Adults with early-onset obsessive-compulsive disorder.

OBJECTIVE: Obsessive-compulsive disorder (OCD) is a clinically heterogeneous disorder with a bimodal age at onset and range of treatment outcomes. This study attempted to ascertain the importance of the age at OCD symptom onset for a better phenotypic precision. Therefore, the authors compared adult OCD patients with an early symptom onset to OCD patients with a later symptom onset. METHOD: Forty-two adult outpatients with OCD were evaluated with semistructured interviews: 21 with symptom onset before the age of 10 (early-onset group) and 21 with symptom onset after the age of 17 (late-onset group). RESULTS: Early onset was associated with higher scores on the Yale-Brown Obsessive Compulsive Scale, higher frequencies of tic-like compulsions, higher frequency of sensory phenomena, and a higher rate of comorbid tic disorders. The early-onset group also responded less well to treatment with clomipramine and selective serotonin reuptake inhibitors. CONCLUSIONS: The results indicate that age at onset may be an important factor in subtyping OCD and that the phenotypic differences found were not restricted to childhood.     

Fluvoxamine treatment of obsessive-compulsive disorder

Sixteen outpatients who met DSM-III criteria for obsessive-compulsive disorder completed a 20-week double-blind, crossover trial with fluvoxamine and placebo. Thirteen (81%) improved with fluvoxamine, while three (19%) improved with placebo. Fluvoxamine treatment was associated with significant improvement on measures of obsessive-compulsive symptoms, anxiety, and depression. Depressed subjects' improvement on obsessive-compulsive measures correlated with improvement in symptoms of depression. Nondepressed subjects also showed improvement on measures of obsessive-compulsive symptoms. In this trial, fluvoxamine was an effective and safe treatment for obsessive-compulsive disorder.     

Nicotine treatment of obsessive-compulsive disorder

Following initial observations of marked effects of nicotine self-medication in a patient with obsessive-compulsive disorder (OCD), another four OCD patients were treated with nicotine for eight weeks in an open label fashion. Patients fulfilling DSM-IV criteria for OCD and with initial Yale-Brown Obsessive-Compulsive Scale (YBOCS) score>15 were included in the study. The patients were scored with YBOCS, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), NIMH Global Obsessive-Compulsive Scale (NIMH) and Global Assessment of Functioning (GAF). Four of five patients receiving nicotine treatment displayed a favourable response with reductions in YBOCS scores. For these four patients, the nicotine chewing gum enabled a more adequate behaviour in stressful, OCD-eliciting, situations. We feel that these results are encouraging enough to warrant a larger, controlled study on nicotine treatment of OCD.     

Zimeldine treatment of obsessive-compulsive disorder

ABSTRACT– Six patients with Obsessive-Compulsive Disorder (DSM III) were treated in an open uncontrolled trial with Zimeldine, for 8 weeks. All six patients had cognitive deficits before treatment. Five patients improved on the clinical symptoms. Four of these showed pronounced amelioration of their cognitive deficits.     

Psychosocial treatment of obsessive-compulsive disorder

Although progress is being made in the application of cognitive therapy to obsessive-compulsive disorder (OCD), behavior therapy, especially exposure and response prevention, is currently the nonpharmacological treatment of choice. The behavioral model of OCD states that obsessive fears give rise to anxiety. This anxiety is then reduced by compulsive behaviors, which are thus maintained by negative reinforcement.While the model falls short of explaining the acquisition of obsessions, it does give an adequate account of the maintenance of compulsive behaviors. For the most part, behavior therapy has been at least as effective as medication and shows lasting benefits at follow up. Impediments to progress in treatment include noncompliance, severe depression, personality disorders and overvalued ideas. Treatment guidelines for behavior therapy are presented. In the cognitive model of OCD, automatic thoughts involving overestimated perceived personal responsibility and exaggerated perceived threat lead to anxiety; compulsive rituals function to reduce this anxiety. The effectiveness of cognitive therapy in the treatment of OCD is assessed and some treatment guidelines are provided. Although behavior therapy is the treatment of choice for OCD, patients can benefit from the addition of antidepressant medication or cognitive therapy, at least during the initial stages of treatment.     

Family-based cognitive-behavioral therapy for pediatric obsessive-compulsive disorder: comparison of intensive and weekly approaches

OBJECTIVE: To examine the relative efficacy of intensive versus weekly cognitive-behavioral therapy (CBT) for children and adolescents with obsessive-compulsive disorder (OCD). METHOD: Forty children and adolescents with OCD (range 7-17 years) were randomized to receive 14 sessions of weekly or intensive (daily psychotherapy sessions) family-based CBT. Assessments were conducted at three time points: pretreatment, posttreatment, and 3-month follow-up. Raters were initially blind to randomization. Primary outcomes included scores on the Children's Yale-Brown Obsessive-Compulsive Scale, remission status, and ratings on the Clinical Global Impression-Severity and Clinical Global Improvement scales. Secondary outcomes included the Child Obsessive Compulsive Impact Scale-Parent Rated, Children's Depression Inventory, Multidimensional Anxiety Scale for Children, and Family Accommodation Scale. Adjunctive pharmacotherapy was not an exclusion criterion. RESULTS: Intensive CBT was as effective as weekly treatment with some advantages present immediately after treatment. No group differences were found at follow-up, with gains being largely maintained over time. Although no group x time interaction was found for the Children's Yale-Brown Obsessive-Compulsive Scale (F(1,38) = 2.2, p = .15), the intensive group was rated on the Clinical Global Impression-Severity as less ill relative to the weekly group (F(1,38) = 9.4, p < .005). At posttreatment, 75% (15/20) of youths in the intensive group and 50% (10/20) in the weekly group met remission status criteria. Ninety percent (18/20) of youths in the intensive group and 65% (13/20) in the weekly group were considered treatment responders on the Clinical Global Improvement (chi1(2) = 3.6, p = .06). CONCLUSIONS: Both intensive and weekly CBT are efficacious treatments for pediatric OCD. Intensive treatment may have slight immediate advantages over weekly CBT, although both modalities have similar outcomes at 3-month follow-up.     

Association studies of serotonin system candidate genes in early-onset obsessive-compulsive disorder.

BACKGROUND: Family-based evidence for association at serotonin system genes SLC6A4, HTR1B, HTR2A, and brain-derived neurotrophic factor (BDNF) has been previously reported in obsessive-compulsive disorder (OCD). Early-onset OCD is a more familial form of the disorder. METHODS: We used the transmission-disequilibrium test of association at common polymorphisms in each of these genes in 54 parent-child trios ascertained through probands with early-onset OCD. RESULTS: No evidence for association was detected at any of the polymorphisms in the entire set of subjects. Nominally significant association was found at the HTR2A rs6311 polymorphism in subjects with tic disorder and OCD (p = .05), replicating a previous finding in Tourette syndrome and OCD. Nominally significant association was also found for the SLC6A4 HT transporter gene-linked polymorphic region (5-HTTLPR) polymorphism for female subjects (p = .03). Neither association would remain significant after statistical correction for multiple testing. Despite no individual study reporting replication, a pooled analysis of five replication studies of the SLC6A4 5-HTTLPR polymorphism supports association (p = .02). CONCLUSIONS: Low power across individual association studies in OCD may lead to a false acceptance of the null hypothesis. Accumulation of evidence from multiple studies will be necessary to evaluate the potential role for these genes in contributing to susceptibility to OCD.     

Successful treatment of refractory obsessive-compulsive disorder

A case study is presented of a 40-year-old man with obsessive-compulsive disorder (OCD). He had been treated with long-term institutional placement, electroconvulsive therapy, exhaustive pharmacotherapy, and psychodynamic and cognitive-behavioral psychotherapy. Nothing had relieved his excessive hand washing and door checking. Records from previous treatment revealed a diagnosis of dissociative identity disorder (DID). This information led to reconceptualization of the OCD symptoms as manifestations of the patient's ego fragmentation. When his fragments were catalogued and addressed, all overt OCD symptoms abated within weeks. It is believed that the patient's most anxious ego fragment communicated dread from the background of the patient's psyche, the executive component only being aware of the anxiety and not the triggering stimulus. The patient was taught to address this fragment verbally to elicit its cooperation, whereupon the fragment stopped sounding alarm, creating anxiety and driving the patient to check and recheck, wash and rewash. Symptoms have returned only when the patient has suspended his announcing behavior and have abated when this was resumed. Connections between OCD and DID are addressed. CONCLUSION: Patients exhibiting refractory OCD symptoms should be assessed for dissociative symptomatology.     

Recognition and treatment of obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is prevalent, chronic, and potentially disabling. It is characterized by recurrent, unwanted, and distressing thoughts (obsessions) and repetitive, irresistible, behaviors (compulsions). Individuals with OCD recognize that the obsessions and compulsions are senseless or excessive yet they are unable to stop these behaviors. Some etiologic theories of OCD suggest a biological origin, including hypotheses involving the serotonergic system, the glutamatergic system, the orbital cortex and the basal ganglia, and streptococcal throat infections in children. Standard treatments for OCD include selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavior therapy. Combining SSRIs with other medications has relatively little empirical support; however, the adjunctive use of antipsychotics has been shown to be effective. Neurosurgery, such as deep brain stimulation, has also been shown to be effective in select patients with debilitating and refractory OCD.     

Fluoxetine treatment of obsessive-compulsive disorder.

Two patients suffering from severe obsessive-compulsive disorder which had proven refractory to clomipramine and/or phenelzine treatment were successfully treated with fluoxetine, a new drug with a strong serotonin uptake inhibiting action. Outcome of treatment was measured on psychometric tests including the Leyton Obsessive Inventory, Hopkins Symptom Checklist-90, Beck Depression Inventory, and daily self-reports of the duration and degree of discomfort of their most severe obsessions. The delay in responding to fluoxetine, the continuing improvement even after one year on the drug, and the prompt relapse with abrupt withdrawal of treatment were noted.     

Trazodone treatment in clomipramine-resistant obsessive-compulsive disorder

Trazodone (TZ) was administered to nine patients suffering from obsessive-compulsive disorder (OCD), who failed to respond to either clomipramine (CMI) or to CMI plus lithium carbonate. The group, as a whole, showed significant but mild improvement. Three patients responded very favorably to TZ. In these three responders, efficacy was substantiated by the return of the original obsessive-compulsive (OC) symptoms following TZ withdrawal and their amelioration after its readministration. Interestingly, the aggravation of OCD symptomatology that has been associated with a specific TZ metabolite was not observed. This study is consistent with previous reports of the anti-OC efficacy of TZ and suggests the involvement of complex serotonergic mechanisms in the pathophysiology of this disorder.     

The psychological treatment of obsessive-compulsive disorder.

The psychological treatment of obsessive-compulsive disorder (OCD) with exposure and response prevention (ERP) methods is one of the great success stories within the field of mental health. Within the span of about 20 years, the prognosis for individuals with OCD has changed from poor to very good as a result of the development of ERP. This success not with-standing, the procedures are far from perfect because a substantial minority of patients still either refuse treatment, drop out prematurely, or fail to benefit. I begin this article with a review of the development of ERP from early animal research on avoidance learning conducted during the 1950s. Next, I discuss the mechanisms of ERP. The bulk of the article reviews the treatment-outcome literature on ERP for OCD and includes comparisons with cognitive therapy--the "new kid on the block" with respect to psychological treatments for OCD.