Lynne M. Drummond

Delayed sleep phase in severe obsessive-compulsive disorder: a systematic case-report survey.

INTRODUCTION To study the prevalence of delayed sleep phase (DSP) in a cohort of inpatients with severe obsessive-compulsive disorder (OCD) and to identify clinical and demographic correlates. METHODS A systematic retrospective case-report study of consecutive OCD admissions to a specialist inpatient unit from January 1995 to December 2003. Nursing and medical records of sleep, demographic, clinical, and other relevant details were recorded. RESULTS Of 194 eligible consecutive case reports, 187 were located, and nursing and medical reports of sleep were identified in all 187 (100%). Thirty-three patients (17.6%) fulfilled operationally defined criteria for DSP after exclusion of possible confounding factors. All the patients with DSP were unemployed. Phase-shifted patients were significantly younger than non-shifted patients (P=.019) and reported an earlier age of onset of their OCD (P=.005). There was a non-significant trend toward more severe OCD in the phase-shifted group, but they were not more depressed than their non-shifted counterparts. CONCLUSION A substantial number of patients with severe, enduring OCD also suffer with DSP, which seems to be specifically linked to OCD as opposed to comorbid depression. Clarification of the etiology within DSP and its interaction with core OCD symptoms on clinical function and disability may identify new treatment targets. To this end, further studies of sleep in OCD using actigraphy and biological measures are indicated.

Treatment of severe, treatment-refractory obsessive-compulsive disorder: A study of inpatient and community treatment

INTRODUCTION This research reports on a prospective outcome study of two cohorts of patients with severe, chronic, resistant obsessive-compulsive disorder (OCD). METHODS One cohort consisted of a total of 52 patients treated in an inpatient setting, while the second group comprised 65 patients treated in a community-outpatient setting. Treatment consistent primarily of intensive graded exposure and self-imposed response prevention augmented with cognitive restructuring. RESULTS The groups demonstrated significant improvement over the course of treatment. In the inpatient and community groups, there was significant improvement over the first 12 weeks of treatment, and further improvement between 12 and 24 weeks. CONCLUSION These results suggest that even for patients who have demonstrated treatment-resistance, there may be benefit in intensive behavioral treatment of OCD. In addition it was found that even for those patients with the most profound refractory OCD and complicating factors inpatient stays of up to 24 weeks were effective in reducing symptoms.

Predicting outcome of treatment for severe, treatment resistant OCD in inpatient and community settings

Treatment of OCD is effective, even for the most chronic and severe cases. It has been difficult to identify predictors of treatment outcome, with little work aimed at predicting treatment outcome in severe OCD. We examined the ability of a range of demographic and psychopathology variables to predict treatment outcome in a cohort of 52 inpatients and a second group of 62 community outpatients with severe, treatment-refractory OCD. Despite both cohorts showing significant improvement in OCD symptoms, reliable predictors were difficult to identify, and were different in the two cohorts. In the inpatient group, marital status was a significant predictor, with those who were married or cohabiting showing better outcome that those not currently in a relationship. This relationship was not observed in the community treatment group. Initial symptom severity was also found to be a significant predictor, but only in the community treatment group, where higher initial severity was associated with greater reduction in symptoms during treatment. Further research examining a wider range of predictors may assist in identifying those factors which predict outcome in severe OCD.

Prevalence of anti-basal ganglia antibodies in adult obsessive–compulsive disorder: cross-sectional study

BACKGROUND Symptoms of obsessive-compulsive disorder (OCD) have been described in neuropsychiatric syndromes associated with streptococcal infections. It is proposed that antibodies raised against streptococcal proteins cross-react with neuronal proteins (antigens) in the brain, particularly in the basal ganglia, which is a brain region implicated in OCD pathogenesis. AIMS To test the hypothesis that post-streptococcal autoimmunity, directed against neuronal antigens, may contribute to the pathogenesis of OCD in adults. METHOD Ninety-six participants with OCD were tested for the presence of anti-streptolysin-O titres (ASOT) and the presence of anti-basal ganglia antibodies (ABGA) in a cross-sectional study. The ABGA were tested for with western blots using three recombinant antigens; aldolase C, enolase and pyruvate kinase. The findings were compared with those in a control group of individuals with depression (n = 33) and schizophrenia (n = 17). RESULTS Positivity for ABGA was observed in 19/96 (19.8%) participants with OCD compared with 2/50 (4%) of controls (Fishers exact test P = 0.012). The majority of positive OCD sera (13/19) had antibodies against the enolase antigen. No clinical variables were associated with ABGA positivity. Positivity for ASOT was not associated with ABGA positivity nor found at an increased incidence in participants with OCD compared with controls. CONCLUSIONS These findings support the hypothesis that central nervous system autoimmunity may have an aetiological role in some adults with OCD. Further study is required to examine whether the antibodies concerned are pathogenic and whether exposure to streptococcal infection in vulnerable individuals is a risk factor for the development of OCD.

Community treatment of severe, refractory obsessive-compulsive disorder

Despite the existence of effective psychological and pharmacological interventions for obsessive-compulsive disorder (OCD), there are a large proportion of individuals for whom intervention is not effective. The study reports on the results of a community treatment service for individuals with treatment-refractory OCD who have not benefitted from previous cognitive behavioural or pharmacological treatment by community mental health services. A total of 205 individuals accepted for treatment by a specialist community OCD treatment service in London were provided with a combination of behavioural, cognitive, and pharmacological treatment within a specialist OCD service, with 158 completing treatment. Treatment was associated with significant reduction in clinician-rated and self-reported OCD symptoms after 12 weeks, with further reductions in OCD symptoms over a subsequent 12-week period. A significant reduction in symptoms of depression was also observed after 12 and 24 weeks. Approximately 40% of individuals treated experienced clinically significant improvement in their symptoms, with approximately 10% deemed to have recovered by the end of treatment. Our results add to previous research into refractory OCD, and provide support for the existence of specialist community treatment services which may provide assistance to individuals who have not responded to previous treatment.

Childhood, adolescent and adult age at onset and related clinical correlates in obsessive–compulsive disorder: a report from the International College of Obsessive–Compulsive Spectrum Disorders (ICOCS)

Abstract Objective: Many studies suggest that age at onset (AAO) is an important factor for clinically differentiating patients with juvenile and adult onset of obsessive–compulsive disorder (OCD). The present international study aimed to assess the prevalence of different AAO groups and compare related socio-demographic and clinical features in a large sample of OCD patients. Methods: A total of 431 OCD outpatients, participating in the ICOCS network, were first categorised in groups with childhood (≤12 years), adolescent (13–17 years) and adult-onset (≥18 years), then in pre-adult and adult onset (≥18 years) and their socio-demographic and clinical features compared. Results: Twenty-one percent (n = 92) of the sample reported childhood onset, 36% (n = 155) adolescent onset, and 43% (n = 184) adult onset. Patients with adult onset showed a significantly higher proportion of females compared with the other subgroups (χ2 = 10.9, p< 0.05). Childhood- and adolescent-onset patients had been more frequently treated with cognitive behavioural therapy (CBT), compared to adult-onset patients (χ2 = 11.5; p < 0.05). The pre-adult- versus adult-onset analysis did not show any additional significant difference. Conclusions: The present international multicentre study confirms that OCD onset occurs more frequently before adult age, with approximately one out of five patients showing childhood onset. Pre-adult onset was associated with higher rate of CBT, while adult onset was more prevalent in females.

Anxiety Disorders: Drug Treatment or Behavioural Cognitive Psychotherapy?

SummaryAnxiety disorders have a high prevalence arid constitute some of the most frequent psychological problems seen in medical practice. The treatment of anxiety disorders has developed rapidly over the last 20 years. The major treatments for anxiety are behavioural cognitive therapy or drugs. Unfortunately, there has been a tendency for workers in this field to polarise and confine themselves to their own approach. Both forms of treatment have disadvantages as well as advantages. Similarly, criticism can be made of much of the research in this area, which has tended to show advantages of drug treatment by those interested in psychopharmacology and advantages of behavioural cognitive therapy by those interested in psychological approaches. This is partly because behavioural cognitive therapists tend to be more interested in behavioural and cognitive changes, whereas biological therapists are more interested in affective change.Despite these somewhat polarised views, treatment recommendations can be made. Current evidence suggests that obsessive-compulsive disorder and agoraphobia respond to both drug and behavioural cognitive therapies, and that combined treatment may be helpful. Combined treatment may also be useful in patients with panic disorder, although the evidence for the efficacy of behavioural cognitive therapy in this disorder is not as strong as that for drug therapy. While generalised anxiety disorder responds to drug therapy, such treatment should be reserved for more severe cases. Behavioural cognitive therapy is the first-line treatment for patients with specific phobias, and, indeed, drugs do not appear to be useful in these conditions. While there is preliminary evidence that both drug therapy and behavioural cognitive therapy are effective in patients with social phobias, hypochondriacal disorder or post-traumatic stress disorder, more data are required before firm conclusions can be drawn about the use of these therapies.Anxiety disorders tend to be chronic conditions; however, evidence supporting the long term efficacy for drugs or behavioural cognitive therapy in most anxiety disorders is lacking. This represents another area for future research.

Danger ideation reduction therapy for the treatment of severe, chronic and resistant obsessive-compulsive disorder

We describe the first application of Danger Ideation Reduction Therapy (DIRT) in the UK. It is a novel approach developed in Australia, for treatment resistant obsessive compulsive disorder with contamination fears. The DIRT program was administered to an inpatient at Springfield Hospital, South London, with severe, treatment resistant obsessive compulsive disorder. Treatment consisted of weekly one hour therapy sessions for 14 weeks. A reduction in symptom severity measured on all scales undertaken was seen by the end of treatment. The Padua Inventory had shown an 85% reduction; Activity checklist an 86% reduction; Y-BOCS an overall 41% reduction and a 33% reduction on the Beck Depression Inventory. The DIRT approach has demonstrated an impressive and consistent improvement, maintained to 6 months post-treatment. More studies are needed to evaluate this treatment further.

Physical complications of severe, chronic obsessive-compulsive disorder: a comparison with general psychiatric inpatients

BACKGROUND This research examines the physical health of patients with severe, chronic obsessive-compulsive disorder (OCD) and compares the findings with patients admitted to an acute general psychiatric ward. METHODS Successive admissions to a specialist inpatient unit treating patients with OCD were included in the study. Information including gender, age, weight and height were recorded along with the results of blood tests for urea, liver function tests and blood lipids. In addition, type and dose of medication were also recorded. These data were compared with information obtained via the case records from successive admissions to a general psychiatric ward. RESULTS A total of 104 patients with OCD and 101 patients admitted to an acute psychiatric unit were studied. OCD patients were generally younger than the controls and were on a lower dose of antipsychotic medication. Despite this, the OCD patients were more likely than the general psychiatric patients to have raised blood lipids. Raised creatinine was also more common among OCD patients. CONCLUSION The study demonstrates that patients with severe OCD have significant evidence of serious physical health problems.

Standards of care for obsessive-compulsive disorder centres

Abstract In recent years, many assessment and care units for obsessive–compulsive disorder (OCD) have been set up in order to detect, diagnose and to properly manage this complex disorder, but there is no consensus regarding the key functions that these units should perform. The International College of Obsessive-Compulsive Spectrum Disorders (ICOCS) together with the Obsessive Compulsive and Related Disorders Network (OCRN) of the European College of Neuropsychopharmacology (ECNP) and the Anxiety and Obsessive Compulsive Disorders Section of the World Psychiaric Association (WPA) has developed a standards of care programme for OCD centres. The goals of this collaborative initiative are promoting basic standards, improving the quality of clinical care and enhance the validity and reliability of research results provided by different facilities and countries.