Andrew G. Guzick

Six-Nine Year Follow-Up of Deep Brain Stimulation for Obsessive-Compulsive Disorder

Objective Deep brain stimulation (DBS) of the ventral capsule/ventral striatum (VC/VS) region has shown promise as a neurosurgical intervention for adults with severe treatment-refractory obsessive-compulsive disorder (OCD). Pilot studies have revealed improvement in obsessive-compulsive symptoms and secondary outcomes following DBS. We sought to establish the long-term safety and effectiveness of DBS of the VC/VS for adults with OCD. Materials and Methods A long term follow-up study (73–112 months) was conducted on the six patients who were enrolled in the original National Institute of Mental Health pilot study of DBS for OCD. Qualitative and quantitative data were collected. Results Reduction in OCD symptoms mirrored the one-year follow-up data. The same four participants who were treatment responders after one year of treatment showed a consistent OCD response (greater than 35% reduction in Yale Brown Obsessive Compulsive Scale (YBOCS)). Another subject, classified as a non-responder, achieved a 26% reduction in YBOCS score at long term follow-up. The only patient who did not achieve a 25% or greater reduction in YBOCS was no longer receiving active DBS treatment. Secondary outcomes generally matched the one-year follow-up with the exception of depressive symptoms, which significantly increased over the follow-up period. Qualitative feedback indicated that DBS was well tolerated by the subjects. Discussion These data indicate that DBS was safe and conferred a long-term benefit in reduction of obsessive-compulsive symptoms. DBS of the VC/VS region did not reveal a sustained response for comorbid depressive symptoms in patients with a primary diagnosis of OCD.

Side-effects of SSRIs disrupt multimodal treatment for pediatric OCD in a randomized-controlled trial

OBJECTIVE Activation Syndrome (AS) is a side-effect of antidepressants consisting of irritability, mania, self-harm, akathisia, and disinhibition. The current study was conducted to analyze how AS may hinder treatment outcome for multimodal treatment for children and adolescents with Obsessive-Compulsive Disorder. METHODS Fifty-six children or adolescents were recruited at two treatment sites in a double-blind randomized-controlled trial where participants received Cognitive-Behavioral Therapy and were randomized to slow titration of sertraline, regular titration of sertraline or placebo. RESULTS Using a recently developed measure of AS, results suggested that higher average levels of irritability, akathisia, and disinhibition significantly interfered with treatment response and explained 18% of the variance in obsessive-compulsive symptoms during treatment. Interestingly, only session-to-session increases in irritability resulted in a session-to-session increase in obsessive-compulsive symptoms. The observed results were unchanged with the addition of SSRI dosage as a covariate. CONCLUSIONS Results provide empirical support for the proposed hypothesis that AS may hinder multimodal treatment outcome for pediatric OCD. These findings suggest that dosage changes due to AS do not explain why those with higher AS had worse multimodal outcome. Other possible mechanisms explaining this observed disruption are proposed, including how AS may interfere with Cognitive-Behavioral Therapy.

Common Barriers to the Dissemination of Exposure Therapy for Youth with Anxiety Disorders

This study investigated the prevalence of common barriers to the use of exposure therapy (ET) in the treatment of youth with anxiety disorders, specifically examining both logistical limitations and negative beliefs about ET. Results from 230 practicing clinicians who treat youth with anxiety disorders found that the top three barriers were session length (56%), lack of training (48%), and concern about parent reaction (47%). Endorsement of barriers to ET was associated with less ET utilization and less optimal implementation of ET. Results suggest that several barriers, especially logistical limitations, must be addressed in order to improve the dissemination of ET.

A pilot study of actigraphy as an objective measure of SSRI activation symptoms: Results from a randomized placebo controlled psychopharmacological treatment study

Selective serotonin reuptake inhibitors (SSRIs) are an efficacious and effective treatment for pediatric obsessive-compulsive disorder (OCD) but have received scrutiny due to a potential side effect constellation called activation syndrome. While recent research introduced a subjective measure of activation syndrome, objective measures have not been tested. This pilot study, using data from a larger randomized-controlled trial, investigated the potential of actigraphy to provide an objective measure of activation symptoms in 44 youths with OCD beginning an SSRI medication regimen. Data were collected over the first four weeks of a multi-site, parallel, double-blind, randomized, placebo controlled psychopharmacological treatment study and statistical modeling was utilized to test how activation syndrome severity predicts daily and nightly activity levels. Results indicated that youths with higher activation symptoms had lower daytime activity levels when treatment averages were analyzed; in contrast youths who experienced onset of activation symptoms one week were more likely to have higher day-time and night-time activity ratings that week. Results support actigraphy as a potential objective measure of activation symptoms. Subsequent studies are needed to confirm these findings and test clinical applications for use by clinicians to monitor activation syndrome during SSRI treatment. National Institutes of Health (5UO1 MH078594-01); NCT00382291.

The progressive cascading model improves exposure delivery in trainee therapists learning exposure therapy for obsessive-compulsive disorder.

Researchers postulate that a lack of training in exposure therapy may underlie the poor dissemination that has been observed. The current study sought to provide support for the progressive cascading model (PCM), which was developed to train novice therapists in exposure-based techniques. The PCM is promising considering its scalability and financial feasibility. Forty-two trainee therapists completed a rotation at a university clinic specializing in obsessive–compulsive disorder where they were trained within the PCM. After training, therapists delivered exposure therapy in a more intense manner with fewer cautious delivery behaviors (e.g., allowing anxiety reduction strategies) and distress reduction behaviors (e.g., reassuring safety). Therapists also had fewer negative beliefs about exposure therapy and reported lower disgust sensitivity post-training. The PCM appears to be a potentially effective training model for teaching exposure-based techniques and warrants additional research. Such a model is timely considering the poor dissemination of exposure therapy and the movement toward competency-based education in graduate school.

The link between ADHD-like inattention and obsessions and compulsions during treatment of youth with OCD ☆

Attention-deficit/hyperactivity disorder (ADHD) has been found to be highly comorbid in children and adolescents with obsessive-compulsive disorder (OCD). Some have proposed, however, that obsessive anxiety may cause inattention and executive dysfunction, leading to inappropriate ADHD diagnoses in those with OCD. If this were the case, these symptoms would be expected to decrease following successful OCD treatment. The present study tested this hypothesis and evaluated whether ADHD symptoms at baseline predicted OCD treatment response. Obsessive-compulsive and ADHD symptoms were assessed in 50 youth enrolled in a randomized controlled trial investigating selective serotonin reuptake inhibitor and cognitive behavioral treatment. Repeated-measures analysis of variance (RMANOVA) revealed that ADHD symptoms at baseline do not significantly predict treatment outcome. A multivariate RMANOVA found that OCD treatment response moderated change in inattention; participants who showed greater reduction in OCD severity experienced greater reduction in ADHD-inattentive symptoms, while those with less substantial reduction in obsessions and compulsions showed less change. These findings suggest that children and adolescents with OCD and inattention may experience meaningful improvements in attention problems following OCD treatment. Thus, in many youth with OCD, inattention may be inherently tied to obsessions and compulsions. Clinicians may consider addressing OCD in treatment before targeting inattentive-type ADHD.

Exposure therapy for youth with anxiety: Utilization rates and predictors of implementation in a sample of practicing clinicians from across the United States

Exposure therapy is a highly effective, evidence-based treatment technique for children and adolescents with anxiety disorders. Regardless, therapists in the community are reported to use exposure relatively rarely compared with other approaches. The goal of the present study was to identify how practicing clinicians treat youth with anxiety disorders across the United States and what factors contribute to their use of exposure therapy. Recruited from public directories, 257 private practice therapists who treat anxious youth were surveyed. Non-exposure cognitive-behavioral techniques like cognitive restructuring and relaxation techniques were used significantly more frequently than exposure. Providers with more training in exposure therapy and fewer negative beliefs about this approach reported using exposure significantly more in the treatment of youth with social anxiety, obsessive-compulsive, and panic disorders. Self-identification as an anxiety disorder specialist significantly predicted exposure use for youth with posttraumatic stress disorder. Most therapists in private practice have minimal training in exposure therapy, perceive a lack of training options, and believe there would be a benefit to acquiring more training. The implications of these findings are discussed, including how to optimally design training opportunities in exposure therapy.

When Exposures Go Right: Effective Exposure-Based Treatment for Obsessive–Compulsive Disorder

Cognitive behavioral therapy with exposure and response prevention (CBT-E/RP) is the first-line treatment for obsessive–compulsive disorder (OCD). Several CBT-E/RP treatment manuals exist, yet clinicians still struggle to implement this evidence-based form of therapy. This article aims to help clinicians implement exposure-based treatment for OCD by providing practical treatment-enhancing strategies. In particular, literature and treatment recommendations related to effective hierarchy formation, strategic exposure design, and optimal exposure implementation is reviewed. Clinical case examples are provided throughout the paper to illustrate important principles, concepts, and recommendations. This paper aims to enhance the delivery of CBT-E/RP and address common questions and concerns that both new and advanced clinicians encounter when learning and applying this form of psychotherapy. Improving the integrity of CBT-E/RP delivery can improve therapeutic outcomes, patient compliance, and successful treatment completion.