An international survey of different transcranial magnetic stimulation (TMS) protocols for patients with obsessive-compulsive disorder (OCD)

This study aims to evaluate current preferences and trends in the delivery of Transcranial Magnetic Stimulation (TMS) for Obsessive-Compulsive Disorder (OCD). A 10-item online questionnaire was developed and conducted online between April to June 2020, surveying providers of TMS for patients with OCD internationally. A total of 27 valid responses were analysed from 10 countries. The most common target for TMS was the supplementary motor area and stimulation was commonly given bilaterally, but techniques differed between centres. Exposure tasks were not commonly used during TMS. The study calls for more research clarifying the best mode of TMS delivery for OCD.

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.

Psychic euosmia among obsessive-compulsive personality disorder patients: A case control study

BACKGROUND

Psychic euosmia (PE) has been described as a supposed psychological predisposition for which pleasant smells elicit an immediate sense of pleasure, order and calmness in obsessive-compulsive personality disorder (OCPD). In this study we tried to verify the interpretation that PE is the counterpart of disgust that has been associated to contamination and moral purity. Disgust and morality are significantly associated in people with obsessive-compulsive personality traits. We expected that OCPD patients would experience higher levels of PE.

AIM

To investigate the PE frequency in OCPD patients and healthy controls (HC) and to evaluate the relationship between PE and disgust.

METHODS

A single-center, case-control study was conducted in an outpatient service for obsessive-compulsive and related disorders. The sample consisted of 129 subjects: 45 OCPD patients and 84 HC. In both groups we submitted the Disgust Scale Revised (DS-R) and the self-report Structured Clinical Interview for DSM-5 Screening Personality Questionnaire to which we added an additional yes or no question to investigate the presence of PE. In order to verify differences between groups, t-test was employed for continuous variables and ² test for categorical variable; odds ratio was employed to analyze group differences in the PE survey. Correlation was explored with Pearson r correlations.

RESULTS

No differences were observed between groups in gender composition or education. A slight significant difference was found in mean age (t = 1.988; P = 0.049). The present study revealed significantly higher proportions of PE among OCPD patients when compared to HC (OR: 5.3, 2.28-12.46). Patients with OCPD were more likely to report PE (n = 36; 80%) whereas a much lower proportion endorsed PE in the HC group (n = 36; 42.9%). Interestingly, no differences were observed between groups in mean score for the Disgust Scale. There was also no difference between the two groups in any of the Disgust Scale Revised subscales. Moreover, no significant correlations were observed in the OCPD group between PE and Disgust Scale Revised subscales.

CONCLUSION

Results suggested that PE might be part of the clinical spectrum of OCPD, and it does not reflect the counterpart of disgust. This could also indicate that this phenomenon is a manifestation of orderliness or incompleteness. Further studies will need to be undertaken to better understand PE and its significance in OCPD.

Screening for depression in primary care with Patient Health Questionnaire-9 (PHQ-9): A systematic review

BACKGROUND

Depression is a leading cause of disability. International guidelines recommend screening for depression and the Patient Health Questionnaire 9 (PHQ-9) has been identified as the most reliable screening tool. We reviewed the evidence for using it within the primary care setting.

METHODS

We retrieved studies from MEDLINE, Embase, PsycINFO, CINAHL and the Cochrane Library that carried out primary care-based depression screening using PHQ-9 in populations older than 12, from 1995 to 2018.

RESULTS

Forty-two studies were included in the systematic review. Most of the studies were cross-sectional (N=40, 95%), conducted in high-income countries (N=27, 71%) and recruited adult populations (N=38, 90%). The accuracy of the PHQ-9 was evaluated in 31 (74%) studies with a two-stage screening system, with structured interview most often carried out by primary care and mental health professionals. Most of the studies employed a cut-off score of 10 (N=24, 57%, total range 5 - 15). The overall sensitivity of PHQ-9 ranged from 0.37 to 0.98, specificity from 0.42 to 0.99, positive predictive value from 0.09 to 0.92, and negative predictive value from 0.8 to 1.

LIMITATIONS

Lack of longitudinal studies, small sample size, and the heterogeneity of primary-care settings limited the generalizability of our results.

CONCLUSIONS

PHQ-9 has been widely validated and is recommended in a two-stage screening process. Longitudinal studies are necessary to provide evidence of long-term screening effectiveness.

Clinical advances in obsessive-compulsive disorder: a position statement by the International College of Obsessive-Compulsive Spectrum Disorders

In this position statement, developed by The International College of Obsessive-Compulsive Spectrum Disorders, a group of international experts responds to recent developments in the evidence-based management of obsessive-compulsive disorder (OCD). The article presents those selected therapeutic advances judged to be of utmost relevance to the treatment of OCD, based on new and emerging evidence from clinical and translational science. Areas covered include refinement in the methods of clinical assessment, the importance of early intervention based on new staging models and the need to provide sustained well-being involving effective relapse prevention. The relative benefits of psychological, pharmacological and somatic treatments are reviewed and novel treatment strategies for difficult to treat OCD, including neurostimulation, as well as new areas for research such as problematic internet use, novel digital interventions, immunological therapies, pharmacogenetics and novel forms of psychotherapy are discussed.

The rates of co-occurring behavioural addictions in treatment-seeking individuals with obsessive-compulsive disorder: a preliminary report

Objectives: To assess the rates of co-occurring putative 'behavioural addictions' in patients with obsessive-compulsive disorder (OCD).Methods: Twenty-three international centres specialising in the treatment of OCD were invited to participate in a survey of the rates of behavioural addictions and other relevant comorbidity within their samples.Results: Sixteen of 23 (69.6%) invited centres from 13 countries had sufficient data to participate in the survey. The use of validated diagnostic tools was discrepant, with most centres relying on a 'clinical diagnosis' to diagnose behavioural addictions. The final sample comprised of 6916 patients with a primary diagnosis of OCD. The reported rates of behavioural addictions were as follows: 8.7% for problematic internet use, 6.8% for compulsive sexual behaviour disorder, 6.4% for compulsive buying, 4.1% for gambling disorder and 3.4% for internet gaming disorder.Conclusions: Behavioural addictions should be better assessed for patients with OCD. The absence of diagnostic scales developed specifically for behavioural addictions and overlapping obsessive-compulsive phenomena such as compulsive checking of information on the internet may explain the relatively high rate of problematic internet use in this sample. The study encourages better efforts to assess and to conceptualise the relatedness of behavioural addictions to obsessive-compulsive 'spectrum' disorders.

Changing characteristics of a Psychiatric Emergency Care Centre. An eight year follow-up study

OBJECTIVE

The objective of this study was to report changes in characteristics of admissions to an established Psychiatric Emergency Care Centre (PECC) eight years after its opening.

METHOD

Key clinical characteristics of admissions to the PECC were documented for 327 patients in 2015 and compared with the 477 patients in 2007, which is when the centre first opened. The characteristics of admission were evaluated using an audit of medical records from June to December in both 2007 and 2015.

RESULTS

Statistically significant differences (p<0.05) between 2007 and 2015 were: a reduction in the numbers of patients admitted with depression; a reduction in the numbers of patients diagnosed with adjustment disorder; an increase in the numbers of patients diagnosed with borderline personality disorder; a reduction in pro re nata (prn) use, including a reduction in the need for chemical restraint with midazolam and a decrease in the length of admission in the PECC.

CONCLUSIONS

The significant reduction in aggression, the use of prn medication and the number of people with longer stays within the PECC support the usefulness of PECCs in relation to patient satisfaction and adherence to admission criteria policy. These factors may be considered as indicators of the efficiency of a PECC.

Advances in the pharmacological management of obsessive-compulsive disorder in the postpartum period

Introduction: Obsessive-compulsive disorder (OCD) is a psychiatric disorder characterized by obsessions and compulsions. Obsessions are defined as intrusive, recurrent and distressing thoughts, images or impulses, whereas compulsions are defined as repetitive behaviors or mental acts. While there is an associated distress, and indeed oftentimes, the individual's awareness that these behaviors are excessive and unreasonable, the individual continues to be disabled by an inability to cease their compulsions. The postpartum period may herald the onset of OCD or precipitate an exacerbation of the preexisting OCD symptoms. Common OCD symptom clusters occur in the postpartum period, with specific challenges associated with motherhood and lactation.Areas covered: This brief review aims to review the extent and nature of publications evaluating pharmacological treatment of OCD in the postpartum period.Expert opinion: Education and training should aim to improve the recognition and treatment of postpartum OCD. Due to the limited nature of studies, more research is required to assess the role of selective serotonin reuptake inhibitors in the postpartum period.

A brief intervention to improve rates and quality of physical examinations for admissions to acute adult psychiatry units

OBJECTIVE

To determine the frequency and quality of physical examinations within 24 h of admission to an acute adult psychiatry unit, and whether a brief intervention involving feedback to clinicians could lead to improvement.

METHOD

Retrospective review of the electronic medical records followed by four brief feedback sessions and email correspondence, followed by a further review of the medical records 1 month later.

RESULTS

The proportion of patients receiving a physical examination increased from 36/71 (50.7%) in the initial audit to 41/64 (64.1%) in the re-audit. The mean score of the quality of physical examinations improved from 7.5 to 9.3 (out of 15). The greatest improvement on re-audit occurred in the documentation of additional cardiac sounds (33.9% increase), additional breath sounds (17.7% increase), breath sounds (17.1% increase), cardiac sounds (14.2% increase) and bowel sounds (12.5% increase).

CONCLUSION

This audit supports the use of brief peer-led feedback to improve the rates and quality of physical examinations.

Level of Insight in Patients With Obsessive-Compulsive Disorder: An Exploratory Comparative Study Between Patients With "Good Insight" and "Poor Insight"

Introduction: Insight may be defined as the ability to perceive and evaluate external reality and to separate it from its subjective aspects. It also refers to the ability to self-assess difficulties and personal qualities. Insight may be a predictor of success in the treatment of obsessive-compulsive disorder (OCD), so that individuals with poor insight tend to become refractory to treatment. The objective of this study is to investigate factors associated with poor insight in individuals with OCD. Methods: This cross-sectional exploratory study used the Brown Belief Assessment Scale as a parameter for the creation of the comparison groups: individuals who obtained null scores (zero) composed the group with preserved or good insight (n = 148), and those with scores above the 75% percentile composed the group with poor insight (n = 124); those with intermediate scores were excluded. Sociodemographic characteristics and clinical and psychopathological aspects, intrinsic and extrinsic to the typical symptoms of OCD, were compared in a univariate analysis. A logistic regression was used to determine which factors associated with critical judgment remained significant. Results: Individuals in the poor insight group differed from those with good insight in regard to: more prevalent use of neuroleptics (p = 0.05); higher untreated time interval (p < 0.001); higher total Yale-Brown obsessive-compulsive scale score and the obsessions and compulsions factors (all factors with p < 0.001); higher dimensional Yale-Brown obsessive-compulsive scale total and dimensional scores (p from 0.04 to 0.001); higher prevalence of contamination/cleaning (p = 0.006) and hoarding (p < 0.001) symptoms dimensions; more prevalent sensory phenomena (p = 0.023); higher levels of depression (p = 0.007); and more prevalent comorbidity with bipolar affective disorder (p = 0.05) and post-traumatic stress disorder (PTSD) (p = 0.04). After analyzing the logistic regression, we conclude that the most important factors associated with poor insight are: the presence of any sensory phenomena (OR: 2.24), use of neuroleptics (OR: 1.66), and hoarding symptoms (OR: 1.15). Conclusion: The variability of insight in patients with OCD seems to be an important psychopathological characteristic in the differentiation of possible subtypes of OCD, since the poor insight is associated with sensory phenomena and greater use of neuroleptics, which makes it possible to conjecture the role of dopaminergic neurocircuits in the neurobiology of this disorder. In addition, there is also an association with the symptoms of hoarding content, admittedly one of the symptomatic contents with less response to conventional OCD treatments. Studies based on neurobiological aspects such as neuroimaging and neuropsychology may help to elucidate more consistently the role of insight in patients with OCD and the repercussions concerning available treatments.

Treatments used for obsessive-compulsive disorder-An international perspective

OBJECTIVE

The objective of this study was to characterise international trends in the use of psychotropic medication, psychological therapies, and novel therapies used to treat obsessive-compulsive disorder (OCD).

METHODS

Researchers in the field of OCD were invited to contribute summary statistics on the characteristics of their samples. Consistency of summary statistics across countries was evaluated.

RESULTS

The study surveyed 19 expert centres from 15 countries (Argentina, Australia, Brazil, China, Germany, Greece, India, Italy, Japan, Mexico, Portugal, South Africa, Spain, the United Kingdom, and the United States) providing a total sample of 7,340 participants. Fluoxetine (n = 972; 13.2%) and fluvoxamine (n = 913; 12.4%) were the most commonly used selective serotonin reuptake inhibitor medications. Risperidone (n = 428; 7.3%) and aripiprazole (n = 415; 7.1%) were the most commonly used antipsychotic agents. Neurostimulation techniques such as transcranial magnetic stimulation, deep brain stimulation, gamma knife surgery, and psychosurgery were used in less than 1% of the sample. There was significant variation in the use and accessibility of exposure and response prevention for OCD.

CONCLUSIONS

The variation between countries in treatments used for OCD needs further evaluation. Exposure and response prevention is not used as frequently as guidelines suggest and appears difficult to access in most countries. Updated treatment guidelines are recommended.

A systematic review of the use of risperidone, paliperidone and aripiprazole as augmenting agents for obsessive-compulsive disorder

INTRODUCTION

Obsessive-compulsive disorder (OCD) is often viewed as a difficult to treat disorder. In some patients, antipsychotics are used to augment the action of serotonin reuptake inhibitors (SRIs), particularly when there is only a partial response to treatment.

AREAS COVERED

This comprehensive literature review aims to assess the effectiveness and tolerability of three commonly used atypical antipsychotic agents: risperidone, paliperidone and aripiprazole, as augmentation agents in the treatment of OCD.

EXPERT OPINION

Antipsychotic augmentation should only be trialed once treatment with selective SRIs at high dose and exposure and response prevention therapy have failed. Currently, there is evidence to support the use of risperidone, paliperidone and aripiprazole as augmentation agents for OCD in adult samples but more studies with larger samples are needed to assess predictors of response to antipsychotic augmentation and to detect any differential effects between the three agents. At this point in time, the choice of antipsychotic is best determined by the side effect profile of the drug and a patient's medication history.

A Meta-Analysis of the Effectiveness of Different Cortical Targets Used in Repetitive Transcranial Magnetic Stimulation (rTMS) for the Treatment of Obsessive-Compulsive Disorder (OCD)

Randomised and sham-controlled trials (RCTs) of repetitive transcranial magnetic stimulation (rTMS) in the treatment of obsessive-compulsive disorder (OCD) have yielded conflicting results, which may be due to the variability in rTMS parameters used. We performed an updated systematic review and meta-analysis on the effectiveness of rTMS for the treatment of OCD and aimed to determine whether certain rTMS parameters, such as cortical target, may be associated with higher treatment effectiveness. After conducting a systematic literature review for RCTs on rTMS for OCD through to 1 December 2016 using MEDLINE, PubMed, Web of Science, PsycINFO, Google, and Google Scholar, we performed a random-effects meta-analysis with the outcome measure as pre-post changes in Yale-Brown Obsessive Compulsive Scale (Y-BOCS) scores. To determine whether rTMS parameters may have influenced treatment effectiveness, studies were further analysed according to cortical target, stimulation frequency, and length of follow-up. Data were obtained from 18 RCTs on rTMS in the treatment of OCD. Overall, rTMS yielded a modest effect in reducing Y-BOCS scores with Hedge's g of 0.79 (95% CI = 0.43-1.15, p < 0.001). Stimulation of the supplementary motor area yielded the greatest reductions in Y-BOCS scores relative to other cortical targets. Subgroup analyses suggested that low frequency rTMS was more effective than high frequency rTMS. The effectiveness of rTMS was also greater at 12 weeks follow-up than at four weeks follow-up. Our meta-analysis implies that low frequency rTMS applied over the supplementary motor area may offer the greatest effectiveness in the treatment of OCD. The therapeutic effects of rTMS also appear to persist post-treatment and may offer beneficial long-term effectiveness. With our findings, it is suggested that future large-scale studies focus on the supplementary motor area and include follow-up periods of 12 weeks or more.

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.

Routine treatment duration for clients attending a community based anxiety disorders clinic

OBJECTIVE

To determine the average duration of treatment at a community-based anxiety disorders clinic.

METHOD

Data were collected on primary disorder, the presence of co-occurring disorders and treatment length (both in terms of number of sessions and weeks of therapy) for 248 consecutive clients.

RESULTS

The mean number of sessions was 13, and average treatment length was 29 weeks. There was substantial variation in treatment duration (range for number of sessions = 1-128, range for treatment duration = 0-186 weeks).

CONCLUSION

Clients with anxiety disorders were often treated in relatively few sessions, in line with randomised controlled trials (RCTs). However, a number of clients required many more sessions and were treated for a longer period of time than clients in RCTs. Health services should be cautious in mandating limits to therapy duration for anxiety disorders given the wide range in the duration of treatment for clients in our sample.

The Nepean Belief Scale: preliminary reliability and validity in obsessive-compulsive disorder

OBJECTIVES

To examine the psychometric characteristics of the Nepean Belief Scale (NBS), a short clinician-administered scale that assesses the characteristics and intensity of beliefs in obsessive-compulsive disorder (OCD).

METHODS

The NBS was administered by two clinicians to 27 subjects with OCD as part of a larger study that included a comprehensive assessment using the Yale-Brown Obsessive Compulsive Symptom Scale (Y-BOCS), the Overvalued Ideas Scale (OVIS) and the Symptom Checklist 90-Revised (SCL-90R). Test-retest reliability of the NBS was assessed by administering the scale 5 days after initial administration.

RESULTS

The 5-item NBS proved easy to use with an assessment time of less than 5 min. Its interrater reliability revealed 99.5% concordance, while the kappa for test-retest reliability was 0.98 (95% CI = 0.95-1.00). Cronbach alpha coefficient for internal consistency was 0.87. The NBS was found to have excellent convergent and discriminant validity.

CONCLUSIONS

Preliminary results suggest that the NBS could be a useful shorter alternative to the currently more widely used instruments for assessing beliefs such as the OVIS and the Brown Assessment of Belief Scale. The NBS has clear instructions and definitions, excellent interrater reliability and convergent validity, and it more accurately measures belief-related insight.

Italian prescribing patterns in obsessive-compulsive disorder

The aim of the present study was to investigate psychopharmacological prescribing patterns in a large sample (n = 1815) of patients suffering from obsessive-compulsive disorder (OCD) recruited in 4 Italian centers specialized in OCD, in comparison to available national and international guidelines. The centers were asked to complete a specific data sheet questionnaire on patients' therapeutic status. Statistical analyses were carried out by SPSS. The results showed that almost all patients referred to the centers of Milan, Pisa and Rome received psychotropic medications, whereas only 59.9% (313) did so in Turin. Selective serotonin reuptake inhibitors were the most used drugs ranging between 49.0% and 71.5%. Clomipramine was prescribed more often in Rome and Pisa than in Milan and Turin. The same was true for other tricyclic antidepressants. Second-generation antipsychotics were more often prescribed in Pisa and in Milan. Mood stabilizers were almost exclusively used in Pisa. Taken together, the overall findings would suggest that, although the main Italian centers specialized in OCD follow available guidelines, a certain degree of variability does exist. This may depend on the different educational background, availability of other specific therapeutic strategies, as well as varying levels of severity and comorbidity of the patients.

Comorbidity, age of onset and suicidality in obsessive-compulsive disorder (OCD): An international collaboration

OBJECTIVES

To collate data from multiple obsessive-compulsive disorder (OCD) treatment centers across seven countries and five continents, and to report findings in relation to OCD comorbidity, age of onset of OCD and comorbid disorders, and suicidality, in a large clinical and ethnically diverse sample, with the aim of investigating cultural variation and the utility of the psychiatric diagnostic classification of obsessive-compulsive and related disorders.

METHODS

Researchers in the field of OCD were invited to contribute summary statistics on current and lifetime psychiatric comorbidity, age of onset of OCD and comorbid disorders and suicidality in their patients with OCD.

RESULTS

Data from 3711 adult patients with primary OCD came from Brazil (n=955), India (n=802), Italy (n=750), South Africa (n=565), Japan (n=322), Australia (n=219), and Spain (n=98). The most common current comorbid disorders were major depressive disorder (28.4%; n=1055), obsessive-compulsive personality disorder (24.5%, n=478), generalized anxiety disorder (19.3%, n=716), specific phobia (19.2%, n=714) and social phobia (18.5%, n=686). Major depression was also the most commonly co-occurring lifetime diagnosis, with a rate of 50.5% (n=1874). OCD generally had an age of onset in late adolescence (mean=17.9years, SD=1.9). Social phobia, specific phobia and body dysmorphic disorder also had an early age of onset. Co-occurring major depressive disorder, generalized anxiety disorder and psychotic disorders tended to have a later age of onset than OCD. Suicidal ideation within the last month was reported by 6.4% (n=200) of patients with OCD and 9.0% (n=314) reported a lifetime history of suicide attempt.

CONCLUSIONS

In this large cross-continental study, comorbidity in OCD was common. The high rates of comorbid major depression and anxiety disorders emphasize the need for clinicians to assess and monitor for these disorders. Earlier ages of onset of OCD, specific phobia and social phobia may indicate some relatedness between these disorders, but this requires further study. Although there do not appear to be significant cultural variations in rates or patterns of comorbidity and suicidality, further research using similar recruitment strategies and controlling for demographic and clinical variables may help to determine whether any sociocultural factors protect against suicidal ideation or psychiatric comorbidity in patients with OCD.