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Reuter B, Miano A, Wassermann J, Elsner B. Why does exposure-based therapy fail in some individuals with obsessive-compulsive disorder? Expert Rev Neurother 2024; 24:723-726. [PMID: 38875186 DOI: 10.1080/14737175.2024.2365949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 06/05/2024] [Indexed: 06/16/2024]
Affiliation(s)
- Benedikt Reuter
- MSB Medical School Berlin, Department of Human Medicine, Berlin, Germany
| | - Annemarie Miano
- MSB Medical School Berlin, Department of Human Medicine, Berlin, Germany
| | - Josepha Wassermann
- MSB Medical School Berlin, Department of Human Medicine, Berlin, Germany
| | - Björn Elsner
- Humboldt-Universität zu Berlin, Department of Psychology, Berlin, Germany
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2
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Zisler EM, Meule A, Koch S, Voderholzer U. Willingness to experience unpleasant thoughts, emotions, and bodily sensations at admission does not predict treatment outcome in inpatients with obsessive-compulsive disorder. DISCOVER MENTAL HEALTH 2024; 4:20. [PMID: 38844591 PMCID: PMC11156830 DOI: 10.1007/s44192-024-00073-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 05/24/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND Some persons with obsessive-compulsive disorder (OCD) refuse or drop out of treatment because of the aversive nature of exposure and response prevention therapy when they have to face and tolerate unpleasant thoughts, emotions, and bodily sensations. Indeed, one study suggested that a higher willingness to experience unpleasant thoughts, emotions, and bodily sensations (WTE) predicts a better treatment outcome, but this finding has not been replicated yet. METHODS We examined whether WTE at admission predicted treatment outcome in a sample of 324 inpatients with OCD who received a multimodal treatment that included cognitive-behavioral therapy with exposure and response prevention sessions. RESULTS Obsessive-compulsive symptoms (based on OCD-specific self-report questionnaires) decreased with medium-to-large effect sizes (all ps < 0.001) and global functioning (based on therapist ratings) increased with a large effect size (d = 1.3, p < 0.001) from admission to discharge. In contrast to previous findings, however, WTE did not predict treatment outcome (all ps > 0.005). The effect of WTE on treatment outcome remained non-significant when controlling for any comorbidity, age, sex, length of stay, and antidepressant medication and was not moderated by these variables. CONCLUSIONS Results indicate that higher WTE at the beginning of inpatient treatment does not facilitate improvements in obsessive-compulsive symptoms from admission to discharge. However, they also indicate that lower WTE at the beginning of inpatient treatment does not adversely affect treatment outcome, that is, even patients who indicate that they are unwilling to face the negative experiences associated with exposure and response prevention can still achieve considerable symptom reductions.
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Affiliation(s)
- Eva M Zisler
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany.
- Schoen Clinic Roseneck, Prien am Chiemsee, Germany.
| | - Adrian Meule
- Department of Psychology, University of Regensburg, Regensburg, Germany
| | - Stefan Koch
- Schoen Clinic Roseneck, Prien am Chiemsee, Germany
| | - Ulrich Voderholzer
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
- Schoen Clinic Roseneck, Prien am Chiemsee, Germany
- Medical Center, Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Endres D, Jelinek L, Domschke K, Voderholzer U. [Treatment-resistant obsessive-compulsive disorders]. DER NERVENARZT 2024; 95:432-439. [PMID: 38466350 DOI: 10.1007/s00115-024-01629-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/07/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Obsessive-compulsive disorders (OCD) are mainly treated with disorder-specific cognitive behavioral therapy using exposure and response management and/or selective serotonin reuptake inhibitors; however, a significant subgroup of patients does not sufficiently benefit from this approach. OBJECTIVE This article provides an overview of treatment-resistant OCD. MATERIAL AND METHODS In this narrative review the definition, causes, diagnostic and therapeutic approaches to treatment-resistant OCD are addressed. RESULTS Treatment resistance can be assumed in the absence of clinically relevant improvement under therapy, in the sense of a reduction of < 25% on the Yale-Brown obsessive-compulsive scale and a score of 4 (no change) on the clinical global impression-improvement scale. The number of unsuccessful treatment attempts required to establish treatment resistance is defined differently. Causative factors include misdiagnosis, a high severity, comorbid disorders, substance use, specific symptom constellations, organic causes, environmental factors, and aggravating factors in psychotherapy and pharmacotherapy. Suggestions for diagnostic and therapeutic approaches based on the German S3 guideline on OCD are presented. CONCLUSION For patients with treatment resistance to first-line therapy, useful diagnostic and therapeutic recommendations are available (psychotherapeutic, psychopharmacological and neurostimulation procedures).
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Affiliation(s)
- Dominique Endres
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland.
| | - Lena Jelinek
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Katharina Domschke
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
- Deutsches Zentrum für Psychische Gesundheit (DZPG), Standort Berlin, Berlin, Deutschland
| | - Ulrich Voderholzer
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
- Schön Klinik Roseneck, Prien am Chiemsee, Deutschland
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum, Ludwig-Maximilians-Universität München, München, Deutschland
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Voderholzer U, Meule A, Koch S, Pfeuffer S, Netter AL, Lehr D, Zisler EM. Effectiveness of One Videoconference-Based Exposure and Response Prevention Session at Home in Adjunction to Inpatient Treatment in Persons With Obsessive-Compulsive Disorder: Nonrandomized Study. JMIR Ment Health 2024; 11:e52790. [PMID: 38477970 DOI: 10.2196/52790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/24/2023] [Accepted: 12/19/2023] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Therapist-guided exposure and response prevention (ERP) for the treatment of obsessive-compulsive disorder (OCD) is frequently conducted within clinical settings but rarely at places where patients are usually confronted with OCD symptom-provoking situations in daily life (eg, at home). OBJECTIVE This study aimed to investigate patients' views on 1 ERP session at home via videoconference and its impact on treatment outcome. METHODS A total of 64 inpatients with OCD received 1 session of therapist-guided videoconference-based ERP at home in adjunction to a multimodal inpatient treatment between 2015 and 2020. RESULTS Compared with 64 age- and sex-matched controls who received a multimodal inpatient treatment without 1 session of videoconference-based ERP at home, patients who received 1 session of videoconference-based ERP in adjunction to a multimodal inpatient treatment showed stronger reductions in OCD symptom severity from admission to discharge. Before the videoconference-based ERP session, patients reported high rationale credibility and treatment expectancy. After the videoconference-based ERP session, patients reported medium-to-high positive mood as well as depth and smoothness of the session, and they perceived the working alliance as high. CONCLUSIONS Results highlight the importance of administering therapist-guided ERP sessions in patients' natural environment to enhance treatment response in OCD. Videoconference-based ERP as add-on to treatment as usual is, therefore, a promising approach to facilitate the application of ERP in patients' natural environment and foster the generalization of ERP conducted in clinical settings.
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Affiliation(s)
- Ulrich Voderholzer
- Schoen Clinic Roseneck, Prien am Chiemsee, Germany
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
- Medical Center, Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Adrian Meule
- Schoen Clinic Roseneck, Prien am Chiemsee, Germany
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
- Institute of Medical Psychology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Stefan Koch
- Schoen Clinic Roseneck, Prien am Chiemsee, Germany
| | | | | | - Dirk Lehr
- Leuphana Universität Lüneburg, Lüneburg, Germany
| | - Eva Maria Zisler
- Schoen Clinic Roseneck, Prien am Chiemsee, Germany
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
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von Zedtwitz K, Tebartz van Elst L, Urbach H, Groppa S, Schiele MA, Prüss H, Domschke K, Stich O, Hannibal L, Endres D. Obsessive-compulsive symptoms and brain lesions compatible with multiple sclerosis. J Neural Transm (Vienna) 2024; 131:281-286. [PMID: 38289491 PMCID: PMC10874305 DOI: 10.1007/s00702-023-02737-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/27/2023] [Indexed: 02/18/2024]
Abstract
Autoimmune-mediated obsessive-compulsive disorder (OCD) can occur in multiple sclerosis (MS). Here, a well-studied case study of a patient with OCD and MS-compatible diagnostic findings is presented. The 42-year-old female patient had displayed OCD symptoms for 6 years. Magnetic resonance imaging (MRI) identified several periventricular and one brainstem lesion suggestive of demyelination. Cerebrospinal fluid (CSF) analyses detected an increased white blood cell count, intrathecal immunoglobulin (Ig) G and IgM synthesis, CSF-specific oligoclonal bands, and a positive MRZ reaction. Neopterin was increased, but sarcoidosis was excluded. In the absence of neurological attacks and clues for MRI-based dissemination in time, a radiologically isolated syndrome, the pre-disease stage of MS, was diagnosed. Neurotransmitter measurements of CSF detected reduced serotonin levels. In the absence of visible strategic demyelinating lesions within the cortico-striato-thalamo-cortical circuits, OCD symptoms may relate to reduced intrathecal serotonin levels and mild neuroinflammatory processes. Serotonin abnormalities in MS should be studied further, as they could potentially explain the association between neuroinflammation and mental illnesses.
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Affiliation(s)
- Katharina von Zedtwitz
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ludger Tebartz van Elst
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sergiu Groppa
- Department of Neurology, Focus Program Translational Neuroscience, Rhine-Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Miriam A Schiele
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Harald Prüss
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany
| | - Katharina Domschke
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Oliver Stich
- Department of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Luciana Hannibal
- Laboratory of Clinical Biochemistry and Metabolism, Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dominique Endres
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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Kolar DR, Meule A, Zisler EM, Schwartz C, Voderholzer U. Effects of acceptance-based strategies on psychological responses to disorder-relevant stimuli in inpatients with obsessive-compulsive disorder: An experimental study. J Behav Ther Exp Psychiatry 2023; 81:101890. [PMID: 37429125 DOI: 10.1016/j.jbtep.2023.101890] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/05/2023] [Accepted: 06/25/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND AND OBJECTIVES Preliminary findings suggest that acceptance and commitment therapy-informed exposure therapy may be an effective treatment for obsessive-compulsive disorder (OCD). However, there is a lack of experimental studies that have examined immediate effects of acceptance-based strategies during exposure to disorder-relevant stimuli in persons with OCD. METHODS Fifty-three inpatients (64% female) with OCD participated in an experimental study during which they were exposed to obsessive-compulsive washing-relevant pictures and were instructed to either passively view these pictures for 5 s (neutral condition), to accept their feelings (acceptance condition) or to intensify their feelings (exposure condition) for 90 s each. RESULTS The acceptance condition led to higher acceptance and lower unpleasantness of patients' current feelings compared to the neutral condition and to lower strength of obsessions and urge to perform compulsions but only when compared to the exposure condition. Higher self-reported OCD symptom severity related to higher unpleasantness and strength of obsessions, particularly in the neutral condition. LIMITATIONS Future studies need to test whether the current findings translate to other stimuli and other forms of obsessions and compulsions. Due to the short duration, the exposure condition might have only mimicked the early phase of exposure and response prevention. CONCLUSIONS Acceptance-based strategies during cue exposure immediately increase acceptance of and reduce unpleasant feelings. In line with the rationale of acceptance-based treatment approaches, which do not aim at immediate disorder-specific symptom reductions, effects on obsessions and compulsions may be more delayed or require repeated training sessions.
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Affiliation(s)
- David R Kolar
- Department of Psychology, University of Regensburg, Regensburg, Germany
| | - Adrian Meule
- Department of Psychiatry and Psychotherapy, LMU University Hospital, LMU Munich, Munich, Germany; Schoen Clinic Roseneck, Prien Am Chiemsee, Germany; Institute of Medical Psychology, Faculty of Medicine, LMU Munich, Germany
| | - Eva M Zisler
- Department of Psychiatry and Psychotherapy, LMU University Hospital, LMU Munich, Munich, Germany; Schoen Clinic Roseneck, Prien Am Chiemsee, Germany.
| | - Caroline Schwartz
- Department of Psychiatry and Psychotherapy, LMU University Hospital, LMU Munich, Munich, Germany
| | - Ulrich Voderholzer
- Department of Psychiatry and Psychotherapy, LMU University Hospital, LMU Munich, Munich, Germany; Schoen Clinic Roseneck, Prien Am Chiemsee, Germany; Medical Center, Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Jelinek L, Schröder J, Bücker L, Miegel F, Baumeister A, Moritz S, Sibilis A, Schultz J. Improving adherence to unguided Internet-based therapy for obsessive-compulsive disorder: A randomized controlled trial. J Affect Disord 2023; 338:472-481. [PMID: 37348657 DOI: 10.1016/j.jad.2023.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 06/11/2023] [Accepted: 06/19/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Adherence to internet-based cognitive-behavioral therapy (iCBT) is often low, possibly reducing its potential. The current study set out to test whether adherence and effects of unguided iCBT for obsessive-compulsive disorder (OCD) could be improved by varying the degree of autonomy in which modules are completed (free choice vs. fixed order). METHODS We randomized 151 individuals with OCD to either an unguided iCBT with a fixed (iCBTfixed) or a free-choice (iCBTfree+) order of the modules. We assessed participants at baseline (t0), eight weeks (t1), and 16 weeks (t2). Primary outcomes were adherence (utilization time, modules completed) and change in OCD severity (Y-BOCS). Secondary outcomes included depression, self-esteem, and treatment satisfaction. We calculated intent-to-treat (ITT) and complete case (CC) analyses. RESULTS Analyses showed that both iCBT programs significantly reduced OCD severity. While groups did not differ on the ITT analyses, for the CC analyses, a greater improvement was found in the iCBTfixed in comparison to the iCBTfree+ group regarding OCD severity and quality of life, with medium effect sizes from t0 to t1 (ηp2 = 0.067-0.077). Time of utilization and number of modules completed did not differ between groups. LIMITATIONS No placebo control group, short follow-up period, self-report assessment. CONCLUSIONS iCBT is effective in improving OCD. Despite similar adherence in the fixed versus the free-choice module order, the study offers tentative evidence that a fixed order of content is associated with better effects. More research on the effects of adherence on outcome is necessary.
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Affiliation(s)
- Lena Jelinek
- Department of Psychotherapy and Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Johanna Schröder
- Department of Psychotherapy and Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Institute for Clinical Psychology and Psychotherapy, Department of Psychology, Medical School Hamburg, Hamburg, Germany
| | - Lara Bücker
- Department of Psychotherapy and Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franziska Miegel
- Department of Psychotherapy and Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Baumeister
- Department of Psychotherapy and Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Steffen Moritz
- Department of Psychotherapy and Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Arne Sibilis
- Department of Psychotherapy and Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Josephine Schultz
- Department of Psychotherapy and Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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