Relation of factor-analyzed symptom dimensions of obsessive-compulsive disorder to personality disorders

OBJECTIVE: To assess the relation between symptom dimensions of obsessive-compulsive disorder (OCD) and comorbid personality disorders (PDs). METHOD: The scores of 75 OCD outpatients on five previously identified symptom dimensions were entered into multiple regression models as predictors of: 1) the presence of any type of PD; 2) the number of PDs; 3) the presence of any cluster A, B or C PD; and 4) the presence of each individual PD. RESULTS: Twenty-eight patients (37.3%) met criteria for one or more PDs. High scores on the 'Hoarding' dimension were strongly related to the presence of any Axis II diagnosis, and to the number of PDs. Cluster C PDs (especially obsessive-compulsive and avoidant) had the highest partial correlations with 'Hoarding'. These results were independent of OCD symptom severity. CONCLUSION: Previous conflicting findings about the prevalence of certain PDs in OCD might be due in part to differences in the constitution of the particular patient groups studied.     

Symptom dimensions in obsessive-compulsive disorder: prediction of cognitive-behavior therapy outcome

OBJECTIVE: A significant number of patients with obsessive-compulsive disorder (OCD) fail to benefit sufficiently from treatments. This study aimed to evaluate whether certain OCD symptom dimensions were associated with cognitive-behavioral therapy (CBT) outcome. METHOD: Symptoms of 104 CBT-treated in-patients with OCD were assessed with the clinician-rated Yale-Brown Obsessive-Compulsive Scale symptom checklist. Logistic regression analyses examined outcome predictors. RESULTS: The most frequent OCD symptoms were aggressive and contamination obsessions, and compulsive checking and cleaning. Patients with hoarding symptoms at baseline (n = 19) were significantly less likely to become treatment responders as compared to patients without these symptoms. Patients with sexual and religious obsessions tended to respond less frequently, although this failed to reach statistical significance (P = 0.07). Regression analyses revealed that higher scores on the hoarding dimension were predictive of non-response, even after controlling for possible confounding variables. CONCLUSION: Our results strongly indicate that in-patients with obsessive-compulsive hoarding respond poorly to CBT.     

Gender differences in obsessive-compulsive symptom dimensions

The aim of our study was to assess the role of gender in OCD symptom dimensions with a multivariate analysis while controlling for history of tic disorders and age at onset of OCD. One hundred and eighty-six consecutive outpatients with a DSM-IV diagnosis of OCD were interviewed. Yale-Brown Obsessive-Compulsive Scale (YBOC-S), YBOC-S Symptom Checklist, and Hamilton Depression and Anxiety Scales were administered to all patients. Lifetime history of tic disorders was assessed with the tic inventory section of the Yale Global Tic Severity Scale. Age at onset of OCD was assessed by direct interview. Statistical analysis was carried out through logistic regression to calculate adjusted female:male odds ratios (OR) for each dimension. A relationship was found between gender and two main OCD dimensions: contamination/cleaning (higher in females; female:male OR=2.02, P=0.03) and sexual/religious (lower in females; female:male OR=0.41, P=0.03). We did not find gender differences in the aggressive/checking, symmetry/ordering, or hoarding dimensions. We also found a greater history of tic disorders in those patients with symptoms from the symmetry/ordering, dimension (P<0.01). Both symmetry/ordering and sexual/religious dimensions were associated with an earlier age at onset of OCD (P<0.05). Gender is a variable that plays a role in the expression of OCD, particularly the contamination/cleaning and sexual/religious dimensions. Our results underscore the need to examine the relationship between OCD dimensions and clinical variables such as gender, tics, age at onset and severity of the disorder to improve the identification of OCD subtypes.     

Addition of cognitive-behaviour therapy for obsessive-compulsive disorder patients non-responding to fluoxetine

OBJECTIVE: Selective serotonin re-uptake inhibitors (SSRIs) and cognitive behaviour therapy (CBT) have both proven to be effective in the treatment of obsessive compulsive disorder (OCD). It is generally recommended that adequate but unsuccessful SSRI treatment is supplemented with CBT, although only one empirical study was conducted to verify this recommendation. The present study examined the effects of supplemental CBT to continued fluoxetine treatment in OCD patients non-responding to fluoxetine alone. METHOD: After 12 weeks of fluoxetine, 14 of 56 out-patients had a reduction rate less than 25% on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and were classified as non-responders. They subsequently received 12 sessions CBT additional to the continued fluoxetine treatment. RESULTS: The mean symptom reduction as rated by the Y-BOCS, for the patients who completed both treatment phases, was 8.5% in the first phase and 41% in the second phase. CONCLUSION: Supplemental CBT for OCD patients, after initial, unsuccessful fluoxetine treatment is shown to be effective.     

Sequential cognitive-behavioral therapy for children with obsessive-compulsive disorder with an inadequate medication response: a case series of five patients

Few data have been reported on the efficacy of cognitive-behavioral therapy (CBT) for youth with obsessive-compulsive disorder (OCD) who have not responded to prior treatment with medication. Given this, we report an open trial of CBT for children who have remained symptomatic following medication trials. Five children with OCD who had an inadequate response to psychotropic medications (e.g., limited response and/or unable to be titrated to a complete dose due to side effects) received treatment in a 3-week intensive CBT program. Assessments were conducted at baseline and after treatment. All participants were classified as treatment responders (much improved or very much improved) and the severity of clinician-rated OCD symptoms and impairment significantly decreased after the intervention. Although a number of limitations of this preliminary report exist, this study provides preliminary support for the utility of an intensive intervention for youth with OCD who have had an inadequate response and/or adverse side effects.     

Group cognitive behavioural therapy for obsessive-compulsive disorder: a systematic review and meta-analysis

Objective: Behaviour therapy with exposure and response prevention (ERP) or cognitive behavioural therapy (CBT) including ERP are considered the psychological treatments of choice for obsessive–compulsive disorder (OCD), but group CBT/ERP has received relatively little research attention in the treatment of OCD. The aim of this study was to provide a meta‐analysis of the effectiveness of group CBT/ERP for OCD. Method: A systematic literature search was conducted and studies were meta‐analysed by means of the Cochrane Review Manager Program with measures of i) pre‐ to post‐effect sizes (ES) and ii) between‐group ES in comparison with different control conditions. Outcome was primarily measured on the Y‐BOCS and ES was calculated in the form of Cohens d. Results: Thirteen trials were included in the meta‐analysis. The overall pre–post‐ES of these trials of 1.18 and a between‐group ES of 1.12 compared with waiting list control in three randomized controlled studies indicate that group CBT/ERP is an effective treatment for OCD. Group CBT achieved better results than pharmacological treatment in two studies. One study found no significant differences between individual and group CBT. Conclusion: Group CBT is an effective treatment for OCD, but more studies are needed to compare the effectiveness of group and individual treatment formats.     

Predictors of treatment outcome in modular cognitive therapy for obsessive-compulsive disorder

Background: The present study sought to identify predictors of outcome for a comprehensive cognitive therapy (CT) developed for patients with obsessive–compulsive disorder (OCD). Methods: Treatment was delivered over 22 sessions and included standard CT methods, as well as specific strategies designed for subtypes of OCD including religious, sexual, and other obsessions. This study of 39 participants assigned to CT examined predictors of outcomes assessed on the Yale‐Brown Obsessive Compulsive Scale. A variety of baseline symptom variables were examined as well as treatment expectancy and motivation. Results: Findings indicated that participants who perceived themselves as having more severe OCD at baseline remained in treatment but more severe symptoms were marginally associated with worse outcome for those who completed therapy. Depressed and anxious mood did not predict post‐test outcome, but more Axis I comorbid diagnoses (mainly major depression and anxiety disorders), predicted more improvement, as did the presence of sexual (but not religious) OCD symptoms, and stronger motivation (but not expectancy). A small rebound in OCD symptoms at 1‐year follow‐up was significantly predicted by higher scores on personality traits, especially for schizotypal (but not obsessive–compulsive personality) traits. Conclusions: Longer treatment may be needed for those with more severe symptoms at the outset. CT may have positive effects not only on OCD symptoms but also on comorbid depressive and anxious disorders and associated underlying core beliefs. Findings are discussed in light of study limitations and research on other predictors. Depression and Anxiety, 2011. © 2011 Wiley‐Liss, Inc.     

Trauma and posttraumatic stress disorder in treatment-resistant obsessive-compulsive disorder

Prior research has indicated a seemingly unique relation between obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) that appears to relate to negative treatment outcome for OCD. However, to date, the prevalence of trauma and PTSD in individuals seeking treatment for OCD is unclear. To begin to address this gap, this study assessed history of traumatic experiences and current PTSD in individuals seeking treatment for treatment-resistant OCD. Trauma predictors of PTSD severity also were examined in this sample. Participants included 104 individuals diagnosed with treatment-resistant OCD who sought treatment over the course of 1 year from OCD specialty treatment facilities. Data were collected via naturalistic retrospective chart reviews of pre-treatment clinical intake files. Findings revealed that 82% of participants reported a history of trauma. Over 39% of the overall sample met criteria for PTSD, whereas almost 50% of individuals with a trauma history met criteria for PTSD. Interpersonal traumas and greater frequency of traumas were most predictive of PTSD severity, and individuals diagnosed with OCD and additional major depressive disorder (MDD) or borderline personality disorder (BPD) appeared at particular risk for a comorbid PTSD diagnosis. PTSD may be relatively common in individuals diagnosed with treatment-resistant OCD; and interpersonal traumas, MDD, and BPD may play a relatively strong predictive role in PTSD diagnosis and severity in such OCD patients.     

Obsessive-compulsive disorder in youth with and without a chronic tic disorder

The goal of this study was to discriminate subtypes of pediatric obsessive-compulsive disorder (OCD) among youth with and without a comorbid tic disorder. Seventy-four youth (M(age)=9.7+/-2.3 years) with a principal diagnosis of OCD, with (n=46) or without (n=28) a comorbid tic disorder, were assessed with a semi-structured diagnostic interview and the Children's Yale Brown Obsessive-Compulsive Scale (CY-BOCS). The CY-BOCS Symptom Checklist was used to categorize obsessions and compulsions. Group differences were analyzed by t tests, chi(2), and discriminant function analyses. Results suggested that subjects without tics had significantly more contamination obsessions, sexual obsessions, and counting compulsions than youth with comorbid tics. Generally speaking, however, youth with and without tics had similar symptom presentations. These data suggest that pediatric OCD patients with and without comorbid tics may have some aspects of symptom presentation that differ, but generally have more OCD symptoms in common than different. Implications of these findings on clinical presentation and treatment efficacy are highlighted.     

Deep brain stimulation for treatment-refractory obsessive-compulsive disorder: psychopathological and neuropsychological outcome in three cases

OBJECTIVE: Investigation of deep brain stimulation (DBS) as a last-resort treatment alternative to capsulotomy in treatment-refractory obsessive-compulsive disorder (OCD). METHOD: Prospective single-case based design with evaluation of DBS impact on emotions, behaviour, personality traits and executive function in three patients with OCD. RESULTS: Two patients experienced sustained improvement of OCD symptoms with DBS. Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) dropped 12 points and 23 points to baseline and Y-BOCS self-rating scale (Y-BOCS-SRS) and Profile of Mood States (POMS) for depression and tension decreased with increasing stimulation amplitude. Total Maladjustment Score on the Brief Psychiatric Rating Scale reduced with 44 and 59% to baseline. Reduction in psychopathology was sustained under continuous stimulation. No deleterious impact of DBS on neuropsychological testing or personality traits measured on a self-rated personality inventory was detected. CONCLUSION: These preliminary findings demonstrate that DBS may have important therapeutic benefits on psychopathology in OCD. No harmful side-effects were detected during follow-up (33/33/39 months, respectively).     

Aripiprazole augmentation of incomplete treatment response in an adolescent male with obsessive-compulsive disorder

We report the case of adolescent male with obsessive-compulsive disorder (OCD) who had an incomplete response to combined cognitive-behavioral therapy (CBT) and sertraline before successful augmentation of CBT with aripiprazole. Standardized assessments indicated significant reductions in OCD symptomatology associated with both initial treatment and aripiprazole augmentation. This case suggests that aripiprazole may have utility as an augmenting agent of CBT in adolescents with OCD and underscores the need for conducting controlled studies to test this hypothesis.     

Quantitative and qualitative aspects of obsessive-compulsive behaviour in children with attention-deficit hyperactivity disorder compared with tic disorder

OBJECTIVE: Within the framework of associated psychopathology in child psychiatric disorders, this study focused on quantitative and qualitative aspects of obsessive-compulsive behaviour (OCB) in both attention-deficit hyperactivity disorder (ADHD) and chronic tic disorder/Tourette's disorder (TD). METHOD: Forty-two healthy controls, 41 children with ADHD and 38 children with TD, aged 9-13 years, were investigated using the Leyton Obsessional Inventory--Child Version (LOI-CV), the Child Behaviour Checklist (CBCL) and an expert-rated structured parent interview to reflect a cross-informant view of OCB. RESULTS: Unexpectedly, self-reports of children with ADHD rather than children with TD showed the highest OCB scores in the LOI-CV. Qualitatively, ADHD-related OCB focused on the item subsets concerning 'dirt and contamination', 'repetition', 'overconscientiousness', and 'hoarding'. In the parent-rated CBCL, similar levels of OCB were reported for ADHD and TD patients. In contrast, only children with TD showed clinically relevant OCB according to expert ratings. CONCLUSION: Not only young TD patients but also children with ADHD should be investigated and monitored carefully for quantitative and qualitative aspects of OCB comorbidity.     

Randomized comparative study of group versus individual cognitive behavioural therapy for obsessive compulsive disorder

Jónsson H, Hougaard E, Bennedsen BE. Randomized comparative study of group versus individual cognitive behavioural therapy for Obsessive Compulsive Disorder. Objective: The primary aim of the study was to compare the effectiveness of group and individual cognitive behaviour therapy (CBT) for obsessive compulsive disorder (OCD). Method: One hundred and ten out‐patients with OCD were randomly assigned to 15 sessions of either group CBT or individual CBT. Outcome measures were administered before and after treatment, as well as at 6‐ and 12‐month follow‐ups. The study was supplemented by a meta‐analysis of accomplished comparative studies of group vs. individual CBT for OCD. Results: Large and stable pre–post effect sizes were found for both treatment conditions in the study (d = 1.06–1.24 on the Yale‐Brown Obsessive Compulsive Scale). There were no significant between‐group differences in outcome at any data point (ds = −0.13 to 0.15). The meta‐analysis of four accomplished comparative studies (including the present one) found a between‐group mean effect size of d = 0.15 favouring individual over group CBT at posttreatment (95% confidence interval, −0.12, 0.42). Conclusion: The results of this study suggest that OCD can be treated effectively with a group format of CBT, thus sparing some therapist resources, although the four accomplished comparative studies do not rule out the possibility of a small superiority of individually conducted CBT.     

Symptoms of eating disorders in obsessive-compulsive disorder

OBJECTIVE: Despite some empirical evidence suggesting an association between primary OCD and eating disorder (ED) within the 'obsessive-compulsive spectrum', the relationship at a symptomatological level has not been investigated. METHOD: First, comparisons of Eating Disorder Inventory (EDI) scores between 61 patients with primary OCD and 288 control subjects were performed. Secondly, the associations between EDI subscores and Hamburg Obsessive-Compulsive Inventory (HZI) dimensions in OCD patients were investigated by multiple regression analyses, controlling for the impact of general psychopathology. RESULTS: The OCD patients showed significantly higher EDI-scores than controls. However, only distinct OCD symptom dimensions were significantly associated with the core symptoms of ED in females. CONCLUSION: Our results point to a differential gender and symptom-specific relationship between OCD and ED, calling into question a simple dimensional conceptualization of the 'obsessive-compulsive spectrum'.     

Low novelty-seeking differentiates obsessive-compulsive disorder from major depression

OBJECTIVE: To make a direct comparison of patients with obsessive-compulsive disorder (OCD) and major depression (MD) and a normal control group in terms of the Temperament and Character Inventory (TCI) personality dimensions. METHOD: Additionally to 43 patients with primary OCD, 43 MD patients and 43 normal subjects who were matched against the OCD patients for sex and age filled out the TCI. RESULTS: Compared to the controls, the OCD and MD patients scored significantly higher on harm avoidance and significantly lower on self-directedness and co-operativeness. The OCD patients scored significantly lower on novelty-seeking than the MD patients and the controls. CONCLUSION: Whereas OCD and MD share similar personality deviations on harm avoidance, self-directedness and co-operativeness, OCD is distinguishable from MD in terms of low novelty-seeking. Low novelty-seeking may have a profound relationship to the specific aetiology of OCD.     

Childhood trauma in obsessive-compulsive disorder, trichotillomania, and controls

There is relatively little data on the link between childhood trauma and obsessive-compulsive/putative obsessive-compulsive spectrum disorders. The revised Childhood Trauma Questionnaire (CTQ), which assesses physical, emotional, and sexual abuse as well as physical and emotional neglect, was administered to female patients with obsessive-compulsive disorder (OCD; n = 74; age: 36.1 plus minus 16.3), TTM (n = 36; age: 31.8 plus minus 12.3), and a group of normal controls (n = 31; age: 21.5 plus minus 1.0). The findings showed a significantly greater severity of childhood trauma in general, and emotional neglect specifically, in the patient groups compared to the controls. Although various factors may play a role in the etiology of both OCD and trichotillomania (TTM), this study is consistent with some evidence from previous studies suggesting that childhood trauma may play a role in the development of these disorders.     

Successful medication withdrawal after cognitive‐behavioral therapy in a treatment‐resistant preadolescent male with obsessive‐compulsive disorder

There are no reports of a child taking a selective serotonin reuptake inhibitor and an atypical anti‐psychotic being successfully tapered from these medications after completion of cognitive‐behavioral therapy (CBT) for obsessive‐compulsive disorder. With this in mind, we report the case of an 8.5‐year–old male who was taking risperidone 0.5 mg bid, sertraline 100 mg, and atomoxetine 25 mg at presentation. After a successful course of CBT, we describe how medications were systematically withdrawn. Implications of this case on practice parameters (e.g., CBT may be an effective augmenting agent for those non‐responsive to initial pharmacological treatments) are highlighted. Depression and Anxiety, 2009. © 2008 Wiley‐Liss, Inc.     

Uncomplicated and comorbid obsessive-compulsive disorder in an epidemiologic sample

This study investigated lifetime prevalence rates, demographic characteristics, childhood conduct disorder and adult antisocial features, suicide attempts, and cognitive impairment in individuals with obsessive-compulsive disorder (OCD) uncomplicated by or comorbid with any other psychiatric disorder. The data are from the NIMH Epidemiologic Catchment Area (ECA) study, and the current analyses compared subjects with uncomplicated OCD (no history of any other lifetime psychiatric disorder), comorbid OCD (with any other lifetime disorder), other lifetime psychiatric disorders, and no lifetime psychiatric disorders across these variables. OCD in its uncomplicated and comorbid form had significantly higher rates of childhood conduct symptoms, adult antisocial personality disorder problems, and of suicide attempts than did no or other disorders. Comorbid OCD subjects had higher rates of mild cognitive impairment on the Mini-Mental Status Exam than did subjects with other disorders. These findings suggest that a subgroup of OCD patients may have impulsive features, including childhood conduct disorder symptoms and an increased rate of suicide attempts; wider clinical attention to these outcomes is needed. Depression and Anxiety 4:111–119, 1996/1997.© 1997 Wiley-Liss, Inc.     

Classification of obsessive-compulsive disorder in childhood and adolescence

OBJECTIVE: In child and adolescent psychiatry the validation of the diagnosis must be seen in the context of development. Comparing different diagnostic formulations DSM-IV and ICD-10-DCR in a clinical sample of children and adolescents suffering from obsessive-compulsive disorder (OCD) and their validation on external criteria represent such a heuristic approach. METHOD: We investigated 61 children seen consecutively in a specialized out-patient clinic for OCD. All of them were assessed by the International Diagnostic Checklists (IDCL). Diagnosis and diagnostic certainty were validated regarding age, age of onset and duration of illness. RESULTS: The agreement between the two diagnostic systems was low. The diagnostic stability of ICD-10-DCR was highly dependent on age, whereas that of the criteria DSM-IV did not depend on age and almost all subjects could be diagnosed definitely. CONCLUSION: This study suggests that the DSM-IV criteria are superior to that of ICD-10-DCR for diagnosing OCD in children and younger adolescents.