The acceptability of Internet-based treatment and characteristics of an adult sample with obsessive compulsive disorder: an Internet survey

Background

Obsessive-compulsive disorder (OCD) is a disabling anxiety disorder, but most individuals delay seeking treatment. Internet-based cognitive behavioural therapy (iCBT) is an innovative service delivery method that may help to improve access to care, but the acceptability to consumers of such programs has not yet been established.

Methodology

People with symptoms of OCD were invited to complete an online survey enquiring about demographic characteristics, symptom severity, and acceptability of Internet-based treatment. Demographic and symptom severity data were compared with people with OCD identified in a national epidemiological survey and with a sample of patients with OCD from a specialist outpatient anxiety clinic.

Participants

129 volunteers to an online Internet survey, 135 patients at a specialist anxiety disorders outpatient clinic, and 297 cases identified in a national epidemiological survey.

Main Measures

Demographic characteristics, and severity of symptoms as measured by the Kessler 10-Item scale, the 12-item World Health Organisation Disability Assessment Schedule - Second Edition and the Yale Brown Obsessive Compulsive Scale - Self Report Version.

Principal Findings

The Internet sample was similar demographically but reported more severe symptoms than the comparison groups, although had similar severity of symptoms of OCD compared with other clinical samples reported in the literature. Participants reported Internet-based treatment for OCD would be highly acceptable.

Conclusions

Internet-based treatment may reduce barriers to accessing treatment to people with OCD. Individuals in this study were similar demographically to other samples and had similar severity of symptoms as those identified in other clinical samples, suggesting that Internet-based treatment using techniques employed in face-to-face treatment may be effective in this group. Internet-based treatments for OCD need to be developed and evaluated.     

Self-Regulation of Anterior Insula with Real-Time fMRI and Its Behavioral Effects in Obsessive-Compulsive Disorder: A Feasibility Study

Introduction

Obsessive-compulsive disorder (OCD) is a common and chronic condition that can have disabling effects throughout the patient''s lifespan. Frequent symptoms among OCD patients include fear of contamination and washing compulsions. Several studies have shown a link between contamination fears, disgust over-reactivity, and insula activation in OCD. In concordance with the role of insula in disgust processing, new neural models based on neuroimaging studies suggest that abnormally high activations of insula could be implicated in OCD psychopathology, at least in the subgroup of patients with contamination fears and washing compulsions.

Methods

In the current study, we used a Brain Computer Interface (BCI) based on real-time functional magnetic resonance imaging (rtfMRI) to aid OCD patients to achieve down-regulation of the Blood Oxygenation Level Dependent (BOLD) signal in anterior insula. Our first aim was to investigate whether patients with contamination obsessions and washing compulsions can learn to volitionally decrease (down-regulate) activity in the insula in the presence of disgust/anxiety provoking stimuli. Our second aim was to evaluate the effect of down-regulation on clinical, behavioural and physiological changes pertaining to OCD symptoms. Hence, several pre- and post-training measures were performed, i.e., confronting the patient with a disgust/anxiety inducing real-world object (Ecological Disgust Test), and subjective rating and physiological responses (heart rate, skin conductance level) of disgust towards provoking pictures.

Results

Results of this pilot study, performed in 3 patients (2 females), show that OCD patients can gain self-control of the BOLD activity of insula, albeit to different degrees. In two patients positive changes in behaviour in the EDT were observed following the rtfMRI trainings. Behavioural changes were also confirmed by reductions in the negative valence and in the subjective perception of disgust towards symptom provoking images.

Conclusion

Although preliminary, results of this study confirmed that insula down-regulation is possible in patients suffering from OCD, and that volitional decreases of insula activation could be used for symptom alleviation in this disorder.     

Goal-directed learning and obsessive–compulsive disorder

Obsessive–compulsive disorder (OCD) has become a paradigmatic case of goal-directed dysfunction in psychiatry. In this article, we review the neurobiological evidence, historical and recent, that originally led to this supposition and continues to support a habit hypothesis of OCD. We will then discuss a number of recent studies that have directly tested this hypothesis, using behavioural experiments in patient populations. Based on this research evidence, which suggests that rather than goal-directed avoidance behaviours, compulsions in OCD may derive from manifestations of excessive habit formation, we present the details of a novel account of the functional relationship between these habits and the full symptom profile of the disorder. Borrowing from a cognitive dissonance framework, we propose that the irrational threat beliefs (obsessions) characteristic of OCD may be a consequence, rather than an instigator, of compulsive behaviour in these patients. This lays the foundation for a potential shift in both clinical and neuropsychological conceptualization of OCD and related disorders. This model may also prove relevant to other putative disorders of compulsivity, such as substance dependence, where the experience of ‘wanting’ drugs may be better understood as post hoc rationalizations of otherwise goal-insensitive, stimulus-driven behaviour.     

Subcutaneous immunoglobulin therapy in a patient with myopathic dropped head syndrome and common variable immunodeficiency

Prominent neck extension weakness is an uncommon clinical entity, also termed dropped-head syndrome, that may be part of a generalized neuromuscular disorder. We report here the case of a woman with dropped-head syndrome and pulmonary arterial hypertension secondary to systemic sclerosis. Subsequently, she developed common variable immunodeficiency and subcutaneous immunoglobulin therapy was started. After two months from the start of therapy we did not observe any improvement in the degree of flexion of the head, although the clinical examination shows an improvement in neck extensor muscle strength. Subcutaneous immunoglobulin therapy could be a possible therapeutic option for the treatment of myopathic neck extensor weakness.     

Ovarian hormones modulate 'compulsive' lever-pressing in female rats

Life events related to the female hormonal cycle may trigger the onset of obsessive-compulsive disorder (OCD) or exacerbate symptoms in women already suffering from it. These observations suggest a possible role for ovarian hormones in the course of this disorder. Yet, the mechanisms that may subserve the modulatory effect of ovarian hormones are currently unknown. The aim of the present study was therefore to test the role of ovarian hormones in the signal attenuation rat model of OCD. Experiment 1 compared the behavior of pre-pubertal and adult male and female rats in the model, and found no age and sex differences in compulsive responding. Experiment 2 found that compulsive responding fluctuates along the estrous cycle, being highest during late diestrous and lowest during estrous. Acute administration of estradiol to pre-pubertal female rats was found to attenuate compulsive behavior (Experiment 3), and withdrawal from chronic administration of estradiol was shown to increase this behavior (Experiment 4). These findings extend the use of the signal attenuation model of OCD to female rats, and by demonstrating that the model is sensitive to the levels of ovarian hormones, provide the basis for using the model to study the role of ovarian hormones in OCD. In addition, the present findings support the hypothesis that the increased risk of onset and exacerbation of OCD in women post-partum may be a result of the decrease in the level of estradiol, which was elevated during pregnancy.     

Real-time fMRI Biofeedback Targeting the Orbitofrontal Cortex for Contamination Anxiety

We present a method for training subjects to control activity in a region of their orbitofrontal cortex associated with contamination anxiety using biofeedback of real-time functional magnetic resonance imaging (rt-fMRI) data. Increased activity of this region is seen in relationship with contamination anxiety both in control subjects¹ and in individuals with obsessive-compulsive disorder (OCD),² a relatively common and often debilitating psychiatric disorder involving contamination anxiety. Although many brain regions have been implicated in OCD, abnormality in the orbitofrontal cortex (OFC) is one of the most consistent findings.^{3, 4} Furthermore, hyperactivity in the OFC has been found to correlate with OCD symptom severity⁵ and decreases in hyperactivity in this region have been reported to correlate with decreased symptom severity.⁶ Therefore, the ability to control this brain area may translate into clinical improvements in obsessive-compulsive symptoms including contamination anxiety. Biofeedback of rt-fMRI data is a new technique in which the temporal pattern of activity in a specific region (or associated with a specific distributed pattern of brain activity) in a subject''s brain is provided as a feedback signal to the subject. Recent reports indicate that people are able to develop control over the activity of specific brain areas when provided with rt-fMRI biofeedback.^7-12 In particular, several studies using this technique to target brain areas involved in emotion processing have reported success in training subjects to control these regions.^13-18 In several cases, rt-fMRI biofeedback training has been reported to induce cognitive, emotional, or clinical changes in subjects.^{8, 9, 13, 19} Here we illustrate this technique as applied to the treatment of contamination anxiety in healthy subjects. This biofeedback intervention will be a valuable basic research tool: it allows researchers to perturb brain function, measure the resulting changes in brain dynamics and relate those to changes in contamination anxiety or other behavioral measures. In addition, the establishment of this method serves as a first step towards the investigation of fMRI-based biofeedback as a therapeutic intervention for OCD. Given that approximately a quarter of patients with OCD receive little benefit from the currently available forms of treatment,^20-22 and that those who do benefit rarely recover completely, new approaches for treating this population are urgently needed.     

引起AECOPD精神神经异常的原因及治疗对策

目的：探讨引起慢性阻塞性肺疾病合并精神神经异常的原因,以制订有针对性的治疗对策。方法：回顾性分析我院自2010年1月到2013年1月期间收治的250例慢性阻塞性肺疾病急性发作期患者的临床资料。结果：32例患者出现精神神经异常症状,占12.80%。其中17例为肺性脑病,占53.13%（17/32）,8例为低渗性脑病,占25.00%（8/32）,5例为药物的不良反应,占15.63%（5/32）,2例为脑梗死,占6.25%（2/32）。所有患者均给予慢性阻塞性肺疾病急性发作的常规治疗方案进行治疗,同时肺性脑病患者给予积极纠正二氧化碳潴留;低渗性脑病患者给予积极纠正电解质紊乱;脑梗死的患者根据情况给予溶栓、脱水、营养脑神经、抗凝、抗血小板聚集等治疗;药物不良反应的患者则给予停止应用相应的药物。经过治疗后,29例症状恢复,占90.63%,3例最终死亡,死亡率为9.38%,其中2例为肺性脑病患者,1例为低渗性脑病患者。结论：对于慢性阻塞性肺疾病急性发作合并精神神经异常的治疗,应根据患者的症状、体征以及辅助检查结果,尽早明确诊断,及时干预,尽快控制病情,防止病情恶化。     

Traitement psychopharmacologique du trouble obsessionnel compulsif de l’enfant et de l’adolescent

The present report review available literature on psychopharmacological treatment of obsessive compulsive disorder (OCD) in children and adolescents. There is now clear evidence that drugs that are potent serotonin reuptake inhibitors (clomipramine and SSRIs) induce a clinically substantial reduction of OC symptoms for most children and adolescents with the disorder. However, improvement is often incomplete, few patients become asymptomatic, and long-term maintenance treatment may be required. Cognitive behavioural treatment, based on graded exposure with response prevention, might have more durable benefits, and is considered as the first line treatment in mild non comorbid OCD. Because OCD frequently occurs in the context of other psychopathology and adaptative difficulties, additional individual and family psychotherapy, pharmacological associations and educational interventions are often necessary.     

Association of headaches and the metals

Lack of specific markers constitutes a problem during diagnosis of headache syndromes. Recently, some metals have gained importance as biological parameters for the diagnosis and during treatment. Low-ionized Mg and high-ionized Ca/Mg in patients with daily migrainous headaches were noted. The blood Na level was shown to increase before and during headache. Headache is also a symptom of the common cold for which zinc may be an effective therapy. The existing relationship between genetic markers of the cluster headache and the efficacy of lithium salts therapy was noted. Headache was also found to be associated with toxic metals. When the health effects of mercury were investigated, the most frequently observed symptom was cephalalgia. Continuous exposure to lead was concomitant with the appearance of symptoms such as headache. In relation to some metabolic links, metals may be introduced as possible biological markers for the diagnosis and during the therapy of different headache syndromes in future clinical trials and laboratory measurements.     

引起AECOPD 精神神经异常的原因及治疗对策

目的：探讨引起慢性阻塞性肺疾病合并精神神经异常的原因,以制订有针对性的治疗对策。方法：回顾性分析我院自2010 年1 月到2013 年1 月期间收治的250 例慢性阻塞性肺疾病急性发作期患者的临床资料。结果：32 例患者出现精神神经异常症 状,占12.80%。其中17 例为肺性脑病,占53.13%（17/32）,8 例为低渗性脑病,占25.00%（8/32）,5 例为药物的不良反应,占15.63% （5/32）,2 例为脑梗死,占6.25%（2/32）。所有患者均给予慢性阻塞性肺疾病急性发作的常规治疗方案进行治疗,同时肺性脑病患 者给予积极纠正二氧化碳潴留;低渗性脑病患者给予积极纠正电解质紊乱;脑梗死的患者根据情况给予溶栓、脱水、营养脑神经、 抗凝、抗血小板聚集等治疗;药物不良反应的患者则给予停止应用相应的药物。经过治疗后,29 例症状恢复,占90.63%,3 例最终 死亡,死亡率为9.38%,其中2 例为肺性脑病患者,1 例为低渗性脑病患者。结论：对于慢性阻塞性肺疾病急性发作合并精神神经 异常的治疗,应根据患者的症状、体征以及辅助检查结果,尽早明确诊断,及时干预,尽快控制病情,防止病情恶化。     

Anti-Ri-associated paraneoplastic cerebellar degeneration. Report of a case and revision of the literature

Paraneoplastic cerebellar degeneration associated with anti-Ri antibodies mainly presents with opsoclonus-myoclonus-ataxia. We report here the case of a patient with anti-Ri-antibody paraneoplastic syndrome, who presented four years after treatment for small-cell lung cancer (SCLC) with oscillopsia and gait disorder. On neurological examination vertical nystagmus, ataxic gait and postural tremor of all four limbs was detected. He died one year after the onset of the symptoms because of a acute exacerbation of his severe chronic obstructive pulmonary disease. No SCLC relapse or new cancer has been detected during the one-year follow-up period.To our knowledge, our patient is the first case of anti-Ri associated disorder with oscillopsia and vertical nystagmus as the initially prominent clinical features. The findings of this case study support the variability of anti-Ri-antibody-associated paraneoplastic syndrome. Further studies must be directed to better characterize the mechanisms underlying this syndrome. Finally, paraneoplastic neurological syndromes should be kept in mind also when a neoplastic disease is not demonstrated.     

Psychosis as a transdiagnostic and extended phenotype in the general population

A large body of research indicates that weak expressions of positive psychotic symptoms (“psychotic experiences”) can be measured in the general population, and likely represent the behavioural manifestation of distributed multifactorial (genetic and non‐genetic) risk for psychosis. Psychotic experiences are a transdiagnostic phenomenon: the majority of individuals with these experiences have a diagnosis of non‐psychotic disorder, particularly common mental disorder, in which psychotic experiences predict greater illness severity and poorer treatment response. Some of the people with common mental disorder and psychotic experiences will present to mental health services meeting criteria for “clinical high risk”. Treatment of the transdiagnostic dimension of psychosis in individuals with common mental disorder who meet “clinical high risk” criteria thus may improve outcome (which cannot be interpreted as prevention of “schizophrenia”). Subthreshold psychotic experiences are transitory in about 80% of individuals, while around 20% go on to develop persistent psychotic experiences and 7% a psychotic disorder, with an annual transition rate of 0.5‐1%. Persistence is associated, on the one hand, with environmental exposures, particularly childhood trauma, and, on the other, with network‐type dynamic interactions between psychotic experiences themselves (e.g., interactions between hallucinatory experiences and delusional ideation) and between symptom dimensions (e.g., interactions between affective symptoms and psychotic experiences, or interactions between subthreshold negative symptoms and psychotic experiences). The study of psychotic experiences is helping to elucidate the mechanisms by which environmental and genetic influences shape the transdiagnostic expression of psychosis proneness, that is mostly transitory but may first become persistent over time and eventually give rise to transition to a psychotic disorder.     

Predictors and Moderators of Internet- and Group-Based Cognitive Behaviour Therapy for Panic Disorder

Internet-based cognitive behaviour therapy (ICBT) can be equally effective as traditional face-to-face cognitive behaviour therapy (CBT) for treating panic disorder (PD). However, little is known about the predictors and moderators of outcome of ICBT when delivered in psychiatric outpatient settings. This study investigated a selection of outcome predictors and moderators of ICBT for panic disorder based on data from a randomised controlled trial where therapist-guided ICBT was compared with group CBT (GCBT) for panic disorder. Participants (N = 104) received 10 weeks of ICBT or GCBT and were assessed before and after treatment, and after six months. Multiple regression analyses were used to test for significant predictors of treatment outcome. Predictors of positive treatment response for both modalities were having low levels of symptom severity and work impairment. In addition, anxiety sensitivity was found to have a small negative relationship with treatment outcome, suggesting that anxiety sensitivity may slightly enhance treatment response. Treatment modality had a moderating effect on the relationship between domestic impairment and outcome and on the relationship between initial age of onset of panic symptoms and treatment outcome, favouring ICBT for patients having had an early onset of PD symptoms and for patients having a high domestic functional impairment. These results suggest that both ICBT and GCBT are effective treatment modalities for PD and that it is possible to predict a significant proportion of the long-term outcome variance based on clinical variables.     

The evolutionary psychology of obsessive-compulsive disorder: the role of cognitive metarepresentation

Repetitive unpleasant thoughts and ritualized behaviors are the key features of obsessive-compulsive disorder (OCD). The classical neuroethological models of OCD rely largely on behavioral similarities between animal stereotypies and human compulsive rituals and are unable to account for the cognitive component of OCD. The cognitive symptoms of OCD need to be addressed in an evolutionary psychological context that incorporates information about human brain evolution. OCD can be understood as an extreme on a continuum of evolved harm-avoidance strategies. A pathological exaggeration of our evolved capacity to cognitively represent future scenarios, including imagined consequences of our own thoughts and actions (metarepresentation), may be part of the set of evolved psychological mechanisms contributing to the psychopathology of OCD. The costly side of the adaptive ability to anticipate future needs or threats could be that etiologically heterogeneous affections of the underlying striatal-frontal brain circuits may render an individual vulnerable to develop OCD.     

Can prefrontal theta cordance differentiate between depression recovery and dissimulation?

We present a case report of a 37-year old woman diagnosed with depressive disorder, first episode, who was admitted into a psychiatric hospital after a failed suicidal attempt. She responded to antidepressant therapy, as evidenced by a >50% reduction in MADRS total score. She was discharged after 4 weeks of treatment, denying any suicidal ideations. The following day the patient committed suicide; she burned herself to death. It is very likely that the patient dissimulated her symptoms and ideations. Subsequently, her quantitative EEG records were retrospectively analyzed. An increase of prefrontal theta cordance value after the first week of mirtazapine therapy was found. Recently three small studies have revealed that decrease of prefrontal theta cordance after 1 week of antidepressant administration can predict clinical response in patients with unipolar depression. In our previous study the absence of a decreased theta prefrontal cordance was associated with lack of treatment response with NPV 1.0 (Bares et al., 2007). Thus, we hypothesize that prefrontal theta cordance could become an objective marker of change of depressive symptoms, independent of patients' compliance and symptom dissimulation, more precise than objective and self-rated depression rating scales.     

Kleine-Levin syndrome: a series of case reports

Kleine-Levin syndrome (KLS) is an intriguing, severe, homogenous disease, with well defined clinical features, but no clear cause or treatment. Therefore studies on KLS were done exclusively with case report or series. There are limited systemic study comparing KLS with controls on phenomenology, cause, investigations and management. We report four cases of KLS presented to us along with core symptoms, hypomanic and catatonic features. Response to treatment also different with one case responded to lithium while others required combination of therapy. KLS is still evolving disorder having cluster of varying symptoms and response to treatment. This needs further exploration and higher studies

     

Obsessive–compulsive adults with and without childhood ADHD symptoms

Obsessive–compulsive disorder (OCD) and attention-deficit and hyperactivity disorder (ADHD) frequently coexist. To understand whether childhood ADHD can increase the risk of OCD in adulthood and whether it influences the phenomenology of OCD, we investigated the symptoms of ADHD during childhood in obsessive–compulsive adults who had never been diagnosed as ADHD. Adults with OCD (n = 83) were given the Wender Utah Rating Scale (WURS), Yale–Brown Obsessive Compulsive Scale (Y-BOCS), Barratt Impulsiveness Scale-11 (BIS-11), Hamilton Depression Rating Scale-17 (HDRS-17) and Beck Anxiety Inventory (BAI). The prevalence of childhood ADHD symptoms was 40.9 % (n = 34) and that of adult ADHD was 16.9 % (n = 14). Patients with childhood ADHD symptoms had an earlier onset of OCD, higher scores of the BAI and BIS-11. The scores of the Y-BOCS and HDRS-17 did not differ between those having and not having childhood ADHD symptoms. Childhood history of ADHD symptoms is common in adult OCD patients who have never been diagnosed as ADHD. Childhood ADHD symptoms are associated with an earlier age of OCD, more severe anxiety and higher impulsiveness. Even remitted ADHD may be a risk factor for OCD in later life.     

强迫症的生物学机制和治疗综述

强迫症是以具有反复强迫思维和强迫行为为特征的一种心理障碍疾病。该病严重影响人们的心理健康和日常生活,因而受到广泛的关注。强迫症病因比较复杂,受到多种因素的影响,家庭环境、社会氛围、个人受教育程度、智力水平及个体的身体素质、健康状况及个性特点等因素与强迫症的产生密切相关。对强迫症的生物学机制的研究主要集中在对相关基因的研究上,其中五羟色胺和多巴胺在强迫症中的作用机制相对来说研究的比较多,也比较成熟,近年来又发现谷氨酸通路和白细胞介素-10也与强迫症的发生有关。与此同时一些治疗强迫症的方法也涌现了出来,如药物治疗和心理治疗。本文拟从强迫症的概念、临床表现、影响因素、生物学机制及其治疗方法等方面的研究进行阐述,以期为今后的研究提供一些参考和依据。     

Provocation of Symmetry/Ordering Symptoms in Anorexia nervosa: A Functional Neuroimaging Study

Anorexia nervosa (AN), obsessive–compulsive disorder (OCD), and obsessive–compulsive personality disorder (OCPD) are often co-morbid; however, the aetiology of such co-morbidity has not been well investigated. This study examined brain activation in women with AN and in healthy control (HC) women during the provocation of symmetry/ordering-related anxiety. During provocation, patients with AN showed more anxiety compared to HCs, which was correlated with the severity of symmetry/ordering symptoms. Activation in the right parietal lobe and right prefrontal cortex (rPFC) in response to provocation was reduced in the AN group compared with the HC group. The reduced right parietal activation observed in the AN group is consistent with parietal lobe involvement in visuospatial cognition and with studies of OCD reporting an association between structural abnormalities in this region and the severity of ‘ordering’ symptoms. Reduced rPFC activation in response to symmetry/ordering provocation has similarities with some, but not all, data collected from patients with AN who were exposed to images of food and bodies. Furthermore, the combination of data from the AN and HC groups showed that rPFC activation during symptom provocation was inversely correlated with the severity of symmetry/ordering symptoms. These data suggest that individuals with AN have a diminished ability to cognitively deal with illness-associated symptoms of provocation. Furthermore, our data also suggest that symptom provocation can progressively overload attempts by the rPFC to exert cognitive control. These findings are discussed in the context of the current neurobiological models of AN.