Clinical features associated with treatment response in obsessive-compulsive disorder
Introduction
Seen in the past as a disorder with a poor prognosis, it is currently accepted that most patients with obsessive-compulsive disorder (OCD) improve after conventional treatments [1]. The potentially devastating nature of this disorder, however, remains unchanged, threatening the social, academic, professional, and family lives of affected individuals.
Variability in OCD treatment outcome supports the notion that OCD is a heterogeneous condition. Efforts to identify homogeneous OCD subtypes have resulted in a variety of studies that have used varying criteria to characterize specific subgroups of patients. Some authors have attempted to determine the association between specific patient characteristics and treatment response. For instance, being single has been associated with a worse prognosis in a 5-year follow-up study [2]. Various studies have suggested that patients in whom hoarding is the main clinical feature present a worse response to treatment with clomipramine (CMI) or selective serotonin reuptake inhibitors (SSRIs) [3], [4] and to cognitive behavioral therapy (CBT) [5]. Lack of response to the same pharmacological treatments was also observed in patients with OCD with poor insight [6], [7]. On the other hand, being treatment-naive, having baseline Yale-Brown obsessive-compulsive scale (Y-BOCS) scores below 23, and low baseline levels of depression have been associated with a good treatment response [8]. Currently, a large body of evidence points to the existence of 2 main putative OCD subtypes: tic-related OCD [9], [10] and early-onset OCD [10], [11], [12]. Both tic-related and early-onset OCD have been associated with a poorer response to antiobsessional agents [11], [13].
Originally observed in patients with tic disorders, sensory phenomena can be described as uncomfortable sensations, feelings, or perceptions that are focal or general in nature and can precede compulsions in the absence of obsessions. Examples include the urge to count, a need to repeat a behavior to alleviate feelings of incompleteness or inner tension, and a need to arrange things until feeling “just right” [9], [14], [15]. Patients report that these phenomena precede the compulsions in the absence of any thought, fear, or worry, and that they are compelled to perform the behaviors until achieving a sense of relief. Clinicians have long observed such subjective experiences among patients with OCD. Leckman et al [16] found that, among the patients studied, the majority reported the occurrence of “just right” perceptions at some point in their illness. In a more recent study, two thirds of the patients studied reported repetitive behaviors preceded by “feelings of things not being ‘just right’” [9]. Despite the absence of systematic evaluations using structured instruments to assess sensory phenomena, anecdotal reports suggest that patients with such symptoms could present a poorer response to CBT [15].
In the present study, we attempted to identify clinical features associated with the short-term response to pharmacological treatment in OCD. Such features include sociodemographic variables, type of obsessive-compulsive symptom (OCS), age at onset of symptoms, and patterns of comorbidity. Patients with tic-related and early-onset OCD have been shown to present a high frequency of sensory phenomena and a poorer treatment response [9], [11]. In view of this, our hypothesis was that tic comorbidity and early onset of OCS, as well as sensory phenomena, are clinical features associated with poorer treatment response. This study is part of a larger investigation, which aims to identify, within the area of OCD phenomenology, more homogeneous subtypes of OCD and their relationship to particular genetic, immunologic, and therapeutic aspects [9], [11], [17], [18], [19].
Section snippets
Methods
This study was approved by the Ethics Committee of the Hospital das Clínicas of the Faculdade de Medicina da Universidade de São Paulo (University of São Paulo School of Medicine). All subjects were given a full explanation of the study procedures, and all gave written informed consent. Ninety-eight consecutive outpatients were recruited from the community through radio and newspaper announcements and participated in a screening interview. Forty-three initiated and 41 completed the study
Results
The mean reduction in Y-BOCS scores for this sample was 47.9% ± 24.5. Approximately 66% (n = 27) of patients presented a reduction of at least 35% in the baseline Y-BOCS scores and a “better” or “much better” rating in the Clinical Global Impression. Among the responders, 54% were treatment-naive. There were no significant differences between the degrees of response of treatment-naive patients and those who had received previous inadequate treatments (such as CMI or SSRIs in lower doses and for
Discussion
Contrary to our hypothesis, the presence of tics and the early onset of OCD were not associated with a poorer response to CMI.
Also unexpectedly, the presence of sensory phenomena was a clinical manifestation associated with greater decreases in baseline Y-BOCS scores after treatment with CMI.
Conventional treatment of tic disorders includes the use of noradrenergic agents such as guanfacine [33]. Previous studies reporting a poor treatment response among patients with tic-related OCD have used
Acknowledgments
This work was supported by grants from Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) to Dr Shavitt (grant no. 99/01548-0), Dr Hounie (98/15013-9), Dr Diniz (99/13005-1), and Dr Miguel (99/08560-6), and from Conselho Nacional de Desenvolvimento Científico e Tecnológico, Brazil, to Dr Miguel (521369/96-7).
The authors thank Dr Lorrin Koran and Dr Michael Jenike for their helpful comments on this manuscript, and Dr Wagner F. Gattaz and the team of Laboratory of Medical Investigation
References (40)
- et al.
Predictors of course in obsessive-compulsive disorder
Psychiatry Res
(1999) - et al.
Overvalued ideation as a predictor of fluvoxamine response in patients with obsessive-compulsive disorder
Psychiatry Res
(2004) - et al.
Is juvenile obsessive-compulsive disorder a developmental subtype of the disorder? A review of the pediatric literature
J Am Acad Child Adolesc Psychiatry
(1998) - et al.
Tic disorders
Psychiatr Clin North Am
(1997) - et al.
The Yale global tic severity scale: initial testing of a clinician-rated scale of tic severity
J Am Acad Child Adolesc Psychiatry
(1989) - et al.
The relationship of obsessive-compulsive disorder to possible spectrum disorders: results from a family study
Biol Psychiatry
(2000) - et al.
Clomipramine efficacy for Tourette syndrome and major depression: a case study
Biol Psychiatry
(1995) - et al.
How to treat OCD in patients with Tourette syndrome
J Psychosom Res
(2003) - et al.
Tourette's syndrome: when habit-forming systems form habits of their own?
Neuron
(2000) - et al.
Efficacy and tolerability of serotonin transport inhibitors in obsessive-compulsive disorder: a meta-analysis
Arch Gen Psychiatry
(1995)
Use of factor-analyzed symptom dimensions to predict outcome with serotonin reuptake inhibitors and placebo in the treatment of obsessive-compulsive disorder
Am J Psychiatry
Treatment of compulsive hoarding
J Clin Psychol
Hoarding and treatment response in 38 nondepressed subjects with obsessive-compulsive disorder
J Clin Psychiatry
Clinical predictors of drug response in obsessive-compulsive disorder
J Clin Psychopharmacol
A score for predicting response to pharmacotherapy in obsessive-compulsive disorder
Int Clin Psychopharmacol
Sensory phenomena in obsessive-compulsive disorder and Tourette's disorder
J Clin Psychiatry
Childhood-onset obsessive compulsive disorder: a tic-related subtype of OCD?
Clin Psychol Rev
Adults with early-onset obsessive-compulsive disorder
Am J Psychiatry
Haloperidol addition in fluvoxamine-refractory obsessive-compulsive disorder: a double blind, placebo-controlled study in patients with and without tics
Arch Gen Psychiatry
Understanding and treating incompleteness in obsessive-compulsive disorder
J Clin Psychol
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