[Obsessive-compulsive disorder as seen by those who are confronted with it: A survey of patients, relatives and clinicians]. / Le trouble obsessionnel compulsif vu par ceux qui y sont confrontés : enquête auprès de patients, de proches et de cliniciens.

INTRODUCTION: Obsessive compulsive disorder (OCD) is one of the most disabling mental health disorders due to its negative impact on the patient's quality of life as well on that of her living caregivers. This disorder generates an additional burden for relatives, which may in turn affect the family dynamics and impair the evolution of the disease. Along with medications, cognitive behavioral therapy (CBT) represents a well-validated first line of treatment for OCD. However, therapeutic responses across patients are uneven with often residual symptoms and limited quality of life improvements. In total, OCD is a severely debilitating disease with repercussions on both personal, social and professional lives of patients and their relatives even after clinically-delivered treatments. The mutual identification of points of convergence and divergence in social representations is a factor that contributes to satisfactory interpersonal relationships. In the care relationship in general and particularly in the field of mental health, taking account of these different representations and expectations is essential for improving the care process: upstream of the care in the choice the therapeutic strategy and in strengthening the therapeutic alliance. Although less studied, the relationship with relatives of patients also depends on representations of each which have a significant impact on clinical outcomes and experience of the disease. OBJECTIVE: To carry out the first study of cross-representations of OCD in three groups of people affected by it: those who suffer, their families and clinicians. HYPOTHESIS: Considering the experiences and knowledge of patients, relatives and clinicians, we assumed that their representations related to OCD would partially overlap. Specifically, we assumed that the positioning of each population compared to the other two would differ depending on the investigated dimensions: nosology, etiology, therapy and psychiatric disability. METHODS: From 2010 to 2011 we conducted an online survey among self-declared OCD-patients (n=86), OCD-patients' relatives (n=38) and clinicians (n=79). The questionnaire included both closed questions regarding the nosology, etiology, therapy and psychiatric disabilities and open questions probing the representations of the disorder and its evolution, its impact on personal, social and professional domains, and on the quality of life. In particular, we investigated how each population conceived the role and involvement of the relatives in the care process and how they dealt daily with the disorder. RESULTS: Confirming our hypothesis, our results showed that representations of OCD converge on the DSM-based definition of the disorder conveyed by patient associations and mass media. The three populations also recognize the burden and the handicap associated with OCD considerably restrict their daily functioning. However, patients and relatives differ from clinicians in their view of the etiology and their expectations of the therapeutic process. Unexpectedly, patients do not report frequent stigmatization although this may reflect their attempt to hide their disorder as a form of self-stigmatization. Patients focus on care modalities (alternative therapies) motivated by quality of life improvement rather than symptom reduction put forward by clinicians. Relatives ask for being involved in the care process. CONCLUSION: Our study emphasizes the importance for health professionals to take into account the expectations of patients and their relatives in order to maximize the therapeutic alliance and efficiency of treatment.

[Can the efficacy of behavioral and cognitive therapy for obsessive compulsive disorder be augmented by innovative computerized adjuvant?] / Peut-on augmenter l'efficacité de la thérapie cognitive et comportementale pour le trouble obsessionnel compulsif par un adjuvant informatique innovant ?

AIM: Cognitive behavioral therapy (CBT) is recognized as an effective treatment for obsessive-compulsive disorder (OCD). To maximize its effectiveness, we designed an "experimental" CBT defined by the addition of a computerized psychoeducative tool. METHOD: In a participative process involving patients through meetings of the French OCD association (AFTOC) and therapists through methodological workshops, we built a therapeutic tool from an experimental checking task. This task, which had been published in an earlier work, was adapted for its psychoeducative dimension. We here report on a randomized double-blind trial which included 35 patients with a moderate to severe OCD (Yale-Brown obsessive-compulsive scale, YBOCS between 16 and 25) predominant checking symptoms, no comorbidities, and 2-month stabilized or no treatment. Patients were randomly assigned to either "standard" versus "experimental" CBT. Both therapies were conducted by four CBT-experienced therapists specialized in OCD through weekly individualized sessions over 3 months. Therapy sessions of the experimental CBT were conducted as the standard CBT except for a short exercise with the computerized psychoeducative tool performed by the patient and debriefed with the therapist at the end of the sessions. Patients were assessed before, during, after therapy and again 6 months later using standard clinical tools and a neurobehavioral assessment based on an original symptom-provocation task with anxiety ratings including three types of photographs: neutral, generic inducing obsessions (e.g., doorknobs, electric wires…) and personalized (taken by the patients in their own environment). RESULTS: Clinically, "standard" and "experimental" CBT resulted in a significant but equivalent improvement (48% vs 45% reduction of the Y-BOCS score; P=0.36; d=0.12). Therapists were satisfied with the psychoeducative dimension of the computerized psychoeducative tool but reported variable acceptance across patients. Patients appreciated its usability. The clinical improvement was associated with a reduction of the task-induced anxiety (r=0.42, P<0.05), especially towards personalized items (-28,2% vs -20.41% for generic and -6.24% for neutral photographs, P<0.001). Mid-therapy response level was predictive of the final improvement (r=0.82, P<0.001). CONCLUSION: The computerized tool may provide a well-accepted therapeutic adjuvant even though it doesn't improve the therapeutic effect. Using a personalized symptom-provocation task reveals the parallel evolution of symptoms and neurobehavioral markers through CBT. Despite the difficulty of improving an evidence-based therapy, mid-therapy results call for investigating the possible adjustments of treatment strategies at an early stage.

Dynamics of psychotherapy-related cerebral haemodynamic changes in obsessive compulsive disorder using a personalized exposure task in functional magnetic resonance imaging.

BACKGROUND: Cognitive behavioural therapy (CBT) is a successful treatment of obsessive compulsive disorder (OCD). It is known to induce changes in cerebral metabolism; however, the dynamics of these changes and their relation to clinical change remain largely unknown, precluding the identification of individualized response biomarkers. METHOD: In order to study the dynamics of treatment response, we performed systematic clinical and functional magnetic resonance imaging (fMRI) evaluation of 35 OCD patients immediately before a 3-month course of CBT, halfway through and at its end, as well as 6 months after. To sensitize fMRI probing, we used an original exposure task using neutral, generic and personalized obsession-inducing images. RESULTS: As expected, CBT produced a significant improvement in OCD. This improvement was continuous over the course of the therapy; therefore, outcome could be predicted by response at mid-therapy (r 2 = 0.67, p < 0.001). Haemodynamic response to the task was located in the anterior cingulate and orbitofrontal cortices and was stronger during exposure to personalized obsession-inducing images. In addition, both the anxiety ratings and the haemodynamic response to the obsession-inducing images in the anterior cingulate and the left but not the right orbitofrontal clusters decreased with symptom improvement. Interestingly, haemodynamic activity continued to decrease after stabilization of clinical symptoms. CONCLUSIONS: Using an innovative and highly sensitive exposure paradigm in fMRI, we showed that clinical and haemodynamic phenotypes have similar time courses during CBT. Our results, which suggest that the initial CBT sessions are crucial, prompt us to investigate the anatomo-functional modifications underlying the very first weeks of the therapy.

Excessive checking for non-anxiogenic stimuli in obsessive-compulsive disorder.

BACKGROUND: Repetitive checking in obsessive-compulsive disorder (OCD) would serve to relieve obsession-related anxiety and/or to compensate memory deficit, but experimental literature on this subject is inconsistent. The main objective is to test the influence of obsession-related anxiety and memory on repetitive checking in OCD. METHODS: Twenty-three OCD checkers, 17 OCD non-checkers and 41 controls performed a delayed-matching-to-sample task with an unrestricted checking option. Some stimuli were obsession-related in order to measure the influence of anxiety on checking. A version of the task without checking possibility was used to assess memory abilities. RESULTS: OCD checkers had similar memory performances but checked more than the other groups when presented with non-anxiogenic stimuli. Level of anxiety associated to the stimulus did not influence the number of checks. CONCLUSIONS: Increased checking in OCD checkers, being independent of memory abilities and primary obsession-related anxiety, would, therefore, be closer to an automated behaviour than a coping strategy.

A challenging task for assessment of checking behaviors in obsessive-compulsive disorder.

OBJECTIVE: The present study concerns the objective and quantitative measurement of checking activity, which represents the most frequently observed compulsions in obsessive-compulsive disorder (OCD). To address this issue, we developed an instrumental task producing repetitive checking in OCD subjects. METHOD: Fifty OCD subjects and 50 normal volunteers (NV) were administered a delayed matching-to-sample task that offered the unrestricted opportunity to verify the choice made. Response accuracy, number of verifications, and response time for choice taken to reflect the degree of uncertainty and doubt were recorded over 50 consecutive trials. RESULTS: Despite similar levels of performance, patients with OCD demonstrated a greater number of verifications and a longer response time for choice before checking than NV. Such behavioral patterns were more pronounced in OCD subjects currently experiencing checking compulsions. CONCLUSION: The present task might be of special relevance for the quantitative assessment of checking behaviors and for determining relationships with cognitive processes.