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Karch S, Maywald M, Schwartz C, Heil C, Neumüller J, Keeser D, Garcia S, Tschentscher N, Pogarell O, Paolini M, Voderholzer U. Neuronal correlates of intensification and acceptance of symptoms during exposure therapy in patients with obsessive-compulsive disorder. Front Psychol 2024; 15:1256046. [PMID: 38375106 PMCID: PMC10875107 DOI: 10.3389/fpsyg.2024.1256046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 01/15/2024] [Indexed: 02/21/2024] Open
Abstract
Introduction Cognitive behaviour therapy with exposure and response prevention is efficient in treating patients with obsessive-compulsive disorder (OCD). Nevertheless, it would be helpful for many patients to complement the therapeutic treatment with acceptance strategies to further increase the therapeutic benefit. The aim of the present study was to examine neurobiological responses to acceptance and intensification strategies during symptom provocation alongside the psychotherapeutic process. Method A total of 23 patients diagnosed with OCD (subtype: washing/contamination fear) was instructed to utilise either an acceptance strategy (ACS) or an intensification strategy (INS) to cope with their emotional and cognitive reactions to personalised symptom-triggering and neutral pictures. Fourteen patients participated twice: at the beginning [T1] and at the end [T2] of an inpatient multimodal treatment including cognitive behaviour therapy with response prevention to assess functional variations. Results For the contrast of T1 and T2, ACS showed increased brain activity in the left inferior frontal gyrus (IFG), left caudate body, and posterior cingulate gyrus (PCC). They also showed decreased activity in the left anterior insula. INS showed decreased activation in right lingual gyrus and right caudate body. At T2, ACS showed increased activation compared to INS in the left cerebrum: IFG, caudate nucleus, middle and superior temporal gyrus, and PCC/cuneus. For the comparison of T1 and T2, the ACS revealed increased brain activity in the left IFG, left caudate body, and right inferior parietal lobe. It showed decreased activity in the left anterior insula. The INS revealed decreased activity in right lingual gyrus and right caudate body.The psychometric questionnaires suggested that patients were able to reduce obsession, compulsion, and depression symptoms. Furthermore, patients rated the ACS as more useful for themselves compared with the INS. Conclusion The increased left IFG activity using ACS (T1 vs. T2) could be interpreted as a better inhibitory top-down process, while the increased PCC response might be due to a better reappraisal strategy after therapy. ACS seems to mobilise neuronal activations under therapy, especially in the left hemisphere. Both strategies showed reductions in emotional networks as a neuronal correlate of therapy success. Overall, ACS may be more efficient than INS, as rated by the patients and as in accordance with neurobiological findings.
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Affiliation(s)
- Susanne Karch
- Department of Psychiatry and Psychotherapy, University Hospital LMU, Munich, Germany
| | - Maximilian Maywald
- Department of Psychiatry and Psychotherapy, University Hospital LMU, Munich, Germany
| | | | - Clara Heil
- Department of Psychiatry and Psychotherapy, University Hospital LMU, Munich, Germany
| | | | - Daniel Keeser
- Department of Psychiatry and Psychotherapy, University Hospital LMU, Munich, Germany
- Department of Radiology, University Hospital LMU, Munich, Germany
| | - Sarah Garcia
- Schoen Clinic Roseneck, Prien am Chiemsee, Germany
| | - Nadja Tschentscher
- Department of Psychiatry and Psychotherapy, University Hospital LMU, Munich, Germany
| | - Oliver Pogarell
- Department of Psychiatry and Psychotherapy, University Hospital LMU, Munich, Germany
| | - Marco Paolini
- Department of Radiology, University Hospital LMU, Munich, Germany
| | - Ulrich Voderholzer
- Department of Psychiatry and Psychotherapy, University Hospital LMU, Munich, Germany
- Schoen Clinic Roseneck, Prien am Chiemsee, Germany
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Wheaton MG, Mcingvale E, Van Meter AR, Björgvinsson T. Quality of the therapeutic working alliance as a factor in intensive residential treatment of obsessive-compulsive disorder. Psychother Res 2023; 33:442-454. [PMID: 36314194 DOI: 10.1080/10503307.2022.2138618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 10/13/2022] [Accepted: 10/16/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Intensive residential treatment (IRT) for obsessive-compulsive disorder (OCD) includes frequent meetings with a cognitive-behavioral therapist. We examined whether this therapeutic working alliance relates to IRT outcomes. METHOD Data came from a naturalistic sample of patients with OCD (n = 124) who received IRT at a specialty OCD clinic. Patients completed measures of OCD severity and well-being at admission and discharge. Both the patient and treating psychologist completed the Working Alliance Inventory-Short Form (WAI-SF). Alliance ratings were tested as predictors in models predicting outcomes (discharge scores adjusting for baseline and treatment duration) as well as logistic regression predicting treatment response (≥35% symptom reduction in OCD symptoms). RESULTS Patient and clinician ratings of the quality of the alliance were weakly yet significantly correlated. Patient ratings of the alliance predicted outcomes, while therapist ratings did not. Moreover, greater discrepancy between patient and client ratings predicted worse outcomes. Patient ratings of the task dimension of the alliance uniquely related to responder status. CONCLUSIONS Patient perceptions of the working alliance, particularly as pertaining to agreement on therapeutic tasks, related to success with IRT for OCD. Further study is needed test interventions to improve task alliance as a strategy to enhance treatment.
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Castle D, Feusner J, Laposa JM, Richter PMA, Hossain R, Lusicic A, Drummond LM. Psychotherapies and digital interventions for OCD in adults: What do we know, what do we need still to explore? Compr Psychiatry 2023; 120:152357. [PMID: 36410261 PMCID: PMC10848818 DOI: 10.1016/j.comppsych.2022.152357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/07/2022] [Accepted: 11/14/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Despite significant advances in the understanding and treatment of obsessive compulsive disorder (OCD), current treatment options are limited in terms of efficacy for symptom remission. Thus, assessing the potential role of iterative or alternate psychotherapies is important. Also, the potential role of digital technologies to enhance the accessibility of these therapies, should not be underestimated. We also need to embrace the idea of a more personalized treatment choice, being cognisant of clinical, genetic and neuroimaging predictors of treatment response. PROCEDURES Non-systematic review of current literature on emerging psychological and digital therapies for OCD, as well as of potential biomarkers of treatment response. FINDINGS A number of 'third wave' therapies (e.g., Acceptance and Commitment Therapy, Mindfulness-Based Cognitive Therapy) have an emerging and encouraging evidence base in OCD. Other approaches entail employment of elements of other psychotherapies such as Dialectical Behaviour Therapy; or trauma-focussed therapies such as Eye Movement Desensitisation and Reprocessing, and Imagery Rescripting and Narrative Therapy. Further strategies include Danger Ideation Reduction Therapy and Habit Reversal. For these latter approaches, large-scale randomised controlled trials are largely lacking, and the precise role of these therapies in treating people with OCD, remains to be clarified. A concentrated 4-day program (the Bergen program) has shown promising short- and long-term results. Exercise, music, and art therapy have not been adequately tested in people with OCD, but may have an adjunctive role. Digital technologies are being actively investigated for enhancing reach and efficacy of psychological therapies for OCD. Biomarkers, including genetic and neuroimaging, are starting to point to a future with more 'personalised medicine informed' treatment strategizing for OCD. CONCLUSIONS There are a number of potential psychological options for the treatment of people with OCD who do not respond adequately to exposure/response prevention or cognitive behaviour therapy. Adjunctive exercise, music, and art therapy might be useful, albeit the evidence base for these is very small. Consideration should be given to different ways of delivering such interventions, including group-based, concentrated, inpatient, or with outreach, where appropriate. Digital technologies are an emerging field with a number of potential applications for aiding the treatment of OCD. Biomarkers for treatment response determination have much potential capacity and deserve further empirical testing.
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Affiliation(s)
- David Castle
- Centre for Addiction and Mental Health, 60 White Squirrel Way, Toronto, Ontario M6J 1H4, Canada; Department of Psychiatry, University of Toronto, 250 College Street, Toronto, Ontario M5T 1R8, Canada.
| | - Jamie Feusner
- Department of Psychiatry, University of Toronto, 250 College Street, Toronto, Ontario M5T 1R8, Canada; Centre for Addiction and Mental Health, 250 College Street, Toronto, Ontario M5T 1RB, Canada
| | - Judith M Laposa
- Department of Psychiatry, University of Toronto, 250 College Street, Toronto, Ontario M5T 1R8, Canada; Campbell Family Mental Health Research Institute, Center for Addiction and Mental Health, 100 Stokes St., Toronto, Ontario M6J 1H4, Canada
| | - Peggy M A Richter
- Department of Psychiatry, University of Toronto, 250 College Street, Toronto, Ontario M5T 1R8, Canada; Frederick W Thompson Anxiety Disorders Centre, Sunnybrook Health Sciences Centre, 2075 Bayview, Toronto, Ontario M4N 3M5, Canada
| | - Rahat Hossain
- Department of Psychiatry, University of Toronto, 250 College Street, Toronto, Ontario M5T 1R8, Canada
| | - Ana Lusicic
- Centre for Addiction and Mental Health, 60 White Squirrel Way, Toronto, Ontario M6J 1H4, Canada; Department of Psychiatry, University of Toronto, 250 College Street, Toronto, Ontario M5T 1R8, Canada
| | - Lynne M Drummond
- Service for OCD/ BDD, South-West London and St George's NHS Trust, Glenburnie Road, London SW17 7DJ, United Kingdom
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Does the network structure of obsessive-compulsive symptoms at treatment admission identify patients at risk for non-response? Behav Res Ther 2022; 156:104151. [PMID: 35728274 PMCID: PMC9810266 DOI: 10.1016/j.brat.2022.104151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 05/12/2022] [Accepted: 06/10/2022] [Indexed: 01/05/2023]
Abstract
Exposure and response prevention is the gold-standard treatment for obsessive compulsive disorder (OCD), yet up to half of patients do not adequately respond. Thus, different approaches to identifying and intervening with non-responders are badly needed. One approach would be to better understand the functional connections among aspects of OCD symptoms and, ultimately, how to target those associations in treatment. In a large sample of patients who completed intensive treatment for OCD and related disorders (N = 1343), we examined whether differences in network structure of OCD symptom aspects existed at baseline between treatment responders versus non-responders. A network comparison test indicated a significant difference between OCD network structure for responders versus non-responders (M = 0.19, p = .02). Consistent differences emerged between responders and non-responders in how they responded to emotional distress. This pattern of associations suggests that non-responders may have been more reactive to their distress by performing compulsions, thereby worsening their functioning. By examining the association between baseline distress intolerance with other symptom aspects that presumably maintain the disorder (e.g., ritualizing), clinicians can more effectively target those associations in treatment.
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OCD and Comorbid Depression: Assessment, Conceptualization, and Cognitive Behavioral Treatment. J Cogn Psychother 2022; 36:191-206. [PMID: 35882535 DOI: 10.1891/jcp-2022-0003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Many individuals with obsessive-compulsive disorder (OCD) also meet criteria for additional diagnoses. Among the most common co-occurring diagnoses are mood disorders-especially depression. This article focuses on the comorbidity between OCD and major depression. After discussing nature of OCD and depression, the rates and clinical impact of depression on OCD, the conceptualization, assessment, and treatment of OCD when it appears along with depression is covered in detail. The derivation and implementation of a cognitive behavioral treatment program specifically for depressed OCD patients is described and illustrated using a case example.
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Falkenstein MJ, Kelley KN, Dattolico D, Kuckertz JM, Bezahler A, Krompinger J, Webb CA, Beard C. Feasibility and Acceptability of Cognitive Bias Modification for Interpretation as an Adjunctive Treatment for OCD and Related Disorders: A Pilot Randomized Controlled Trial. Behav Ther 2022; 53:294-309. [PMID: 35227405 DOI: 10.1016/j.beth.2021.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 08/26/2021] [Accepted: 09/16/2021] [Indexed: 11/25/2022]
Abstract
Cognitive models implicate interpretation bias in the development and maintenance of obsessive compulsive and related disorders (OCRDs), and research supports Cognitive Bias Modification for Interpretation (CBM-I) in targeting this mechanism. However, prior studies in OCRDs have been limited to nonclinical populations, adolescents, and adults in a laboratory setting. This study evaluated the feasibility and acceptability of CBM-I as an adjunctive intervention during intensive/residential treatment (IRT) for adults with OCRDs. We modified a lab-based CBM-I training for adults seeking IRT for OCRDs, and conducted a feasibility trial (N = 4) and subsequent pilot RCT; participants (N = 31) were randomized to receive CBM-I or psychoeducation. Benchmarks were met for feasibility, acceptability, and target engagement. From pre- to post-intervention, the CBM-I group showed a large effect for change in interpretation bias (d = .90), whereas this effect was trivial (d = .06) for psychoeducation. This was the first study to evaluate CBM-I in naturalistic treatment for adults seeking IRT for OCRDs. Findings support the feasibility and acceptability of CBM-I in this novel sample and setting. A larger scale RCT is needed to determine whether CBM-I can enhance OCRD treatment response.
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Alić M, de Leeuw A, Selier J, van Megen H, Visser H. Responsiveness and other psychometric properties of the Y-BOCS Severity Scale-Second Edition (Y-BOCS-II) in a Dutch clinical sample. Clin Psychol Psychother 2022; 29:1355-1363. [PMID: 35080071 DOI: 10.1002/cpp.2715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 01/23/2022] [Accepted: 01/24/2022] [Indexed: 11/06/2022]
Abstract
The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) is a widely used clinician-rated interview to assess the presence and severity of obsessive-compulsive disorder (OCD). The scale is revised (Y-BOCS-II) to overcome several psychometric limitations, for example by extending the scoring for better discrimination within higher severity levels. The aim of the present study was to examine the responsiveness and other psychometric properties of the Y-BOCS-II Severity Scale in a Dutch clinical sample. The Y-BOCS-II is translated into Dutch (Y-BOCS-II) and administered to 110 patients seeking therapy for OCD. This was done twice, before and after treatment. The original Y-BOCS was simultaneously rated. Self-report measures regarding depression, symptom severity and OCD symptoms were assessed. The Y-BOCS-II has a good internal consistency (Cronbach's α=0.84), test-retest (ICC=0.89) and inter-rater reliability (ICC=0.98). The construct validity proved to be modest to good. The responsiveness over time was in favour of the Y-BOCS-II, compared with the YBOCS-I, particularly in the moderate-severely affected OCD patients. The Y-BOCS-II severity scale is a reliable and valid instrument for accurately assessing the severity of OCD symptoms and for measuring treatment-induced change. This second version also has clinical and psychometric advantages over the YBOCS-I. When these findings are sufficiently replicated, use of the YBOCS-II as the new common standard seems recommendable.
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Affiliation(s)
- Mediha Alić
- Marina de Wolf centrum, Mental Health Care Institute, GGZ Centraal, Ermelo, the Netherlands
| | - Aart de Leeuw
- Altrecht Academisch Angstcentrum, Mental Health Care Institute, Utrecht, the Netherlands
| | - Jonathan Selier
- Marina de Wolf centrum, Mental Health Care Institute, GGZ Centraal, Ermelo, the Netherlands
| | - Harold van Megen
- Marina de Wolf centrum, Mental Health Care Institute, GGZ Centraal, Ermelo, the Netherlands
| | - Henny Visser
- Marina de Wolf centrum, Mental Health Care Institute, GGZ Centraal, Ermelo, the Netherlands
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Pittenger C, Brennan BP, Koran L, Mathews CA, Nestadt G, Pato M, Phillips KA, Rodriguez CI, Simpson HB, Skapinakis P, Stein DJ, Storch EA. Specialty knowledge and competency standards for pharmacotherapy for adult obsessive-compulsive disorder. Psychiatry Res 2021; 300:113853. [PMID: 33975093 PMCID: PMC8536398 DOI: 10.1016/j.psychres.2021.113853] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 03/01/2021] [Indexed: 12/12/2022]
Abstract
Obsessive-compulsive disorder (OCD) affects approximately one person in 40 and causes substantial suffering. Evidence-based treatments can benefit many; however, optimal treatment can be difficult to access. Diagnosis is frequently delayed, and pharmacological and psychotherapeutic interventions often fail to follow evidence-based guidelines. To ameliorate this distressing situation, the International OCD Accreditation Task Force of the Canadian Institute for Obsessive-Compulsive Disorders has developed knowledge and competency standards for specialized treatments for OCD through the lifespan. These are foundational to evidence-based practice and will form the basis for upcoming ATF development of certification/accreditation programs. Here, we present specialty standards for the pharmacological treatment of adult OCD. We emphasize the importance of integrating pharmacotherapy with clear diagnosis, appreciation of complicating factors, and evidence-based cognitive behavioral therapy. Clear evidence exists to inform first- and second-line pharmacological treatments. In disease refractory to these initial efforts, multiple strategies have been investigated, but the evidence is more equivocal. These standards summarize this limited evidence to give the specialist practitioner a solid basis on which to make difficult decisions in complex cases. It is hoped that further research will lead to development of a clear, multi-step treatment algorithm to support each step in clinical decision-making.
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Affiliation(s)
- Christopher Pittenger
- Department of Psychiatry and Yale Child Study Center, Yale University School of Medicine, New Haven, CT, United States.
| | - Brian P Brennan
- Biological Psychiatry Laboratory and Obsessive-Compulsive Disorder Institute, McLean Hospital, Belmont, MA, United States; Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Lorrin Koran
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Carol A Mathews
- Department of Psychiatry, University of Florida, Gainesville, FL, United States
| | - Gerald Nestadt
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Michele Pato
- Institute for Genomic Health and Department of Psychiatry, SUNY Downstate College of Medicine, Brooklyn, NY, United States
| | - Katharine A Phillips
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, and Department of Psychiatry, Weill Cornell Medical College, New York, NY, United States
| | - Carolyn I Rodriguez
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States
| | - H Blair Simpson
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; Office of Mental Health, Research Foundation for Mental Hygiene, New York Psychiatric Institute, New York, NY, United States
| | - Petros Skapinakis
- Department of Psychiatry, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Dan J Stein
- Department of Psychiatry and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Eric A Storch
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
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du Mortier JAM, Remmerswaal KCP, Batelaan NM, Visser HAD, Twisk JWR, van Oppen P, van Balkom AJLM. Predictors of Intensive Treatment in Patients With Obsessive-Compulsive Disorder. Front Psychiatry 2021; 12:659401. [PMID: 33912087 PMCID: PMC8072047 DOI: 10.3389/fpsyt.2021.659401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/11/2021] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
| | - Karin C P Remmerswaal
- Amsterdam UMC, Vrije Universiteit, Department of Psychiatry, Amsterdam Public Health Institute and GGZ inGeest Specialized Mental Health Care, Amsterdam, Netherlands
| | - Neeltje M Batelaan
- Amsterdam UMC, Vrije Universiteit, Department of Psychiatry, Amsterdam Public Health Institute and GGZ inGeest Specialized Mental Health Care, Amsterdam, Netherlands
| | | | - Jos W R Twisk
- Amsterdam UMC, Vrije Universiteit, Epidemiology and Biostatistics, Amsterdam, Netherlands
| | - Patricia van Oppen
- Amsterdam UMC, Vrije Universiteit, Department of Psychiatry, Amsterdam Public Health Institute and GGZ inGeest Specialized Mental Health Care, Amsterdam, Netherlands
| | - Anton J L M van Balkom
- Amsterdam UMC, Vrije Universiteit, Department of Psychiatry, Amsterdam Public Health Institute and GGZ inGeest Specialized Mental Health Care, Amsterdam, Netherlands
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van Geijtenbeek-de Vos van Steenwijk M, de Leeuw A, van Megen H, Selier J, Visser H. Proof of Principle: Is a Pre-treatment Behavior Approach Test a Potential Predictor for Response to Intensive Residential Treatment in Patients With Treatment Refractory Obsessive Compulsive Disorder? Front Psychiatry 2021; 12:662069. [PMID: 34366912 PMCID: PMC8333859 DOI: 10.3389/fpsyt.2021.662069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 06/10/2021] [Indexed: 11/13/2022] Open
Abstract
Patients with severe and treatment refractory obsessive compulsive disorder (OCD) are usually referred to a specialized center for intensive residential treatment (IRT), consisting of exposure and response prevention (EX/RP), pharmacotherapy and additional therapies. About 50% of the patients does not respond to IRT. Currently we are not able to predict treatment response. If we were to have predictive tools, we could personify treatment at an earlier stage. Recent studies show that early adherence and willingness to EX/RP and low avoidance during EX/RP measured during treatment were associated with treatment response. In this observational study willingness and ability of patients with severe and treatment refractory OCD (N = 58) is conceptualized by a behavioral measurement, measured before the start of 12 weeks of IRT, using a Behavior Approach Test (BAT), as opposed to relying on self-report measurements. A medium or strong association between pre-treatment performance on the BAT and treatment response would justify next steps to test the BAT as a predictive tool for IRT. Results of regression analyses showed that there is a significant association between the performance on the BAT and change in OCD symptom severity after IRT. However, the effect-size is too small to use the BAT in its current form as predictor in clinical practice. The principle of the association between pre-treatment behaviorally measured willingness and ability to fully engage in EX/RP, and treatment response has now been proven. To ultimately design a predictive tool, future research is needed to refine a behavioral measurement of pre-treatment willingness and ability.
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Affiliation(s)
| | - Aart de Leeuw
- Academisch Angstcentrum, Altrecht, Utrecht, Netherlands
| | - Harold van Megen
- Marina de Wolfcentrum, Centrum Voor Psychotherapie, GGZ Centraal, Ermelo, Netherlands
| | - Jonathan Selier
- Marina de Wolfcentrum, Centrum Voor Psychotherapie, GGZ Centraal, Ermelo, Netherlands
| | - Henny Visser
- Marina de Wolfcentrum, Centrum Voor Psychotherapie, GGZ Centraal, Ermelo, Netherlands
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Balachander S, Bajaj A, Hazari N, Kumar A, Anand N, Manjula M, Sudhir PM, Cherian AV, Narayanaswamy JC, Jaisoorya TS, Math SB, Kandavel T, Arumugham SS, Janardhan Reddy YC. Long-term Outcomes of Intensive Inpatient Care for Severe, Resistant Obsessive-Compulsive Disorder: Résultats à long terme de soins intensifs à des patients hospitalisés pour un trouble obsessionnel-compulsif grave et résistant. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2020; 65:779-789. [PMID: 32452212 PMCID: PMC7564695 DOI: 10.1177/0706743720927830] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE A substantial proportion of severely ill patients with obsessive-compulsive disorder (OCD) do not respond to serotonin reuptake inhibitors (SRIs) and are unable to practice cognitive behavioral therapy (CBT) on an out-patient basis. We report the short-term (at discharge) and long-term (up to 2 years) outcome of a multimodal inpatient treatment program that included therapist-assisted intensive CBT with adjunctive pharmacotherapy for severely ill OCD patients who are often resistant to SRIs and are either unresponsive or unable to practice outpatient CBT. METHODS A total of 420 patients, admitted between January 2012 and December 2017 were eligible for the analysis. They were evaluated using the Mini International Neuropsychiatric Interview, the Yale-Brown Obsessive Compulsive Scale (YBOCS), and the Clinical Global Impression (CGI) scale. All patients received 4 to 5 therapist-assisted CBT sessions per week along with standard pharmacotherapy. Naturalistic follow-up information at 3, 6, 12, and 24 months were recorded. RESULTS At baseline, patients were mostly severely ill (YBOCS = 29.9 ± 4.5) and nonresponsive to ≥2 SRIs (83%). Mean duration of inpatient stay was 42.7 ± 25.3 days. At discharge, there was a significant decline in the mean YBOCS score (29.9 ± 4.5 vs. 18.1 ± 7.7, P < .001, Cohen's d = 1.64); 211/420 (50%) were responders (≥35% YBOCS reduction and CGI-I≤2) and an additional 86/420 (21%) were partial responders (25% to 35% YBOCS reduction and CGI-I≤3). Using latent class growth modeling of the follow-up data, 4 distinct classes were identified, which include "remitters" (14.5%), "responders" (36.5%), "minimal responders" (34.7%), and "nonresponders" (14.6%). Shorter duration of illness, better insight, and lesser contamination/washing symptoms predicted better response in both short- and long-term follow-up. CONCLUSION Intensive, inpatient-based care for OCD may be an effective option for patients with severe OCD and should be considered routinely in those who do not respond with outpatient treatment.
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Affiliation(s)
- Srinivas Balachander
- Obsessive-Compulsive Disorder Clinic, Department of Psychiatry, 29148National Institute of Mental Health and Neuro Science (NIMHANS), Bangalore, India
| | - Aakash Bajaj
- Department of Biostatistics, 29148NIMHANS, Bangalore, India
| | - Nandita Hazari
- Obsessive-Compulsive Disorder Clinic, Department of Psychiatry, 29148National Institute of Mental Health and Neuro Science (NIMHANS), Bangalore, India
| | - Ajay Kumar
- Obsessive-Compulsive Disorder Clinic, Department of Psychiatry, 29148National Institute of Mental Health and Neuro Science (NIMHANS), Bangalore, India.,Department of Clinical Psychology, 29148NIMHANS, Bangalore, India
| | - Nitin Anand
- Obsessive-Compulsive Disorder Clinic, Department of Psychiatry, 29148National Institute of Mental Health and Neuro Science (NIMHANS), Bangalore, India.,Department of Clinical Psychology, 29148NIMHANS, Bangalore, India
| | - M Manjula
- Obsessive-Compulsive Disorder Clinic, Department of Psychiatry, 29148National Institute of Mental Health and Neuro Science (NIMHANS), Bangalore, India.,Department of Clinical Psychology, 29148NIMHANS, Bangalore, India
| | - Paulomi M Sudhir
- Obsessive-Compulsive Disorder Clinic, Department of Psychiatry, 29148National Institute of Mental Health and Neuro Science (NIMHANS), Bangalore, India.,Department of Clinical Psychology, 29148NIMHANS, Bangalore, India
| | - Anish V Cherian
- Department of Psychiatric Social Work, 29148NIMHANS, Bangalore, India
| | - Janardhanan C Narayanaswamy
- Obsessive-Compulsive Disorder Clinic, Department of Psychiatry, 29148National Institute of Mental Health and Neuro Science (NIMHANS), Bangalore, India
| | - T S Jaisoorya
- Obsessive-Compulsive Disorder Clinic, Department of Psychiatry, 29148National Institute of Mental Health and Neuro Science (NIMHANS), Bangalore, India
| | - Suresh Bada Math
- Obsessive-Compulsive Disorder Clinic, Department of Psychiatry, 29148National Institute of Mental Health and Neuro Science (NIMHANS), Bangalore, India
| | | | - Shyam Sundar Arumugham
- Obsessive-Compulsive Disorder Clinic, Department of Psychiatry, 29148National Institute of Mental Health and Neuro Science (NIMHANS), Bangalore, India
| | - Y C Janardhan Reddy
- Obsessive-Compulsive Disorder Clinic, Department of Psychiatry, 29148National Institute of Mental Health and Neuro Science (NIMHANS), Bangalore, India
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Wetterneck CT, Leonard RC, Adams TG, Riemann BC, Grau P, Franklin ME. The effects of depression on the treatment of OCD in a residential sample. Bull Menninger Clin 2020; 84:12-33. [PMID: 33074022 DOI: 10.1521/bumc.2020.84.suppa.12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Studies investigating the impact of depressive symptoms on obsessive-compulsive disorder (OCD) treatment have yielded mixed findings. The purpose of the study is to extend previous research, which primarily used outpatient samples, to determine whether depression affects OCD treatment outcome among patients receiving intensive residential treatment. OCD patients receiving residential treatment based primarily on exposure and response prevention (ERP) provided data regarding symptoms of depression and OCD at admission and discharge. Patients reported large and significant reductions in OCD symptoms over the course of treatment. Change in OCD symptoms was not significantly affected by depressive symptoms, including patients with severe depressive symptoms. Change in depressive symptoms over the course of treatment was, however, robustly related to change in OCD symptoms, especially among patients who began treatment with severe symptoms of depression. These findings suggest that cognitive-behavior therapy delivered in a residential treatment setting drastically reduces OCD symptoms regardless of depressive symptoms.
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Affiliation(s)
- Chad T Wetterneck
- Trauma Recovery Services, Rogers Behavioral Health, Oconomowoc, Wisconsin
| | | | - Thomas G Adams
- Rogers Behavioral Health, Oconomowoc, Wisconsin.,Yale University School of Medicine, Department of Psychiatry, New Haven, Connecticut.,Rogers Behavioral Health, as well as the Clinical Neuroscience Division of the VA National Center for PTSD, West Haven, Connecticut
| | | | - Peter Grau
- Department of Counseling and Education at Marquette University, Milwaukee, Wisconsin
| | - Martin E Franklin
- Rogers Behavioral Health, Oconomowoc, Wisconsin.,Department of Psychiatry at the University of Pennsylvania, Philadelphia, Pennsylvania
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13
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Nanjundaswamy MH, Arumugham SS, Narayanaswamy JC, Reddy YCJ. A prospective study of intensive in-patient treatment for obsessive-compulsive disorder. Psychiatry Res 2020; 291:113303. [PMID: 32763556 DOI: 10.1016/j.psychres.2020.113303] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/09/2020] [Accepted: 07/12/2020] [Indexed: 11/30/2022]
Abstract
Multimodal in-patient treatment incorporating intensive cognitive-behaviour therapy (CBT) and medication management is a promising alternative for obsessive-compulsive disorder (OCD) patients who do not respond to standard out-patient treatment. We prospectively examined the short-term outcome and predictors of outcome of intensive in-patient treatment in a largely pharmacotherapy-resistant OCD sample. Fifty eight consecutive patients, admitted for treatment of OCD were evaluated at admission, at discharge and 2 months post-discharge for psychiatric diagnosis, personality disorders, obsessive beliefs, insight into obsessions and severity of obsessive-compulsive, depressive and anxiety symptoms. All patients received comprehensive treatment consisting of a combination of pharmacotherapy and intensive CBT. The mean Y-BOCS score was 29.38(±5.72) at admission, which reduced to 16.62(±7.91) at discharge and 16.75(±8.85) at follow-up. Thirty five participants (60.3%) met the prespecified criteria for response and 19 (32.8%) for remission. There was a significant reduction in Y-BOCS scores at discharge [43.67 (23.81)%] and post-discharge follow-up [2.18 (29.32)%] as compared to baseline (p<0.01). Baseline Browns Assessment of Beleifs Scale score (insight) was the only variable that statistically differentiated responders and non-responders. In-patient treatment is an effective treatment for medication resistant, severe and chronic OCD. Poor insight is a potential predictor of non-response to in-patient treatment.
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Affiliation(s)
- Madhuri H Nanjundaswamy
- Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India 560029
| | - Shyam Sundar Arumugham
- Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India 560029.
| | - Janardhanan C Narayanaswamy
- Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India 560029
| | - Y C Janardhan Reddy
- Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India 560029
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14
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Falkenstein MJ, Schreck M, Potluri S, Nota JA, Kelley KN, Beard C, Elias JA. Longitudinal Relations of Obsessive Beliefs, Obsessions, and Compulsions During Treatment for Obsessive Compulsive Disorder. COGNITIVE THERAPY AND RESEARCH 2020. [DOI: 10.1007/s10608-020-10093-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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15
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Tibi L, van Oppen P, van Balkom AJLM, Eikelenboom M, Emmelkamp PMG, Anholt GE. Predictors of treatment outcome in OCD: An interpersonal perspective. J Anxiety Disord 2019; 68:102153. [PMID: 31704634 DOI: 10.1016/j.janxdis.2019.102153] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 09/02/2019] [Accepted: 10/13/2019] [Indexed: 10/25/2022]
Abstract
Although effective treatments for obsessive compulsive disorder (OCD) are increasingly available, a considerable percentage of patients fails to respond or relapses. Predictors associated with improved outcome of OCD were identified. However, information on interpersonal determinants is lacking. This study investigated the contribution of attachment style and expressed emotion to the outcome of exposure and response prevention (ERP), while accounting for previously documented intrapersonal (i.e., symptom severity and personality pathology) predictors. Using logistic regression analyses and multi-level modeling, we examined predictors of treatment completion and outcome among 118 adult OCD patients who entered ERP. We assessed outcome at post treatment, and at four and 13 months from treatment completion. OCD baseline severity and fearful attachment style emerged as the main moderators of treatment outcome. Severe and fearfully attached patients were more likely to dropout prematurely. The improvement of fearful clients was attenuated throughout treatment and follow-up compared to non-fearful clients. However, their symptom worsening at the long-term was also mitigated. Severe OCD patients had a more rapid symptom reduction during treatment and at follow-up, compared to less severe clients. The findings suggest that both baseline OCD severity and fearful attachment style play a role in the long-term outcome of ERP.
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Affiliation(s)
- Lee Tibi
- Department of Psychology, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
| | - Patricia van Oppen
- Department of Psychiatry and the Amsterdam Public Health Research Institute, VU University Medical Center, GGZ InGeest, Amsterdam, the Netherlands
| | - Anton J L M van Balkom
- Department of Psychiatry and the Amsterdam Public Health Research Institute, VU University Medical Center, GGZ InGeest, Amsterdam, the Netherlands
| | - Merijn Eikelenboom
- Department of Psychiatry and the Amsterdam Public Health Research Institute, VU University Medical Center, GGZ InGeest, Amsterdam, the Netherlands
| | - Paul M G Emmelkamp
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, the Netherlands
| | - Gideon E Anholt
- Department of Psychology, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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16
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Wheaton MG, Pinto AM, Cervoni C, Crosby JM, Tifft ED, Mathes BM, Garner LE, Van Kirk N, Elias JA, Pinto A. Perfectionism in Intensive Residential Treatment of Obsessive–Compulsive Disorder. COGNITIVE THERAPY AND RESEARCH 2019. [DOI: 10.1007/s10608-019-10047-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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17
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Albert U, Marazziti D, Di Salvo G, Solia F, Rosso G, Maina G. A Systematic Review of Evidence-based Treatment Strategies for Obsessive- compulsive Disorder Resistant to first-line Pharmacotherapy. Curr Med Chem 2019; 25:5647-5661. [PMID: 29278206 DOI: 10.2174/0929867325666171222163645] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/19/2017] [Accepted: 11/22/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND Serotonin reuptake inhibitors (SRIs) and cognitive-behavioral psychotherapy (CBT) are first-line treatments for obsessive-compulsive disorder (OCD). However, a significant proportion of patients do not respond satisfactorily to first-choice treatments. Several options have been investigated for the management of resistant patients. OBJECTIVE The aim of the present paper is to systematically review the available literature concerning the strategies for the treatment of resistant adult patients with OCD. METHOD We first reviewed studies concerning the definition of treatment-resistant OCD; we then analyzed results of studies evaluating several different strategies in resistant patients. We limited our review to double-blind, placebo-controlled studies performed in adult patients with OCD whose resistance to a first adequate (in terms of duration and dosage) SRI trial was documented and where outcome was clearly defined in terms of decrease in Yale-Brown Obsessive-Compulsive Scale (YBOCS) scores and/or response/ remission rates (according to the YBOCS). RESULTS We identified five strategies supported by positive results in placebo-controlled randomized studies: 1) antipsychotic addition to SRIs (16 RCTs, of them 10 positive; 4 head-to-head RCTs); among antipsychotics, available RCTs examined the addition of haloperidol (butyrophenone), pimozide (diphenyl-butylpiperidine), risperidone (SDA: serotonin- dopamine antagonist), paliperidone (SDA), olanzapine (MARTA: multi-acting receptor targeted antipsychotic), quetiapine (MARTA) and aripiprazole (partial dopamine agonist); 2) CBT addition to medication (2 positive RCTs); 3) switch to intravenous clomipramine (SRI) administration (2 positive RCTs); 4) switch to paroxetine (SSRI: selective serotonin reuptake inhibitor) or venlafaxine (SNRI: serotonin-norepinephrine reuptake inhibitor) when the first trial was negative (1 positive RCT); and 5) the addition of medications other than an antipsychotic to SRIs (18 RCTs performed with several different compounds, with only 4 positive studies). CONCLUSION Treatment-resistant OCD remains a significant challenge to psychiatrists. To date, the most effective strategy is the addition of antipsychotics (aripiprazole and risperidone) to SRIs; another effective strategy is CBT addition to medications. Other strategies, such as the switch to another first-line treatment or the switch to intravenous administration are promising but need further confirmation in double-blind studies. The addition of medications other than antipsychotics remains to be studied, as several negative studies exist and positive ones need confirmation (only 1 positive study).
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Affiliation(s)
- Umberto Albert
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy; A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Donatella Marazziti
- Dipartimento di Medicina Clinica e Sperimentale, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Gabriele Di Salvo
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy; A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Francesca Solia
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy; A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Gianluca Rosso
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy; A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Giuseppe Maina
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy; A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
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18
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Siwiec SG, Riemann BC, Lee HJ. Predictors of acute outcomes for intensive residential treatment of obsessive-compulsive disorder. Clin Psychol Psychother 2019; 26:661-672. [PMID: 31273851 DOI: 10.1002/cpp.2389] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 06/20/2019] [Accepted: 06/25/2019] [Indexed: 11/09/2022]
Abstract
For those who suffer with chronic and disruptive obsessive-compulsive disorder (OCD), who have not been sufficiently helped by outpatient treatments or medications, intensive residential treatment (IRT) is often the next best treatment option. To date, research of the predictors of treatment outcome in IRT for OCD are mixed and sometimes contradictory. Additionally, although comorbidity is common for patients in this setting, the inclusion of comorbidity as a potential predictor of outcome has been mostly lacking in research to date. The current study aimed to address these issues by utilizing optimal indices of treatment outcomes, while incorporating comorbidity into our analyses, in order to identify the predictors of treatment outcomes in the IRT for OCD setting. To this end, we analysed outcome data from 379 patients receiving IRT for OCD at the Rogers Memorial OCD Center between August 2012, and December 2017. Results indicated that the most important predictor of treatment outcome was obsession severity at admission. Specifically, higher obsession severity at admission predicted poorer treatment outcomes at discharge. Clinical implications and suggestions for future research were discussed in the manuscript.
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Affiliation(s)
- Stephan G Siwiec
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | | | - Han-Joo Lee
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
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19
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Abstract
PURPOSE OF REVIEW This review highlights recent research regarding gender differences in OCD, with a focus on prevalence, course of illness, symptom presentation, comorbidity, and treatment response. RECENT FINDINGS Overall, findings remain mixed. OCD may be more common among males in childhood, but is more common among females in adolescence and adulthood. Males tend to report an earlier age of onset and present with symptoms related to blasphemous thoughts. Females often describe symptom onset as occurring during or after puberty or pregnancy and present with symptoms related to contamination and/or aggressive obsessions. Females also tend to report significantly higher depression and anxiety. There are no reported gender differences in treatment outcome. Gender may play a role in the onset, presentation, and impact of OCD symptoms. However, more work is needed to account for differences across studies, with one promising future direction being the study of reproductive hormones.
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20
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Ponzini G, Van Kirk N, Schreck M, Nota JA, Schofield CA, Gironda C, Elias J. Does Motivation Impact OCD Symptom Severity? An Exploration of Longitudinal Effects. Behav Ther 2019; 50:300-313. [PMID: 30824247 DOI: 10.1016/j.beth.2018.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 06/11/2018] [Accepted: 06/11/2018] [Indexed: 11/24/2022]
Abstract
Understanding the role of patient motivation in OCD treatment is of clinical importance given the requisite autonomous role of patients in Exposure and Response Prevention. The present study investigated state- and trait-like relations between three variables: two previously established motivational constructs, readiness to change (RTC) and committed action (CA), derived from the University of Rhode Island Change Assessment, and OCD symptom severity as measured by the self-report Yale-Brown Obsessive Compulsive Scale (Y-BOCS-SR). Utilizing a random-intercept cross-lagged panel model (RI-CLPM) design, we assessed autoregressive, within-time correlations, and cross-lagged effects of RTC, CA, and Y-BOCS-SR scores at admission, month 1 of treatment, and discharge from an intensive/residential treatment program for OCD. Results revealed significant autoregressive (i.e., state-like) effects for CA and Y-BOCS-SR, negative within-time correlations between state CA and Y-BOCS-SR across all time points, a positive within-time correlation between state CA and RTC at admission, and a cross-lagged effect between state Y-BOCS-SR at month 1 of treatment and state RTC at discharge. Results also demonstrated that the stability of the RTC variable was attributable to trait-like factors in the present sample. This study is novel in its use of RI-CLPM in an OCD sample and represents an important addition to the literature on the longitudinal impacts of dynamic constructs of motivation. Our findings may provide future researchers with strategies to supplement ERP with CA-driven motivational interviewing.
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Affiliation(s)
| | | | | | | | | | - Christina Gironda
- Partners Healthcare, Partners Community Physicians Organization (PCPO)
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21
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Falkenstein MJ, Nota JA, Krompinger JW, Schreck M, Garner LE, Potluri S, Van Kirk N, Ponzini G, Tifft E, Brennan BP, Mathes B, Cattie J, Crosby JM, Elias JA. Empirically-derived response trajectories of intensive residential treatment in obsessive-compulsive disorder: A growth mixture modeling approach. J Affect Disord 2019; 245:827-833. [PMID: 30699866 PMCID: PMC9632647 DOI: 10.1016/j.jad.2018.11.075] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 11/01/2018] [Accepted: 11/11/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND This study investigated distinct trajectories of treatment response in a naturalistic intensive/residential treatment (IRT) program for adults with severe obsessive-compulsive disorder (OCD). We hypothesized that: (1) distinct trajectories would emerge and (2) demographic variables, psychiatric comorbidity, OCD symptom subtype, level of insight, previous exposure and response prevention (ERP) treatment, and quality of life, would differentially predict assignment to these trajectories. METHODS Participants included 305 individuals with primary OCD admitted for IRT. RESULTS Two trajectories emerged over the course of the first eight weeks of treatment, with the vast majority of participants demonstrating treatment response. The first trajectory (96%, n = 292) showed a negative, linear treatment response (a.k.a. "linear responders") and more severe OCD symptoms at admission. The second trajectory (4%, n = 13) had less severe OCD symptoms at admission and did not exhibit a significant overall change in symptoms over the course of treatment. More specifically, this second trajectory or "u-shaped responders" show a non-significant linear response through week four of treatment, followed by slightly increased symptoms in week five. Assignment to these classes was not differentially predicted by hypothesized predictor variables. LIMITATIONS Our final model had inconsistent fit indices and small class prevalance of the u-shaped responder group; therefore, model selection was based on both fit indices and substantive meaning. CONCLUSIONS This study emprically derived two distinct trajectories of OCD symptom severity over the course of IRT. These findings have the potential to refine IRT for patients with severe OCD, and to potentially guide future investigation into the optimal delivery of ERP treatment for OCD generally.
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Affiliation(s)
| | | | | | - Meghan Schreck
- McLean Hospital/Harvard Medical School, Belmont, MA, United States.
| | | | - Sriramya Potluri
- McLean Hospital/Harvard Medical School, Belmont, MA, United States.
| | | | | | - Eric Tifft
- McLean Hospital/Harvard Medical School, Belmont, MA, United States.
| | | | - Brittany Mathes
- McLean Hospital/Harvard Medical School, Belmont, MA, United States.
| | - Jordan Cattie
- McLean Hospital/Harvard Medical School, Belmont, MA, United States.
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22
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Does Exposure and Response Prevention Behaviorally Activate Patients With Obsessive-Compulsive Disorder? A Preliminary Test. Behav Ther 2019; 50:214-224. [PMID: 30661561 DOI: 10.1016/j.beth.2018.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 05/22/2018] [Accepted: 05/25/2018] [Indexed: 11/20/2022]
Abstract
Exposure and response prevention (ERP) and behavioral activation (BA) are effective treatments for obsessive-compulsive disorder (OCD) and depression, respectively. Patients with OCD often exhibit depression; furthermore, ERP for OCD is associated with reduced depressive symptoms. To our knowledge, no study has examined whether ERP itself functions to behaviorally activate patients with concurrent OCD and depressive symptoms. This prospective study was designed to test the hypotheses that (a) OCD exposure hierarchy completion, increased BA, and depressive symptom reduction would all be related, and (b) pre- to posttreatment changes in BA would mediate the direct effect of OCD hierarchy completion on posttreatment depressive symptoms, even after controlling for pretreatment depressive symptoms, pretreatment BA, pre- to posttreatment reductions in OCD symptoms, treatment duration, and antidepressant medication use. Patients (N = 90) with a primary diagnosis of OCD who received residential ERP for OCD completed a self-report battery at pre- and posttreatment. Exposure hierarchy completion, increases in BA, and decreases in depression were all significantly correlated (rs ranged .33 to .44). The effect of hierarchy completion on posttreatment depressive symptoms was fully mediated by pre- to posttreatment changes in BA. Findings highlight the potential for ERP to exert antidepressant effects by behaviorally activating patients. Limitations, clinical implications, and future directions are discussed.
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Kay B, Eken S, Jacobi D, Riemann B, Storch EA. Outcome of multidisciplinary, CBT-focused treatment for pediatric OCD. Gen Hosp Psychiatry 2016; 42:7-8. [PMID: 27638964 DOI: 10.1016/j.genhosppsych.2016.06.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 05/31/2016] [Accepted: 06/02/2016] [Indexed: 10/21/2022]
Affiliation(s)
| | | | | | | | - Eric A Storch
- Rogers Memorial Hospital; Department of Pediatrics, University of South Florida; Department of Psychology, University of South Florida; Department of Health Policy and Management, University of South Florida; Department of Psychiatry & Behavioral Neurosciences, University of South Florida; All Children's Hospital - Johns Hopkins Medicine
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24
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Diedrich A, Sckopke P, Schwartz C, Schlegl S, Osen B, Stierle C, Voderholzer U. Change in obsessive beliefs as predictor and mediator of symptom change during treatment of obsessive-compulsive disorder - a process-outcome study. BMC Psychiatry 2016; 16:220. [PMID: 27388205 PMCID: PMC4937602 DOI: 10.1186/s12888-016-0914-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 06/08/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Cognitive models of obsessive-compulsive disorder suggest that changes in obsessive beliefs are a key mechanism of treatments for obsessive-compulsive disorder. Thus, in the present process-outcome study, we tested whether changes in obsessive beliefs during a primarily cognitive behavioral inpatient treatment predicted treatment outcome and whether these changes mediated symptom changes over the course of treatment. METHODS Seventy-one consecutively admitted inpatients with obsessive-compulsive disorder were assessed with the Yale-Brown Obsessive-Compulsive Scale and the Obsessive Beliefs Questionnaire at treatment intake, after six weeks of treatment and at discharge, and with the Beck-Depression-Inventory-II at intake and discharge. RESULTS Changes in obsessive beliefs during the first six weeks of treatment predicted obsessive-compulsive symptoms at discharge when controlling for obsessive-compulsive and depressive symptoms at intake in a hierarchical regression analysis. Multilevel mediation analyses showed that reductions in obsessive beliefs partially mediated improvements in obsessive-compulsive symptoms over time. CONCLUSIONS Our findings indicate that decreasing obsessive beliefs in inpatient cognitive behavioral therapy for obsessive-compulsive disorder might be a promising treatment approach.
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Affiliation(s)
- Alice Diedrich
- Department of Psychiatry and Psychotherapy, University of Munich (LMU), Nußbaumstr. 7, 80336, Munich, Germany.
| | - Philipp Sckopke
- Department of Psychology, University of Munich (LMU), Leopoldstr. 13, 80802 Munich, Germany
| | - Caroline Schwartz
- Department of Psychiatry and Psychotherapy, University of Munich (LMU), Nußbaumstr. 7, 80336 Munich, Germany
| | - Sandra Schlegl
- Department of Psychiatry and Psychotherapy, University of Munich (LMU), Nußbaumstr. 7, 80336 Munich, Germany
| | - Bernhard Osen
- Schön Clinic Bad Bramstedt, Birkenweg 10, 24576 Bad Bramstedt, Germany
| | - Christian Stierle
- Schön Clinic Bad Bramstedt, Birkenweg 10, 24576 Bad Bramstedt, Germany
| | - Ulrich Voderholzer
- Schön Clinic Roseneck, Am Roseneck 6, 83209 Prien am Chiemsee, Germany ,Department of Psychiatry and Psychotherapy, University of Freiburg, Hauptstr. 5, 79104 Freiburg, Germany
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25
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Brennan BP, Jensen JE, Perriello C, Pope HG, Jenike MA, Hudson JI, Rauch SL, Kaufman MJ. LOWER POSTERIOR CINGULATE CORTEX GLUTATHIONE LEVELS IN OBSESSIVE-COMPULSIVE DISORDER. BIOLOGICAL PSYCHIATRY: COGNITIVE NEUROSCIENCE AND NEUROIMAGING 2016; 1:116-124. [PMID: 26949749 DOI: 10.1016/j.bpsc.2015.12.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Several lines of evidence support the hypothesis that lower cerebral levels of glutathione (GSH), associated with increased oxidative stress, may contribute to obsessive-compulsive disorder (OCD). However, no studies to date have investigated brain GSH levels in individuals with OCD. METHODS Twenty-nine individuals with OCD and 25 age-, sex-, and race-matched comparison individuals without OCD underwent single voxel 2D J-resolved proton magnetic resonance spectroscopy (MRS) to examine GSH levels in the posterior cingulate cortex (PCC). MRS data were analyzed using LCModel and a simulated basis set. Group metabolite differences referenced to total creatine (Cr), as well as relationships between metabolite ratios and symptom severity as measured by the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), were analyzed using linear regression with adjustment for age, sex, and race. RESULTS One OCD participant failed to produce usable PCC MRS data. We found significantly lower PCC GSH/Cr in OCD participants compared with non-OCD participants (β = -0.027 [95% CI: -0.049 to -5.9 × 10-3]; P = 0.014). PCC GSH/Cr was not significantly associated with total Y-BOCS score in the OCD group (β = 5.7 × 10-4 [95% CI: -4.8 × 10-3 to 5.9 × 10-3]; P = 0.83). CONCLUSIONS Lower PCC GSH/Cr may be indicative of increased oxidative stress secondary to hypermetabolism in this brain region in OCD. Future MRS studies are warranted to investigate GSH levels in other brain regions that comprise the cortico-striato-thalamo-cortical circuit thought to be abnormal in OCD.
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Affiliation(s)
- Brian P Brennan
- Biological Psychiatry Laboratory, McLean Hospital, Belmont, MA; Obsessive-Compulsive Disorders Institute, McLean Hospital, Belmont, MA; Department of Psychiatry, Harvard Medical School, Boston, MA
| | - J Eric Jensen
- Department of Psychiatry, Harvard Medical School, Boston, MA; McLean Imaging Center, McLean Hospital, Belmont, MA
| | | | - Harrison G Pope
- Biological Psychiatry Laboratory, McLean Hospital, Belmont, MA; Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Michael A Jenike
- Obsessive-Compulsive Disorders Institute, McLean Hospital, Belmont, MA; Department of Psychiatry, Harvard Medical School, Boston, MA
| | - James I Hudson
- Biological Psychiatry Laboratory, McLean Hospital, Belmont, MA; Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Scott L Rauch
- Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Marc J Kaufman
- Department of Psychiatry, Harvard Medical School, Boston, MA; McLean Imaging Center, McLean Hospital, Belmont, MA
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Brennan BP, Tkachenko O, Schwab ZJ, Juelich RJ, Ryan EM, Athey AJ, Pope HG, Jenike MA, Baker JT, Killgore WDS, Hudson JI, Jensen JE, Rauch SL. An Examination of Rostral Anterior Cingulate Cortex Function and Neurochemistry in Obsessive-Compulsive Disorder. Neuropsychopharmacology 2015; 40:1866-76. [PMID: 25662837 PMCID: PMC4839510 DOI: 10.1038/npp.2015.36] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 01/12/2015] [Accepted: 01/13/2015] [Indexed: 12/31/2022]
Abstract
The anterior cingulate cortex is implicated in the neurobiology of obsessive-compulsive disorder (OCD). However, few studies have examined functional and neurochemical abnormalities specifically in the rostral subdivision of the ACC (rACC) in OCD patients. We used functional magnetic resonance imaging (fMRI) during an emotional counting Stroop task and single-voxel J-resolved proton magnetic resonance spectroscopy ((1)H-MRS) in the rACC to examine the function and neurochemistry of the rACC in individuals with OCD and comparison individuals without OCD. Between-group differences in rACC activation and glutamine/glutamate ratio (Gln/Glu), Glu, and Gln levels, as well as associations between rACC activation, Gln/Glu, Glu, Gln, behavioral, and clinical measures were examined using linear regression. In a sample of 30 participants with OCD and 29 age- and sex-matched participants without OCD, participants with OCD displayed significantly reduced rACC deactivation compared with those without OCD in response to OCD-specific words versus neutral words on the emotional counting Stroop task. However, Gln/Glu, Glu, and Gln in the rACC did not differ between groups nor was there an association between reduced rACC deactivation and Gln/Glu, Glu, or Gln in the OCD group. Taken together, these findings strengthen the evidence for rACC dysfunction in OCD, but weigh against an underlying association with abnormal rACC glutamatergic neurotransmission.
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Affiliation(s)
- Brian P Brennan
- Biological Psychiatry Laboratory, McLean Hospital, Belmont, MA, USA,Obsessive-Compulsive Disorders Institute, McLean Hospital, Belmont, MA, USA,Department of Psychiatry, Harvard Medical School, Boston, MA, USA,McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA, Tel: +1 617 855 2911, Fax: +1 617 855 3585, E-mail:
| | - Olga Tkachenko
- Social, Cognitive, and Affective Neuroscience Laboratory, McLean Hospital, Belmont, MA, USA
| | - Zachary J Schwab
- Social, Cognitive, and Affective Neuroscience Laboratory, McLean Hospital, Belmont, MA, USA
| | | | - Erin M Ryan
- Biological Psychiatry Laboratory, McLean Hospital, Belmont, MA, USA
| | - Alison J Athey
- Biological Psychiatry Laboratory, McLean Hospital, Belmont, MA, USA
| | - Harrison G Pope
- Biological Psychiatry Laboratory, McLean Hospital, Belmont, MA, USA,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Michael A Jenike
- Obsessive-Compulsive Disorders Institute, McLean Hospital, Belmont, MA, USA,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Justin T Baker
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA,Psychotic Disorders Division, McLean Hospital, Belmont, MA, USA
| | - William DS Killgore
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA,Social, Cognitive, and Affective Neuroscience Laboratory, McLean Hospital, Belmont, MA, USA,Department of Psychiatry, University of Arizona College of Medicine, Tucson, AZ, USA
| | - James I Hudson
- Biological Psychiatry Laboratory, McLean Hospital, Belmont, MA, USA,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - J Eric Jensen
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA,McLean Imaging Center, McLean Hospital, Belmont, MA, USA
| | - Scott L Rauch
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA,Social, Cognitive, and Affective Neuroscience Laboratory, McLean Hospital, Belmont, MA, USA
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