Thomas Jans

Long-term outcome and prognosis of obsessive–compulsive disorder with onset in childhood or adolescence

Abstract The aim of the catch-up follow-up study is to describe the long-term outcome of obsessive–compulsive disorder (OCD) with onset in childhood and adolescence. The psychiatric morbidity in adulthood including personality disorders was assessed and predictors in childhood for the course of obsessive–compulsive symptoms were examined. The total study group consisted of the entire patient population treated for OCD at our departments for child and adolescent psychiatry between 1980 and 1991. We reassessed 55 patients personally by way of structured interviews. The mean age of onset of OCD was 12.5 years and the mean follow-up time was 11.2 years. At the follow-up investigation 71% of the patients met the criteria for some form of psychiatric disorder, while 36% were still suffering from OCD. Of the patients with a present diagnosis of OCD 70% had at least one further clinical disorder (especially anxiety and affective disorders). The most frequent personality disorders diagnosed were obsessive–compulsive (25.5%), avoidant (21.8%), and paranoid (12.7%) personality disorders. In-patient treatment, terminating treatment against advice and tics in childhood or adolescence significantly correlated with more severe OC symptoms in adulthood.

Effects of Group Psychotherapy, Individual Counseling, Methylphenidate, and Placebo in the Treatment of Adult Attention-Deficit/Hyperactivity Disorder: A Randomized Clinical Trial

IMPORTANCE Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder with high prevalence in adulthood. There is a recognized need to assess the efficacy of psychotherapy in adult ADHD. OBJECTIVE To evaluate the efficacy of cognitive behavioral group psychotherapy (GPT) compared with individual clinical management (CM) and that of methylphenidate hydrochloride compared with placebo. DESIGN, SETTING, AND PARTICIPANTS Prospective, multicenter, randomized clinical trial of 18- to 58-year-old outpatients with ADHD from 7 German study centers. Patients were recruited between January 2007 and August 2010, treatment was finalized in August 2011, and final follow-up assessments occurred in March 2013. INTERVENTIONS Sessions of GPT and CM were held weekly for the first 12 weeks and monthly thereafter (9 months). Patients received either methylphenidate or placebo for 1 year. MAIN OUTCOMES AND MEASURES The primary outcome was the change in the ADHD Index of the Conners Adult ADHD Rating Scale from baseline to the end of the 3-month intensive treatment (blinded observer ratings). Secondary outcomes included ADHD ratings after 1 year, blinded observer ratings using the Clinical Global Impression Scale, and self-ratings of depression. RESULTS Among 1480 prescreened patients, 518 were assessed for eligibility, 433 were centrally randomized, and 419 were analyzed as randomized. After 3 months, the ADHD Index all-group baseline mean of 20.6 improved to adjusted means of 17.6 for GPT and 16.5 for CM, with no significant difference between groups. Methylphenidate (adjusted mean, 16.2) was superior to placebo (adjusted mean, 17.9) (difference, -1.7; 97.5% CI, -3.0 to -0.4; P = .003). After 1 year, treatment effects remained essentially stable. Descriptive analyses showed that methylphenidate was superior to placebo in patients assigned to GPT (difference, -1.7; 95% CI, -3.2 to -0.1; P = .04) or CM (difference, -1.7; 95% CI, -3.3 to -0.2; P = .03). Regarding depression, no significant differences were found. In contrast, GPT was superior to CM for all visits in the Clinical Global Impression global assessment of effectiveness. CONCLUSION AND RELEVANCE Highly structured group intervention did not outperform individual CM with regard to the primary outcome. Psychological interventions resulted in better outcomes during a 1-year period when combined with methylphenidate as compared with placebo. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN54096201.

Obsessive-compulsive disorder in children and adolescents.

BACKGROUND Early-onset obsessive-compulsive disorder (OCD) is one of the more common mental illnesses of children and adolescents, with prevalence of 1% to 3%. Its manifestations often lead to severe impairment and to conflict in the family. In this review, we summarize the manifestations, comorbidity, pathophysiology, and course of this disease as well as current modes of diagnosis and treatment. METHODS We selectively review the relevant literature and the German-language guidelines for the diagnosis and treatment of mental illnesses in children and adolescents. RESULTS Obsessive-compulsive manifestations are of many types and cause severe impairment. Comorbid mental disturbances are present in as many as 70% of patients. The disease takes a chronic course in more than 40% of patients. Cognitive behavioral therapy is the treatment of first choice, followed by combination pharmacotherapy including selective serotonin reuptake inhibitors (SSRI) and then by SSRI alone. CONCLUSION OCD often begins in childhood or adolescence. There are empirically based neurobiological and cognitive-behavioral models of its pathophysiology. Multiaxial diagnostic evaluation permits early diagnosis. Behavioral therapy and medications are highly effective treatments, but the disorder nonetheless takes a chronic course in a large percentage of patients.

German Validation of the Conners Adult ADHD Rating Scale–Self-Report: Confirmation of Factor Structure in a Large Sample of Participants with ADHD

Objective: The Conners Adult ADHD Rating Scales (CAARS) assess symptoms specific to adults that are frequently used and have been translated into German. The current study tests the factor structure of the CAARS in a large sample of German adults with ADHD and compares the means of the CAARS subscales with those of healthy German controls. Method: CAARS were completed by 466 participants with ADHD and 851 healthy control participants. Confirmatory factor analysis was used to establish model fit with the American original. Comparisons between participants with ADHD and healthy controls and influences of gender, age, and degree of education were analyzed. Results: Confirmatory factor analysis showed a very good fit with the model for the American original. Differences between ADHD participants and healthy controls on all Conners Adult ADHD Rating Scales–Self-Report (CAARS-S) subscales were substantial and significant. Conclusion: The factor structure of the original American model was successfully replicated in this sample of adult German ADHD participants.

Phänomenologie und Komorbidität der Zwangsstörung bei Kindern und Jugendlichen

Zusammenfassung: Fragestellung: Gegenstand der Studie waren die Symptomatologie und die Komorbiditat der Zwangsstorung mit Beginn im Kindes- und Jugendalter. Methodik: Untersucht wurde eine Inanspruchnahmestichprobe von 55 kinder- und jugendpsychiatrischen Patienten (29 mannlich, 26 weiblich), die uberwiegend stationar behandelt wurden (95%). Strukturierte diagnostische Interviews zur Erfassung von Zwangsstorung und weiteren psychischen Storungen wurden zu Befragungen von Eltern und Kind eingesetzt. Ergebnis: Das mittlere Alter bei Beginn der Zwangsstorung betrug 11,3 Jahre. Jungen waren bei Storungsbeginn etwas, aber nicht statistisch signifikant junger als Madchen. Zwangshandlungen bezogen sich vorwiegend auf Waschen und Sauberkeit, Kontrollieren sowie Wiederholungen, Ordnen und Zahlen. Zwangsgedanken beinhalteten vor allem Verunreinigung, die Erwartung schlimmer Ereignisse, Sexualitat oder Aggression. In der klinischen Behandlungsroutine wurden seltener eine gemischte Zwangsstorung mit Gedanken und Han...

Long-term outcome and prognosis of dissociative disorder with onset in childhood or adolescence.

BackgroundIn the majority of cases short-term treatment outcome of juvenile dissociative disorder is rather favourable. In contrast, the long-term course seems to be less positive, but meaningful results are still fragmentary. The aim of this follow-up study is to bridge this gap to some extent describing the long-term outcome of juvenile dissociative disorder in a clinical sample. To our knowledge there is no comparable other long-term follow-up study which is based on a case definition according to actual classification systems using standardized interviews for individual assessment of the patients at the time of follow-up.MethodsThe total study group was made up of all patients treated for dissociative disorder at our department for child and adolescent psychiatry between 1983 and 1992 (N = 62). Two of these former patients committed suicide during the follow-up period (3%). We got information on the clinical course of 27 former patients (44%). 17 out of these 27 former patients were female (63%). The mean age of onset of dissociative disorder was11.7 years and the mean follow-up time was 12.4 years. Most of the patients were reassessed personally (n = 23) at a mean age of 24.8 years using structured interviews covering dissociative disorders, other Axis I disorders and personality disorders (Heidelberg Dissociation Inventory HDI; Expert System for Diagnosing Mental Disorders, DIA-X; Structured Clinical Interview for DSM-IV, SCID-II). Social adjustment was assessed by a semi-structured interview and by patient self report (Social Adjustment Scale – Self Report, SAS-SR). Psychosocial outcome variables were additionally assessed in 36 healthy controls (67% female, mean age = 22.9 years).ResultsAt the time of follow-up investigation 82.6% of the patients met the criteria for some form of psychiatric disorder, while 26.1% were still suffering from dissociative disorder. A total of 56.5% presented with an Axis I disorder (especially anxiety, dissociative and somatoform disorders). Personality disorders were seen in 47.8% (especially borderline, obsessive-compulsive and negativistic personality disorders). More dissociative symptoms and inpatient treatment in childhood or adolescence were significantly related to a lower level of psychosocial adjustment in adulthood.ConclusionTreatment strategies have to consider that in a significant portion of young patients initial recovery may not be stable over time. Limitations of the study refer to the small sample size and the low rate of former patients taking part in the follow-up investigation.

Internalizing and externalizing behavior in adult ADHD

Although there are many studies available investigating internalizing and externalizing behavior in childhood and adolescent manifestations of attention-deficit/hyperactivity disorder, there is limited information about their relevance in adults featuring persistence of the disease. We examined a large sample of 910 adults affected with attention-deficit/hyperactivity disorders (AADHD) for internalizing and externalizing behavior. Regarding correlates of internalizing behavior, AADHD probands showed significantly higher scores of the anxiety- and depression-related personality traits Neuroticism and Harm Avoidance, compared with reference values. The lifetime comorbidity of depressive disorders, anxiety disorders, and anxious or fearful Cluster C personality disorders (PDs) is elevated in AADHD patients compared with general population. Regarding correlates of externalizing behavior, patients affected with AADHD show significantly lower scores of Conscientiousness and significantly higher scores of Novelty Seeking than the published German reference values. Emotional, dramatic, or erratic Cluster B PDs were most frequent in AADHD. Internalizing and externalizing behavior notably affected psychosocial status to a similar extent. The frequency of both internalizing and externalizing behavior in AADHD might reflect an underlying emotional regulation disorder.

Die Bedeutung des Vorliegens einer Aufmerksamkeitsdefizit- und Hyperaktivitätsstörung (ADHS) bei Müttern für die Behandlung ihrer Kinder mit ADHS - Überblick und Skizze des Studienprotokolls einer multizentrischen randomisierten kontrollierten Psychotherapiestudie

Given its high heritability, ADHD frequently affects both children and their parents. In addition to co-morbid psychiatric disorders, adults with ADHD often complain of psychosocial difficulties, including family conflicts and poor parenting skills. Inconsistent childrearing practices and parent-child conflicts negatively affect the course of ADHD in children. Moreover, in the case of parental ADHD, the efficacy of parent training as part of the treatment for the childs ADHD seems to be reduced. This article presents a review of the impact of ADHD in mothers on the treatment of their ADHD children. Subsequently, the study protocol of a randomized controlled multi-centre trial to resolve the question of the efficacy of combined treatment of mothers and children is outlined. The main objective of the study is to evaluate whether the treatment of maternal ADHD enhances the efficacy of subsequent parent training as part of the treatment of ADHD in their children. 144 mother-child-pairs (both affected by ADHD according to DSM-IV criteria) are allocated to the trial. Mothers are randomized either to the treatment group (cognitive-behavioural group psychotherapy in combination with open methylphenidate treatment (Medikinet retard) titrated upward individually until the maximum dose of 1.3 mg/kg/day) or to the control group (supportive counselling). After 13 weeks of treatment individualised parent training is administered to both groups of mothers. Treatment comparisons of the primary endpoint (externalizing symptoms in the children) will be performed within a linear regression model.Zusammenfassung: Die ADHS weist eine hohe Erblichkeit auf. Kinder mit ADHS haben deswegen haufiger auch betroffene Eltern. Im Erwachsenenalter ist die Storung gekennzeichnet durch hohe Komorbiditatsraten und psychosoziale Beeintrachtigungen, die sich auch negativ auf Familienklima und erzieherische Kompetenzen auswirken. Inkonsistente Erziehungspraktiken und haufige Eltern-Kind-Konflikte tragen zur Stabilisierung der Storung bei Kindern bei. Es gibt auch Hinweise darauf, dass bei Vorliegen einer ADHS auf Elternseite die Wirksamkeit psychosozialer Interventionen zur Behandlung der ADHS des Kindes vermindert ist. Im Artikel wird ein Uberblick uber die Bedeutung des Vorliegens einer ADHS bei Muttern fur die Behandlung ihrer Kinder mit ADHS gegeben. Im Anschluss wird das Studienprotokoll einer kontrollierten randomisierten Behandlungsstudie zur Fragestellung skizziert, ob die Behandlung der ADHS der Mutter die Wirksamkeit eines Elterntrainings zur Behandlung der ADHS des Kindes erhoht. 144 Mutter-Kind-Paare (...

Sex- and Subtype-Related Differences in the Comorbidity of Adult ADHDs

Objective: Comorbidity in adult ADHD (aADHD) has been investigated in a large number of studies using varying research approaches with divergent results. In contrast, there is limited information about sex- or subtype-related differences from studies with small sample size. Method: A large sample of 910 individuals (458 males, 452 females) affected with aADHD was recruited at a tertiary referral center. All probands underwent a four-step procedure for diagnosing aADHD, including the Structured Clinical Interview of Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) Axis I disorders to assess comorbidity. This study will provide additional information regarding the co-morbidity of Axis I disorders in the currently largest clinical referral sample. However, the main objective of this study is to gain information about sex- or subtype-related differences. Results: Affected females show higher rates of mood (61% vs. 49%), anxiety (32% vs. 22%), and eating disorders (16% vs. 1%) than affected males, while substance use disorders were more frequent in affected males (45% vs. 29%), which mirrors sex differences in prevalence in the general population. There were hardly any relevant differences in comorbidities between subtypes, with the exception of the inattentive subtype having an especially low prevalence of panic disorder. Comorbidity in general and substance use disorders in particular, but not sex or subtype, were highly predictive of lower psychosocial status. Conclusion: Sex-related differences in the comorbidity of aADHD are more pronounced than subtype-related differences.

Interaktion, Familienklima, Erziehungsziele und Erziehungspraktiken in Familien mit einem zwangskranken Kind

Interaction, Family Environment, Educational Goals and Childrearing Practices in Families with a Child Suffering from Obsessive-Compulsive Disorder Objective: The study focuses on family interactions and the upbringing environment of children and adolescents with obsessive- compulsive disorder (OCD). The degree to which the family is involved in the child’s OCD symptoms, the frequency and forms of its aggressive behavior toward family members, and features of family functioning were assessed. Patients and Methods: 23 boys and 19 girls with a mean age of 12.7 years suffering from OCD according to ICD-10 and DSM-IV criteria, as well as 40 mothers and 35 fathers participated in the study. Assessments were carried out by means of structured interviews and questionnaires. Results: 85% of the parents reported that members of the family were involved in the OCD symptoms of the affected child. Most of the children and adolescents were verbally or physically aggressive, especially toward their mother. The general family environment was not disturbed except regarding interactions specifically related to the child’s OCD symptoms. Parents and children did not report childrearing practices significantly different from the standardized values of the family inventory applied. The educational goals reported indicated a rather low educational engagement of the fathers, but again there were essentially no substantial differences compared to standardized values. Conclusions: Our study does not support reports in the literature which point to specific, undesirable educational practices of the parents of children with OCD. There were no features of upbringing indicating strict religiosity, extreme ambition, prevention of the development of the child’s autonomy, conflict avoidance or tendency to isolation on the part of the family. The family members’ significant involvement in the child’s OCD symptoms and the vehemence with which the child demands this involvement must be taken into account in the therapy of childhood OCD.