Long-term efficacy of exposure and ritual prevention therapy and serotonergic medications for obsessive-compulsive disorder

What is the long-term outcome of patients with obsessive-compulsive disorder (OCD) who are treated with exposure and response (ritual) prevention (EX/RP) alone, serotonergic medications alone, or their combination? How is the long-term outcome of these patients affected by the discontinuation? Follow-up assessments were conducted with 62 patients treated for OCD an average of 17 months posttreatment (range: 6-43 months). Patients received one of three treatments: serotonergic medications (fluvoxamine or clomipramine), intensive behavior therapy involving EX/RP, or intensive EX/RP with concurrent antidepressant medication. At follow-up, no differences in OCD symptom severity were found among the three treatment groups. However, when current medication use was taken into consideration, differences among the three treatment groups emerged. Among patients who were medication-free at the time of follow-up assessment (n=37), those in the EX/RP-alone and EX/RP-with-medication groups had lower symptom severity ratings than those in the medication-only group on 4 out of 6 measures. There were no differences in OCD severity ratings among patients taking medications at follow-up (n=25). Although these findings are interpreted with caution due to the uncontrolled nature of the study, results suggested that long-term outcome may be superior following EX/RP than following serotonergic medications, after discontinuation. For patients who remain on medications, the treatment produced benefits equivalent to EX/RP.     

D-Cycloserine for Treatment Nonresponders With Obsessive-Compulsive Disorder: A Case Report

Despite being the most effective treatment available, as many as one third of patients who receive exposure and response prevention (ERP) for obsessive-compulsive disorder (OCD) do not initially respond to treatment. Recent research suggests that the n-methyl d-aspartate (NMDA) receptor partial agonist D-Cycloserine (DCS) may speed up the course of ERP for OCD rather than enhance it. Thus, it is unclear whether DCS would benefit patients who have proven nonresponsive to ERP and serotonin reuptake inhibitors. The present study evaluated the ability of DCS to enhance ERP for 2 patients with OCD who previously had failed to show adequate response to treatment using time-series analysis. Both patients experienced greater reductions with DCS augmented ERP than they did with prior treatment; however, 1 patient relapsed by the 1-month follow-up. DCS augmented ERP might be an effective method for boosting outcomes in individuals who do not readily respond to ERP.     

Die stationäre Behandlung von Zwangsstörungen mit multimodaler Verhaltenstherapie

The results of a 1-year-follow-up study concerning the treatment of 30 in-patients suffering from obsessive-compulsive disorder (OCD) are presented. This prospective study was carried out at the Psychosomatic Hospital Windach. Beside a multimodal setting the central treatment component was flooding and response prevention. Group analysis showed significant improvements in all measures (BDI, STAI-X1, Y-BOCS and self-ratings). The results of the follow-up indicate, that more than 70% of the patients maintained their positive treatment response over 1 year (symptom improvement >30%). The average reduction of symptoms was 42%. Average treatment duration was 12 weeks. A high initial depression score (BDI >18) predicted a worse outcome.     

Community treatment of severe, refractory obsessive-compulsive disorder

Despite the existence of effective psychological and pharmacological interventions for obsessive-compulsive disorder (OCD), there are a large proportion of individuals for whom intervention is not effective. The study reports on the results of a community treatment service for individuals with treatment-refractory OCD who have not benefitted from previous cognitive behavioural or pharmacological treatment by community mental health services. A total of 205 individuals accepted for treatment by a specialist community OCD treatment service in London were provided with a combination of behavioural, cognitive, and pharmacological treatment within a specialist OCD service, with 158 completing treatment. Treatment was associated with significant reduction in clinician-rated and self-reported OCD symptoms after 12 weeks, with further reductions in OCD symptoms over a subsequent 12-week period. A significant reduction in symptoms of depression was also observed after 12 and 24 weeks. Approximately 40% of individuals treated experienced clinically significant improvement in their symptoms, with approximately 10% deemed to have recovered by the end of treatment. Our results add to previous research into refractory OCD, and provide support for the existence of specialist community treatment services which may provide assistance to individuals who have not responded to previous treatment.     

Change in metacognitions predicts outcome in obsessive–compulsive disorder patients undergoing treatment with exposure and response prevention

Wells' (Wells, A. (1997). Cognitive therapy of anxiety disorders: a practice manual and conceptual guide. Chichester, UK: Wiley) metacognitive model of obsessive–compulsive disorder (OCD) predicts that metacognitions must change in order for psychological treatment to be effective. The aim of this study was to explore: (1) if metacognitions change in patients undergoing exposure treatment for OCD; (2) to determine the extent to which cognitive and metacognitive change predicts symptom improvement and recovery. The sample consisted of 83 outpatients with a diagnosis of OCD who completed exposure and response prevention treatment. The Yale–Brown Obsessive–Compulsive Scale (Y-BOCS), the Metacognitions Questionnaire (MCQ-30) and the Obsessive Beliefs Questionnaire (OBQ-44) were administered before treatment, after treatment, and at 12-month follow-up. Treatment resulted in significant changes in symptoms, metacognition score, responsibility and perfectionism. Regression analysis using post-treatment Y-BOCS as the dependent variable indicated that when the overlap between predictors was controlled for, only changes in metacognition were significant. Changes in metacognitions explained 22% of the variance in symptoms at post-treatment when controlling for pre-treatment symptoms and changes in mood. A further regression revealed that two MCQ-30 subscales made individual contributions. The patients had significantly higher scores compared to community controls on the MCQ-30. Patients who achieved clinical significant change had lower scores on the MCQ-30 compared to patients who did not change. The results did not change significantly from post-treatment to follow-up assessment. These findings provide further support for the importance of metacognitions in treating OCD.     

The Treatment of Mental Contamination: A Case Series

The recommended treatment for obsessive-compulsive disorder (OCD) is cognitive behavior therapy (CBT) incorporating exposure and response prevention (ERP), which is effective for approximately 50% of patients. However, there has been little advance in treatment outcomes since the introduction of ERP in 1979. It has been suggested that some progress can be made in treating contamination obsessions and washing compulsions by addressing feelings of dirtiness and contamination that arise without physical contact with a tangible contaminant. To date, the treatment of these “mental contamination” fears in OCD has not been systematically explored. This paper reports on a case series of 12 participants with OCD who received 10 to 20 sessions of a CBT-based treatment for mental contamination. At the end of treatment, 7 participants no longer met the diagnostic criteria for OCD and mental contamination and these gains were maintained at 6-month follow-up. The clinical implications of these findings are discussed.     

Pharmacological treatment of childhood obsessive-compulsive disorder: from theory to practice

Discusses pharmacological treatment of childhood obsessive-compulsive disorder (OCD), chronic and underrecognized psychiatric condition that affects up to 2% to 3% of children and adolescents. Research in OCD in children, including neuropharmacology, brain imaging, genetics, and clinical phenomenology, informs current views of OCD pathophysiology. Contemporary research supports the notion of a dysregulation in serotonin subsystems in the central nervous system, with target areas of dysfunction including basal ganglia and orbitofrontal cortex. Pharmacotherapy, along with cognitive-behavioral approaches, constitutes the indicated treatment for childhood OCD. Pharmacological treatment is best guided by a phenomenological understanding of the type of obsessions and compulsions, the intensity and frequency of their presentation with attention to behavioral reinforcements, and psychosocial factors that affect the course of the disease. Serotonin-enhancing agents, such as fluoxetine, fluvoxamine, paroxetine, and sertraline and citalopram (SSRIs) are first-line pharmacological agents, whereas refractory symptoms can be treated by augmentation with neuroleptics or other agents. Clomipramine is as effective as the SSRIs but its use may be accompanied by increased side effects. Genetic factors probably influence susceptibility to OCD as well as response to treatment, and the elucidation of these and other risk factors will be important elements in the future understanding and treatment of this disorder.     

The impact of pretrauma analogue GAD and posttraumatic emotional reactivity following exposure to the September 11 terrorist attacks: a longitudinal study

The relation between analogue generalized anxiety disorder (GAD) assessed the day before the events of September 11, 2001 (9/11) and long-term outcome was examined in 44 young adults who were directly exposed the following day to the terrorist attacks in New York City. After controlling for high exposure to the attacks, preattack analogue GAD was associated with greater social and work disability, loss of psychosocial resources, anxiety and mood symptoms, and worry, but not symptoms of posttraumatic stress, assessed 12 months after 9/11. Fear and avoidance of emotions assessed 4 months after 9/11 statistically mediated the relation between preattack analogue GAD and social and work disability, loss of psychosocial support, mood and anxiety symptoms, and worry at 12-month follow-up. Avoidance of emotions 4 months after 9/11 also mediated the relation between preattack analogue GAD and posttraumatic stress symptoms 12 months after 9/11.     

Treating Obsessive-Compulsive Disorder in Intimate Relationships: A Pilot Study of Couple-Based Cognitive-Behavior Therapy

Although cognitive-behavioral therapy (CBT) involving exposure and response prevention (ERP) is an established treatment for obsessive-compulsive disorder (OCD), not all patients respond optimally, and some show relapse upon discontinuation. Research suggests that for OCD patients in close relationships, targeting relationship dynamics enhances the effects of CBT. In the present study, we developed and pilot tested a 16-session couple-based CBT program for patients with OCD and their romantic partners. This program included (a) partner-assisted ERP, (b) techniques targeting maladaptive relationship patterns focal to OCD (e.g., symptom accommodation), and (c) techniques targeting non OCD-related relationship stressors. OCD, related symptoms, and relationship functioning were assessed at baseline, immediately following treatment (posttest), and at 6- and 12-month follow-up. At posttest, substantial improvements in OCD symptoms, relationship functioning, and depression were observed. Improvements in OCD symptoms were maintained up to 1 year. Results are compared to findings from studies of individual CBT for OCD and discussed in terms of the importance of addressing interpersonal processes that maintain OCD symptoms.     

Teilstationäre Psychotherapie

Psychotherapeutic day clinics increasingly take over responsibility for the treatment of patients who cannot be cared for satisfactorily, respectively, at all in an inpatient setting. Psychotherapy in a day clinic setting is a treatment in its own right which has progressively established itself between inpatient and outpatient treatment. Empirically raised up to date data prove the efficacy and the efficiency of psychotherapeutic treatment in day clinics. Accordingly, the goal of the present study is to investigate the outcomes of psychotherapeutic treatment in a day clinic with a psychodynamic concept. Since 1996 the psychotherapeutic day clinic Basel empirically assesses the treatment course of all admitted patients. Patients and therapists fill in questionnaires upon admittance, two months into the course of treatment and upon discharge (SCL-90-R, PSKB-Se-R, OPD etc.) Our results indicate that significant improvements of symptoms as well as of socio-communicative competency can be achieved during treatment which remain stable even after discharge (first follow-up three months after discharge). Comparing outcome data of patients treated in full-time inpatient setting and of patients who undergo partial hospitalization we found that outcome was at least equivalent. Additionally we found that the diagnosis of a personality disorder influenced treatment results significantly in some symptom specific spheres.     

A standardized behavioral group treatment program for obsessive-compulsive disorder: preliminary outcomes

This paper provides outcome data about the efficacy of a behavioral group therapy program for obsessive-compulsive disorder (OCD). Thirty-six patients completed a 7-week outpatient treatment program which provides: (1) education about OCD and its treatment, (2) instruction in a cognitive and behavioral approach to the self-treatment of OCD and (3) guided behavioral treatment. Significant improvement in obsession, compulsion, and depression scores were observed at completion of the group and at 3 month follow-up. Significant improvement in obsessions and compulsions was observed for both patients taking anti-obsessional medications and those who did not.     

Cognitive behavior therapy in treatment-naive children and adolescents with obsessive-compulsive disorder: an open trial

This work aims is to evaluate the therapeutic efficacy of cognitive behavior therapy (CBT) in pediatric patients with obsessive-compulsive disorder (OCD) who had not previously been treated with either pharmacotherapy or psychotherapy and who remained medication-free during CBT. Sixteen OCD outpatients, 8-17 years of age, were treated in a 12-week open trial with manualized CBT. Target symptoms were rated at two-week intervals with the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), the National Institute of Mental Health Global Obsessive-Compulsive Scale (NIMH Global), the Clinical Global Impression Scale (CGI), and the Hamilton Anxiety Rating Scale (Ham-A). Statistical analyses showed a significant benefit for treatment. Ten patients experienced at least a 50% reduction in symptoms on the CY-BOCS; seven were asymptomatic on the NIMH Global. These results build on previous reports that CBT may be effective in the acute treatment of pediatric OCD. Further, the results of this study suggest that CBT can be efficacious in alleviating OCD symptoms in the absence of pharmacotherapy. These results must be considered preliminary, given the small sample size and open administration of treatment.     

Adapting Mindfulness-based Stress Reduction for the Treatment of Obsessive-compulsive Disorder: A Case Report

Obsessive-compulsive disorder (OCD) is an illness characterized by intrusive and distressing thoughts, images, or impulses (i.e., obsessions) and by repetitive mental or behavioral acts (i.e., compulsions) performed to prevent or reduce distress. Efficacious treatments for OCD include psychotropic medications and exposure and response prevention (EX/RP). The following case report presents an individual diagnosed with OCD who refused treatment with medication or EX/RP and was treated using an adapted Mindfulness-Based Stress Reduction (MBSR) program. After an 8-week adapted MBSR program, the endpoint evaluation revealed clinically significant reductions in symptoms of OCD as well as an increased capacity to evoke a state of mindfulness. Discussion includes generalizability of these findings, potential mechanisms of action, and the role of an adapted MBSR in the treatment of OCD.     

Cognitive Mediation of Symptom Change in Exposure and Response Prevention for Obsessive-Compulsive Disorder

This study examined cognitive mediators of symptom change during exposure and response prevention (EX/RP) for obsessive–compulsive disorder (OCD). Based on cognitive models of OCD, obsessive beliefs were hypothesized as a mediator of symptom change. Participants were 70 patients with primary OCD receiving EX/RP either as part of a randomized controlled trial (n = 38) or in open treatment following nonresponse to risperidone or placebo in the same trial (n = 32). Blinded evaluations of OCD severity and self-report assessments of three domains of obsessive beliefs (i.e., responsibility/threat of harm, importance/control of thoughts, and perfectionism/intolerance of uncertainty) were administered during acute (Weeks 0, 4 and 8) and maintenance treatment (Weeks 12 and 24). Study hypotheses were examined using cross-lagged multilevel modeling. Contrary to predictions, the obsessive beliefs domains investigated did not mediate subsequent OCD symptom reduction. In addition, OCD symptoms did not significantly mediate subsequent change in obsessive beliefs. The present study did not find evidence of cognitive mediation during EX/RP for OCD, highlighting the need to investigate other plausible mediators of symptom improvement.     

Behavioural group therapy for obsessive-compulsive disorder in Norway. An open community-based trial

The aim of the current study was to test the effectiveness of ERP-based 12 weeks group therapy for OCD patients in a community-based, general Norwegian outpatient clinic. The sample consisted of 54 patients diagnosed with OCD. The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the Beck Depression Inventory (BDI) and the Spielberger State Anxiety Inventory (STAI-S) were administered before treatment, after treatment and at 3- and 12-month follow-ups. Analyses with mixed models for repeated measurements showed that group behavioural therapy offered to OCD patients significantly improved ratings of obsessive-compulsive symptoms, depression and anxiety. These improvements were maintained at 3- and 12-month follow-ups and an additional reduction in obsessive-compulsive symptoms was observed from post-treatment to 3-month follow-up. However, the delayed effect of therapy was no longer present at 12-month follow-up. The results also revealed that the patients had a lower chance for an increased outcome category (e.g. from unchanged to improved or recovered) with high scores on STAI-S at the given observation times (post-treatment, 3- and 12-months follow-ups). Depressive symptoms (BDI) at post-treatment and follow-ups had no significant influences on the three categories of outcome for OCD. In conclusion, the results indicate that behavioural group therapy can successfully be delivered to patients with considerable comorbidity in a real world setting conducted by therapists with limited training in the CBT.     

Remote treatment of bulimia nervosa and binge eating disorder: a randomized trial of Internet-assisted cognitive behavioural therapy

The present study investigated the efficacy of self-help based on cognitive behaviour therapy in combination with Internet support in the treatment of bulimia nervosa and binge eating disorder. After confirming the diagnosis with an in-person interview, 73 patients were randomly allocated to treatment or a waiting list control group. Treated individuals showed marked improvement after 12 weeks of self-help compared to the control group on both primary and secondary outcome measures. Intent-to-treat analyses revealed that 37% (46% among completers) had no binge eating or purging at the end of the treatment and a considerable number of patients achieved clinically significant improvement on most of the other measures as well. The results were maintained at the 6-month follow-up, and provide evidence to support the continued use and development of self-help programmes.     

Stepped care for obsessive-compulsive disorder: An open trial

This study evaluated the effectiveness and treatment costs associated with a stepped care protocol of exposure and response prevention (EX/RP) for obsessive-compulsive disorder (OCD). In the current open trial, patients (N = 14) began with self-directed EX/RP and minimal therapist guidance over the course of six weeks (Step 1). During this phase of treatment, no therapist-directed exposures were conducted. Those who did not respond optimally to Step 1 went on to Step 2, which consisted of 15 sessions of twice-weekly therapist-directed exposures. Results of this study show promise for stepped care utilizing EX/RP for some patients with OCD, with a response rate of 88% and a 60% reduction on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score among treatment completers. Significant improvements were found in Y-BOCS from pre to post-treatment for both Step 1 and Step 2 completers. Forty-five percent of participants (n = 5) responded following completion of Step 1, resulting in reduced cost of treatment among these participants. All participants who responded to Step 1 maintained acute gains during the brief follow-up period. Limitations include a small sample size and high attrition rate.     

Efficacy and predictors of long-term treatment success for Cognitive-Behavioral Treatment and Behavioral Weight-Loss-Treatment in overweight individuals with binge eating disorder

ObjectiveThe aim of the study was to assess the long-term efficacy of Cognitive-Behavioral Treatment (CBT) and Behavioral Weight-Loss-Treatment (BWLT) in patients with binge eating disorder (BED) and to identify potential predictors of long-term treatment success.MethodIn a sample of overweight to obese BED patients from a randomized comparative trial we evaluated the efficacy of four months of CBT or BWLT, followed by 12 months extended care, and a final follow-up assessment 6 years after the end of active treatment. Outcomes included binge eating, eating disorder pathology, depressive feelings, and body mass index.ResultsAfter a strong improvement during active treatment, outcomes worsened during follow-up, yet remained improved at 6-year follow-up relative to pretreatment values. Long-term effects between CBT and BWLT were comparable. Rapid response during the early treatment phase was the only characteristic that was predictive of favorable treatment outcome in the long term.ConclusionsBoth CBT and BWLT can be considered to be comparably efficacious in the long-term. Patients not responding strongly enough during the first four therapy sessions might be in need of tailored interventions early during the treatment phase.     

Emotional responsiveness and obsessive-compulsive behaviour

Abstract

Several clinicians have proposed that patients with obsessive-compulsive disorder (OCD) are unusually sensitive to unpleasant events. We tested a non-clinical sample of obsessive-compulsive (O-C) subjects who reported in diagnostic interviews that they experienced significant problems with obsessions and/or compulsions. Excerpts from three emotion-eliciting films were shown to 10 O-C males, 12 O-C females, 12 normal males, and 12 normal females. Emotional response was measured by using a self-report instrument and by recording facial expressions, which were coded for both appropriate emotional reactions as well as reactions that may represent efforts to mask or control the display of negative emotion. The groups did not differ with regard to subjective response to the film clips, but facial responses indicated that O-C subjects made more efforts to suppress the expression of fear (inappropriate smiles/laughs) during the frightening film clip. In spite of these responses, male O-C subjects also tended to reveal more frightened facial expressions than male control subjects. This finding is believed to illustrate one component of a model in which exaggerated emotional response is a precursor to the development of OCD.     

Could Treatment Matching Patients’ Beliefs About Depression Improve Outcomes?

Patients’ beliefs about depression and expectations for treatment can influence outcomes of major depressive disorder (MDD) treatments. We hypothesized that patients with weaker biological beliefs (less endorsement of [a] biochemical causes and [b] need for medication) and more optimistic treatment expectations (greater improvement and shorter time to improvement), have better outcomes in cognitive therapy (CT). Outpatients with recurrent MDD who received acute-phase CT (N = 152), and a subset of partial or unstable responders (N = 51) randomized to 8 months of continuation CT or fluoxetine with clinical management, completed repeated measures of beliefs, expectations, and depression. As hypothesized, patients with weaker biological beliefs about depression, and patients who expected a shorter time to improvement, experienced greater change in depressive symptoms and more frequent response to acute-phase CT. Moreover, responders who received continuation treatment better matched to their biological beliefs (i.e., responders with weaker biological beliefs about depression who received continuation CT, or responders with stronger biological beliefs about depression who received continuation fluoxetine) had fewer depressive symptoms and less relapse/recurrence by 32 months after acute-phase CT than did responders who received mismatched continuation treatment. Specific screening and/or intervention targeting patients’ biological beliefs about depression could increase CT efficacy.