Impact of the peripartum period on the longitudinal course of obsessive-compulsive disorder.

Some women are vulnerable to developing new onset obsessive-compulsive disorder (OCD) or having an exacerbation of pre-existing OCD during reproductive cycle events. Reports on the impact of the peripartum period on pre-existing OCD are inconsistent, with both worsening and improving symptom severity described. Studies have primarily been retrospective or have collected few data points, which limits the investigators' ability to capture the range of OCD symptoms during this time period, systematically and prospectively. The objective of this investigation was to add to the existing literature on the impact of the peripartum period on the course of pre-existing OCD. We conducted a secondary analysis of a subset data from the Brown Longitudinal Obsessive Compulsive Study, a prospective, observational study of OCD course. Nineteen women who experienced a pregnancy during the course of the study (9.5% of overall sample of women) were followed on average for 486 ± 133 weeks. Weekly psychiatric status ratings (PSRs) of OCD severity were compared between peripartum and non-peripartum periods. We found that the peripartum period did not significantly impact the course of OCD severity in the majority of women (N = 13, 69%). Of the minority of women with measurable variability in OCD symptoms, no statistically significant difference in PSR scores was observed between peripartum and non-peripartum periods. In this novel yet small dataset, the severity of OCD does not appear to worsen for most women during the peripartum period.

Longitudinal course of body-focused repetitive behaviors in obsessive-compulsive disorder.

BACKGROUND: The course of body-focused repetitive behaviors (BFRBs) (eg, trichotillomania, skin picking, and nail biting) has received scant research attention. We sought to understand the longitudinal course of BFRBs over an 8-year period and whether the co-occurrence of a BFRB with obsessive-compulsive disorder (OCD) affects the course of OCD. METHODS: Three hundred ninety-five participants with OCD completed annual interviews using the Longitudinal Interval Follow-up Evaluation to estimate BFRB and OCD symptom severity during each week of follow-up. RESULTS: Of the 395 participants, 83 (21%) had a co-occurring BFRB. In almost one-half of the participants, BFRB onset occurred before OCD. Participants with OCD and BFRB spent the majority of the rating period experiencing full BFRB symptoms. Having a BFRB was associated with spending less time in remission from OCD. CONCLUSIONS: Although BFRBs have long been known to be common in individuals with OCD, these data demonstrate that most individuals who have a co-occurring BFRB with OCD do not experience BFRB remission and that having a BFRB predicts a worse course for OCD.

Who qualifies for deep brain stimulation for OCD? Data from a naturalistic clinical sample.

A few patients with obsessive-compulsive disorder (OCD) remain severely impaired despite exhausting best-practice treatments. For them, neurosurgery (stereotactic ablation or deep brain stimulation) might be considered. The authors investigated the proportion of treatment-seeking OCD patients, in a naturalistic clinical sample, who met contemporary neurosurgery selection criteria. Using comprehensive baseline data on diagnosis, severity, and treatment history for adult patients from the NIMH-supported Brown Longitudinal OCD Study, only 2 of 325 patients met screening criteria for neurosurgery. This finding prompts consideration of new models for clinical trials with limited samples as well as methods of refining entry criteria for such invasive treatments.

Excluding the typical patient: thirty years of pharmacotherapy efficacy trials for obsessive-compulsive disorder.

BACKGROUND: Over the past 30 years, clinical trials have resulted in several successful pharmacotherapies for obsessive-compulsive disorder (OCD), yet patients in clinical settings often report inadequate response. This study compares clinical characteristics of treatment-seeking OCD patients to the inclusion/exclusion criteria used in pharmacotherapy trials. METHODS: The sample consisted of 325 community members with a DSM-IV diagnosis of OCD who underwent systematic interviews with clinicians knowledgeable in the diagnosis and treatment of OCD. We compiled pharmacotherapy studies for OCD published between 1980 and 2010 using Medline, PubMed, and library resources, and estimated the proportion of patients in each decade satisfying the most common inclusion/exclusion criteria. RESULTS: We included 39 clinical trials and found 72% of the 325 patients would have been excluded from trials conducted between 1980 and 2010. Exclusion was projected as dramatically lower for trials conducted between 1980 and 1989 (19.7%) compared with 74.8% for trials conducted between 1990 and 1999 and 76.9% for trials between 2000 and 2010. CONCLUSIONS: The majority of treatment-seeking individuals with OCD would not qualify for OCD treatment studies due to comorbid psychiatric disorders, and failure to meet OCD severity threshold criteria. This illustrates the need to include a more community-representative sample of OCD patients in clinical trials examining pharmacotherapy efficacy.

Long-term course of pediatric obsessive-compulsive disorder: 3 years of prospective follow-up.

OBJECTIVE: This study assesses the long-term course of treatment-seeking youth with a primary diagnosis of DSM-IV OCD. METHOD: Sixty youth and their parents completed intake interviews and annual follow-up interviews for 3 years using the youth version of the Longitudinal Interval Follow-up Evaluation (Y-LIFE) and Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Remission was defined as no longer meeting DSM-IV criteria for OCD for 8 weeks or more, and recurrence was defined as meeting full criteria for OCD for 4 consecutive weeks after having achieved symptom remission. Remission rates for youth were compared to rates of adults participating in the same study. RESULTS: The probability of achieving partial remission of OCD was 0.53 and the probability of achieving full remission was 0.27. Among the 24 youth participants who achieved remission, 79% stayed in remission throughout the study (mean of 88 weeks of follow-up) and 21% experienced a recurrence of symptoms. Better functioning at intake and a shorter latency to initial OCD treatment were associated with faster onset of remission (P<.001). CONCLUSIONS: Remission is more likely among youth versus adults with OCD. Treatment early in the course of illness and before substantial impact on functioning predicted a better course.

Course and clinical correlates of obsessive-compulsive disorder with or without comorbid personality disorder.

BACKGROUND: Personality disorders (PDs) are often comorbid with obsessive-compulsive disorder (OCD) which may influence symptom presentation and course. This investigation sought to examine the impact of comorbid PDs on clinical presentation and symptom chronicity in a large, prospective longitudinal OCD study. METHODS: Participants (n = 263) were treatment-seeking adults with a primary diagnosis of OCD separated into two groups: individuals with and without a co-occurring PD. We conducted two-tailed t-tests to compare symptom severity, functioning, and quality of life between the OCD + PD group (n = 117) and the OCD w/o PD group (n = 146). Chronicity analyses were conducted to compare the amount of time in-episode for OCD and major depressive disorder (MDD) between the two groups. RESULTS: The OCD + PD group reported greater OCD and depression severity, lower levels of psychosocial functioning and worse quality of life than the OCD w/o PD group. The OCD + PD group exhibited greater OCD and MDD symptom chronicity; over 5 years the OCD + PD group spent 16.2 % weeks longer at full criteria for OCD and three times as many weeks in episode for MDD than the OCD w/o PD group. LIMITATIONS: Focusing on PDs as a group limited our ability to make observations about specific PDs. Further, the participants in our sample were predominantly White and all were treatment seeking which limits the generalizability of our findings. CONCLUSIONS: Our results suggest that those with OCD and comorbid PDs present with greater overall impairment and may require additional considerations during treatment conceptualization and planning.

Psychometric evaluation of the Brown Assessment of Beliefs Scale in body dysmorphic disorder.

The Brown Assessment of Beliefs Scale (BABS) is a widely used measure that assesses insight/delusionality-an important dimension of psychopathology-both dimensionally and categorically (e.g., delusional versus nondelusional). The BABS has been shown to have good psychometric properties in a number of disorders, but sample sizes were small. In the present study, 327 subjects with body dysmorphic disorder (BDD) were interviewed with the BABS to assess insight regarding appearance beliefs. Other measures were administered. Intraclass correlation coefficients demonstrated excellent interrater reliability and test-retest reliability; internal consistency was strong. Principal components factor analysis identified one factor accounting for 60% of the variance. Analyses with measures of severity of BDD, depressive symptoms, and general psychopathology indicated good discriminant validity. Among the treated subjects, the BABS was sensitive to change but not identical to improvement in symptom severity. These findings provide further evidence that the BABS is a reliable and valid measure of insight/delusionality.

The relationship between obsessive-compulsive disorder symptom subtypes and social adjustment.

Background: Although it has been widely established that poor social functioning is a characteristic of obsessive-compulsive disorder (OCD), little research has examined the relationship between OCD symptom subtypes and domains of social functioning. Thus, the present study sought to examine the specific ways in which impairment in social adjustment occurs in each symptom subtype of OCD. Methods: A total of 325 adult participants with a primary diagnosis of OCD were included in the study. Hierarchical linear regressions were used to compare the extent to which OCD symptom subtypes predicted social adjustment domains after controlling for OCD and depression severity. Results: Hoarding was shown to be significantly associated with work functioning. Whereas both contamination and symmetry subtypes were significantly associated with social functioning, only the contamination subtype was associated with functioning within the family unit. The symptom subtypes of doubt and taboo thoughts were not significantly associated with any domains of social adjustment. Conclusion: Consistent with previous research, our results suggest a differential impact of OCD symptom subtypes on social adjustment. They offer important implications for the specific domains to target in treatment for different symptom subtypes.

What Sustains Residency Program Directors: Social and Interpersonal Factors That Foster Recruitment and Support Retention.

Residency program directors' careers follow several trajectories. For many, the role is relatively short term, lasting 3 to 5 years, during which time the program director may gain educational and administrative experience. However, a sizeable cohort of program directors have remained as program directors for a decade or more, and some have filled the role for the majority of their careers. Over the years, the role of the academic residency program director has become increasingly affected by administrative responsibilities, including scheduling, documentation, and reporting requirements, along with increasing clinical demands that may conflict with ensuring resident wellness and lead to insufficient time to do the job. Burnout in this role is understandable. Given these obstacles, why should any young faculty member choose to become a training director? The authors of this commentary have each served as a residency program director for decades, aggregating approximately 150 years of program director experiences. Based on their collective reflections, the authors describe social and interpersonal aspects of the program director role that have enhanced their professional satisfaction and well-being. These include overseeing residency cycle events from initial interviews through graduation and certification; assuming leadership and social roles in academic departments; counseling, mentoring, and assisting residents with work-personal life difficulties; and helping trainees and programs weather a variety of traumatic circumstances. These life-enriching experiences can compensate for the challenging aspects of these roles and sustain program directors through exceptionally rewarding careers.

Prevalence and clinical characteristics of mental rituals in a longitudinal clinical sample of obsessive-compulsive disorder.

BACKGROUND: Obsessive-compulsive disorder (OCD) is a chronic and debilitating anxiety disorder associated with significant impairment in quality of life and functioning. Research examining the differences in clinical correlates and treatment response associated with different obsessions in OCD has yielded important findings underscoring the heterogeneous nature of this disorder. To date, most of this research has focused on differences associated with primary obsessions, and little attention has been paid to the clinical utility of studying how compulsive symptoms affect clinical course. Virtually no systematic research has explored the clinical characteristics of one understudied symptom presentation, mental rituals, and what impact this primary symptom has on severity and course of illness. Mental rituals, or compulsions without overt signs, represent unique clinical challenges but often go understudied for numerous methodological and clinical reasons. METHODS: In this study, we explored the impact of primary mental rituals on clinical severity and chronicity in a large, longitudinal sample of OCD patients (N = 225) over 4 years. RESULTS: Mental rituals were a primary presenting symptom for a sizable percentage of the sample (12.9%). Primary mental rituals were associated with greater clinical severity and lower functioning at intake, as well as a more chronic course of illness, as participants with primary mental rituals spent nearly 1 year longer in full DSM-IV criteria episodes over the 4-year follow-up interval than OCD patients without mental rituals. CONCLUSIONS: These results suggest that mental rituals are uniquely impairing and highlight the need for further empirical exploration and consideration in treatment.

Impulse-control disorders in children and adolescents with obsessive-compulsive disorder.

The aim of this study was to examine current prevalences, clinical correlates and patterns of co-occurrence of impulse-control disorders (ICDs) in children and adolescents with obsessive-compulsive disorder (OCD). We examined rates and clinical correlates of comorbid ICDs in 70 consecutive child and adolescent subjects with lifetime DSM-IV OCD (32.9% females; mean age = 13.8 +/- 2.9 years). Comorbidity data were obtained with structured clinical interviews using DSM-IV criteria. OCD severity was assessed with the Child Yale-Brown Obsessive-Compulsive Scale. All variables were compared in OCD subjects with and without current ICDs. 12 (17.1%) subjects met criteria for a current ICD. Pathological skin picking and compulsive nail biting were the most common ICDs with current rates of 12.8% and 10.0%, respectively. OCD subjects with current ICDs were significantly more likely to have a co-occurring tic disorder (66.7% vs. 20.7%). Although having an ICD was associated with greater numerical scores of OCD symptomatology, these differences were not statistically significant. There were no sex-specific patterns of ICD occurrence in children and adolescents with OCD. Certain ICDs are common among children and adolescents with OCD. Better identification of ICDs in children and adolescents with OCD is needed, as are empirically validated treatments for youth with co-occurring ICDs.

Directionality of change in obsessive compulsive disorder (OCD) and suicidal ideation over six years in a naturalistic clinical sample✰.

BACKGROUND: Obsessive compulsive disorder (OCD) is associated with elevated suicide risk, but the directionality of the association between OCD severity and suicidal ideation has not been established, which was the goal of this study. METHODS: Participants (n = 325) were adults with either a current or past diagnosis of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) OCD who were assessed annually for suicidal ideation and OCD symptom severity for six years. Cross-lagged panel analyses statistically compared unidirectional and bidirectional models over time. Serious suicide-related adverse events were reported. RESULTS: The best-fitting and most parsimonious model included paths predicting suicidal ideation from OCD symptom severity, but not vice versa. These results were confirmed by comparing a model with cross-lagged paths constrained equal to a freely estimated model. Higher OCD symptom severity in a given year was associated with a higher suicidal ideation severity in the subsequent year. Five suicide-related adverse events were reported throughout the duration of the study, including two suicide deaths and three suicide attempts. LIMITATIONS: The study relied on a single-item, annual measure of suicidal ideation in adults, with substantial variability in severity of suicide risk, and missing data increased with later observations in the study. DISCUSSION: OCD symptom severity predicted next year suicidal ideation severity. In contrast, suicidal ideation severity in a given year did not predict next-year OCD symptom severity in this OCD sample. Thus, rather than waiting for suicidal ideation to resolve, clinicians should consider providing empirically supported treatments for OCD.

OCD with comorbid OCPD: a subtype of OCD?

OBJECTIVE: The current study examined the validity of using comorbid obsessive-compulsive personality disorder (OCPD) to identify a subtype of individuals with obsessive-compulsive disorder (OCD). METHOD: Data for the current study were drawn from an ongoing, longitudinal study of the course of OCD and include intake assessments for 238 subjects with primary and current DSM-IV OCD who were treatment seeking. RESULTS: More than one fourth of the subjects (N=65, 27%) met criteria for comorbid OCPD. As compared to OCD-OCPD subjects, the OCD+OCPD subjects had a significantly younger age at onset of first OC symptoms (p=0.013), and a higher rate of symmetry and hoarding obsessions, and cleaning, ordering, repeating, and hoarding compulsions (all p's<0.01). Individuals with OCD+OCPD had higher rates of comorbid anxiety disorders (p=0.007) and avoidant personality disorder (p=0.006). The OCD+OCPD subjects also had significantly lower ratings of global functioning (p=0.001) and more impaired social functioning (p=0.004), despite a lack of significant differences on overall severity of OCD symptoms. CONCLUSIONS: Our findings indicate that individuals with both OCD and OCPD have distinct clinical characteristics in terms of age at onset of initial OC symptoms, the types of obsessions and compulsions they experience, and psychiatric comorbidity. Our findings, coupled with data from family studies showing a higher than expected frequency of OCPD in first degree relatives of OCD probands, suggest that OCD associated with OCPD may represent a specific subtype of OCD. Additional research is warranted to further establish the validity of this subtype.

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.

The Brown Incompleteness Scale (BINCS): Measure development and initial evaluation.

BACKGROUND: In recent years, incompleteness has received increased clinical attention as a core motivation underlying obsessive-compulsive spectrum disorders. Yet, assessment of incompleteness has relied almost exclusively on self-report and has assumed a unitary conceptualization of this phenomenon. Therefore, we sought to develop and validate a new multi-faceted clinician-administered measure of incompleteness. The Brown Incompleteness Scale (BINCS) consists of 21 items; each rated on a 5-point scale, with higher scores indicating a greater degree of incompleteness. The current study describes the measure's development and preliminary validation. METHODS: The scale was administered to 100 consecutive participants who were part of a longitudinal follow-up study of OCD. The reliability, validity, and factor analytic structure of the scale were evaluated. RESULTS: Exploratory factor analysis supported a two-factor solution, which can best be described as representing both behavioral and sensory manifestations of incompleteness. CONCLUSIONS: The BINCS demonstrated strong internal consistency as well as convergent and divergent validity. This clinician-administered scale will provide a more comprehensive clinical assessment of patients with incompleteness.

Gamma Ventral Capsulotomy in Intractable Obsessive-Compulsive Disorder.

BACKGROUND: Despite the development of effective pharmacologic and cognitive behavioral treatments for obsessive-compulsive disorder (OCD), some patients continue to be treatment-refractory and severely impaired. Fiber tracts connecting orbitofrontal and dorsal anterior cingulate cortex with subcortical nuclei have been the target of neurosurgical lesions as well as deep brain stimulation in these patients. We report on the safety and efficacy of ventral gamma capsulotomy for patients with intractable OCD. METHODS: Fifty-five patients with severely disabling, treatment-refractory OCD received bilateral lesions in the ventral portion of the anterior limb of the internal capsule over a 20-year period using the Leksell Gamma Knife. The patients were prospectively followed over 3 years with psychiatric, neurologic, and neuropsychological assessments of safety and efficacy, as well as structural neuroimaging. RESULTS: Thirty-one of 55 patients (56%) had an improvement in the primary efficacy measure, the Yale-Brown Obsessive Compulsive Scale, of ≥35% over the 3-year follow-up period. Patients had significant improvements in depression, anxiety, quality of life, and global functioning. Patients tolerated the procedure well without significant acute adverse events. Five patients (9%) developed transient edema that required short courses of dexamethasone. Three patients (5%) developed cysts at long-term follow-up, 1 of whom developed radionecrosis resulting in an ongoing minimally conscious state. CONCLUSIONS: Gamma Knife ventral capsulotomy is an effective radiosurgical procedure for many treatment-refractory OCD patients. A minority of patients developed cysts at long-term follow-up, 1 of whom had permanent neurological sequelae.

Taboo thoughts and doubt/checking: a refinement of the factor structure for obsessive-compulsive disorder symptoms.

The purpose of this report was to improve upon earlier factor analyses of obsessive-compulsive disorder (OCD) symptom categories by minimizing the heterogeneity in the aggressive obsessions category. An exploratory factor analysis was conducted on data from 293 adults with primary OCD. The resulting five factors (Symmetry/Ordering, Hoarding, Doubt/Checking, Contamination/Cleaning, and Taboo Thoughts) are phenomenologically more homogeneous than prior category-based factors and are consistent with those derived in previous item-level analyses.

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.

Is anorexia nervosa a delusional disorder? An assessment of eating beliefs in anorexia nervosa.

Anorexia nervosa (AN) is a serious mental illness, characterized in part by intense and irrational beliefs about shape and weight, including fear of gaining weight. Although these beliefs are considered to be a diagnostic criterion for the illness, they have not been systematically characterized. This study used the Brown Assessment of Beliefs Scale (BABS) to identify the dominant belief that interfered with eating in a sample of underweight patients with AN (N=25). The degree of insight was assessed quantitatively. The majority of participants (68%) spontaneously reported a dominant belief consistent with fear of gaining weight or becoming fat. Twenty percent of patients were categorized as delusional. The total score on the BABS was significantly correlated with the drive-for-thinness subscale of the Eating Disorders Inventory (EDI) (r=0.41, p=0.04), but did not correlate with overall measures of AN severity (body mass index [BMI], duration of illness, lowest BMI, other subscales of the EDI, or total EDI score). These findings highlight the centrality of fear of fat in AN and suggest the possibility that there is a subgroup of patients whose concerns about their weight reaches delusional proportions. This subpopulation of patients warrants further study, since patients with more delusional beliefs may have a form of AN that is more refractory to treatment.

Symptom subtype and quality of life in obsessive-compulsive disorder.

Quality of life (QoL) is significantly impaired in OCD across several facets of life, such as social, occupational, and family functioning, subjective sense of well-being, and enjoyment of leisure activities. The present study examined the relationship between 5 symptom subtypes of OCD (contamination, symmetry, hoarding, overresponsibility for harm, and taboo) and QoL. Participants were 325 adults with OCD enrolled in the Brown Longitudinal Obsessive Compulsive Study. Hierarchical linear regression analyses indicated hoarding, contamination, symmetry, and overresponsibility for harm were associated with impairment in household functioning, enjoyment of leisure activities, social relationships, and physical health. The implications of these findings are discussed.