Management of obsessive–compulsive disorder with virtual reality-based exposure

Extended-Reality Technologies: An Overview of Emerging Applications in Medical Education and Clinical Care.

      Obsessive-compulsive disorder (OCD) is a type of anxiety disorder in which a person has unreasonable thoughts and fears (obsessions) that lead him to engage in repetitive behaviors (compulsions). A person affected with OCD may realize that his obsessions are not reasonable and may try to ignore or stop them, but he is driven to perform compulsive acts in an effort to ease his distress. OCD usually centers on themes which lead to ritualistic behaviour that ultimately affects the person's life. In this paper a case study of OCD with the symptoms of obsessions of contamination associated with mild depression and Parkinson’s disease is discussed which was successfully treated with some Ayurvedic formulations for about 2 months.Â

Virtual Reality (VR) is positioned to transform the treatment of psychological conditions, by overcoming the disconnect between clients’ lived experiences and clinical or research settings. In aide of this, a novel VR exposure therapy system was developed and validated in people with moderate-severe Obsessive-Compulsive Disorder (OCD). Promisingly, when participant responses were compared to the existing best-practice in psychotherapy, equivalent heart and respiration rates, and self-reported anxiety, were produced. VR helps patients engage better with their treatment and maintains the therapeutic relationship. These findings can improve treatment for the 3 percent of people worldwide living with severe functional impacts of OCD.

The second generation antipsychotic of clozapine has superior efficacy compared to other antipsychotics especially for treatment-resistant schizophrenia. In up to 20% of patients receiving clozapine treatment, the side effect of obsessive compulsive symptoms or obsessive compulsive disorder occurs. These obsessive compulsive side effects sometimes cause cessation of the use of clozapine and sometimes causes difficulties in treating the psychotic symptoms due to dose reductions. This manuscript presents a case with resistant schizophrenia who developed obsessive compulsive disorder secondary to clozapine treatment and was successfully treated with clomipramine and aims to discuss the case accompanied by the literature. [Med-Science 2019; 8(2.000): 449-50]

BackgroundFace-to-face individual cognitive behavioral therapy (CBT) and internet-based CBT (ICBT) without videoconferencing are known to have long-term effectiveness for obsessive-compulsive disorder (OCD), panic disorder (PD), and social anxiety disorder (SAD). However, videoconference-delivered CBT (VCBT) has not been investigated regarding its long-term effectiveness and cost-effectiveness.ObjectiveThe purpose of this study was to investigate the long-term effectiveness and cost-effectiveness of VCBT for patients with OCD, PD, or SAD in Japan via a 1-year follow-up to our previous 16-week single-arm study.MethodsWritten informed consent was obtained from 25 of 29 eligible patients with OCD, PD, and SAD who had completed VCBT in our clinical trial. Participants were assessed at baseline, end of treatment, and at the follow-up end points of 3, 6, and 12 months. Outcomes were the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Panic Disorder Severity Scale (PDSS), Liebowitz Social Anxiety Scale (LSAS), Patient Health Questionnaire–9 (PHQ-9), General Anxiety Disorder–7 (GAD-7), and EuroQol-5D-5L (EQ-5D-5L). To analyze long-term effectiveness, we used mixed-model analysis of variance. To analyze cost-effectiveness, we employed relevant public data and derived data on VCBT implementation costs from Japanese national health insurance data.ResultsFour males and 21 females with an average age of 35.1 (SD 8.6) years participated in the 1-year follow-up study. Principal diagnoses were OCD (n=10), PD (n=7), and SAD (n=8). The change at 12 months on the Y-BOCS was −4.1 (F1=4.45, P=.04), the change in PDSS was −4.4 (F1=6.83, P=.001), and the change in LSAS was −30.9 (F1=6.73, P=.01). The change in the PHQ-9 at 12 months was −2.7 (F1=7.72, P=.007), and the change in the GAD-7 was −3.0 (F1=7.09, P=.009). QALY at 12 months was 0.7469 (SE 0.0353, 95% Cl 0.6728-0.821), and the change was a significant increase of 0.0379 (P=.01). Total costs to provide the VCBT were ¥60,800 to ¥81,960 per patient. The set threshold was ¥189,500 ($1723, €1579, and £1354) calculated based on willingness to pay in Japan.ConclusionsVCBT was a cost-effective way to effectively treat Japanese patients with OCD, PD, or SAD.Trial RegistrationUniversity Hospital Medical Information Network Clinical Trials Registry UMIN000026609; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000030495

ObjectiveTherapeutic alliance has consistently been found to predict treatment outcomes across various psychotherapies and patient diagnosis. However, the relationship between therapeutic alliance and outcome in Cognitive Behavioral Therapy (CBT) has shown mixed results. This study investigated the impact of different aspects of therapeutic alliance in CBT for Obsessive-Compulsive Disorder (OCD).MethodData from two previously completed randomized controlled trials of 208 patients with OCD and their therapists were analyzed. Therapeutic alliance was assessed at week 4 of treatment with the patient-rated and therapist-rated Working Alliance Inventory (WAI), which includes three subscales to measure alliance domains (Goal, Task and Bond). Higher WAI score reflects a better therapeutic relationship. OCD severity was rated by independent assessors at baseline and post-treatment using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Linear regression analyses were used to examine the effects of the different aspects of therapeutic alliance on treatment outcome, adjusted for baseline symptom severity.ResultsA higher total WAI score as rated by therapists significantly predicted a lower post-treatment Y-BOCS. Further, higher scores on the Goal and Task subscales of the WAI were associated with lower post-treatment severity. However, these significant outcomes reflected only small effect sizes.ConclusionsIn the treatment of OCD, the strength of the therapeutic alliance contributes to outcomes, though to a limited extent. Effective OCD treatment involves the delivery of specific therapy interventions, in the context of a strong therapeutic alliance.

INTRODUCTION:Obsessive Compulsive Disorder can be a debilitating illness for many, and management and treatment modalities have been studied extensively to treat it. The effect of Cognitive Behavioral Therapy as a tool has been studied and proven to be efficacious in OCD. rTMS, though widely used to treat and manage depression and anxiety, has also been shown to be helpful in OCD. In real world settings at our institute, a combination of pharmacotherapy (comprising of antiobsessional drugs), psychotherapy and rTMS are used to treat OCD patients (moderate to severe). This study is to evaluate the efficacy of pharmacotherapy, psychotherapy and rTMS sessions concurrently as a multimodal treatment model.METHOD:Retrospective review and analysis of records of 46 IPD and OPD patients(from January 2018 to January 2021) with OCD, all of whom received 20 sessions of rTMS as part of routine clinical care. Of 46 patients, 26 received rTMS over the Left DLPFC and 20 over both SMA and Left DLPFC. They were also undergoing CBT sessions on a weekly basis.These patients were on pharmacotherapy which involved anti obsessional drugs, dosage monitored on follow up, on a weekly basis. A minimum reduction of 20 percent inYale-Brown Obsessive Compulsive Scale (YBOCS) scores was used to classify outcome as partial(20% to 39% difference in YBOCS) or complete response(40% difference in YBOCS and above). Statistical analysis was done using SPSS and Microsoft Excel.Selection Criteria:Male and Female patients with OCD above the age of 18 and below the age of 55 with one or more of the following:1. Moderate to Severe OCD (Ybocs rating of 16 and above) 2.Treatment Resistant OCD3. Intolerance to pharmacotherapy 4.Patient Preference.OBJECTIVE:To assess, and evaluate the effectiveness of pharmacotherapy, rTMS in OCD patients undergoing weekly CBT sessions. rTMS sessions targeting the DLPFC (Dorsolateral Prefrontal Cortex) and SMA (Supplementary Motor Area) in patients with OCD in real world clinical practice settings. The present study explored the potential predictors of response to rTMS treatment as an adjuvant to CBT sessions,and pharmacotherapy.DESIGN:Retrospective and Comparative data study of patients of age group 18 to 55 of both genders rated with Y-BOCS rating scale, undergoing pharmacotherapy,rTMS and Cognitive Behavioral Therapy for OCD (moderate to severe)Results:Results showed that regular concurrent treatment of OCD with pharmacotherapy, 20 sessions of rTMs, and weekly Cognitive Behavioral Therapy in 46 patients showed a minimum YBOCS reduction of 20 % in 82 % of patients whereas 8 patients showed minimal or no change to the concurrent treatment. Out of 17 Female patients, 100 % showed a minimum reduction of 20 % in YBOCS Rating scale. Out of 29 males, 21 males i.e. 72 % showed significant reduction in YBOCS Rating scale. 20 patients i.e 43% patients showed complete response (minimum 40% change in YBOCS) and 39% showed partial response (20 to 39% change in YBOCS).Conclusion:The concurrent role of pharmacotherapy in rTMS and CBT in OCD patients showed significant improvement in 82 percent of the patients, which showed the efficacy of a multimodal treatment model followed in our institute. Figures and charts will be utilised to provide a detailed and illustrative approach.

Accessible online at: www.karger.com/pps ‘Case management’ is a section which addresses biopsychosocial management of cases in clinical medicine. It integrates research evidence with clinical experience. Full disclosure of conflict of interest is required. However, clinicians with substantial conflicts of interest (owing a patent, being a stockholder or executive or serving in the board of directors or being a regular consultant in a company with commercial interests tied to the research discussed) cannot contribute. The patient is a 35-year-old married woman with an obsessive compulsive disorder. She had a 21-year history of obsessive thoughts and ritualistic behaviors including compulsive checking which had become persistent since the birth of her first child. There is no evidence of comorbidity, except for a mild generalized anxiety disorder. She wants to know which treatment is right for her at this point.

Exposure therapy in virtual reality (VR) is well established for anxiety disorders. While early studies show promise for VR-based exposure and response prevention (ERP) in obsessive-compulsive disorder (OCD), a key challenge of traditional VR is the weak sense of presence, deemed crucial for effectiveness. To evaluate the feasibility and efficacy of ERP in mixed reality (MERP). This randomized clinical trial (RCT) included 2 outpatient treatment groups, MERP vs self-guided ERP (SERP) from March 15, 2022, to October 26, 2024. Participants were required to be 18 to 80 years of age and have contamination-related OCD (C-OCD). Exclusion criteria consisted of schizophrenia or bipolar disorder, severe substance use disorder, acute suicidality, and ongoing inpatient treatment. Patients' symptom severity was assessed by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) before (baseline) and after the 6-week intervention period as well as 3 months after posttreatment (follow-up). Six sessions of MERP or SERP. Main outcome was the severity of OCD symptoms in the past 7 days on the Y-BOCS. Sense of presence and subjective appraisal were the secondary outcomes. Thirty-six participants fulfilled inclusion criteria. Twenty-four participants (66.7%) were female; mean (SD) age was 35.42 (14.03) years. Both groups had severe OCD symptoms, with major depressive disorder as the most common comorbidity (23 [63.9%]). Twenty-nine participants (80.6%) completed the postintervention and follow-up assessments. At baseline, patients in the MERP group had a mean (SD) Y-BOCS score of 26.94 (5.83), while the SERP group had a mean (SD) score of 24.22 (4.12). The decline in patients' OCD symptoms (Y-BOCS) was similar in the MERP (mean difference, 3.15) and the SERP groups (mean difference, 1.47) (ηp2 = 0.002; 95% CI, -3.187 to 3.893). Significant improvements were observed within the MERP group from baseline to post treatment across several psychopathological variables, including OCD symptoms, with a medium to large effect (Cohen d, 0.584-0.931; 95% CI, 0.026-1.551). Sense of presence was moderate (mean [SD], ≤3.24 [≤2.07]). Subjective appraisal was heterogeneous. This RCT on MERP in C-OCD provided important insights. While there were no significant between-group differences, changes in psychopathology within the MERP group suggest some level of effectiveness. However, the limited impact indicates that the full potential of MERP has not yet been realized, and future research should aim to improve immersion and overall effectiveness. German Clinical Trial Registry: DRKS00020969.

Data from several previous studies link clomipramine's potent serotonergic effects to its clinical efficacy in reducing the symptoms of obsessive-compulsive disorder (OCD). To investigate this relationship further, we administered the serotonin (5-HT) receptor antagonist, metergoline, and placebo to ten patients with OCD in a crossover study carried out under double-blind, random-assignment conditions. In a previous study of untreated patients with OCD, we found no differences in the behavioral response to single-dose administration of metergoline or placebo. In the present study, patients with OCD receiving clomipramine hydrochloride on a long-term basis (with an average 40% lessening in OC symptoms) responded to a four-day period of administration of metergoline with significantly greater self- and observer-rated anxiety compared with the four-day placebo period. Obsessive-compulsive symptoms also tended to be greater during the metergoline phase, with significant drug-time interactions for both OC symptoms and anxiety peaking on day 4 of the metergoline phase. As anticipated, metergoline lowered plasma prolactin concentrations (providing evidence of physiologically significant 5-HT antagonism) but did not alter plasma clomipramine concentrations. These data further support the hypothesis that clomipramine's therapeutic behavioral effects in OCD are mediated via serotonergic mechanisms.

We may view most of our daily activities as rational action selections; however, we sometimes reinforce maladaptive behaviors despite having explicit environmental knowledge. In this study, we model obsessive-compulsive disorder (OCD) symptoms as implicitly learned maladaptive behaviors. Simulations in the reinforcement learning framework show that agents implicitly learn to respond to intrusive thoughts when the memory trace signal for past actions decays differently for positive and negative prediction errors. Moreover, this model extends our understanding of therapeutic effects of behavioral therapy in OCD. Using empirical data, we confirm that patients with OCD show extremely imbalanced traces, which are normalized by serotonin enhancers. We find that healthy participants also vary in their obsessive-compulsive tendencies, consistent with the degree of imbalanced traces. These behavioral characteristics can be generalized to variations in the healthy population beyond the spectrum of clinical phenotypes.

IntroductionChildhood Obsessive-Compulsive Disorder (OCD) is a prevalent and impairing condition that can be effectively treated with Cognitive Behavior Therapy (CBT). However, a majority of children and adolescents do not have access to CBT. Internet-delivered CBT (ICBT) has been suggested as a way to increase availability to effective psychological treatments. Yet, the research on ICBT in children and adolescents has been lagging behind significantly both when it comes to quantitative as well as qualitative studies. The aim of the current study was to describe the experience of ICBT in adolescents with OCD.MethodEight adolescents with OCD that had received ICBT were interviewed with qualitative methodology regarding their experiences of the intervention. Data was summarized into thematic categories.ResultsTwo overarching themes were identified, autonomy and support, each consisting of three primary themes (self-efficacy, flexibility, secure self-disclosure and clinician support, parental support, identification/normalization, respectively).ConclusionsThe experiential hierarchical model that was identified in this study is, in part, transferrable to previous research. In addition, it highlights the need of further study of important process variables of ICBT in young patient populations.

The goal of this study was to assess Chinese therapists' beliefs about exposure therapy and to examine the psychometric properties of the Chinese version of the Therapist Beliefs about Exposure Scale (TBES). Modification of therapists' beliefs about exposure therapy was also assessed following attendance at an exposure and response prevention therapy (ERP) training workshop. A total of 203 therapists participated in the study. The TBES and a measure of anxiety sensitivity were administered in Chinese. After a half-day ERP training workshop, the Chinese version of the TBES was administered to the participants again. The Chinese version of the TBES demonstrated adequate internal consistency, moderate item-level psychometric properties, and a normal distribution in the sample in this study. The TBES scores of the participants decreased significantly after they attended an ERP training course. The reduction in TBES scores was significantly correlated with therapists' caseload of clients with obsessive-compulsive disorder. The results of this study support the reliability of the Chinese version of the TBES. Chinese therapists had more negative beliefs about exposure than did American therapists who were evaluated in a different study; however, therapists' negative beliefs were significantly reduced after they attended an ERP training workshop. Future studies are encouraged to explore effective strategies to improve the disseminiation and delivery of exposure therapy in China.

Despite extensive coverage of a relationship between memory performance and executive function in the obsessive-compulsive disorder (OCD) literature, the relative contributions of specific aspects of executive control have remained elusive. We, therefore, extend our previous multilevel meta-analysis (Persson et al., 2021), where demand on executive function was the most significant determinant of memory deficits in OCD, and provide a finer-grained analysis of executive control via a segregation into top-down (attentional control, maintenance and updating, planning) and bottom-up (perceptual integration, perceptual salience) contributions. Our multilevel meta-analytic approach allowed us to accommodate the interdependency of 255 effect sizes from 131 studies, totaling 4,101 OCD patients. Results revealed that maintenance and updating (top-down) and perceptual integration (bottom-up) predicted memory performance generally, and specifically in those with clinical OCD. Exploratory analyses suggested that this effect may be somewhat different among subclinical OCD groups; however, these findings should be considered with conceptual and analytical caveats in mind. We explain these results via deficient sensory (perceptual integration) and working memory (maintenance and updating) gating mechanisms and propose a model to accommodate their expression in OC symptoms. In conclusion, our meta-analysis has expanded understanding of cognitive performance in OCD and identifies the possibility of untapped cognitive targets for intervention. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Replacing intrusive thoughts: Investigating thought control in relation to OCD symptoms