Does cognitive-behavioral therapy response among adults with obsessive–compulsive disorder differ as a function of certain comorbidities?

doi:10.1016/j.janxdis.2010.03.013

Journal of Anxiety Disorders

Volume 24, Issue 6, August 2010, Pages 547-552

https://doi.org/10.1016/j.janxdis.2010.03.013 Get rights and content

Abstract

This study examines the impact of several of the most common comorbid psychiatric disorders (i.e., generalized anxiety disorder (GAD); major depressive disorder (MDD); social phobia, and panic disorder) on cognitive-behavioral therapy (CBT) response in adults with obsessive–compulsive disorder (OCD). One hundred and forty-three adults with OCD (range = 18–79 years) received 14 sessions of weekly or intensive CBT. Assessments were conducted before and after treatment. Primary outcomes included scores on the Yale-Brown Obsessive–Compulsive Scale (Y-BOCS), response rates, and remission status. Sixty-nine percent of participants met criteria for at least one comorbid diagnosis. Although baseline OCD severity was slightly higher among individuals with OCD + MDD and OCD + GAD (in comparison to those with OCD-only), neither the presence nor the number of pre-treatment comorbid disorders predicated symptom severity, treatment response, remission, or clinically significant change rates at post-treatment. These data suggest that CBT for OCD is robust to the presence of certain common Axis-I comorbidities.

Section snippets

Participants

One hundred and forty-three patients (male = 68, female = 75) participated in this study across two sites. Enrollment sites included two university-based OCD specialty centers, one in the Southeastern United States and the other in South East Queensland, Australia. Demographic variables (i.e., age, gender, ethnicity) and clinical dimensions (i.e., symptom severity, comorbidity) did not differ across recruitment sites. Inclusion criteria required that subjects have a current primary diagnosis of OCD

Preliminary analyses

The overall sample consisted of 143 patients, 98 (69%) of who met criteria for at least one comorbid psychiatric disorder. Comorbid diagnoses included: GAD (n = 54; 38%), MDD (n = 44; 31%), social phobia (SP; n = 42; 30%), and panic disorder (PD; n = 24; 17%). Other comorbid conditions were present in varying degrees (e.g., PTSD; specific phobia; tic disorders) but not included in analyses given their low frequency. In addition to OCD, participants met criteria for an average of 1.1 (SD = 1.0) additional

Discussion

While CBT is indicated as the first line treatment of choice for OCD, more information is needed about how comorbid diagnoses might impact outcome. Previous studies have examined the impact of depressive disorders on response rates (e.g., Abramowitz et al., 2000); however, little data exists on symptom remission, which is considered a practical indicator of change that corresponds with improved quality of life (Huppert, Simpson, Nissenson, Liebowitz, & Foa, 2009). The present study extends the

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Psychiatric comorbidities are common throughout clinical practice. This article discusses the prevalence and etiology of psychiatric comorbidities, in addition to commenting on clinical implications and future directions. Modern comorbidity research frequently evaluates whether psychiatric comorbidity reflects the presence of two or more distinct conditions, or different manifestations of an underlying/overarching form of psychopathology. While the field has often relied upon categorical approaches to psychiatric comorbidities, a dimensional approach to diagnosing psychiatric disorders has the potential to address criticisms of the categorical approach, aid clinicians in working with complex clinical presentations, and present novel opportunities for future comorbidity research.
Predictors of treatment response to intensive cognitive-behavioral therapy for pediatric obsessive-compulsive disorder
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Intensive outpatient treatments for pediatric obsessive-compulsive disorder (OCD) have demonstrated efficacy for treating youth with OCD and may be especially useful for youth with severe symptomology and/or those who are partial- or non-responders to other forms of intervention. However, participation in these treatments can present challenges for youth and their families, and it is unclear if intensive treatments are more appropriate for certain individuals than others. Identification of potential predictors of treatment response and viability of intensive treatment at an individual level may aid families in their decision to participate in intensive cognitive-behavioral therapy (CBT). The present study aimed to examine the effects of three categories of predictors (demographics, OCD symptom characteristics, and comorbidity) on key target outcomes (post-treatment symptom severity, remission, and treatment response). Participants included 78 youth with a primary diagnosis of OCD who received 14 sessions of family based intensive CBT treatment over 3 weeks. Of the entire sample, 88.5% were classified as treatment responders, with 62.8% of the sample achieving clinical remission. Results identified three significant predictor variables (i.e., symptom severity, family accommodation, and gender) for post-treatment symptom severity and remission status within the context of the examined predictive models. No variables were identified as predictive of treatment response, and comorbidity was not identified as a predictor variable for any treatment outcome.
The effect of comorbid major depressive disorder or bipolar disorder on cognitive behavioral therapy for social anxiety disorder
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Citation Excerpt :
Similarly, the current results are consistent with the findings of a large randomized controlled trial (N=1004) which showed that although comorbid depression was associated with starting and ending treatment with more severe anxiety symptoms in a sample of individuals with mixed anxiety disorders2, co-occurring depression did not interfere with the magnitude of gains from computerized CBT, medication management, or both (Campbell-Sills et al., 2012). The present findings are also in agreement with the results of previous studies on the impact of comorbid depression on CBT for panic disorder (Allen et al., 2010) and obsessive–compulsive disorder (Storch et al., 2010), which found that comorbid depression did not interfere with anxiety symptom reduction. Further, our results are in line with those of Bowen and D׳Arcy (2003), who found that in a sample of individuals with panic disorder, hypomanic symptoms did not have a negative effect on response to CBT.
Major depressive disorder (MDD) and bipolar disorder (BD) commonly co-occur in individuals with social anxiety disorder (SAD), yet whether these comorbidities influence the outcomes of cognitive behavioral therapy (CBT) for SAD is unclear.
The present study examined the degree to which individuals with SAD and comorbid MDD (SAD+MDD; n=76), comorbid BD (SAD+BD; n=19), a comorbid anxiety disorder (SAD+ANX; n=27), or no comorbid diagnoses (SAD+NCO; n=41) benefitted from CBT for SAD. Individuals were screened using the Structured Clinical Interview for DSM-IV and then completed the Social Phobia Inventory and the Depression Anxiety Stress Scales before and after 12-weeks of group CBT for SAD.
At pretreatment the SAD+MDD and SAD+BD groups reported higher social anxiety symptoms than the SAD+ANX and SAD+NCO groups. All groups reported large and significant improvement in social anxiety with CBT. However, at posttreatment the SAD+MDD and SAD+BD groups continued to have higher social anxiety symptoms than the SAD+NCO group, and the SAD+ANX group did not differ in social anxiety symptoms from any group. The sample also showed small and statistically significant improvement in depressive symptoms with CBT for SAD.
Information about medication was not collected in the present study, and we did not assess the long-term effects of CBT.
Our results suggest that CBT for SAD is an effective treatment even in the presence of comorbid mood disorders in the short-term, although extending the course of treatment may be helpful for this population and should be investigated in future research.
Cognitive functioning in medication-free obsessive-compulsive patients treated with cognitive-behavioural therapy
2013, Journal of Obsessive-Compulsive and Related Disorders
Citation Excerpt :
A high score e.g. in the PAS does not necessarily imply a co-morbid anxiety or panic disorder. Therefore, the focus of our study is different from the one in Storch et al. (2010). Our results indicate that CBT might be a useful therapy regardless of the patient's initial level of cognitive functioning.
So far it is still uncertain whether neuropsychological test results in obsessive-compulsive disorder (OCD) change after CBT and whether neuropsychological and clinical variables predict response to CBT. 60 medication-free patients hospitalised for severe OCD were treated with CBT including exposure and response prevention (ERP). Pre- and Post-treatment patients completed a cognitive test battery covering a broad range of neuropsychological and clinical variables. The Yale Brown Obsessive Compulsive Scale (Y-BOCS) was used to assess symptom severity. A healthy control group matched for age, gender, intelligence and education completed the same neuropsychological test battery, with similar test–retest intervals as the patients. Analyses showed significantly worse cognitive functioning in patients compared to healthy controls before treatment on many measures. After CBT patients had significantly improved test results regarding speed of information processing, verbal fluency, visuo-constructive functions and set shifting ability while controls did not perform better at the second testing. None of the neuropsychological and clinical variables assessed was significantly correlated with treatment outcome. These results indicate that cognitive dysfunctions in OCD are in part state-dependent and reversible after treatment. Moreover, our results suggest that CBT is successful even in those patients who exhibit cognitive dysfunctions and who are severely affected at the beginning of treatment.
Quality of life in obsessive-compulsive disorder: The role of mediating variables
2013, Psychiatry Research
Citation Excerpt :
When left untreated, OCD runs a chronic and debilitating course often contributing to interpersonal and psychological difficulties (Norberg et al., 2008). Comorbidity is common in those with OCD with approximately 70% of patients having a comorbid condition, most frequently depressive disorders or another anxiety disorder (Rasmussen, 1994; Storch et al., 2010). Obsessive-compulsive disorder has been associated with considerable functional impairment with the World Health Organization reporting that OCD accounts for 2.5% of global years lost due to disability (Ayuso-Mateos, 2000).
This study examined the association of various clinical features of obsessive-compulsive disorder (OCD) with quality of life (QoL) in 102 adults with a principal diagnosis of OCD. Participants were assessed by trained clinicians using the Anxiety Disorders Interview Schedule 4th edition, the Yale-Brown Obsessive-Compulsive Scale, and an unstructured clinical interview. Subjects completed the MOS-36 Item Short Form Health Survey, and Beck Depression Inventory-II. Obsessive-compulsive symptom severity was negatively correlated with emotional health, social functioning and general health QoL. Depressive symptoms mediated the relationship between obsessive-compulsive symptom severity and emotional health, social functioning and general health QoL. Additionally, interference of obsessive-compulsive symptoms mediated the relationship between obsessive-compulsive symptom severity and emotional health, social functioning and general health QoL. Resistance against obsessive-compulsive symptoms mediated the relationship between obsessive-compulsive symptom severity and social functioning QoL. Diminished QoL is present in persons with OCD and is essential in understanding the complete clinical picture of OCD.
Does time-intensive ERP attenuate the negative impact of comorbid personality disorders on the outcome of treatment-resistant OCD?
2013, Journal of Behavior Therapy and Experimental Psychiatry
There is growing interest regarding patients with obsessive-compulsive disorder (OCD) who do not fully respond to cognitive-behavioural therapy (CBT). Limited data are available on the role of Comorbid Personality Disorders (CPDs) in the outcome of treatment-resistant obsessive-compulsive disorder (OCD), despite the fact that CPDs are considered a predictor of a poorer outcome. This study investigated whether a time-intensive scheduling of treatment could be an effective strategy aimed at attenuating the negative influence of CPDs on outcome in a sample of 49 inpatients with a primary diagnosis of treatment-resistant OCD.
38 inpatients completed the five-week individual treatment consisting of daily and prolonged sessions of exposure with response prevention (ERP) delivered for 2 h in the morning and 2 h in the afternoon. 44% of the sample received a full diagnosis of one or more CPDs. Following a pre-post-test design, outcome measures included the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Beck Depression Inventory-II (BDI-II) and Beck Anxiety Inventory (BAI).
Data showed that the treatment was effective and indicated that CPDs were not a significant predictor of treatment failure.
Future larger studies should evaluate the role of specific clusters of CPDs on the outcome of resistant OCD.
These findings suggest that an intensive treatment could be effective for severely ill patients who have not responded to weekly outpatient sessions and could also attenuate the negative impact of CPDs on outcome, evidencing the importance of a tailored therapeutic approach for patients who need a rapid reduction in OCD-related impairment.

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Does cognitive-behavioral therapy response among adults with obsessive–compulsive disorder differ as a function of certain comorbidities?

Abstract

Section snippets

Participants

Preliminary analyses

Discussion

Behavior Therapy

Behavior Therapy

Behavior Therapy

Biological Psychiatry

Psychiatry Research

Behaviour Therapy

Psychiatric Clinics of North America

Journal of Anxiety Disorders

Clinical Psychology Review

Behaviour Research and Therapy

Psychiatric Clinics of North America

Behaviour Therapy

Clinical Psychology Review

Comprehensive Psychiatry

Journal of Anxiety Disorders

Behaviour Research and Therapy

Comprehensive Psychiatry

Psychiatric Research

Journal of the American Academy of Child and Adolescent Psychiatry

Behaviour Research and Therapy

Journal of Anxiety Disorders

Effectiveness of psychological and pharmacological treatments for obsessive–compulsive disorder: A quantitative review

Journal of Consulting and Clinical Psychology

Obsessive–compulsive patients with comorbid personality disorder: Associated problems and response to a comprehensive behavior therapy

Journal of Clinical Psychiatry

Effect of axis II diagnosis on treatment outcome with clomipramine in 55 patients with obsessive–compulsive disorder

Archives of General Psychiatry

Cognitive-behavioral family treatment of childhood obsessive–compulsive disorder: A controlled trial

Journal of the American Academy of Child and Adolescent Psychiatry

Sertraline and fluoxetine treatment of obsessive–compulsive disorder: Results of a double-blind, 6-month treatment study

Journal of Clinical Psychopharmacology

Treatment outcome for adolescent obsessive–compulsive disorder in a specialized hospital setting

Journal of Psychiatric Practice

Anxiety Disorders Interview Schedule Adult Version (ADIS-IV): Client interview schedule

Tourette's disorder with and without obsessive–compulsive disorder in adults: Are they different?

Journal of Nervous and Mental Disease