Helmut Peter

Dissociation as a Predictor of Cognitive Behavior Therapy Outcome in Patients with Obsessive-Compulsive Disorder

Background: Previous studies have found a strong association between dissociation and obsessive-compulsive disorder (OCD). The purpose of the present study was to evaluate whether dissociation is a predictor of cognitive behavior therapy (CBT) outcome in patients with OCD. Methods: Fifty-two patients with OCD were assessed using the Dissociative Experience Scale (DES), the Yale-Brown Obsessive-Compulsive Scale and the Beck Depression Inventory. CBT lasted on average 9.5 weeks and included exposure therapy. Results: Patients who dropped out due to noncompliance had higher baseline DES scores and depression scores compared to the 43 patients (83%) who completed the study. Significant OCD symptom reduction at posttreatment was observed in study completers with a large effect size (d = 1.7). More severe OCD symptoms at posttreatment were associated with higher DES scores at baseline, and treatment nonresponders had significantly higher baseline DES scores compared to responders. These associations with outcome were mainly due to the DES subfactor absorption-imaginative involvement. In regression analyses, higher absorption-imaginative involvement scores at baseline predicted poorer CBT outcome, even after controlling for depressive symptoms, comorbid axis I disorders and concomitant psychotropic drugs. Conclusions: Results from this preliminary study suggest that higher levels of dissociation (particularly absorption-imaginative involvement) in patients with OCD might predict poorer CBT outcome. If our results can be replicated, treatment outcome might be improved by additional interventions for those patients with OCD who indicate high levels of dissociation, for example by using interventions aimed at improving coping with emotionally stressful situations.

Long–term course and outcome of obsessive–compulsive patientsafter cognitive–behavioral therapy in combination with eitherfluvoxamine or placebo

AbstractLongitudinal studies with very long follow–up periods of patients with obsessive–compulsive disorder (OCD) who have received adequate treatment are rare. In the current study, 30 of 37 inpatients (81%) with severe OCD were followed up 6–8 years after treatment with cognitive–behavioral therapy (CBT) in combination with either fluvoxamine or placebo in a randomized design. The significant improvements (with large effectsizes) in obsessive–compulsive symptoms from pre- to post–treatment (41% reduction on the Y–BOCS) remained stable at follow–up (45 %). Responder rates, defined as ≥35% reduction on the Y–BOCS, were 67% and 60%, respectively. Depressive symptoms decreased significantly not only from pre- to post–treatment but also during follow–up. Re–hospitalization, which occurred in 11 patients (37 %), was associated with more severe depressive symptoms at pre–treatment and living without a partner. Full symptom remission at follow–up, defined as both Y–BOCS total score ≤ 7 and no longer meeting diagnostic criteria for OCD, was achieved by 8 patients (27 %). Patients without full remission at follow–up had a significantly longer history of OCD, assessed at pretreatment, compared to remitted patients. The shortterm treatment outcome had no predictive value for the long–term course. Throughout the naturalistic follow–up, nearly all patients (29 patients) received additional psychotherapy and/or medication. This might indicate that such chronic OCD patients usually need additional therapeutic support after effective inpatient treatment to maintain their improvements over long periods.

A Prospective Study of Alexithymia in Obsessive-Compulsive Patients Treated with Multimodal Cognitive-Behavioral Therapy

Background: Alexithymia as a predictor of treatment outcome in psychotherapy has often been discussed but rarely evaluated in prospective studies. The present study evaluated the absolute and relative stability of alexithymia in patients with obsessive-compulsive disorder (OCD), and the predictive value of alexithymia for the outcome of treatment. Methods: We conducted a prospective study with 42 inpatients receiving intensive, multimodal cognitive-behavioral therapy (CBT). Patients were assessed for alexithymia at pre- and post-treatment with the 20-item Toronto Alexithymia Scale (TAS-20), for obsessive-compulsive symptoms and depression with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and the 21-item Hamilton Depression Rating Scale (HDRS). Results: OCD and comorbid depression showed a highly significant symptom-reduction from pre- to post-treatment while no absolute changes in the TAS-20 total scores and its factors 1 and 3 occurred. Only factor 2 scores decreased significantly, but with a smaller effect size than the effect sizes for the changes in Y-BOCS and HDRS. Alexithymia scores at pre-treatment correlated significantly with alexithymia scores at the end of treatment, indicating its relative stability. In the linear regression analyses, no variables were identified that predicted significantly the outcome of treatment. Conclusions: Our findings support the view that alexithymia is a stable personality trait rather than a state-dependent phenomenon in obsessive-compulsive patients. Alexithymia scores do not predict response to multimodal CBT in OCD. It might be an effect of CBT that patients could at least partly regain or newly learn the capability to describe their feelings.

Diurnal variation of cortisol in panic disorder.

Abstract In patients with panic disorder ( n =23), daytime salivary cortisol levels were determined in 2-h spans on 3 consecutive days and compared with 23 age- and sex-matched healthy controls. Additionally, nocturnal urinary free cortisol levels were measured. Daytime salivary cortisol levels were numerically higher in the patients, although the difference did not reach statistical significance. In a subgroup of 14 patients with higher illness severity (as expressed by a score ≥22 on the Panic and Agoraphobia Scale), salivary cortisol levels were significantly higher than in the controls. Mean nocturnal urinary cortisol levels were significantly higher in the whole group of patients and also in the more severely ill subgroup when compared with controls. Cortisol elevations seem to be more pronounced during the night and occurred mainly in more severely ill panic patients.

Serum cholesterol level comparison: control subjects, anxiety disorder patients, and obsessive-compulsive disorder patients.

Objective: To determine whether panic disorder is associated with elevated serum cholesterol levels. Serum cholesterol levels of panic disorder patients are reported to be elevated. This could explain the higher-than-expected cardiovascular mortality in this population. Some evidence exists wherein cholesterol levels are also increased in patients with general anxiety disorder and phobias. To date, there are only 2 reports on cholesterol levels of obsessive-compulsive disorder (OCD) patients, giving controversial results. Method: We compared serum cholesterol levels of anxiety disorder patients, OCD patients, and normal control subjects with each other (n = 60 in each group). Serum cholesterol was measured in each subject before treatment. Subjects of the 3 groups were matched by age and sex. Results: Patients with anxiety disorders and OCD had elevated cholesterol levels, compared with normal control subjects. Cholesterol levels in OCD patients were comparable with those in patients with phobia. Conclusions: Our data support the assumption that elevation in cholesterol level is not a specific feature of panic disorder (as most assumed), but more generally associated with anxiety disorders. Increased cholesterol levels in patients with anxiety disorders and OCD may be of clinical relevance.

Serum cholesterol in patients with obsessive compulsive disorder during treatment with behavior therapy and SSRI or placebo.

Objective: Patients with panic disorder are reported to have elevated cholesterol levels. There is also some evidence that cholesterol elevation is not so much a specific condition in panic disorder but is generally associated with anxiety. So far, there is little data on cholesterol levels in patients with obsessive compulsive disorders (OCD) which is also classified as anxiety disorder. Method: Thirty-three patients with OCD participated in the study. Serum cholesterol was measured as pretreatment and at the end of a ten-week treatment-period. All patients received behavior therapy and, in a double-blind fashion, fluvoxamine or placebo. Severity of OCD was assessed by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). Results: Pretreatment cholesterol values of OCD patients were compared with cholesterol levels of thirty panic disorder patients and thirty normal controls. OCD patients had elevated cholesterol levels comparable with those of panic disorder patients. Cholesterol levels decreased significantly from pre- to posttreatment. OCD patients with high cholesterol levels (≥ 240 mg/dl, n = 7) could make best use of the treatment whereas patients with desirable cholesterol levels (< 200 mg/dl, n = 11) did not change their cholesterol during treatment. Conclusions: Our data support the assumption that not only panic disorder but also other anxiety disorders, e.g., obsessive compulsive disorders, may be associated with serum cholesterol elevations. Effective treatment (behavior therapy and/or treatment with a selective serotonin reuptake inhibitor [SSRI]) seems to decrease cholesterol levels, especially in patients with pathological cholesterol elevations.

Childhood Separation Anxiety and Separation Events in Women with Agoraphobia with or without Panic Disorder

Objective: This study aimed to investigate the association between separation anxiety and actual separation events during childhood in adult patients with agoraphobia with or without panic disorder (PD). Method: Forty-two women with agoraphobia with or without PD participated in long-term follow-ups after exposure-in-vivo treatment. We assessed separation anxiety and separation events from age 0 to 18 years, as well as adult separation from a spouse. Results: Childhood separation experiences (55%) and separation anxiety were significantly higher in patients than in healthy subjects, but both conditions were not associated with each other. Childhood separation anxiety was related to adult separation events. Conclusions: Retrospective measures of childhood separation anxiety appear to be confounded by adult separation events. Thus the conclusion of whether childhood anxiety is a consequence of actual childhood separation events cannot be drawn, owing to a lacking association between both ratings.

Kombinationstherapie bei Angststörungen: Aktuelle Datenlage und Empfehlungen für den klinischen Alltag

Combined Therapy in Anxiety Disorders: Current Data and Recommendations for the Clinical Practice Method:Over the past couple of years there has been a definite increase in studies on the effects of combined behavioral and pharmacological treatments of anxiety disorders. But their results have been partially contradictory and the interpretation of outcomes has sometimes been controversial. This article reviews the results of controlled studies for the different subtypes of anxiety disorders. Results:Although a few studies with patients with panic disorder and agoraphobia show an earlier response to combined treatment compared to behavior therapy alone, altogether the results are inconsistent. The combination of an initial pharmacotherapy alone with additional behavior therapy before drug discontinuation is helpful to reduce the otherwise high relapse-rates. Sometimes, the subsequent treatment of non-responders in behavior therapy or psychopharmacotherapy with the alternative method is helpful. ConclusionsNo convincing evidence was found that the parallel combination is generally more effective in any of the anxiety disorders than the single treatment. In the individual case, the decision for or against a combined treatment is dependent on several factors which are only partly investigated in controlled clinical trials. Especially the severity of the anxiety symptoms, comorbid symptomatology and the number of treatment refusers and dropouts have to be mentioned in this context. These factors, the results of naturalistic studies and ‘clinical experience’ have influenced our conclusions for clinical practice from the controlled studies.

Kombinationsbehandlung mit Verhaltenstherapie und Pharmakotherapie bei Zwangsstörungen: Forschungsstand und Behandlungspraxis

Combined Behavioral and Pharmacological Treatment for Obsessive-Compulsive Disorders: Research Findings and Clinical Practice In obsessive-compulsive disorders (OCD), when are Behavior Therapy (BT) and Pharmacotherapy (PhT) to be applied simultaneously or sequentially? The answer still largely depends on the expert’s professional orientation. This paper reviews the actual state of the art as published (including the latest metaanalyses) for BT and PhT separately, as well as for their combined application. In most studies direct comparison, exposure treatment, one SRI, and several SSRIs do not differ significantly in pre-post outcome. Yet, some studies do imply a better effectiveness of the only SRI investigated; nevertheless, most authors do not regard this a clinical superiority because of the more risky and unpleasant side effects compared to the SSRIs. Long-term effectiveness has only been shown for BT, as no relevant long-term PhT studies have been published. Simultaneous use of BT and PhT has significantly superior pre-post effects compared to BT alone in compulsions with high secondary depression and in predominant obsessions. Whether this holds true at follow-up is currently under investigation. Several studies showed better numerical pre-post improvement of the combination, the clinical meaning of which is judged differently in the publications. To sum up, BT alone clearly comes out as first-choice treatment (also with regard to cost-effectiveness) for the majority of OCD patients, even though in most countries it is the least applied. In spite of this apparently ‘evidence- based’ conclusion from reviewing the very recent literature, several problems remain: outcomes of meta-analyses have been far too much dependent on the varying methodology applied; reports about ‘treatment responders’ are still difficult to compare, as different operationalizations of ‘response’ have been used; the reported percentages of ‘responders’ do not necessarily indicate the percentage of relevant improvement from a clinician’s perspective or with regard to daily life functioning. Finally, almost all the studies reviewed were conducted by Anglo-American or Dutch authors – and the treatments used in these publications were very different in intensity and duration from those applied in outpatient and inpatient BT therapy in Germany. Implications for treatment and research are discussed.

Early traumatic life events, parental attitudes, family history, and birth risk factors in patients with depressive disorder and healthy controls

Abstract Objective. Only few studies have compared the frequency of traumatic life events during childhood in inpatients with depression with a healthy control group. Methods. Consecutively admitted inpatients with depression (n = 79), most of whom belonged to the melancholic subtype (n = 73; 92.4%), and healthy controls (n = 110) were investigated using a comprehensive retrospective interview with 203 questions regarding childhood traumatic life events, parental attitudes, family history of psychiatric disorders and birth risk factors. Results. Depressed patients had significantly more severe traumatic events (mean score 1.33; SD 1.4) than control subjects (0.85; SD 1.2) on a 0–10 point “severe trauma scale”. 70.9% (n = 56) of the depressed patients, but only 48.2% (n = 53) of the controls reported at least one severe traumatic event. When looking at single events, only few differences were found between patients and controls. Compared to controls, patients described significantly higher rates of psychiatric disorders in their families, in particular depression. Parental rearing styles were rated as more unfavorable in the patient group. In a logistic regression model, of all possible etiological factors examined, only a family history of psychiatric disorders showed a significant influence (OR = 3.6). Conclusions. Melancholic depression seems to be less associated with traumatic events than other psychiatric disorders.