in information processing

Patients with Obsessive-Compulsive Disorder (OCD) present neuropsychological deficits across different cognitive domains, especially in executive functioning and information processing speed. Some studies have even suggested that speed deficits may underlie poor neuropsychological performance. However, this hypothesis remains unanswered in both OCD general population and OCD refractory subgroup. In addition, it is not clear whether such deficits are secondary to the clinical symptoms or may constitute a primary deficit. The aim of this study was to explore the speed of processing hypothesis in treatment-refractory OCD patients, and to clarify to what extent slowness is related to psychopathological symptoms. Both clinical and neuropsychological examination was conducted to assess 39 OCD refractory patients candidates for neurosurgery and 39 healthy matched individuals. Principal component analysis revealed a three-component structure in the neuropsychological battery being used, including a speed of processing, working memory, and conflict monitoring components. Group comparisons revealed that OCD patients performed significantly worse than healthy individuals in speed measures, but no differences were found in executive tests not influenced by time. Correlation analyses revealed a lack of association between neuropsychological and clinical measures. The results suggest that treatment-refractory OCD patients exhibit a primary deficit in information processing speed independent of clinical symptoms.

Stressful Life Events and the Clinical Expression of Obsessive-Compulsive Disorder (OCD): An Exploratory Study

BACKGROUND

In obsessive-compulsive disorder (OCD), symptom content and severity appear to fluctuate over the course of the life cycle in accordance with stressful life events. The objective of this paper was to compare OCD patients with and without reported stressful life events (SLEs) in terms of the sociodemographics of patients and the clinical characteristics of OCD.

METHODS

This was a cross-sectional study involving 1001 patients with OCD. Data concerning SLEs were collected via the Yale OCD Natural History Questionnaire, while for OCD symptoms, the Dimensional Yale-Brown Obsessive-Compulsive Scale was used.

RESULTS

Of the 1001 OCD patients, 605 (60.5%) reported experiencing at least one SLE in their lifetime. Self-declared nonwhite skin color (odds ratio (OR) = 1.51), the presence of a sensory phenomenon (OR = 1.47), and comorbidity with post-traumatic stress disorder (PTSD) (OR = 2.38) were some of the logistic regression variables related to the reported SLEs with relevant statistical significance and risk (i.e., OR) values.

CONCLUSIONS

Our results indicate that SLEs may make Brazilian OCD patients vulnerable to the onset or exacerbation of obsessive-compulsive symptoms. The positive association of the occurrence of SLEs and sensory phenomena in this population could corroborate that environmental influences impact the neurobiology associated with OCD, and likely with other psychiatric disorders as well.

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.

Dynamic Psychotherapy: The Therapeutic Process in the Treatment of Obsessive-Compulsive Disorder

Dynamic Psychotherapy (DP) was developed to overcome the limitations of traditional psychoanalysis, responding to a broader demand of patients who seek help to cope with specific problems in the short term, such as Obsessive-Compulsive Disorder (OCD). OCD is a chronic disabling mental disorder that leads to substantial distress, functional disability and severe occupational and social impairments. Recognizing the literature gap in this field, and the improvements reported by dynamic therapists who have dealt with patients suffering from OCD, a study on the treatment of these patients was conducted in order to discuss the effects of this technique. The method involved a narrative literature review and the analysis of two clinical cases to discuss therapeutic processes, which include the specificities of OCD patients and the mechanisms adopted in the treatment through DP. The therapist’s active stance seemed to be essential to encourage the patient to face feared situations and identify the core conflict. Both patients who were treated through DP presented similarities, such as high anxiety, feelings of guilt and inhibition of aggressive and sexual impulses. Through emotional exploration, confrontation of defensive functioning and interpretative interventions of inner conflicts, patients had reached awareness of their hidden feelings and experiences, and their symptoms and feelings of guilt decreased. They also showed significant improvements in their interpersonal relationships. Although both treatments do not fit into short-term therapies, this technique has led to long-term results, providing evidence that DP may produce favorable outcomes in the treatment of OCD.

Innovative Educational Initiatives to Train Psychodynamic Psychiatrists in Underserved Areas of the World

Psychodynamic psychiatry remains a challenging subject to teach in underserved areas, where enthusiasm to learn is substantial. Besides logistical and psychiatric workforce shortcomings, sensible cultural adaptations to make psychodynamic psychiatry relevant outside of high-income countries require creative effort. Innovative pedagogical methods that include carefully crafted mentoring and incorporate videoconferencing in combination with site visits can be implemented through international collaborations. Emphasis on mentoring is essential to adequately train future psychodynamic psychotherapy supervisors. Examples of World Psychiatric Association initiatives in countries such as Indonesia, Iran, Malaysia, and Thailand are presented as possible models to emulate elsewhere.