Development of the Treatment Adherence Survey-patient version (TAS-P) for OCD

This paper reports on the development and initial psychometric evaluation of the Treatment Adherence Survey-patient version (TAS-P), a brief instrument designed to assess patient adherence to Cognitive-Behavioral Therapy (CBT) and pharmacotherapy recommendations for OCD. Eighty individuals with Obsessive Compulsive Disorder (OCD) were administered the TAS-P as part of the intake interview of a prospective, observational study of the course of OCD. Results demonstrated excellent test-retest reliability. Responses on the TAS-P were also significantly correlated with scores on a self-report measure of general treatment adherence and with data collected from a chart-review, demonstrating concurrent validity. Treatment adherence was not explained by demographic variables. However, participants who reported nonadherence to CBT recommendations had more severe OCD symptoms at the time of intake than those who did not endorse CBT nonadherence (mean Y-BOCS = 23.27 +/- 7.5 versus 18.20 +/- 8.0, respectively). Results suggest that the TAS-P is a promising instrument for assessing reasons for nonadherence to recommendations for CBT and pharmacotherapy interventions.     

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.     

The distinctiveness of compulsive hoarding from obsessive-compulsive disorder

The present study investigated the relation of compulsive hoarding to other obsessive-compulsive disorder (OCD) symptoms in a sample of 162 patients with OCD. Obsessions and compulsions reported on the Anxiety Disorders Interview Schedule for DSM-IV were submitted to an exploratory factor analysis. Results suggested a four-factor model: "Certainty," "Contamination," "Obsessions," and "Numbers/Ordering." Hoarding did not load on any factor. The sample was divided into three groups: pure hoarding, nonhoarding OCD, and mixed OCD and hoarding. The hoarding group endorsed significantly less anxiety, worry, stress, and negative affect on self-report measures than the mixed and nonhoarding groups. Although hoarding sometimes functions as a compulsion among individuals with OCD, hoarding in the absence of other OCD symptoms may be a clinically distinct syndrome.     

Imagery special issue: intrusive images and memories of earlier adverse events in patients with obsessive compulsive disorder

Mental imagery is increasingly considered to be an important feature in anxiety disorders. The aim of this study was to investigate the prevalence and characteristics of mental images in obsessive compulsive disorder (OCD) and their possible association with earlier adverse events. A consecutive sample of 37 patients with OCD admitted to a specialist unit was interviewed using a semi-structured interview. Thirty (81%) patients with OCD reported mental images. Most images were either memories of earlier adverse events (n=10 or 34%) or were associated with them (n=13 or 45%). Patients with mental images had more obsessive compulsive symptoms, responsibility beliefs and anxiety than those without. Previous research has shown that patients with OCD and comorbid posttraumatic stress disorder might not benefit as much from standard behavioural treatment as those without. Consequently, additional therapeutic interventions such as imaginal reliving and restructuring of meaning or imagery modification of traumatic memories might be helpful in OCD patients with mental images that are linked to earlier adverse events.     

Tourette syndrome in youth with and without obsessive compulsive disorder and attention deficit hyperactivity disorder

Chronic tic disorders (TD) are consistently found to have high rates of comorbidity with obsessive-compulsive disorder (OCD) and attention deficit hyperactivity disorder (ADHD). The purpose of this study is to compare the severity of TD only to TD with comorbid OCD or ADHD based on severity of tics, measures of psychopathology and additional comorbid diagnoses. Baseline data from 158 youth with a chronic TD who participated in two longitudinal studies were examined. Fifty-three percent (N = 85) of the youth also met criteria for a diagnosis of OCD, 38.6 % (n = 61) met criteria for ADHD and 24.1 % (N = 38) met criteria for both. Measures of interest addressed severity of tics, symptoms of anxiety, depression, ADHD, psychosocial stress, global functioning and the presence of comorbid diagnoses. Youth with comorbid TD and OCD were characterized by more severe tics, increased levels of depressive and anxious symptoms, heightened psychosocial stress and poorer global functioning. Youth with comorbid TD and ADHD did not differ from those with TD alone on measures of tic severity, but experienced greater psychosocial stress and poorer global functioning. Subjects with comorbid TD and OCD had more internalizing disorders than those without OCD, while those with comorbid ADHD were more likely to meet criteria for oppositional defiant disorder. TD with OCD is a more severe subtype of TD than TD without OCD. TD with ADHD is associated with higher psychosocial stress and more externalizing behaviors. Further research is needed into the underlying relationships between these closely associated conditions.     

Case study: bibliotherapy and extinction treatment of obsessive-compulsive disorder in a 5-year-old boy

Cognitive-behavioral therapy (CBT) is an effective treatment for childhood obsessive-compulsive disorder (OCD). However, no case studies of children younger than 7 years old have been published. This case report describes a 5-year-old boy with severe OCD. Treatment consisted of parent- and teacher-directed extinction of compulsive reassurance-seeking, and bibliotherapy with an age-appropriate book on OCD. Compulsive behavior decreased rapidly and remained at a low level through the remainder of treatment. At posttreatment and at 1- and 3-month follow-up assessments, the patient's OCD symptoms were markedly improved. This report suggests that very young children may respond well to brief CBT.     

Rapid effects of brief intensive cognitive-behavioral therapy on brain glucose metabolism in obsessive-compulsive disorder

Brief intensive cognitive-behavioral therapy (CBT) using exposure and response prevention significantly improves obsessive-compulsive disorder (OCD) symptoms in as little as 4 weeks. However, it has been thought that much longer treatment was needed to produce the changes in brain function seen in neuroimaging studies of OCD. We sought to elucidate the brain mediation of response to brief intensive CBT for OCD and determine whether this treatment could induce functional brain changes previously seen after longer trials of pharmacotherapy or standard CBT. [(18)F]-fluorodeoxyglucose positron emission tomography brain scans were obtained on 10 OCD patients before and after 4 weeks of intensive individual CBT. Twelve normal controls were scanned twice, several weeks apart, without treatment. Regional glucose metabolic changes were compared between groups. OCD symptoms, depression, anxiety and overall functioning improved robustly with treatment. Significant changes in normalized regional glucose metabolism were seen after brief intensive CBT (P=0.04). Compared to controls, OCD patients showed significant bilateral decreases in normalized thalamic metabolism with intensive CBT but had a significant increase in right dorsal anterior cingulate cortex activity that correlated strongly with the degree of improvement in OCD symptoms (P=0.02). The rapid response of OCD to intensive CBT is mediated by a distinct pattern of changes in regional brain function. Reduction of thalamic activity may be a final common pathway for improvement in OCD, but response to intensive CBT may require activation of dorsal anterior cingulate cortex, a region involved in reappraisal and suppression of negative emotions.     

Neurosteroids modulate compulsive and persistent behavior in rodents: Implications for obsessive–compulsive disorder

Neurosteroids are reported to modulate GABAergic and glutamatergic pathways that then influence serotonin and dopamine, the neurotransmitters implicated in pathophysiology of obsessive–compulsive disorder (OCD). Fluoxetine, a selective serotonin reuptake inhibitor clinically used in OCD is reported to increase the levels of neurosteroids like allopregnanolone, whereas OCD patients exhibit higher plasma levels of dehydroepiandrosterone 3-sulphate (DHEAS), a neuroactive steroid having opposite effects to that of allopregnanolone. Hence, it was contemplated that neurosteroids may influence obsessive–compulsive behavior. To test this possibility we studied the influence of various neurosteroids on two behavioral models of OCD, namely marble-burying behavior in mice and 8-OH-DPAT induced disruption of spontaneous alternation behavior (SAB) in rats. The results revealed that allopregnanolone (1 µg/mouse, i.c.v) and progesterone (20 mg/kg, s.c.) reduced the marble-burying behavior in mice, whereas dehydroisoandrosterone 3-sulphate (DHAS) (5 mg/kg, i.p.) exacerbated the same. The effects of allopregnanolone were comparable to that of fluoxetine (10 mg/kg, i.p.). In view of the report that restraint stress increases the levels of allopregnanolone and isolation stress decreases the same, we studied the effect of these stressors on marble-burying behavior; wherein it was found to be less in restraint stress exposed mice, and higher in socially isolated mice. Restrain stress-induced attenuation of marble-burying behavior was blocked by finasteride, a neurosteroid biosynthesis blocker. In rat model of SAB disruption, acute and chronic treatment with allopregnanolone (1 µg/mouse, i.c.v.) reduced 8-OH-DPAT-induced persistent behavior, whereas treatment with DHAS (5 mg/kg, i.p.) had an opposite effect. In conclusion, the studies indicate that neurosteroids can modulate obsessive–compulsive behavior in a bidirectional manner, and could serve as an effective target in the management of OCD.     

Self-help with minimal therapist contact for obsessive-compulsive disorder: a review.

Though there are effective psychological and drug treatments for obsessive-compulsive disorder (OCD), many patients remain inadequately treated or untreated. Making effective self-treatment guidance available may increase the number of patients being helped. In this review, database and manual literature searches were performed of case studies, open and randomised controlled trials (RCTs) of bibliotherapy, self-help groups, telecare and computer-aided self-help for OCD. We found no RCTs of bibliotherapy or self-help groups for OCD. Three open studies showed the efficacy of brief exposure and ritual prevention (ERP) instructions delivered by a live therapist by phone. A vicarious ERP computer program was effective in a small open study. Fully interactive computer-aided self-help by ERP for OCD was efficacious in two open studies and a large multicentre RCT, and in a small RCT compliance and outcome with that program was enhanced by brief scheduled support from a clinician. Although more research is needed, self-help approaches have the potential to help many more patients who would otherwise remain inadequately treated or untreated. Their dissemination could save resources used by health care providers. We propose a stepped care model for the treatment of OCD.     

Assessment of obsessive-compulsive disorder: review and future directions

Careful evaluation of obsessive-compulsive disorder (OCD) is critical owing to its under-recognition, difficulty ascertaining accurate diagnoses and the need for detailed treatment planning. We review current methods for the assessment of OCD in adults, including unstandardized clinical interviews, standardized diagnostic and other clinical interviews, patient- and family-report measures, and brief or web-based screening measures. Depending upon the question of interest, clinicians and researchers may select from these measures to best assess obsessive-compulsive symptoms in multiple settings. Current research regarding the assessment of OCD has focused on the underlying symptom dimensions, suggesting that each symptom dimension may be associated with different etiology and require tailored treatment. In the future, research may show that effective assessment of OCD involves identification of relevant symptom dimensions to facilitate the choice of appropriate treatment.     

Stressful life events and material deprivation in hoarding disorder

Traumatic life events and early material deprivation have been identified as potential environmental risk factors for the development of pathological hoarding behavior, but the evidence so far is preliminary and confounded by the presence of comorbid obsessive-compulsive disorder (OCD). This study retrospectively examined the occurrence of traumatic/stressful life events and material deprivation in four well-characterized groups: hoarding disorder without comorbid OCD (HD; n = 24), hoarding disorder with comorbid OCD (HD + OCD; n = 20), OCD without hoarding symptoms (OCD; n = 17), and non-clinical controls (Control; n = 20). Participants completed clinician and self-administered measures of hoarding, OCD, depression, psychological adjustment, and traumatic experience. Semi-structured interviews were undertaken to assess the temporal relation between traumatic/stressful life events and the onset and worsening of hoarding symptoms, and to determine the level of material deprivation. Although rates of post-traumatic stress disorder were comparable across all three clinical groups, hoarders (regardless of the presence of comorbid OCD) reported greater exposure to a range of traumatic and stressful life events compared to the two non-hoarding groups. Results remained unchanged after controlling for age, gender, education level, depression, and obsessive-compulsive symptoms. The total number of traumatic life events correlated significantly with the severity of hoarding but not of obsessive-compulsive symptoms. About half (52%) of hoarding individuals linked the onset of hoarding difficulties to stressful life circumstances, although this was significantly less common among those reporting early childhood onset of hoarding behavior. There was no link between levels of material deprivation and hoarding. Results support a link between trauma, life stress and hoarding, which may help to inform the conceptualization and treatment of hoarding disorder, but await confirmation in a representative epidemiological sample and using a longitudinal design.     

Persistent,unwanted erections in an 8-year-old boy

Although unusual somatic preoccupations can be seen in somatoform disorders and obsessive-compulsive disorder (OCD), unwanted penile erections have been described only in two cases of OCD, both adults. In the present case an 8-year-old boy developed unwanted erections, other obsessive-compulsive symptoms, as well as symptoms of posttraumatic stress disorder, such that he met criteria for both disorders. Treatment consisted of sertraline combined with individual play therapy and family therapy, following which the patient reported modest improvement in symptoms of both disorders.     

Repetitive behaviors in Tourette's syndrome and OCD with and without tics: what are the differences?

Gilles de la Tourette Syndrome (GTS) and obsessive-compulsive disorder (OCD) share obsessive-compulsive phenomena. The aims of this study were to compare the OC symptom distribution between GTS and OCD and to investigate whether a subdivision of these phenomena into obsessions, compulsions and 'impulsions' is useful in distinguishing GTS and OCD patients. Thirty-two GTS, 31 OCD (10 with tics, 21 without tics) and 29 control subjects were studied using the Leiden repetitive behaviors semi-structured interview to assess GTS as well as OCD-related behaviors. Each reported repetitive thought or action was evaluated on the presence of anxiety and on goal-directedness. This information was used to define whether the behavior was an obsession, compulsion, or 'impulsion'. Both the GTS and OCD study groups showed higher scores than control subjects on rating scales measuring depression, OC behavior and anxiety. In GTS, Y-BOCS severity scores and trait anxiety were lower than in the OCD groups. Furthermore, GTS patients differed from OCD patients in the distribution of symptoms. Aggressive repetitive thoughts, contamination worries and washing behaviors were reported more frequently by tic-free OCD, while mental play, echophenomena, touching and (self)-injurious behaviors were reported more frequently by GTS. OCD individuals with tics were intermediate, but closer to tic-free OCD. GTS individuals reported significantly more 'impulsions' and fewer obsessions and compulsions than OCD individuals with and without tics. Factor analysis revealed three factors accounting for 44% of the variance, resulting in an 'impulsive' factor related to GTS, a 'compulsive' factor related to OCD and an 'obsessive' factor related to tic-free OCD. In conclusion, OCD individuals reported more anxiety and goal-directedness associated with their behaviors than did GTS subjects. The distinction between obsessions, compulsions and impulsions is of importance in identifying Tourette-related vs. non-Tourette-related repetitions.     

The relationship between types and severity of repetitive behaviors in Gilles de la Tourette's disorder and obsessive-compulsive disorder

BACKGROUND: This study investigated which categories of obsessive-compulsive and Tourette-related behaviors in Gilles de la Tourette's disorder and obsessive-compulsive disorder (OCD) without tics are experienced as most severe across the study groups and what the differences are in symptom distribution between the study groups. METHOD: Fourteen subjects with both Tourette's disorder and OCD, 18 subjects with Tourette's only, 21 subjects with OCD (no tics), and 29 control subjects were studied using a semistructured interview designed to equally assess Tourette- and OCD-related behaviors according to DSM-III-R criteria. Each reported repetitive behavior was evaluated on the presence of anxiety and on goal-directedness. Anxiety-related items were categorized as obsessions or compulsions and non-anxiety-related items as impulsions. Severity of each reported item was assessed with respect to time per day consumed and amount of distress and interference induced by the item. Following these criteria, each reported item was classified as a symptom, a subthreshold symptom, or just as being present. RESULTS: Across the study groups, obsessions were experienced as more severe than (Tourette-related) impulsions and compulsions. Within the study groups, patients with both Tourette's disorder and OCD reported more symptomatic Tourette-related impulsions, such as mental play, echophenomena, and impulsive or self-injurious behaviors; less overall symptomatic obsessions; and less symptomatic washing than patients with OCD (no tics). The differences among individuals with Tourette's with or without OCD reflected differences in symptom severity rather than differences in symptom distribution. CONCLUSION: Obsessions are more time consuming, distressing, and interfering than compulsions and impulsions. Furthermore, the symptomatic repetitive behaviors were distributed differently among patients with both Tourette's disorder and OCD and patients with OCD (no tics). Patients with Tourette's and OCD are phenomenologically more similar to Tourette's than to OCD. These differences possibly represent differences in underlying pathophysiology between Tourette's and tic-free OCD.     

Obsessive compulsive disorder during pregnancy and the postpartum period

Research into psychiatric illnesses during pregnancy and the postpartum period has focused primarily on mood disorders and psychosis. However, recent reports suggest that during pregnancy and the postpartum period psychiatric patients run an increased risk of developing the symptoms of obsessive compulsive disorder (OCD) or if they already have these symptoms, the severity is likely to increase. We report two cases of OCD in pregnancy and in the postpartum period. In addition, we present a brief review of the literature that is currently available on this topic.     

Traumatic and Adverse Attachment Childhood Experiences are not Characteristic of OCD but of Depression in Adolescents

We investigated whether adverse attachment experience might contribute to the development of obsessive–compulsive disorder (OCD). We interviewed 100 adolescents, 25 each with primary OCD, depressive disorder (DD), OCD plus DD and general population controls (CTRs) using the adult attachment interview to assess attachment experiences (AEs), including traumatic and adverse AE (TAE). Adolescents with OCD, OCD+DD and DD had little evidence of secure base/safe haven parental behaviour and their childhood attachment needs judged to be rejected as compared to the controls. Overprotection was not characteristic of OCD, and parents using the child for their own needs (elevated levels of involving/role reversal) occurred only in DD, with low levels in OCD, OCD+DD and CTR. Traumatic experiences, often multiple, and/or attachment related were reported significantly more often in the DD group, and was less common in OCD+DD, CTR and particularly in the OCD group. In OCD, little TAE was reported and adverse AE were less serious and seem unlikely to contribute directly to OCD aetiology. In DD and to some degree in OCD+DD serious AE/TAE may have some etiological significance for the depressive states.     

Repetitive Behaviour in Children with High Functioning Autism and Obsessive Compulsive Disorder

Children with Autism Spectrum Disorders (ASD) and children with Obsessive Compulsive Disorder (OCD) were compared on a range of repetitive behaviours. Parents reported similar levels of sameness behaviour and repetitive movements in the clinical groups, although children with OCD engaged in more repetitive behaviour focussed around routines and rituals. Children with OCD reported more compulsions and obsessions than children with ASD; both groups reported more compulsions and obsessions than a typically developing comparison group. Types of compulsions and obsessions tended to be less sophisticated in children with ASD than those with OCD. Sameness behaviour was more prevalent in younger children with OCD, but for children with ASD, age was not significantly related to sameness behaviour, repetitive movements, compulsions, or obsessions.     

Obsessive-compulsive disorder and immunocompetence

OBJECTIVE: A postinfectious, autoimmune response may be associated with the development of pediatric obsessive-compulsive disorder (OCD). According to this model, antistreptococcal antibodies cross-react with basal ganglia neurons following streptococcus infection. This autoimmune reaction disrupts a basal ganglia-thalamocortical circuit and generates obsessive-compulsive symptoms. One implication of this model is that prolonged immunologic stress may be a risk factor for OCD. That is, immunologic stress may compromise the blood-brain barrier and permit the influx of antistriatal antibodies into the central nervous system. This article explores one part of this putative relationship by investigating whether adult OCD patients, compared to members of other psychiatric groups, demonstrate a higher incidence of recurrent infections and other conditions suggestive of compromised immune function. METHOD: To test this hypothesis, we conducted a medical records review of 100 consecutive patients evaluated at a private psychiatric clinic specializing in the treatment of anxiety disorders. Sixty-five patients met diagnostic criteria for an Axis-I syndrome. Primary diagnoses included OCD, posttraumatic stress disorder, social anxiety disorder, generalized anxiety disorder, panic disorder with agoraphobia, and dysthymic disorder. Each medical record was reviewed for the presence of target syndromes or presenting symptoms suggestive of compromised immune function. RESULTS: Chart review revealed an increased rate of immune-related symptoms and syndromes among OCD patients in comparison to other anxiety and mood disorder groups. Groups did not differ significantly in the incidence of non-immune symptoms and syndromes. CONCLUSION: Adult OCD patients appear to have an increased rate of immune-related diseases above and beyond that seen in other psychiatric disorders.     

Severity of subjective cognitive impairment in patients with obsessive-compulsive disorder and depression

Previous research on obsessive-compulsive disorder (OCD) has consistently found cognitive impairments in the domains of executive and nonverbal (memory) functioning, particularly in patients with comorbid depressive symptoms. In contrast, little is known about the degree to which such deficits are cognizant to patients or the degree to which these impairments interfere with daily activities. The aim of the present study was to assess prevalence and specificity of subjective cognitive dysfunction in OCD patients. A self-rating scale, the Subjective Neurocognition Inventory (SNI), was administered to 67 OCD patients upon admission to hospital. Forty healthy and 30 depressed participants served as controls. Relative to healthy participants, OCD patients reported greater impairment on SNI subscales measuring psychomotor speed, selective and divided attention. Impairments in the OCD group were particularly pronounced in patients with severe OCD or depressive psychopathology. OCD patients were no more disturbed than depressed participants on any of the domains tested. Memory problems were only reported by a minority of OCD patients-even in patients with checking compulsions. In conjunction with prior studies showing few memory difficulties in non-depressed OCD patients, present findings further challenge the memory deficit hypothesis which claims that checking compulsions are a dysfunctional compensation for real or imagined forgetfulness.