Study evaluates efficacy of CBT in obsessive-compulsive disorder

This study evaluates the efficacy of a specialized form of psychotherapy (cognitive behavioral therapy) in clinical presentations characterized by the joint presence of obsessions and psychotic symptoms. The most promising results were OCD symptom reduction and improved insight of the patients into their illness. The advantage of adding CBT is the absence of potential risks of psychotic exacerbation or increased aggressiveness. SRIs may be used in patients who either refuse or do not respond to CBT and, vice versa, CBT may be tried in patients who did not respond to medication or are at higher risk of psychotic exacerbation.

A study that is published in the current issue of Psychotherapy and Psychosomatics evaluates the efficacy of a specialized form of psychotherapy in clinical presentations characterized by the joint presence of obsessions and psychotic symptoms. Despite the high prevalence and disabling effects of obsessive-compulsive disorder-schizophrenia or schizoaffective disorder (OCD-SCH/SA) comorbidity, only a few studies have investigated treatment strategies for this difficult-to-treat condition. Some investigators and the American Psychiatric Association guidelines suggest treating OCD co-occurring with SCH by combining either typical or atypical antipsychotics with SRIs. However, evidence on the beneficial effect of these combinations is inconclusive. Furthermore, an antipsychotic-SRI combination could produce a clinically significant pharmacokinetic drug interaction. Hence, alternative therapeutic approaches for OCD-SCH/SA are needed. The aims of this open naturalistic study were to examine adherence to and the effectiveness of adjunctive CBT for OCD in patients with stabilized SCH/SA.

Consecutive patients seen between 1 January 2003 and 1 January 2008 at the 'Istituto di Psicopatologia' in Rome were screened for eligibility. Inclusion criteria were as follows: (1) age 18-65 years; (2) meeting DSM-IV criteria for OCD and either SCH or SA as assessed by the Structured Clinical Interview for DSM-IV; (3) OCD of at least moderate severity [Yale-Brown Obsessive Compulsive Scale (Y-BOCS) total score ≥ 16], and (4) stabilized SCH or SA, even if symptoms were not entirely absent (Positive and Negative Symptoms Scale total score ≤ 75). The exclusion criterion was the presence of neurological conditions inducing OCD. Twenty-one patients (13 males, 8 females) were enrolled; the mean age was 29.3 years (range 18-37). Nine patients (43%) had SCH and 12 (57%) SA. The mean duration of OCD was 6.8 years (range 1-16.7). The temporal onset of OCD was subsequent to SCH/SA in 11 patients (6 SCH, 5 SA), anterior in 3 SA patients and concomitant in 7 patients (3 SCH, 4 SA). Four patients presented at least one other Axis I lifetime comorbid disorder. Pharmacological treatments for SCH/SA were chosen by the first author (A.T.) based on the patient's clinical condition, and follow-up visits were scheduled as required, ranging from every week to every few months. CBT was conducted by 4 cognitive behavioral psychologists with ≥ 5 years of experience in treating OCD. CBT consisted of imaginal and in vivo exposure, ritual prevention and/or delay, cognitive therapy and other ad hoc intervention used to supplement exposure and ritual prevention strategies.

Obsessive-compulsive symptoms were assessed using the Y-BOCS. The clinical severity of illness was assessed using the Clinical Global Impressions-Severity (CGI-S) scale and overall functioning using the Global Assessment of Functioning scale. Scales were administered at baseline (T0) and after 6 (T1) and 12 months (T2) of CBT. The Clinical Global Impressions-Improvement (CGI-I) scale was used to evaluate improvement at T1 and T2. Schizophrenic and schizoaffective symptoms at T0 were assessed using the Positive and Negative Symptoms Scale.

A repeated-measures ANOVA for Y-BOCS and the CGI-S and the Global Assessment of Functioning Scales was conducted. All outcome measures showed statistically significant improvements at 6 months and slower improvement afterwards. There was no differential change over time in SA versus SCH, except for a significantly greater functional improvement in SA from T0 to T1. At T2, 52% of patients (11/21) were rated as 'much/very much' improved (CGI-I), 33% (7/21) were responders and 19% (4/21) were remitters. The results of this study indicate good adherence to CBT and a 24% dropout rate consistent with the literature for patients with OCD and without SCH/SA comorbidity (13-36%).

The most promising results were OCD symptom reduction and improved insight of the patients into their illness. The proportion of responders and remitters is in line with clinical trials on the efficacy of adjunctive fluvoxamine with antipsychotics in patients with OCD and SCH. However, the advantage of adding CBT is the absence of potential risks of psychotic exacerbation or increased aggressiveness. To determine if improvement was stable over time, a follow-up evaluation was planned after the end of CBT. SRIs may be used in patients who either refuse or do not respond to CBT and, vice versa, CBT may be tried in patients who did not respond to medication or are at higher risk of psychotic exacerbation.

Source: Psychotherapy and Psychosomatics