Hisato Matsunaga

A Long-Term Trial of the Effectiveness and Safety of Atypical Antipsychotic Agents in Augmenting SSRI-Refractory Obsessive-Compulsive Disorder

OBJECTIVE Although atypical antipsychotic agents have been found effective in the augmentation of serotonin reuptake inhibitors (SRIs) for treatment-resistant obsessive-compulsive disorder (OCD) in short-term trials, there are few data on the effectiveness and safety of these agents in clinical settings over the long term. METHOD Subjects (N = 46) who responded to selective SRIs (SSRIs) in an initial 12-week trial were continued on SSRI monotherapy plus cognitive-behavioral therapy (CBT) for 1 year. Subjects (N = 44) who failed to respond to SSRIs were randomly assigned to 1 of 3 atypical antipsychotics -- olanzapine, quetiapine, or risperidone -- and were consecutively treated using SSRI + atypical antipsychotics combined with CBT for 1 year. This study was conducted from January 2006 to November 2007 at Osaka City University Graduate School of Medicine Hospital, Japan. RESULTS Augmentation with atypical antipsychotics reduced mean +/- SD Yale-Brown Obsessive Compulsive Scale (YBOCS) total scores in SSRI-refractory OCD patients (at initial assessment = 29.3 +/- 9.9, after 1 year = 19.3 +/- 6.8). However, compared to SSRI responders (at initial assessment = 25.8 +/- 11.4, after 1 year = 13.7 +/- 4.6), total YBOCS scores in those who required atypical antipsychotic augmentation were initially higher, and they remained at higher levels than those of SRI responders after 1 year of the treatments. CONCLUSIONS Our work does not sufficiently support the long-term effectiveness of the atypical antipsychotics in the augmentation of SSRIs for treatment-resistant OCD patients. Even though this approach seems useful for some types of OCD patients, such as those with symmetry/ordering and hoarding symptoms, these data emphasize the limitations of the current pharmacotherapeutic options in treatment-refractory OCD, and their chronic use raises a number of safety concerns. TRIAL REGISTRATION (ClinicalTrials.gov) Identifier NCT00854919.

Personality disorders in patients with eating disorders in Japan

We assessed the prevalence of personality disorders (PD) using the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) in 36 patients with restricting anorexia nervosa, 30 patients with anorexia nervosa and bulimia nervosa, and 42 patients with bulimia nervosa. Of the 108 patients, 51% met the criteria for at least one PD. The patients with PD had more severe clinical features in terms of bulimic behaviors, concurrent depressive, anxious, and obsessive-compulsive symptoms, and psychopathology related to eating disorders compared to the patients without any PD. The patients with PD, especially borderline PD, also had more severe global functioning and greater numbers of suicidal attempts and hospital admissions. We compare these results with those reported in the Western world and discuss them cross-culturally.

Impulse control disorders and “behavioural addictions” in the ICD-11

Psychiatric classifications have traditionally recognized a number of conditions as representing impulse control disorders. These have included pathological gambling, intermittent explosive disorder, kleptomania, pyromania, and trichotillomania.

The classification of Obsessive-Compulsive and Related Disorders in the ICD-11.

BACKGROUND To present the rationale for the new Obsessive-Compulsive and Related Disorders (OCRD) grouping in the Mental and Behavioural Disorders chapter of the Eleventh Revision of the World Health Organizations International Classification of Diseases and Related Health Problems (ICD-11), including the conceptualization and essential features of disorders in this grouping. METHODS Review of the recommendations of the ICD-11 Working Group on the Classification for OCRD. These sought to maximize clinical utility, global applicability, and scientific validity. RESULTS The rationale for the grouping is based on common clinical features of included disorders including repetitive unwanted thoughts and associated behaviours, and is supported by emerging evidence from imaging, neurochemical, and genetic studies. The proposed grouping includes obsessive-compulsive disorder, body dysmorphic disorder, hypochondriasis, olfactory reference disorder, and hoarding disorder. Body-focused repetitive behaviour disorders, including trichotillomania and excoriation disorder are also included. Tourette disorder, a neurological disorder in ICD-11, and personality disorder with anankastic features, a personality disorder in ICD-11, are recommended for cross-referencing. LIMITATIONS Alternative nosological conceptualizations have been described in the literature and have some merit and empirical basis. Further work is needed to determine whether the proposed ICD-11 OCRD grouping and diagnostic guidelines are mostly likely to achieve the goals of maximizing clinical utility and global applicability. CONCLUSION It is anticipated that creation of an OCRD grouping will contribute to accurate identification and appropriate treatment of affected patients as well as research efforts aimed at improving our understanding of the prevalence, assessment, and management of its constituent disorders.

Personality disorders in patients with obsessive‐compulsive disorder in Japan

A total of 75 patients with obsessive‐compulsive disorder (OCD) were studied in order to investigate the characteristics of OCD symptoms and the comorbidity of personality disorders (PD). Contamination obsessions and checking compulsions were most commonly found in patients, of whom 53% met the criteria for at least one PD. Among comorbid PD, the anxious‐fearful (cluster C) PDs, such as avoidant, obsessive‐compulsive and dependent PD, were most prevalent, followed by the odd‐eccentric (cluster A) PDs, such as paranoid and schizotypal PD. The patients with PD had more severe social maladaptation and concurrent depressive and anxious symptoms than the patients without any PD, despite the similar severity of OCD symptoms. These results are consistent with those reported in the Western world, and are considered to be relatively stable cross‐culturally.

A 2012 Evidence-Based Algorithm for the Pharmacotherapy for Obsessive-Compulsive Disorder

There is a need to synthesize the growing body of literature on the pharmacotherapeutic management of patients with obsessive-compulsive disorder for clinicians working at a primary care level. We have aimed to generate a simple, easy-to-follow algorithm for the primary care practitioner. This seven-step algorithm addresses diagnosis of obsessive-compulsive disorder, initiation of pharmacotherapy, monitoring and maintenance treatment, and guidelines for the management of patients who are resistant to initial therapy. In creating this algorithm, we have drawn on the body of published evidence, as well as on expert opinion.

Event‐related potentials in patients with obsessive–compulsive disorder

Twenty‐three unmedicated patients with obsessive–compulsive disorder (OCD) were compared with 12 unmedicated patients with social phobia (SP) and 18 age‐matched normal controls (C) using a two‐tone auditory oddball event‐related potentials (ERP) paradigm. The OCD group showed significantly shorter P300 latencies and shorter N200 latencies for target stimuli than the SP and the C groups. The OCD patients also tended to have greater N200 negativity compared with normal controls. However, there were no significant relationships between these ERP abnormalities in OCD patients and the type or severity of their OCD symptoms. In the mean ERP waveforms, increased N200 negativity for target stimuli, as well as the provocation in the later part of N200 for non‐target stimuli, were more commonly observed in the OCD and the SP groups compared with the C group. These results raise the possibility that the shorter N200 and P300 latencies in OCD patients may be an OCD‐specific phenomenon that is more closely related to the biological basis for OCD, rather than the characteristics of their OCD symptoms. On the other hand, increased negativity in the N200 region, even for non‐target stimuli, may represent the common abnormalities among anxiety disorders.

Psychopathological characteristics of recovered bulimics who have a history of physical or sexual abuse

We sought to clarify the influence of a history of sexual or physical abuse on a variety of psychopathologies in subjects with bulimia nervosa (BN). To avoid confounding effects, the presence of a history of sexual or physical abuse, lifetime axis I disorders, and personality disorders were assessed through direct structured interviews in 44 subjects recovered from BN for at least 1 year. Twenty abused subjects (45%) were significantly more likely than 24 subjects without abuse to have severe general psychopathology and eating disturbance. Compared with nonabused subjects, abused subjects showed a trend toward more frequent lifetime diagnoses of posttraumatic stress disorder and substance dependence. These results suggest that abusive experiences may be associated with some psychopathology of BN, particularly related to anxiety, substance abuse, and more severe core eating disorder pathology.

The clinical utility of symptom dimensions in obsessive-compulsive disorder.

Factor analyses in obsessive-compulsive disorder (OCD) have consistently identified several different symptom dimensions. Nevertheless the clinical utility of identifying such symptom dimensions remains somewhat unclear. On the basis of their principal symptoms, 343 OCD patients were divided into four symptom dimension subgroups; 1) contamination/washing, 2) hoarding, 3) symmetry/repeating and ordering, and 4) forbidden thoughts/checking. Clinical variables including 1-year treatment outcome were compared across these patient subgroups. Most patients (74%) could distinctively be categorized as falling into a particular symptom subgroup. The groups were differentially characterized by some demographic and clinical features. For instance, both the symmetry and hoarding groups were significantly associated with decreased global functioning and greater OCD severity. Moreover the hoarding group was significantly more likely than the others to show longer duration of illness, lower rate of marriage, poor insight, and poorer outcome. However, about a quarter of the participants could not be classified definitively into a particular group. Our findings provide partial support for the clinical utility of a simple measure of symptom dimensions in OCD. In clinical settings, however, the limitations of such a simple measure of predominant symptom dimensions should be borne in mind and further work on their validity and utility is needed.

Prevalence and symptomatology of comorbid obsessive–compulsive disorder among bulimic patients

This study sought to assess the prevalence and symptomatology of comorbid obsessive– compulsive disorder (OCD) among Japanese subjects who met the DSM‐III‐R criteria for bulimia nervosa (BN). The Structured Clinical Interview for DSM‐III‐R Patient Version was used to distinguish 26 BN patients with concurrent OCD from 52 BN patients without OCD. Obsessive–compulsive symptoms in BN subjects with concurrent OCD were evaluated using the Japanese version of the Yale‐Brown Obsessive–Compulsive Scale. There were no differences in the prevalence of concurrent OCD between BN subjects with and without a lifetime history of anorexia nervosa. Among BN subjects with concurrent OCD, symptoms related to symmetry and order were most frequently identified, followed by contamination and aggressive obsessions, and checking and cleaning/washing compulsions. Bulimia nervosa subjects with concurrent OCD were more likely than subjects without OCD to have more severe mood and core eating disorder psychopathology. Comorbid OCD is a common phenomenon in Japanese bulimics (33%) similar to that suggested in BN subjects in the Western countries. Obsessive– compulsive symptoms related to symmetry and order were most frequently observed in BN subjects with concurrent OCD, which was a similar finding to that reported among restricting anorexic subjects.