Psychotherapy of obsessive-compulsive disorder and spectrum: established facts and advances, 1995-2005.

Dropout rates and refractory cases persist, for reasons that remain unexplained. There are few predictor variables and few innovative approaches to deal with them. New treatment approaches must be developed to improve treatment response even for the responders. Studies show that symptoms are reduced minimally (30% 50%). No new ways of dealing with treatment-refractory cases have been developed. Studies now include more co-morbid cases, however, and their inclusion may account for some of the lack of progress in improvement rates. It needs to be seen whether patients who have one or more comorbid conditions do as well as patients who do not have comorbidity and whether the number or type of comorbid disorders accounts for treatment response. Perhaps better results would be seen with pure OCD cases. Certainly results now are more generalizable to clinical practice. Now it is important to look for alternative treatment approaches and to apply cognitive therapy to more specific problems. Cognitive therapy seems to be helpful with the disorders of the obsessive-compulsive spectrum. The attrition rate is lower when cognitive therapy is used in the treatment of hypochondriasis, and cognitive therapy also is helpful in reducing OVI , which is more severe in body dysmorphic disorder and hypochondriasis. The role of cognitive therapy in OVI needs further exploration.

Possible basal ganglia pathology in children with complex symptoms.

BACKGROUND: Clinical observation of children presenting with a myriad of motor, behavioral, emotional, and sensorial symptoms who do not respond to treatment led to the hypothesis that these children may constitute a unique population, perhaps even a new clinical entity. The literature on child and adolescent psychopathology does not specifically address the phenomenological, diagnostic, and etiological factors that make these children unique. For this reason, a preliminary study was conducted to identify additional symptoms and features that make these children different. METHOD: Data were collected in 2001 on 7 children with complex symptomatology using the Behavior Assessment System for Children, the Anxiety Disorders Interview Schedule for DSM-IV, and a neurological illnesses and symptoms questionnaire designed by the authors. RESULTS: On average, these children met full DSM-IV criteria for 1 to 5 diagnoses. The most prevalent diagnoses were attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, oppositional defiant disorder, and pervasive developmental disorder. These children also exhibited a high incidence of sensory hyperarousal, aggressiveness, hypersexuality, and neuroethological behaviors. Almost all of the children also had indications of a history of bacterial or viral infection. CONCLUSION: The specific symptoms identified and the biological factors found in many of the children seem to suggest basal ganglia involvement.

Overvalued ideation as a predictor of fluvoxamine response in patients with obsessive-compulsive disorder.

The presence of overvalued ideation (OVI) in patients with obsessive-compulsive disorder (OCD) has been theoretically linked to poorer treatment outcome. OVI has recently been shown to predict treatment outcome in OCD. The purpose of the present study is to determine whether OVI predicts medication treatment response, controlling for initial symptom severity and measurement error. The sample consisted of 34 outpatients diagnosed with OCD who completed an open-label clinical trial of fluvoxamine of 10 weeks' duration. Clinicians administered the Overvalued Ideas Scale (OVIS) at baseline. Symptom severity was rated at baseline and at the end of week 10 using the Yale-Brown Obsessive-Compulsive Scale. Of those who completed the trial, 68% showed a reliable change in obsessions and 62% showed a reliable change in compulsions. Analysis of variance showed that baseline OVIS predicted outcome for obsessions, but not compulsions. A key limitation was the relatively low number of individuals in the upper quartile on the OVIS, thus reducing the predictive power of the measure in relation to treatment outcome. Future research should examine medication treatment outcome with higher scoring patients.

Neuroanatomical correlates and somatosensorial disturbances in body dysmorphic disorder.

Body dysmorphic disorder (BDD) is a condition characterized by an intense preoccupation with an imagined or slight defect in physical appearance. Although there is a general consensus that psychosocial factors play a major role in the development of BDD, there is some evidence suggesting that an organic somatosensorial disturbance may also exist in this condition. Several psychiatric and neurological disorders, including the interparietal syndrome, Gertsman's syndrome, inferoparietal syndrome, phantom limb syndrome, genital retraction syndrome, panencephalitis, cerebrovascular syndromes, and pharyngeal streptococcia affecting the basal ganglia, can present with somatosensorial disturbances similar to BDD. The cerebral pathology in all these disorders appears to be localized in the parietal-occipital region, indicating that cerebral involvement may also be associated with BDD. An interdependence exists between cerebral regions through integrated neural networks that enable efficient processing of information. Disturbances in these association pathways can lead to an imbalance in the extensive cerebral loops. Therefore, it is possible that a defect in information-processing may play a role in the pathogenesis of BDD.

Computerized perceptual analysis of patients with body dysmorphic disorder: a pilot study.

Many factors influence the development of body image, one of which is the perception we have of our body. Perception can refer to actual visual input or the interpretation of vision; in other words, cognitive appraisal. The goal of this preliminary study is to determine if three groups (body dysmorphic disorder, obsessive-compulsive disorder, and a non-psychiatric control group) differed in the perception of their faces. Thirty individuals, 10 in each group, were asked to make changes to a computerized image of their face. In addition, affective and perceptual tests were administered. The groups did not differ on affective and perceptual organizational measures, although the obsessive-compulsive disorder group reported a higher level of anxiety than the body dysmorphic disorder group. Imaging software showed that facial features were modified by patients with body dysmorphic disorder and obsessive-compulsive disorder in about 50% of cases. No modifications were made in the control group. Future studies need to investigate the possible causes of these differences.

The Children's Yale-Brown Obsessive-Compulsive Scale: item structure in an outpatient setting.

The Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) is one of the most popular measures of symptom severity for childhood obsessive-compulsive disorder (OCD). This study describes the factor structure of the CY-BOCS. A total of 233 children diagnosed with OCD were evaluated with the CY-BOCS. The results indicated that 2 alternate 2-factor solutions (obsessions and compulsions; severity and disturbance) fit the data set best. The results also suggested that items assessing resistance to obsessions and compulsions provide unreliable evaluations of these symptoms in children with OCD. Recommendations for modifications to the CY-BOCS as well as clinical applications and for future research with the measure are made.

Basal ganglia hemorrhagic ablation associated with temporary suppression of obsessive-compulsive symptoms.

Currently, basal ganglia (BG) are considered regulators of motor and emotional activity. It's operationality encompass Obsessive Compulsive Disorder (OCD). The case of a patient suffering with severe OCD is described of note, his symptoms disappeared following a hemorrhage of the left BG. However, once the hemorrhage was reabsorbed his symptoms returned. It is possible that lesions affecting cerebral OCD association circuits may influence the evolution of obsessive-compulsive symptoms.

The pathophysiology of body dysmorphic disorder.

Body dysmorphic disorder (BDD) is an often severe and disabling condition, affecting up to 2% of the population. Despite its prevalence and clinical significance, very little is known about the pathophysiology of BDD. However, clues to its possible neurobiological substrates and abnormalities in information processing are starting to emerge. This article reviews findings from genetic, brain lesion, neuroimaging, neuropsychological, and psychopharmacological studies that have allowed us to develop a tentative model of the functional neuroanatomy of BDD. There is likely a complex interplay of dysfunctions in several brain networks underlying the pathophysiology of BDD. A combination of dysfunctions in frontal-subcortical circuits, temporal, parietal, and limbic structures, and possibly involving hemispheric imbalances in information processing, may produce both the characteristic symptoms and neurocognitive deficits seen in BDD. An improved understanding of the pathophysiology of BDD will be crucial to guide the development of better treatments.

Motivation to change as a predictor of treatment response in obsessive compulsive disorder.

BACKGROUND: Motivation to change has been shown to predict treatment outcome in various areas of mental health but has never been examined in obsessive compulsive disorder (OCD). The purpose of this report is to present the first use of the University of Rhode Island Change Assessment (URICA) in an OCD pharmacotherapy sample and to determine whether motivation to change predicts degree of treatment response in this group. METHODS: The sample consisted of 32 outpatients diagnosed with OCD who completed an open-label 10-week trial of fluvoxamine. Participants completed the URICA at baseline. OCD symptom severity was rated at baseline and end of treatment. RESULTS: While overall readiness was not related to change in severity, high scores on the Precontemplation subscale (indicating greater resistance to changing OC behaviors) were associated with less change pre- to post-treatment. CONCLUSIONS: Preliminary findings indicate that greater resistance to change is associated with less improvement in OCD symptom severity following pharmacotherapy. As this is the first use of the URICA as a predictor of OCD response, future research should further examine the role of motivation to change in treatment outcome in a larger OCD sample.

Rates of abuse in body dysmorphic disorder and obsessive-compulsive disorder.

Body dysmorphic disorder (BDD) continues to challenge professionals due to symptom severity, co-morbidity, suicidal ideation, and overvalued ideation. Despite the disorder's severity, little research exists. Clinical observation suggests a noteworthy history of abuse; therefore the present study investigated the reported rate of physical, sexual, and emotional abuse in BDD patients. OCD patients were chosen as a comparison group because BDD is considered to be an obsessive-compulsive spectrum disorder. A group survey design was used (N=50 for each group). Results show significantly higher levels of emotional and sexual abuse in the BDD sample versus the OCD sample. No significant differences were found in physical abuse. Abuse may be a contributing factor in BDD, but not in OCD.

Fluvoxamine-controlled release formulation for the treatment of generalized social anxiety disorder.

BACKGROUND: Generalized social anxiety disorder is a highly prevalent anxiety disorder with deleterious effects on social and family relationships, as well as work performance. We report the results of a multicenter, randomized, placebo-controlled trial comparing the efficacy, safety, and tolerability of fluvoxamine controlled release (CR) to placebo in patients with generalized social anxiety disorder. METHODS: A total of 279 adult patients meeting all inclusion/exclusion criteria was recruited at 23 United States sites and randomly assigned to receive either fluvoxamine CR (100-300 mg/d) or placebo for 12 weeks. The dose could be increased, based on efficacy and tolerability, in increments of 50 mg/d at weekly intervals. The dosage remained constant during weeks 6 to 12. RESULTS: Treatment with fluvoxamine CR resulted in statistically and clinically significant improvements in symptoms associated with generalized social anxiety disorder as early as week 4 on the Liebowitz Social Anxiety Scale and the Clinical Global Impression Scale Global Improvement, and at week 6 on the Sheehan Disability Scale, Clinical Global Impression Scale Severity of Illness and the Patient Global Impression of Improvement Scale. The most frequent adverse events reported by patients on fluvoxamine CR were headache, nausea, somnolence, and insomnia. No weight gain was observed for either treatment group, and at end point, there were no differences between treatments on overall sexual function, as measured by the Arizona Sexual Experience Scale. CONCLUSIONS: Both physician and patient-rated scales indicate that fluvoxamine CR is effective and safe for the treatment of generalized social anxiety disorder.

Basal ganglia hemorrhagic ablation associated with temporary suppression of obsessive-compulsive symptoms

Currently, basal ganglia (BG) are considered regulators of motor and emotional activity. It's operationality encompass Obsessive Compulsive Disorder (OCD). The case of a patient suffering with severe OCD is described of note, his symptoms disappeared following a hemorrhage of the left BG. However, once the hemorrhage was reabsorbed his symptoms returned. It is possible that lesions affecting cerebral OCD association circuits may influence the evolution of obsessive-compulsive symptoms

Overvalued ideas and their impact on treatment outcome

Introduçäo: A existência de idéias superestimadas (IS) em pacientes com transtorno obsessivo-compulsivo (TOC) vem sendo teoricamente relacionada a resultado insatisfatório do tratamento. Como até o momento näo existem medidas quantitativas das idéias superestimadas, a relaçäo entre IS e resultado fica restrita ao campo hipotético. Houve algumas tentativas de avaliações simples. Era pedido aos pacientes que avaliassem a intensidade de suas convicções, em uma escala de 1 a 10. A seguir, fazia-se a avaliaçäo clínica da fixidez das convicções de 1 a 5, e os pacientes eram classificados segundo o item 11 (insight) da Escala Yale-Brown de Sintomas Obsessivo-complusivos (Y-BOCS). A proposta deste estudo era determinar a relaçäo existente entre IS, gravidade dos sintomas do TOC e melhora. Método: Vinte pacientes com DOC participaram do estudo. Todos eles foram submetidos ao tratamento de prevençäo de exposiçäo e reaçäo (PER), durante seis dias por semana, com sessões de 90 minutos, e medicados com inibidores seletivos de recaptaçäo de serotonina. Os medicamentos näo foram alterados durante o curso do tratamento. Antes de entrar no estudo, todos os pacientes já recebiam tratametno medicamentosos há, pelo menos, três meses. As escalas de avaliaçäo usadas foram Escala de Idéias Superestimadas (OVIS), Y-BOCS, Inventário Beck para Depressäo e Inventário Beck para Ansiedade. Resultados: Os resultados indicaram que idéias superestimadas näo se correlacionavam necessariamente com a gravidade dos sintomas, medidos pela Y-BOCS. Quanto maior o grau medido pela OVIS, menor era a variaçäo na Y-BOCS. Conclusäo: Idéias superestimadas parecem ser um importante fator de prediçäo de um resultado insatisfatório para o tratamento

Clinical and theoretical issues in self-injurious behavior

This article presents an overview of pathological self-injurious behavior (SIB). Historical and cultural aspects, epidemiology, classifications and clinical aspects and pathogenesis are described. The importance of comprehensive assessment of symptomatology and functions of SIB for treatment planning are discussed

Estudio demográfico del trastorno obsesivo-compulsivo / Demographic study of obsessive compulsive disorder

Este estudio está en un amplio grupo (N=157) aquejado de trastorno obsesivo compulsivo (TOC), sin comorbilidad. Se comparó esta muestra con la población general del Estado de Nueva York, como grupo comparativo, según las seguientes variables: proporción de sexos, edad al comienzo de la enfermedad, edad en la que se manifestaron los síntomas, estado civil, ocupación, traumas en el nacimiento, abuso de sustancias, religión, tratamiento psiquiátrico anterior e historia de los padres. Se descubrió, para el sexo, una proporción de 1:1, con una importante diferencia, sin embargo, para la variable de edad al comienzo de la enfermedad (mujeres = 20,8 años; hombres = 16,3 años), y para la edad en la que se manifestaron los síntomas (mujeres = 26,4 años; hombres = 20,3 años. Otros hallazgos significativos incluyen: son más los pacientes varones solteros, son menos las pacientes viudas, son más los empleados administrativos y los abstemios, son menos los drogadictos y los consumidores de alcohol si se establece la comparación con la población en general. Asimismo, se encontró una cantidad significativamente mayor de pacientes ateos y agnósticos. Por primera vez, los hallazgos pueden evaluarse en contraposición con un grupos comparativo