Obsessive-compulsive disorder: an overview

In this article, which is the first in a three-part series, the authors provide an overview of the current state of our knowledge of the phenomenology, etiology, and diagnosis of OCD. The DSM-IV criteria for OCD are presented and explicated. Disorders that are commonly comorbid with OCD (e.g., major depressive disorder, other anxiety dis-orders, Tourette's disorder) are described. The authors also discuss disorders such as body dysmorphic disorder that may be related to OCD and are often termed OCD spectrum disorders. OCD is likely to have multiple causes and the authors discuss behavioral, neuroanatomical, and neurochemical theories of OCD. Two treatments have demonstrated efficacy in OCD, cognitive-behavioral therapy and pharmacotherapy with serotonergic reuptake inhibitors, and the authors discuss how these treatments may work in light of what is known about the etiology of the disorder. The different subtypes of OCD that have been proposed are described along with their implications for treatment. The article concludes with a discussion of diagnosis that provides specific guidance for the clinician on how to assess a patient for possible OCD. The next two articles in this series will cover cognitive-behavioral and medication treatment in detail.     

A School-Based Treatment Model for Pediatric Obsessive-Compulsive Disorder

School psychologists have expertise in the realm of school-based assessment and intervention for behavioral, educational, and psychological difficulties. Recent evidence indicates that many school psychologists lack evidenced based knowledge about assessment and treatment of pediatric Obsessive-Compulsive Disorder (OCD). Pediatric OCD is a relatively common disorder that contributes to substantial impairment in educational and psychosocial domains. Evidence based treatment of pediatric OCD, particularly cognitive-behavioral therapy, has shown to be efficacious. Therefore, the aims of this paper are to provide a review of empirically established treatments for pediatric OCD, and present a school-based problem-solving model that school psychologists can utilize to conceptualize, assess, and treat OCD.     

Cognitive behavioral therapy of childhood OCD.

Obsessive-compulsive disorder is a chronic, recurrent, and often disabling disorder in childhood. Comorbid emotional and behavioral disturbance and family dysfunction are common and can serve to complicate both course of illness and treatment outcome. Although traditional psychotherapies have not been shown to be effective for treating core OCD symptoms, controlled trials with adults have shown cognitive-behavioral approaches that include ERP to be highly effective in treating the disorder. The recent development and open evaluation of a handful of standardized and developmentally sensitive ERP-based treatment protocols for childhood OCD indicates that this treatment approach is similarly effective and well-tolerated in teh younger age group. These studies also suggest that adjunctive interventions including family involvement in treatment, anxiety management training, cognitive restructuring, contingency management, and supportive therapy may enhance the efficacy of ERP through the enhancement of treatment compliance and motivation. More study is needed to evaluate the best use of medication and CBT in children and adolescents.     

Clinicians' views on management of obsessive-compulsive disorders in children and adolescents

Research on obsessive-compulsive disorder (OCD) in children and adolescents has led to important developments with clinical implications as regards assessment and treatment. These developments have resulted in new guidelines and recommendations as to what is regarded to be an adequate treatment of the disorder. The objective of the present study was to examine if these developments have led to changes in the views on clinical management of childhood OCD among child psychiatry personnel in Norway. A national survey was conducted by means of a questionnaire addressing preferences and practices among clinicians in their assessment and management of OCD, the clinicians self-reported experienced treatment success, and need to develop clinical skills on assessing and treating childhood OCD. Seventy-nine clinicians (58.5%) responded. The results showed that cognitive/behavioural, family and medication approaches were preferred over psychodynamic and humanistic approaches in the management of OCD. The preferred cognitive/behavioural approach seems to be more cognitive than behavioural, and only one-third of clinicians reported frequent use of anxiety-provoking methods in treatment of childhood OCD. Clinicians that self-rated the Clinical Global Improvement Scale on their last treated OCD case indicated moderate treatment success. Because of low numbers of OCD cases in the clinics, the majority of clinicians are rated as inexperienced in the management of the disorder and results show a need for adequate training opportunities. It is concluded that clinicians have accommodated to recommended standards in the management of childhood OCD, but some results are contradictory and do not justify conclusive statements. The study needs to be supplemented by research focusing on more specific elements of the preferred treatments, thus narrowing the scope of the present study.     

Thematic similarity and clinical outcome in obsessive-compulsive disorder group treatment

Despite the existence of efficacious cognitive-behavioral group treatments for obsessive-compulsive disorder (OCD), no data has been presented regarding the potential impact of symptom or thematic similarity among group members. The purpose of this study was to evaluate the effect of thematic similarity among group members on outcome after cognitive-behavioral (CBT) or exposure/response prevention (ERP) treatment for OCD. Results consistently demonstrated across a range of measures no impact of thematic similarity, nor any interaction of similarity by treatment type (ERP versus CBT), on treatment outcome. These data suggest that OCD treatment groups can be formed based on consecutive client intake without negatively impacting efficacy.     

An integrative approach to the treatment of obsessive-compulsive disorder

We reviewed the research literature concerning the etiology and treatment of obsessive-compulsive disorder (OCD). Cognitive behavioral and neurobiological treatments were the two most frequently used treatment approaches. The majority of research on the treatment of OCD has focused on implementing these treatment approaches in isolation, rather than in combination, which has often resulted in a high symptom relapse rate. We focused on integrating the most effective elements of each treatment approach into a new treatment regimen. More specifically, the longlasting benefits of cognitive behavioral therapy and the rapid symptom relief of neurobiological treatments are integrated in such a manner as to take full advantage of each, while at the same time controlling for the shortcomings of each treatment approach. It is proposed that this newly integrated treatment approach represents a superior treatment regimen, as compared with the combined treatment approaches currently used.     

Psychotherapy of compulsive disorder in children and adolescents--an overview

The literature on evaluated methods of psychotherapy for the treatment of obsessive-compulsive disorders (OCD) in children and adolescents is reviewed and the following cognitive-behavioral treatment modules are described: psychoeducation, exposure with response prevention, family-based interventions, and cognitive as well as meta-cognitive techniques. Behavior therapy, especially exposure with response prevention, has been shown to be an effective treatment. Severe cases require a combined therapy with serotonin-reuptake inhibitors, while "thought stopping" cannot be recommended as an effective therapy for obsessions. New cognitive and meta-cognitive approaches should be evaluated to determine whether they might advance treatment. Controlled therapy studies are needed in order to evaluate the different effects and underlying efficacy factors of, as well as the indications and contraindications for different strategies of treatment for obsessive-compulsive disorder in childhood and adolescence.     

Childhood-onset obsessive-compulsive disorder and tic disorders: case report and literature review

A subgroup of childhood-onset obsessive-compulsive disorder (OCD) and tic disorders has been found to have a postinfectious autoimmune-mediated etiology. Clinical observations and systematic investigations have shown that a subgroup of children with OCD and/or tic disorders have the onset and subsequent exacerbations of their symptoms following infections with group A beta-hemolytic streptococci (GABHS). This subgroup has been designated by the acronym PANDAS: pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. Five clinical characteristics define the PANDAS subgroup: presence of OCD and/or tic disorder, prepubertal symptom onset, sudden onset or abrupt exacerbations, association with neurological abnormalities during exacerbations (adventitious movements or motoric hyperactivity), and the temporal association between symptom exacerbations and GABHS infections. The proposed poststreptococcal inflammatory etiology provides a unique opportunity for treatment and prevention, including immunomodulatory therapies such as plasma exchange and intravenous immunoglobulin. A placebo-controlled trial revealed that both intravenous immunoglobulin and plasma exchange were effective in reducing neuropsychiatric symptom severity (40 and 55% reductions, respectively) for a group of severely ill children in the PANDAS subgroup. Further research is required to determine why the treatments are helpful and to ascertain whether or not antibiotic prophylaxis can help prevent poststreptococcal symptom exacerbations.     

Home-based cognitive-behavioral treatment of chronic, refractory obsessive-compulsive disorder can be effective. Single case analysis of four patients

Four patients with obsessive-compulsive disorder (OCD) were referred for home-based cognitive-behavioral therapy. All patients had failed extensive trials of behavioral and cognitive therapy and pharmacotherapy in a variety of settings (e.g., outpatient, inpatient, and day program) and were generally considered chronic and refractory to treatment. Generalization from treatment sites to natural settings in which they lived did not occur. They were evaluated at baseline, after treatment, and at an 18-month follow-up using the Yale-Brown Obsessive Compulsive Scale. Conducting end-state functioning and reliable change assessment according to the methods specified by Jacobson and Truax, the authors found that 3 patients achieved clinically significant gains after treatment and 2 patients maintained those gains at the 18-month follow-up. Data suggested better overall adjustment for 3 of the patients at follow-up. This study demonstrates the effectiveness of home-based cognitive-behavioral therapy for chronic, refractory OCD; implications for further, controlled trials are discussed.     

Anxiety Disorders and Obsessive-Compulsive Disorder in Individuals with Autism Spectrum Disorder

Purpose of Review

This review aims to synthesize the most recent research on anxiety disorders and obsessive-compulsive disorder (OCD) in individuals with autism spectrum disorder (ASD) and discuss the relationship between these conditions and challenges for assessment. Furthermore, implications for treatment and future directions are discussed.

Recent Findings

Research suggests that anxiety disorders and OCD are highly prevalent in individuals with ASD. However, the significant overlap of ASD features with anxiety and OCD symptomology makes differential diagnosis of these disorders particularly challenging. Though several treatments for anxiety have been adapted for youth with ASD (e.g., cognitive behavior therapy), pharmacological treatments and treatments for adults are still marked undeveloped.

Summary

Despite the high prevalence of anxiety disorders and OCD in ASD and some recent advances in assessment and treatment, research is needed to clarify the multifaceted relationship of these conditions and develop tailored assessment and treatment approaches appropriate for a full range of individuals with ASD.

     

L’approche psychologique des troubles anxieux : information, soutien et psychothérapies

Anxiety disorders (panic disorder, generalized anxiety disorders, phobia) are very prevalent and have frequently serious consequences on social, familial and professional adaptation. Their treatments are in some cases based on pharmacotherapy, but in most cases on psychological approaches. In particular, cognitive-behavioral therapies have for a long time demonstrated their efficacy. The behavioral techniques consist on relaxation learning and on exposition to feared stimuli. The cognitive treatments aim to identify the dysfunctional process of thinking and to modify anxiogenic cognitive schemes. Social phobia are frequently treated with group therapy, including social skills training, exposure techniques and cognitive restructuration. These methods have to be applied by trained clinicians, but non-specialized physicians could play three key roles in the treatment process: diagnostic recognition, patients information and orientation towards specific psychological treatment.     

Should nonsuicidal self-injury be a putative obsessive-compulsive-related condition? A critical appraisal

Nonsuicidal self-injury (NSSI) has many behavioral and cognitive features that would make it appear to be closely tied to obsessive-compulsive disorder (OCD). Obsessive-compulsive-related disorders (OCRDs) have been described in the literature as conditions that share a common phenomenology, neurobiology, and treatment response. The authors reviewed the literature describing the degree that NSSI is similar to, and distinct from, OCRDs based on these hypothesized common areas. They conclude with recommendations for conceptualization that draws partly from the OCRD literature and from cognitive-behavioral models of rumination.     

Les interventions basées sur la pleine conscience dans le trouble obsessionnel compulsif : mécanismes d’action et présentation d’une étude pilote

Obsessive-compulsive disorder (OCD) is a frequent and severe disease, potentially inducing a major impairment for the patient and burden for their family. Recent research in psychiatry and neuroscience have led to better comprehension of the disease's mechanisms and helped to improve its treatment. However, a large proportion of patients have refractory symptoms, including for traditional cognitive and behavioral therapy by exposure and response prevention (ERP), leading clinicians to look for new treatments. Mindfulness-based interventions (MBI) are a new type of approach, initially based on Buddhist meditation, which aims to provide better consciousness of the present moment. It has been successfully developed in some psychiatric diseases and other general medical conditions such as chronic pain. The two main programs using mindfulness meditation, Mindfulness-based stress reduction (MBSR) and Mindfulness-based cognitive therapy (MBCT), have shown effectiveness for the reduction of depressive and anxiety symptoms and relapses of depressive episodes in unipolar depression. It has no side effects and is well tolerated by patients. Its action relies on the specific correction of cognitive deficits in attention, emotion regulation and executive functions which are shared by OCD, GAD and depression. For OCD, we make the hypothesis that Mindfulness-Based Interventions could reduce the cognitive bias specifically existing in this pathology, such as dysfunctional beliefs, and therefore improve the symptoms. This article first reviews the existing literature on clinical trials involving Mindfulness-Based Interventions in OCD which comprises a small number of clinical studies based on very different types of protocols. At this time, and due to the lack of gold-standard studies with a large number of patients, no proof of the efficiency of mindfulness-based interventions in OCD has been shown. In a second section, following our hypothesis on the mechanisms of specific and non-specific action of this therapy in OCD, we propose a cognitive model of mindfulness-based therapy action in OCD involving the correction of OCD's cognitive bias. In this model, mindfulness-based therapy is supposed to treat specifically the cognitive aspects of the disease, while ERP is focused on its behavioral part. Then we present a clinical study aiming to prove the feasibility and the interest of the use of mindfulness in OCD, carried out in two different clinical centers. One of them used MBCT while the second used MBSR. Its results show the feasibility of mindfulness-based therapy in OCD patients and tend to prove that it could be more effective in young patients suffering from less severe forms of OCD. In parallel, attention tests and fMRI scans were done at the beginning and at the end of the therapy. Their results will be published separately. We also discuss the putative role of a specific form of MBCT adapted for OCD, specifically for its benefits in psychoeducation, which could reduce the dysfunctional beliefs present in OCD patients. Finally, we propose a therapeutic strategy in which the MBCT could complement the classical ERP therapy, as a “maintenance” treatment, aiming to extend the relapse of OCD symptoms. This article is a step further in the use of mindfulness-based therapy for OCD which could be added to the existing treatments reducing the patient's symptoms and improving their quality of life.     

Obsessive-compulsive disorder in children.

Childhood OCD is a chronic and commonly disabling disorder with a lifetime prevalence of 2% to 3%. Traditionally OCD was a neglected diagnosis, but renewed research interest over the past decade has led to significant advances in the understanding of the disorder in young people. OCD is relatively consistent across the age span in terms of prevalence, phenomenology, etiology, and response to treatment. Comorbidity, especially depression and other anxiety disorders, is common in children with OCD and may exert a negative influence on treatment response and long-term outcome. Nevertheless, CBT and SSRI therapy have been shown to be effective and well-tolerated therapies for children with OCD.     

Non-pharmacological treatments of insomnia

Insomnia is a prevalent and complex disorder to treat. This article reviews the prevalence, etiology, diagnosis and treatment of insomnia. With regard to treatment, there now exists an extensive literature demonstrating that compared with pharmacological treatments a range of non-pharmacological therapies are of proven clinical efficacy and durability. These include, for example, stimulus control therapy, bedtime restriction therapy, relaxation therapy, cognitive therapy and bright light therapy. These therapies are summarized and evaluated. It is recommended that therapists consider non-drug treatments based on cognitive-behavioral principles when managing a patient with insomnia.     

Thérapie comportementale et cognitive du trouble obsessionnel et compulsif et des troubles de la personnalité comorbides : thérapie de groupe

Obsessive-compulsive disorder (OCD) is a chronic, recurrent, and often disabling disorder. Comorbid emotional and personality disorder are common and can serve to complicate both course of illness and treatment outcome. Controlled trials with adults have shown cognitive-behavior therapy (CBT) that includes exposure and response prevention (ERP) to be highly effective for treating the disorder. It means exposing the patient to the very thing that causes fear and anxiety, and using all his strength to simply accept the experience instead of relying on compulsions to counteract it. The basic concept of CBT is: by changing the behavior, the patient eventually changes how he thinks and feels. CBT usually works fairly quickly, and it relies mostly on action, not insight. In this article we describe a cognitive-behavioral group treatment for both OCD symptoms and comorbid personality disorder. By an evaluable patient analysis; statistically and clinically significant pretreatment to posttreatment change occurred in OCD diagnostic status and severity. Some personality traits also changed. The results of this study, the first to evaluate this dimension of the personality disorders comorbidities in the OCD and their evolution with a behavioural and cognitive psychotherapy, are very encouraging. Indeed, evolution of the fields and facets of the personality changed positively.     

An emerging role for escitalopram in the treatment of obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a common and severe neuropsychiatric disorder treated by both behavioral and pharmacologic techniques. Despite the availability of treatments for OCD, including the selective serotonin reuptake inhibitors (SSRIs), many OCD patients have an inadequate response to current treatments. As such, additional approaches to the management of OCD are required. A potential but little studied treatment for OCD is the SSRI escitalopram. Escitalopram is the S-enantiomer of citalopram, the preparation containing both S and R enantiomers of citalopram. Not only is escitalopram the most selective of the SSRIs, it is also devoid of R-citalopram, which may interfere with the effects of the S enantiomer. Escitalopram appears to be effective in depression and several anxiety disorders, including social anxiety disorder and generalized anxiety disorder, conditions in which it also appears reasonably well tolerated. Enantiomeric specificity, high serotonin reuptake selectivity, comparatively good tolerability and favorable pharmacokinetics, and preliminary evidence of efficacy in OCD suggest a potential role for the use of escitalopram in the treatment of OCD. Nevertheless, additional work including evaluating the use of escitalopram with behavioral interventions and in long-term treatment of OCD is needed to clarify its overall role in managing OCD.     

New Developments in Cognitive-Behavioral Therapy for Social Anxiety Disorder

Social anxiety disorder (SAD) is a highly prevalent and chronic disorder that causes considerable psychosocial impairment. This article reviews recent changes in the definition of SAD in DSM-5 and summarizes the current evidence for effective cognitive-behavioral treatments in adults, children, and adolescents. Current data suggests that cognitive-behavioral therapy (CBT) is efficacious in the treatment of this condition. Among different CBT approaches, individual cognitive therapy may be associated with the largest effect sizes. In this review, interventions targeting dysfunctional cognitive processes that contribute to the effective treatment of SAD are discussed. Some recent findings from neuroimaging research and studies on the augmentation of CBT using neuroenhancers indicate that changes in emotion regulation as well as fear extinction are important psychological mediators of positive outcome. Furthermore, internet-delivered CBT is a promising field of technological innovation that may improve access to effective treatments. Despite the availability of effective treatments, treatment-resistant SAD remains a common problem in clinical practice that requires more research efforts. Finally, potential areas for further development of CBT as well as its dissemination in health care are summarized.     

Obsessive-compulsive disorder:Evidence-based treatments and future directions for research

Over the past three decades, obsessive-compulsive disorder(OCD) has moved from an almost untreatable,life-long psychiatric disorder to a highly manageable one. This is a very welcome change to the 1%-3% of children and adults with this disorder as, thanks to advances in both pharmacological and psychological therapies, prognosis for those afflicted with OCD is quite good in the long term, even though most have comorbid disorders that are also problematic. We still have far to go, however, until OCD can be described as either easily treatable or the effective treatments are widely known about among clinicians. This review focuses on the current state of the art in treatment for OCD and where we still are coming up short in our work as a scientific community. For example, while the impact of medications is quite strong for adults in reducing OCD symptoms, current drugs are only somewhat effective for children. In addition, there are unacceptably high relapse rates across both populations when treated with pharmacological alone. Even in the cognitive-behavioral treatments, which show higher effect sizes and lower relapse rates than drug therapies, drop-out rates are at a quarter of those who begin treatment. This means a sizable portion of the OCD population who do obtain effective treatments(which appears to be only a portion of the overall population) are not effectively treated.Suggestions for future avenues of research are also presented. These are primarily focused on(1) increased dissemination of effective therapies;(2) augmentation of treatments for those with residual symptoms, both for psychotherapy and pharmacotherapy; and(3) the impact of comorbid disorders on treatment outcome.     

Obsessive-Compulsive Disorder in Children and Adolescents

Obsessive-compulsive disorder (OCD) is estimated to affect between 0.5% and 2% of children and adolescents. The majority of clinical cases has both obsessions and compulsions. Depression, anxiety and tic disorders are common comorbid diagnoses, and assessment can therefore be complex. Several theories have been proposed for the aetiology and maintenance of the disorder, including cognitive-behavioural and neuropsychiatric theories. Cognitive-behavioural and pharmacological treatments are both probably efficacious therapies for children and adolescents but further research is needed to compare these treatments with each other, and to examine the use of combination therapies in controlled trials.