Effects of exercise on obsessive-compulsive disorder symptoms: a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis assessed the efficacy of exercise in reducing OCD symptoms.

METHODS

We searched PubMed, Cochrane Central Register of Controlled Trials, MEDLINE, Scopus and grey literature until March 2022. The study was preregistered at Prospero (CRD42021283931). We included randomised controlled and pre-post trials assessing physical activity as an intervention for OCD. Risk of bias was assessed using the Cochrane ROBINS-I tool and the RoB2 tool.

RESULTS

The analysis included 6 trials (N = 92); 2 were RCTS and 4 were pre-post design studies. A random-effects meta-analysis of pre-post data identified a large reduction of OCD symptoms following exercise (g = 1.33 [95%CI 1.06-1.61]; k = 6). Exercise was also associated with significant pre-post reductions in anxiety (g = 0.71 [95%CI 0.37-1.05; k = 4) and depression (g = 0.57 [95%CI 0.26-0.89]; k = 2). Risk of bias was moderate-high in uncontrolled trials on the ROBINS-I and RCTs showed 'some concerns' on the RoB2.

CONCLUSION

Exercise was associated with a large pre-post reduction of OCD symptoms; however, few trials were of robust quality and all were at risk of bias. Further well-powered and better quality RCTs are required to assess the role of exercise as an intervention for OCD.KEY POINTSStudies exploring exercise as an adjunct therapy for OCD have small participant numbers, therefore a systematic review and meta-analysis is needed to estimate potential efficacy.Pre-post analysis shows that exercise was associated with a large reduction of OCD symptomsThe current systematic review and meta-analysis points to the potential for exercise to be beneficial for the treatment for OCD symptoms. However, more well-powered and better controlled RCTs are required to fully assess the benefit of exercise for the treatment of OCD symptoms.

Psychotherapies and digital interventions for OCD in adults: What do we know, what do we need still to explore?

BACKGROUND

Despite significant advances in the understanding and treatment of obsessive compulsive disorder (OCD), current treatment options are limited in terms of efficacy for symptom remission. Thus, assessing the potential role of iterative or alternate psychotherapies is important. Also, the potential role of digital technologies to enhance the accessibility of these therapies, should not be underestimated. We also need to embrace the idea of a more personalized treatment choice, being cognisant of clinical, genetic and neuroimaging predictors of treatment response.

PROCEDURES

Non-systematic review of current literature on emerging psychological and digital therapies for OCD, as well as of potential biomarkers of treatment response.

FINDINGS

A number of 'third wave' therapies (e.g., Acceptance and Commitment Therapy, Mindfulness-Based Cognitive Therapy) have an emerging and encouraging evidence base in OCD. Other approaches entail employment of elements of other psychotherapies such as Dialectical Behaviour Therapy; or trauma-focussed therapies such as Eye Movement Desensitisation and Reprocessing, and Imagery Rescripting and Narrative Therapy. Further strategies include Danger Ideation Reduction Therapy and Habit Reversal. For these latter approaches, large-scale randomised controlled trials are largely lacking, and the precise role of these therapies in treating people with OCD, remains to be clarified. A concentrated 4-day program (the Bergen program) has shown promising short- and long-term results. Exercise, music, and art therapy have not been adequately tested in people with OCD, but may have an adjunctive role. Digital technologies are being actively investigated for enhancing reach and efficacy of psychological therapies for OCD. Biomarkers, including genetic and neuroimaging, are starting to point to a future with more 'personalised medicine informed' treatment strategizing for OCD.

CONCLUSIONS

There are a number of potential psychological options for the treatment of people with OCD who do not respond adequately to exposure/response prevention or cognitive behaviour therapy. Adjunctive exercise, music, and art therapy might be useful, albeit the evidence base for these is very small. Consideration should be given to different ways of delivering such interventions, including group-based, concentrated, inpatient, or with outreach, where appropriate. Digital technologies are an emerging field with a number of potential applications for aiding the treatment of OCD. Biomarkers for treatment response determination have much potential capacity and deserve further empirical testing.

Meta-analysis of cognitive behaviour therapy and selective serotonin reuptake inhibitors for the treatment of hypochondriasis: Implications for trial design

BACKGROUND

Classification of hypochondriasis as an obsessive-compulsive and related disorder in the International Classification of Diseases 11th Revision (ICD-11) has generated new heuristics for treatment of this common, chronic and disabling disorder. Standard treatment involves cognitive behaviour therapy (CBT) or selective serotonin reuptake inhibitors (SSRIs), but no meta-analysis has so far considered hypochondriasis as a structured diagnosis or assessed the role of medication. A clearer understanding of the relative effectiveness of these interventions and identification of clinically relevant factors moderating the treatment response is needed for clinical guideline development.

METHODS

The current systematic review and meta-analysis of interventions for hypochondriasis was preregistered on PROSPERO (CRD42020185768) and follows PRISMA guidelines. We searched MEDLINE, PsycINFO, and Cochrane Library databases until July 2021 for randomized controlled trials (RCTs) of interventions for patients diagnosed with hypochondriasis (or historical diagnostic equivalents). We assessed aspects of study quality using: the CONSORT Checklist for evaluation of RCTs, the Cochrane Risk of Bias 2 tool, researcher allegiance and treatment fidelity. The primary outcome was improvement in hypochondriasis symptoms, comparing intervention and control groups at trial endpoint. Moderator variables were assessed using subgroup and meta-regression analyses.

RESULTS

Searches identified 13 randomised controlled trials (RCTs) (N = 1405); 12 included CBT (N = 1212) and three included SSRI (N = 193) arms as the experimental intervention. Random effects meta-analysis yielded a moderate-to-large effect size for CBT versus all controls (g = -0.70 [95% CI -0.99 to -0.41], k = 18, I² = 81.1%). Funnel plot asymmetry indicated possible publication bias and two potentially missing trials, reducing the effect size (g = -0.60 [95% CI -0.88 to -0.32]). Subgroup analysis showed that choice of control significantly moderated effect size, with those in CBT vs. wait-list (g = -1.32 [95% CI -1.75 to -0.90], k = 7, I² = 0%) being double those of CBT vs. psychological or pharmacological placebo controls (g = -0.58 [95% CI -0.95 to -0.22], k = 7, I² = 82%). Analysis of studies directly comparing CBT and SSRIs found a numerical, but not statistical advantage for SSRIs (g = 0.21 [95% CI -0.46 to 0.87], k = 2, I² = 58.34%) and a modest effect size emerged for SSRIs vs. pill placebo (g = -0.29 [95% CI -0.57 to -0.01], k = 3, I² = 0%). Most studies (11/13) were rated as high on potential researcher allegiance bias in favour of CBT. Meta-regressions revealed that effect sizes were larger in younger participants, and smaller in better quality and more recent RCTs and those with greater CBT fidelity.

CONCLUSION

CBT and SSRIs are effective in the acute treatment of hypochondriasis, with some indication that intervention at a younger age produces better outcomes for CBT. In the case of CBT, effect sizes appear to have been significantly inflated by the use of wait list controls, and researcher allegiance bias. We recommend that a definitive, adequately controlled trial, designed with respect to the methodological issues raised in this meta-analysis, is needed to determine the magnitude effects for CBT and SSRIs with confidence and the long-term effect of treatments, to inform mental health service provision for this overlooked patient group.

The role of gender in a large international OCD sample: A Report from the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS) Network

INTRODUCTION

Obsessive-compulsive disorder (OCD) is characterized by a range of phenotypic expressions. Gender may be a relevant factor in mediating the disorder's heterogeneity. The aim of the present report was to explore a large multisite clinical sample of OCD patients, hypothesizing existing demographic, geographical and clinical differences between male and female patients with OCD.

METHODS

Socio-demographic and clinical variables of 491 adult OCD outpatients recruited in the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS) network were investigated with a retrospective analysis on a previously gathered set of data from eleven countries worldwide. Patients were assessed through structured clinical interviews, the Yale- Brown Obsessive-Compulsive Scale (Y-BOCS), the Montgomery-Asberg Depression Rating Scale (MADRS) and the Self-rating Depression Scale (SDS).

RESULTS

Among females, adult onset (>18 years old) was significantly over-represented (67% vs. 33%, p < 0.005), and females showed a significantly older age at illness onset compared with males (20.85 ± 10.76 vs. 17.71 ± 8.96 years, p < 0.005). Females also had a significantly lower education level than males (13.09 ± 4.02 vs. 13.98 ± 3.85 years; p < 0.05), a significantly higher rate of being married (50.8% vs. 33.5%; p < 0.001) and a higher rate of living with a partner (47.5% vs. 37.6%; p < 0.001) than males. Nonetheless, no significant gender differences emerged in terms of the severity of OCD symptoms nor in the severity of comorbid depressive symptoms. No predictive effect of gender was found for Y-BOCS, MADRS and SDS severity.

DISCUSSION/CONCLUSIONS

Our findings showed significant differences between genders in OCD. A sexually dimorphic pattern of genetic susceptibility may have a crucial role to OCD clinical heterogeneity, potentially requiring different specific therapeutic strategies. Further research is warranted to validate gender as an important determinant of the heterogeneity in OCD.

A Randomized Trial Directly Comparing Ventral Capsule and Anteromedial Subthalamic Nucleus Stimulation in Obsessive-Compulsive Disorder: Clinical and Imaging Evidence for Dissociable Effects

(Appeared originally in Biological Psychiatry 2019; 85:726-734) Reprinted under Creative Commons CC-BY license.

Does coronavirus pose a challenge to the diagnoses of anxiety and depression? A view from psychiatry

Some authors have suggested that the emergence of the novel coronavirus, SARS-CoV-2, and the subsequent pandemic has meant that the constructs of pathological anxiety and depression are meaningless owing to widespread anxiety and depressive symptoms. This paper examines what is required to make a diagnosis of a depressive or anxiety disorder and how this may differ from fleeting symptomatology in response to specific situations or stimuli. All people experience the emotions of both anxiety and depression, but far fewer have a persistent anxiety or depressive syndrome which interferes with their quality of life and functioning. The pandemic and its issues are then discussed, and existing studies examining the reactions of people living through the pandemic are presented. Finally, the paper examines possible ways to cope at times of increased stress and how we can try to protect ourselves from long-term mental health sequelae of chronic stress.

Body dysmorphic disorder: a treatment synthesis and consensus on behalf of the International College of Obsessive-Compulsive Spectrum Disorders and the Obsessive Compulsive and Related Disorders Network of the European College of Neuropsychopharmacology

Body dysmorphic disorder (BDD) is characterized by a preoccupation with a perceived appearance flaw or flaws that are not observable to others. BDD is associated with distress and impairment of functioning. Psychiatric comorbidities, including depression, social anxiety, and obsessive-compulsive disorder are common and impact treatment. Treatment should encompass psychoeducation, particularly addressing the dangers associated with cosmetic procedures, and may require high doses of selective serotonin reuptake inhibitors* (SSRI*) and protracted periods to establish full benefit. If there is an inadequate response to SSRIs, various adjunctive medications can be employed including atypical antipsychotics*, anxiolytics*, and the anticonvulsant levetiracetam*. However, large-scale randomized controlled trials are lacking and BDD is not an approved indication for these medications. Oxytocin* may have a potential role in treating BDD, but this requires further exploration. Cognitive-behavioural therapy has good evidence for efficacy for BDD, and on-line and telephone-assisted forms of therapy are showing promise. CBT for BDD should be customized to address such issues as mirror use, perturbations of gaze, and misinterpretation of others' emotions, as well as overvalued ideas about how others view the individual.

Optimal treatment for obsessive compulsive disorder: a randomized controlled feasibility study of the clinical-effectiveness and cost-effectiveness of cognitive-behavioural therapy, selective serotonin reuptake inhibitors and their combination in the management of obsessive compulsive disorder

Established treatments for obsessive compulsive disorder (OCD) include cognitive behaviour therapy (CBT) and selective serotonin reuptake inhibitor (SSRI) medication. Combined treatment may outperform monotherapy, but few studies have investigated this. A total of 49 community-based adults with OCD were randomly assigned to CBT, SSRI, or SSRI+CBT. Sertraline (50-200 mg/day) was given as the SSRI for 52 weeks. A 16-h-manualized individual CBT was delivered over 8 weeks with four follow-up sessions. Assessors were 'blinded' to treatment allocation. A preliminary health economic evaluation was conducted. At week 16, combined treatment (n=13) was associated with the largest improvement, sertraline (n=7) the next largest and CBT (n=9) the smallest on the observed case analysis. The effect size (Cohen's d) comparing the improvement in Yale Brown Obsessive Compulsive Scale on CBT versus combined treatment was -0.39 and versus sertraline was -0.27. Between 16 and 52 weeks, the greatest clinical improvement was seen with sertraline, but participant discontinuation prevented reliable analysis. Compared with sertraline, the mean costs were higher for CBT and for combined treatment. The mean Quality Adjusted Life Year scores for sertraline were 0.1823 (95% confidence interval: 0.0447-0.3199) greater than for CBT and 0.1135 (95% confidence interval: -0.0290-0.2560), greater than for combined treatment. Combined treatment appeared the most clinically effective option, especially over CBT, but the advantages over SSRI monotherapy were not sustained beyond 16 weeks. SSRI monotherapy was the most cost-effective. A definitive study can and should be conducted.

The problem with registrar research

In recent years registrars on psychiatric training rotations have been encouraged to begin their research careers early. Most of them are in such (training posts) for three and a half years. A few with extensive previous experience in other areas of medicine will be in post for less than this. The usual pattern of work with such schemes is to change both posts and accompanying routine every six months. At no point during this time will they have time allocated for research per se unless they are a fortunate member of some of the training rotations which include this in the weekly timetable. Such time has to be begged, stolen or borrowed from the hapless consultant who is all too aware of the service shortfall in his or her own area. If the registrar is fortunate enough to find an accommodating senior, this may not be the situation in his or her next post, which renders long term research well nigh impossible.

Use of specialist services for obsessive–compulsive and body dysmorphic disorders across England

Aims and method

In April 2007, the National Specialist Commissioning Team of the Department of Health commissioned a group of services to provide treatment to patients with the most severe and profound obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD). We decided to examine the usage of these services across England 4–5 years after the start of the new funding arrangements. This survey used data about patients treated in the financial year 2011–2012.

Results

Despite the services offering intensive home-based as well as residential and in-patient services, there was a greater proportion of referrals from London, the South East of England and counties closer to London.

Clinical implications

It is important that all patients, regardless of where they live, have access to highly specialist services for OCD and BDD. We discuss potential ways of improving this access but we hope this paper will act as a discussion forum whereby we can receive feedback from others.

Psychotherapy training and experience of successful candidates in the MRCPsych examinations

We conducted a survey of the psychotherapy training of a national sample of successful MRCPsych candidates to discover the extent of their psychotherapy training and their opinion about its adequacy. Ninety doctors answered the survey. Overall 71% of trainees had clinical experience in behavioural–cognitive psychotherapy and 78% in psychodynamic psychotherapy with fewer gaining experience in group and family psychotherapies. The majority of trainees were dissatisfied with the extent of their behavioural-cognitive psychotherapy training (82%) and psychodynamic training (50%). Trainees felt that their psychotherapy training was an important component of their psychiatric training.

Teaching interview skills to preclinical medical students

The early years of medical students' experience can clearly be important in shaping their attitudes for the future. Typically pre-clinical students are bombarded with basic science subjects and many express the view that it is difficult to see the relevance of much of their academic study to their ambition of working with people. The Behavioural Science Course which is generally held during the students' second year is one of the few courses which is devoted to the functioning of the whole person in society. Typically, this course includes psychology and medical sociology.

Service user involvement in training: the trainees' view

Aims and Method

A questionnaire survey was conducted of trainees across the South-West London and St George's Basic Specialist Training Scheme in Psychiatry to explore their attitudes towards service user involvement in training.

Results

Fifty-two completed questionnaires were received; 20 trainees (38%) had not attended teaching sessions where a user was present; 35 trainees (67%) were agreeable to service user involvement in examinations. Reservations concerned the objectivity of service users in examination rating and their role as an expert on assessing the trainee's skill. Awareness of user involvement strategies and policies in their trusts were not matched with actual participation.

Clinical Implications

Service users should be involved in teaching in an expert capacity and also in examinations, with safeguards regarding transparency and objectivity of the marking schemes in place.

Specialised in-patient treatment for severe, chronic, resistant obsessive–compulsive disorder

Aims and Method

A naturalistic study was conducted to examine the outcome on self-report and observer-rated measures in patients with severe, chronic, resistant obsessive–compulsive disorder (OCD) admitted to a specialised in-patient unit.

Results

Twenty-six patients were admitted over the study period. The mean age of all patients was 37 years (s.d.=13.8, range 18–61 years) and they had a mean duration of OCD of 18.4 years (s.d.=10.9, range 4–40 years). Instruments measuring severity demonstrated a 37–67% reduction in obsessive–compulsive symptoms and a 64% reduction in depressive symptoms after an average of almost 15 weeks in hospital.

Clinical Implications

This study demonstrates that specialised in-patient care can benefit a small group of severely ill patients with OCD who fail to respond to treatment in primary and secondary care.

Childhood, adolescent and adult age at onset and related clinical correlates in obsessive-compulsive disorder: a report from the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS)

OBJECTIVE

Many studies suggest that age at onset (AAO) is an important factor for clinically differentiating patients with juvenile and adult onset of obsessive-compulsive disorder (OCD). The present international study aimed to assess the prevalence of different AAO groups and compare related socio-demographic and clinical features in a large sample of OCD patients.

METHODS

A total of 431 OCD outpatients, participating in the ICOCS network, were first categorised in groups with childhood (≤12 years), adolescent (13-17 years) and adult-onset (≥18 years), then in pre-adult and adult onset (≥18 years) and their socio-demographic and clinical features compared.

RESULTS

Twenty-one percent (n = 92) of the sample reported childhood onset, 36% (n = 155) adolescent onset, and 43% (n = 184) adult onset. Patients with adult onset showed a significantly higher proportion of females compared with the other subgroups (χ(2 )=( )10.9, p< 0.05). Childhood- and adolescent-onset patients had been more frequently treated with cognitive behavioural therapy (CBT), compared to adult-onset patients (χ(2 )=( )11.5; p < 0.05). The pre-adult- versus adult-onset analysis did not show any additional significant difference.

CONCLUSIONS

The present international multicentre study confirms that OCD onset occurs more frequently before adult age, with approximately one out of five patients showing childhood onset. Pre-adult onset was associated with higher rate of CBT, while adult onset was more prevalent in females.

Compliance of community teams with specialist service recommendations for obsessive-compulsive and body dysmorphic disorders

Aims and method To examine how often referring community mental health teams (CMHTs) utilised treatment recommendations made by the national highly specialised service for patients with severe obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD). We analysed all patient notes for admissions to the unit (August 2012-August 2014) and recorded how many treatment recommendations were implemented by CMHTs prior to admission and at 6 months post-discharge. Results Overall, 66% of our recommendations were met by CMHTs prior to admission and 74% after discharge. Most recommendations concerned medication and the continued need for care coordination by the CMHT. Clinical implications A significant proportion of patients in our audit did not receive optimum treatment in the community as recommended by our service. As highly specialised services are a limited resource and these patients have not responded to previous treatment, this has implications for the use of such resources.

Physical complications of severe, chronic obsessive-compulsive disorder: a comparison with general psychiatric inpatients

BACKGROUND

This research examines the physical health of patients with severe, chronic obsessive-compulsive disorder (OCD) and compares the findings with patients admitted to an acute general psychiatric ward.

METHODS

Successive admissions to a specialist inpatient unit treating patients with OCD were included in the study. Information including gender, age, weight and height were recorded along with the results of blood tests for urea, liver function tests and blood lipids. In addition, type and dose of medication were also recorded. These data were compared with information obtained via the case records from successive admissions to a general psychiatric ward.

RESULTS

A total of 104 patients with OCD and 101 patients admitted to an acute psychiatric unit were studied. OCD patients were generally younger than the controls and were on a lower dose of antipsychotic medication. Despite this, the OCD patients were more likely than the general psychiatric patients to have raised blood lipids. Raised creatinine was also more common among OCD patients.

CONCLUSION

The study demonstrates that patients with severe OCD have significant evidence of serious physical health problems.

How should we measure delayed sleep phase shift in severe, refractory obsessive-compulsive disorder?

OBJECTIVE

A previous study, based upon direct nursing observations, showed almost half of a cohort of inpatients with severe, enduring OCD also suffered from delayed sleep phase shift. Males, younger patients and those with more severe symptoms were most likely to be affected. However, the ward environment may have had a direct effect on sleeping patterns. In this study we compared the accuracy of actigraphic measurements with that of the "gold standard" of direct nursing observation, and other clinical sleep scales. We postulated that actigraphy would prove a reliable, acceptable, and valid alternative.

METHODS

All patients admitted over 29 months to a specialized treatment unit for severe, chronic refractory OCD were invited to participate. We collected demographic data, clinical measures of OCD and depressive symptom severity, self-rated measures of social and occupational disability and sleep, nursing records based upon direct observation of sleep onset and duration, and actigraphy records.

RESULTS

Evaluable data was obtained from 36 patients (22 males) with an average age of 37 years and profound OCD symptoms measured by the Yale-Brown Obsessive-Compulsive Scale. According to direct nursing observation, 12 patients (33%) showed delayed sleep phase shift. Actigraphic recordings demonstrated good agreement (kappa = 0.63) with nursing observation as did the St George's Insomnia Questionnaire (kappa = 0.66).

CONCLUSION

This study demonstrates that actigraphy is a reliable method of recording sleep/activity cycles in severe, enduring OCD.

Prevalence of anti-basal ganglia antibodies in adult obsessive-compulsive disorder: cross-sectional study

BACKGROUND

Symptoms of obsessive-compulsive disorder (OCD) have been described in neuropsychiatric syndromes associated with streptococcal infections. It is proposed that antibodies raised against streptococcal proteins cross-react with neuronal proteins (antigens) in the brain, particularly in the basal ganglia, which is a brain region implicated in OCD pathogenesis.

AIMS

To test the hypothesis that post-streptococcal autoimmunity, directed against neuronal antigens, may contribute to the pathogenesis of OCD in adults.

METHOD

Ninety-six participants with OCD were tested for the presence of anti-streptolysin-O titres (ASOT) and the presence of anti-basal ganglia antibodies (ABGA) in a cross-sectional study. The ABGA were tested for with western blots using three recombinant antigens; aldolase C, enolase and pyruvate kinase. The findings were compared with those in a control group of individuals with depression (n = 33) and schizophrenia (n = 17).

RESULTS

Positivity for ABGA was observed in 19/96 (19.8%) participants with OCD compared with 2/50 (4%) of controls (Fisher's exact test P = 0.012). The majority of positive OCD sera (13/19) had antibodies against the enolase antigen. No clinical variables were associated with ABGA positivity. Positivity for ASOT was not associated with ABGA positivity nor found at an increased incidence in participants with OCD compared with controls.

CONCLUSIONS

These findings support the hypothesis that central nervous system autoimmunity may have an aetiological role in some adults with OCD. Further study is required to examine whether the antibodies concerned are pathogenic and whether exposure to streptococcal infection in vulnerable individuals is a risk factor for the development of OCD.

Obsessive–Compulsive Contamination Fears and Anorexia Nervosa: The Application of the New Psycho-Educational Treatment of Danger Ideation Reduction Therapy (DIRT)

The case history of a woman with severe and enduring anorexia nervosa and obsessive–compulsive disorder (OCD) with contamination fears is presented. These contamination fears centred on her fear of contamination by fat and fatty substances as she worried about gaining weight. Previous treatment with graded exposure had shown no clinically significant benefits. She was admitted to a specialist unit for the treatment of OCD as an inpatient. Due to the previous failure of the recognised psychological treatments for OCD it was decided to use the new psychoeducational approach of danger ideation reduction therapy (DIRT). This treatment resulted in an improvement in her OCD symptoms despite the fact that the emphasis of the treatment was on the risk of bacteria and dirt. It is believed that this is the first documented case of DIRT being used for a patient with anorexia nervosa and OCD.

Predicting outcome of treatment for severe, treatment resistant OCD in inpatient and community settings

Treatment of OCD is effective, even for the most chronic and severe cases. It has been difficult to identify predictors of treatment outcome, with little work aimed at predicting treatment outcome in severe OCD. We examined the ability of a range of demographic and psychopathology variables to predict treatment outcome in a cohort of 52 inpatients and a second group of 62 community outpatients with severe, treatment-refractory OCD. Despite both cohorts showing significant improvement in OCD symptoms, reliable predictors were difficult to identify, and were different in the two cohorts. In the inpatient group, marital status was a significant predictor, with those who were married or cohabiting showing better outcome that those not currently in a relationship. This relationship was not observed in the community treatment group. Initial symptom severity was also found to be a significant predictor, but only in the community treatment group, where higher initial severity was associated with greater reduction in symptoms during treatment. Further research examining a wider range of predictors may assist in identifying those factors which predict outcome in severe OCD.

A prospective study of delayed sleep phase syndrome in patients with severe resistant obsessive-compulsive disorder

There have been relatively few studies examining sleep in patients with obsessive-compulsive disorder (OCD) and these have produced contradictory findings. A recent retrospective study identified a possible association between OCD and a circadian rhythm sleep disorder known as delayed sleep phase syndrome (DSPS). Patients with this pattern of sleeping go to bed and get up much later than normal. They are unable to shift their sleep to an earlier time and, as a result, suffer considerable disruption to social and occupational functioning. In this study, we examined the sleep of patients with OCD prospectively. We aimed to establish the frequency of DSPS in this population and any associated clinical or demographic factors which might be implicated in its aetiology.

Obsessive-compulsive disorder and rectal prolapse

A 47-year-old woman with a long-standing history of obsessive-compulsive disorder relating to dirt and germs is presented. Her fear of developing bowel cancer led her to manually evacuate faeces from her rectum five times a day and to a resultant rectal prolapse. Treatment involved prolonged graduated exposure to the patient's feared contaminants and ritual avoidance. After 5 months of inpatient therapy, the patient reported a subjective 70% improvement in her symptoms. As her obsessive-compulsive disorder symptoms improved, the patient's rectal prolapse disappeared.

Treatment choice for agoraphobic women: exposure or cognitive-behaviour therapy?

OBJECTIVES

The paper describes a treatment trial where exposure was compared with cognitive-behaviour therapy in the treatment of 39 female participants with a diagnosis of agoraphobia (DSM-111-R). The primary objective of the study was to see if cognitive therapy enhanced the effectiveness of exposure in the treatment of agoraphobia.

DESIGN

Participants were randomly assigned to either exposure or cognitive-behaviour therapy. The two treatment groups were balanced for severity and duration of agoraphobia, presence of panic disorder, and age.

METHODS

The exposure and the cognitive-behaviour therapy groups received the same amount of therapist-assisted exposure to feared situations but the participants in the cognitive-behaviour therapy group were, additionally, taught to identify and challenge negative automatic thoughts and dysfunctional assumptions. In the cognitive-behaviour therapy condition exposure was presented as an opportunity to identify and challenge negative thoughts. In the exposure condition, participants were given a behavioural rationale for doing exposure. Participants were seen individually for 10 sessions. Assessments were carried out before and after the treatment programme and, also, six months later. Assessments included self-reports of fear and avoidance, a behavioural test and questionnaire measures of relevant cognitions. Thirteen participants dropped out of treatment leaving 14 in the exposure condition and 12 in the cognitive-behaviour condition. Therapy sessions were taped and a sample of tapes was given to a judge who rated the quality of the cognitive-behaviour therapy.

RESULTS

Substantial improvement was seen on virtually all measures irrespective of treatment condition both at the end of treatment and six months later. The cognitive-behaviour therapy group and the exposure group did not differ significantly at post-treatment or at six-month follow-up.

Religion, ethnicity and obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is seen in many contrasting cultures but it is not known if the form of the disorder varies between these cultures. There have been anecdotal case reports where religion appeared to play a significant aetiological role in the disorder but the relationship between religion and OCD has not previously been systematically studied. This study was a retrospective, casenote study comparing the country of birth and religious affiliation of three groups of 50 patients. Its aim was to investigate the aetiological role played by religion in the development of OCD. The groups were patients with OCD from a specialist behavioural-cognitive unit, patients assessed in a specialist psycho-dynamic psychotherapy department and patients attending a general adult psychiatry outpatient department. More patients with OCD affiliated themselves with a religion as opposed to either of the other two groups. This difference disappeared when the type of religion was taken into account so that no conclusive relationship between OCD and religion could be identified. The findings do not diminish the importance of religion in the development of OCD in some individuals and suggest that future research in this area should include examination of the rigidity of upbringing and personal perception of the experience of strict rules or imposed religious practices.

The treatment of severe, chronic, resistant obsessive-compulsive disorder. An evaluation of an in-patient programme using behavioural psychotherapy in combination with other treatments

This study examined 49 in-patients with obsessive-compulsive disorder who were treated over three years. The patients had failed to respond to previous treatment. Treatment consisted of in-patient exposure, occasionally combined with other interventions individually tailored to the patient's specific difficulties. This resulted in significant clinical improvements and an average 40% reduction in rituals in 31 (63.3%) of these chronic patients. These gains were maintained at an average 19-month follow-up. Checking rituals were more likely to be associated with good outcome. Women had a later onset of the disorder and a slight tendency to better prognosis. No other predictors of outcome were found.

Behavioural approaches to anxiety disorders

Powerful behavioural treatments for many patients with anxiety disorders have been widely available since the 1970s. Despite this, the majority of such patients have continued to be treated with psychotrophic drugs. Recent litigation against the manufacturers of benzodiazepine drugs has made the public increasingly concerned about the prescription of anxiolytic agents. In parallel with the fall in popularity of drug treatment, advances have been made which increase the availability and applicability of behavioural treatments for these patients. This paper examines the impact of the development of self-exposure and cognitive methods on a number of common anxiety syndromes. Clinical examples of self-exposure are given to demonstrate the simplicity of the technique.

Hysterical conversion and dissociation arising as a complication of behavioural psychotherapy treatment of obsessive-compulsive neurosis

The case history of a patient with obsessive-compulsive disorder who developed hysterical conversion and dissociative symptoms during exposure treatment is described. The theoretical implications of this finding are discussed.

Acne excoriée--a case report of treatment using habit reversal

Acne excoriée is a self-inflicted skin condition in which the sufferer has an urge to pick real or imagined acnieform lesions and which results in a worsening and spreading of the acne. The condition differs from most artefactual dermatoses as the patient usually spontaneously admits the self-inflicted nature of the condition. Although this condition is considered to be a neurotic manifestation of the patient, traditional psychiatric treatments have proved unsuccessful.

Delayed emergence of obsessive-compulsive neurosis following head injury. Case report and review of its theoretical implications

A patient with obsessive-compulsive neurosis arising six months after minor head injury is described. The theoretical implications of this case are discussed. A neuropsychological model to explain the onset of the disorder in this and previously reported cases is suggested.

Paradoxical intention and anti-exposure in a non-compliant, obsessive-compulsive ritualiser

A woman with persistent obsessive-compulsive rituals showed limited improvement with exposure therapy, because of her refusal to comply fully with treatment and a lack of homework practice. She was negativistic towards therapists. Following a relapse, she was asked to try anti-exposure and to increase rituals. Paradoxically, this led to marked self exposure to the feared situation, and self-imposed response prevention, with resultant improvement, whereas anti-exposure instructions are generally anti-therapeutic in obsessive-compulsive disorder.

Obsessive-compulsive disorder occurring as a complication in benzodiazepine withdrawal

A case history of obsessive-compulsive disorder occurring in a 32-year-old woman after benzodiazepine withdrawal is presented. The possible biochemical and neuropsychological mechanisms involved in the etiology and maintenance of this condition are reviewed.

Creatine phosphokinase levels in the newborn and their use in screening for Duchenne muscular dystrophy

The PKU sample, if taken after the 3rd day, is suitable for Duchenne muscular dystrophy screening using creatine phosphokinase (CPK) levels. 101 babies (53 girls and 48 boys) had CPK levels measured on filter paper blood specimens taken by heel prick on the 1st and 4th days of life. The method used was that described by Zellweger and Antonik (1975). The CPK levels were markedly raised on the 1st day of life but by the 4th they had reduced to within 3 times the upper limit of the normal range for adults. 10,000 boys were then screened for Duchenne muscular dystrophy using the PKU sample, and 2 cases were found.