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van Veen SMP, Ruissen AM, Beekman ATF, Evans N, Widdershoven GAM. Establishing irremediable psychiatric suffering in the context of medical assistance in dying in the Netherlands: a qualitative study. CMAJ 2022; 194:E485-E491. [PMID: 35273025 PMCID: PMC8985907 DOI: 10.1503/cmaj.210929] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2022] [Indexed: 01/04/2023] Open
Abstract
Background: Establishing irremediability of suffering is a central challenge in determining the appropriateness of medical assistance in dying (MAiD) for patients with a psychiatric disorder. We sought to evaluate how experienced psychiatrists define irremediable psychiatric suffering in the context of MAiD and what challenges they face while establishing irremediable psychiatric suffering. Methods: We conducted a qualitative study of psychiatrists in the Netherlands with experience assessing irremediable psychiatric suffering in the context of MAiD. We collected data from in-depth, semistructured interviews focused on the definition of irremediable psychiatric suffering and on the challenges in establishing irremediability. We analyzed themes using a modified grounded theory approach. Results: The study included 11 psychiatrists. Although irremediable psychiatric suffering is a prospective concept, most participants relied on retrospective dimensions to define it, such as a history of failed treatments, and expressed that uncertainty was inevitable in this process. When establishing irremediable psychiatric suffering, participants identified challenges related to diagnosis and treatment. The main diagnostic challenge identified was the frequent co-occurrence of more than 1 psychiatric diagnosis. Important challenges related to treatment included assessing the quality of past treatments, establishing when limits of treatment had been reached and managing “treatment fatigue.” Interpretation: Challenges regarding the definition, diagnosis and treatment of irremediable psychiatric suffering complicate the process of establishing it in the context of MAiD. Development of consensus clinical criteria for irremediable psychiatric suffering in this context and further research to understand “treatment fatigue” among patients with psychiatric disorders may help address these challenges. Registration: This study was preregistered under osf.io/2jrnd.
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Affiliation(s)
- Sisco M P van Veen
- Department of Ethics, Law and Humanities (van Veen, Ruissen, Evans, Widdershoven), Amsterdam University Medical Center; Department of Psychiatry (van Veen, Beekman), Amsterdam University Medical Center; 113 Suicide Prevention (van Veen), Amsterdam, the Netherlands
| | - Andrea M Ruissen
- Department of Ethics, Law and Humanities (van Veen, Ruissen, Evans, Widdershoven), Amsterdam University Medical Center; Department of Psychiatry (van Veen, Beekman), Amsterdam University Medical Center; 113 Suicide Prevention (van Veen), Amsterdam, the Netherlands
| | - Aartjan T F Beekman
- Department of Ethics, Law and Humanities (van Veen, Ruissen, Evans, Widdershoven), Amsterdam University Medical Center; Department of Psychiatry (van Veen, Beekman), Amsterdam University Medical Center; 113 Suicide Prevention (van Veen), Amsterdam, the Netherlands
| | - Natalie Evans
- Department of Ethics, Law and Humanities (van Veen, Ruissen, Evans, Widdershoven), Amsterdam University Medical Center; Department of Psychiatry (van Veen, Beekman), Amsterdam University Medical Center; 113 Suicide Prevention (van Veen), Amsterdam, the Netherlands
| | - Guy A M Widdershoven
- Department of Ethics, Law and Humanities (van Veen, Ruissen, Evans, Widdershoven), Amsterdam University Medical Center; Department of Psychiatry (van Veen, Beekman), Amsterdam University Medical Center; 113 Suicide Prevention (van Veen), Amsterdam, the Netherlands
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Safiloo S, Mehrabi Y, Asadi S, Khodakarim S. Response to Fluvoxamine in the Obsessive-Compulsive Disorder Patients: Bayesian Ordinal Quantile Regression. Clin Pract Epidemiol Ment Health 2021; 17:146-151. [PMID: 34880926 PMCID: PMC8595981 DOI: 10.2174/1745017902117010151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 07/26/2021] [Accepted: 08/09/2021] [Indexed: 11/22/2022]
Abstract
Background: Obsessive-Compulsive Disorder (OCD) is a chronic neuropsychiatric disorder associated with unpleasant thoughts or mental images, making the patient repeat physical or mental behaviors to relieve discomfort. 40-60% of patients do not respond to Serotonin Reuptake Inhibitors, including fluvoxamine therapy. Introduction: The aim of the study is to identify the predictors of fluvoxamine therapy in OCD patients by Bayesian Ordinal Quantile Regression Model. Methods: This study was performed on 109 patients with OCD. Three methods, including Bayesian ordinal quantile, probit, and logistic regression models, were applied to identify predictors of response to fluvoxamine. The accuracy and weighted kappa were used to evaluate these models. Results: Our result showed that rs3780413 (mean=-0.69, sd=0.39) and cleaning dimension (mean=-0.61, sd=0.20) had reverse effects on response to fluvoxamine therapy in Bayesian ordinal probit and logistic regression models. In the 75th quantile regression model, marital status (mean=1.62, sd=0.47) and family history (mean=1.33, sd=0.61) had a direct effect, and cleaning (mean=-1.10, sd=0.37) and somatic (mean=-0.58, sd=0.27) dimensions had reverse effects on response to fluvoxamine therapy. Conclusion: Response to fluvoxamine is a multifactorial problem and can be different in the levels of socio-demographic, genetic, and clinical predictors. Marital status, familial history, cleaning, and somatic dimensions are associated with response to fluvoxamine therapy.
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Affiliation(s)
- Samad Safiloo
- School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Yadollah Mehrabi
- School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sareh Asadi
- Neurobiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Soheila Khodakarim
- School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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3
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Del Casale A, Sorice S, Padovano A, Simmaco M, Ferracuti S, Lamis DA, Rapinesi C, Sani G, Girardi P, Kotzalidis GD, Pompili M. Psychopharmacological Treatment of Obsessive-Compulsive Disorder (OCD). Curr Neuropharmacol 2020; 17:710-736. [PMID: 30101713 PMCID: PMC7059159 DOI: 10.2174/1570159x16666180813155017] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 07/06/2018] [Accepted: 08/12/2018] [Indexed: 02/07/2023] Open
Abstract
Background: Obsessive-compulsive disorder (OCD) is associated with affective and cognitive symptoms causing personal distress and reduced global functioning. These have considerable societal costs due to healthcare service utilization. Objective: Our aim was to assess the efficacy of pharmacological interventions in OCD and clinical guidelines, providing a comprehensive overview of this field. Methods: We searched the PubMed database for papers dealing with drug treatment of OCD, with a specific focus on clinical guidelines, treatments with antidepressants, antipsychotics, mood stabilizers, off-label medications, and pharmacogenomics. Results: Prolonged administration of selective serotonin reuptake inhibitors (SSRIs) is most effective. Better results can be obtained with a SSRI combined with cognitive behavioral therapy (CBT) or the similarly oriented exposure and response prevention (ERP). Refractory OCD could be treated with different strategies, including a switch to another SSRI or clomipramine, or augmentation with an atypical antipsychotic. The addition of medications other than antipsychotics or intravenous antidepressant administration needs further investigation, as the evidence is inconsistent. Pharmacogenomics and personalization of therapy could reduce treatment resistance. Conclusions: SSRI/clomipramine in combination with CBT/ERP is associated with the optimal response compared to each treatment alone or to other treatments. New strategies for refractory OCD are needed. The role of pharmacogenomics could become preponderant in the coming years.
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Affiliation(s)
- Antonio Del Casale
- Department of Neuroscience, Mental Health, and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sapienza University, Unit of Psychiatry, Sant'Andrea University Hospital, Rome, Italy
| | - Serena Sorice
- Residency School in Psychiatry, Faculty of Medicine and Psychology, Sapienza University, Unit of Psychiatry, Sant'Andrea University Hospital, Rome, Italy
| | - Alessio Padovano
- Residency School in Psychiatry, Faculty of Medicine and Psychology, Sapienza University, Unit of Psychiatry, Sant'Andrea University Hospital, Rome, Italy
| | - Maurizio Simmaco
- Department of Neuroscience, Mental Health, and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sapienza University, Unit of Psychiatry, Sant'Andrea University Hospital, Rome, Italy
| | | | - Dorian A Lamis
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States
| | - Chiara Rapinesi
- Department of Neuroscience, Mental Health, and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sapienza University, Unit of Psychiatry, Sant'Andrea University Hospital, Rome, Italy
| | - Gabriele Sani
- Department of Neuroscience, Mental Health, and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sapienza University, Unit of Psychiatry, Sant'Andrea University Hospital, Rome, Italy
| | - Paolo Girardi
- Department of Neuroscience, Mental Health, and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sapienza University, Unit of Psychiatry, Sant'Andrea University Hospital, Rome, Italy
| | - Georgios D Kotzalidis
- Department of Neuroscience, Mental Health, and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sapienza University, Unit of Psychiatry, Sant'Andrea University Hospital, Rome, Italy
| | - Maurizio Pompili
- Department of Neuroscience, Mental Health, and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sapienza University, Unit of Psychiatry, Sant'Andrea University Hospital, Rome, Italy
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Menchon JM, Bobes J, Alamo C, Alonso P, García-Portilla MP, Ibáñez Á, Real E, Bousoño M, Saiz-Gonzalez MD, Saiz-Ruiz J. Pharmacological treatment of obsessive compulsive disorder in adults: A clinical practice guideline based on the ADAPTE methodology. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2019; 12:77-91. [PMID: 30850318 DOI: 10.1016/j.rpsm.2019.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 12/31/2018] [Accepted: 01/08/2019] [Indexed: 01/04/2023]
Abstract
Despite the existence of effective evidence-based treatments for the management of obsessive-compulsive disorder (OCD), the therapeutic approach to this disease remains suboptimal. The availability of a therapeutic pharmacological guideline for OCD could help to improve the management of the disease in our setting and to reduce the burden of disease for the patient. With the sponsorship of the Spanish Society of Psychiatry, a group of experts has developed a guideline for the pharmacological treatment of OCD based on the recommendations of existing guidelines and following the methodology of the ADAPTE Collaboration. This article summarises the process of preparing this guideline and the recommendations adopted by consensus by a guideline panel grouped into five areas of interest: acute treatment, duration of treatment, predictors of response and special symptoms, partial response to lack of response to treatment, and special populations.
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Affiliation(s)
- Jose M Menchon
- Servicio de Psiquiatría, Hospital Universitario de Bellvitge, Universidad de Barcelona, L'Hospitalet de Llobregrat, Barcelona, España; Instituto de Investigación Biomédica de Bellvitge (IDIBELL); Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM).
| | - Julio Bobes
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM); Departamento. de Medicina - Psiquiatría, Universidad de Oviedo, Oviedo, Asturias, España; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA)
| | - Cecilio Alamo
- Facultad de Medicina y Ciencias de la Salud, Universidad de Alcalá, Alcalá de Henares, Madrid, España
| | - Pino Alonso
- Servicio de Psiquiatría, Hospital Universitario de Bellvitge, Universidad de Barcelona, L'Hospitalet de Llobregrat, Barcelona, España; Instituto de Investigación Biomédica de Bellvitge (IDIBELL); Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM)
| | - María Paz García-Portilla
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM); Departamento. de Medicina - Psiquiatría, Universidad de Oviedo, Oviedo, Asturias, España
| | - Ángela Ibáñez
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM); Servicio de Psiquiatría, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, España; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, España
| | - Eva Real
- Servicio de Psiquiatría, Hospital Universitario de Bellvitge, Universidad de Barcelona, L'Hospitalet de Llobregrat, Barcelona, España; Instituto de Investigación Biomédica de Bellvitge (IDIBELL); Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM)
| | - Manuel Bousoño
- Departamento. de Medicina - Psiquiatría, Universidad de Oviedo, Oviedo, Asturias, España
| | | | - Jeronimo Saiz-Ruiz
- Servicio de Psiquiatría, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, España
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Abstract
Obsessive-compulsive disorder (OCD) affects 1%-3% of children worldwide and has a profound impact on quality of life for patients and families. Although our understanding of the underlying etiology remains limited, data from neuroimaging and genetic studies as well as the efficacy of serotonergic medications suggest the disorder is associated with the fundamental alterations in the function of cortico-striato-thalamocortical circuits. Significant delays to diagnosis are common, ultimately leading to more severe functional impairment with long-term developmental consequences. The clinical assessment requires a detailed history of specific OCD symptoms as well as psychiatric and medical comorbidities. Standardized assessment tools may aid in evaluating and tracking symptom severity and both individual and family functioning. In the majority of children, an interdisciplinary approach that combines cognitive behavioral therapy with a serotonin reuptake inhibitor leads to meaningful symptom improvement, although some patients experience a chronic, episodic course. There are limited data to guide the management of treatment-refractory illness in children, although atypical antipsychotics and glutamate-modulating agents may be used cautiously as augmenting agents. This review outlines a clinical approach to the diagnosis and management of OCD, highlighting associated challenges, and limitations to our current knowledge.
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Affiliation(s)
- Clara Westwell-Roper
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - S Evelyn Stewart
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, Canada.,BC Children's Hospital Research Institute, Vancouver, Canada.,BC Mental Health and Substance Use Research Institute, Vancouver, Canada
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Fontenelle LF, Yücel M. A Clinical Staging Model for Obsessive-Compulsive Disorder: Is It Ready for Prime Time? EClinicalMedicine 2019; 7:65-72. [PMID: 31193644 PMCID: PMC6537549 DOI: 10.1016/j.eclinm.2019.01.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 01/30/2019] [Accepted: 01/30/2019] [Indexed: 01/02/2023] Open
Abstract
Recent changes to the diagnostic classification of obsessive-compulsive disorder (OCD), including its removal from the anxiety/neurotic, stress-related and somatoform disorders chapters of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and International Classification of Diseases 11th Revision (ICD-11), are based on growing evidence of unique pathogenic signatures and linked diagnostic and treatment approaches. In this review, we build on these recent developments and propose a 'clinical staging model' of OCD that integrates the severity of symptoms and phase of illness for personalised case management. A clinical staging model is especially relevant for the early identification and management of subthreshold OCD - a substantial and largely neglected portion of the population who, despite having milder symptoms, experience harms that may impact personal relationships, work-related functioning and productivity. Research on the pathogenesis, classification and management of such cases is needed, including the development of new outcomes measures that prove sensitive to changes in future clinical trials. Early intervention strategies in OCD are likely to yield better long-term outcomes.
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Affiliation(s)
- Leonardo F. Fontenelle
- Obsessive, Compulsive, and Anxiety Spectrum Research Program, Institute of Psychiatry, Federal University of Rio de Janeiro, Brazil
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
- Brain & Mental Health Research Hub, Turner Institute for Brain and Mental Health, Monash University, Victoria, Australia
- Corresponding author at: Rua Visconde de Pirajá, 547, 617, Ipanema, Rio de Janeiro-RJ, CEP: 22410-003, Brazil.
| | - Murat Yücel
- Brain & Mental Health Research Hub, Turner Institute for Brain and Mental Health, Monash University, Victoria, Australia
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7
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Hasanpour H, Ghavamizadeh Meibodi R, Navi K, Asadi S. Novel ensemble method for the prediction of response to fluvoxamine treatment of obsessive-compulsive disorder. Neuropsychiatr Dis Treat 2018; 14:2027-2038. [PMID: 30127613 PMCID: PMC6091249 DOI: 10.2147/ndt.s173388] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE About 30% of obsessive-compulsive disorder (OCD) patients exhibit an inadequate response to pharmacotherapy. The detection of clinical variables associated with treatment response may result in achievement of remission in shorter period, preventing illness development and reducing socioeconomic costs. METHODS In total, 330 subjects with OCD diagnosis underwent 12-week pharmacotherapy with fluvoxamine (150-300 mg). Treatment response was ≥25% reduction in Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score. In total, 36 clinical attributes of 151 subjects who had completed their treatment course were analyzed. Data mining algorithms included missing value handling, feature selection, and new analytical method based on ensemble classification. The results were compared with those of other traditional classification algorithms such as decision tree, support vector machines, k-nearest neighbor, and random forest. RESULTS Sexual and contamination obsessions are high-ranked predictors of resistance to fluvoxamine pharmacotherapy as well as high Y-BOCS obsessive score. Our results showed that the proposed analysis strategy has good ability to distinguish responder and nonresponder patients according to their clinical features with 86% accuracy, 79% sensitivity, and 89% specificity. CONCLUSION This study proposed an analytical approach which is an accurate and a sensitive method for the analysis of high-dimensional medical data sets containing more number of missing values. The treatment of OCD could be improved by better understanding of the predictors of pharmacotherapy, which may lead to more effective treatment of patients with OCD.
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Affiliation(s)
- Hesam Hasanpour
- Department of Computer Science and Engineering, Shahid Beheshti University, Tehran, Iran
| | | | - Keivan Navi
- Department of Computer Science and Engineering, Shahid Beheshti University, Tehran, Iran
| | - Sareh Asadi
- Neuroscience Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran,
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Hazari N, Narayanaswamy JC, Arumugham SS. Predictors of response to serotonin reuptake inhibitors in obsessive-compulsive disorder. Expert Rev Neurother 2016; 16:1175-91. [DOI: 10.1080/14737175.2016.1199960] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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9
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Batmaz S, Yildiz M, Songur E. Psychopharmacological treatment differences in autogenous and reactive obsessions: A retrospective chart review. Nord J Psychiatry 2016; 70:31-7. [PMID: 25952115 DOI: 10.3109/08039488.2015.1041157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Identification of homogeneous subgroups of obsessive compulsive disorder (OCD) patients may have important implications for improving effective treatment options. It has been proposed that obsessive thoughts can be classified into two subtypes, i.e. autogenous and reactive obsessions. Although it has been shown that patients with autogenous obsessions may display a worse response to treatment, no studies have yet addressed whether there is a different need for the psychopharmacological treatment options in the subtypes of OCD patients. AIM To investigate the clinical characteristics and treatment differences between autogenous (A-OCD) and reactive (R-OCD) subtypes of OCD patients. METHODS Both OCD subgroups (n = 50 for A-OCD, n = 130 for R-OCD) were compared with each other in terms of their demographic and clinical parameters. Odds ratio values for gender, treatment options, co-morbidity, severity of OCD, and response to treatment were computed. Multivariate hierarchical regression analyses were performed to identify any predictors for treatment options, severity of OCD, and response to treatment. RESULTS Our results indicated that the A-OCD and R-OCD groups differed from each other on some demographic and clinical variables in addition to their psychopharmacological treatment needs. Patients in the A-OCD group were found to be prescribed an atypical antipsychotic 2.3 times more likely than the R-OCD group. The odds for a combination treatment, or the improvement of OCD symptoms from baseline levels did not differ between the two subtypes of obsession groups. CONCLUSIONS Autogenous and reactive subtypes of obsessions may need to be offered different psychopharmacological treatment options.
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Affiliation(s)
- Sedat Batmaz
- a Sedat Batmaz, Gaziosmanpasa University, School of Medicine , Department of Psychiatry , Tokat , Turkey
| | - Mesut Yildiz
- b Mesut Yildiz, Gaziosmanpasa University, School of Medicine , Department of Psychiatry , Tokat , Turkey
| | - Emrah Songur
- c Emrah Songur, Gaziosmanpasa University, School of Medicine , Department of Psychiatry , Tokat , Turkey
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10
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Brennan BP, Lee C, Elias JA, Crosby JM, Mathes BM, Andre MC, Gironda CM, Pope HG, Jenike MA, Fitzmaurice GM, Hudson JI. Intensive residential treatment for severe obsessive-compulsive disorder: characterizing treatment course and predictors of response. J Psychiatr Res 2014; 56:98-105. [PMID: 24909787 PMCID: PMC4112460 DOI: 10.1016/j.jpsychires.2014.05.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 04/14/2014] [Accepted: 05/13/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Intensive residential treatment (IRT) is effective for severe, treatment-resistant obsessive-compulsive disorder (OCD). We sought to characterize predictors and course of response to IRT. METHODS Admission, monthly, and discharge data were collected on individuals receiving IRT. We examined the association between baseline characteristics and percent change in OCD symptoms as measured by the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) using linear regression. We compared baseline characteristics of IRT responders (≥35% reduction in Y-BOCS) versus non-responders, and of patients who did versus those who did not achieve wellness (Y-BOCS ≤ 12) using non-parametric tests. To examine the course of OCD severity over time, we used linear mixed-effects models with randomly varying intercepts and slopes. RESULTS We evaluated 281 individuals admitted to an IRT program. Greater baseline Y-BOCS scores were associated with a significantly greater percent reduction in Y-BOCS scores (β = -1.49 ([95% confidence interval: -2.06 to -0.93]; P < .001)). IRT responders showed significantly greater baseline Y-BOCS scores than non-responders (mean (SD) 28 (5.2) vs. 25.6 (5.8); P = .003) and lower past-year alcohol use scores than non-responders (1.4 (1.9) vs. 2.1 (2.2); P = .01). Participants who achieved wellness displayed lower hoarding factor scores than those who did not (5 (4.6) vs. 9.53 (6.3); P = .03). OCD symptoms declined rapidly over the first month but more slowly over the remaining two months. CONCLUSIONS Higher baseline OCD severity, lower past-year alcohol use, and fewer hoarding symptoms predicted better response to IRT. IRT yielded an initial rapid reduction in OCD symptoms, followed by a slower decline after the first month.
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Affiliation(s)
- Brian P. Brennan
- Biological Psychiatry Laboratory, McLean Hospital, Belmont, MA,Obsessive-Compulsive Disorder Institute, McLean Hospital, Belmont, MA,Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Catherine Lee
- Department of Biostatistics, Harvard School of Public Health, Boston, MA
| | - Jason A. Elias
- Obsessive-Compulsive Disorder Institute, McLean Hospital, Belmont, MA,Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Jesse M. Crosby
- Obsessive-Compulsive Disorder Institute, McLean Hospital, Belmont, MA
| | | | - Marie-Christine Andre
- Obsessive-Compulsive Disorder Institute, McLean Hospital, Belmont, MA,Psychology Department, Suffolk University, Boston, MA
| | | | - Harrison G. Pope
- Biological Psychiatry Laboratory, McLean Hospital, Belmont, MA,Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Michael A. Jenike
- Obsessive-Compulsive Disorder Institute, McLean Hospital, Belmont, MA,Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Garrett M. Fitzmaurice
- Department of Biostatistics, Harvard School of Public Health, Boston, MA,Laboratory for Psychiatric Biostatistics, McLean Hospital, Belmont, MA
| | - James I. Hudson
- Biological Psychiatry Laboratory, McLean Hospital, Belmont, MA,Department of Psychiatry, Harvard Medical School, Boston, MA
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11
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Van Ameringen M, Simpson W, Patterson B, Dell'Osso B, Fineberg N, Hollander E, Hranov L, Hranov G, Lochner C, Karamustafalioglu O, Marazziti D, Menchon JM, Nicolini H, Pallanti S, Stein DJ, Zohar J. Pharmacological treatment strategies in obsessive compulsive disorder: A cross-sectional view in nine international OCD centers. J Psychopharmacol 2014; 28:596-602. [PMID: 24429223 DOI: 10.1177/0269881113517955] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE It is unknown what next-step strategies are being used in clinical practice for patients with obsessive-compulsive disorder (OCD) who do not respond to first-line treatment. As part of a cross-sectional study of OCD, treatment and symptom information was collected. METHOD Consecutive OCD out-patients in nine international centers were evaluated by self-report measures and clinical/structured interviews. OCD symptom severity was evaluated by the Yale Brown Obsessive Compulsive Scale (YBOCS) and Clinical Global Impression-Severity Scale (CGI-S). Clinical response to current treatment was evaluated by the CGI-Improvement Scale (CGI-I ≤ 2). RESULTS In total, 361 participants reported taking medication; 77.6% were taking a selective serotonin reuptake inhibitor; 50% reported use of at least one augmentation strategy. Antipsychotics were most often prescribed as augmenters (30.3%), followed by benzodiazepines (24.9%) and antidepressants (21.9%). No differences in OCD symptom severity were found between patients taking different classes of augmentation agents. CONCLUSIONS Results from this international cross-sectional study indicate that current OCD treatment is in line with evidence-based treatment guidelines. Although augmentation strategies are widely used, no significant differences in OCD symptom severity were found between monotherapy and augmentation or between different therapeutic agents.
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Affiliation(s)
- Michael Van Ameringen
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - William Simpson
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada MiNDS Neuroscience Graduate Program, McMaster University, St. Joseph's Healthcare, Hamilton, ON, Canada
| | - Beth Patterson
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Bernardo Dell'Osso
- Department of Psychiatry of the Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico of Milano, Milan, Italy
| | - Naomi Fineberg
- National Obsessive Compulsive Disorders Treatment Service, Hertfordshire Partnership NHS Foundation Trust, Queen Elizabeth II Hospital, Welwyn Garden City, UK; University of Hertfordshire, Postgraduate Medical School, Hatfield, UK
| | - Eric Hollander
- Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Montefiore Medical Center, New York, NY, USA
| | - Luchezar Hranov
- University Hospital of Neurology and Psychiatry, St. Naum of Sofia, Sofia, Bulgaria
| | - Georgi Hranov
- University Hospital of Neurology and Psychiatry, St. Naum of Sofia, Sofia, Bulgaria
| | - Christine Lochner
- MRC Unit on Anxiety and Stress Disorders, Department of Psychiatry, University of Stellenbosch, Stellenbosch, South Africa
| | | | - Donatella Marazziti
- Dipartimento di Psichiatria, Neurobiologia, Farmacologia e Biotecnologie", University of Pisa, Pisa, Italy
| | - Jose M Menchon
- IDIBELL-University Hospital of Bellvitage, CIBERSAM University of Barcelona, Barcelona, Spain
| | - Humberto Nicolini
- Center for Genomic Sciences, Universidad Autónoma de la Ciudad de México and Carracci Medical Group, Mexico City, Mexico
| | - Stefano Pallanti
- Institute of Neuroscience, Università di Firenze, Firenze, Italy
| | - Dan J Stein
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Joseph Zohar
- Chaim Sheba Medical Center, Department of Psychiatry, Tel Aviv, Israel
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12
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Predicting obsessive-compulsive disorder severity combining neuroimaging and machine learning methods. J Affect Disord 2013; 150:1213-6. [PMID: 23769292 DOI: 10.1016/j.jad.2013.05.041] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 05/17/2013] [Indexed: 01/11/2023]
Abstract
BACKGROUND Recently, machine learning methods have been used to discriminate, on an individual basis, patients from healthy controls through brain structural magnetic resonance imaging (MRI). However, the application of these methods to predict the severity of psychiatric symptoms is less common. METHODS Herein, support vector regression (SVR) was employed to evaluate whether gray matter volumes encompassing cortical-subcortical loops contain discriminative information to predict obsessive-compulsive disorder (OCD) symptom severity in 37 treatment-naïve adult OCD patients. RESULTS The Pearson correlation coefficient between predicted and observed symptom severity scores was 0.49 (p=0.002) for total Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS) and 0.44 (p=0.006) for total Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). The regions that contained the most discriminative information were the left medial orbitofrontal cortex and the left putamen for both scales. LIMITATIONS Our sample is relatively small and our results must be replicated with independent and larger samples. CONCLUSIONS These results indicate that machine learning methods such as SVR analysis may identify neurobiological markers to predict OCD symptom severity based on individual structural MRI datasets.
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Brakoulias V, Starcevic V, Berle D, Milicevic D, Moses K, Hannan A, Sammut P, Martin A. The use of psychotropic agents for the symptoms of obsessive-compulsive disorder. Australas Psychiatry 2013; 21:117-21. [PMID: 23426097 DOI: 10.1177/1039856212470502] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To describe the use of psychotropic agents in a sample of subjects with obsessive-compulsive disorder (OCD), and in particular the differences associated with different OCD symptoms. METHOD A total of 154 subjects participated in a study assessing OCD symptom subtypes, called the Nepean OCD Study. In addition to a comprehensive evaluation of the subjects' OCD symptoms using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Vancouver Obsessive-Compulsive Inventory (VOCI), and the Sheehan Disability Scale (SDS), the subjects' medication history was recorded. The association between symptom severity, disability, OCD symptom subtypes and the use of psychotropic agents was examined. RESULTS Psychotropic medication was taken by 93 (60.4%) participants. In the majority of cases (n=55, 59.1%), selective serotonin reuptake inhibitors (SSRIs) were taken, and of the SSRIs, the most commonly used agent was escitalopram (n=21, 22.6%). Psychotropic agents were more likely to be taken by subjects with higher Y-BOCS and SDS scores. Hoarding was associated with a lower likelihood of psychotropic use, whereas unacceptable/taboo thoughts were associated with an increased likelihood of psychotropic and antipsychotic use. CONCLUSION Patients with OCD are more likely to be taking psychotropic agents if they have a more severe illness, greater disability and more prominent unacceptable/taboo thoughts.
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Affiliation(s)
- Vlasios Brakoulias
- University of Sydney, Sydney Medical School (Nepean), Penrith, NSW, Australia.
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14
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Abstract
Psychiatric symptomatology is often subjective, but it can be partly made more objective for the purposes of evaluation. Esquirol was the first modern psychiatrist to stress the need for a scientific approach to treatment evaluation. The kinetics of treatment is complex because different components of the clinical picture improve at a different pace. Assessment of treatment requires prior definition of end point, response, and nonresponse. Response is influenced by several factors, such as placebo effect, diagnostic category and subtypes, and patient heterogeneity. Treatment response may be predicted from clinical and biological parameters. This article lists the main causes of nonresponse, and suggests how to remedy them.
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Affiliation(s)
- Jean-Paul Macher
- FORENAP, Institute for Research in Neuroscience and Neuropsychiatry, Rouffach, France
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15
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Taylor S. Early versus late onset obsessive-compulsive disorder: evidence for distinct subtypes. Clin Psychol Rev 2011; 31:1083-100. [PMID: 21820387 DOI: 10.1016/j.cpr.2011.06.007] [Citation(s) in RCA: 172] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Revised: 06/13/2011] [Accepted: 06/14/2011] [Indexed: 12/16/2022]
Abstract
The distinction between early versus late onset is important for understanding many different kinds of disorders. In an effort to identify etiologically homogeneous subtypes of obsessive-compulsive disorder (OCD), numerous studies have investigated whether early onset OCD (EO) can be reliably distinguished from a comparatively later onset form of the disorder (LO). The present article presents a systematic review and evaluation of this subtyping scheme, including meta-analyses and re-analyses of raw data. Regarding the latter, latent class analyses of nine datasets, including clinical and community samples, consistently indicated that age-of-onset is not a unimodal phenomena. Evidence suggests that there are two distinguishable groups; EO (mean onset 11 years) and LO (mean onset 23 years). Approximately three-quarters of cases of OCD (76%) were classified as EO. Meta-analyses indicated that EO, compared to LO, is (a) more likely to occur in males, (b) associated with greater OCD global severity and higher prevalence of most types of OC symptoms, (c) more likely to be comorbid with tics and possibly with other putative obsessive-compulsive spectrum disorders, and (d) associated with a greater prevalence of OCD in first-degree relatives. EO and LO were also distinguishable on other psychosocial and biological variables. Overall, results support the view that EO and LO are distinct subtypes of OCD. Comparisons with other, potentially overlapping OCD subtyping schemes are discussed, implications for DSM-V are considered, and important directions for future investigation are proposed.
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Affiliation(s)
- Steven Taylor
- Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC, Canada V6T 2A1.
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16
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Starcevic V, Berle D, Brakoulias V, Sammut P, Moses K, Milicevic D, Hannan A. Functions of compulsions in obsessive-compulsive disorder. Aust N Z J Psychiatry 2011; 45:449-57. [PMID: 21510720 DOI: 10.3109/00048674.2011.567243] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES The key function of compulsions in obsessive-compulsive disorder (OCD) is to alleviate anxiety or distress caused by the obsessions, but compulsions may also have other functions. The main aim of this study was to systematically ascertain what motivates individuals with OCD to perform compulsions. METHOD A total of 108 adults with OCD were assessed with the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the Functions of Compulsions Interview. The latter instrument elicits the functions of identified compulsions. RESULTS The functions of 218 compulsions were identified. The mean number of functions per compulsion in the whole sample was 2.94 and the vast majority of compulsions (85.3%) were performed for more than one reason. The total number of functions of compulsions endorsed for the three main compulsions correlated with Y-BOCS total scores (r = 0.37, p < 0.001). Compulsions were most frequently performed automatically and to decrease distress or anxiety, but there was substantial variation, depending on the type of compulsion. Hoarding was often performed for reasons not related to any other compulsion (involving a perceived need for collected objects), whereas ordering/symmetry/repeating compulsions were frequently performed to achieve a 'just right' feeling. Checking was frequently performed because of the belief that something bad or unpleasant would happen if one failed to check; washing/cleaning compulsions were most frequently performed to decrease distress or anxiety and automatically, and mental compulsions were performed automatically far more often than for other reasons. CONCLUSIONS The majority of compulsions have more than one function and they are often performed automatically. The finding of different functions of compulsions in different types of compulsions provides some support to the subtyping of OCD on the basis of obsessions and compulsions. Identifying functions of compulsions allows better understanding of the functional relationship between obsessions and compulsions, which may have implications for cognitive-behavioural therapy of OCD.
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Affiliation(s)
- Vladan Starcevic
- University of Sydney, Sydney Medical School, Discipline of Psychiatry, Nepean Hospital, Department of Psychiatry, Penrith, NSW, Australia.
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Maher M, Huppert JD, Chen H, Duan N, Foa EB, Liebowitz MR, Simpson HB. Moderators and predictors of response to cognitive-behavioral therapy augmentation of pharmacotherapy in obsessive-compulsive disorder. Psychol Med 2010; 40:2013-2023. [PMID: 20416137 PMCID: PMC3953340 DOI: 10.1017/s0033291710000620] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Cognitive-behavioral therapy (CBT) consisting of exposure and response prevention (EX/RP) is efficacious as a treatment for obsessive-compulsive disorder (OCD). However, about half of patients have a partial or poor response to EX/RP treatment. This study examined potential predictors and moderators of CBT augmentation of pharmacotherapy, to identify variables associated with a poorer response to OCD treatment. METHOD Data were drawn from a large randomized controlled trial that compared the augmenting effects of EX/RP to stress management training (SMT; an active CBT control) among 108 participants receiving a therapeutic dose of a serotonin reuptake inhibitor (SRI). Stepwise regression was used to determine the model specification. RESULTS Pretreatment OCD severity and gender were significant moderators of outcome: severity affected SMT (but not EX/RP) outcome; and gender affected EX/RP (but not SMT) outcome. Adjusting for treatment type and pretreatment severity, significant predictors included greater co-morbidity, number of past SRI trials, and lower quality of life (QoL). Significant moderators, including their main-effects, and predictors accounted for 37.2% of the total variance in outcome, comparable to the impact of treatment type alone (R2=30.5%). These findings were replicated in the subgroup analysis of EX/RP alone (R2=55.2%). CONCLUSIONS This is the first randomized controlled study to examine moderators and predictors of CBT augmentation of SRI pharmacotherapy. Although effect sizes for individual predictors tended to be small, their combined effect was comparable to that of treatment. Thus, future research should examine whether monitoring for a combination of these risk factors and targeting them with multi-modular strategies can improve EX/RP outcome.
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Affiliation(s)
| | - Jonathan D. Huppert
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA
- Department of Psychology, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Henian Chen
- New York State Psychiatric Institute, New York, NY
- Department of Psychiatry, Columbia University, New York, NY
| | - Naihua Duan
- New York State Psychiatric Institute, New York, NY
- Department of Psychiatry, Columbia University, New York, NY
| | - Edna B. Foa
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Michael R. Liebowitz
- New York State Psychiatric Institute, New York, NY
- Department of Psychiatry, Columbia University, New York, NY
| | - Helen Blair Simpson
- New York State Psychiatric Institute, New York, NY
- Department of Psychiatry, Columbia University, New York, NY
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18
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Abstract
Knowledge of pharmacotherapeutic treatment options in obsessive-compulsive disorder (OCD) has grown considerably over the past 40 years. Serotonergic antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) and clomipramine, are the established pharmacologic first-line treatment of OCD. Medium to large dosages and acute treatment for at least 3 months are recommended until efficacy is assessed. In case of significant improvement, maintenance treatment is necessary. Unfortunately, about half of the patients do not respond sufficiently to oral serotonergic antidepressants; augmentation with atypical antipsychotics is an established second-line drug treatment strategy. Alternatives include intravenous serotonergic antidepressants and combination with or switch to cognitive behavioral psychotherapy. Remarkably, a considerable proportion of OCD patients still do not receive rational drug treatment. Novel research approaches, such as preliminary treatment studies with glutamatergic substances, and trials with further drugs, as well as needed aspects of future research, are reviewed.
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Affiliation(s)
- Michael Kellner
- University Hospital Hamburg-Eppendorf, Dept of Psychiatry and Psychotherapy, Anxiety Spectrum Disorders Unit, Hamburg, Germany.
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19
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Marazziti D, Consoli G. Treatment strategies for obsessive-compulsive disorder. Expert Opin Pharmacother 2010; 11:331-43. [DOI: 10.1517/14656560903446948] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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20
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Invasive circuitry-based neurotherapeutics: stereotactic ablation and deep brain stimulation for OCD. Neuropsychopharmacology 2010; 35:317-36. [PMID: 19759530 PMCID: PMC3055421 DOI: 10.1038/npp.2009.128] [Citation(s) in RCA: 268] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Psychiatric neurosurgery, specifically stereotactic ablation, has continued since the 1940s, mainly at a few centers in Europe and the US. Since the late 1990s, the resurgence of interest in this field has been remarkable; reports of both lesion procedures and the newer technique of deep brain stimulation (DBS) have increased rapidly. In early 2009, the US FDA granted limited humanitarian approval for DBS for otherwise intractable obsessive-compulsive disorder (OCD), the first such approval for a psychiatric illness. Several factors explain the emergence of DBS and continued small-scale use of refined lesion procedures. DBS and stereotactic ablation have been successful and widely used for movement disorders. There remains an unmet clinical need: current drug and behavioral treatments offer limited benefit to some seriously ill people. Understandings of the neurocircuitry underlying psychopathology and the response to treatment, while still works in progress, are much enhanced. Here, we review modern lesion procedures and DBS for OCD in the context of neurocircuitry. A key issue is that clinical benefit can be obtained after surgeries targeting different brain structures. This fits well with anatomical models, in which circuits connecting orbitofrontal cortex (OFC), medial prefrontal cortex (mPFC), basal ganglia, and thalamus are central to OCD pathophysiology and treatment response. As in movement disorders, dedicated interdisciplinary teams, here led by psychiatrists, are required to implement these procedures and maintain care for patients so treated. Available data, although limited, support the promise of stereotactic ablation or DBS in carefully selected patients. Benefit in such cases appears not to be confined to obsessions and compulsions, but includes changes in affective state. Caution is imperative, and key issues in long-term management of psychiatric neurosurgery patients deserve focused attention. DBS and contemporary ablation also present different patterns of potential benefits and burdens. Translational research to elucidate how targeting specific nodes in putative OCD circuitry might lead to therapeutic gains is accelerating in tandem with clinical use.
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Potenza MN, Koran LM, Pallanti S. The relationship between impulse-control disorders and obsessive-compulsive disorder: a current understanding and future research directions. Psychiatry Res 2009; 170:22-31. [PMID: 19811840 PMCID: PMC2792582 DOI: 10.1016/j.psychres.2008.06.036] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2007] [Revised: 07/03/2007] [Accepted: 06/12/2008] [Indexed: 10/20/2022]
Abstract
Impulse-control disorders (ICDs) constitute a heterogeneous group of conditions linked diagnostically by difficulties in resisting "the impulse, drive, or temptation to perform an act that is harmful to the person or to others." Specific ICDs share clinical, phenomenological and biological features with obsessive-compulsive disorder (OCD) that have suggested that these disorders might be categorized together. However, other data suggest significant differences between OCD and ICDs. In this article, clinical, phenomenological and biological features of the formal ICDs are reviewed and compared and contrasted with those of OCD. Available data indicate substantial differences between ICDs and OCD that suggest independent categorizations. Existing research gaps are identified and avenues for future research suggested.
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Affiliation(s)
- Marc Nicholas Potenza
- Associate Professor of Psychiatry, Department of Psychiatry, Yale University School of Medicine, Connecticut Mental Health Center, Room S-104, 34 Park Street, New Haven, CT, 06519, USA, . Tel: 203-974-7356. Fax: 203-974-7366
| | - Lorrin Michael Koran
- Professor of Psychiatry, Emeritus, Department of Psychiatry and Behavioural Sciences, Stanford University Medical Center, Stanford, CA, 94305
| | - Stefano Pallanti
- Professor of Psychiatry, University of the Studies of Florence, Florence, Italy, Adjunct Professor of Psychiatry, Mount Sinai School of Medicine, NY, New York.
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Common genetic, clinical, demographic and psychosocial predictors of response to pharmacotherapy in mood and anxiety disorders. Int Clin Psychopharmacol 2009; 24:1-18. [PMID: 19060722 DOI: 10.1097/yic.0b013e32831db2d7] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The aim of this study is to summarize available knowledge about common genetic, clinical, demographic and psychosocial predictors of response to pharmacotherapy in mood and anxiety disorders. A literature search was carried out by using MEDLINE and references of selected articles. The search included articles published up to March 2008. The main genetic finding concerns the serotonin transporter gene promoter polymorphisms, the long variant of which seems to be related to a positive response to therapy in mood disorders and could also have a role in the treatment of anxiety disorders. Among other predictors, the main factors common to both classes of disorder are comorbid axis II disorders and early onset of illness, which are related to a worse response to therapy and concomitant good physical conditions, absence of earlier treatments, early administration and response to therapies, and higher self- directedness, which is related to a better outcome. Many common predictors have been identified and these seem to be related to features covering the totality of patients that go beyond specific characteristics of single disorders. Possible limitations and suggestions for future research based on a more integrated vision of human complexity are discussed.
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Abstract
There are high expectations about the capabilities of pharmacogenetics to tailor psychotropic treatment and "personalize" treatment. While a large number of associations, with generally small effect size, have been discovered, a "test" with widespread use and adoption is still missing. A more realistic picture, recognizing the important contribution of clinical and environmental factors toward overall clinical outcome has emerged. In this emerging view, genetic findings, if considered individually, may have limited clinical applications. Thus, in recent years, combinations of information in several genes have been used for the selection of appropriate therapeutic doses and for the prediction of agranulocytosis, hyperlipidemia, and response to antipsychotic and antidepressant medications. While these tests based on multiple genes show greater predictive ability than individual allele tests, their net impact on clinical consequence and costs is limited, thus leading to limited penetration into widespread clinical use. As one looks at other branches of medicine, there are successful examples of pharmacogenetic tests guiding treatment, and thus, it is reasonable to hope that with the incorporation of clinical and environmental information and the identification of new genes drawn from genome-wide analysis, will improve the predictive utility of these tests leading to their increased use by clinicians.
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Affiliation(s)
- Maria J. Arranz
- Section of Schizophrenia, Imaging and Therapeutics, Division of Psychological Medicine and Psychiatry, Institute of Psychiatry, King’s College, PO51, London SE5 8AF, UK,To whom correspondence should be addressed; tel. 44-0-207-848 0343, e-mail:
| | - Shitij Kapur
- Section of Schizophrenia, Imaging and Therapeutics, Division of Psychological Medicine and Psychiatry, Institute of Psychiatry, King’s College, PO51, London SE5 8AF, UK
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Starcevic V, Brakoulias V. Symptom subtypes of obsessive-compulsive disorder: are they relevant for treatment? Aust N Z J Psychiatry 2008; 42:651-61. [PMID: 18622773 DOI: 10.1080/00048670802203442] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Several symptom subtypes of obsessive-compulsive disorder (OCD) have been identified on the basis of the predominant obsessions and compulsions. The objectives of the present article were to review the literature on the relationship between OCD symptom subtypes and treatment response and to suggest strategies that might assist with the choice of treatment and improve treatment outcome in patients with various subtypes. An extensive literature search was performed, relevant studies were identified, and their results reported. Overt compulsions were generally associated with a relatively good response to the behaviour therapy technique of exposure and response prevention (ERP) and with poorer response to serotonin re-uptake inhibitors (SRIs). Washing/cleaning and checking compulsions tend to respond well to ERP, whereas the majority of studies show that washing/cleaning compulsions are associated with a poorer response to SRIs. Most studies suggest that patients with the symmetry, ordering and arranging subtype do not fare worse with ERP and SRIs than patients with other symptom subtypes. Some studies suggested that obsessions might respond to SRIs somewhat better than to ERP. In the majority of the studies, hoarding and the subtype characterized by sexual or religious obsessions and absence of overt compulsions ('pure obsessions') have been associated with poor response to ERP and SRIs. It was concluded that treatment strategies cannot be precisely tailored to OCD symptom subtypes. Many other factors influence the outcome of treatment and need to be considered along with the symptom subtypes when making decisions about treatment. While ERP and SRIs remain the mainstay of treatment regardless of the symptom subtype, the addition of cognitive therapy techniques and/or antipsychotic medications may enhance treatment response in the presence of certain features discussed in the article.
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Affiliation(s)
- Vladan Starcevic
- University of Sydney, Discipline of Psychological Medicine, NSW, Australia.
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Abstract
INTRODUCTION There is a substantial body of evidence that obsessive-compulsive disorder (OCD) symptoms can be grouped into a series of discrete dimensions, and some evidence that not all OCD symptom dimensions respond equally well to pharmacologic or psychotherapeutic intervention. The response of OCD symptom dimensions to 12 weeks of treatment with escitalopram or placebo was investigated. METHODS Data from a randomized, double-blind, placebo-controlled study of escitalopram in 466 adults with OCD were analyzed. Exploratory factor analysis of individual items of the Yale-Brown Obsessive-Compulsive Scale checklist was performed and subscale scores based on the extracted factors were determined. Analyses of covariance were undertaken to determine whether inclusion of each subscale score in these models impacted on the efficacy of escitalopram versus placebo. RESULTS Exploratory factor analysis of individual Yale-Brown Obsessive-Compulsive Scale items yielded 5 factors (contamination/cleaning, harm/checking, hoarding/symmetry, religious/sexual, and somatic/hypochondriacal). Analyses of covariance including all the subscales demonstrated that escitalopram was more effective than placebo. There was a significant interaction for the hoarding/symmetry factor, which was associated with a poor treatment response. CONCLUSION Escitalopram shows good efficacy across the range of OCD symptom dimensions. Nevertheless, hoarding/symmetry was associated with a poorer treatment response. Hoarding/symmetry may be particularly characteristic of an early-onset group of OCD patients, with the involvement of neurotransmitters other than serotonin. Further work is needed to delineate fully the subtypes of OCD, and their correlates with underlying psychobiology and treatment responsivity.
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Saxena S, Brody AL, Maidment KM, Baxter LR. Paroxetine treatment of compulsive hoarding. J Psychiatr Res 2007; 41:481-7. [PMID: 16790250 PMCID: PMC2876089 DOI: 10.1016/j.jpsychires.2006.05.001] [Citation(s) in RCA: 128] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2006] [Revised: 05/02/2006] [Accepted: 05/03/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Compulsive hoarding, found in many patients with obsessive-compulsive disorder (OCD), has been associated with poor response to serotonin reuptake inhibitor (SRI) medications in some reports. However, no prior study has quantitatively measured response to standardized pharmacotherapy in compulsive hoarders. We sought to determine whether compulsive hoarders would respond as well as non-hoarding OCD patients to the SRI, paroxetine. METHODS Seventy-nine patients with OCD (32 patients with the compulsive hoarding syndrome and 47 patients without prominent hoarding symptoms) were treated openly with paroxetine (mean dose 41.6+/-12.8 mg/day; mean duration 80.4+/-23.5 days) according to a standardized protocol, from 3/1993 to 7/2005. All subjects were free of psychotropic medication for at least four weeks prior to study entry. No psychotherapy or psychotropic medications except paroxetine were allowed during the study period. Subjects were assessed before and after treatment with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Scale (Ham-A), Global Assessment Scale (GAS), and Clinical Global Impression/Improvement (CGI) scale. RESULTS Both compulsive hoarders and non-hoarding OCD patients improved significantly with treatment (p<0.001), with nearly identical changes in Y-BOCS, HDRS, Ham-A, and GAS scores. There were no significant differences between groups in the proportions of patients who completed or responded to treatment. Hoarding symptoms improved as much as other OCD symptoms. CONCLUSIONS Compulsive hoarders responded as well to paroxetine treatment as non-hoarding OCD patients, suggesting that SRI medications are effective for compulsive hoarding. Controlled trials of SRI medications for compulsive hoarding are now warranted.
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Affiliation(s)
- Sanjaya Saxena
- UCSD Department of Psychiatry, VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, United States
- Corresponding author. Tel.: +1 858 642 3472; fax: +1 858 642 6442. (S. Saxena)
| | - Arthur L. Brody
- UCLA Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, United States
| | - Karron M. Maidment
- UCLA Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, United States
| | - Lewis R. Baxter
- University of Florida, Department of Psychiatry, Gainesville, FL, United States
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Kempe PT, van Oppen P, de Haan E, Twisk JWR, Sluis A, Smit JH, van Dyck R, van Balkom AJLM. Predictors of course in obsessive-compulsive disorder: logistic regression versus Cox regression for recurrent events. Acta Psychiatr Scand 2007; 116:201-10. [PMID: 17655562 DOI: 10.1111/j.1600-0447.2007.00997.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Two methods for predicting remissions in obsessive-compulsive disorder (OCD) treatment are evaluated. Y-BOCS measurements of 88 patients with a primary OCD (DSM-III-R) diagnosis were performed over a 16-week treatment period, and during three follow-ups. METHOD Remission at any measurement was defined as a Y-BOCS score lower than thirteen combined with a reduction of seven points when compared with baseline. Logistic regression models were compared with a Cox regression for recurrent events model. RESULTS Logistic regression yielded different models at different evaluation times. The recurrent events model remained stable when fewer measurements were used. Higher baseline levels of neuroticism and more severe OCD symptoms were associated with a lower chance of remission, early age of onset and more depressive symptoms with a higher chance. CONCLUSION Choice of outcome time affects logistic regression prediction models. Recurrent events analysis uses all information on remissions and relapses. Short- and long-term predictors for OCD remission show overlap.
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Affiliation(s)
- P T Kempe
- Department of Psychiatry and Institute for Research in Extramural Medicine, VU University Medical Center, GGZ Buitenamstel, The Netherlands
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Storch EA, Larson MJ, Shapira NA, Ward HE, Murphy TK, Geffken GR, Valerio H, Goodman WK. Clinical predictors of early fluoxetine treatment response in obsessive-compulsive disorder. Depress Anxiety 2007; 23:429-33. [PMID: 16841343 DOI: 10.1002/da.20197] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Despite wide use, relatively little is known about sociodemographic and clinical characteristics that predict early fluoxetine response. What research has been conducted has produced inconsistent findings, which may be due to the statistical procedures used, and no studies to date have examined predictors of early fluoxetine treatment response. Sixty adults with obsessive-compulsive disorder (OCD) completed an open-label fluoxetine trial for 8 weeks (up to 40 mg) after a 1-week, single-blind, placebo run-in before baseline assessment. The baseline and posttreatment assessment battery included the Yale-Brown Obsessive Compulsive Scale, the Hamilton Rating Scale for Depression, and the Yale Global Tic Severity Scale. Patient characteristics included illness duration, age, age of onset, gender, and pharmacological treatment history. Independent t-tests and multiple logistic regression analysis showed that longer illness duration, older age, and greater symptom severity were associated with nonresponse. Our findings highlight the impact of functional psychiatric impairment on determining those who may respond to treatment. Furthermore, findings suggest early predictors of patients with certain characteristics who may ultimately need adjunctive care to facilitate response.
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Affiliation(s)
- Eric A Storch
- Department of Psychiatry, University of Florida, Gainesville, Florida 32610, USA.
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Shavitt RG, Belotto C, Curi M, Hounie AG, Rosário-Campos MC, Diniz JB, Ferrão YA, Pato MT, Miguel EC. Clinical features associated with treatment response in obsessive-compulsive disorder. Compr Psychiatry 2006; 47:276-81. [PMID: 16769302 DOI: 10.1016/j.comppsych.2005.09.001] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2005] [Revised: 06/09/2005] [Accepted: 09/12/2005] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE This study aims to investigate the effect of sociodemographic and clinical features on the short-term response to pharmacological treatment in obsessive-compulsive disorder (OCD). We focused especially on investigating factors previously associated with poorer prognosis, such as comorbidity with tic disorders, early onset of symptoms, and sensory phenomena preceding compulsions, which have been described as common in both tic-related and early-onset OCD. METHOD The study involved 41 consecutive adult patients with OCD diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria and was conducted at the OCD Spectrum Disorders Clinic of the University of Sao Paulo School of Medicine in São Paulo, Brazil, between January of 2000 and December of 2001. All patients were treated exclusively with oral clomipramine for 14 weeks. Treatment response, measured for Yale-Brown Obsessive-Compulsive Scale score decrease from baseline, was assessed by an investigator blinded as to the variables of interest present. RESULTS Linear regression analysis showed that having a partner and sensory phenomena preceding compulsions were associated with better response to clomipramine treatment (P = .04 and P = .002, respectively). Tic comorbidity and early onset of symptoms were not associated with poorer response. CONCLUSIONS In OCD, having a partner and sensory phenomena preceding compulsions seem to be associated with a favorable response to pharmacological treatment.
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Affiliation(s)
- Roseli G Shavitt
- Department of Psychiatry, University of São Paulo School of Medicine, Caixa Postal 8091, São Paulo, Brazil.
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Denys D. Pharmacotherapy of obsessive-compulsive disorder and obsessive-compulsive spectrum disorders. Psychiatr Clin North Am 2006; 29:553-84, xi. [PMID: 16650723 DOI: 10.1016/j.psc.2006.02.013] [Citation(s) in RCA: 131] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This article reviews new developments of pharmacotherapy in obsessive-compulsive disorder (OCD) and OC spectrum disorders of the past five years. New developments primarily involved the ex-tension of evidence of efficacy of serotonin reuptake inhibitors(SRIs), the use of atypical antipsychotics in addition to SRIs for treatment refractory patients, the combination of pharmacotherapy with behavior therapy, and studies assessing predictors of response. Today, frontline pharmacological treatment of OCD still consists of drugs with potent serotonin reuptake inhibition proper-ties. In case of non-response, treatment options comprise adding another drug, increasing the dose, switching drugs, or changing the mode of delivery.
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Affiliation(s)
- Damiaan Denys
- Department of Anxiety Disorders, Rudolf Magnus Institute of Neuroscience, Utrecht, The Netherlands.
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Uguz F, Askin R, Cilli AS, Besiroglu L. Comparison of treatment responses and clinical characteristics of early-onset and late-onset obsessive-compulsive disorder. Int J Psychiatry Clin Pract 2006; 10:291-6. [PMID: 24941149 DOI: 10.1080/13651500600811271] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective. The clinical characteristics and response to pharmacotherapy of adult patients with early-onset and late-onset obsessive-compulsive disorder (OCD) were compared in this study. Methods. A total of 50 outpatients with OCD diagnosed according to DSM-IV criteria (early-onset: 20; late-onset: 30) were included in the study. After initial clinical evaluation with The Structured Clinical Interview for DSM-IV/Clinical Version (SCID-I/CV), The Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) and Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), all patients were treated with fluvoxamine, sertraline or paroxetine for 12 weeks. Treatment response was defined as a ≥35% reduction in the Y-BOCS-total scores from baseline in a 12-week follow-up period. Results. Forty-three patients (early-onset: 16; late-onset: 27) completed the study. The early-onset group had higher frequencies of symmetry/exactness obsessions and ordering/arranging compulsions, and the late-onset group had higher mean age at assessment. Nine (56.3%) patients with early-onset and 18 (66.7%) with late-onset responded to pharmacotherapy. The difference between response rates was not statistically significant. Conclusions. Our study suggests that although there are some phenomenological differences between patients with early-onset OCD and late-onset OCD, these patients have similar responses to pharmacotherapy.
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Affiliation(s)
- Faruk Uguz
- Department of Psychiatry, Meram Faculty of Medicine, Selçuk University, Konya, Turkey
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Moritz S, Kloss M, Jacobsen D, Fricke S, Cutler C, Brassen S, Hand I. Neurocognitive impairment does not predict treatment outcome in obsessive-compulsive disorder. Behav Res Ther 2005; 43:811-9. [PMID: 15959930 DOI: 10.1016/j.brat.2004.06.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
There is conflicting evidence pertaining to whether or not neurocognitive task performance at baseline predicts treatment response in obsessive-compulsive disorder (OCD). In the present study, we administered a set of executive neurocognitive tests with a putative sensitivity for treatment outcome to a sample of 138 OCD patients. Additionally, subjective neurocognitive dysfunction was determined via a questionnaire. All patients participated in a cognitive-behavioural treatment program (CBT). Results showed that responders (n = 73) did not differ from non-responders (n = 65) on any of the parameters except for decreased performance on the delayed alternation test (p < .1, effect size: .61). A subsidiary analysis revealed that slowing on the Trail-Making Test A and an enhanced rate of perserveration errors on the Wisconsin Card Sorting Test predicted poor outcome for the treatment of compulsions. It is concluded that neurocognitive impairment does not represent a reliable early warning sign for non-response to CBT.
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Affiliation(s)
- Steffen Moritz
- Universitätsklinikum Hamburg-Eppendorf, Klinik für Psychiatrie und Psychotherapie, Hamburg, Germany.
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De Berardis D, Campanella D, Gambi F, Sepede G, Salini G, Carano A, La Rovere R, Pelusi L, Penna L, Cicconetti A, Cotellessa C, Salerno RM, Ferro FM. Insight and alexithymia in adult outpatients with obsessive-compulsive disorder. Eur Arch Psychiatry Clin Neurosci 2005; 255:350-8. [PMID: 15711867 DOI: 10.1007/s00406-005-0573-y] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2004] [Accepted: 12/09/2004] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To elucidate the relationships between insight and alexithymia in a sample of adult outpatients with obsessive-compulsive disorder (OCD). METHODS 112 adult outpatients with OCD were tested. Severity of OCD was assessed with the first 10-items of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and score for item # 11 on the Y-BOCS was considered as a measure of insight. Alexithymia was measured with 20-item Toronto Alexithymia Scale (TAS-20). Additional measures were Maudsley Hospital Obsessive Compulsive Inventory (MOCI) and Montgomery Asberg Depression Rating Scale (MADRS). RESULTS Of the patients, 29.5% showed poor or no insight. Patients with poor or no insight were more alexithymic than patients with excellent, good and moderate insight. TAS-20 total score and subfactors positively correlated with score for item # 11 on the Y-BOCS, severity of OCD and MADRS scores. In stepwise regression model, MADRS scores, factor 3 of TAS-20 (Externally Oriented Thinking), somatic and hoarding-saving obsessions were significantly associated with lower insight. CONCLUSIONS Results show a relationship between poor or absent insight and high alexithymia levels in OCD patients.
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Affiliation(s)
- Domenico De Berardis
- Department of Oncology and Neurosciences, Institute of Psychiatry, University G.D'Annunzio of Chieti Palazzina SE.BI., Scuole di Specializzazione, via dei Vestini, 31, 66013, Chieti, Italy.
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Abstract
Although treatment with different compounds such as tricyclic antidepressants, selective serotonin reuptake inhibitors, high-potency benzodiazepines, and monoamine oxidase inhibitors has been proven effective in anxiety disorders, 20% to 40% of patients are nonresponders. Given the limited efficacy, the delayed onset of response (it takes several weeks before a clinical effect can be seen for most of these drugs), and the occurrence of side effects associated with pharmacotherapy, predicting response in anxiety disorders would be immensely valuable. This review surveys the literature over the past years on predictors of response to pharmacotherapy in obsessive-compulsive disorder, social anxiety disorder, panic disorder, and posttraumatic stress disorder. Prediction of treatment response may be founded on demographic and clinical variables, neurochemical and electrophysiologic parameters, imaging studies, and genetic markers.
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Affiliation(s)
- Damiaan Denys
- Rudolf Magnus Institute of Neuroscience, Department of Psychiatry, University Medical Center, 3508 GA Utrecht, The Netherlands.
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