Barriers to treatment and service utilization in an internet sample of individuals with obsessive–compulsive symptoms

Background: Despite the increasing dissemination of treatment for Obsessive–Compulsive Disorder (OCD) in the past decade, the majority of individuals with OCD are not receiving appropriate treatment. This study examined rates of treatment utilization and barriers to treatment in an internet sample of individuals with self‐reported OCD. Methods: One hundred and seventy‐five participants completed an online survey examining OCD symptoms, psychosocial measures, barriers to treatment, and treatment utilization. Results: Sixty percent of the sample reported receiving treatment for their OCD symptoms. The majority of participants who sought pharmacotherapy received SSRIs, whereas the majority who sought psychotherapeutic treatment received “talk therapy.” The cost of treatment, lack of insurance coverage, shame, and doubt that treatment would be effective were the most commonly endorsed barriers to treatment among the sample. Conclusions: Findings demonstrated relatively low treatment utilization rates among the sample, with many participants receiving treatments other than the gold‐standard medication and psychotherapy treatments (i.e. SSRIs and cognitive behavioral therapy, respectively). Furthermore, a large portion of the sample endorsed many barriers to treatment seeking, such as logistic and financial barriers; stigma, shame, and discrimination barriers; and treatment perception and satisfaction barriers. This study highlights the need for more effective treatment dissemination in OCD. Depression and Anxiety, 2010. © 2010 Wiley‐Liss, Inc.     

A psychodynamic clinician's foray into cognitive-behavioral therapy utilizing exposure-response prevention for obsessive-compulsive disorder

Research suggests that, by itself or as an adjunct to pharmacotherapy, cognitive-behavioral therapy (CBT) involving exposure with response prevention (ERP) is an effective treatment for Obsessive-Compulsive Disorder (OCD). However, there is a shortage of clinicians trained in this form of therapy. Although many psychodynamic clinicians treat individuals with OCD using traditional therapy that may assist them with their relationships, there is little evidence that such treatment is effective in ameliorating the OCD symptoms. As there is a clear need for more clinicians trained in CBT for OCD, it may be possible for practitioners trained in psychodynamic or other modalities to learn ERP. Such cross-theoretical training involves a number of challenges. These include the therapist's own anxiety about ERP, understanding resistance, and reconsidering therapeutic boundaries. The first author describes his experiences as a psychodynamically-trained psychologist venturing into ERP in an attempt to demonstrate that although there are barriers they are not insurmountable.     

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.

     

Brief Report: Exposure and Response Prevention for Obsessive Compulsive Disorder in a 12-year-old with Autism

Obsessive Compulsive Disorder (OCD) involves exaggerated or excessive worry about threatening and non-threatening stimuli coupled with impairing rituals believed to reduce anxiety. Autism Spectrum Disorders (ASD) are characterized by impairment in social and communicative activities as well as restricted and repetitive behaviors. Approximately 2% of children with ASD are also diagnosed with OCD. Although there is extensive research demonstrating the effectiveness of behavioral interventions for pediatric OCD, little is known about how effective these treatments are for children who have a dual diagnosis of OCD and ASD. This report describes a 12-year-old male with Autism who was treated successfully with cognitive behavioral therapy with exposure and response prevention. This case study provides initial support that cognitive-behavioral therapy is effective in symptom reduction for children with comorbid autism and OCD.     

Modular Cognitive Therapy for Obsessive-Compulsive Disorder: A Wait-List Controlled Trial

The current study examined the efficacy of cognitive therapy (CT) in reducing symptoms of obsessive-compulsive disorder (OCD). Twenty-nine individuals with OCD were assigned according to therapist availability to a 12-week wait period or the immediate start of 22 sessions (over 24 weeks) of flexible, modular CT. After 12 weeks of treatment, the CT group, but not the wait-list group, exhibited significant improvement in OCD symptoms. The combined sample of patients who underwent 24 weeks of CT improved significantly from pre- to post-treatment and symptoms remained significantly improved at 3-month follow-up. OCD symptoms rose slightly between posttreatment and 12-month follow-up, but, remained significantly lower than at pretreatment. Overall, modular CT appears to be an effective and acceptable treatment for OCD.     

The effect of aerobic exercise alone and in combination with cognitive behavioural therapy on obsessive compulsive disorder: A randomized control study

PurposeCognitive behavioural therapy (CBT) has been found to be an effective treatment for OCD, but there remains a significant proportion of individuals who fail to show a treatment response. Aerobic exercise has previously been associated with decreases in anxiety and depression, as well as improvements in OCD symptoms in small-scale studies. The purpose of the present research was to use a randomized control trial design to examine the effects of exercise alone and in combination with CBT, on OCD symptoms and secondary symptoms.Method125 participants were randomly assigned to one of four treatment groups: waitlist control, exercise, CBT, and CBT with exercise. OCD symptom severity was measured at four points over the course of treatment, secondary outcome measures were gathered at three points over treatment.ResultsCBT alone and combined with exercise was associated with significantly greater OCD symptom reduction than exercise alone or the control groups. Total exercise frequency predicted OCD symptom reduction in the groups in which exercise was measured. Group membership did not significantly predict reductions in secondary outcome measures.ConclusionExercise frequency, rather than the presence or absence of exercise, appears to predict OCD symptom reduction, as did participation in CBT.     

Fixity of belief, perceptual aberration, and magical ideation in obsessive–compulsive disorder

Clinicians and researchers have pondered the intersection of obsessive-compulsive disorder (OCD) and psychosis. We examined the records of 395 individuals seeking treatment for OCD and classified participants according to their most frequent or distressing obsession and compulsion. All participants completed measures of fixity of belief, perceptual distortions, magical ideation, and psychotic symptoms. Results indicated that individuals who reported fear of harming self or others via overwhelming impulse or by mistake, and those with religious obsessions, had poorer insight and more perceptual distortions and magical ideation than did individuals with other types of obsessions. These results did not appear to reflect mere differences in OCD severity. Results are discussed in light of previous findings showing that psychotic-like symptoms are associated with attenuated treatment outcome in OCD. More research is needed to assess the absolute magnitude of psychotic-like features in OCD patients with impulse/mistake and religious obsessions and to examine whether these features interfere with standard cognitive-behavioral therapy.     

Electroconvulsive Therapy on Severe Obsessive-Compulsive Disorder Comorbid Depressive Symptoms

Electroconvulsive therapy (ECT) is not currently used as a first-line treatment for obsessive-compulsive disorder (OCD). However, several related case reports have demonstrated that ECT seems to be effective for severe OCD, especially when first-line therapies have failed. In this study, we describe the courses, detailed parameters, effects, and follow-up information relating to three patients with severe OCD who were treated by modified bifrontal ECT after their first-line anti-OCD treatments pharmacotherapy, behavioral therapy, and cognitive behavioral therapy failed. The number of ECT procedures administered in each case is as follows: Case 1, eight; Case 2, three; and Case 3, four. In all three cases, the patients'' depressive symptoms improved considerably after the ECT procedures. In addition, the condition of all three patients'' OCD significantly improved and remained stable at regular follow-ups. ECT may play an effective role in treating severe OCD.     

Quality of life and functional impairment in obsessive-compulsive disorder: a comparison of patients with and without comorbidity, patients in remission, and healthy controls

Background: Several studies have demonstrated that obsessive–compulsive disorder (OCD) is associated with interference in quality of life (QOL) and functional impairment. However, these studies did not compare individuals in remission to individuals who continue to have the disorder, predominantly used comparisons with norms and not with a matched normal sample, and did not always consider the impact of comorbidity. Methods: We administered multiple measures that assess QOL and functional impairment to 66 OCD patients who had previously consented for a clinical trial and to 36 age and sex matched individuals who denied any psychiatric history. Results: Results confirm that OCD was associated with significantly lower QOL and functional impairment compared to healthy controls (HCs) in areas of work, social life, and family life. Individuals with OCD and other comorbid psychiatric diagnoses showed the poorest QOL and functioning, with comorbid depression accounting for much of the variance. The levels of QOL and functioning in individuals in remission tended to lie in between HCs and individuals with current OCD: their QOL or functioning did not differ significantly from HCs nor did they consistently differ significantly from those who had current OCD. Conclusion: These results suggest that individuals who are in remission have improved levels of QOL and functioning, whereas individuals with OCD are significantly impaired, and individuals with OCD and comorbid disorders are the most impaired. Treatment strategies should be focused on achieving remission of all symptoms to have the greatest impact on functioning and QOL. Depression and Anxiety, 2009. Published 2008 Wiley‐Liss, Inc.     

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.     

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.     

A randomized clinical trial of cognitive-behavioral group therapy and sertraline in the treatment of obsessive-compulsive disorder

BACKGROUND: Cognitive-behavioral group therapy (CBGT) and serotonin reuptake inhibitors have proven efficacy in reducing symptoms of obsessive-compulsive disorder (OCD). There is no consensus about which of these forms of treatment is more effective. This study was conducted to evaluate the efficacy of CBGT as compared to that of sertraline in reducing OCD symptoms. METHOD: Fifty-six outpatients with an OCD diagnosis, according to DSM-IV criteria, participated in the randomized clinical trial: 28 took 100 mg/day of sertraline and 28 underwent CBGT for 12 weeks. Efficacy of treatments was rated according to the reduction in scores on the Yale-Brown Obsessive Compulsive Scale (YBOCS) and the Clinical Global Impressions-Severity of Illness scale. The trial was performed in 4 successive periods from March 2002 to December 2003. RESULTS: Both treatments were effective, although patients treated with CBGT obtained a mean YBOCS reduction of symptoms of 44%, while those treated with sertraline obtained only a 28% reduction (p = .033). Cognitive-behavioral group therapy was also significantly more effective in reducing the intensity of compulsions (p = .030). Further, 8 patients (32%) treated with CBGT presented a complete remission of OCD symptoms (YBOCS score < or = 8) as compared to only 1 patient (4%) among those who received sertraline (p = .023). CONCLUSION: Cognitive-behavioral group therapy and sertraline have shown to be effective in reducing OCD symptoms. Nevertheless, the rate of symptom reduction, intensity reduction of compulsions, and percentage of patients who obtained full remission were significantly higher in patients treated with CBGT.     

Sleep duration and timing in obsessive-compulsive disorder (OCD): evidence for circadian phase delay

ObjectivesTo investigate potential delays in endogenous melatonin in individuals with obsessive-compulsive disorder (OCD).MethodsFirst, data are presented for 15 individuals with OCD and matched healthy controls. Next, nine additional participants with OCD who did not have matched controls were added, resulting in a sample of 24 individuals with OCD. All participants were assessed for sleep and circadian rhythm disturbance. Dim light melatonin onset (DLMO) was derived from salivary melatonin and was used in conjunction with sleep diaries, interview measures, and questionnaires. A subset of the OCD group (n = 16) also used actigraphy.ResultsIn sum, 42% percent (10/24) of the patients with OCD met the criteria for delayed sleep-wake phase disorder (DSWPD) in comparison to 0% in the control sample. DLMO was significantly later in individuals with OCD compared to controls. DLMO and bedtime were not significantly associated with the severity of obsessive-compulsive symptoms or negative affect.ConclusionsReplication of the findings presented herein, particularly the DLMO results, is warranted. Further, there are now three studies showing that nearly ½ of individuals with OCD meet criteria for a DSWPD. Future studies can explore the mechanisms underlying these connections and the implications of this comorbidity. These findings may increase our understanding of OCD and inform future interventions.     

Sensitivity of self-beliefs in obsessive compulsive disorder

Aspects of self-concept have been implicated in recent cognitive theories of obsessive compulsive disorder (OCD). It has been proposed that OCD is associated with perceptions of incompetence in self-domains considered important by the individual. A previous study in nonclinical individuals found that such "sensitivity of self" in the areas of job competence, morality and social acceptability was associated with elevated OCD symptoms and related beliefs. This study examined whether self-sensitivity is related to higher OCD symptoms and cognitions in individuals with OCD, and whether such self-sensitivity is specific to OCD versus other anxiety disorders. Clinical samples with OCD (N=30), other anxiety disorders (N=20) and a community control sample (N=32) participated in the study. It was found that in the OCD group, sensitivity in moral domains, but not job competence or social acceptability, was associated with higher levels of OCD symptoms and OCD-related beliefs. Sensitivity in the domains of morality and job competence was found in the OCD cohort, whereas individuals with other anxiety disorders did not show such sensitivity, suggesting some specificity of relationships to OCD. Implications for theory and therapy are discussed.     

Neurobiological model of obsessive–compulsive disorder: Evidence from recent neuropsychological and neuroimaging findings

Obsessive–compulsive disorder (OCD) was previously considered refractory to most types of therapeutic intervention. There is now, however, ample evidence that selective serotonin reuptake inhibitors and behavior therapy are highly effective methods for treatment of OCD. Furthermore, recent neurobiological studies of OCD have found a close correlation between clinical symptoms, cognitive function, and brain function. A large number of previous neuroimaging studies using positron emission tomography, single‐photon emission computed tomography or functional magnetic resonance imaging (fMRI) have identified abnormally high activities throughout the frontal cortex and subcortical structures in patients with OCD. Most studies reported excessive activation of these areas during symptom provocation. Furthermore, these hyperactivities were decreased after successful treatment using either selective serotonin reuptake inhibitors or behavioral therapy. Based on these findings, an orbitofronto‐striatal model has been postulated as an abnormal neural circuit that mediates symptomatic expression of OCD. On the other hand, previous neuropsychological studies of OCD have reported cognitive dysfunction in executive function, attention, nonverbal memory, and visuospatial skills. Moreover, recent fMRI studies have revealed a correlation between neuropsychological dysfunction and clinical symptoms in OCD by using neuropsychological tasks during fMRI. The evidence from fMRI studies suggests that broader regions, including dorsolateral prefrontal and posterior regions, might be involved in the pathophysiology of OCD. Further, we should consider that OCD is heterogeneous and might have several different neural systems related to clinical factors, such as symptom dimensions. This review outlines recent neuropsychological and neuroimaging studies of OCD. We will also describe several neurobiological models that have been developed recently. Advanced findings in these fields will update the conventional biological model of OCD.     

Treatment-resistant Obsessive-compulsive Disorder in Young People: Assessment and Treatment Strategies

Cognitive behaviour therapy (CBT) and selective serotonin reuptake inhibitors have both been established as effective interventions for paediatric obsessive-compulsive disorder (OCD), with CBT being the recommended first-line treatment in most cases. While the majority of young people respond well to these treatments, a significant proportion remain symptomatic. Although the research on treatment-resistant OCD remains limited, increasing empirical attention is being paid to predictors of treatment outcome in young people with OCD, and efforts are being made to identify the factors that hinder recovery. This article outlines potential barriers in treatment and highlights strategies for optimising outcome, with particular focus on cognitive behavioural techniques.     

Late-onset obsessive compulsive disorder: clinical characteristics and psychiatric comorbidity

There has been little research examining clinical correlates of late-onset OCD in a large sample of individuals with a primary diagnosis of OCD. Using a sample of 293 consecutive subjects with lifetime DSM-IV OCD, we compared subjects with late-onset (after age 30 years) OCD to those with earlier onset on a variety of clinical measures. Symptom severity was examined using the Yale-Brown Obsessive Compulsive Scale. Thirty-three (11.3%) of the 293 subjects with OCD reported onset of OCD on or after age 30 years (mean age of OCD onset of 38.8+/-9.7 years). Subjects with late-onset had significantly shorter durations of illness prior to receiving treatment, less severe obsessinality, and a trend demonstrating a greater likelihood of responding to cognitive behavioral therapy (CBT). Late-onset OCD subjects were also significantly less likely to report contamination, religious, or somatic obsessions. Comorbidity, insight, depressive symptoms, quality of life, and social functioning did not differ between groups. These preliminary results suggest that although onset on or after age 30 years is fairly uncommon among people with OCD, individuals developing OCD later in life have similar clinical characteristics as those with earlier onset and may respond better to CBT.     

Specificity of disgust vulnerability in the distinction and treatment of OCD

A growing body of research has implicated disgust as a potential risk factor for the development and maintenance of obsessive-compulsive disorder (OCD). The first aim of the present study was to determine whether related, yet distinct, disgust vulnerabilities are endorsed more strongly by individuals with OCD than by those with another anxiety disorder. The second aim was to examine the unique contributions of changes in disgust to symptom improvement observed with exposure-based treatment for OCD. In study 1, individuals with OCD, generalized anxiety disorder (GAD), and nonclinical controls (NCCs) completed a measure of disgust propensity and disgust sensitivity. Compared to NCCs and individuals with GAD, those with OCD more strongly endorsed disgust propensity. However, individuals with OCD did not significantly differ from individuals with GAD in disgust sensitivity, although both groups reported significantly higher disgust sensitivity levels compared to NCCs. Study 2 comprised mediation analyses of symptom improvement among individuals with OCD and revealed that decreases in disgust propensity over time mediated improvement in OCD symptoms, even after controlling for improvements in negative affect. The implications of these findings for conceptualizing the role of disgust in the nature and treatment of OCD are discussed.     

Evidence for successful implementation of exposure and response prevention in a naturalistic group format for pediatric OCD

Background: Although exposure and response prevention (ERP) is an effective treatment for youth with obsessive–compulsive disorder (OCD), the majority of studies, randomized clinical trials of individual therapy, find variability in treatment response. We evaluated the potential role of individual differences in OCD presentation, comorbid disorders, age, and gender on treatment effects. Moreover, we examined these potential effects in a group format in a naturalistic, clinic‐based sample of patients. Methods: Pediatric patients with a DSM‐IV diagnosis of OCD ( n =41) were treated with ERP in an intensive outpatient community‐based program. OCD, mood, and anxiety symptom severity was measured at baseline, during treatment, and at discharge. Trajectories and predictors of treatment outcome were measured using linear growth models. Results: We found that group‐based ERP was effective in reducing pediatric OCD symptom severity in a naturalistic treatment setting irrespective of age or gender. Furthermore, ERP was found to be effective at reducing depressive symptoms but not other anxiety symptoms. We also found inter‐individual variability in the discharge levels of contamination, symmetry, and intrusive sexual thoughts and in the rate of severity reduction of intrusive sexual thoughts. Conclusion: Group‐based ERP is an effective treatment for children and adolescents with OCD. Several factors, including symptom dimensions and comorbid psychopathology, are associated with treatment response and outcome in this pediatric population. Depression and Anxiety, 2011. © 2011 Wiley‐Liss, Inc.     

Augmenting treatment of obsessive-compulsive disorder with Antonovsky's sense of coherence theory

TOPIC: The complex nature of obsessive-compulsive disorder (OCD) necessitates a multifaceted approach to treatment. PURPOSE: To examine Antonovsky's sense of coherence theory as a framework for psychotherapy to optimize treatment for individuals with OCD. SOURCES: Selective literature review. CONCLUSIONS: Antonovsky's sense of coherence theory provides a theoretical framework for understanding the multiple pathways by which cognitive behavioral therapy can maintain and improve outcomes for people struggling with OCD.