Patterns of remission and relapse in obsessive-compulsive disorder: a 2-year prospective study

Long-term stability in obsessive thoughts and compulsive behavior in the general population: a longitudinal study in Sweden

OBJECTIVE

Obsessive thoughts and compulsive behavior and their related disorder Obsessive-Compulsive Disorder (OCD) commonly occur in the general population. Clinical populations indicate a high level of stability, although there are few longitudinal studies in the general population. The recommended drug treatments are SSRIs/TCAs. However, there are few long-term follow up studies. The goal of this study was to 1) examine the occurrence and stability of obsessions, compulsions, and OCD in a longitudinal population-based survey, 2) investigate the use of SSRI and TCA and the potential effect on symptoms.

METHODS

A ten-year longitudinal general population in Stockholm was used (2000 and 2010, n = 5650) Obsessional washing, checking, intrusive unpleasant thoughts and the level of suffering due to these symptoms were measured by self-report. Information on use of SSRIs and TCAs by these individuals was obtained from registers. Stability was examined using contingency tables and multinomial logistic regression.

RESULTS

At baseline, 2.1, 11.7 and 11.9% reported obsessional washing, checking and intrusive thoughts. A total of 5% reported considerable suffering from these (i.e. OCD). Based on psychiatric interview only 0.4% had OCD. Ten years later a quarter of OCD cases were still classified as having OCD, one quarter reported any obsessive or compulsive symptom and half were classified as symptom-free. Treatment receipt was low and controlling for medication did not change the stability.

CONCLUSION

Obsessive thoughts and compulsive behavior are common and stable. While this group is potentially undertreated, there is no indication that those treated display a different pattern of recovery.

Microbial Reprogramming in Obsessive-Compulsive Disorders: A Review of Gut-Brain Communication and Emerging Evidence

Obsessive-compulsive disorder (OCD) is a debilitating mental health disorder characterized by intrusive thoughts (obsessions) and repetitive behaviors (compulsions). Dysbiosis, an imbalance in the gut microbial composition, has been associated with various health conditions, including mental health disorders, autism, and inflammatory diseases. While the exact mechanisms underlying OCD remain unclear, this review presents a growing body of evidence suggesting a potential link between dysbiosis and the multifaceted etiology of OCD, interacting with genetic, neurobiological, immunological, and environmental factors. This review highlights the emerging evidence implicating the gut microbiota in the pathophysiology of OCD and its potential as a target for novel therapeutic approaches. We propose a model that positions dysbiosis as the central unifying element in the neurochemical, immunological, genetic, and environmental factors leading to OCD. The potential and challenges of microbial reprogramming strategies, such as probiotics and fecal transplants in OCD therapeutics, are discussed. This review raises awareness of the importance of adopting a holistic approach that considers the interplay between the gut and the brain to develop interventions that account for the multifaceted nature of OCD and contribute to the advancement of more personalized approaches.

Symptom improvement and remission in untreated adults seeking treatment for obsessive-compulsive disorder: A systematic review and meta-analysis

Obsessive-compulsive disorder (OCD) is a common psychiatric condition that results in significant distress and impairment, and high societal costs. OCD is widely considered to be a chronic condition, however, our understanding of the chronicity of the disorder, and the incidence of spontaneous remission, has largely relied on longitudinal studies of individuals who have received treatment. The aim of the current study is to examine symptom improvement and rate of spontaneous remission in individuals with OCD who were assigned to a no-treatment control group within a randomized controlled trial using a meta-analytic approach. Twelve studies (n = 282; mean age = 35.52; 60.03 % female) were included in the meta-analysis. The pooled within-group effect size was negligible (g = -0.14; 95 % CI [-0.25, -0.04]) and only 4 % of participants demonstrated spontaneous remission across an average of 10.92 weeks (event rate = 0.04; [95 % CI: 0.01, 0.11]). Sample size and duration of OCD symptoms significantly moderated the effect size for symptom change. No moderators were found for symptom remission. The findings add to the small body of literature demonstrating that OCD has a chronic and unremitting course without treatment.

Efficacy and fMRI-based response predictors to mindfulness-based cognitive therapy in obsessive-compulsive disorder: Study protocol for a randomised clinical trial

BACKGROUND

Around 40-50% of patients with obsessive-compulsive disorder (OCD) suffer from obsessions and compulsions after receiving first-line treatments. Mindfulness-based cognitive therapy (MBCT) has been proposed as a reasonable augmentation strategy for OCD. MBCT trains to decentre from distressful thoughts and emotions by focusing on them voluntarily and with consciousness. This practice develops alternative ways to deal with obsessions, which could increase non-reactivity behaviours and, in turn, reduce compulsions. This study aims to investigate the efficacy of MBCT to improve OCD symptoms. Secondly, it pursues to investigate which socio-demographic, clinical, and neurobiological characteristics mediate or moderate the MBCT response; and identify potential biomarkers of positive/negative response.

METHODS

This study is a randomised clinical trial (RCT) of 60 OCD patients who do not respond to first-line treatments. Participants will be randomised to either an MBCT program or treatment as usual. The MBCT group will undergo 10 weekly sessions of 120min. Principal outcome: change in OCD severity symptoms using clinician and self-reported measures. Also, participants will undergo a comprehensive evaluation assessing comorbid clinical variables, neuropsychological functioning and thought content. Finally, a comprehensive neuroimaging protocol using structural and functional magnetic resonance imaging will be acquired in a 3T scanner. All data will be obtained at baseline and post-intervention.

DISCUSSION

This study will assess the efficacy of mindfulness in OCD patients who do not achieve clinical recovery after usual treatment. It is the first RCT in this subject examining clinical, neuropsychological and neuroimaging variables to examine the neural patterns associated with the MBCT response.

CLINICAL TRIALS REGISTRATION

NCT03128749.

A New Scrupulosity Scale for the Dimensional Obsessive-Compulsive Scale (DOCS): Validation With Clinical and Nonclinical Samples

Scrupulous obsessions are a prominent presentation of obsessive-compulsive disorder (OCD). Previous conceptualizations of scrupulosity have indicated that it belongs to the unacceptable thoughts dimension, which pertains to sexual, violent, and religious obsessive themes. However, research suggests that scrupulous symptoms may differ from other unacceptable thoughts symptoms, necessitating the need for targeted and thorough assessment. We added a Scrupulous or Religious Thoughts subscale (DOCS-SR) to the Dimensional Obsessive-Compulsive Scale (DOCS) and tested its factorial structure, psychometric properties, and clinical correlates in a nonclinical and clinical sample. In the first study, nonclinical participants (N = 203) completed the DOCS-SR, which was subjected to an exploratory factor analysis. Analyses revealed that the DOCS-SR reflected a one-factor solution and possessed acceptable internal consistency, as well as strong convergent validity with clinical correlates of OCD. In the second study, we administered the DOCS, as well as the DOCS-SR to a clinical sample (N = 314). An exploratory factor analysis and confirmatory factor analysis both suggested that the four subscales and additional DOCS-SR represented a five-factor solution. Internal consistency and convergent validity were strong. The DOCS Unacceptable Thoughts subscale and the DOCS-SR shared a moderate correlation but evidenced differences in associations with other correlates. This suggested both convergent and divergent validity. Collectively, our results support the utility of examining the individual components of the unacceptable thoughts dimension of OCD for effective assessment and treatment planning.

Behavioral Therapy Teams for Obsessive-Compulsive Disorder: Lessons Learned From a Pilot Randomized Trial in a Community Mental Health Center

Community mental health centers (CMHCs) provide the majority of mental health services for low-income individuals in the United States. Exposure and response prevention (ERP), the psychotherapy of choice for obsessive-compulsive disorder (OCD), is rarely delivered in CMHCs. This study aimed to establish the acceptability and feasibility of testing a behavioral therapy team (BTT) intervention to deliver ERP in CMHCs. BTT consisted of individual information-gathering sessions followed by 12 weeks of group ERP and concurrent home-based coaching sessions. The sample consisted of 47 low-income individuals with OCD who were randomized to receive BTT or treatment as usual (TAU). Symptom severity and quality-of-life measures were assessed at pretreatment, posttreatment, and 3- and 6-month posttreatment. Feasibility of training CMHC staff was partially successful. CMHC therapists successfully completed rigorous training and delivered ERP with high fidelity. However, training paraprofessionals as ERP coaches was more challenging. ERP was feasible and acceptable to patients. BTT participants were more likely than TAU participants to attend their first therapy session and attended significantly more treatment sessions. A large between-group effect size was observed for reduction in OCD symptoms at posttreatment but differences were not maintained across 3- and 6-month follow-ups. For BTT participants, within-group effect sizes reflecting change from baseline to posttreatment were large. For TAU participants, depression scores did not change during the active treatment phase but gradually improved during follow-up. Results support feasibility and acceptability of ERP for this patient population. Findings also underscore the importance of implementation frameworks to help understand factors that impact training professionals.

Naturalistic outcome of medication-naïve obsessive compulsive disorder treated with serotonin reuptake inhibitors

OBJECTIVE

The data on the course of obsessive compulsive disorder (OCD) is mostly derived from studying chronic, severely ill patients with varying degree of treatment resistance. We studied the course and outcome of OCD patients who were medication-naïve at initial assessment compared to those who were medicated.

MATERIAL AND METHODS

We analyzed the clinical chart data of all patients with a primary diagnosis of OCD attending a speciality OCD clinic in India during a specified period and compared outcome between medication-naïve (n = 75) and medicated (n = 117) patients.

RESULTS

The mean time to remission was shorter in the medication-naïve [18.99 months (95 % CI: 14.61-23.37)] compared to medicated [33.91 months (95 % CI: 27.55-40.28)] patients. The survival distribution of the two groups was significantly different as per the log-rank test (χ2 = 5.76, p = 0.02). In the Cox proportional hazards regression, medication-naïve status predicted time to remission. Overall, the rate of remission was the same in both groups (57 %).

CONCLUSIONS

Medication-naïve OCD patients seem to remit faster than the previously treated patients. Future prospective naturalistic studies can compare the outcome of medication naïve OCD patients treated with medications and CBT.

A Naturalistic Study of the Maintenance of Gains Made With Treatment of Patients With Profound Treatment-Refractory Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) generally responds to first-line treatment but patients often relapse. The United Kingdom National OCD Inpatient Service treats patients who have failed to respond to at least two trials of SRI, augmented with a dopamine blocker and two trials of ERP. Despite this, they have profound treatment-refractory OCD and require 24-h nursing care due to severe OCD. We examined patients' Y-BOCS score on admission, discharge and at each follow-up from all patients discharged over 5 years (02/01/2014-31/12/18). Data were analysed using SPSS. Paired student t-tests were used to assess improvement from admission to discharge and each follow-up. Over 5 years, 130 adult patients were treated: 79 male and 51 female with an average age of 42.3 years (20-82; sd14.4). Their ethnic backgrounds were; 115 Caucasian, 11 South Asian, 1 Chinese, and 3 Unspecified. On admission, the average Y-BOCS total score was 36.9 (30-40; sd2.6). At discharge, patients had improved on average by 36% (Y-BOCS reduction to 23.4 = moderate OCD). Similar reduction in Y-BOCS continued throughout the year with an average Y-BOCS of 22.9 at 1 month (n = 69); 23 at 3 months (n = 70); 21.3 at 6 months (n = 78) and 21.9 at 1 year (n = 77). Twenty-seven patients did not attend any follow-up appointment whilst others attended at least one appointment with the majority attending more than 3. Using student t-test, improvements at discharge, 1, 3, 6, and 12 months post-treatment showed a highly significant improvement (p < 0.001). Gains made following inpatient treatment for treatment-refractory OCD were generally maintained until 1 year post-treatment.

Childhood trauma and attachment style predict the four-year course of obsessive compulsive disorder: Findings from the Netherlands obsessive compulsive disorder study

INTRODUCTION

Obsessive compulsive disorder (OCD) is a chronic psychiatric disorder where most patients do not reach full symptomatic remission. Identifying predictors of course can improve patients' care by informing clinicians on prognosis and enhancing treatment strategies. Several predictors associated with improved outcome of OCD were identified. However, research focused mainly on clinical, illness-related predictors of the course of OCD. This study examined the contribution of environmental and interpersonal predictors on the long-term outcome of OCD, in addition to the previously identified clinical indicators.

METHODS

We used the baseline, two and four-year data of 382 adult OCD patients participating in the naturalistic cohort study of the Netherlands Obsessive Compulsive Disorder Association (NOCDA). Remission was assessed using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). Predictors of outcome were assessed at baseline, via clinician-rated and self-report instruments.

RESULTS

Remission at two and at four-year follow-up ranged from 11% to 26%. Early age of onset and the presence of childhood trauma predicted a worse four-year course. Secure attachment style emerged as a protective predictor of improved outcome.

LIMITATIONS

The naturalistic design of our study did not enable a systematic estimation the effect of treatments received during the follow-up period. Furthermore, age of onset and childhood trauma were assessed retrospectively, which may contribute to recall bias.

CONCLUSION

Results coincide with previous prediction research and stress the importance of adaptive interpersonal functioning in the course of OCD. Clinical implications and future research directions are discussed.

Catechol-O-methyltransferase gene Val158Met polymorphism and obsessive compulsive disorder susceptibility: a meta-analysis

Obsessive-compulsive disorder (OCD) is a common psychiatric disorder that affects approximately 1-3% of the general population. It is characterized by disabling obsessions (intrusive unwanted thoughts) and/or compulsions (ritualized repetitive behaviors). Catechol-O-methyltransferase (COMT) enzyme has an important role in inactivation of dopamine and higher dopamine levels may be implicated in OCD, hence COMT gene is a suitable candidate for OCD. Several case-control studies have evaluated the role of COMT Val 158Met (rs4680;472G- > A) polymorphism as a risk factor for OCD but the results remained inconclusive, hence present meta-analysis was designed to find out correct assessment. All studies that investigated the association of COMT gene Val158Met polymorphism with OCD risk, were considered in the present meta-analysis. Statistical analysis was performed with the software program MetaAnalyst. In the current meta-analysis, 14 case-control studies with 1435 OCD cases and 2753 healthy controls were included. The results indicated significant association between COMT Val158Met polymorphism and OCD risk using allele contrast, homozygote and dominant models (OR_{A vs G} = 1.14; 95% CI = 1.02-1.27; p = 0.01; OR_AAvs.GG = 1.33; 95% CI = 1.09-1.62, p = 0.004; OR_{AA + AGvs.GG} = 1.14; 95% CI = 1.0-1.32; p = 0.04). In subgroup analysis based on case gender, meta-analysis of male cases showed significant association using all five genetic models (OR_AAvsGG = 1.99; 95%CI = 1.42-2.59; p = <0.001; OR_{AA + AGvs.GG} = 1.59; 95% CI = 1.20-2.10; p = 0.001), but did not show any association between COMT Val 158Met polymorphism and OCD risk in females. In conclusion, results of present meta-analysis supports that the COMT Val158Met polymorphism is a risk factor for OCD especially for males.

The heterogeneous course of OCD - A scoping review on the variety of definitions

Although effective treatments exist, obsessive-compulsive disorder (OCD) is, according to the views of patients and experts, still associated with chronicity, a term with no clear and consistent definition. To improve patient care and to foster research, a clear distinction between the various concepts of chronicity cited in the literature is crucial. The aim was thus to explicate central concepts related to courses and trajectories in OCD based on an explorative, scoping search of the existing literature. Our review revealed a considerable lack in content validity, as the concepts were operationalized inconsistently. Concepts related to symptom improvement were (complete) recovery, partial/full remission and partial/full response. Terms used in relation with symptom stability or worsening were chronic/continuous, intermittent and episodic course, waxing and waning, relapse, recurrence, deterioration and treatment-refractoriness. All concepts are explained and visualized as a result of the review. Further, based on authors' remarks, we present recommendations on how to enhance care for chronic OCD patients, namely training psychotherapists to apply CBT as intended, managing patient beliefs about disease and treatment, and adapting psychotherapy to OCD subtypes. Finally, we then propose a literature-based definition of treatment-refractory OCD.

Comorbidity of Obsessive-Compulsive Disorder and Schizotypal Personality Disorder: Clinical Response and Treatment Resistance to Pharmacotherapy in a 3-Year Follow-Up Naturalistic Study

The present study aims to analyze the clinical and socio-demographic characteristics of patients with obsessive-compulsive disorder (OCD) in comorbidity with schizotypal personality disorder (SPD), as well as the response rate to pharmacological treatments. OCD+SPD patients had a younger age at onset, a higher probability to have more severe obsessive-compulsive symptoms, a higher rate of schizophrenia spectrum disorders in their first-degree relatives, and a poorer insight compared to OCD patients. During the 3-year follow-up period, these patients showed a lower rate of recovery, thus requiring augmentation with different psychotropic medications, including low doses of antipsychotics. Our findings suggest that the comorbidity of OCD and SPD causes a poor treatment response, and a reduced probability to recover using standard pharmacological treatment strategies. Further investigations are needed to identify alternative strategies, including psychoeducation and cognitive behavioral therapy, to manage such frequent comorbidity in clinical practice.

Course and outcome of obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is generally believed to follow a chronic waxing and waning course. The onset of illness has a bimodal peak - in early adolescence and in early adulthood. Consultation and initiation of treatment are often delayed for several years. Studies over the past 2-3 decades have found that the long-term outcomes in OCD are not necessarily bleak and that at least half the treatment-seeking patients with OCD show symptomatic remission over long term. A short duration illness, of low severity that is treated early and intensively, with continued maintenance treatment over long term possibly has a good outcome. Recent studies have also identified neuroimaging and neuropsychological correlates of good outcome, but these need further replication. This paper presents an overview of conceptual issues and studies on long-term outcome of OCD and predictors of outcome.

The role of personality disorders in obsessive-compulsive disorder

Personality disorders are a common comorbidity in obsessive-compulsive disorder (OCD). The effect of comorbidity on the symptom presentation, course, and treatment outcome of OCD is being discussed here. OCD and obsessive-compulsive personality disorder (OCPD) though similar in their symptom presentation, are distinct constructs. Schizotypal disorder, OCPD, and two or more comorbid personality disorders have been found to be consistently associated with a poor course of illness and treatment response. Further research is needed to determine treatment strategies to handle the personality pathology in OCD.

A call for prevention and early intervention in obsessive-compulsive disorder

BACKGROUND

Evidence suggests that many people with obsessive-compulsive disorder (OCD) have subclinical symptoms years before the development of their disorder and that early treatment may reduce its severity.

AIM

To explore prevention and early intervention strategies for OCD.

METHODS

A narrative literature review was conducted.

RESULTS

The literature in relation to the prevention of OCD is sparse. Genetic and environmental factors appear to be relevant to the aetiology of OCD, for example, the observation that hoarding symptoms and contamination/cleaning symptoms are more likely to also be present in first-degree relatives. Psychoeducation and the reduction of family accommodation, that is the act of parents, siblings or partners accommodating to the high-risk individual's requests to comply with their compulsions, are promising areas for prevention and early intervention in high-risk groups. Tertiary prevention has also been limited by an inadequate number of trained clinicians to deliver evidence-based treatments.

CONCLUSIONS

Much more research is needed in relation to the prevention of OCD. There is limited scope for primary prevention with respect to biological aetiological factors, but there is potential for strategies addressing environmental factors (eg, family factors). The effectiveness of psychoeducation for parents with OCD as a primary prevention strategy for OCD in their children requires scientific evaluation. Improving access to effective treatments for OCD would also improve tertiary prevention.

Acceptability, Feasibility, and Effectiveness of Internet-Based Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder in New York

Cognitive-behavioral therapy (CBT), consisting of exposure and response prevention (EX/RP), is both efficacious and preferred by patients with obsessive-compulsive disorder (OCD), yet few receive this treatment in practice. This study describes the implementation of an Internet-based CBT program (ICBT) developed in Sweden in individuals seeking OCD treatment in New York. After translating and adapting the Swedish ICBT for OCD, we conducted an open trial with 40 adults with OCD. Using the RE-AIM implementation science framework, we assessed the acceptability, feasibility, and effectiveness of ICBT. The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was the primary outcome measure. Of 40 enrolled, 28 participants completed the 10-week ICBT. In the intent-to-treat sample (N = 40), Y-BOCS scores decreased significantly over time (F = 28.12, df = 2, 49, p < . 001). Depressive severity (F = 5.87, df = 2, 48, p < . 001), and quality of life (F = 12.34, df = 2, 48, p < . 001) also improved. Sensitivity analyses among treatment completers (N = 28) confirmed the intent-to-treat results, with a large effect size for Y-BOCS change (Cohen's d = 1.38). ICBT took less time to implement than face-to face EX/RP and participants were very to mostly satisfied with ICBT. On a par with results in Sweden, the adapted ICBT program reduced OCD and depressive symptoms and improved quality of life among individuals with moderate to severe OCD. Given its acceptability and feasibility, ICBT deserves further study as a way to increase access to CBT for OCD in the United States.

Ten-year follow-up study of Japanese patients with obsessive-compulsive disorder

AIM

Obsessive-compulsive disorder (OCD) is a well-known chronic illness. This study retrospectively investigated 10-year outcomes and associated clinical factors in Japanese OCD patients. We focused on the impact of several sociocultural factors, including medical expenses and insurance systems specific to each country, on the differences or biases in follow-up procedures of OCD.

METHODS

Seventy-nine patients diagnosed with OCD who received a standardized combination of treatments for 10 continuous years were divided into three groups according to their improvement rates on the Yale-Brown Obsessive-Compulsive Scale after 10 years of treatment.

RESULTS

A survival analysis revealed that the rate of patients achieving full remission increased every year. Following 10 years of treatment, 56% of OCD patients experienced 'full remission' for at least 1 year. Consequently, 48% exhibited full remission, and 37% exhibited partial remission at the end-point of this study. We identified several factors that were predictive of poorer outcomes, including lower Global Assessment of Functioning Scale scores and the presence of hoarding symptoms or involvement behaviors. In addition, improvement rates after 1 year significantly predicted better 10-year outcomes.

CONCLUSION

Our findings highlight the transcultural nature of long-term outcomes of OCD treatment, which appear to be independent of sociocultural differences.

Cortico-Striatal-Thalamic Loop Circuits of the Orbitofrontal Cortex: Promising Therapeutic Targets in Psychiatric Illness

Corticostriatal circuits through the orbitofrontal cortex (OFC) play key roles in complex human behaviors such as evaluation, affect regulation and reward-based decision-making. Importantly, the medial and lateral OFC (mOFC and lOFC) circuits have functionally and anatomically distinct connectivity profiles which differentially contribute to the various aspects of goal-directed behavior. OFC corticostriatal circuits have been consistently implicated across a wide range of psychiatric disorders, including major depressive disorder (MDD), obsessive compulsive disorder (OCD), and substance use disorders (SUDs). Furthermore, psychiatric disorders related to OFC corticostriatal dysfunction can be addressed via conventional and novel neurostimulatory techniques, including deep brain stimulation (DBS), electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), and transcranial direct current stimulation (tDCS). Such techniques elicit changes in OFC corticostriatal activity, resulting in changes in clinical symptomatology. Here we review the available literature regarding how disturbances in mOFC and lOFC corticostriatal functioning may lead to psychiatric symptomatology in the aforementioned disorders, and how psychiatric treatments may exert their therapeutic effect by rectifying abnormal OFC corticostriatal activity. First, we review the role of OFC corticostriatal circuits in reward-guided learning, decision-making, affect regulation and reappraisal. Second, we discuss the role of OFC corticostriatal circuit dysfunction across a wide range of psychiatric disorders. Third, we review available evidence that the therapeutic mechanisms of various neuromodulation techniques may directly involve rectifying abnormal activity in mOFC and lOFC corticostriatal circuits. Finally, we examine the potential of future applications of therapeutic brain stimulation targeted at OFC circuitry; specifically, the role of OFC brain stimulation in the growing field of individually-tailored therapies and personalized medicine in psychiatry.

How durable is the effect of low intensity CBT for depression and anxiety? Remission and relapse in a longitudinal cohort study

BACKGROUND

Depression and anxiety disorders are relapse-prone conditions, even after successful treatment with pharmacotherapy or psychotherapy. Cognitive behavioural therapy (CBT) is known to prevent relapse, but there is little evidence of the durability of remission after low intensity forms of CBT (LiCBT).

METHOD

This study aimed to examine relapse rates 12 months after completing routinely-delivered LiCBT. A cohort of 439 LiCBT completers with remission of symptoms provided monthly depression (PHQ-9) and anxiety (GAD-7) measures during 12 months after treatment. Survival analysis was conducted to model time-to-relapse while controlling for patient characteristics.

RESULTS

Overall, 53% of cases relapsed within 1 year. Of these relapse events, the majority (79%) occurred within the first 6 months post-treatment. Cases reporting residual depression symptoms (PHQ-9 = 5 to 9) at the end of treatment had significantly higher risk of relapse (hazard ratio = 1.90, p < 0.001).

CONCLUSIONS

The high rate of relapse after LiCBT highlights the need for relapse prevention, particularly for those with residual depression symptoms.

Defining cognitive-behavior therapy response and remission in pediatric OCD: a signal detection analysis of the Children's Yale-Brown Obsessive Compulsive Scale

The objective of the study was to examine the optimal Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) percent reduction and raw cutoffs for predicting cognitive-behavioral treatment (CBT) response among children and adolescents with obsessive-compulsive disorder (OCD). The sample consisted of children and adolescents with OCD (N = 241) participating in the first step of the Nordic long-term OCD treatment study and receiving 14 weekly sessions of CBT in the form of exposure and response prevention. Evaluations were conducted pre- and post-treatment, included the CY-BOCS, Clinical Global Impressions-severity/improvement. The results showed that the most efficient CY-BOCS cutoffs were 35 % reduction for treatment response, 55 % reduction for remission, and a post-treatment CY-BOCS raw total score of 11 for treatment remission. Overall, our results diverge from previous research on pediatric OCD with more conservative cutoffs (higher cutoff reduction for response and remission, and lower raw score for remission). Further research on optimal cutoffs is needed.

An empirical investigation of incompleteness in a large clinical sample of obsessive compulsive disorder

Obsessive Compulsive Disorder (OCD) is a disorder with heterogeneous clinical presentations. To advance our understanding of this heterogeneity we investigated the prevalence and clinical features associated with incompleteness (INC), a putative underlying core feature of OCD. We predicted INC would be prominent in individuals with OCD and associated with greater severity and impairment. We examined the impact of INC in 307 adults with primary OCD. Participants with clinically significant INC (22.8% of the sample) had significantly greater OCD severity, greater rates of comorbidity, poorer ratings of functioning, lower quality of life, and higher rates of unemployment and disability. Participants with clinically significant INC were also more likely to be diagnosed with OCPD and to endorse symmetry/exactness obsessions and ordering/arranging compulsions than those who reported low INC. Our findings provide evidence that INC is associated with greater severity, comorbidity, and impairment, highlighting the need for improved assessment and treatment of INC in OCD.

Obsessive-compulsive disorder in pregnancy and the postpartum period: course of illness and obstetrical outcome

The study aimed to examine the course of obsessive-compulsive disorder (OCD) across pregnancy and its impact on obstetric and neonatal outcomes. Women enrolled prior to 20-week gestation in a prospective, observational study. The Structured Clinical Interview for DSM-IV was completed to obtain lifetime Axis I diagnoses. A total of 56 women with OCD were followed at 1 to 3-month intervals through 52 weeks postpartum. Each visit, the Yale-Brown Obsessive Compulsive Scale (YBOCS), clinical assessment, and medication/exposure tracking were performed. Obstetric and neonatal data were abstracted from the medical record. In subjects with OCD, associations between perinatal obsessive-compulsive symptoms (OCSs) and outcomes were examined. Additionally, outcomes were compared to 156 matched psychiatric patients without OCD. Maternal age inversely correlated with the YBOCS scores across the study period (β = -0.5161, p = .0378). Cesarean section was associated with increased OCSs in the postpartum period compared to vaginal delivery (β = 5.3632, p = 0.043). No associations were found between severity of perinatal obsessions or compulsions and any specific obstetric or neonatal complications. Subjects without OCD had higher frequency of fetal loss compared to mothers with OCD (χ (2) = 4.03, p = 0.043). These novel prospective data fail to identify an association of OCSs with adverse outcomes. In contrast, there is an association of delivery method and younger maternal age with increased postnatal symptoms of OCD. Psychiatric subjects without OCD may have a higher risk of miscarriage and intrauterine fetal demise compared to subjects with OCD.

Cognitive behavioral therapy in pharmacoresistant obsessive-compulsive disorder

BACKGROUND

The aim of the study was to determine whether patients with obsessive-compulsive disorder (OCD) resistant to drug therapy may improve their condition using intensive, systematic cognitive behavioral therapy (CBT) lasting for 6 weeks, and whether it is possible to predict the therapeutic effect using demographic, clinical, and selected psychological characteristics at baseline.

METHODS

Sixty-six OCD patients were included in the study, of which 57 completed the program. The diagnosis was confirmed using the structured Mini International Neuropsychiatric Interview. Patients were rated using the objective and subjective forms of the Yale-Brown Obsessive Compulsive Scale, objective and subjective forms of the Clinical Global Impression, Beck Anxiety Inventory, Beck Depression Inventory, Dissociative Experiences Scale, 20-item Somatoform Dissociation Questionnaire, and the Sheehan Disability Scale before their treatment, and with subjective Yale-Brown Obsessive Compulsive Scale, objective and subjective Clinical Global Impression, Beck Anxiety Inventory, and Beck Depression Inventory at the end of the treatment. Patients were treated with antidepressants and daily intensive group CBT for the 6-week period.

RESULTS

During the 6-week intensive CBT program in combination with pharmacotherapy, there was a significant improvement in patients suffering from OCD resistant to drug treatment. There were statistically significantly decrease in the scores assessing the severity of OCD symptoms, anxiety, and depressive feelings. A lower treatment effect was achieved specifically in patients who 1) showed fewer OCD themes in symptomatology, 2) showed a higher level of somatoform dissociation, 3) had poor insight, and 4) had a higher initial level of overall severity of the disorder. Remission of the disorder was more likely in patients who had 1) good insight, 2) a lower initial level of anxiety, and 3) no comorbid depressive disorder.

Factors Associated with Depression in Obsessive-Compulsive Disorder: A Cross-Sectional Study

INTRODUCTION

Major depressive disorder (MDD) is the most frequent comorbid psychiatric condition associated with obsessive-compulsive disorder (OCD). This study aimed to evaluate the prevalence of current depression in OCD, differences in socio-demographic and clinical characteristics, and obsessive-compulsive symptoms between OCD patients with and without depression. Additionally, factors associated with comorbid depression were investigated in our study.

METHODS

In total, 140 OCD patients, of which 63 were OCD patients with MDD (OCD+MDD, n=63) and 77 were OCD patients without depression (OCD-MDD, n=77) were included in the study. All patients were diagnosed with OCD using the Structured Clinical Interview for DSM-IV. The Yale-Brown Obsessive-Compulsive Scale, Beck Anxiety Scale, and Beck Depression Scale were administered to all patients. After the socio-demographic and clinical variables and scales were accomplished, the OCD patients divided into two groups as OCD with or without depression and we compared their mean scores of the variables and scales. Univariate analyses were followed by logistic regression.

RESULTS

There were no significant differences in age, gender, marital status, period without treatment, profession, medical and family history, and social support between the two groups. Anxiety, depression, and obsession and compulsion scores were significantly higher in the OCD+MDD group. The avoidance, insight, instability, and retardation scores of the OCD+MDD group were also significantly higher than those of the OCD-MDD group.

CONCLUSION

Our study suggests that many factors are strongly associated with depression in OCD. Positive correlations between poor insight, severity of obsession and compulsion, and stressful life events during the last six months increased the risk of depression in OCD. Our study suggests that high level of avoidance, instability and retardation, history of suicidal attempt, and delayed treatment are other notable factors associated with the development of depression in OCD.

Predictive value of familiality, stressful life events and gender on the course of obsessive-compulsive disorder

BACKGROUND

Familiality, stressful life events (SLE) and gender significantly affect the onset of obsessive-compulsive disorder (OCD). However, their combined impact on the probability of OCD chronicity is largely unknown. With the objective of clarifying their predictive value, we tested a model of interaction effects between these influences.

METHODS

A sample of 449 patients with OCD was systematically assessed for familial loading, exposure to stressful life events, gender and course of the disease at the OCD referral unit at Bellvitge University Hospital. Multiple ordinal logistic regression was used to test interaction models.

RESULTS

Familiality presented a main negative association with chronicity (OR=0.83, CI97.5%=0.70-0.98). This association was additively moderated by both exposure to SLE before onset and gender, and showed a positive slope among female patients not exposed to SLE before onset (Familiality*SLEbo: OR=0.69, CI97.5%=0.47-1; Familiality*gender: OR=1.30, CI97.5%=0.91-1.84).

LIMITATIONS

The findings are based on cross-sectional data. Assessment of course is based on a retrospective measure, which may imply the possibility of overestimation of chronicity.

CONCLUSIONS

The predictive value of familiality on the course of OCD is only partially informative as both SLEbo and gender modify the association. When other risk factors are included in the model, familiality may predict decreased chances of chronicity. The mediation effects identified could explain the discrepancies found in previous research on this topic. Increased chances of presenting a chronic course of OCD may be found in association with familial vulnerability among female patients not exposed to SLEbo.

Cognitive-behavioral therapy for obsessive-compulsive disorder: access to treatment, prediction of long-term outcome with neuroimaging

This article reviews issues related to a major challenge to the field for obsessive-compulsive disorder (OCD): improving access to cognitive-behavioral therapy (CBT). Patient-related barriers to access include the stigma of OCD and reluctance to take on the demands of CBT. Patient-external factors include the shortage of trained CBT therapists and the high costs of CBT. The second half of the review focuses on one partial, yet plausible aid to improve access - prediction of long-term response to CBT, particularly using neuroimaging methods. Recent pilot data are presented revealing a potential for pretreatment resting-state functional magnetic resonance imaging and magnetic resonance spectroscopy of the brain to forecast OCD symptom severity up to 1 year after completing CBT.

Homosexual Obsessive Compulsive Disorder (HOCD): A Rare Case Report

Homosexual Obsessive Compulsive Disorder (HOCD) is marked by excessive fear of becoming or being homosexual. The subjects often experience intrusive, unwanted mental images of homosexual behaviour. The excessive uncontrolled thoughts/doubts are very distressing and lead to compulsions in form of checking. We present a rare such case who was suffering from HOCD.

Brain connectivity and prediction of relapse after cognitive-behavioral therapy in obsessive-compulsive disorder

BACKGROUND

Intensive cognitive-behavioral therapy (CBT) can effectively reduce symptoms in obsessive-compulsive disorder (OCD). However, many relapse after treatment. Few studies have investigated biological markers predictive of follow-up clinical status. The objective was to determine if brain network connectivity patterns prior to intensive CBT predict worsening of clinical symptoms during follow-up.

METHODS

We acquired resting-state functional magnetic resonance imaging data from 17 adults with OCD prior to and following 4 weeks of intensive CBT. Functional connectivity data were analyzed to yield graph-theory metrics. We examined the relationship between pre-treatment connectome properties and OCD clinical symptoms before and after treatment and during a 12-month follow-up period.

RESULTS

Mean OCD symptom decrease was 40.4 ± 16.4% pre- to post-treatment (64.7% responded; 58.8% remitted), but 35.3% experienced clinically significant worsening during follow-up. From pre- to post-treatment, small-worldness and clustering coefficient significantly increased. Decreases in modularity correlated with decreases in OCD symptoms. Higher pre-treatment small-world connectivity was significantly associated with worsening of OCD symptoms during the follow-up period. Psychometric and neurocognitive measures pre- and post-treatment were not significant predictors.

CONCLUSION

This is the first graph-theory connectivity study of the effects of CBT in OCD, and the first to test associations with follow-up clinical status. Results show functional network efficiency as a biomarker of CBT response and relapse in OCD. CBT increases network efficiency as it alleviates symptoms in most patients, but those entering therapy with already high network efficiency are at greater risk of relapse. Results have potential clinical implications for treatment selection.

Mindfulness-based cognitive therapy in obsessive-compulsive disorder: protocol of a randomized controlled trial

BACKGROUND

Obsessive-compulsive disorder (OCD) is a very disabling condition with a chronic course, if left untreated. Though cognitive behavioral treatment (CBT) with or without selective serotonin reuptake inhibitors (SSRI) is the method of choice, up to one third of individuals with obsessive-compulsive disorder (OCD) do not respond to treatment in terms of at least 35% improvement of symptoms. Mindfulness based cognitive therapy (MBCT) is an 8-week group program that could help OCD patients with no or only partial response to CBT to reduce OC symptoms and develop a helpful attitude towards obsessions and compulsive urges.

METHODS/DESIGN

This study is a prospective, bicentric, assessor-blinded, randomized, actively-controlled clinical trial. 128 patients with primary diagnosis of OCD according to DSM-IV and no or only partial response to CBT will be recruited from in- and outpatient services as well as online forums and the media. Patients will be randomized to either an MBCT intervention group or to a psycho-educative coaching group (OCD-EP) as an active control condition. All participants will undergo eight weekly sessions with a length of 120 minutes each of a structured group program. We hypothesize that MBCT will be superior to OCD-EP in reducing obsessive-compulsive symptoms as measured by the Yale-Brown-Obsessive-Compulsive Scale (Y-BOCS) following the intervention and at 6- and 12-months-follow-up. Secondary outcome measures include depressive symptoms, quality of life, metacognitive beliefs, self-compassion, mindful awareness and approach-avoidance tendencies as measured by an approach avoidance task.

DISCUSSION

The results of this study will elucidate the benefits of MBCT for OCD patients who did not sufficiently benefit from CBT. To our knowledge, this is the first randomized controlled study assessing the effects of MBCT on symptom severity and associated parameters in OCD.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00004525 . Registered 19 March 2013.

Comorbidity in obsessive-compulsive disorder (OCD): a report from the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS)

BACKGROUND

Obsessive-compulsive disorder (OCD) is often associated with significant psychiatric comorbidity. Comorbid disorders include mood and anxiety disorders as well as obsessive-compulsive spectrum disorders (OCSDs). This paper aims to investigate comorbidity of DSM Axis I-disorders, including OCSDs, in patients with OCD from 10 centers affiliated with the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS).

METHODS

This is a cross-sectional study of comorbidity of Axis I disorders including OCSDs in 457 outpatients with primary OCD (37% male; 63% female), with ages ranging from 12 to 88years (mean: 39.8±13). Treating clinicians assessed Axis I disorders using the Mini International Neuropsychiatric Interview and assessed OCSDs using the Structured Clinical Interview for OCD related/spectrum disorders (SCID-OCSD).

RESULTS

In terms of the OCSDs, highest comorbidity rates were found for tic disorder (12.5%), BDD (8.71%) and self-injurious behavior (7.43%). In terms of the other Axis I-disorders, major depressive disorder (MDD; 15%), social anxiety disorder (SAD; 14%), generalized anxiety disorder (GAD; 13%) and dysthymic disorder (13%) were most prevalent.

DISCUSSION

High comorbidity of some OCSDs in OCD supports the formal recognition of these conditions in a separate chapter of the nosology. Rates of other Axis I disorders are high in both the general population and in OCSDs, indicating that these may often also need to be the focus of intervention in OCD.

Long-term course of pediatric obsessive-compulsive disorder: 3 years of prospective follow-up

OBJECTIVE

This study assesses the long-term course of treatment-seeking youth with a primary diagnosis of DSM-IV OCD.

METHOD

Sixty youth and their parents completed intake interviews and annual follow-up interviews for 3 years using the youth version of the Longitudinal Interval Follow-up Evaluation (Y-LIFE) and Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Remission was defined as no longer meeting DSM-IV criteria for OCD for 8 weeks or more, and recurrence was defined as meeting full criteria for OCD for 4 consecutive weeks after having achieved symptom remission. Remission rates for youth were compared to rates of adults participating in the same study.

RESULTS

The probability of achieving partial remission of OCD was 0.53 and the probability of achieving full remission was 0.27. Among the 24 youth participants who achieved remission, 79% stayed in remission throughout the study (mean of 88 weeks of follow-up) and 21% experienced a recurrence of symptoms. Better functioning at intake and a shorter latency to initial OCD treatment were associated with faster onset of remission (P<.001).

CONCLUSIONS

Remission is more likely among youth versus adults with OCD. Treatment early in the course of illness and before substantial impact on functioning predicted a better course.

The impact of comorbid body dysmorphic disorder on the response to sequential pharmacological trials for obsessive-compulsive disorder

Our aim was to investigate the impact of comorbid body dysmorphic disorder (BDD) on the response to sequential pharmacological trials in adult obsessive-compulsive disorder (OCD) patients. The sequential trial initially involved fluoxetine monotherapy followed by one of three randomized, add-on strategies: placebo, clomipramine or quetiapine. We included 138 patients in the initial phase of fluoxetine, up to 80 mg or the maximum tolerated dosage, for 12 weeks. We invited 70 non-responders to participate in the add-on trial; as 54 accepted, we allocated 18 to each treatment group and followed them for an additional 12 weeks. To evaluate the combined effects of sex, age, age at onset, initial severity, type of augmentation and BDD on the response to sequential treatments, we constructed a model using generalized estimating equations (GEE). Of the 39 patients who completed the study (OCD-BDD, n = 13; OCD-non-BDD, n = 26), the OCD-BDD patients were less likely to be classified as responders than the OCD-non-BDD patients (Pearson Chi-Square = 4.4; p = 0.036). In the GEE model, BDD was not significantly associated with a worse response to sequential treatments (z-robust = 1.77; p = 0.07). The predictive potential of BDD regarding sequential treatment strategies for OCD did not survive when the analyses were controlled for other clinical characteristics.

Panic Disorder and Agoraphobia in OCD patients: clinical profile and possible treatment implications

OBJECTIVE

Panic Disorder (PD) and agoraphobia (AG) are frequently comorbid with obsessive-compulsive disorder (OCD), but the correlates of these comorbidities in OCD are fairly unknown. The study aims were to: 1) estimate the prevalence of PD with or without AG (PD), AG without panic (AG) and PD and/or AG (PD/AG) in a large clinical sample of OCD patients and 2) compare the characteristics of individuals with and without these comorbid conditions.

METHOD

A cross-sectional study with 1001 patients of the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders using several assessment instruments, including the Dimensional Yale-Brown Obsessive-Compulsive Scale and the Structured Clinical Interview for DSM-IV-TR Axis I Disorders. Bivariate analyses were followed by logistic regression models.

RESULTS

The lifetime prevalence of PD was 15.3% (N=153), of AG 4.9% (N=49), and of PD/AG 20.2% (N=202). After logistic regression, hypochondriasis and specific phobia were common correlates of the three study groups. PD comorbidity was also associated with higher levels of anxiety, having children, major depression, bipolar I, generalized anxiety and posttraumatic stress disorders. Other independent correlates of AG were: dysthymia, bipolar II disorder, social phobia, impulsive-compulsive internet use, bulimia nervosa and binge eating disorder. Patients with PD/AG were also more likely to be married and to present high anxiety, separation anxiety disorder, major depression, impulsive-compulsive internet use, generalized anxiety, posttraumatic stress and binge eating disorders.

CONCLUSIONS

Some distinct correlates were obtained for PD and AG in OCD patients, indicating the need for more specific and tailored treatment strategies for individuals with each of these clinical profiles.

Obsessive-compulsive disorder; chronic versus non-chronic symptoms

OBJECTIVE

Understanding chronicity in OCD is hampered by contradictory findings arising from dissimilar definitions of chronic OCD. The purpose of this study was to investigate the magnitude of chronicity in OCD and to examine if chronic OCD is critically different from non-chronic OCD, using a chronicity definition that reflects empirical findings.

METHOD

Baseline data of the Netherlands Obsessive Compulsive Disorder Association (NOCDA) study, in which 379 OCD patients participated, were analyzed. Chronic OCD was defined as "continuous presence of at least moderately severe OCD symptoms during at least two years", and was assessed retrospectively using a Life-Chart Interview.

RESULTS

Application of the chronicity criterion resulted in two groups with highly distinguishable course patterns. The majority of the sample (61.7%) reported a chronic course. Patients with a chronic course reported significantly more severe OCD symptoms, more illness burden, more comorbidity, an earlier OCD onset and more contamination and washing - and symmetry and ordering symptoms. Multivariable logistic regression analysis revealed that chronic OCD was independently associated with more OCD-subtypes (p<0.001), contamination and washing symptoms (p<0.001), earlier OCD onset (p=0.05) and higher severity of compulsions (p<.01).

LIMITATIONS

The findings are based on a cross-sectional survey. Furthermore course was assessed retrospectively, implying the possibility of overestimation of persistence and severity of symptoms.

CONCLUSION

Chronicity is the rule rather than the exception in OCD in clinical samples. Chronic OCD is critically different from non-chronic OCD. Further attempts to break down the heterogeneity of OCD in homogeneous course subtypes should be made to allow for a more precise determination of the pathogenesis of OCD and better treatment.

The effect of personality disorders on treatment outcomes in patients with obsessive-compulsive disorders

The effect of comorbid personality disorders (PD) on treatment outcomes in obsessive-compulsive disorder (OCD) is unclear. The authors systematically review results from investigations of therapy outcomes in adult patients with OCD and a comorbid PD. PsycINFO and MEDLINE were searched for original articles. Twenty-three studies assessing PDs through interviews were selected. Cluster A PDs, particularly schizotypal PD, narcissistic PD, and the presence of two or more comorbid PDs, were associated with poorer treatment outcomes in patients with OCD. With regard to other PDs and clusters, the results are inconsistent or the sample sizes are too small to reach a conclusion. OCD patients with different comorbid PDs differ in their therapeutic response to treatment. To optimize the treatment of OCD, the predictive value of PDs on the treatment outcome should be further investigated, and treatment of Axis I and II comorbidity requires more attention.

Randomized controlled crossover trial of ketamine in obsessive-compulsive disorder: proof-of-concept

Serotonin reuptake inhibitors (SRIs), the first-line pharmacological treatment for obsessive-compulsive disorder (OCD), have two limitations: incomplete symptom relief and 2-3 months lag time before clinically meaningful improvement. New medications with faster onset are needed. As converging evidence suggests a role for the glutamate system in the pathophysiology of OCD, we tested whether a single dose of ketamine, a non-competitive N-methyl-D-aspartate (NMDA) glutamate receptor antagonist, could achieve rapid anti-obsessional effects. In a randomized, double-blind, placebo-controlled, crossover design, drug-free OCD adults (n=15) with near-constant obsessions received two 40-min intravenous infusions, one of saline and one of ketamine (0.5 mg/kg), spaced at least 1-week apart. The OCD visual analog scale (OCD-VAS) and the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) were used to assess OCD symptoms. Unexpectedly, ketamine's effects within the crossover design showed significant (p<0.005) carryover effects (ie, lasting longer than 1 week). As a result, only the first-phase data were used in additional analyses. Specifically, those receiving ketamine (n=8) reported significant improvement in obsessions (measured by OCD-VAS) during the infusion compared with subjects receiving placebo (n=7). One-week post-infusion, 50% of those receiving ketamine (n=8) met criteria for treatment response (≥35% Y-BOCS reduction) vs 0% of those receiving placebo (n=7). Rapid anti-OCD effects from a single intravenous dose of ketamine can persist for at least 1 week in some OCD patients with constant intrusive thoughts. This is the first randomized, controlled trial to demonstrate that a drug affecting glutamate neurotransmission can reduce OCD symptoms without the presence of an SRI and is consistent with a glutamatergic hypothesis of OCD.

Clinical relevance of comorbidity in obsessive compulsive disorder: the Netherlands OCD Association study

BACKGROUND

This study describes lifetime and current rates of comorbidity, its onset and its consequences in a large clinical sample of patients with obsessive compulsive disorder (OCD). A wide range of risk factors and clinical characteristics were also examined to determine whether pure OCD is different from OCD with current comorbidity. Finally, the temporal sequencing of the disorders was examined.

METHOD

Data were obtained from the Netherlands Obsessive Compulsive Disorder Association (NOCDA) study. A sample of 382 participants with current OCD (during the past month) was evaluated.

RESULTS

Current comorbidity occurred in 55% of patients with OCD, while 78% suffered from lifetime comorbidity. Comorbidity is associated with more severe OCD, anxiety and depressive symptoms and more negative consequences on daily life. Multiple comorbid disorders often precede OCD and influence both its course and severity. Childhood trauma and neuroticism are vulnerability factors for the development of multiple comorbid disorders in OCD.

LIMITATIONS

It should be noted that causal inferences about the association between risk factors and OCD are precluded since our results were based on cross-sectional data.

CONCLUSION

(Multiple) comorbidity in OCD is clinically relevant since it is associated with a specific pattern of vulnerability, with greater chronicity, with more severe OCD and more negative consequences on daily life. This indicates that the diagnosis and treatment of all comorbid disorders is clinically relevant, and clinicians should be especially aware of multiple disorders in cases of childhood trauma and high levels of neuroticism. Primary OCD has a different developmental and comorbidity pattern compared to secondary OCD.

Clinical predictors of long-term outcome in obsessive-compulsive disorder

BACKGROUND

The purpose of this study was to investigate demographic and clinical factors associated with the long-term outcome of obsessive-compulsive disorder (OCD).

METHODS

A hundred ninety-six previously untreated patients with DSM-IV criteria OCD completed a 12-week randomized open trial of group cognitive-behavioral therapy (GCBT) or fluoxetine, followed by 21 months of individualized, uncontrolled treatment, according to international guidelines for OCD treatment. OCD severity was assessed using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) at different times over the follow-up period. Demographics and several clinical variables were assessed at baseline.

RESULTS

Fifty percent of subjects improved at least 35% from baseline, and 21.3% responded fully (final Y-BOCS score < or = 8). Worse prognosis was associated with earlier age at onset of OCD (P = 0.045), longer duration of illness (P = 0.001) presence of at least one comorbid psychiatric disorder (P = 0.001), comorbidity with a mood disorder (P = 0.002), higher baseline Beck-Depression scores (P = 0.011), positive family history of tics (P = 0.008), and positive family history of anxiety disorders (P = 0.008). Type of initial treatment was not associated with long-term outcome. After correction for multiple testing, the presence of at least one comorbid disorder, the presence of a depressive disorder, and duration of OCD remained significant.

CONCLUSIONS

Patients under cognitive-behavioral or pharmacological treatment improved continuously in the long run, regardless of initial treatment modality or degree of early response, suggesting that OCD patients benefit from continuous treatment. Psychiatric comorbidity, especially depressive disorders, may impair the long-term outcome of OCD patients.

The use of psychotropic agents for the symptoms of obsessive-compulsive disorder

OBJECTIVE

To describe the use of psychotropic agents in a sample of subjects with obsessive-compulsive disorder (OCD), and in particular the differences associated with different OCD symptoms.

METHOD

A total of 154 subjects participated in a study assessing OCD symptom subtypes, called the Nepean OCD Study. In addition to a comprehensive evaluation of the subjects' OCD symptoms using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Vancouver Obsessive-Compulsive Inventory (VOCI), and the Sheehan Disability Scale (SDS), the subjects' medication history was recorded. The association between symptom severity, disability, OCD symptom subtypes and the use of psychotropic agents was examined.

RESULTS

Psychotropic medication was taken by 93 (60.4%) participants. In the majority of cases (n=55, 59.1%), selective serotonin reuptake inhibitors (SSRIs) were taken, and of the SSRIs, the most commonly used agent was escitalopram (n=21, 22.6%). Psychotropic agents were more likely to be taken by subjects with higher Y-BOCS and SDS scores. Hoarding was associated with a lower likelihood of psychotropic use, whereas unacceptable/taboo thoughts were associated with an increased likelihood of psychotropic and antipsychotic use.

CONCLUSION

Patients with OCD are more likely to be taking psychotropic agents if they have a more severe illness, greater disability and more prominent unacceptable/taboo thoughts.

Suicidal behaviour of Indian patients with obsessive compulsive disorder

BACKGROUND SETTING AND DESIGN

The chronicity, distress, high rates of comorbidity and varying degree of non response to treatment in Obsessive Compulsive Disorder (OCD) may contribute to suicidal behavior. There is relatively little information on suicidal behavior in OCD subjects. Our study design is Single point non-invasive, cross sectional, clinical study of new and follow up cases.

MATERIALS AND METHODS

Assessment of Suicidal Behavior in patients of OCD attending the adult Psychiatry O.P.D. of Chatrapati Shahuji Maharaj Medical University (CSMMU) U.P. Lucknow using (DSM-IV) criteria for diagnosis of Obsessive Compulsive Disorder, Structured Clinical Interview for DSM-IV Axis-I disorders, Yale Brown Obsessive Compulsive Rating Scale, Scale for Suicidal Ideation (SSI), Beck's Hopelessness Scale (BHS).

STATISTICAL ANALYSIS

Mean standard deviation and t test for independent samples, Pearson's correlation coefficient.

RESULTS

Statistically significant differences were seen in the SSI score between the "Clinical" and "Sub-Clinical" cases with Clinical group having higher scores. Value of correlation coefficient between YBOCS score and SSI and BHS score is positive and statistically significant (P<0.01).

CONCLUSION

"Clinical" group of patients had significantly higher scores of suicidal ideation measured by Scale of Suicidal Ideation (SSI). There was a significantly positive correlation between disease severity (YBOCS Score) and degree of suicidal ideation (SIS Score).

Five-year course of obsessive-compulsive disorder: predictors of remission and relapse

BACKGROUND

Obsessive-compulsive disorder (OCD) is a heterogeneous and disabling condition; however, no studies have examined symptom categories or subtypes as predictors of long-term clinical course in adults with primary OCD.

METHOD

A total of 213 adults with DSM-IV OCD were recruited from several mental health treatment sites between July 2001 and February 2006 as part of the Brown Longitudinal Obsessive Compulsive Study, a prospective, naturalistic study of treatment-seeking adults with primary OCD. OCD symptoms were assessed annually over the 5-year follow-up period using the Longitudinal Interval Follow-Up Evaluation.

RESULTS

Thirty-nine percent of participants experienced either a partial (22.1%) or a full (16.9%) remission. Two OCD symptom dimensions impacted remission. Participants with primary obsessions regarding overresponsibility for harm were nearly twice as likely to experience a remission (P < .05), whereas only 2 of 21 participants (9.5%) with primary hoarding achieved remission. Other predictors of increased remission were lower OCD severity (P < .0001) and shorter duration of illness (P < .0001). Fifty-nine percent of participants who remitted subsequently relapsed. Participants with obsessive-compulsive personality disorder were more than twice as likely to relapse (P < .005). Participants were also particularly vulnerable to relapse if they experienced partial remission versus full remission (70% vs 45%; P < .05).

CONCLUSIONS

The contributions of OCD symptom categories and comorbid obsessive-compulsive personality disorder are critically important to advancing our understanding of the prognosis and ultimately the successful treatment of OCD. Longer duration of illness was also found to be a significant predictor of course, highlighting the critical importance of early detection and treatment of OCD. Furthermore, having full remission as a treatment target is an important consideration for the prevention of relapse in this disorder.

Outlining new frontiers for the comprehension of obsessive-compulsive disorder: a review of its relationship with fear and anxiety

Anxiety is an important component of the psychopathology of the obsessive-compulsive disorder (OCD). So far, most interventions that have proven to be effective for treating OCD are similar to those developed for other anxiety disorders. However, neurobiological studies of OCD came to conclusions that are not always compatible with those previously associated with other anxiety disorders.

OBJECTIVES

The aim of this study is to review the degree of overlap between OCD and other anxiety disorders phenomenology and pathophysiology to support the rationale that guides research in this field.

RESULTS

Clues about the neurocircuits involved in the manifestation of anxiety disorders have been obtained through the study of animal anxiety models, and structural and functional neuroimaging in humans. These investigations suggest that in OCD, in addition to dysfunction in cortico-striatal pathways, the functioning of an alternative neurocircuitry, which involves amygdalo-cortical interactions and participates in fear conditioning and extinction processes, may be impaired.

CONCLUSION

It is likely that anxiety is a relevant dimension of OCD that impacts on other features of this disorder. Therefore, future studies may benefit from the investigation of the expression of fear and anxiety by OCD patients according to their type of obsessions and compulsions, age of OCD onset, comorbidities, and patterns of treatment response.

Social phobia in obsessive-compulsive disorder: prevalence and correlates

BACKGROUND

Social Phobia (SP) is an anxiety disorder that frequently co-occurs with obsessive-compulsive disorder (OCD); however, studies that evaluate clinical factors associated with this specific comorbidity are rare. The aim was to estimate the prevalence of SP in a large multicenter sample of OCD patients and compare the characteristics of individuals with and without SP.

METHOD

A cross-sectional study with 1001 patients of the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders using several assessment instruments, including the Dimensional Yale-Brown Obsessive-Compulsive Scale and the Structured Clinical Interview for DSM-IV Axis I Disorders. Univariate analyses were followed by logistic regression.

RESULTS

Lifetime prevalence of SP was 34.6% (N=346). The following variables remained associated with SP comorbidity after logistic regression: male sex, lower socioeconomic status, body dysmorphic disorder, specific phobia, dysthymia, generalized anxiety disorder, agoraphobia, Tourette syndrome and binge eating disorder.

LIMITATIONS

The cross-sectional design does not permit the inference of causal relationships; some retrospective information may have been subject to recall bias; all patients were being treated in tertiary services, therefore generalization of the results to other samples of OCD sufferers should be cautious. Despite the large sample size, some hypotheses may not have been confirmed due to the small number of cases with these characteristics (type 2 error).

CONCLUSION

SP is frequent among OCD patients and co-occurs with other disorders that have common phenomenological features. These findings have important implications for clinical practice, indicating the need for broader treatment approaches for individuals with this profile.

Persistence of Obsessive Compulsive Symptoms: Similarities and Contrasts with Symptoms of Depression in a Turkish Sample

Contemporary cognitive theories of obsessive-compulsive disorder (OCD) propose that certain types of dysfunctional beliefs and assumptions play a salient role in the genesis and persistence of OCD (e.g., Clark, 2004; Rachman, 1993, 1997; Salkovskis, 1985). The present study aimed to examine whether the three proposed dysfunctional beliefs — inflated sense of responsibility, thought suppression, and thought-action fusion — play a significant role particularly on the persistence of obsessive–compulsive (OC) symptoms, as compared to other emotional disorders, such as symptoms of depression. The participants of the present study were 109 undergraduate university students, who completed a set of questionnaires, including The Responsibility Attitude Scale (RAS), The Thought Action Fusion Scale (TAF), The White Bear Suppression Inventory (WBSI), The Maudsley Obsessive–Compulsive Inventory (MOCI), and The Beck Depression Inventory (BDI). After a 4-week interval, participants were again asked to complete the MOCI and BDI. Two separate hierarchical regression equations were formulated to examine the factors significantly accounting for the residual changes from Time 1 to Time 2 assessments of OC and depressive symptomatologies. Results of these analyses indicated that while thought suppression (WBSI scores) played a significant role on the persistence of both OC and depressive symptoms across time, the role of inflated sense of responsibility (RAS scores) was specific to the persistence of OC symptoms.

Genetic Factors Underlie Stability of Obsessive–Compulsive Symptoms

The contribution of genetic and environmental factors to the stability of obsessive–compulsive (OC) symptoms has not yet been established in adult population based samples. We obtained the Young Adult Self Report Obsessive–Compulsive Subscale in mono- and dizygotic twins from the population-based Netherlands Twin Register in 1991, 1995 and 1997 and the Padua Inventory Revised Abbreviated in 2002. Stability of OC symptoms was analyzed as a function of genetic and environmental components. Heritability of OC behavior was around 40% at each time-point, independent of the instrument used. OC behavior was moderately stable with correlations ranging between r = .2 (for 11-year intervals), .4 (for 4–5 year intervals) and .6 (for 2 year intervals). Genetic correlations across time were higher, varying between .4 and .9, indicating that the stability of OC symptoms is mainly due to stable genetic factors. This study showed a moderate heritability and stability for OC behavior in adults. Genetic stability across time is high.