Efficacy and tolerability of pharmacotherapy for obsessive-compulsive personality disorder: a systematic review of randomized controlled trials.

INTRODUCTION: Although obsessive-compulsive personality disorder (OCPD) is one of the most prevalent personality disorders, it is one of the least studied. There is debate as to whether pharmacotherapy is efficacious for OCPD. We aimed to systematically evaluate the efficacy and tolerability of pharmacotherapy for OCPD. AREAS COVERED: This systematic review found two randomized controlled trials investigating pharmacotherapy of OCPD. In a study of major depression (n = 308) with comorbid OCPD (n = 71), citalopram was more effective for OCPD than sertraline with fewer drop-outs from treatment. In a small study of OCPD (n = 24), fluvoxamine was more effective than placebo, and there was a low drop-out rate. Risk of bias and quality assessment of these studies was not possible, and findings have very low levels of certainty. EXPERT OPINION: Two studies provide preliminary evidence in support of citalopram and fluvoxamine for OCPD. Further randomized controlled trials are required before firm conclusions can be drawn regarding efficacy of pharmacotherapy for OCPD.

Walking on eggshells: A life defined by obsessive-compulsive personality disorder.

WHAT IS KNOWN ON THE SUBJECT?: Obsessive-compulsive personality disorder (OCPD), which is experienced by 2.1-7.9% of the population, is characterized by an excessive need for orderliness, neatness and perfectionism. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: Existing studies on OCPD commonly focus on the physiological aspects, treatment and/or comparison of features with other disorders. Studies that explore the personal experiences related to OCPD are lacking and so the human element of this condition is missing. This paper contributes to this gap by presenting a glimpse into life with OCPD. The narrative is provided by the daughter of a person who lived with OCPD and presents the ordeals, victories and aspects of everyday life as framed by the condition. Whilst personality disorders such as OCPD are subjected to a high level of stigma, this relative's story shows that love and compassion can be found even in the darkest corridors that OCPD can take one to. As the story shows, behind every disorder there is a human being and the disorder is not the totality of that being. In this view, the paper sheds light on the human element related to the condition. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The paper highlights the need for continuous, hands-on community support to those experiencing OCPD and their significant others. In order to enhance continuity of care, support is ideally centralized and provided by one keyworker who builds a strong therapeutic relationship with the person and their loved ones.

The intertwined path of perfectionism and self-criticism in a client with obsessive-compulsive personality disorder.

Psychotherapy for obsessive-compulsive personality disorder (OCPD), where perfectionism is a defining criterion, is understudied. Despite a high prevalence few evidence-based treatments are available for the presentation. Here we describe the course of a 6-month program of metacognitive interpersonal therapy with an OCPD patient with prominent perfectionism and self-criticism, which were considered primary outcomes of the case study. Therapy aimed initially at increasing awareness of maladaptive interpersonal schemas and promoting a healthy self. First, behavioral experiments were used to try and counteract perfectionism. Second, experiential techniques, such as guided imagery and rescripting, were used to help the client in connect with different, healthier aspects of the self, thus increasing personal and interpersonal wellbeing. Qualitative and quantitative outcomes at the intervention end and at 1-month follow-up are summarized. Finally, we reflect on how this case study can inform treatment of perfectionism in OCPD.

[Virtual reality exposure therapy for post-traumatic stress disorders, obsessive-compulsive disorders and anxiety disorders: Indications, added value and limitations]. / La thérapie par exposition en réalité virtuelle pour les états de stress post-traumatiques, les troubles obsessionnels compulsifs et les troubles anxieux : indications, plus-value et limites.

The exposure in cognitive behavioral therapy (CBT) is a well-known intervention, widely investigated in scientific research. Several studies have shown the benefits of this intervention in the treatment of anxiety disorders, obsessive-compulsive disorders (OCD) and post-traumatic stress disorders (PTSD). The different exposure techniques are mainly based on the emotional processing of fear theory and use an emotional stimulation of fear, following by its habituation. However, new approaches have emerged and are based on the inhibitory learning theory. The virtual reality technology allows emotional involvement from patients and represents a complementary approach to the classical modalities of exposure therapy (e.g., mental or in vivo expositions). This modern approach presents specific features that need to be taken into account by the therapist. Firstly, the presence feeling, which is defined as the "be there" feeling. This feeling is dependent on immersive technical features and personality factors. Secondly, virtual reality sickness, similar to motion sickness, represents a limitation that might prejudice a virtual therapy. The main scientific investigations of Virtual Reality Exposure Therapy (VRET) for treating social phobia, specific phobia, PTSD, and panic disorders are encouraging and demonstrate a similar effectiveness between both in vivo and in virtuo exposures. The scarce investigations on generalized anxiety disorders and OCD also suggeste a similar effectiveness between these exposures. However, further scientific investigations are needed to support these preliminary findings. The attrition rates and deteriorating states are similar to classical CBT approaches. Nevertheless, scientific literature presents several limits: 1) much of the research on this topic has interest conflicts (e.g., developers are also authors of a large number of studies); 2) there is a high heterogeneity of materials and virtual environments used; 3) important measures are not always taken into account in scientific research (e.g., the presence feeling); and 4) a massive use of waiting lists as a control measure. Despite these limitations, the VRET have strong silver linings: 1) the easy access to exposure (less limited than standard exposure techniques) and a cost reduction; 2) highly guaranteed security; 3) the anonymization of exposures (i.e., the patients do not risk meeting someone they know during the exposure therapy); 4) the therapist has a greater control of exposures; 5) a standardization of the exposures; 6) a greater involvement in therapy for technophile patients. Virtual exposure also seems to be generally more accepted by patients.

Treatment of obsessive-compulsive disorders (OCD) and obsessive-compulsive-related disorders (OCRD). / Leczenie zaburzen obsesyjno-kompulsyjnych (OCD) i zaburzen powiazanych (OCRD).

The purpose of this article is to present an overview of current knowledge on the treatment of obsessive-compulsive and obsessive-compulsive-related disorders (OCRD - according to DSM-5). The article presents commonly used pharmacological treatments and psychotherapy, as well as surgical and other forms of treatment. According to the analyses that have been made, the variety of responses to the pharmacological treatment of obsessive-compulsive disorders (OCD) depending on the kinds of symptoms is not relevant enough to justify these other forms of treatment. Instead, the choice of medication should be made based on other factors, such as the severity of symptoms and the level of insight into the illness or the symptoms of other disorders co-occurring with the obsessions. These factors are also significant in psychotherapy, but in this case, the dependency between the types of obsessions and compulsions and the therapeutic approach has greater importance. Generally speaking, in OCRD treatment, atendency to use other forms of treatment can be observed for disorders based mainly on the mechanism of compulsivity or impulsivity. Hopes for a more effective treatment are related to the types of pharmacological treatment and modifications of psychotherapeutic methods based on the development happening in the cognitive behavioural approach.

Recovery and Nonrecovery After Psychotherapy With Transference Interpretation: Two Case Studies.

The First Experimental Study of Transference Interpretation (FEST), conducted in Norway, is a dismantling, randomized clinical trial of the long-term effects of transference interpretation (TI). This article examines two case studies of women with poor quality of object relations (QOR), one who was rated as recovered after psychotherapy and one who was rated as not recovered. Both received TI. In general, women with poor QOR needed TI to recover, but some members of this group did not recover, even with TI. The therapist's negative countertransference and tendency to use controlling interventions was more pronounced with the poor-outcome patient. In addition, the poor-outcome patient had three subthreshold personality disorders in addition to obsessive-compulsive personality disorder. In childhood she had experienced substantial emotional abuse and some physical abuse. She was less motivated before therapy and more evasive during therapy than the good-outcome patient. The good-outcome patient also had obsessive-compulsive personality disorder but no subthreshold personality disorders, and her childhood home environment was more secure, although her parents were distant. She was more open to the therapist than the poor-outcome patient was. This article illustrates that different people require different techniques even though they belong to the same group (low QOR) that, in the FEST study, did well with TI.

Outcome, comorbidity and prognosis in anorexia nervosa. / Przebieg choroby, wspólchorobowosc i czynniki rokownicze w jadlowstrecie psychicznym.

Anorexia nervosa (AN) is a relatively common disorder, especially in adolescent and young adult women. The lifetime prevalence of AN in females ranges from 1.2 to 2.2%. The prevalence in males is 10-times lower. The condition is associated with a high risk of chronic course and poor prognosis in terms of treatment and the risk of death. Longer follow-up periods seemed to correspond with increased improvement rates and increased mortality. Onset of the disorder during adolescence is associated with better prognosis. It is reported that as much as 70% to over 80% of patients in this age group achieve remission. Worse outcomes are observed in patients who required hospitalization and in adults. Recent studies indicate improved prognosis for cure and lower mortality rates than previously reported. However, the recovery can take several years and AN is associated with high risk of developing other psychiatric disorders during the patients' lifetime, even after recovery from AN (mainly: affective disorders, anxiety disorders, obsessive-compulsive disorders, substance abuse disorders). Studies indicate that bulimic symptoms often occur in the course of anorexia nervosa (especially within 2-3 years from the onset of AN). The authors present a review of literature on the course, comorbidity, mortality, and prognostic factors in AN. Better knowledge of the course of anorexia can contribute to more realistic expectations of the pace of symptomatic improvement, as well as to a creation of therapeutic programs which are better adapted to the needs of the patients.

The Relationship between Obsessive Compulsive Personality and Obsessive Compulsive Disorder Treatment Outcomes: Predictive Utility and Clinically Significant Change.

BACKGROUND: The evidence regarding whether co-morbid obsessive compulsive personality disorder (OCPD) is associated with treatment outcomes in obsessive compulsive disorder (OCD) is mixed, with some research indicating that OCPD is associated with poorer response, and some showing that it is associated with improved response. AIMS: We sought to explore the role of OCPD diagnosis and the personality domain of conscientiousness on treatment outcomes for exposure and response prevention for OCD. METHOD: The impact of co-morbid OCPD and conscientiousness on treatment outcomes was examined in a clinical sample of 46 participants with OCD. RESULTS: OCPD diagnosis and scores on conscientiousness were not associated with poorer post-treatment OCD severity, as indexed by Yale-Brown Obsessive Compulsive Scale (YBOCS) scores, although the relative sample size of OCPD was small and thus generalizability is limited. CONCLUSION: This study found no evidence that OCPD or conscientiousness were associated with treatment outcomes for OCD. Further research with larger clinical samples is required.

The role of avoidant and obsessive-compulsive personality disorder traits in matching patients with major depression to cognitive behavioral and psychodynamic therapy: A replication study.

BACKGROUND: Barber and Muenz (1996) reported that cognitive behavior therapy (CBT) was more effective than interpersonal therapy (IPT) for depressed patients with elevated levels of avoidant personality disorder, while IPT was more effective than CBT in patients with elevated levels of obsessive-compulsive personality disorder. These findings may have important clinical implications, but have not yet been replicated. METHODS: We conducted a study using data from a randomized clinical trial comparing the efficacy of CBT and short-term psychodynamic supportive psychotherapy in the outpatient treatment of depression. RESULTS: We found no evidence indicating that avoidant patients may benefit more from CBT compared to short-term psychodynamic supportive therapy (SPSP). CONCLUSIONS: Our results indicate that treatment effect does not depend on the level of avoidance, or obsessive-compulsiveness personality disorders further examine the influence of personality disorders on the effectiveness of CBT or psychodynamic therapy in the treatment of depression.

The Impact of Obsessive Compulsive Personality Disorder on Cognitive Behaviour Therapy for Obsessive Compulsive Disorder.

BACKGROUND: It is often suggested that, in general, co-morbid personality disorders are likely to interfere with CBT based treatment of Axis I disorders, given that personality disorders are regarded as dispositional and are therefore considered less amenable to change than axis I psychiatric disorders. AIMS: The present study aimed to investigate the impact of co-occurring obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD) on cognitive-behavioural treatment for OCD. METHOD: 92 individuals with a diagnosis of OCD participated in this study. Data were drawn from measures taken at initial assessment and following cognitive-behavioural treatment at a specialist treatment centre for anxiety disorders. RESULTS: At assessment, participants with OCD and OCPD had greater overall OCD symptom severity, as well as doubting, ordering and hoarding symptoms relative to those without OCPD; however, participants with co-morbid OCD and OCPD demonstrated greater treatment gains in terms of OCD severity, checking and ordering than those without OCPD. Individuals with OCD and OCPD had higher levels of checking, ordering and overall OCD severity at initial assessment; however, at post-treatment they had similar scores to those without OCPD. CONCLUSION: The implications of these findings are discussed in the light of research on axis I and II co-morbidity and the impact of axis II disorders on treatment for axis I disorders.

The cost and impact of compulsivity: A research perspective.

Compulsivity is the defining feature of various psychiatric disorders including Obsessive Compulsive Related Disorders (OCRDs), and other compulsive, impulsive, and addictive disorders. These disorders are disabling, chronic conditions with an early onset and high rates of comorbidity, misdiagnoses, and delay in treatment onset. Disorders of compulsivity are responsible for considerable socioeconomic burden to society. We review the costs and impacts of compulsivity. In order to facilitate earlier diagnosis and targeted treatments, we examine the overlapping mechanisms that underlie compulsivity. We reconceptualize psychiatric disorders based on core features of compulsivity, highlight challenges in harmonizing research in children and adults, describe newer research methodologies, and point to future directions that can impact the costs and impact of disorders of compulsivity.

Compulsivity in obsessive-compulsive disorder and addictions.

Compulsive behaviors are driven by repetitive urges and typically involve the experience of limited voluntary control over these urges, a diminished ability to delay or inhibit these behaviors, and a tendency to perform repetitive acts in a habitual or stereotyped manner. Compulsivity is not only a central characteristic of obsessive-compulsive disorder (OCD) but is also crucial to addiction. Based on this analogy, OCD has been proposed to be part of the concept of behavioral addiction along with other non-drug-related disorders that share compulsivity, such as pathological gambling, skin-picking, trichotillomania and compulsive eating. In this review, we investigate the neurobiological overlap between compulsivity in substance-use disorders, OCD and behavioral addictions as a validation for the construct of compulsivity that could be adopted in the Research Domain Criteria (RDoC). The reviewed data suggest that compulsivity in OCD and addictions is related to impaired reward and punishment processing with attenuated dopamine release in the ventral striatum, negative reinforcement in limbic systems, cognitive and behavioral inflexibility with diminished serotonergic prefrontal control, and habitual responding with imbalances between ventral and dorsal frontostriatal recruitment. Frontostriatal abnormalities of compulsivity are promising targets for neuromodulation and other interventions for OCD and addictions. We conclude that compulsivity encompasses many of the RDoC constructs in a trans-diagnostic fashion with a common brain circuit dysfunction that can help identifying appropriate prevention and treatment targets.

The role of habit in compulsivity.

Compulsivity has been recently characterized as a manifestation of an imbalance between the brain׳s goal-directed and habit-learning systems. Habits are perhaps the most fundamental building block of animal learning, and it is therefore unsurprising that there are multiple ways in which the development and execution of habits can be promoted/discouraged. Delineating these neurocognitive routes may be critical to understanding if and how habits contribute to the many faces of compulsivity observed across a range of psychiatric disorders. In this review, we distinguish the contribution of excessive stimulus-response habit learning from that of deficient goal-directed control over action and response inhibition, and discuss the role of stress and anxiety as likely contributors to the transition from goal-directed action to habit. To this end, behavioural, pharmacological, neurobiological and clinical evidence are synthesised and a hypothesis is formulated to capture how habits fit into a model of compulsivity as a trans-diagnostic psychiatric trait.

Human compulsivity: A perspective from evolutionary medicine.

Biological explanations address not only proximal mechanisms (for example, the underlying neurobiology of obsessive-compulsive disorder), but also distal mechanisms (that is, a consideration of how particular neurobiological mechanisms evolved). Evolutionary medicine has emphasized a series of explanations for vulnerability to disease, including constraints, mismatch, and tradeoffs. The current paper will consider compulsive symptoms in obsessive-compulsive and related disorders and behavioral addictions from this evolutionary perspective. It will argue that while obsessive-compulsive disorder (OCD) is typically best conceptualized as a dysfunction, it is theoretically and clinically valuable to understand some symptoms of obsessive-compulsive and related disorders in terms of useful defenses. The symptoms of behavioral addictions can also be conceptualized in evolutionary terms (for example, mismatch), which in turn provides a sound foundation for approaching assessment and intervention.

New treatment models for compulsive disorders.

Obsessive compulsive disorder (OCD) as well as related disorders such as body dysmorphic disorder, tic disorder, and trichotillomania are all common and often debilitating. Although treatments are available, more effective approaches to these problems are needed. Thus this review article presents what is currently known about OCD and related disorders and suggests that understanding OCD more broadly as a compulsive disorder may allow for more effective treatment options. Toward that goal, the review presents new models of psychopharmacology and psychotherapy, as well as new brain stimulation strategies. Treatment advances, grounded in the neuroscience, have promise in advancing treatment response for OCD as well as other disorders of compulsivity.

Mindfulness for personality disorders.

PURPOSE OF REVIEW: Third-wave cognitive-behaviour therapies such as dialectical behaviour therapy have demonstrated effectiveness in the treatment of personality disorders, which are considered difficult to treat. These therapies typically incorporate some component of mindfulness practice. The current study examines current applications and effectiveness of mindfulness to the treatment of personality disorders. RECENT FINDINGS: The majority of evidence available focuses on borderline personality disorder, and highlights positive associations between mindfulness practice and reduced psychiatric and clinical symptoms, less emotional reactivity, and less impulsivity. Fewer studies examine the other personality disorders, though emerging case studies have applied mindfulness techniques to treatment with antisocial, avoidant, paranoid, and obsessive-compulsive personality disorders. SUMMARY: Mindfulness is a promising clinical tool for the treatment of personality disorders, and appears to be adaptable to the unique features of different types of personality disorders. However, further empirical research with greater methodological rigour is required to clarify the effectiveness of mindfulness as a specific skill component, and to identify the underlying mechanisms that contribute to therapeutic change.

Behavioural addiction-A rising tide?

The term 'addiction' was traditionally used in relation to centrally active substances, such as cocaine, alcohol, or nicotine. Addiction is not a unitary construct but rather incorporates a number of features, such as repetitive engagement in behaviours that are rewarding (at least initially), loss of control (spiralling engagement over time), persistence despite untoward functional consequences, and physical dependence (evidenced by withdrawal symptoms when intake of the substance diminishes). It has been suggested that certain psychiatric disorders characterized by maladaptive, repetitive behaviours share parallels with substance addiction and therefore represent 'behavioural addictions'. This perspective has influenced the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which now has a category 'Substance Related and Addictive Disorders', including gambling disorder. Could other disorders characterised by repetitive behaviours, besides gambling disorder, also be considered 'addictions'? Potential examples include kleptomania, compulsive sexual behaviour, 'Internet addiction', trichotillomania (hair pulling disorder), and skin-picking disorder. This paper seeks to define what is meant by 'behavioural addiction', and critically considers the evidence for and against this conceptualisation in respect of the above conditions, from perspectives of aetiology, phenomenology, co-morbidity, neurobiology, and treatment. Research in this area has important implications for future diagnostic classification systems, neurobiological models, and novel treatment directions.

Brain circuitry of compulsivity.

Compulsivity is associated with alterations in the structure and the function of parallel and interacting brain circuits involved in emotional processing (involving both the reward and the fear circuits), cognitive control, and motor functioning. These brain circuits develop during the pre-natal period and early childhood under strong genetic and environmental influences. In this review we bring together literature on cognitive, emotional, and behavioral processes in compulsivity, based mainly on studies in patients with obsessive-compulsive disorder and addiction. Disease symptoms normally change over time. Goal-directed behaviors, in response to reward or anxiety, often become more habitual over time. During the course of compulsive disorders the mental processes and repetitive behaviors themselves contribute to the neuroplastic changes in the involved circuits, mainly in case of chronicity. On the other hand, successful treatment is able to normalize altered circuit functioning or to induce compensatory mechanisms. We conclude that insight in the neurobiological characteristics of the individual symptom profile and disease course, including the potential targets for neuroplasticity is an unmet need to advance the field.

Radically Open-Dialectical Behavior Therapy for Disorders of Over-Control: Signaling Matters.

Radically Open-Dialectical Behavior Therapy (RO-DBT) is a transdiagnostic treatment designed to address a spectrum of difficult-to-treat disorders sharing similar phenotypic and genotypic features associated with maladaptive over-control-such as anorexia nervosa, chronic depression, and obsessive compulsive personality disorder. Over-control has been linked to social isolation, aloof and distant relationships, cognitive rigidity, high detailedfocused processing, risk aversion, strong needs for structure, inhibited emotional expression, and hyper-perfectionism. While resting on the dialectical underpinnings of standard DBT, the therapeutic strategies, core skills, and theoretical perspectives in RO-DBT often substantially differ. For example, RO-DBT contends that emotional loneliness secondary to low openness and social-signaling deficits represents the core problem of over-control, not emotion dysregulation. RO-DBT also significantly differs from other treatment approaches, most notably by linking the communicative functions of emotional expression to the formation of close social bonds and via skills targeting social-signaling and changing neurophysiological arousal. The aim of this paper is to provide a brief overview of the core theoretical principles and unique treatment strategies underlying RO-DBT.