Homa Noshirvani

Obsessive-compulsive beliefs and treatment outcome

Of 49 compulsive ritualizers one-third perceived their obsessive thoughts as a rational and felt that their rituals warded off some unwanted or feared event (the content of their obsessions). The more bizarre the obsessive belief the more strongly it was defended and 12% of cases made no attempt to resist the urge to ritualize. Neither fixity of belief nor resistance to compulsive urges were related to duration of illness. Patients with bizarre and fixed obsessive beliefs responded as well to treatment (all but three received exposure), as did patients whose obsessions were less bizarre and recognized as senseless. There was no difference in outcome between patients who initially found it hard to control their obsessions or never resisted the urge to ritualize and those who initially could control obsessions or resist rituals. One year after starting treatment, patients whose obsessions and compulsions had improved with treatment recognized their irrationality more readily and controlled their compulsive urges more easily. Beliefs appeared to normalize as a function of habituation.

Agoraphobics 5 years after imipramine and exposure. Outcome and predictors.

Five years after treatment in a controlled trial, in which all had received self-exposure homework, a group of 40 agoraphobic outpatients retained marked improvement in agoraphobia, mood, and free-floating anxiety. Frequency of spontaneous panics decreased as much in those who had placebo and self-exposure as in those who received imipramine and self-exposure. Few patients, however, were completely well at 5 years and over half had received further treatment for agoraphobia during the follow-up. Patients who were still highly phobic at the end of the clinical trial were more often prescribed psychotropic medication during follow-up and remained phobic at 5 years. Phobic improvement had generalized more in those patients with very low than in those with moderate pretreatment Hamilton depression scores. Frequency of initial spontaneous panics did not predict outcome. Improvement in agoraphobia was associated with improved marital adjustment. Those who began with the best marital, work, and social adjustment were more improved in their phobias 5 years later.

Pre-treatment predictors of treatment outcome in panic disorder and agoraphobia treated with alprazolam and exposure

Pre-treatment predictors of treatment outcome were examined in a group of 144 patients with panic disorder and agoraphobia randomly allocated to alprazolam+exposure (AE), placebo+exposure (PE), alprazolam+relaxation (AR), and placebo+relaxation (PR). First-time psychotropic medication use, severity of agoraphobic disability, and longer duration of illness predicted less global improvement at post-treatment. Pre-treatment severity of agoraphobia predicted less improvement both in the short- and the long-term. Predictors of poorer outcome at 6-month follow-up were older age, past history of depression, severity of phobia targets, and longer duration of illness. Sex, source of referral, pre-treatment depression-anxiety-panic, and expectancy from treatment did not relate to outcome.

DO COGNITIVE AND EXPOSURE TREATMENTS IMPROVE VARIOUS PTSD SYMPTOMS DIFFERENTLY? A RANDOMIZED CONTROLLED TRIAL

This study (part of a larger one whose main outcomes were reported by Marks, Lovell, Noshirvani, Thrasher & Livanou, 1998) investigated the impact of exposure therapy and cognitive restructuring alone and combined on the individual symptoms of PTSD and on associated features. Exposure therapy was expected to act mainly on fear and avoidance, and cognitive restructuring mainly on detachment, restricted range of affect, and associated features of PTSD. Seventy-seven PTSD outpatients were randomly allocated to one of four treatments: 1) exposure alone; 2) cognitive restructuring alone; 3) combined exposure and cognitive restructuring; or 4) relaxation (placebo control). The active treatments were superior to relaxation in improving clusters of PTSD symptoms and associated features and some but not all individual symptoms and associated features of PTSD. Exposure and cognitive restructuring improved almost all individual symptoms similarly.

Agoraphobia and Panic Disorder: 3.5 Years after Alprazolam and/or Exposure Treatment

BACKGROUND Long-term follow-ups after controlled studies of exposure therapy for agoraphobia/panic are few. Most of these studies found that improvement during treatment persists to the end of follow-up. METHODS Out of 69 patients with panic disorder plus agoraphobia who had been in an 8-week controlled study of alprazolam and/or exposure, 31 were followed up at a mean of 3.5 years later (4 years after trial entry). The 31 patients followed up included more cases who had relapsed at week 43 than did the group which did not attend the 3.5-year follow-up. RESULTS As a group, followed-up cases maintained their gains over the 3.5 years, more so among ex-exposure than ex-relaxation cases. Ex-exposure patients did significantly better than relaxation patients on disability and survival time. Ex-alprazolam and ex-exposure patients did not differ significantly on any variable at the 3.5-year follow-up. No baseline variable predicted outcome at follow-up. CONCLUSIONS Present results modestly confirm those of previous studies finding lasting improvement years after exposure, though some residual symptoms were the norm.

Urinary cortisol during exposure in obsessive-compulsive ritualizers

Nineteen obsessive-compulsive (OC) ritualizers were exposed to both brief and prolonged neutral and aversive stimuli (the latter evoked a significant urge to ritualize). Urinary cortisol and subjective anxiety were measured over 3 1/2 hours throughout the experiment, and cortisol secretion was compared to a control session the previous day. Both groups showed higher cortisol secretion after exposure compared to the control session. Only the group that received prolonged aversive stimuli, in addition to brief aversive and neutral stimuli, showed significantly higher urinary cortisol levels after the session. Cortisol response correlated with subjective anxiety reports during prolonged aversive stimulation only.

Relationship of skin conductance activity to clinical features in obsessive-compulsive ritualizers

Before treatment 49 obsessive-compulsive (o-c) ritualizers were presented with two series of brief stimuli--15,100db tones (brief neutral) and 15 presentations of a ritual-evoking object (brief aversive). Habituation of skin conductance (SC) responses to the tones was reduced compared with that previously found in normal subjects. Neither habituation rates to tones nor aversive stimuli were related to coexisting anxiety or depression or to the severity of o-c symptoms. The increased arousal induced by the aversive stimuli was sustained, that induced by the tones was short-lived and SC level and subjective anxiety had returned to resting levels by the end of the tone series. Concordance between SC activity and subjective anxiety was much greater during and after the presentations of ritual evoking stimuli than of tones. There were few correlations between SC and clinical measures, though patients who strongly resisted and were able to control their compulsive urges were more aroused.

Should Treatment Distinguish Anxiogenic from Anxiolytic Obsessive-Compulsive Ruminations?

In a small pilot controlled study over 8 weeks, 12 obsessive-compulsive ruminators listened for 2 h daily to their own audiotaped voice either (1) describing their anxiogenic thoughts (exposure) but omitting anxiolytic thoughts (mental/cognitive rituals), or (2) reading neutral prose or poetry. Taking all patients, both groups improved similarly. However, exposure patients who became anxious early in exposure slightly more improved. Consistent with this, in a clinical audit of 57 ruminators treated by trainee clinicians over 12 years, outcome improved significantly once practice changed so that exposure only involved anxiogenic thoughts, not anxiolytic thoughts, the latter being stopped.

Alprazolam withdrawal symptoms in agoraphobia with panic disorder : observations from a controlled Anglo-Canadian study

The study examines the effect of discontinuing alprazolam in panic disorder+agoraphobia patients. Fifty-seven alprazolam and 50 placebo agoraphobia+panic disorder patients, who had participated in an 8 week double- blind controlled study of alprazolam at average doses of 5 mg daily, were withdrawn gradually from their medication over the subsequent 8 weeks. The effects of discontinuation of medication on anxiety, panic, depression, phobia and withdrawal symptoms were examined during the taper phase and over the following 6 months. Alprazolam patients deteriorated on anxiety, panics, Hamilton depression and phobia. There was no difference between the two drug groups on rebound. Serious withdrawal symptoms did not arise, but weight loss, sweating and muscle twitching were more common in alprazolam patients. The deterioration in alprazolam patients persisted up to 6 months post-taper. A high dose of alprazolam at week 8 was the best predictor of subsequent deterioration. Discontinuation of alprazolam leads to recurrence of the original disorder in some patients. Rebound and severe withdrawal reactions were not found during gradual taper of alprazolam, but minor withdrawal symptoms did arise. The study shows the importance of using gradual taper to minimize withdrawal effects.