Treatment Outcome In Obsessive-compulsive Disorder Research Articles

High-Density Exposure Therapy for Obsessive-Compulsive Inpatients: A 1-Year Follow-Up1

Background: This study evaluates the effects of individual high-density exposure (2–3 weeks, all day) plus response prevention therapy on 85 unselected inpatients suffering from obsessive-compulsive disorder (OCD). Methods: Twenty-eight therapist practitioners performed treatment. Results: At 1-year follow-up, self-ratings indicated that patients on average felt much improved. Impairment by both obsessions and compulsions was significantly reduced (p < 0.001 in each case), and OCD symptoms as assessed by two OCD questionnaires had also decreased significantly, as had depressiveness and overall symptomatology (all p < 0.001). Defining improvements as >30% successes, as done in other OCD treatment outcome studies, success rates were 68 and 69%, respectively, for the two OCD questionnaire scores, 75% for self-rated impairment by obsessions and 84.5% for compulsions, 85.6% for overall psychopathology (General Symptom Index), and 75% for depressiveness (Beck Depression Inventory). Effect sizes were >1 SD for all of the measures included. Conclusions: We conclude that long-term effects for high-density treatment of unselected OCD patients bring about as good results as treatments with exposure and response prevention performed with selected patient samples in a research context.

Assessment of obsessions and compulsions: Reliability, validity, and sensitivity to treatment effects

Advances in the treatment of obsessive-compulsive disorder (OCD) require reliable and valid measures of sufficient sensitivity to detect treatment effects. The present article critically reviews the instruments used in OCD treatment-outcome research. Behavioral methods, self-report inventories, and observer-rated scales are reviewed with respect to content, reliability, validity, and sensitivity to treatment effects. The latter was determined by meta-analyses of trials of behavior therapy (exposure plus response prevention) and clomipramine. Little is known about the psychometric properties of behavioral assessment methods, and they are used increasingly less often in outcome research, despite certain advantages. Self-report inventories tend to have acceptable reliability and validity, except for the SCL-90-R OC scale (and its predecessors) which has weak discriminant validity and appears to be essentially a measure of nonspecific distress. Little is known about the reliability and vatiduy of most observer-rated scales, despite the fact that they are popular in treatment outcome research. All measures appear sensitive to treatment effects, although observer-rated scales tend to yield larger effect sizes than self-report measures. For treatment outcome research, the Yale-Brown Obsessive Compulsive Scale (YBOCS) appears to be the best available instrument in terms of range of obsessive-compulsive features assessed, reliability, validity, and sensitivity to treatment effects. Computer-administered and self-report versions of the YBOCS have been developed, which appear promising but require further evaluation. The effects of treatment may be best understood by using measures of specific symptoms rather than relying on global measures of symptom severity. The YBOCS can be readily used for these purposes. The article concludes by considering additional requirements for a comprehensive assessment of obsessions and compulsions.

A pilot study of biological predictors of treatment outcome in obsessive-compulsive disorder

Although serotonin reuptake blockers such as clomipramine (The Clomipramine Collaborative Study Group 1991) and fluoxetine (Liebowitz et al 1989) are at least partially effective in approximately 60% of patients with obsessive-compulsive disorder (OCD), up to 40% of patients remain refractory. The ability to predict which patients will have a poor response to serotonin (5-HT) reuptake blockers is of clinical interest, as adequate medication trials may involve a minimum of 10-12 weeks, and other alternatives, such as behavior therapy, exist. Some evidence suggests that OCD patients with schizotypal personality (Jenike et al 1986) or with multiple axis II diagnoses (Baer et al 1992) may have a poor response to 5-HT reuptake blockers. In the multicenter clomipramine study, baseline characteristics such as age, gender, duration, severity of OCD, and depression did not correlate significantly with outcome (DeVeaugh-Geiss et al 1990). Phenomenological subtypes of OCD also do not appear to correlate with outcome (Goodman et al 1989). Although some studies fail to show an association between blood levels of clomipramine or desmethylclomipramine and trcatment outcome (Flament et al 1985; Thoren et al 1980), others report that higher clomipramine, but not desmethylclomipramine levels are associated with better outcome (Mavissakalian et al 1990). Other biological variables predictive of treatment outcome have not yet been clearly determined. Selective response of OCD to 5-HT reuptake blockers suggests that serotonin dysfunction may play an important role in this disorder (Zohar and Insel 1987). This hypothesis has been strengthened by pharmacological challenge ~tudies (Zohar et al 1987). We previously reported on the use of the partial 5-HT agonist m-chlorophenyipiperazine (mCPP) to assess 5-HT sensitivity in OCD (Hollander et al 1992). Eleven out of 20 patients (55%) experienced exacerbation of OCD symptoms following mCPP, but none had exacerbations after placebo. Prolactin re-

Predictors of treatment outcome in obsessive-compulsive disorder : Eric Hollander, M.D., Concetta M. DeCaria, M.S., Jihad B. Saoud, M.S., Sari Trungold, B.A., Maxim Frenkel, M.D., Michael R. Liebowitz, M.D. Columbia University/NYS Psychiatric Institute New York, NY 10032.

Predictors of treatment outcome in obsessive-compulsive disorder : Eric Hollander, M.D., Concetta M. DeCaria, M.S., Jihad B. Saoud, M.S., Sari Trungold, B.A., Maxim Frenkel, M.D., Michael R. Liebowitz, M.D. Columbia University/NYS Psychiatric Institute New York, NY 10032.