Cognitive behavioural therapy in the treatment of pure obsessional obsessive-compulsive disorder

Is Compulsive Hoarding a Genetically and Neurobiologically Discrete Syndrome? Implications for Diagnostic Classification

Although standard diagnostic classifications consider obsessive-compulsive disorder (OCD) to be a single diagnostic entity, it has become clear that it is a heterogeneous disorder, with great variability in clinical presentation. This heterogeneity has complicated the interpretation of clinical, neurobiological, and genetic studies in OCD. Therefore, researchers have sought to identify clinically meaningful phenotypes that might be more homogeneous and heritable to facilitate our understanding of the etiology and pathophysiology of OCD and ultimately lead to improved treatments (1). Factor analytic studies have consistently identified four principal OCD symptom dimensions: 1) harm-related, aggressive, sexual, and religious obsessions with checking compulsions; 2) symmetry obsessions with arranging and repeating compulsions; 3) contamination obsessions with cleaning compulsions; and 4) hoarding and saving symptoms (1, 2). These symptom factors are relatively stable over time and show different patterns of genetic inheritance, age at onset, comorbidity, and treatment response (see 1 for review). Cluster analyses, which seek to identify mutually exclusive, categorical subgroups, indicate that some of these symptom factors, such as hoarding, may constitute discrete subtypes of OCD (3, 4). Hoarding is defined as the acquisition of and inability to discard items, even though they appear (to others) to have no value (5). Hoarding behavior has been observed in several neuropsychiatric disorders, including schizophrenia, dementia, eating disorders, autism, and mental retardation, as well as in non-clinical populations, but it is most commonly found in OCD (6). 30% to 40% of OCD patients report hoarding and saving symptoms (6–8), and about 10% to 15% have hoarding as their most prominent symptom factor (3, 6). Compulsive hoarding is most commonly driven by obsessional fears of losing important items that the patient believes will be needed later, distorted beliefs about the importance of possessions, excessive acquisition, and exaggerated emotional attachments to possessions (5). Compulsive hoarding and saving leads to clutter that can cover living and work spaces, rendering them unusable. Hoarding frequently causes significant impairment in social and occupational functioning. In severe cases, it can produce health risks from infestations, falls, fires, and inability to cook or eat in the home (6). In this issue of the Journal, Jack Samuels, Ph.D., et al. report results from the OCD Collaborative Genetics Study, finding “suggestive” linkage of compulsive hoarding to a marker on chromosome 14 in families with OCD. The linkage became stronger when only families with two or more family members with compulsive hoarding were tested. Compulsive hoarding is well known to run in families. Hoarding behaviors are significantly more prevalent in the relatives of hoarding OCD patients than nonhoarding OCD patients (9). In the OCD Collaborative Genetics Study, hoarding was the most strongly familial of the OCD symptom factors, with robust correlations among sibling pairs (10). Only two previous genetic studies have examined the hoarding phenotype. Lochner et al. (8) found that the met/met (L/L) genotype of the catechol O-methyltransferase val158met polymorphism on chromosome 22q11 was significantly more prevalent in Afrikaner OCD patients with

Participants of expert group on CPG for Obsessive Compulsive Disorder Adarsh Tripathi, Om Prakash Singh, Paramjeet Singh, Tushar Jagawat, M, Aleem Siddiqui, K.K. Verma, D.M. Mathur INTRODUCTION Obsessive-compulsive disorder (OCD) is a common psychiatric illness with lifetime prevalence of 1-3% [1]. It is the fourth-most common psychiatric illness and a leading cause of disability. OCD is associated with significant impairment in functioning, quality of life and disability. If untreated, OCD is a chronic illness with a waxing and waning of symptoms. A recent meta-analysis of long-term naturalistic prospective studies demonstrated that nearly a half of patients experience remission with much higher rates of remission in Indian patients compared to those in the west [2]. Early diagnosis and appropriate treatment may improve outcomes. Despite OCD being a common mental illness, most seek treatment after several years of suffering. Those who suffer from OCD tend to be secretive about their symptoms and suffer from shame and embarrassment. Less than a third of OCD sufferers receive appropriate pharmacotherapy and even less receive evidence-based psychotherapy. Symptoms The hallmarks of OCD are presence of obsessions and compulsions. Obsessions are repetitive, unwanted, intrusive thoughts, images or urges that are mostly ego-dystonic and cause severe distress or anxiety. Compulsions (or rituals) are repetitive behaviours or mental acts that are performed in response to an obsession to reduce anxiety/distress or prevent a dreaded consequence. Obsessions and compulsions are time consuming, distressing and are often resisted unsuccessfully. Clinical manifestations of OCD are remarkably similar across cultures and geographic locations. Common obsessions and compulsions and symptom dimensions identified through factor-analytical studies are shown in Table 1.Table 1: Common symptoms of OCDDiagnosis Many people experience intrusive thoughts and exhibit repetitive behaviours. A diagnosis of OCD is made only if symptoms are time consuming (e.g., more than an hour per day), distressing or cause significant interference in functioning. This is reflected in DSM-5 diagnosis of OCD and in the upcoming ICD-11 [3]. The ICD-11 criteria for OCD are likely to be very similar to the DSM-5 criteria [34]. The ICD-11 may include an insight specifier along the same lines as DSM-5. There are sweeping changes to the description of OCD in the proposed ICD-11. Duration criteria and subtyping of OCD may be removed in the revision for lack of evidence and clinical relevance. In ICD-10, a diagnosis of OCD was discouraged in the presence of schizophrenia, tic disorder or depression. This criterion too may be removed paving the way to make a diagnosis of OCD even in the presence of these comorbid disorders. Another major change to the diagnosis of OCD is creation of OCD and related disorders in DSM-5 (and in the ICD-11) and exit from the group of anxiety disorders. Many disorders are included in this group: body dysmorphic disorder (BDD), trichotillomania (TTM), skin picking disorder, hoarding disorder, substance/medication-Induced obsessive-compulsive and related disorder and obsessive-compulsive and related disorder due to another medical condition. In the upcoming ICD-11, few other conditions find a place in this group that include tic disorders, hypochondriasis and olfactory reference syndrome. All these disorders are grouped together based on shared clinical features (e.g., repetitive behaviours), comorbidity patterns, familiality, neuropsychological deficits, treatment response and importantly shared brain circuitry abnormalities. Hoarding disorder which may not share many features with OCD is grouped along with OCD because of historical association with OCD and obsessive-compulsive personality disorder. Comorbidity OCD is often comorbid with other psychiatric disorders. It is important to assess all patients with OCD for associated psychiatric comorbidity since they may have an effect on treatment outcome if left untreated. Depression and anxiety disorders are present in over a half of patients seeking treatment for OCD. Common comorbid disorders are listed in Table 2. Those with early onset OCD, in particular those with onset in childhood have high rates of attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and tic disorders.Table 2: Comorbid disorders in OCDBipolar disorder, in particular type 2, is reported to be not uncommon in OCD [5]. Similarly, OCD is not uncommon in those with primary diagnosis of bipolar disorder [67]. OCD when comorbid with bipolar disorder tends to run an episodic course [8] with worsening of symptoms in depressive phases and improvement in hypomania/ mania phases. It is important to recognise OCD-bipolar comorbidity because of treatment implications. The specific serotonin-reuptake inhibitors (SSRIs) traditionally used to treat OCD may induce switch to mania or rapid cycling course. Obsessive-compulsive symptoms and OCD are not uncommon in schizophrenia. Nearly a third of schizophrenia patients report OC symptoms or OCD. Presence of OCD may have a negative effect on the long-term course of schizophrenia. Therefore treatment of OCD with SSRIs and cognitive-behavior therapy (CBT)/behavior therapy (BT) may have to be considered although there is not much of systematic evidence supporting their efficacy in treatment of OCD in schizophrenia. COMMON INGREDIENTS OF MANAGEMENT PLAN Common ingredients of managing OCD include the following: Detailed assessment of symptoms and comorbid patterns including suicidal behaviours either by unstructured clinical interview alone or supplementation with structured assessments. Decision on setting for treatment (outpatient vs. inpatient care depending upon the severity, treatment resistance etc.) Detailed psychoeducation of the patient and family member (s) about OCD, its course and treatment options including duration of treatment. Choice of treatment: drugs vs. CBT vs. combination In the Indian context, SSRIs are first-line treatments preferred over CBT because of feasibility, affordability and limited number of trained therapists. CBT may be considered if SSRIs alone are not beneficial. Discussion on side-effects of drugs; in women risks vs. benefits of drugs during pregnancy and in the post-partum period Follow-up plan after initiating treatment ASSESSMENT AND EVALUATION In routine clinical practice, use of structured / semistructured interviews and rating scales may not be necessary. They are optional. However, they may be used when the clinician needs supplementary information. A list of useful instruments in the assessment of OCD is provided in Table 3.Table 3: Commonly used instruments to assess OCD (optional)The Yale-Brown Obsessive-Compulsive Scale (YBOCS) is the most widely used severity rating scale for OCD in both adults [9] and children [10] and is considered a gold standard instrument to measure severity of OCD. It is a 10-item observer-rating scale, also available as self-rated instrument. It measures the overall severity of obsessive-compulsive symptoms for the preceding week. The YBOCS is a global measure of symptoms and does not provide severity of individual symptom dimensions. A total score of ≥ 16 is considered to be indicative of clinically significant OCD. The YBOCS severity scale also has an associated symptom check list of 15 categories of obsessions and compulsions including miscellaneous symptoms. The checklist elicits both current (1 month) and past symptoms. On the YBOCS item-11 insight scale, the insight is graded as follows: 0 = excellent (fully rational thinking), 1= good insight (readily acknowledges absurdity or excessiveness but has some lingering doubts), 2 = fair insight (reluctantly admits absurdity, but waivers; has some unrealistic fear but no fixed conviction), 3 = poor insight (overvalued ideas; maintains they are not unreasonable or excessive, but acknowledges validity of contrary evidence), and 4 = lack of insight (delusional). A higher score on the Y–BOCS item-11 indicates poorer insight. FORMULATING A TREATMENT PLAN Formulating a treatment begins with correct diagnosis of OCD as per the DSM or ICD classificatory systems. When feasible a structured clinical interview is recommended to obtain a comprehensive account of patient's problems. Once a diagnosis is established, a detailed assessment of symptom profile is mandatory. Family members often accommodate patient's rituals and contribute to poor outcome. In most severely ill patients, an elaborate family assessment may be needed. Once assessment is complete, short-term and long-term goals of treatment have to be established. Enhancing treatment adherence is a vital aspect of formulating a treatment plan. It is important to educate patients about lag in the onset of action of drugs and that improvement may occur over several months of continuous treatment. Brief education about basic principles of psychotherapy should be explained if psychotherapy is being planned. Essentials of formulating a treatment plan are summarized in Table 4. All patients and their immediate family members should be provided psychoeducation about OCD (Table 5).Table 4: Essentials of formulating a treatment planTable 5: Components of psychoeducationCHOICE OF TREATMENT SETTINGS In the Indian scenario, treatment is either on an outpatient or an inpatient basis. Outpatient treatment is usually sufficient for most OCD patients who are mild to moderately ill and for those who are likely to be adherent to treatment. Patients may be followed-up at periodic intervals, initially once in a month or two and subsequently at longer intervals depending upon the response to treatment and tolerability and side-effects. Hospital treatment may be considered for those who are at high suicide risk, dangerous to self or others, and intolerant to side-effects. Many severely ill and treatment-resistant patients may require prolonged (2-3 months) hospitalization for intensive treatment with CBT and for rationalization of pharmacotherapy. Inpatient care may also be required for severe depression, mania or psychosis that may be comorbid with OCD. Admission in rehabilitation services may be necessary for some patients who may not have benefited from standard treatments including inpatient care. PHARMACOLOGICAL TREATMENT The clinical practice guideline is framed based on a review of relevant scientific literature. As a first step, we framed relevant questions which arise in the minds of the practitioner while treating a patient suffering from OCD. A literature search was conducted in PubMed to answer these questions. We also reviewed the existing guidelines on treatment of OCD [11121314]. After a thorough literature review, the treatment strategies were rated based on the Strength of Recommendation Taxonomy (SORT) [15]. Consistent evidence from multiple randomized controlled trials (RCT) constitutes the highest level of evidence for a recommendation. However, the external validity of RCTs has been questioned due to the rigid protocols in undertaking the studies. A practitioner may make a clinical decision based on the available evidence considering other relevant factors that influence the decision making process. A non-exhaustive list of these factors might include psychiatric and other medical comorbidities, previous treatment trials, affordability, accessibility, hypersensitivity, side-effect profile, patients' values etc. RELEVANT CLINICAL ISSUES First-line pharmacological treatment for OCD Meta-analyses of RCTs show that selective-serotonin reuptake inhibitors (SSRIs) are significantly more effective than placebo in the treatment of OCD [16]. SSRIs are associated with many adverse effects but are usually well tolerated. The only other medication which has shown to be consistently effective in OCD is the serotoninergic tricyclic antidepressant clomipramine. Clomipramine has been found to be significantly more effective than placebo in multiple RCTs and meta-analysis of RCTs [16]. Network meta-analysis comparing the efficacy of clomipramine vs. SSRIs failed to find any efficacy advantage over SSRIs [16]. Most head-to-head comparison trials have not found any significant difference between the efficacy of clomipramine and SSRIs [17]. Further, meta-analyses and individual RCTs have found that the tolerability of clomipramine is worse than that of SSRIs [1317]. The anticholinergic, cardiac and neurological side effects of clomipramine may be problematic in this regard. CONSIDERING THE CONSISTENT EFFICACY AND BETTER TOLERABILITY, GUIDELINES RECOMMEND SSRIs AS FIRST LINE TREATMENT FOR OCD (TABLE 6). Choice of SSRITable 6: Medications recommended as monotherapy in OCDMeta-analyses comparing the different SSRIs [16] and direct head-to-head comparisons [1718] have not shown superiority of any one SSRI over the other. SSRIs differ to some extent in their propensity to cause certain adverse effects and drug interactions. However, there is no unequivocal evidence to suggest that these differences may be clinically meaningful. Recently, concerns have been raised regarding cardiac adverse effects with high dose of citalopram, which is commonly used in OCD. Hence, high-dose citalopram may be used with caution in those with risk for arrhythmias. THE PRACTITIONER IS RECOMMENDED TO CHOOSE AN SSRI FOR AN INDIVIDUAL PATIENT BASED ON FACTORS SUCH AS PREVIOUS RESPONSE, COMORBIDITY, TOLERABILITY, ACCEPTABILITY, ADVERSE EFFECTS, COST AND DRUG INTERACTIONS. Dose of SSRI It is generally recommended that OCD be treated with a higher dose of SSRI than that used in depression (Table 5). A meta-analysis of fixed-dose comparison studies have found a greater efficacy with higher doses of SSRI (60-80 mg fluoxetine equivalent) compared to medium (40-50 mg fluoxetine equivalent) and low doses (20-30 mg fluoxetine equivalent) [19]. However, all three dose ranges were significantly more effective than placebo. The increased efficacy comes at the cost of poor tolerability as evidenced by increased dropouts due to adverse effects [19]. A review of individual fixed-dose comparison studies found that the dose-response relationship is more evident for escitalopram, fluoxetine and paroxetine, while it is less clear-cut for citalopram and sertraline [17]. Clomipramine has not been tested in such fixed dose comparison studies. However, most studies have employed a flexible dosing at 150-250 mg [17]. It should be remembered that there is likely to be inter-individual differences in pharmacokinetic profile of drugs due to intrinsic variations in drug metabolism and drug interactions. GUIDELINES RECOMMEND TREATMENT OF OCD WITH HIGHER DOSE OF SSRIs. HOWEVER, IF AN INDIVIDUAL PATIENT IS NOT ABLE TO TOLERATE HIGHER DOSE, LOW TO MEDIUM DOSE TREATMENT CAN BE CONSIDERED. Duration of trial and dose titration A recent meta-analysis of 17 RCTs found that SSRIs separate from placebo as early as 2 weeks and that majority of improvement occurs early on in the course of treatment [20]. However, improvements seen early in the course of treatment may not be always clinically meaningful. In many patients, clinically meaningful improvements may be seen only after weeks or months of treatment. It is recommended that an adequate trial of a SSRI (or clomipramine) should be at least for 12 weeks to account for the lag in the onset of action. The APA guidelines recommend upward titration to the maximum FDA-approved doses by 4-6 weeks and continuation in that dose for another 6-8 weeks or so to determine efficacy [11]. Certain clinical and biological predictors of treatment response to SSRIs have been identified but they are not robust predictors (Table 7).Table 7: Predictors of response to SSRIsGUIDELINES RECOMMEND CONTINUING MAXIMALLY TOLERATED EFFECTIVE DOSE OF A SSRI FOR AT LEAST 12 WEEKS FOR JUDGING ITS EFFICACY. GUIDELINES ALSO RECOMMEND DOSE ESCALATION TO EFFECTIVE DOSE RANGES WITHIN 4-6 WEEKS AND CONTINUATION IN THE SAME DOSE FOR ANOTHER 6-8 WEEKS. 2. Other medications that can be tried as monotherapy in OCD Venlafaxine, a serotonin-norepinephrine reuptake inhibitor with preferential serotonergic action, has been studied in comparison to paroxetine in a double blinded study and clomipramine in a single blinded study. The studies found no difference in the efficacy between venlafaxine and the comparator agents in acute control of OCD. Given the absence of evidence from placebo-controlled trials, venlafaxine is not the first-line treatment for OCD. Hence, the guidelines consider venlafaxine as a second-line monotherapy agent in the treatment of OCD. Mirtazapine has been studied as a monotherapy in two small open-label trials with inconsistent findings. Therefore, mirtazapine cannot be recommended as monotherapy in treatment of OCD. 3. Treatment strategy for non-responders to first-line treatment Definitions of treatment outcome [21] are given in Table 8. Estimates suggest that around 40-70% patients show an adequate response to a trial of SSRI with a remission rate of 10-40% [16]. Clinicians often face the subsequent challenge of partial and non-response to SSRIs. Continuing improvement has been noticed with prolonged trial of SSRIs as discussed above. Hence, the initial trial may be continued further if there is evidence of ongoing improvement. A general treatment algorithm for OCD and for non-responders to SSRIs is shown in Figures 1 and 2 respectively.Table 8: Definitions of treatment outcome in OCDFigure 1: Treatment algorithm for treating a patient with OCD. *First line treatment chosen based on feasibility and severity of illness, #CBT/BT- Cognitive behavior therapy/Behavior therapy, @SSRI – Selective serotonin reuptake inhibitor, %rTMSrepetitive transcranial magnetic stimulation, $ - tDCS- transcranial direct current stimulation. ** Preferred for severe OCDFigure 2: Strategies for non-responders to SSRIs. SSRI-Selective serotonin reuptake inhibitors, CBT/BT-Cognitive behavior therapy/behavior therapy, rTMS- repetitive transcranial magnetic stimulationa. Switching to another medication Switching to another first-line medication has been found to be effective; experts provide a rough estimate of 40-50% response rate for the second SSRI and decreasing response rates with further trials. Switching to a second SSRI is suggested for non-responders to a first SSRI. In partial responders, changing medication may entail loss of the response to the earlier medication. Hence, switching is recommended in partial responders only if there are severe persisting symptoms or upon failure of other augmenting strategies such as CBT and atypical antipsychotics. b. Switching / Augmenting with CBT/BT It is uncertain whether initiating a combination of BT/CBT simultaneously with SSRI is advantageous compared to either treatment alone. However, CBT/BT has been proven to be effective as an augmenter in partial/non-responders to SSRIs [182223]. Where feasible, CBT/BT is a potential first-line augmenting option for partial/non-responders to SSRI treatment. c. Augmenting with another medication (Table 9)Table 9: Pharmacological augmenting agents in medications have been commonly tried as to SSRIs. and have the are the most widely studied augmenting agents of SSRIs The literature on is with including small doses and duration of treatment with both and of treatment resistance etc. recent meta-analyses of RCTs on found that as a group was significantly more effective than placebo in decreasing YBOCS a third of patients to and are consistently found to be effective as augmenting The evidence for should be with caution as it was based on a single study. A comparing and placebo of SSRI found that not separate from placebo in augmenting efficacy This study has raised questions on the efficacy of as an and have not been consistently found to be while other have not been studied Meta-analyses not any on adequate dose and duration of treatment should be used in low doses (e.g., mg of mg for a period of at least weeks for an adequate of in the should be considered after the benefits and risks of long-term BASED ON THE AND BE THE FIRST FOR PHARMACOLOGICAL agents There is a supporting the use of drugs in OCD. The agents have been studied in OCD found effective in 2 double blinded and one single blinded found effective in 2 double blinded RCTs effective in 2 small but inconsistent in two RCTs from three has to be studied BASED ON THE AND ITS BETTER TOLERABILITY, IS AS THE FIRST agents including and are reported to be effective and well in small RCTs However, due to the of the individual are recommended as second line augmenting agents along with evidence that clomipramine can be an effective augmenting Clomipramine and SSRI combination should be used with fluoxetine and as they may clomipramine related adverse effects cardiac serotonin due to pharmacokinetic interactions. Clomipramine of SSRI may be tried but adequate to be in the potential adverse effects of the Mirtazapine has been found to the response with no significant benefits and may be considered as an augmenting agent in partial responders and Other augmenting agents and have not been found effective and are not recommended as augmenting The and efficacy of and drugs have to be studied they are recommended for routine clinical has been found to have acute effects in a which needs and the strategy can be recommended for routine clinical Other strategies there to be some short-term benefits for clomipramine in treatment patients, the benefits are This is not available in and is not recommended at present for clinical There are a few trials the of higher than recommended doses of SSRIs to mg of mg of in This strategy should be considered and may be used only in patients after other OF of patients not to available pharmacological and and treatments the have been tried in has not been for the treatment of OCD. in the of and not provide evidence for the efficacy of Hence, is not recommended as a treatment for OCD and may be considered for the treatment of comorbid conditions severe and disorders, if 2. transcranial magnetic the of and of or decreasing their based on the of stimulation. The in OCD are usually not with available of has been tried in which have with other in OCD. trials of low or high over either have but low over supplementary and However, the evidence has not been very the have to be in with There is no evidence that effects for longer than the trial The guideline as an for further and not for routine clinical 3. direct current is another and which either or the of the depending on the of the There are only a few and an open-label trial on in OCD. It has to be more it can be recommended for clinical use in OCD. in specific of the which is to be in OCD. can be with the of or with the of and a of as are in treatment OCD in a few to the these are generally employed in treatment patients (Table in the of studies that around of patients improve over months There is some that may be more effective in OCD and that its efficacy may be similar to that of brain may be associated with short-term and adverse effects including personality and adverse effects although rates are not criteria for brain brain is a high of in the the of action is it is to for OCD has been in controlled studies of and A recent meta-analysis found a rate of with a YBOCS of around is an and is associated with and adverse Further, the needs to be which may be can be recommended in OCD patients (Table after regarding the and of the The are not in and the are only one aspect of a comprehensive treatment which should may be considered only in patients after of patients for treatment severity of illness and Patients should be explained about the of benefits and They should be by an of a a and a for for The treatment should be conducted of a of and with of adverse criteria for to are shown in Table FOR OCD (TABLE Cognitive / and in has been shown to be in the treatment of OCD All treatment guidelines have suggested the use of CBT as a first-line treatment CBT for OCD is a first-line treatment option for OCD. is the most important of CBT along with When are monotherapy may be recommended in mild to moderately ill In severely ill patients a combination of CBT and SSRI is CBT as an strategy It is uncertain whether initiating a combination of and SSRI is advantageous compared to either treatment alone. However, CBT/BT is found to be effective in augmenting SSRIs in partial/non-responders to SSRIs [34]. A recent study found CBT to be to and placebo in augmenting SSRIs in OCD Patients in the CBT group

Although standard diagnostic classifications consider obsessive-compulsive disorder (OCD) to be a single diagnostic entity, it has become clear that it is a heterogeneous disorder, with great variability in clinical presentation. This heterogeneity has complicated the interpretation of clinical, neurobiological, and genetic studies in OCD. Therefore, researchers have sought to identify clinically meaningful phenotypes that might be more homogeneous and heritable to facilitate our understanding of the etiology and pathophysiology of OCD and ultimately lead to improved treatments (1). Factor analytic studies have consistently identified four principal OCD symptom dimensions: 1) harm-related, aggressive, sexual, and religious obsessions with checking compulsions; 2) symmetry obsessions with arranging and repeating compulsions; 3) contamination obsessions with cleaning compulsions; and 4) hoarding and saving symptoms (1, 2). These symptom factors are relatively stable over time and show different patterns of genetic inheritance, age at onset, comorbidity, and treatment response (see 1 for review). Cluster analyses, which seek to identify mutually exclusive, categorical subgroups, indicate that some of these symptom factors, such as hoarding, may constitute discrete subtypes of OCD (3, 4). Hoarding is defined as the acquisition of and inability to discard items, even though they appear (to others) to have no value (5). Hoarding behavior has been observed in several neuropsychiatric disorders, including schizophrenia, dementia, eating disorders, autism, and mental retardation, as well as in non-clinical populations, but it is most commonly found in OCD (6). 30% to 40% of OCD patients report hoarding and saving symptoms (6–8), and about 10% to 15% have hoarding as their most prominent symptom factor (3, 6). Compulsive hoarding is most commonly driven by obsessional fears of losing important items that the patient believes will be needed later, distorted beliefs about the importance of possessions, excessive acquisition, and exaggerated emotional attachments to possessions (5). Compulsive hoarding and saving leads to clutter that can cover living and work spaces, rendering them unusable. Hoarding frequently causes significant impairment in social and occupational functioning. In severe cases, it can produce health risks from infestations, falls, fires, and inability to cook or eat in the home (6). In this issue of the Journal, Jack Samuels, Ph.D., et al. report results from the OCD Collaborative Genetics Study, finding “suggestive” linkage of compulsive hoarding to a marker on chromosome 14 in families with OCD. The linkage became stronger when only families with two or more family members with compulsive hoarding were tested. Compulsive hoarding is well known to run in families. Hoarding behaviors are significantly more prevalent in the relatives of hoarding OCD patients than nonhoarding OCD patients (9). In the OCD Collaborative Genetics Study, hoarding was the most strongly familial of the OCD symptom factors, with robust correlations among sibling pairs (10). Only two previous genetic studies have examined the hoarding phenotype. Lochner et al. (8) found that the met/met (L/L) genotype of the catechol O-methyltransferase val158met polymorphism on chromosome 22q11 was significantly more prevalent in Afrikaner OCD patients with

Practice Parameter for the Assessment and Treatment of Children and Adolescents With Obsessive-Compulsive Disorder

Forming a Doctor-Patient Alliance During COVID-19 to Enhance Treatment Outcomes for Obsessive-Compulsive Disorder.

Decision letter: Characterizing a psychiatric symptom dimension related to deficits in goal-directed control

When a patient presents with both psychotic and obsessive-compulsive symptoms, the clinician is faced with a differential diagnosis that includes comorbid schizophrenia and obsessive-compulsive disorder (OCD), OCD with poor insight, and schizophrenia with antipsychotic-induced obsessive-compulsive symptoms. If the psychotic symptoms are subthresh-old or attenuated in form, the individual may have OCD and putative prodromal schizophrenia. The authors present a case to outline a strategy for differentiating among these possible diagnoses and for optimizing treatment.

Roughly, six million Americans are afflicted with Obsessive-Compulsive Disorder (OCD). As clinicians are well aware that OCD is often an extremely serious and emotionally crippling disease. Overcoming Obsessive Thoughts by Christine Purdon and David A. Clark is a book designed to assist the sufferers of OCD overcome their obsessions and compulsions by having the reader participate in various activities that, the authors recommend, span a six to eight week period. Their approach is based on Cognitive Behavioral Therapy (CBT) focusing on exposure plus response prevention and how to change one's thoughts about their obsessions while not engaging in any neutralizing acts. Exposure and response prevention is the treatment of choice for OCD (Huppert & Roth, 2003; Abramowitz & Kalsy, 2001) with large clinically significant outcomes (Abramowitz, 1998). The treatment of OCD with behavioral methods has been found to be a well-established treatment (Task Force on Promotion and Dissemination of Psychological Procedures, 1995). Several-self help manuals based on CBT already exist; however, this book makes a very coherent argument as to why it is the compulsive strategies people with develop for coping with obsessive thoughts are counterproductive. Acceptance of thinking behavior is a form of response prevention and can facilitate therapeutic exposure. In addition, the book is very reader friendly. To help the reader establish a sense of normalcy, the authors assure the reader that obsessive thoughts are a part of every person's lives however; the difference lies in the interpretations of those thoughts by the person experiencing them. For example, the authors talk about the case of Neema who has a thought of swerving into the next lane of traffic and reacts by telling herself that she is not the type of person who do such a thing as compared to Ravi who has the same thought and decides not to continue to drive and thinks himself to be a murderous person at heart. In fact, Ravi will go to extremes to avoid the possibility of his acting out his thought. The book lays out several activities in which the reader can do to help them overcome their OCD and provides several examples for illustration purposes. The activities require nothing more than a notebook and the time invested in taking control of ones OCD. In the notebook, the reader is often requested to items such as characteristics of obsessions, compulsions, and control strategies on a numerical scale or a scale indicating most discomfort or least discomfort. The book is easy to read and follow with two chapters dedicated to specific types of obsessions and compulsions: ones of harm, violence and sex, and ones of a religious nature. This book begins, after giving the reader background information on OCD by having the reader complete a symptom profile of their obsessive compulsive thoughts in order to prepare the reader to better be able to understand and complete the exercises in this book. This is broken down into two steps: identifying the behavioral component and the cognitive component. Both components require the reader to complete two exercises that do not take up too much time. This profiling is a necessary step as it helps the reader identify the behavioral and cognitive aspects of their OCD and in helping the reader to identify the most troubling obsessions first. This is an important task, since the reader is looking for relief of OCD symptoms, it necessary to begin with the most troubling obsessions. The reader is introduced to an explanation of obsessive compulsive cycle that occurs when one begins to experience the obsessive thought and the hypersensitivity that occurs due to the initiation of the neutralizing, compulsion, or avoidance tactics and how this cycle can continue unless one is willing to change their thought patterns about the obsession. The heart of the book is geared to learning the skills to combat OCD. …

Contents: Preface. Part I: Clinical Subtypes and Spectrum. E. Hollander, C.M. Wong, Spectrum, Boundary, and Subtyping Issues: Implications for Treatment-Refractory Obsessive-Compulsive Disorder. K.A. Phillips, Connection Between Obsessive-Compulsive Disorder and Body Dysmorphic Disorder. J.F. Leckman, C.J. McDougle, D.L. Pauls, B.S. Peterson, D.E. Grice, R.A. King, L. Scahill, L.H. Price, S.A. Rasmussen, Tic-Related Versus Non-Tic-Related Obsessive-Compulsive Disorder. M.J. Byerly, W.K. Goodman, C. Cuadros, Comorbid Schizophrenia: Implications for Treatment of Obsessive-Compulsive Disorder. Part II: Pathophysiology and Etiology. G.L. Hanna, Clinical and Family-Genetic Studies of Childhood Obsessive-Compulsive Disorder. R.J. McNally, Information-Processing Abnormalities in Obsessive-Compulsive Disorder. P. van Oppen, P.M.G. Emmelkamp, Issues in Cognitive Treatment of Obsessive-Compulsive Disorder. S.L. Rauch, C.R. Savage, Investigating Cortico-Striatal Pathophysiology in Obsessive-Compulsive Disorders: Procedural Learning and Imaging Probes. Part III: Assessment. U. Feske, D.L. Chambless, A Review of Assessment Measures for Obsessive-Compulsive Disorder. S.W. Kim, Measuring Outcome in Drug Trials of Obsessive-Compulsive Disorder. Part IV: Cognitive-Behavioral Treatments. P.M. Salkovskis, C. Richards, E. Forrester, Psychological Treatment of Refractory Obsessive-Compulsive Disorder and Related Problems. C.A. Pollard, Inpatient Treatment of Refractory Obsessive-Compulsive Disorder. F.A. Neziroglu, K.P. Stevens, B. Liquori, J.A. Yaryura-Tobias, Cognitive and Behavioral Treatment of Obsessive-Compulsive Spectrum Disorders. G. Steketee, N.J. Henninger, C.A. Pollard, Predicting Treatment Outcome for Obsessive-Compulsive Disorder: Effects of Comorbidity. Part V: Drug and Other Somatic Treatments. T.A. Pigott, S. Seay, Pharmacotherapy of Obsessive-Compulsive Disorder: Overview and Treatment-Refractory Strategies. I. Iancu, P.N. Dannon, M. Lustig, Y. Sasson, J. Zohar, Preferential Efficacy of Serotonergic Medication in Obsessive-Compulsive Disorder: From Practice to Theory. J. DeVeaugh-Geiss, R. Katz, Clomipramine in the Treatment of Obsessive-Compulsive Disorder. W.K. Goodman, H.E. Ward, A. Kablinger, T.K. Murphy, Biological Approaches to Treatment-Resistant Obsessive-Compulsive Disorder. C.J. McDougle, C.N. Epperson, L.H. Price, The Role of Neuroleptics in Treatment-Refractory Obsessive-Compulsive Disorder. B.A. Fallon, M.R. Liebowitz, Intravenous Clomipramine for Obsessive-Compulsive Disorder. W.A. Hewlett, Benzodiazepines in the Treatment of Obsessive-Compulsive Disorder. M.V. Rudorfer, Electroconvulsive Therapy in Treatment-Refractory Obsessive-Compulsive Disorder. M.A. Jenike, Neurosurgical Treatment of Obsessive-Compulsive Disorder. Part VI: Combined Treatment. D.A. Speigel, Combined Drug and Behavioral Treatments for Obsessive-Compulsive Disorder: Early Findings. M.J. Kozak, M.R. Liebowitz, E.B. Foa, Cognitive Behavior Therapy and Pharmacotherapy for Obsessive-Compulsive Disorder: The NIMH-Sponsored Collaborative Study. Part VII: Mechanisms of Action. S. Rachman, R. Shafran, The Mechanisms of Behavioral Treatment and the Problem of Therapeutic Failures. P. Blier, R. Bergeron, G. Pineyro, M. El Mansari, Understanding the Mechanism of Action of Serotonin Reuptake Inhibitors in Obsessive-Compulsive Disorder: A Step Toward More Effective Treatments? L.R. Baxter, Jr., R.F. Ackermann, N.R. Swerdlow, A. Brody, S. Saxena, J.M. Schwartz, J.M. Gregoritch, P. Stoessel, M.E. Phelps, Specific Brain System Mediation of Obsessive-Compulsive Disorder Responsive to Either Medication or Behavior Therapy.

Differences and similarities between obsessive and ruminative thoughts in obsessive-compulsive and depressed patients: A comparative study

Obsessive-Compulsive Disorder (OCD) is an anxiety disorder that causes one to have unwanted obsessions and compulsions. Obsessions are distressing thoughts that tend to arise spontaneously and regularly. Compulsions are repetitive actions and rituals that are executed in an attempt to control the obsessions. Individuals with OCD have little control over their thoughts and compulsions, so the unwanted thoughts and behaviours generate a significant amount of anxiety for these individuals. A common treatment for OCD is Cognitive-Behavioural Therapy (CBT). CBT is an active and behaviour-oriented treatment model. More specifically, treatment involves changing clients’ mindsets as well as encouraging them to make physical changes to their environment. The purpose of this research project was to investigate the benefits and limitations of using Cognitive Behavioural Therapy to treat Obsessive Compulsive Disorder. Based on a review of the literature, the project outlines the benefits and limitations of three specific techniques used by cognitive behavioural therapists: Exposure plus Response Prevention (ERP), Thought Stopping, and Rational Emotive Behaviour Therapy. The general benefits and limitations of using CBT to treat OCD are discussed. Results show that all three specific CBT techniques have been proven effective in treating OCD. However, some limitations, such as failure to maintain therapy gains long-term, were noted. On a broader level, CBT was shown to be the optimal therapy for individuals with OCD. In particular, Exposure plus Response Prevention therapy has proven to be the best therapy technique for individuals with OCD. General limitations, such as the time-consuming nature of CBT for OCD, were also noted.

Background:Obsessive-compulsive disorder (OCD) is considered a heterogeneous disorder. One of the traditional approaches to subtype OCD is based on the predominance of obsessions, compulsions or both. Some studies suggest that the “predominantly obsessive” subtype of OCD may have poor outcome, whereas few other studies suggest that “mixed” OCD is associated with poor outcome. Therefore, it is not clear if the long-term course of “predominantly obsessive” subjects is different from those with “mixed” OCD. In the establishment of diagnostic validity of psychiatric conditions, differential course is an important validating factor.Aim:This study compares the 5-6 year course of the “predominantly obsessive” subtype with that of the “mixed” subtype of OCD with the objective of determining if the course of OCD differs according to subtypes and whether course could be a validating factor for subtyping OCD based on predominance of obsessions, compulsions or both.Setting and Design:Tertiary hospital, institutional setting. The study has a retrospective cohort design.Materials and Methods:Fifty-four subjects with “predominantly obsessions” and an equal number of the “mixed” subtype of OCD were recruited from the database of a specialty OCD clinic of a major psychiatric hospital. They were followed up after 5-6 years. The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) checklist and severity rating scale was used for assessing OCD. The course of OCD was determined according to predefined criteria.Statistics:The Chi-square/Fisher's exact test and the independent samples “t” test were used to compare categorical and continuous variables, respectively. Correlations were tested using the Pearson's correlation analysis.Results:Thirty-eight “predominantly obsessive” (70%) and 39 “mixed” (72%) OCD subjects could be traced and evaluated. The course of illness was similar in the two subtypes. A majority of the sample (72%) did not have clinical OCD at follow-up.Conclusions:“Predominantly obsessive” subjects have a course similar to those with “mixed” OCD. Clinically, it is reassuring to know that obsessive subjects do not have an unfavorable course as was suggested by some previous studies. In this sample, course did not validate the subtyping method employed, but it would be premature to conclude that the subtyping method employed is incorrect based on the course alone. Prospective study of the course in larger samples and neurobiological and family-genetic data may help further validation.

Obsessive-compulsive disorder (OCD) is a chronic debilitating anxiety disorder characterized by two distinct phenomena: obsessions which are recurrent, intrusive thoughts, images or impulses, and/or compulsions which are repetitive covert or overt actions that are carried out to decrease anxiety. OCD commonly affects young adults, is associated with other comorbid mental illnesses and often has a large treatment gap (the proportion of individuals who have OCD and require care but do not receive treatment). OCD thus runs a chronic and disabling course which compromises an individual's functioning and well-being and ultimately has a rather detrimental impact on the lives of both patients and their families. Researchers and clinicians are increasingly paying attention to humanistic outcomes to encompass broader indicators of disease burden and outcome, one of which is quality of life (QoL). In this review, we provide a summary of the current knowledge of QoL in OCD, its socio-demographic and clinical correlates, and the effects of therapeutic interventions on QoL among those with OCD. Overall, studies indicate that those with OCD had diminished QoL across all domains relative to normative comparison subjects. Patients with OCD scored better on QoL domains than patients with major depressive disorder (MDD), whereas they showed no difference or scored worse than patients with schizophrenia. Although research on socio-demographic correlates of QoL in OCD is largely contradictory, most studies suggest that symptom severity and comorbid depression or depressive symptoms are predictors of decreased QoL in OCD, with numerous studies showing this association across multiple domains associated with QoL. Studies assessing QoL as an outcome of treatment have found an improvement in QoL in people with OCD after treatment with pharmacotherapy or cognitive behavioural therapy with some studies suggesting that this improvement in QoL is correlated with improvement in symptoms. A few studies have also evaluated other forms of treatment like partial hospitalisation programmes and deep brain stimulation for those with treatment-resistant OCD and found that QoL scores improve with treatment. A major gap in the field is the lack of instruments that measure QoL specifically in patients with OCD. It is evident that OCD affects specific domains and thus there is a pressing need for the development of multidimensional instruments that are reliable and valid. There is also a need for studies assessing QoL in individuals with OCD among both clinical and community samples with adequate sample size to examine socio-demographic and clinical correlates simultaneously. These populations ought to be followed longitudinally to examine QoL with the clinical course of the illness, and to help establish temporal relationships. Studies that examine improvements in QoL with treatment need to be designed carefully: sample size requirements should be met, raters must be blinded, and randomly assigning subjects to different arms would ensure that some of the inherent biases in open-label studies are avoided. QoL is an important component that measures the impact of OCD on an individual and QoL goals must be incorporated as an outcome measure of therapeutic interventions.

Subtypes of obsessive-compulsive disorder: Implications for specialized cognitive behavior therapy