Major depressive disorder and axis I diagnostic comorbidity

BACKGROUND: Recognition of comorbid conditions in patients presenting for the treatment of depression is clinically important because the presence of other disorders can influence treatment planning. In the present study, we examined the frequency of diagnostic comorbidity in psychiatric outpatients presenting for treatment of nonbipolar major depressive disorder (MDD) and patients' desire for treatment for the comorbid disorders. METHOD: Four hundred seventy-nine psychiatric outpatients with DSM-IV nonbipolar MDD were evaluated with a modified version of the Structured Clinical Interview for DSM-IV. RESULTS: Excluding nicotine dependence, at the time of the evaluation 64.1% (N = 307) of the patients met criteria for at least 1 of the 23 specific Axis I disorders, and more than one third (36.7%, N = 176) had 2 or more disorders. Anxiety disorders, as a group, were the most frequent current comorbid disorders (56.8%), and social phobia was the most frequent individual disorder. Including subthreshold conditions, the percentage of patients with at least 1 disorder increased to 73.5%. When the scope of assessment was expanded to include nicotine dependence, nicotine dependence was the most frequent lifetime individual disorder (38.2%) and the second most frequent current disorder (27.3%). There was considerable variability among the disorders regarding desire for treatment of the comorbid condition. CONCLUSION: The majority of nonbipolar depressed patients have a current comorbid disorder, especially an anxiety disorder, although the actual rate of comorbidity depends on the breadth of the assessment.     

Axis I and II comorbidity in agoraphobia: prediction of psychotherapy outcome in a clinical setting

The impact of concurrent Axis I and Axis II disorder diagnoses on the efficacy of psychotherapy in a clinical setting for panic disorder with agoraphobia was studied in a sample of 51 agoraphobic outpatients. Diagnoses were based on the Structured Clinical Interview for DSM-III-R. The effects of secondary major depression, dysthymia, generalized anxiety disorder, and avoidant personality disorder were examined via multiple regression analyses. Major depression was associated with less improvement on phobic behavior at 6-month follow-up, whereas dysthymia and avoidant personality disorder predicted less reduction in the frequency of panic attacks at posttest and follow-up, respectively. There was little evidence that generalized anxiety was associated with poorer outcome in this sample. Limitations to the internal validity of the study include uncontrolled use of medication and naturalistic treatment during the follow-up period.     

Impact of comorbidity on cognitive-behavioral therapy response in pediatric obsessive-compulsive disorder

ObjectiveTo examine the impact of psychiatric comorbidity on cognitive-behavioral therapy response in children and adolescents with obsessive-compulsive disorder.MethodNinety-six youths with obsessive-compulsive disorder (range 7-19 years) received 14 sessions of weekly or intensive family-based cognitive-behavioral therapy. Assessments were conducted before and after treatment. Primary outcomes included scores on the Children's Yale-Brown Obsessive-Compulsive Scale, response rates, and remission status.ResultsSeventy-four percent of participants met criteria for at least one comorbid diagnosis. In general, participants with one or more comorbid diagnoses had lower treatment response and remission rates relative to those without a comorbid diagnosis. The number of comorbid conditions was negatively related to outcome. The presence of attention-deficit/hyperactivity disorder and disruptive behavior disorders was related to lower treatment response rates, and the presence of disruptive behavior disorders and major depressive disorder were related to lower remission rates.ConclusionsThe presence of a comorbid disorder, particularly disruptive behavior, major depressive, and attention-deficit/hyperactivity disorders, has a negative impact on treatment response. Assessing for psychiatric disorders before treatment entry and treating these comorbid conditions before or during cognitive-behavioral therapy may improve final outcome. Comorbid anxiety or tic disorders do not seem to negatively affect response.     

Heterogeneity and comorbidity of obsessive-compulsive disorder

Although the DSM-IV-TR suggests that obsessive-compulsive disorder (OCD) is a coherent syndrome, scientific evidence offers a compelling case that OCD is highly heterogeneous and possibly composed of many different subtypes. OCD can display completely distinct symptom patterns thus making it difficult to identify a single "textbook" profile of OCD. The present state of research concerning subtyping is presented. There is a high comorbidity with depression and anxiety disorders, but all together data concerning OCD comorbidity are still not convincing. Currently obsessive-compulsive spectrum disorders (OCS) are described as a set of disorders lying on a continuum from compulsive to impulsive, with the unifying feature being an inability to regulate behaviour as a consequence of defects in inhibition. OCS disorders fall into three major clusters: impulsive disorders, disorders associated with appearance in bodily sensations, and neurological disorders characterized by repetitive behaviour. How these putative OCS disorders overlap with and are independent from obsessive-compulsive disorder itself is thoroughly discussed.     

Effects of behavior therapy on regional cerebral blood flow in obsessive-compulsive disorder

Very few functional neuroimaging studies have been performed on patients with obsessive-compulsive disorder (OCD) undergoing behavior therapy, even though it is recognized to be an effective treatment for this disorder. We measured the regional cerebral blood flow (rCBF) using the Xenon inhalation method in 31 treatment-refractory patients with OCD and the same number of age-matched normal controls. We also studied changes in rCBF in 22 OCD patients who had demonstrated a significant improvement after the behavior therapy. The OCD patients showed a significant bilateral elevation in the rCBF in the basal ganglia compared with the normal controls. After successful treatment, a significant decrease was found in the rCBF in the right head of the caudate nucleus that tended to correlate with clinical improvement.     

Symptom dimensions and cognitive-behavioural therapy outcome for pediatric obsessive-compulsive disorder

Objective: To examine whether obsessive‐compulsive disorder (OCD) symptom subtypes are associated with response rates to cognitive‐behavioural therapy (CBT) among pediatric patients. Method: Ninety‐two children and adolescents with OCD (range = 7–19 years) received 14 sessions of weekly or intensive (daily psychotherapy sessions) family‐based CBT. Assessments were conducted at baseline and post‐treatment. Primary outcomes included scores on the Children’s Yale‐Brown Obsessive‐Compulsive Scale (CY‐BOCS), remission status, and ratings on the Clinical Global Improvement (CGI) and Clinical Global Impression – Severity (CGI‐Severity) scales. Results: Seventy‐six per cent of study participants (n = 70) were classified as treatment responders. Patients with aggressive/checking symptoms at baseline showed a trend (P = 0.06) toward improved treatment response and exhibited greater pre/post‐treatment CGI‐Severity change than those who endorsed only non‐aggressive/checking symptoms. Step‐wise linear regression analysis indicated higher scores on the aggressive/checking dimension were predictive of treatment‐related change in the CGI‐Severity index. Regression analysis with CY‐BOCS score as the dependent variable showed no difference between OCD subtypes. Conclusion: Response to CBT in pediatric OCD patients does not differ substantially across subtypes.     

Augmentation of behavior therapy with D-cycloserine for obsessive-compulsive disorder

OBJECTIVE: This study examined whether d-cycloserine, a partial agonist at the N-methyl-D-aspartate (NMDA) glutamatergic receptor, enhances the efficacy of behavior therapy for obsessive-compulsive disorder (OCD). METHOD: A randomized, double-blind, placebo-controlled trial investigating D-cycloserine versus placebo augmentation of behavior therapy was conducted in 23 OCD patients. Patients first underwent a diagnostic interview and pretreatment evaluation, followed by a psychoeducational/treatment planning session. Then they received 10 behavior therapy sessions. Treatment sessions were conducted twice per week. One hour before each of the behavior therapy sessions, the participants received either D-cycloserine, 100 mg, or a placebo. RESULTS: Relative to the placebo group, the D-cycloserine group's OCD symptoms were significantly more improved at mid-treatment, and the D-cycloserine group's depressive symptoms were significantly more improved at posttreatment. CONCLUSIONS: These data provide support for the use of D-cycloserine as an augmentation of behavior therapy for OCD and extend findings in animals and other human disorders suggesting that behavior therapy acts by way of long-term potentiation of glutamatergic pathways and that the effects of behavior therapy are potentiated by an NMDA agonist.     

Effect of axis II diagnoses on treatment outcome with clomipramine in 55 patients with obsessive-compulsive disorder.

We used the Structured Interview for DSM-III Personality Disorders to diagnose DSM-III personality disorders systematically in 55 patients with obsessive-compulsive disorder in the active-treatment cell of a controlled trial of clomipramine hydrochloride. Patients with a cluster A personality disorder had significantly higher obsessive-compulsive disorder severity scores at baseline, and the number of personality disorders was strongly related to baseline severity of obsessive-compulsive disorder symptoms. At the conclusion of the 12-week study, we found no significant difference in treatment outcome with clomipramine between those patients with at least one personality disorder and those with no personality disorders. However, the presence of schizotypal, borderline, and avoidant personality disorders, along with total number of personality disorders, did predict poorer treatment outcome. These variables were strongly related to having at least one cluster A personality disorder diagnosis, which was also a strong predictor of poorer outcome. Implications of these findings are discussed.     

Antidepressants in the treatment of agoraphobia and obsessive-compulsive disorder

Agoraphobia and obsessive-compulsive disorder share many similarities, not the least of which is their response to behavioral and pharmacological treatments. The mechanism of action of antidepressants in these complex anxiety disorders is not known. The question as to whether they possess antiphobic/antiobsessional properties, independent of their antidepressant effect, is controversial and unlikely to be solved on symptomatic grounds alone. A fruitful approach is indicated by recent biochemical findings that link their obsessional effect to the serotonergic neurotransmitter system. The use of agents with more specific biochemical action should permit a more accurate differentiation of antiphobic/antiobsessional and antidepressant effects. Furthermore, the exploration of the role of neurotransmitter systems in agoraphobia and obsessive-compulsive disorder might further elucidate the relationship between depressive disorders and anxiety disorders.     

Patterns of comorbidity in panic disorder and agoraphobia.

Diagnoses of comorbid disorders were determined in a sample of 54 patients with panic disorder as defined in DSM-III-R. The sample was divided into the following three groups: (1) uncomplicated panic disorder (PDU); (2) panic disorder with mild agoraphobia (PDM); and (3) panic disorder with moderate to severe agoraphobia (PDA). In comparison with patients with PDU, patients with PDA had higher comorbidity rates in general, received multiple comorbid diagnoses more frequently, had a higher prevalence of major depression, dysthymia, social phobia, generalized anxiety disorder, and obsessive-compulsive disorder, and scored higher on most measures of self-rated psychopathology. These findings support the notion that PDA may be a disorder essentially different from PDU.     

The comorbidity of multiple personality disorder and DSM-III-R axis II disorders

Our ability to differentiate MPD from DSM-III-R Axis I disorders has become increasingly refined. Differentiation of MPD from the Axis II personality disorders is an area of more recent clinical investigation. MPD can be found comorbidity with many other psychiatric conditions. It is found in association with each of the DSM-III-R personality disorders. At the present time, however, we lack research data that define the prevalence of the comorbidity of MPD with the personality disorders. Objective study of this area is complicated by the paucity of instruments available to assess personality dimensions in the presence of a DD. In addition, the currently available personality inventories tend to overdiagnose BPD in patients with a high level of distress and acuity of symptoms. The diagnosis of a personality disorder in a patient with MPD is made on the basis of the assessment of the "whole" human being. It is based on the presence of a pervasive and relatively inflexible pattern of behaviors that reflects the individual predominant mode of being. The diagnosis of a personality disorder is not made on the basis of personality traits contained within any single alternate personality or groups of personalities. The personality disorders defined by DSM-III-R are a heterogeneous group of conditions whose individual etiologies reflect a complex interplay of constitutional, genetic, environmental, interpersonal, and psychodynamic factors. The interplay is variable and diverse between these determinants of the personality disorders and the traumatic forces that result in the development of a DD. For the Cluster A personality disorders (schizoid, schizotypal, paranoid), there is evidence supporting a relationship with specific psychotic illnesses. The combination of dissociative pathology with these personality disorders commonly results in a greater impairment of reality testing than in either condition alone. The Cluster B personality disorders (histrionic, narcissistic, borderline, antisocial) and Cluster C personality disorders (avoidant, compulsive, dependent, passive-aggressive) are believed to be primarily developmental disturbances. Comorbidity of these personality disorders with MPD involves consideration of the interaction of many developmental processes with the psychological impact of severe childhood trauma. Many MPD patients present with an apparent mixed personality profile consisting of an array of avoidant, compulsive, borderline, narcissistic, dependent, and passive-aggressive features. Although this article explores comorbidity of MPD with each of the personality disorders defined in DSM-III-R individually, it seems likely that a number of posttraumatic personality organizations can be defined that commonly coexist with MPD.(ABSTRACT TRUNCATED AT 400 WORDS)     

Open trial of cognitive behavior therapy for childhood obsessive-compulsive disorder

Examined the utility of CBT for childhood obsessive-compulsive disorder (OCD) including a preliminary exploration of predictors of response to this form of treatment. A total of 42 youngsters (mean age 11.8 years, 60% female, 52% on medication at baseline) with DSM-IV OCD were treated openly using a developmentally sensitive treatment protocol based on exposure plus response prevention (ERP). The treatment response rate (CGI < 2) was 79% with a mean decrease from baseline in NIMH global scores of 45%. Response was not related to age, gender, baseline medication status, comorbid symptomatology, or therapist experience. Poorer outcome was associated with more severe obsessions and greater OCD-related academic impairment at baseline. When presented in a developmentally appropriate manner, CBT is a useful treatment for childhood OCD. Controlled trials are needed to provide a more rigorous test of this treatment approach and provide better information regarding potential mediators and moderators of outcome.     

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.     

Melancholia and axis II comorbidity

This study assessed whether the rates of comorbid personality disorders differed between DSM-IV melancholic and nonmelancholic major depressive disorder. We evaluated 260 consecutive depressed outpatients (140 women [53.8%]; mean age, 39.01 +/- 10.4 years) with DSM-III-R major depressive disorder (MDD). MDD was diagnosed with the use of the Structured Clinical Interview for DSM-III-R-Patient Edition (SCID-P); enrolled patients were required to have a score >/= 16 on the 17-item Hamilton Rating Scale for Depression (HAM-D-17). The presence of the melancholic subtype of major depression was determined with the use of a DSM-IV checklist, while the presence of personality disorders was assessed using the Structured Clinical Interview for DSM-III-R-Personality Disorders (SCID-II). Of the 102 (39.2%) patients who met criteria for melancholic depression and the 158 (60.7%) who did not, there were no significant differences in age, gender, or rates of personality disorder diagnoses. We observed no significant difference in rates of individual personality disorder clusters between melancholic and nonmelancholic depressed patients. Our findings of comparable rates of comorbid personality disorders between melancholic and nonmelancholic depression are consistent with the decision made by the DSM-IV task force to drop the DSM-III-R melancholic feature criterion of "no significant personality disturbance before first major depressive episode" as they challenge the usefulness of trying to establish such absence of premorbid personality features in acutely depressed patients.     

基于网络的认知行为疗法治疗强迫症的研究进展

基于网络的认知行为疗法（ICBT）是由认知行为疗法（CBT）发展而来一种心理治疗方法。 ICBT可以提高CBT对精神障碍和其他临床问题的可用性和可接受性，可以有效减少医疗和社会成本并 增加治疗的成本效益。现将对ICBT的概念、优势、理论、局限进行介绍，并对近十年内ICBT治疗强迫 症的疗效和成本效益研究进行系统性综述，为ICBT 治疗强迫症的相关研究提供参考。     

Correlates and impact of obsessive-compulsive comorbidity in bipolar disorder

Background

Anxiety morbidity in general is frequent and harmful in bipolar disorder. Little is known, however, whether obsessive-compulsive comorbidity entails particular effects. This report aims to evaluate the prevalence and impact of obsessive-compulsive disorder (OCD) comorbidity in a relatively large clinical sample of bipolar disorder, with other lifetime anxiety comorbidities used as a more rigorous control group.

Methods

A cross-sectional study in a consecutive clinical sample, with anxiety comorbidity derived from the intake Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, was conducted. Anxiety was assessed with the Hamilton Anxiety Rating Scale. The Young Mania Rating Scale and the Hamilton Depression Rating Scale were used to assess (hypo)manic and depressive symptoms. The domains of the WHOQOL BREF were used to evaluate quality of life.

Results

Lifetime prevalence of OCD comorbidity was 12.4%. No cases of OCD were detected during mania. Compared with subjects with no anxiety comorbidity, those with lifetime OCD were more likely to have a history of suicide attempts, rapid cycling, and alcohol dependence. Patients with OCD had a lower score on all domains of the WHOQOL. Compared with those with other lifetime anxiety disorders, those with OCD had more anxiety, which mediated a lower WHOQOL social domain.

Conclusions

Bipolar disorder patients with obsessive-compulsive comorbidity have a number of indicators of an overall more severe illness. The presence of more anxiety symptoms and a lower social quality of life may be more specific features of the bipolar-OCD comorbidity.     

The outcome of behavior therapy for agoraphobia in relation to marital adjustment.

After intensively treating 18 agoraphobic patients with 13 1/2 hours of exposure in vivo, we examined the effects on both patients and their spouses over a period of six months, using questionnaire measures of symptoms and marital adjustment. Those patients whose marriages were rated as unsatisfactory before treatment improved less during treatment, and were significantly more likely to relapse during follow-up, than those patients with satisfactory marriages. The marriages of nine patients appeared to be adversely influenced by their symptomatic improvement, and two distinct types of marital interaction were observed in relation to this. In one pattern, the patients' symptoms appeared to strengthen aspects of largely affectionless "compulsory" marriages; in the other, the patients' symptoms appeared to protect their spouses from recognizing or examining aspects of their own personal and interpersonal problems.