The effect of treatment on quality of life and functioning in OCD

Internet-based acceptance and commitment therapy for obsessive-compulsive symptoms: A randomized controlled trial

Subthreshold obsessive-compulsive symptoms (OCS) are associated with increased distress, help seeking behaviours, and functional problems, and may predict progression into further mental health problems. This study investigated the effectiveness of a four-module internet-based acceptance and commitment therapy (iACT) for adults with OCS compared to internet-based progressive relaxation training (iPRT). Eighty-nine adults with OCS participated in a single-blinded randomised controlled trial of iACT or iPRT. Self-report assessments of OCS, psychological flexibility, and quality of life, among others, were measured at baseline, post-treatment, and at three-month follow-up. Both iACT and iPRT showed large pre-post improvements in OCS (b = 6.32, p < 0.001, d = 0.8) and medium improvements in psychological flexibility (b = -0.38, p = 0.011, d = 0.47) and quality of life (b = -5.26, p = 0.008, d = 0.58), with no significant differences in effects between groups. All improvements were maintained at follow-up. There were no differences in attrition or adherence between groups. iACT was rated more favourably by participants at post-treatment, and there were some differences in qualitative feedback across groups. These findings suggest both iPRT and iACT may be helpful in improving mental health in adults with OCS, but that iACT may be more acceptable.

Long-Term Safety and Efficacy of Focused Ultrasound Capsulotomy for Obsessive-Compulsive Disorder and Major Depressive Disorder

BACKGROUND

Magnetic resonance-guided focused ultrasound (MRgFUS) trials targeting the anterior limb of the internal capsule have shown promising results. We evaluated the long-term safety and efficacy of MRgFUS capsulotomy in patients with obsessive-compulsive disorder (OCD) and major depressive disorder (MDD).

METHODS

This phase 1, single-center, open-label study recruited patients with treatment-resistant OCD and MDD. Outcomes were measured 6 months, 12 months, and 18 to 24 months (long term) after MRgFUS capsulotomy. Neuropsychological testing and neuroimaging were conducted at baseline and 12 months postoperatively. The primary outcome was safety. The secondary outcome was clinical response, defined for OCD as a ≥35% improvement in Yale-Brown Obsessive Compulsive Scale scores and for MDD as a ≥50% reduction in Hamilton Depression Rating Scale scores compared with baseline.

RESULTS

No serious adverse effects were registered. In patients with OCD (n= 15), baseline Yale-Brown Obsessive Compulsive Scale scores (31.9 ± 1.2) were significantly reduced by 23% (p = .01) at 6 months and 35% (p < .0001) at 12 months. In patients with MDD (n = 12), a 26% and 25% nonsignificant reduction in Hamilton Depression Rating Scale scores (baseline 24.3 ± 1.2) was observed at 6 months and 12 months, respectively. Neuropsychological testing revealed no negative effects of capsulotomy. In the OCD and MDD cohorts, we found a correlation between clinical outcome and lesion laterality, with more medial left-placed lesions (OCD, p = .08) and more lateral right-placed lesions (MDD, p < .05) being respectively associated with a stronger response. In the MDD cohort, more ventral tracts appeared to be associated with a poorer response.

CONCLUSIONS

MRgFUS capsulotomy is safe in patients with OCD and MDD and particularly effective in the former population.

Multifaceted, Brief Intensive Home-Based Exposure Treatment in Patients with Obsessive-Compulsive Disorder Who are Nonresponsive to Regular Cognitive Behavior Therapy: An Uncontrolled Pilot Study

OBJECTIVE

To test a multifaceted treatment program for patients with obsessive-compulsive disorder (OCD) who did not respond to regular cognitive behavior therapy (CBT). The treatment addresses several factors that may play a role in maintaining OCD.

METHODS

We designed a treatment consisting of a 6-day intensive, individual exposure in vivo with response prevention (ERP) format, with 24 therapist-assisted treatment hours at the patient's home and 12 self-controlled ERP hours, including behavioral activation and family interventions. Next, we investigated the effect (obsessive-compulsive symptoms, comorbidity, functioning, quality of life, OCD-related interaction patterns) and feasibility (dropout, treatment satisfaction, and organization) of this program using pre-post-tests, pre-follow-up tests, and qualitative data from patients, family members, and therapists.

RESULTS

In a sample of 22 participants, obsessive-compulsive symptoms (Y-BOCS pre: 28.7, post: 15.9; Wilcoxon S-R tests P<0.01) improved significantly, as did most other effect measures. Results were largely, but not completely, preserved at 3-month follow-up. There was only 1 dropout. Patients, family members, and therapists were satisfied with the treatment. Implementation of the treatment did not pose difficulties.

CONCLUSIONS

In nonresponders with OCD, a multifaceted, brief, intensive home-based ERP program targeting factors maintaining OCD is promising and feasible. Extra care is needed to maintain improvement.

Evidence-Based Supported Employment for Individuals With Obsessive-Compulsive Disorder

Individuals with obsessive-compulsive disorder (OCD), a chronic and disabling psychiatric disorder, experience high rates of occupational impairment. OCD symptoms commonly affect individuals' vocational aspirations and result in disability and the need for financial support, problems that are not addressed by current clinical practice guideline recommendations for treating OCD. This Open Forum highlights the need to address occupational impairment caused by OCD and makes the case for formally evaluating whether evidence-based supported employment can help individuals with OCD find and succeed in meaningful work.

Brazilian research consortium on obsessive-compulsive spectrum disorders guidelines for the treatment of adult obsessive-compulsive disorder. Part II: Cognitive-Behavior Therapy treatment

OBJECTIVE

To summarize the evidence-based cognitive-behavioral therapy (CBT) treatment and propose clinical interventions for adult patients with obsessive-compulsive disorder (OCD).

METHODS

A systematic review of the literature on CBT interventions for the treatment of adult OCD, comprising behavior therapy and exposure and response prevention (ERP) was done. The objective of this study is to present updated clinical guidelines to clinicians, providing comprehensive details regarding the necessary procedures to be incorporated into the CBT protocol. We searched the literature published from 2013-2020 in five databases (PubMed, Cochrane, Embase, Psycinfo and Lilacs), considering: study design, primary outcome measures, type of publication and language. Selected articles were assessed for quality with validated tools. Treatment recommendations were classified according to levels of evidence developed by the American College of Cardiology and the American Heart Association (ACC/AHA).

RESULTS

We examined 44 new studies used to update the APA guidelines from 2013. High-quality evidence supports CBT including ERP techniques as the first-line CBT treatment for OCD. In addition, protocols for internet-delivered CBT have also demonstrated their efficacy for the treatment of adults with OCD.

CONCLUSION

CBT based on ERP is a widely used treatment according to high-quality scientific evidence to treat adults with OCD.

Impact of severe mental illnesses on health-related quality of life among patients attending the Institute of Psychiatry, Rawalpindi from 2019 to 2021: A cross-sectional study

BACKGROUND

Severe mental illnesses have huge impact on health-related quality of life. They contribute to significant morbidity in terms of number of number of years of life lost in form DALYS (disability adjusted life years) and shorter life expectancy and early mortality. There is limited evidence on their burden in low- and middle-income countries like Pakistan.

OBJECTIVE

To determine the health-related quality of life in patients suffering from severe mental illness (schizophrenia, depression, and bipolar affective disorder) and demographic factors associated with poor health related quality of life in these patients.

METHODOLOGY

This was descriptive cross sectional, using retrospective record view of data. Study was done under IMPACT (Improving Mental And Physical health Together) Program, which conducted a multi-morbidity survey conducted at institute of psychiatry, Benazir Bhutto hospital, Rawalpindi, using EQ 5d 5l (EURO QOL 5D5L) questionnaire having both subjective (EQVAS) and objective domains.

RESULTS

The study included 922 SMI patients, of whom 555 participants (60.2%) were males and 367(39.69%) were females. The participants suffered from major depressive disorder (422;45.8%), followed by bipolar affective disorder (392; 42.51%) and schizophrenia (108;11.7%). Most participants were in a younger age group with (80%) of population being below 50 years old and had education level below secondary education (57.4%). In the analysis of association between EQ-VAS (subjective quality of life scale) and demographic factors, a significant association was found for marital status(p<0.001), gender (p< 0.001) and education (p< 0.001). Women had lower EQ-VAS scores (M = 49.43±SD = 27.72) as compared to males (M = 58.81±SD = 27.1) and individuals with lower educational status also had lower mean scores. Additionally, participants who were single, divorced or widowed also had lower mean EQVAS scores. When health related quality of life was analyzed across SMI, it was lower in all SMI, but was significantly lower for depression in both subjective and objective domains of health related of quality-of-life instrument.

CONCLUSION

Health related quality of life is an important outcome measure and regular assessment of both subjective and objective aspects should be incorporated in management plans of patients suffering from severe mental illnesses.

Relationship between gene-environment interaction and obsessive-compulsive disorder: A systematic review

BACKGROUND

Gene-environment interaction (G × E) refers to the change of genetic effects under the participation of environmental factors resulting in differences in genetic expression. G × E has been studied in the occurrence and development of many neuropsychiatric disorders, including obsessive-compulsive disorder (OCD).

AIM

A systematic review was conducted to investigate the role of G × E plays in OCD. This review explored the relationship between G × E and the susceptibility to OCD occurrence, disease progression, and treatment response.

METHODS

This systematic literature search was performed using Web of Science, PubMed, Cochrane Library, and CNKI. Seven studies were selected, which included seven genes (BDNF, COMT, MAO, 5-HTT, SMAD4, PGRN, and SLC1A1) polymorphisms, polygenic risk score (PRS), and two environmental factors (childhood trauma and stressful life events).

RESULTS

Information from this systematic review indicated that G × E increased the susceptibility to OCD, played a crucial role in the clinical characteristics, and had an inconsistent impact on treatment response of OCD.

FUTURE DIRECTIONS

The multi-omics studies and the inclusion of G × E in future GWAS studies of OCD should be drawn more attention, which may contribute to a deeper understanding of the etiology of OCD as well as guide therapeutic interventions for the disease.

Sexual Orientation Intrusive Thoughts and Well-Being: The Mediating Role of Psychological Inflexibility

Sexual orientation intrusive thoughts are a debilitating form of obsessive-compulsive disorder. The present study aimed to elucidate how psychological inflexibility and dysfunctional beliefs may impact the relationships of sexual orientation intrusive thoughts and obsessive-compulsive (OC) symptoms with well-being. A total of 181 undergraduate students completed measures of sexual orientation intrusive thoughts, OC symptoms, psychological inflexibility, dysfunctional beliefs, and well-being. Results indicated positive correlations between psychological inflexibility, sexual orientation intrusive thoughts, dysfunctional beliefs, and OC symptoms, along with negative correlations between well-being and sexual orientation intrusive thoughts, OC symptoms, dysfunctional beliefs, and psychological inflexibility. Psychological inflexibility acted as a mediator between sexual orientation intrusive thoughts and well-being and between OC symptoms and well-being. Dysfunctional beliefs were not a significant mediator. These results suggest that psychological inflexibility may partially explain the association between OC symptoms and well-being, pointing toward the need for future research on the impact of psychological inflexibility on well-being in the context of OC symptoms.

Clinical Considerations for an Evidence-Based Assessment for Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is an impairing mental health disease, generally beginning in childhood, affecting up to ∼3% of the population. Using evidence-based assessments (EBAs) is the starting point for the accurate diagnosis and treatment of OCD. EBAs consist of structured and semistructured clinician-administered interviews, parent-report and child-report, and self-report for adults. This article details the practical application, psychometric properties, and limitations of available assessments to determine the presence of OCD and evaluate OCD symptom severity. The following reviews measurement of constructs relevant to OCD (ie, insight, family accommodation, impairment) and details considerations for best clinical interview practices.

Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is characterized by the presence of debilitating obsessions and compulsions. Cognitive and behavioral models of OCD provide a strong theoretic and empirical foundation for informing effective psychotherapeutic treatment. Cognitive-behavioral therapy (CBT) for OCD, which includes a deliberate emphasis on exposure and response/ritual prevention, has consistently demonstrated robust efficacy for the treatment of pediatric and adult OCD and is the front-line psychotherapeutic treatment for OCD. Two case vignettes describing CBT for OCD in practice as well as recommendations for clinicians are provided.

The Relationship Among Autistic Traits, Impulsivity, and Functionality in Patients With Obsessive-Compulsive Disorder

ABSTRACT

Obsessive-compulsive disorder (OCD) is a chronic mental disorder that causes disabilities. This study investigated the relationship among impulsivity, autistic traits, and disabilities in patients with OCD. We included 88 patients with OCD and 90 healthy volunteers without any mental disorders. The participants were evaluated using the Yale-Brown Obsessive-Compulsive Scale, Autism Spectrum Quotient (AQ), Barratt Impulsiveness Scale-11 (BIS-11), and World Health Organization Disability Assessment Schedule (WHODAS 2.0). Regression analyses revealed that AQ-attention switching and BIS-attentional subscale scores were associated with WHODAS-overall score in the OCD group ( p = 0.017 and p = 0.034, respectively). In the OCD group, AQ total, social skills, and communication subdomain scores partially mediated the relationship between impulsivity and disability. BIS total, attentional, and nonplanning subscale scores partially mediated the relationship between autistic traits and disability. Developing new treatment strategies for cognitive recovery, in addition to traditional treatment approaches in patients with OCD, may help increase functionality in patients with OCD.

Virtual reality exposure and response prevention in the treatment of obsessive-compulsive disorder in patients with contamination subtype in comparison with in vivo exposure therapy: a randomized clinical controlled trial

BACKGROUND

Obsessive-Compulsive Disorder (OCD) is characterized by disturbing and unwanted thoughts as well as repetitive and time-consuming behaviors that interfere with performance. Cognitive Behavior Therapy (CBT) has shown to have beneficial effects on reducing OCD symptoms as the first line of treatment. Moreover, Virtual Reality (VR) has been a more feasible and accessible intervention for OCD in recent years. Regarding the point, the objective of this study was to evaluate the effectiveness of virtual reality exposure and response prevention (VRERP) in the treatment of the OCD contamination subtype.

METHODS

A total number of 36 adults with OCD-contamination subtype were registered and randomly assigned to the intervention and control groups. The intervention group received a 60-min CBT including a "contaminated" virtual environment while the control group received CBT as a standardized treatment. Out of these, 29 patients completed the treatment in 12 weekly sessions. The patients completed the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Beck Depression Inventory-II (BDI-II), Beck Anxiety Inventory (BAI), Obsessive Beliefs Questionnaire-44(OBQ-44), and World Health Organization Disability Assessment Scale-2 (WHODAS-2) at week 0, week 12 and after 3 months follow-up.

RESULTS

Based on the results of the repeated measure analysis of variances, the total score of obsession and compulsion subscales of Y-BOCS significantly decreased as a primary outcome in the intervention group (F = 60.97, P < 0.001, partial eta squared = 0.82; F = 20.46, P < 0.001, partial eta squared = 0.61; F = 29.57, P < 0.001, partial eta squared = 0.69; respectively). The total score of BDI-II and BAI was reduced in both groups but there was no significant difference between them (BDI-II: F = 0.54, P = 0.47, partial eta squared = 0.02; BAI: F = 3.12, P = 0.06, partial eta squared = 0.19). However, there was a significant difference in the OBQ-44 (F = 16.78, P < 0.001, partial eta squared = 0.56) and the total WHODAS-2 score between the groups (F = 14.64, P < 0.001, partial eta squared = 0.53).

CONCLUSIONS

This study demonstrated the effectiveness of VRERP in the treatment of the OCD-contamination subtype. Therefore, VRERP can be used in CBT as an alternative exposure tool.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials, IRCT ID: IRCT20210214050353N1 , Registered on 16/10/2021.

The effect of exposure and response prevention therapy on obsessive-compulsive disorder: A systematic review and meta-analysis

This meta-analysis mainly examined the effect size of exposure and response prevention (ERP) for obsessive-compulsive disorder (OCD) when compared with different control conditions, and the difference in the efficacy of different variants of ERP in the treatment of OCD. Thirty studies were included, involving 39 randomized controlled trials with 1793 participants, from 30 studies up to January 18, 2022. Hedge's g was calculated using random-effects models. The results showed that ERP had a definite effect on OCD (g = 0.37), and its effect was significant when the control condition was placebo (g = 0.97) or drug (g = 0.59). However, ERP did not show statistical differences with other therapies in improving OCD (g = -0.07). In addition, we found that both therapist and self-controlled exposure (at the same time as the therapist controls, self-control is exercised after the therapy session) and total response prevention can better improve OCD symptoms. In addition, compared with the control group, ERP reduced depression (g = 0.15) and anxiety symptoms (g = 0.23) in patients with OCD. Meta-regression results showed that the longer the length of sessions, the better the treatment effect (t = 2.41, p = 0.022).

Quality of life in pediatric patients with obsessive-compulsive disorder during and 3 years after stepped-care treatment

The present study aimed to investigate the long-term quality of life (QoL) in a large sample of pediatric obsessive-compulsive disorder (OCD) patients. The study included 220 pediatric OCD patients from the Nordic Long-term OCD Treatment Study (NordLOTS) who were evaluated at seven time points before, during, and after stepped-care treatment over a 3-year follow-up period. Data from three symptom severity trajectory classes formed the basis of the QoL evaluation: acute (n = 127, N = 147), slow (n = 46, N = 63), and limited responders (n = 47, N = 59). Patients' QoL was assessed using parent and child ratings of the revised Questionnaire for Measuring Health-related Quality of Life in Children and Adolescents (KINDL-R). QoL was analyzed by trajectory class using a random mixed effects model. The association between pre-treatment factors and long-term QoL was investigated across classes in a multivariate model. Three years after treatment, the acute responder class had reached QoL levels from a general population, whereas the limited responder class had not. The slow responder class reached norm levels for the child-rated QoL only. Higher levels of co-occurring externalizing symptoms before treatment were associated with lower parent-rated QoL during follow-up, while adolescence and higher levels of co-occurring internalizing symptoms were associated with lower child-rated QoL during follow-up. For some patients, residual OCD symptoms in the years after treatment, even at levels below assumed clinical significance, are associated with compromised QoL. Co-occurring symptoms could be part of the explanation. Assessing QoL after OCD treatment, beyond the clinician-rated symptom severity, could detect patients in need of further treatment and/or assessment. Trial registry: Nordic Long-term Obsessive-Compulsive Disorder (OCD) Treatment Study; www.controlled-trials.com ; ISRCTN66385119.

The Role of Childhood Trauma in Psychosis and Schizophrenia: A Systematic Review

Schizophrenia (SCZ) is a prevalent cause of disability worldwide. Distinguished mainly by psychosis, behavioral alterations could range from hallucinations to delusions. This systematic review examines evidence of a relationship between childhood trauma/adverse life events and psychosis, especially in SCZ. A methodical search provided reproducible results using these five databases: PubMed, ScienceDirect, Semantic Scholar, JSTOR, and Cochrane Library. The systematic search focused on articles published between July 2016 and July 2021. The search strategy utilized specific keywords relevant to SCZ, psychosis, and childhood trauma. The formulation of specified inclusion and exclusion criteria was necessary to ensure a comprehensive narrowed-down search, such as the inclusion of free full-text articles published or translated in English and exclusion of irrelevant subject areas. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a strategic search initially identified 741 articles; three additional articles were identified from citation searching. After relevance screening, duplicate removal, and quality appraisal, 12 studies from databases/registers and three from citation searching met the criteria proving relevance to our review with minimal evidence of bias. The final selected 15 studies included observational studies and reviews. A review of relevant data unveiled findings on childhood adversity, individual lived experiences, and their involvement in SCZ. Evidence suggests that certain neurobiological processes occur in brain after trauma. The inflammation and dysregulation from oxidative stress predispose patients to an at-risk-mental state, facilitating the progression to SCZ. This review encourages further evaluation of early trauma detection and the potential benefits of early intervention.

Therapeutic Alliance and Treatment Outcome in Cognitive Behavior Therapy for Obsessive-Compulsive Disorder

OBJECTIVE

Therapeutic alliance has consistently been found to predict treatment outcomes across various psychotherapies and patient diagnosis. However, the relationship between therapeutic alliance and outcome in Cognitive Behavioral Therapy (CBT) has shown mixed results. This study investigated the impact of different aspects of therapeutic alliance in CBT for Obsessive-Compulsive Disorder (OCD).

METHOD

Data from two previously completed randomized controlled trials of 208 patients with OCD and their therapists were analyzed. Therapeutic alliance was assessed at week 4 of treatment with the patient-rated and therapist-rated Working Alliance Inventory (WAI), which includes three subscales to measure alliance domains (Goal, Task and Bond). Higher WAI score reflects a better therapeutic relationship. OCD severity was rated by independent assessors at baseline and post-treatment using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Linear regression analyses were used to examine the effects of the different aspects of therapeutic alliance on treatment outcome, adjusted for baseline symptom severity.

RESULTS

A higher total WAI score as rated by therapists significantly predicted a lower post-treatment Y-BOCS. Further, higher scores on the Goal and Task subscales of the WAI were associated with lower post-treatment severity. However, these significant outcomes reflected only small effect sizes.

CONCLUSIONS

In the treatment of OCD, the strength of the therapeutic alliance contributes to outcomes, though to a limited extent. Effective OCD treatment involves the delivery of specific therapy interventions, in the context of a strong therapeutic alliance.

Feasibility and acceptability of transcranial stimulation in obsessive-compulsive symptoms (FEATSOCS): study protocol for a randomised controlled trial of transcranial direct current stimulation (tDCS) in obsessive-compulsive disorder (OCD)

BACKGROUND

Obsessive-compulsive disorder (OCD) is a neuropsychiatric disorder which often proves refractory to current treatment approaches. Transcranial direct current stimulation (tDCS), a noninvasive form of neurostimulation, with potential for development as a self-administered intervention, has shown potential as a safe and efficacious treatment for OCD in a small number of trials. The two most promising stimulation sites are located above the orbitofrontal cortex (OFC) and the supplementary motor area (SMA).

METHODS

The aim of this feasibility study is to inform the development of a definitive trial, focussing on the acceptability, safety of the intervention, feasibility of recruitment, adherence and tolerability to tDCS and study assessments and the size of the treatment effect. To this end, we will deliver a double-blind, sham-controlled, crossover randomised multicentre study in 25 adults with OCD. Each participant will receive three courses of tDCS (SMA, OFC and sham), randomly allocated and given in counterbalanced order. Each course comprises four 20-min stimulations, delivered over two consecutive days, separated by at least 4 weeks' washout period. We will collect information about recruitment, study conduct and tDCS delivery. Blinded raters will assess clinical outcomes before, during and up to 4 weeks after stimulation using validated scales. We will include relevant objective neurocognitive tasks, testing cognitive flexibility, motor disinhibition, cooperation and habit learning.

DISCUSSION

We will analyse the magnitude of the effect of the interventions on OCD symptoms alongside the standard deviation of the outcome measure, to estimate effect size and determine the optimal stimulation target. We will also measure the duration of the effect of stimulation, to provide information on spacing treatments efficiently. We will evaluate the usefulness and limitations of specific neurocognitive tests to determine a definitive test battery. Additionally, qualitative data will be collected from participants to better understand their experience of taking part in a tDCS intervention, as well as the impact on their overall quality of life. These clinical outcomes will enable the project team to further refine the methodology to ensure optimal efficiency in terms of both delivering and assessing the treatment in a full-scale trial.

TRIAL REGISTRATION

ISRCTN17937049 . (date applied 08/07/2019). Recruitment (ongoing) began 23rd July 2019 and is anticipated to complete 30th April 2021.

Predictors for 12-month long-term outcome in patients with obsessive-compulsive disorder: The influence of duration of untreated illness and age at onset

BACKGROUND

It remains unknown whether the duration of untreated illness (DUI) may play a critical role in clinical improvement of patients with obsessive-compulsive disorder (OCD). Using a relatively large sample of subjects with OCD, this study investigated the potential impact of the DUI on patients' clinical course and long-term treatment response.

METHODS

Two hundred and seven patients with OCD recruited by the OCD outpatient clinic of our university hospital participated in the study. The sample was divided into two groups according to the median DUI (DUI≤3 years and DUI >3 years). Patients were treated with selective serotonin reuptake inhibitors or venlafaxine for 48 weeks in open-label conditions. Treatment response and other clinical variables were analysed.

RESULTS

The total sample showed a mean (SD) DUI of 4.07 (3.5) years, and the mean (SD) illness duration was 6.27 (6.5) years. More than half of the patients had not been treated before (56.5% for OCD). With a median of 3 years as cutoff DUI, response rates were found to be significantly higher in subjects with a short DUI (p < 0.001). Regression analyses showed that a short (≤3 years) DUI and later age at onset predicted better response and higher Y-BOCS scores percentage changes at the endpoint of 48 weeks (β = -1.11, p = 0.003). In addition, there was no correlation between DUI and age of onset in the total patients (r = -0.13, p＞0.05).

CONCLUSIONS

This preliminary study suggests associations between a shorter duration of untreated OCD and favourable long-term outcomes, and a longer DUI with a worse clinical course.

Predictors of Intensive Treatment in Patients With Obsessive-Compulsive Disorder

Background: Few studies have investigated which patients with obsessive-compulsive disorder (OCD) do not recover through regular cognitive behavior therapy or pharmacotherapy and subsequently end up in intensive treatment like day treatment or inpatient treatment. Knowing the predictors of intensive treatment in these patients is significant because it could prevent intensive treatment. This study has identified predictors of intensive treatment in patients with OCD. Methods: Using 6-year longitudinal data of the Netherlands Obsessive Compulsive Disorder Association (NOCDA), potential predictors of intensive treatment were assessed in patients with OCD (n = 419). Intensive treatment was assessed using the Treatment Inventory Costs in Patients with Psychiatric Disorders (TIC-P). Examined potential predictors were: sociodemographics, and clinical and psychosocial characteristics. Logistic Generalized Estimating Equations was used to estimate to what extent the various characteristics (at baseline, 2- and 4-year assessment) predicted intensive treatment in the following 2 years, averaged over the three assessment periods. Results: Being single, more severe comorbid depression, use of psychotropic medication, and a low quality of life predicted intensive treatment in the following 2 years. Conclusions: Therapists should be aware that patients with OCD who are single, who have more severe comorbid depression, who use psychotropic medication, and who have a low quality of life or a drop in quality of life are at risk for intensive treatment. Intensive treatment might be prevented by focusing regular treatment not only on OCD symptoms but also on comorbid depression and on quality of life. Intensive treatment might be improved by providing extra support in treatment or by adjusting treatment to impairments due to comorbid depressive symptoms or a low quality of life.

Innovations in the Delivery of Exposure and Response Prevention for Obsessive-Compulsive Disorder

Obsessive-Compulsive Disorder is an important cause of global health-related disability. In the last several decades, exposure and response prevention (EX/RP) has emerged as one of the most evidence-based treatments for adult and pediatric OCD. Recommended as a first-line treatment in practice guidelines for OCD, EX/RP, when expertly delivered, can be superior to serotonin reuptake inhibitor (SRI) medications alone and superior to adding antipsychotic medication to augment SRI treatment response. Despite a robust evidence base, EX/RP is not widely available. Moreover, although effective, only about half of patients who receive a standard course of EX/RP will achieve remission.This chapter will review innovations in delivering EX/RP, focusing on technology-based methods designed to increase access to EX/RP and translational neuroscience approaches to personalizing and optimizing EX/RP. Technology-based innovations to deliver EX/RP include video conferencing, internet-based treatment, and smartphone apps. Of these, internet-based, clinician-supported treatment has the most evidence base to date. Relevant to all technology-based innovations are the need for advances in the ethical, regulatory and financial aspects of understanding how access to EX/RP may be delivered to individuals of diverse socioeconomic backgrounds in accordance with professional standards and regulations and covered by healthcare.Advances in our understanding of the neural processes underlying learning and memory have led to new ways to combine EX/RP with medications, behavioral interventions, or neuromodulatory methods, with the goal of enhancing the functioning of brain circuits that subserve fear processing and cognitive control. Among the pharmacological approaches to enhancing EX/RP outcome, both ketamine and cannabinoids show promise in small open trials but are in need of further study. Studies to train cognitive control are at an early stage of development yet provide preliminary evidence that training neural processes may be a new path to personalize treatment. How best to combine EX/RP with different types of neuromodulation is being actively studied.Together these innovations in the delivery of EX/RP for OCD hold great promise for improving outcomes of care for individuals with OCD by increasing the availability and the individual treatment effects of this already effective treatment.

Beyond the Constraints of an RCT: Naturalistic Treatment Outcomes for Anxiety-Related Disorders

Despite considerable data from randomized controlled trials supporting use of behavioral therapies for anxiety disorders and anxiety-related disorders, there is a relative scarcity of data demonstrating that such findings are generalizable to patients in nonresearch settings, and a lack of standardized repeated outcome measurement in such settings. Using one of the largest examinations of naturalistic outcomes of behavioral therapies in treatment-seeking patients (N = 489), we examined the clinical characteristics and treatment outcomes of patients seeking treatment for anxiety and anxiety-related disorders in the past 3 years. Patients seeking treatment at a clinic specializing in cognitive-behavioral therapy (CBT) completed self-report questionnaires via an electronic data capture system and diagnostic interview at baseline, and were reassessed at mid- and posttreatment. Patients with anxiety and related disorders were assessed for changes in symptom severity and secondary outcomes (impairment/functioning, quality of life, and depression) over the course of therapy. Patients showed clinically significant and statistically reliable improvement in anxiety symptom severity scores over treatment (p < .001), after controlling for number of sessions received. Patients also showed significant improvement in depression, quality of life, and functioning (p values ≤ .001). We also found significant improvement in disorder-specific symptoms, including obsessive-compulsive disorder, posttraumatic stress disorder, generalized anxiety disorder, and social anxiety disorder (p values ≤ .001). Importance of, and ways to facilitate, integration of more routine assessment of a broader range of symptoms via online assessment systems and methods to better determine the effectiveness of CBT in naturalistic clinics are discussed.

Placebo Effect in Obsessive-Compulsive Disorder (OCD). Placebo Response and Placebo Responders in OCD: The Trend Over Time

BACKGROUND

Placebo response appears to be increasing in antidepressant, antipsychotic and various internal medicine trials. A similar trend has been reported for OCD during 1989-1999. Placebo response is generally considered as the extent to which placebo treatment is associated with core symptom improvement. In this analysis, we used Joinpoint regression to assess the time trend of both placebo response and placebo responder rates according to the year of publication with no time restriction in OCD drug trials.

METHODS

We included drug and/or psychotherapy trials vs. placebo from PubMed, Embase, CINAHL, and PsycINFO retrieved through the search (placebo OR sham) AND (obsessive* OR OCD). We included studies through investigator consensus. We then performed on data of included studies log-linear joinpoint segmented regression models using a p<0.05 cutoff.

RESULTS

We included 113 studies from 112 published papers. Placebo mean annual response rates in OCD studies significantly increased from 1991 to 2017 with an annual percent change (APC) of 0.66%, while placebo mean annual responder rates also significantly increased from 2010 to 2017, with an APC of 5.45%. Drug mean annual response rates in OCD studies significantly increased from 1987 to 2012 with an APC of 0.72%, while the corresponding responder rates did not show statistically significant APC changes between 1984 and 2017.

CONCLUSION

We observed a tendency for placebo to increase both measures of response in OCD clinical drug trials through the years that tend to approximate the responses shown by drugs. Changes in the type of study (moving from classical head to head comparisons to add-on studies in treatmentresistant populations) and countries involved in experimentation may partially account for some portion of these results. It appears that placebo effects are becoming more elusive and out of control.

Four-year course of quality of life and obsessive-compulsive disorder

OBJECTIVE

Patients with obsessive compulsive disorder (OCD) have high disease burden. It is important to restore quality of life (QoL) in treatment, so that patients become able to live a fulfilling life. Little is known about the longitudinal course of QoL in patients with OCD, its association with remission from OCD, and about factors that contribute to an unfavourable course of QoL in remitting patients.

METHODS

Study on the 4-year course of QoL of patients with chronic (n = 144), intermittent (n = 22), and remitting OCD (n = 73) using longitudinal data of the Netherlands Obsessive Compulsive Disorder Association (NOCDA; complete data: n = 239; imputed data n = 382). The EuroQol five-dimensional questionnaire (EQ-5D) utility score was used to assess QoL. In patients with remitting OCD, we examined patient characteristics that contributed to an unfavourable course of QoL, including sociodemographics, OCD characteristics, psychiatric comorbidity, and personality traits.

RESULTS

Course of QoL was associated with course of OCD. QoL improved in those who remitted from OCD; however, even in these patients, QoL remained significantly below the population norms. The correlation between QoL and severity of OCD was only moderate: r = - 0.40 indicating that other factors besides OCD severity contribute to QoL. In remitters, more severe anxiety and depression symptoms were related to a lower QoL. Results were similar in complete and imputed data sets.

CONCLUSIONS

Remission from OCD is associated with improvement of QoL, but comorbid anxiety and depression symptoms hamper the improvement of QoL. QoL could be improved by reducing OCD symptoms in patients with OCD and by treating comorbid anxiety and depression symptoms in remitting patients.

Integrating family therapy into exposure-based CBT for a Spanish patient with obsessive scrupulosity

Obsessive-compulsive symptom profiles vary widely among individuals and may be affected by cultural backgrounds. In the case of scrupulosity, moral and religious principles are the target of obsessive-compulsive symptoms. Cognitive biases and beliefs have special relevance in the origin and maintenance of obsessive scrupulosity. In addition, rigid and exaggerated beliefs about morality are held by these patients. Moral and religious principles are mainly transmitted by family. These influences may be more prominent in cultures, such as the Spanish culture, where family and religion are important values for individuals. The authors describe the treatment of a Spanish patient with obsessive scrupulosity. Family therapy strategies were integrated into exposure-based CBT in order to facilitate the modification of beliefs, behaviors, and pathological family relationships. The patient exhibited clinically significant improvements in OCD symptoms. Findings from this case show the need for individualized interventions that take into consideration cultural, social, and family factors.

Executive functions, selective attention and information processing in patients with obsessive compulsive disorder: A study from west of Iran

Obsessive-compulsive disorder (OCD) is associated with cognitive dysfunction. Deeper and wider knowledge of the cognitive components of these patients can play an important role in better understanding of this disorder. This study aimed to compare executive function, selective attention and information processing in OCD patients and healthy controls. The current study was performed on 54 patients meeting DSM-5 criteria for OCD and 54 healthy subjects who matched with patients in gender, age, marital and educational status. The cognitive functions were assessed by The Stroop test, Wisconsin Cart Sorting Test (WCST), Paced Auditory Serial Addition Test (PASAT) and the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). The performance of the OCD group was significantly worse than the healthy group in comparison with the all subscales of the Stroop and WSCT tests. Also, functions in information processing among two groups were statistically significant for 3- and 2-second PASAT. The results demonstrated that OCD patients have deficits in several aspects of cognitive functions. Hence, the treatment of these patients can be contributed by paying more attention to these deficits.

Raphe nuclei echogenicity changes in obsessive-compulsive disorder

Background: Dysregulation of serotonin system is hypothesized to play the main role in the etiology of obsessive-compulsive disorder (OCD). Transcranial sonography (TCS) is a helpful noninvasive and low-cost tool for the assessment of subcortical brain architectures, mainly basal nuclei, cerebellar central structures, and midbrain. In this study, an ultrasound assessment was performed for a sample of the patients with OCD and healthy control group to evaluate echogenicity of midbrain raphe nuclei (RN).

Methods: A total of 35 patients with OCD and 35 healthy controls of similar age and sex entered the study. Semi-structured clinical interview was performed according to the DSM IV-TR criteria to verify OCD. Echogenicity of the midbrain RN was assessed by an experienced neurologist applying TCS. The echogenicity of the 2 groups was compared using chi- square test. SPSS software (version 18, PASW) was used for statistical analysis and p-value of less than 0.05 was considered significant.

Results: In this study, 15 OCD patients (42.9%) and 11 (31.4%) controls showed decreased echogenicity of midbrain RN. Also, the results of the chi-square test showed that the midbrain RN echogenicity was not significantly lower in patients with OCD compared to the control group (p= 0.322).

Conclusion: Although decreased midbrain RN echogenicity is a characteristic of patients with major depression, it was not shown in OCD patients in this study, which can be explained by the involvement of RN projections rather that RN serotoninergic neurons.

Three-Week Inpatient Treatment of Obsessive-Compulsive Disorder: A 6-Month Follow-Up Study

Background: Specialized inpatient or residential treatment might be an alternative treatment approach for patients with obsessive-compulsive disorder (OCD) that do not respond satisfactorily to the standard outpatient treatment formats.

Method: The aim of this open trial was to investigate the 6-month effectiveness of a 3-week inpatient treatment of OCD, where exposure with response prevention (ERP) was the main treatment intervention. The sample consisted of 187 adult patients with OCD, all with previous treatment attempts for OCD.

Results: The sample showed significant reductions in symptoms of OCD and depression. The effect sizes were large for obsessive-compulsive symptoms and moderate to large for depressive symptoms. At discharge, 79.7% of the intent-to-treat (ITT) group were classified as treatment responders (≥35% reduction in Y-BOCS scores). However, some participants experienced relapse, as 61.5% of the ITT group were classified as treatment responders at 6-month follow-up. Antidepressant use appeared not to influence the outcome. Only pre-treatment levels of obsessive-compulsive symptoms emerged as a significant predictor of relapse.

Conclusion: The 3-week inpatient programme produced similar treatment effects as previous inpatient and residential studies of longer duration (2 – 3 months). The results suggest that patients with severe OCD can be treated efficiently using this brief inpatient format. However, better relapse prevention interventions are needed.