Effective Treatment For Obsessive-compulsive Disorder Research Articles

Improvement in Distress Tolerance as a Mechanism of Symptom Reduction During Intensive Exposure and Response Prevention–Based Treatment for OCD

Exposure and Response Prevention (ERP) is an effective treatment for obsessive-compulsive disorder (OCD), yet the specific underlying mechanisms by which ERP improves symptoms remain unclear. Initial theories suggested that habituation to triggering events and stimuli was the key therapeutic factor in ERP, while other theories highlight the role of developing the ability to tolerate distress, rather than reduction of distress. The current study examined improvements in distress tolerance as a mechanism of OCD, anxiety, and depressive symptom reductions during an ERP-based intensive program. Participants (N = 180) completed weekly measures of distress intolerance, and symptom severity of OCD, anxiety, and depression. Using Multi-Level Structural Equation Modeling, we found that participants experienced significant weekly decreases in OCD, anxiety, and depressive symptom severity across the course of their ERP-based treatment. Weekly reductions in OCD symptom severity were partially accounted for by weekly improvements in participants’ ability to tolerate distress, particularly for obsession symptoms. This effect was also significant for anxiety and depressive symptom severity, above and beyond the effects of weekly reductions in OCD symptom severity. The current study suggests improving the ability to tolerate distress represents a transdiagnostic mechanism of symptom severity reduction in OCD, anxiety, and depressive psychopathology via intensive ERP-based psychotherapy programming. Limitations and future directions for improving treatments for OCD, anxiety, and depressive symptoms are discussed.

Efficacy and acceptability of a self-guided internet-delivered cognitive-behavioral educational program for obsessive-compulsive symptoms with international recruitment

ABSTRACT Cognitive-behavioural therapy is an effective treatment for obsessive-compulsive disorder (OCD). However, there are many barriers in accessing this treatment, with stigma being a particularly prominent barrier for many patients. Self-guided internet-delivered cognitive-behavioural therapy (ICBT), which does not require any contact with a therapist, has the potential to overcome this barrier. However, there is limited research on the efficacy of self-guided ICBT for OCD. The aim of the current study was to examine the efficacy of self-guided ICBT for OCD in a large international sample. Two hundred and sixteen participants were included in the study (Mage = 34.00; SD = 12.57; 72.7% female). On the primary outcome measure, the Yale-Brown Obsessive-Compulsive Scale (YBOCS), a medium within-group effect size was found from pre-treatment to post-treatment (g = 0.63), and a large within-group effect size was found from pre-treatment to 3-month follow-up (g = 0.98). Approximately one-quarter to one-third of participants met criteria for clinically significant improvement at post-treatment and 3-month follow-up (11% and 17% met criteria for remission at post-treatment and 3-month follow-up, respectively). These results demonstrate that self-guided ICBT may be an efficacious treatment for individuals with OCD who cannot or do not wish to engage with a mental health professional, resulting in medium to large effect sizes.

Personalized Medicine in the Treatment of a Patient With Obsessive-Compulsive Disorder With Clomipramine.

Clomipramine (CIMI) is an effective treatment for obsessive-compulsive disorder in patients who have failed to respond to trials of selective serotonin transport inhibitors (eg, sertraline). The case presented here illustrates how knowledge of the pharmacodynamics and pharmacokinetics of CIMI in a specific patient can be used to personalize treatment to optimize the likelihood of efficacy (ie, maximum benefit to risk ratio). The approach described in this column considered: (1) the patient's diminished ability to clear CIMI and its major metabolite, desmethlyclomipramine due to a genetic deficiency in cytochrome P450 2D6 enzyme activity, and (2) the patient's ability to extensively convert CIMI to desmethlyclomipramine. That conversion impairs the ability to inhibit the serotonin transporter, the mechanism that is most likely responsible for the efficacy of CIMI in obsessive-compulsive disorder.

Clinical and demographic characteristics of patients with obsessive-compulsive symptoms using internet-delivered and face-to-face cognitive behavior therapy

ABSTRACT Objective Internet-delivered cognitive behavioural therapy (ICBT) is an effective treatment for obsessive-compulsive disorder (OCD). However, little is known about the characteristics of individuals who engage with this treatment and whether they are comparable to those who engage in face-to-face treatment for OCD. The aim of the current study was to examine the demographic and clinical characteristics of participants who engaged in a large open trial of self-guided ICBT for OCD and compare their characteristics with those who completed face-to-face treatment for OCD, as described in large, published studies. Method Three hundred and twenty-three participants (Mage = 33.27; SD = 12.22; 74.1% female) were included in the study. Results Participants in the ICBT group were significantly younger in age, were more likely to be female, and less likely to take psychotropic medication for their OCD symptoms, compared to participants who completed face-to-face treatment. There were no significant differences between the groups on OCD symptom severity or on depressive symptom severity. Conclusion Although slight differences in demographic characteristics were found between the ICBT group and face-to-face CBT group, the groups had similar clinical characteristics, indicating individuals who seek both treatment modalities are comparable to one another.

The effectiveness of metacognitive therapy in comparison to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial

BackgroundThe recommended psychological treatment of choice for obsessive-compulsive disorder (OCD) is exposure with response prevention (ERP). Although this treatment is quite effective, recovery rates are modest and attrition rate is relatively high. Also, ERP treatment requires amounts of therapist time. A possible way to improve OCD treatment is by taking into account key cognitive processes involved in the development and maintenance of the disorder. The metacognitive model is such an account and pilot findings suggest that the associated metacognitive therapy (MCT) might be an effective treatment for OCD. MethodsIn the present study, a randomized controlled trial (RCT) is used to assess the effectiveness of MCT in comparison to ERP in an outpatient clinical sample of patients with OCD. ResultsBoth MCT and ERP produced significant pre-treatment to post-treatment decreases in obsessive-compulsive, comorbid psychological symptoms and metacognitive beliefs, both with moderate to large within-group effect sizes and high proportions of significant clinical change. Drop-out rates were low and treatment gains were maintained at six-month follow-up. There were no differences in efficacy observed between MCT and ERP treatments. ConclusionsMCT proves to be a promising treatment of OCD.

Falling into the OCD trap: Are clinicians hesitant to encourage exposure therapy for repugnant obsessions?

Obsessive-compulsive disorder (OCD) can involve repugnant obsessions with aggressive, sexual, and/or religious themes. Although exposure and response prevention (ERP) is an effective treatment for OCD, negative beliefs about exposure are common and may cause clinicians to be hesitant to encourage exposures, especially for repugnant obsessions. This study examined whether clinicians’ willingness to encourage challenging exposures differed depending on the repugnant obsession subtype (i.e., intentional harm, accidental harm, religion, pedophilia, and sexual orientation). The impact of clinical experience on the results was also investigated. A survey of five clinical vignettes was completed by 155 clinicians with experience treating OCD. Results suggested that clinicians were significantly less likely to encourage an in vivo exposure for intentional harm, accidental harm, and pedophilia obsessions as compared to other subtypes and were less likely to encourage an imaginal exposure for pedophilic obsessions as compared to all other subtypes. Clinicians reported varying levels of comfort in encouraging clients to face feared thoughts/triggers depending on the content of symptoms, which may contribute to suboptimal treatment for those with pedophilic and harm obsessions. Clinician experience had limited impact on these findings, highlighting the need for more training about ERP being a safe and effective intervention across symptom presentations.

Narrating Perinatal Obsessive-Compulsive Disorder Through Blogs

Abstract Purpose: To describe women's experiences of perinatal obsessive-compulsive disorder (OCD) as written in their blogs. Study Design and Method: This qualitative descriptive study examined perinatal OCD blogs identified using Google search engine. Krippendorff's thematic content analysis method for qualitative data was used. The unit of analysis included segments of the bloggers' descriptions of their perinatal OCD. Clustering and dendrograms were used to group the data into themes. Results: Forty-three different posts from women in the United Kingdom, United States, Australia, and South Africa were analyzed. Five themes were identified that described women's experiences of perinatal OCD as told in their blogs: (1) Starting to tighten its grip during pregnancy, (2) Keeping horrific secrets all to themselves, (3) Tortured with terrifying images and thoughts, (4) Driven to compulsive behaviors to protect their infants, and (5) Long difficult road to recovery but so worth it. Clinical Implications: Perinatal OCD is a hidden problem that can have negative consequences for mothers and for their infants and families if not diagnosed or if misdiagnosed. There are effective treatments for OCD, but first nurses and other health care providers need to identify the women who are struggling with this anxiety disorder. During the perinatal period nurses can screen women for OCD. Developing a trusting relationship with pregnant and postpartum women is critical for nurses so that their patients can feel safe enough to share their horrific secret thoughts.

Acceptance and Commitment Therapy for obsessive compulsive disorder in a Brazilian context: Treatment of three cases

Previous research indicates that a combination of Acceptance and Commitment Therapy (ACT) and Exposure and Response Prevention (ERP) is an effective treatment for obsessive-compulsive disorder (OCD). However, there are no studies to date of ACT for OCD in Latin American populations. Because socio-cultural context influences OCD symptomatology, it is worth adapting and testing ACT for OCD in such cultures. Three patients seeking treatment for OCD at a public health center in Rio De Janeiro, Brazil were treated with 16 sessions of ACT and ERP. All participants showed decreased OCD scores from baseline to post-treatment that remained lower at follow-up, suggesting that a version of ACT for OCD adapted for a Brazilian cultural context was effective. The intervention also had positive effects on depression, quality of life, and psychological flexibility. This paper focuses on the adaptations that reflect the unique needs of Brazilian culture, as well as how to integrate ACT within existing systems of care. This study shows the effectiveness of this approach in Brazil and offers promise for future cultural adaptations of ACT in other Latin American contexts.

Therapeutic Alliance and Treatment Outcome in Cognitive Behavior Therapy for Obsessive-Compulsive Disorder.

ObjectiveTherapeutic alliance has consistently been found to predict treatment outcomes across various psychotherapies and patient diagnosis. However, the relationship between therapeutic alliance and outcome in Cognitive Behavioral Therapy (CBT) has shown mixed results. This study investigated the impact of different aspects of therapeutic alliance in CBT for Obsessive-Compulsive Disorder (OCD).MethodData from two previously completed randomized controlled trials of 208 patients with OCD and their therapists were analyzed. Therapeutic alliance was assessed at week 4 of treatment with the patient-rated and therapist-rated Working Alliance Inventory (WAI), which includes three subscales to measure alliance domains (Goal, Task and Bond). Higher WAI score reflects a better therapeutic relationship. OCD severity was rated by independent assessors at baseline and post-treatment using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Linear regression analyses were used to examine the effects of the different aspects of therapeutic alliance on treatment outcome, adjusted for baseline symptom severity.ResultsA higher total WAI score as rated by therapists significantly predicted a lower post-treatment Y-BOCS. Further, higher scores on the Goal and Task subscales of the WAI were associated with lower post-treatment severity. However, these significant outcomes reflected only small effect sizes.ConclusionsIn the treatment of OCD, the strength of the therapeutic alliance contributes to outcomes, though to a limited extent. Effective OCD treatment involves the delivery of specific therapy interventions, in the context of a strong therapeutic alliance.

A Five-Day Intensive Treatment for Pediatric Obsessive-Compulsive Disorder: A Multiple Baseline Design Pilot Study

ABSTRACT The need for effective treatments for obsessive-compulsive disorder (OCD) in childhood is evident given that as many as 50% of the adults with OCD report symptom onset before age 15. Despite the growing evidence supporting the efficacy of Exposure and Response Prevention (ERP) for youth with OCD, children seeking services for their OCD symptoms often do not receive ERP because of difficulties with treatment accessibility. Brief time-intensive treatment programs may be a feasible treatment option for children and their families who do not have access to ERP treatment and/or live in an area where therapists trained in ERP are limited. To evaluate the initial efficacy, feasibility, and acceptability of a brief, five-day intensive ERP program for pediatric OCD, eight children with OCD were randomized to a one-week, two-week, or three-week baseline period in a single-case, non-concurrent multiple-baseline experimental design. In most cases, there were clinically significant improvements in OCD symptoms with the implementation of treatment; moreover, treatment gains were maintained at 3-month follow-up. Children and families perceived the program to be acceptable, feasible, and beneficial. This study extends the support for the efficacy and feasibility of a five-day intensive treatment program for pediatric OCD.

Obsessive-Compulsive Disorders.

This article describes the phenomenology and clinical presentation of obsessive-compulsive disorder (OCD), a common but underdiagnosed psychiatric disorder. Guidance for effectively identifying obsessive-compulsive symptoms is provided, and treatment options, including psychotherapy, pharmacologic management, and neuromodulation approaches for treatment-resistant OCD, are discussed. OCD affects 2% to 3% of adults worldwide and is associated with substantial individual disability and societal costs. Lack of recognition of common OCD symptom types, in addition to shame and fear of stigma on the part of patients, has created an average delay in diagnosis by almost 10 years and a delay in effective treatment (ie, a treatment gap) of nearly 2 years. Cognitive-behavioral therapy (CBT), specifically a form of CBT that includes a type of behavioral intervention called exposure and response prevention, remains the most effective form of treatment for OCD. If CBT is not effective or not available, pharmacologic treatment with selective serotonin reuptake inhibitors (SSRIs) or clomipramine, a nonselective serotonin reuptake inhibitor, can also be of benefit. Neuromodulation approaches such as deep brain stimulation and transcranial magnetic stimulation are rapidly emerging as effective treatments for OCD, particularly for patients who have not experienced an adequate response to psychotherapy or pharmacologic management. OCD affects more than one in every 50 adults in the United States but is recognized and adequately treated in fewer than half of those affected. Early intervention and appropriate treatment can substantially reduce OCD symptom severity, improve quality of life, and minimize the functional disability associated with this chronic and often debilitating illness.

Internet-delivered cognitive-behaviour therapy (ICBT) for obsessive-compulsive disorder when delivered as routine clinical care: A phase IV clinical trial

Cognitive-behaviour therapy (CBT) is an effective treatment for obsessive-compulsive disorder (OCD), but many patients experience difficulty accessing this treatment. Internet-delivered CBT (ICBT) enhances access to CBT for individuals with OCD and has been shown to be efficacious in Phase I, II, and III clinical trials. However, there are fewer studies investigating ICBT for OCD in Phase IV clinical trials, which demonstrate the effectiveness of the intervention when provided as part of routine care. The aim of the present study was to report on the effectiveness of ICBT for OCD, using data from Australia’s MindSpot Clinic, a federally funded treatment service that provides free ICBT to Australian adults with anxiety, depression, and pain conditions. A total of 225 MindSpot users (68 % female; Mage = 34.82; SD = 11.02) were included in the study. Within-group effect sizes at post-treatment on the Yale-Brown Obsessive-Compulsive Scale, indicated medium effect sizes (g = 0.6; 95 % CI: 0.5−0.7), increasing to large effects at three-month follow up (g = 0.9; 95 % CI: 0.8–1.0). Effects on secondary outcome measures including measures of depression, generalized anxiety, and psychological distress ranged from (g = 0.5–0.6) at post-treatment and (g = 0.5–0.7) at three-month follow up. Results from benchmarking analyses indicated that the results from routine care were significantly smaller than those found in a recent clinical trial using the same treatment protocol. The results indicate that ICBT delivered in real world settings is associated with meaningful improvements in OCD symptoms, however future research may wish to examine which patients respond best to this treatment approach and how to enhance outcomes.

The Role of Antioxidants in the Management of Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a chronic neuropsychiatric disorder that has a significant effect on the quality of life. The most effective treatment for OCD is the combination of selective serotonin reuptake inhibitors (SSRI) with cognitive behavior therapy (CBT). However, several adverse effects have been linked with this usual pharmacotherapy, and it is unsuccessful in many patients. The exact pathophysiology of OCD is not completely known, though the role of oxidative stress in its pathogenesis has been proposed recently. This review presents an overview of animal and human studies of antioxidant treatment for OCD. The use of antioxidants against oxidative stress is a novel treatment for several neurodegenerative and neuropsychiatric disorders. Among antioxidants, NAC was one of the most studied drugs on OCD, and it showed a significant improvement in OCD symptoms. Thus, antioxidants could be promising as an adjuvant treatment for OCD. However, a limited number of human studies are conducted on these agents, and for better judgment, human studies with a large sample size are necessary.

Invasive and Non-invasive Neurostimulation for OCD.

It becomes increasingly clear that (non-)invasive neurostimulation is an effective treatment for obsessive-compulsive disorder (OCD). In this chapter we review the available evidence on techniques and targets, clinical results including a meta-analysis, mechanisms of action, and animal research. We focus on deep brain stimulation (DBS), but also cover non-invasive neurostimulation including transcranial magnetic stimulation (TMS). Data shows that most DBS studies target the ventral capsule/ventral striatum (VC/VS), with an overall 76% response rate in treatment-refractory OCD. Also TMS holds clinical promise. Increased insight in the normalizing effects of neurostimulation on cortico-striatal-thalamic-cortical (CSTC) loops - through neuroimaging and animal research - provides novel opportunities to further optimize treatment strategies. Advancing clinical implementation of neurostimulation techniques is essential to ameliorate the lives of the many treatment-refractory OCD patients.

Ahead of the Curve: Responses From Patients in Treatment for Obsessive-Compulsive Disorder to Coronavirus Disease 2019.

Alongside concern about the physical health impacts of the coronavirus disease 2019 (COVID-19) crisis, public health officials have also raised concerns about the potential for massive mental health impact. This has led many to wonder, how are individuals with obsessive-compulsive disorder (OCD), and especially those with contamination fears, doing in the era of COVID-19? We present data from eight patients in our residential treatment program for OCD who were admitted prior to any COVID-19 restrictions and continued in treatment at the facility during the pandemic. Much like the general population, our patients varied in the ways they were impacted by COVID-19, yet the majority experienced improvements in OCD symptoms despite the context. This is not to downplay the many ways in which our patients were personally affected by COVID-19. Rather our patients’ relatively resilient responses mirror our program’s treatment model, which emphasizes exposure and response prevention (ERP) within the complementary framework of acceptance and commitment therapy (ACT). The intention of this article is to challenge the notion that by definition this population will fare worse than the general public or that ERP cannot proceed effectively during this time. In contrast, we underscore that effective OCD treatment can and should continue in the era of COVID-19.

Metacognitive Training for Obsessive-Compulsive Disorder: a study protocol for a randomized controlled trial

BackgroundA high number of patients with obsessive-compulsive disorder (OCD) do not receive cognitive-behavioral therapy with exposure and response prevention, which is the most effective treatment for OCD. Therefore, Metacognitive Training for OCD (MCT-OCD) was developed, which is a structured group therapy aiming at the modification of dysfunctional (meta-)cognitive biases, beliefs and coping styles. It can be administered by less trained personnel, thus may reach a higher number of patients.An uncontrolled pilot study (MCT-OCD pilot version) provided first evidence that the training is highly accepted by patients; OC symptoms decreased with a high effect size (η2partial = 0.50). The aim of the present study is to address the shortcomings of the pilot study (e.g., no control group) and to assess the efficacy of the revised version of the MCT-OCD in the framework of a randomized controlled trial.MethodsEighty patients with OCD will be recruited. After a blinded assessment at baseline (−t1), patients will be randomly assigned either to the intervention group (MCT-OCD; n = 40) or to a care as usual control group (n = 40). The MCT-OCD aims to enhance patients’ metacognitive competence in eight modules by addressing dysfunctional (meta-)cognitive biases and beliefs associated with OCD (e.g., intolerance of uncertainty). After 8 weeks, patients will be invited to a post assessment (t1), and then they will receive a follow-up online questionnaire 3 months following t1 (t2). The primary outcome is the Y-BOCS total score, and the secondary outcomes include the HDRS, OCI-R, OBQ-44, MCQ-30, WHOQOL-BREF, BDI-II, and subjective appraisal ratings of the MCT-OCD. We expect that OC symptoms will decrease more in the intervention group compared with the care as usual control group from –t1 to t1 and that treatment gains will be maintained until t2.DiscussionThe planned study is the first to investigate the MCT-OCD, a promising new treatment, in a randomized controlled trial. The MCT-OCD may help to overcome existing treatment barriers for patients with OCD.Trial registrationGerman Registry for Clinical Studies (DRKS00013539), 22.02.2018.

Long-Term Stability of Benefits of Cognitive Behavioral Therapy for Obsessive Compulsive Disorder Depends on Symptom Remission During Treatment.

Cognitive behavioral therapy (CBT) is an effective treatment for obsessive-compulsive disorder (OCD) and may afford stable long-term improvements. It is not clear, however, how stability or symptom recurrence can be predicted at the time of termination of CBT. In a 1-year follow-up intention-to-treat study with 120 OCD patients receiving individual CBT at a university outpatient unit, we investigated the predictive value of international consensus criteria for response only (Y-BOCS score reduction by at least 35%) and remission status (Y-BOCS score ≤ 12). Secondly, we applied receiver-operating characteristic (ROC) curves in order to find an optimal cut-off score to classify for deterioration and for sustained gains. Response only at post-treatment increased the likelihood of deterioration at follow-up compared to remission at an odds ratio of 8.8. Moreover, ROC curves indicated that a post-treatment score of ≥ 13 differentiated optimally between patients with and without symptom deterioration at follow-up assessment. The optimal cut-off score to classify for any sustained gains (response, remission, or both) at follow-up relative to baseline was 12. Importantly, previous findings of generally high long-term symptom stability after treatment in OCD could be replicated. The findings highlight the clinical importance of reaching remission during CBT, and suggest that a recently published expert consensus for defining remission has high utility.

Effects of Bergen 4-Day Treatment on Resting-State Graph Features in Obsessive-Compulsive Disorder

BackgroundExposure and response prevention is an effective treatment for obsessive-compulsive disorder (OCD), but it is unclear how symptom reduction is related to changes in the brain. We aimed to determine the effects of a 4-day concentrated exposure and response prevention program (Bergen 4-day treatment) on the static and dynamic functional connectome in patients with OCD. MethodsThirty-four patients with OCD (25 unmedicated) underwent resting-state functional magnetic resonance imaging the day before the Bergen 4-day treatment, and 28 (21 unmedicated) were rescanned after 1 week. Twenty-eight healthy control subjects were also scanned for baseline comparisons and 19 of them were rescanned after 1 week. Static and dynamic graph measures were quantified to determine network topology at the global, subnetwork, and regional levels (including efficiency, clustering, between-subnetwork connectivity, and node flexibility in module allegiance). The Yale-Brown Obsessive Compulsive Scale was used to measure symptom severity. ResultsTwenty-four patients (86%) responded to treatment. We found significant group × time effects in frontoparietal-limbic connectivity (ηp2 = 0.19, p = .03) and flexibility of the right subgenual anterior cingulate cortex (ηp2 = 0.18, p = .03), where, in both cases, unmedicated patients showed significant decreases while healthy control subjects showed no significant changes. Healthy control subjects showed increases in global and subnetwork efficiency and clustering coefficient, particularly in the somatomotor subnetwork. ConclusionsConcentrated exposure and response prevention in unmedicated patients with OCD leads to decreased connectivity between the frontoparietal and limbic subnetworks and less flexibility of the connectivity of the subgenual anterior cingulate cortex, suggesting a more independent and stable network topology. This may represent less limbic interference on cognitive control subnetworks after treatment.

Obsessive-compulsive disorder.

Obsessive-compulsive disorder (OCD) is a highly prevalent and chronic condition that is associated with substantial global disability. OCD is the key example of the 'obsessive-compulsive and related disorders', a group of conditions which are now classified together in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and the International Classification of Diseases, 11th Revision, and which are often underdiagnosed and undertreated. In addition, OCD is an important example of a neuropsychiatric disorder in which rigorous research on phenomenology, psychobiology, pharmacotherapy and psychotherapy has contributed to better recognition, assessment and outcomes. Although OCD is a relatively homogenous disorder with similar symptom dimensions globally, individualized assessment of symptoms, the degree of insight, and the extent of comorbidity is needed. Several neurobiological mechanisms underlying OCD have been identified, including specific brain circuits that underpin OCD. In addition, laboratory models have demonstrated how cellular and molecular dysfunction underpins repetitive stereotyped behaviours, and the genetic architecture of OCD is increasingly understood. Effective treatments for OCD include serotonin reuptake inhibitors and cognitive-behavioural therapy, and neurosurgery for those with intractable symptoms. Integration of global mental health and translational neuroscience approaches could further advance knowledge on OCD and improve clinical outcomes.

HIGH FREQUENCY DEEP REPETITIVE TRANSCRANIAL MAGNETIC STIMULATION (dTMS) OF MEDIAL PREFRONTAL AND ANTERIOR CINGULATE CORTICES IN PATIENTS WITH OCD: A DOUBLE-BLIND, PLACEBO CONTROLLED, PERSPECTIVE MULTI-CENTER STUDY

Introduction Obsessive compulsive disorder (OCD) is a disabling disease with an annual prevalence of 1.2%. Currently approved medications only result in a reduction of symptoms for 40-60% of patients leaving most patients significantly affected. Symptom severity is correlated to the degree of hyperconnectivity in the cortico-stiriato-thalamic circuit and increased glucose metabolism in the anterior cingulate cortex during symptom provocation and at rest. Methods Ninety-four OCD patients who met inclusion/exclusion criteria (age 22-68, YBOCS≥20 despite SSRI treatment and/or CBT, stable on medications or therapy for at least two months) were randomized to receive active or sham treatment for twenty-nine sessions over six weeks. Deep transcranial magnetic stimulation(dTMS) was applied over the medial prefrontal(mPFC) and anterior cingulate cortices(ACC) using the H7 dTMS coil. Once the coil was in the treatment position, the patient’s symptoms were provoked using an individualized script tailored to the patient’s obsessions and compulsions. Subsequently, dTMS was administered for eighteen minutes at 100% resting motor threshold of the foot, 20HZ pulse frequency, in 2 second trains, with a 20 second inter-train interval totaling 2000 pulses. The sham coil was designed to have the same sound, scalp and facial sensation of the real coil without stimulating the brain directly. Results The mean age of the subjects was 38.7 (±11.75), 58.7%male, 78.8% Caucasian, mean age of onset was 13, 98% had failed medications approved for OCD and 68.7% had failed CBT. At the end of week 6 (the primary endpoint) the YBOCS decreased by 5.7 points (95% CI: [3.3;8.2]) in the dTMS arm and by 3.0 points (95% CI: [0.7;5.4]) in the control arm (p-value: 0.0157). Response (≥30% decrease/20% decrease in the YBOCS) rates were dTMS 38.10% in the dTMS arm and 11.11% in the sham arm (p-value:0.0033). Partial response rates were (≥20% decrease in the YBOCS) 54.76 in the dTMS arm and 26.67% in the sham arm (p-value: 0.0076). At week 10 (follow up) the YBOCS decreased by 6.2 points (95% CI: [3.6;8.7]) in the dTMS arm and by 3.8 points (95% CI: [1.4;6.2]) in the control arm (p-value: 0.0459). There were no serious adverse events related to the treatment. The most frequent adverse event, headache, did not differ in frequency between the two arms. Conclusions High frequency dTMS of the ACC was found to be an effective treatment for OCD. This approach is an additional intervention in the toolbox for treating OCD.