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.

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.

Directionality of change in obsessive compulsive disorder and depression over six years of prospective follow-up.

Major Depressive Disorder (MDD) is often comorbid with obsessive-compulsive disorder (OCD) yet little is known about the directionality of the association between OCD and depression symptoms. We aim to investigate the effect OCD symptoms has on depression symptoms and vice versa over an extended period of time. This is one of the first longitudinal studies to evaluate the relationship between OCD and depression in a large clinical sample. Participants (n = 324) were treatment-seeking adults with a primary diagnosis of OCD. OCD and depression symptoms were assessed annually over the six-year follow-up period. Random intercepts cross-lagged panel models (RI-CLPM) were conducted to compare unidirectional and bidirectional models over time. The best-fitting and most parsimonious model included paths with OCD symptoms predicting depression symptoms, but not vice versa. OCD symptom severity in a given year predicted next year depression severity. However, depression severity did not predict next-year OCD symptom severity in this sample. Our results suggest that depression severity may be secondary to OCD symptoms and treating OCD should be prioritized over treating depression.

Personality traits as predictors of OCD remission: A longitudinal study.

BACKGROUND: Personality traits may confer vulnerability to psychopathology. However, few studies have examined the association between personality traits and obsessive-compulsive disorder (OCD) course. The present study investigates personality traits, OCD symptom severity, and illness duration as a predictor of OCD remission. METHODS: 166 treatment-seeking adults with OCD, recruited as part of the Brown Longitudinal Obsessive-Compulsive Study, completed the NEO Five-Factor Inventory 3 (NEO-FFI) and were in episode for OCD at time of NEO-FFI completion. Participants were followed for up to 3 years. RESULTS: Results suggest individuals with OCD had a 21 % likelihood of reaching remission over the course of 3 years. Greater OCD symptom severity and longer illness duration were associated with a decreased likelihood of remission. Among the five factors of personality, only low extraversion was associated with a decreased rate of remission. Neuroticism, openness, agreeableness, and conscientiousness were not associated with remission. LIMITATIONS: As this was an observational study, treatment was not controlled precluding examination of treatment on course. Further, data collected on age of onset and symptom severity during follow up were retrospective and therefore are also subject to recall bias. CONCLUSIONS: Our findings provide preliminary support that personality traits are potential factors impacting course and symptom presentation. Future research is necessary to determine the mechanisms in which personality traits may influence the presentation and course of OCD.

Using electronic patient-reported measures to characterize symptoms and improvement in inpatient psychiatric units.

Patient-reported measures are an important tool in personalizing care and monitoring clinical outcomes. This work presents results from the routine collection of self-report measures from individuals (n = 753) admitted to depression and anxiety inpatient units at McLean Hospital. 93.7% participated in the Clinical Measurement Initiative (CMI) between September 2020 and February 2022 on the most established unit. The average time between admission and discharge measures was 12.6 days and an attrition rate of 10.4% was observed on this unit. Missingness of discharge assessments was unrelated to symptom severity or comorbidities. We discuss the feasibility of deploying patient-reported measures as part of routine care in an inpatient psychiatric setting. Systematic evaluation of potential treatment modifiers (e.g., personality disorder, trauma history, and substance misuse) may be valuable in better serving those impacted by psychiatric illness.

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.

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.

Transforming Psychiatry from the Classroom to the Clinic: Lessons from the National Neuroscience Curriculum Initiative.

OBJECTIVE: Individual residency programs often struggle to keep pace with scientific advances and new training requirements. Integrating a modern neuroscience perspective into the clinical practice of psychiatry is particularly emblematic of these challenges. The National Neuroscience Curriculum Initiative (NNCI) was established in 2013 to develop a comprehensive set of shared, open-access resources for teaching neuroscience in psychiatry. METHODS: The NNCI developed a collaborative, team-based approach with a peer-review process for generating and reviewing content. Teaching resources have included interactive sessions for the classroom paired with a comprehensive facilitator's guide. Brief accessible reviews and short videos have been developed for self-study and teaching in clinical settings. Dissemination efforts have included hands-on training for educators through national workshops. All resources are freely available on the NNCI website. Outcome measures have included the number of educational resources developed, feedback from workshop attendees, the number of US psychiatry residency programs who have adopted NNCI resources, as well as analytics from the NNCI website. RESULTS: To date, the NNCI has developed over 150 teaching sessions, reflecting the work of 129 authors from 49 institutions. The NNCI has run over 50 faculty development workshops in collaboration with numerous national and international organizations. Between March 2015 and June 2019, the website (www.NNCIonline.org) has hosted 48,640 unique users from 161 countries with 500,953 page views. More than 200 psychiatry training programs have reported implementing NNCI teaching materials. CONCLUSIONS: This multisite collaborative provides a model for integrating cutting-edge science into medical education and the practice of medicine more broadly.

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.

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.

The impact of lifetime PTSD on the seven-year course and clinical characteristics of OCD.

Research has suggested that the co-occurrence of PTSD in individuals with OCD is associated with more severe symptoms and less responsivity to empirically supported treatment as compared to individuals with OCD and no history of PTSD. However, much of this work has been limited by non-empirical case report design, cross-sectional and retrospective analyses, or small sample sizes. The current study extended this research by comparing the clinical characteristics of individuals with OCD with and without a lifetime PTSD diagnosis in a large, naturalistic, longitudinal sample over the course of seven years. At baseline, individuals with comorbid lifetime PTSD reported significantly more severe symptoms of OCD (including symptom levels and insight), lower quality of life, and higher rates of comorbid lifetime mood and substance use disorders than participants without lifetime PTSD. Further, individuals with comorbid OCD and lifetime PTSD reported significantly more severe OCD symptoms over the course of seven years than those without lifetime PTSD. These results are largely consistent with the existing literature and support the need to consider PTSD symptoms in the assessment and treatment of OCD.

A cross-cultural clinical comparison between subjects with obsessive-compulsive disorder from the United States and Brazil.

Although OCD is a global problem, the literature comparing, in a direct and standardized way, the manifestations across countries is scarce. Therefore, questions remain as to whether some important clinical findings are replicable worldwide, especially in the developing world. The objective of this study was to perform a clinical comparison of OCD patients recruited in the United States (U.S.) and Brazil. Our sample consisted of 1187 adult, treatment-seeking OCD outpatients from the U.S. (n=236) and Brazil (n=951). With regards to the demographics, U.S. participants with OCD were older, more likely to identify as Caucasian, had achieved a higher educational level, and were less likely to be partnered when compared to Brazilians. Concerning the clinical variables, after controlling for demographics the two samples presented largely similar profiles. Brazilian participants with OCD, however, endorsed significantly greater rates of generalized anxiety disorder and post-traumatic stress disorder, whereas U.S. subjects were significantly more likely to endorse a lifetime history of addiction (alcohol-use and substance-use disorders). This is the largest direct cross-cultural comparison to date in the OCD field. Our results provide much needed insight regarding the development of culture-sensitive treatments.

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.

The Use of a Small Private Online Course to Allow Educators to Share Teaching Resources Across Diverse Sites: The Future of Psychiatric Case Conferences?

OBJECTIVE: The authors sought to demonstrate the feasibility of integrating small private online course (SPOC) technology with flipped classroom techniques in order to improve neuroscience education across diverse training sites. METHODS: Post-graduate medical educators used SPOC web conferencing software and video technology to implement an integrated case conference and in-depth neuroscience discussion. RESULTS: Ten psychiatry training programs from across the USA and from two international sites took part in the conference. Feedback from participants was largely positive. CONCLUSION: This pilot demonstrated the feasibility of such a program and provided a diverse audience with the opportunity to engage in an interactive learning experience with expert faculty discussants. This may be a useful model for programs with limited local expertise to expand their teaching efforts in a wide range of topics.

An empirical investigation of incompleteness in a large clinical sample of obsessive compulsive disorder.

Obsessive Compulsive Disorder (OCD) is a disorder with heterogeneous clinical presentations. To advance our understanding of this heterogeneity we investigated the prevalence and clinical features associated with incompleteness (INC), a putative underlying core feature of OCD. We predicted INC would be prominent in individuals with OCD and associated with greater severity and impairment. We examined the impact of INC in 307 adults with primary OCD. Participants with clinically significant INC (22.8% of the sample) had significantly greater OCD severity, greater rates of comorbidity, poorer ratings of functioning, lower quality of life, and higher rates of unemployment and disability. Participants with clinically significant INC were also more likely to be diagnosed with OCPD and to endorse symmetry/exactness obsessions and ordering/arranging compulsions than those who reported low INC. Our findings provide evidence that INC is associated with greater severity, comorbidity, and impairment, highlighting the need for improved assessment and treatment of INC in OCD.

Parental Accommodation Predicts Symptom Severity at Long-term Follow-Up in Children with Obsessive-Compulsive Disorder.

Pediatric obsessive-compulsive disorder (OCD) is a chronic condition affecting millions of children. Though well intentioned, accommodation (i.e., a parent's attempt to assuage their child's distress and anxiety) is thought to increase OCD symptom severity and may cause greater OCD-related impairment. The present study sought to examine the relative contribution of parental accommodation in predicting OCD symptom severity. Children between the ages of 6 and 18 (and their parents) participated in a prospective, longitudinal study investigating the course of pediatric OCD utilizing a longitudinal design. Data was collected at intake (n = 30) and two-years (n = 22) post-intake controlling for age, anxiety and depression. Parental accommodation (measured at intake) significantly predicted OCD symptom severity and was the strongest predictor at both intake and two-year follow-up. These preliminary findings highlight the importance of further research seeking to delineate factors relevant to the development and maintenance of accommodation as well as parent-level variables that might mediate the relationship between accommodation and OCD symptom severity.

Predicting course of illness in patients with severe obsessive-compulsive disorder.

OBJECTIVE: Few data are available to inform clinical expectations about course and prognosis of severe obsessive-compulsive disorder (OCD). Such information is necessary to guide clinicians and to inform criteria for invasive interventions for severe and intractable OCD. This study sought to examine course and prospective predictors of a chronic course in patients with severe OCD over 5 years. METHOD: A selected subset of adults in the Brown Longitudinal Obsessive-Compulsive Study (BLOCS) was included. Adult BLOCS participants were enrolled between 2001 and 2006. All participants in the current study (N = 113) had DSM-IV OCD diagnosis, severe OCD symptoms at baseline, and at least 1 year of follow-up data. RESULTS: Cox proportional hazard models were used to examine the general pattern of course in the severe OCD sample based on Longitudinal Interval Follow-Up Evaluation (LIFE) psychiatric status ratings, as well as test predictors of chronically severe course. Results indicated that approximately half of patients with severe OCD at baseline had illness drop to a moderate or lower range of severity during 5 years of follow-up (50.4%) and that marked improvement was rare after 3 years of severe illness. The only unique predictor of a more chronically severe course was patient report of ever having been housebound for a week or more due to OCD symptoms (P < .05). CONCLUSIONS: Findings of this study were 3-fold: (1) half of participants with severe OCD have symptom improvement over 5 years of follow-up, (2) the majority of participants that drop out of the severe range of symptom severity do so within the first 3 years of follow-up, and (3) patient-reported history of being housebound for 1 week or more due to OCD is a significant predictor of OCD's remaining severe over the 5-year follow-up.

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.