Management of obsessive compulsive disorder

The Neuronal Glutamate Transporter EAAT3 in Obsessive-Compulsive Disorder

Obsessive compulsive disorder (OCD) is a heterogeneous psychiatric disorder affecting 1%–3% of the population worldwide. About half of OCD afflicted individuals do not respond to currently available pharmacotherapy, which is mainly based on serotonin reuptake inhibition. Therefore, there is a critical need to search novel and improved therapeutic targets to treat this devastating disorder. In recent years, accumulating evidence has supported the glutamatergic hypothesis of OCD, and particularly pointing a potential role for the neuronal glutamate transporter EAAT3. This mini-review summarizes recent findings regarding the neurobiological basis of OCD, with an emphasis on the glutamatergic neurotransmission and EAAT3 as a key player in OCD etiology.

Metacognitive therapy versus exposure and response prevention for pediatric obsessive-compulsive disorder. A case series with randomized allocation

BACKGROUND

Exposure with ritual prevention (ERP) is the psychotherapeutic treatment of choice for pediatric obsessive-compulsive disorder (OCD). In the present study, a new treatment rationale - metacognitive therapy (MCT) for children - was developed and evaluated.

METHODS

Ten children and adolescents with OCD were randomly assigned to either MCT or ERP therapy condition. Patients were assessed before and after treatment and at the 3-month and 2-year follow-up by means of symptom severity interviews. Depressive symptoms were also assessed. Manualized treatment involved up to 20 sessions on a weekly basis.

RESULTS

We found clinically and statistically significant improvements in symptom severity after treatment. At the 3-month and 2-year follow-up, the attained improvements during treatment were retained.

CONCLUSIONS

Despite some methodological limitations, results showed that MCT proved to be a promising psychotherapeutic alternative to the well-established ERP in the treatment of pediatric OCD. Further investigations into the efficacy of MCT are necessary to answer questions as to the working mechanisms underlying therapy for OCD.

Dissociation as a predictor of cognitive behavior therapy outcome in patients with obsessive-compulsive disorder

BACKGROUND

Previous studies have found a strong association between dissociation and obsessive-compulsive disorder (OCD). The purpose of the present study was to evaluate whether dissociation is a predictor of cognitive behavior therapy (CBT) outcome in patients with OCD.

METHODS

Fifty-two patients with OCD were assessed using the Dissociative Experience Scale (DES), the Yale-Brown Obsessive-Compulsive Scale and the Beck Depression Inventory. CBT lasted on average 9.5 weeks and included exposure therapy.

RESULTS

Patients who dropped out due to noncompliance had higher baseline DES scores and depression scores compared to the 43 patients (83%) who completed the study. Significant OCD symptom reduction at posttreatment was observed in study completers with a large effect size (d = 1.7). More severe OCD symptoms at posttreatment were associated with higher DES scores at baseline, and treatment nonresponders had significantly higher baseline DES scores compared to responders. These associations with outcome were mainly due to the DES subfactor absorption-imaginative involvement. In regression analyses, higher absorption-imaginative involvement scores at baseline predicted poorer CBT outcome, even after controlling for depressive symptoms, comorbid axis I disorders and concomitant psychotropic drugs.

CONCLUSIONS

Results from this preliminary study suggest that higher levels of dissociation (particularly absorption-imaginative involvement) in patients with OCD might predict poorer CBT outcome. If our results can be replicated, treatment outcome might be improved by additional interventions for those patients with OCD who indicate high levels of dissociation, for example by using interventions aimed at improving coping with emotionally stressful situations.

Combining Pharmacotherapy with Cognitive‐Behavioral Interventions for Obsessive‐Compulsive Disorder

This paper reviews the evidence-based literature concerning the efficacy and effectiveness of cognitive behavior therapy (CBT), drug treatment and their combination for obsessive compulsive disorder (OCD). After a brief outline of the seminal studies, the state of the art is presented with reference to the consensual recommendations proposed in the last 10 years. Management of OCD rests on potent selective serotonin reuptake inhibitors and CBT, used separately, sequentially, or concurrently. A hierarchical model for clinical decision-making is reported. With greater severity of OCD, it is recommended to add medications. However, the response rate is still too low in many patients, and some patients remain refractory to any kind of treatment. This stresses the importance of joint efforts of psychological and biological teams to develop new treatments.

Long-term course and outcome of obsessive-compulsive patients after cognitive-behavioral therapy in combination with either fluvoxamine or placebo: a 7-year follow-up of a randomized double-blind trial

Longitudinal studies with very long follow-up periods of patients with obsessive-compulsive disorder (OCD) who have received adequate treatment are rare. In the current study, 30 of 37 inpatients (81%) with severe OCD were followed up 6-8 years after treatment with cognitive-behavioral therapy (CBT) in combination with either fluvoxamine or placebo in a randomized design. The significant improvements (with large effectsizes) in obsessive-compulsive symptoms from pre- to post-treatment (41% reduction on the Y-BOCS) remained stable at follow-up (45 %). Responder rates, defined as > or = 35% reduction on the Y-BOCS, were 67% and 60%, respectively. Depressive symptoms decreased significantly not only from pre- to post-treatment but also during follow-up. Re-hospitalization, which occurred in 11 patients (37 %), was associated with more severe depressive symptoms at pre-treatment and living without a partner. Full symptom remission at follow-up, defined as both Y-BOCS total score < or = 7 and no longer meeting diagnostic criteria for OCD, was achieved by 8 patients (27 %). Patients without full remission at follow-up had a significantly longer history of OCD, assessed at pretreatment, compared to remitted patients. The shortterm treatment outcome had no predictive value for the long-term course. Throughout the naturalistic follow-up, nearly all patients (29 patients) received additional psychotherapy and/or medication. This might indicate that such chronic OCD patients usually need additional therapeutic support after effective inpatient treatment to maintain their improvements over long periods.