Placebo-controlled trial of fluoxetine and phenelzine for obsessive-compulsive disorder

OBJECTIVE

It is now well documented that fluoxetine is a viable treatment option for patients with obsessive-compulsive disorder (OCD), and there is a small body of evidence indicating that monoamine oxidase inhibitors may be effective in at least a subset of patients. The authors conducted a 10-week placebo-controlled trial of these two agents in patients who met DSM-III-R criteria for OCD.

METHOD

Sixty-four subjects were randomly assigned to receive placebo, phenelzine (60 mg/day), or fluoxetine (80 mg/day). These doses were achieved by the end of week 3 of the active phase of the study. Outcomes were assessed with standardized instruments to measure OCD, mood, and anxiety.

RESULTS

Fifty-four patients completed the study. There was a significant difference among the three treatments on one OCD scale, with fluoxetine-treated patients improving significantly more than those in the placebo or phenelzine group. A subgroup of OCD patients with symmetry obsessions did respond to phenelzine.

CONCLUSIONS

This study provides no evidence to support the use of phenelzine in OCD except possibly for those patients with symmetry or other atypical obsessions. There was also no support for the hypothesis that patients with high levels of anxiety would respond preferentially to phenelzine.

Trichotillomania: clinical aspects and treatment strategies

Trichotillomania is a disorder of compulsive hair pulling that often results in alopecia. The clinical features include the pulling of hair from the scalp, eyebrows, and eyelashes, sometimes symmetrically; pubic and other bodily hair may also be plucked. The disorder is present in 0.6% of college students. The majority of sufferers who seek treatment are female, with usual age of onset between 11 and 16 years. Trichotillomania can occur in a wide variety of psychiatric disorders, and patients with the condition may be more likely to have a lifetime diagnosis of depression or an anxiety, eating, or substance abuse disorder. Although empirically derived treatment guidelines are still lacking, the current literature suggests that behavior therapy and pharmacotherapy are the most efficacious treatments for adult trichotillomania. Controlled trials with pharmacotherapy (clomipramine) have shown significant reductions in hair pulling over the short term. Controlled investigations of behavior therapy have not been conducted, but several treatment series suggest efficacy. At least three reports also suggest that behavior therapy and pharmacotherapy bring some improvement in childhood trichotillomania, although this has not been empirically studied. A case illustrating the combination of behavior therapy techniques and pharmacotherapy in the treatment of trichotillomania is presented.

Standardized assessment of personality disorders in obsessive-compulsive disorder

We assessed 96 patients with obsessive-compulsive disorder for DSM-III personality disorder diagnoses with a standardized interview instrument (Structured Interview for the DSM-III Personality Disorders). Fifty patients (52%) met criteria for at least one personality disorder, with mixed, dependent, and histrionic personality disorders most frequently diagnosed. Compulsive personality disorder was diagnosed in only 6 patients (6%), 5 of whom had had onset of obsessive-compulsive symptoms before the age of 10 years, indicating that DSM-III compulsive personality disorder is not invariably a premorbid condition for the development of obsessive-compulsive disorder. Schizotypal personality disorder, at 5%, was found to be less common than in past samples, reflecting differences in either assessment methods or sampling.

A controlled trial of fluvoxamine in obsessive-compulsive disorder: implications for a serotonergic theory

Thirty-eight patients with primary obsessive-compulsive disorder participated in a 10-week, double-blind, placebo-controlled trial of the potent, selective serotonin reuptake inhibitor fluvoxamine. Fluvoxamine was significantly better than placebo on two of three measures of improvement in obsessive-compulsive symptoms. The authors also compared studies of the serotonergic agents fluvoxamine, sertraline, fluoxetine, and clomipramine and found that a greater effect size was associated with less serotonergic specificity and that some ability to affect other neurotransmitter systems may be a necessary but not sufficient requirement for antiobsessional activity. These data lend only partial support to a serotonin hypothesis of obsessive-compulsive disorder.

Sertraline in obsessive-compulsive disorder: a double-blind comparison with placebo

Many agents that affect the brain's serotonergic system appear to be at least partially effective in the treatment of patients with obsessive-compulsive disorder. However, in this 10-week double-blind trial in which 10 patients received sertraline and nine received placebo, sertraline was ineffective according to four measures of obsessive-compulsive symptoms. The authors discuss the implications of these preliminary findings for the serotonergic theory of obsessive-compulsive disorder and the need to explore the role of other neurochemical systems in this disorder.

Use of a portable computer program to assist behavioral treatment in a case of obsessive compulsive disorder

This case study describes the development and use of a portable computer program to assist in behavioral treatment of obsessive compulsive disorder. A 58-year-old female with a 37-year history of compulsive checking rituals, who had mild improvement following 36 months of standard behavioral techniques and pharmacotherapy, showed improved compliance with behavioral treatments of exposure and response prevention following use of the portable computer program. Computer records indicated marked reductions in frequency of checking rituals and a 91-week follow-up indicated that treatment effects were maintained at home where the patient had resumed using the laptop computer. She had stopped using the pocket computer outside the home, and there her checking rituals had returned to baseline levels.

Obsessive-compulsive disorder, depression, and the dexamethasone suppression test

Five of 29 obsessive-compulsive disorder patients were dexamethasone suppression test (DST) nonsuppressors, all of whom met standard Hamilton Depression Rating scale criteria for at least mild depression. None of 24 nondepressed obsessive-compulsive disorder patients had an abnormal DST. The relationship of the DST to specificity of psychiatric diagnoses is discussed.

MMPI correlates of obsessive-compulsive disorder

The MMPI was administered to 32 patients with pure obsessive-compulsive disorder. Twelve of the patients had been previously misdiagnosed as having schizophrenia, 10 had been treated with neuroleptics, and 1 developed severe tardive dyskinesia. An MMPI profile for obsessive-compulsive disorder is described.

Concomitant obsessive-compulsive disorder and schizotypal personality disorder

Despite advances in the management of patients with obsessive-compulsive disorder, some remain refractory to treatment. The authors retrospectively examined characteristics of 43 treatment-resistant obsessive-compulsive patients and found that those with concomitant schizotypal personality disorder had an extremely high rate of treatment failure. Of the 29 treated nonschizotypal patients, 26 (90%) improved at least moderately; only one of 14 (7%) schizotypal patients improved. In addition, the number of schizotypal features in each patient was strongly negatively correlated with treatment outcome.

Behavioral treatment in two cases of obsessive-compulsive disorder with concomitant bipolar affective disorder

The authors describe two cases of obsessive-compulsive disorder with concomitant bipolar affective disorder. Behavior therapy consisting of in vivo exposure plus response prevention controlled the obsessive-compulsive symptoms only after the affective illness was well controlled pharmacologically.