Neuromodulation of OCD: A review of invasive and non-invasive methods

Early research into neural correlates of obsessive compulsive disorder (OCD) has focused on individual components, several network-based models have emerged from more recent data on dysfunction within brain networks, including the the lateral orbitofrontal cortex (lOFC)-ventromedial caudate, limbic, salience, and default mode networks. Moreover, the interplay between multiple brain networks has been increasingly recognized. As the understanding of the neural circuitry underlying the pathophysiology of OCD continues to evolve, so will too our ability to specifically target these networks using invasive and noninvasive methods. This review discusses the rationale for and theory behind neuromodulation in the treatment of OCD.

Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder: 2021 Update

In this update of a previous review, the authors discuss cognitive-behavioral therapy (CBT) with exposure and response prevention for obsessive-compulsive disorder (OCD). This efficacious modality avoids side effects common to psychotropic medication and reduces risk of relapse once treatment has ended. Psychotherapy involves identification and ranking of stimuli that provoke obsessions, exposure to these stimuli while preventing compulsions, and cognitive restructuring. The family of the OCD patient plays a significant role in treatment. This article includes expanded research on family-focused CBT and treatment of pediatric OCD. The family's accommodation and emotional response to a patient's symptoms may interfere with therapy and perpetuate the disorder. The treatment of pediatric OCD involves the same considerations. However, the form of obsessions and compulsions may differ and therapeutic techniques are modified to make them age appropriate.

Knowledge and competency standards for specialized cognitive behavior therapy for adult obsessive-compulsive disorder

Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illness for as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.

Psychometric properties of the Family Accommodation Scale for Obsessive-Compulsive Disorder-Patient Version

In obsessive-compulsive disorder (OCD), family accommodation is a frequently occurring phenomenon that has been linked to attenuated treatment response, increased obsessive-compulsive symptom severity, and lower levels of functioning. No patient-report version of family accommodation exists, with available measures relying on relatives as informants. However, adult patients with OCD often present to clinical services alone, frequently making it impractical to obtain information from these informants. Consequently, a standardized patient-reported measure of family accommodation proves salient in clinical practice. The present study examined the psychometric properties of the Family Accommodation Scale for Obsessive-Compulsive Disorder-Patient Version (FAS-PV). Sixty-one adults with OCD were administered clinician-rated measures of OCD symptom severity and self-report questionnaires examining functional impairment, family functioning, and emotional/behavioral difficulties. Fifty-four relatives completed self-report measures assessing family accommodation and family functioning. The majority of the adult OCD participants (89%) endorsed at least 1 type of accommodating behavior in the previous week. The FAS-PV total score demonstrated good internal consistency and test-retest reliability. Convergent validity was evidenced by strong associations with scores on another measure of family accommodation, OCD symptom severity, OCD-related family functioning, anxiety, and functional impairment. Divergent validity was supported through nonsignificant correlations with depressive symptoms and impulsivity. The FAS-PV did not significantly differ from the relative-reported measure of family accommodation in terms of the internal consistency or mean of the total scores. Ultimately, the FAS-PV scores demonstrated sound psychometric properties and validity in assessing family accommodation from the patient's perspective, encouraging its use in research and clinical practice.

Patient and family factors associated with family accommodation in obsessive-compulsive disorder

AIM

Obsessive-compulsive disorder (OCD) impacts family functioning as family members modify their personal and family routines, participate in rituals, and provide reassurance. These behaviors have been identified as family accommodation (FA), a phenomenon that, if ignored, may facilitate OCD symptoms and lead to poorer prognosis. Because FA has been recognized as a predictor of treatment outcome, we examined the prevalence of FA and identified patient and family sociodemographic and clinical variables associated with FA in an outpatient sample.

METHODS

The study comprised 228 subjects, namely, 114 patients with OCD and 114 family members, assessed before the patients entered a 12-session cognitive behavioral group therapy program. A multivariate linear regression model was used to control for confounding factors and to evaluate variables independently associated with FA. FA was evaluated using the Family Accommodation Scale for Obsessive-Compulsive Disorder-Interviewer Rated.

RESULTS

FA was found to be highly prevalent among family members. Two patient factors positively associated with FA were OCD severity as measured by the Clinical Global Impressions Scale and higher scores on the Obsessions dimension of the Obsessive-Compulsive Inventory-Revised. Family members' characteristics that were positively associated with FA were higher scores on the Obsessive-Compulsive Inventory - Revised hoarding subscale and being the patient's spouse.

CONCLUSION

Our findings suggest that the early identification of patients and family members who could benefit from interventions aimed at reducing FA could improve treatment outcomes.

Development and preliminary psychometric evaluation of a self-rated version of the Family Accommodation Scale for Obsessive-Compulsive Disorder

Family accommodation (FA) in obsessive-compulsive disorder (OCD) refers to family members' or significant others' participation in or facilitation of patients' rituals and/or avoidance. With recent studies pointing to FA as a predictor of poorer treatment outcome, there is heightened interest in developing family-based interventions for OCD aimed at reducing FA. The interviewer-rated Family Accommodation Scale for OCD (FAS-IR) is the gold standard for assessing the types and severity of FA in OCD families. However, the cost of training interviewers and the time required for administration may limit its use in some settings. A valid self-rated version could be administered for research and clinical purposes with minimal burden and has the potential to be more widely used. The present study reports on the development and initial psychometric testing of the Family Accommodation Scale for OCD-Self Rated Version (FAS-SR). The FAS-SR was compared to the FAS-IR in a sample of 41 relatives of individuals with primary OCD, demonstrating excellent internal consistency, strong agreement with the FAS-IR, and expected convergence with criterion measures. Though further study using the self-rated version is needed, these findings suggest that the FAS-SR is a valid measure of FA and a time-saving, less costly alternative to the FAS-IR.

Family approaches to treatment for obsessive compulsive disorder

This article reviews the family constellation of patients with obsessive compulsive disorder (OCD), the presence of OCD symptoms among family members, and familial aspects including parental attachment, expressed emotion (EE), and family accommodation. Some evidence supports a negative effect of hostility, emotional over-involvement, and criticism perceived by the patient on behavioral treatment outcome. However, actual criticism observed by the relative during an interview was associated with more benefit from therapy. Family accommodation predicted poorer family functioning and more severe OCD symptoms after behavioral treatment. A review of the limited treatment literature indicates no actual tests of the effects of psycho-educational and supportive treatments, although several reports suggest they are useful for families and patients. Including relatives in treatment has proved beneficial in some studies, especially with children, but not in others. Multiple family groups that focus on behavioral contracting for exposure and stopping rituals may be a promising intervention. Likewise, efforts to reduce family accommodation in the context of behavioral treatment have proved useful. Additional research on the content, process and effects of family interventions for OCD is much needed.