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Complex Decision Making and Uncertainty in Obsessive-Compulsive Disorder

Obsessive-Compulsive Disorder (OCD) is a prevalent and highly debilitating mental health disorder that is not yet well understood. This thesis offers a comprehensive investigation of OCD from a range of cognitive and computational perspectives. It begins with a review of existing studies relevant to the computational psychiatry of OCD. Based on the review, I propose a neurocomputational framework and highlight consistent findings and open questions in the field. In the first empirical study in Chapter 3, I probe the ecological validity of a dominant finding: the critical role of uncertainty for obsessive-compulsive (OC) symptoms and its link to information search. I show that in the general public, OC symptoms were disproportionately affected by the Covid-19 pandemic, a situation of high uncertainty, and positively associated with increased information seeking. Next, I evaluate the psychometric quality of a widely used cognitive behavioural task that yielded important findings on OCD (Chapter 4). I provide support for the task and guidance on which measures should and should not be used in future studies while pointing out that its link to sub-clinical psychiatric symptoms is unclear. In Chapter 5, I combine two dominant lines of research on OCD by investigating cognitive flexibility and confidence in a study that compares patients with OCD to healthy controls. The results showed no significant differences in accuracy between groups, but patients with OCD exhibited longer reaction times and lower confidence ratings with increased susceptibility to external feedback. In Chapter 6, I examine these findings further using a novel cognitive flexibility task that includes measures of decision-making uncertainty and attentional patterns. Overall, this thesis contributes to the field of OCD research by highlighting and challenging existing cognitive findings on OCD. It identifies important research avenues and adds novel findings pointing out the important role of decision making and uncertainty in OCD.

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Clinical advances in obsessive-compulsive disorder: a position statement by the International College of Obsessive-Compulsive Spectrum Disorders

Fineberg, Naomi A. a,,b,,c ; Hollander, Eric d ; Pallanti, Stefano e,,f ; Walitza, Susanne g,,h,,i ; Grünblatt, Edna g,,h,,i ; Dell’Osso, Bernardo Maria j,,k,,l,,m ; Albert, Umberto n ; Geller, Daniel A. o ; Brakoulias, Vlasios p,,q ; Janardhan Reddy, Y.C. r ; Arumugham, Shyam Sundar r ; Shavitt, Roseli G. s ; Drummond, Lynne t ; Grancini, Benedetta b,,j ; De Carlo, Vera b,,j ; Cinosi, Eduardo a,,b ; Chamberlain, Samuel R. u,,v ; Ioannidis, Konstantinos u,,v ; Rodriguez, Carolyn I. k,,w ; Garg, Kabir b ; Castle, David x ; Van Ameringen, Michael y,,z ; Stein, Dan J. aa ; Carmi, Lior bb,,cc ; Zohar, Joseph bb,,dd ; Menchon, Jose M. ee

a University of Hertfordshire, Hatfield

b Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, Hertfordshire

c University of Cambridge School of Clinical Medicine, Cambridge, UK

d Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA

e Istituto di Neuroscienze, University of Florence, Firenze, Italy

f Albert Einstein College of Medicine, Bronx, New York, USA

g Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, University of Zurich

h Neuroscience Center Zurich, University of Zurich and ETH Zurich

i Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland

j University of Milan, Department of Biomedical and Clinical Sciences Luigi Sacco, Ospedale Sacco-Polo Universitario, ASST Fatebenefratelli-Sacco, Milan, Italy

k Department of Psychiatry and Behavioural Sciences, Stanford University, California, USA

l CRC ‘Aldo Ravelli’ for Neurotechnology and Experimental Brain Therapeutics, University of Milan, Milan

m Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford

n Department of Medicine, Surgery and Health Sciences, UCO Clinica Psichiatrica, University of Trieste, Trieste, Italy

o Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA

p Western Sydney Obsessive-Compulsive and Related Disorders Service, Western Sydney Local Health District, Blacktown Hospital, Blacktown, New South Wales

q Translational Research Health Institute (THRI), Clinical and Health Psychology Research Initiative (CaHPRI) and School of Medicine, Western Sydney University, Sydney, Australia

r OCD Clinic, Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India

s OCD Spectrum Disorders Program, Institute and Department of Psychiatry, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo-SP, Brazil

t Consultant Psychiatrist, SW London and St George’s NHS Trust and St George’s, University of London, London

u Department of Psychiatry, University of Cambridge, Cambridge

v Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK

w Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA

x St. Vincent’s Hospital Melbourne and The University of Melbourne, Melbourne, Australia

y Department of Psychiatry and Behavioural Neurosciences, McMaster University

z Hamilton Health Sciences, Hamilton, Ontario, Canada

aa SA MRC Unit on Risk and Resilience in Mental Disorders, Department of Psychiatry and Neuroscience Institute, University of Cape Town, Cape Town, South Africa

bb The Post Trauma Center, Chaim Sheba Medical Center, Ramat Gan

cc The Data Science Institution, The Interdisciplinary Center, Herzliya

dd Tel Aviv University, Tel Aviv-Yafo, Israel

ee Department of Psychiatry, Bellvitge University Hospital-IDIBELL, University of Barcelona, Cibersam, Barcelona, Spain

Received 27 January 2020 Accepted 16 March 2020

Correspondence to Kabir Garg, Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, Hertfordshire, UK, E-mail: [email protected]

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CC-BY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

In this position statement, developed by The International College of Obsessive-Compulsive Spectrum Disorders, a group of international experts responds to recent developments in the evidence-based management of obsessive-compulsive disorder (OCD). The article presents those selected therapeutic advances judged to be of utmost relevance to the treatment of OCD, based on new and emerging evidence from clinical and translational science. Areas covered include refinement in the methods of clinical assessment, the importance of early intervention based on new staging models and the need to provide sustained well-being involving effective relapse prevention. The relative benefits of psychological, pharmacological and somatic treatments are reviewed and novel treatment strategies for difficult to treat OCD, including neurostimulation, as well as new areas for research such as problematic internet use, novel digital interventions, immunological therapies, pharmacogenetics and novel forms of psychotherapy are discussed.

Introduction

Once a neglected illness, obsessive-compulsive disorder (OCD) is now recognized as a common, highly disabling and potentially treatable early-onset brain disorder. Clinical and translational research in OCD grows apace, and over the past 10 years has contributed to substantial advances in understanding of the phenomenology, brain-based biology and treatment response, leading to innovations in nosological conceptualizations, therapeutic interventions and services. Recent changes in the DSM-5 ( American Psychiatric Association, 2013 ) and ICD-11 ( WHO, 2018 ) diagnostic classification systems have set OCD at the head of a new family of obsessive-compulsive spectrum disorders [otherwise known as Obsessive-Compulsive or Related Disorders, or, Obsessive-Compulsive and Related Disorders (OCRDs)], including body dysmorphic, hoarding, hair-pulling, skin picking and olfactory reference disorders and hypochondriasis, all sharing compulsive behaviour as a cardinal characteristic. Serotonin reuptake inhibitors [selective serotonin reuptake inhibitors (SSRIs), clomipramine] or cognitive behavioural therapy (CBT) involving exposure and response prevention (ERP), represent the mainstay of contemporary treatment for OCD, with emerging evidence suggesting that early intervention produces better outcomes ( Fineberg et al., 2019 ). However, a substantial minority of patients still fail to respond either in any meaningful way, or in terms of residual symptoms. Treatment-resistant OCD has become a fruitful research focus for clinical treatment and specialist services development, worldwide.

A number of evidence-based clinical guidelines for managing OCD have been published ( Bandelow et al., 2012 ; Baldwin et al., 2014 ; Sookman et al., 2015 ). However, recent feedback from topic experts and stakeholders (National Institute for Health and Care Excellence, 2019) has identified the need for an update, highlighting that clinical practice has progressed in many areas. This includes evidence of efficacy for new pharmacological interventions and augmentation therapies among treatment-resistant groups, advances in invasive and noninvasive neurostimulation technology as well as rapid advances in information technology and telecommunications and the introduction of technology-enhanced interventions. Yet, in many parts of the world, access to recommended treatments and specialist care services, in particular for children, remains limited.

The International College of Obsessive-Compulsive Spectrum Disorders (ICOCS; www.ICOCS.org ) is a global network of expert clinicians, researchers and ‘experts by experience of OCD’, whose principal objective is to support and stimulate the study and treatment of obsessive-compulsive spectrum disorders. In recognition of the need for updated clinical guidance on the treatment of OCD, the ICOCS has developed this position statement, based on expert consensus and including a balanced representation of genders, child versus adult psychiatrists and early career scientists, with global and ethnic diversity. Agreement was reached on the key issues to be covered at a series of meetings, and the authors of each section were chosen based on their expertise in that area. An initial draft was prepared, based on a literature review, and circulated first among the authors and then to all ICOCS members and iterative edits were incorporated. In sum, we have selected those recent therapeutic advances judged by a range of experts to be of most relevance to the treatment of OCD, including products that are not licensed or labelled for treatment of OCD by the US Food and Drug Administration (FDA) ( Table 1 ), which are marked with an asterisk (*) throughout the article, based on new and emerging evidence from clinical and translational science

Global assessment of obsessive-compulsive disorder

A comprehensive assessment of OCD requires trained clinicians who perform direct interviews with the patient and, whenever possible, with family members, so that an accurate diagnosis can be determined and individualized treatment can be tailored. The hallmarks of OCD are obsessions (recurrent, intrusive, unwanted thoughts, images or impulses and compulsions (repititive behaviours or mental acts that the individual feels compelled to perform), these can present together or separately.The most common symptom dimensions of OCD are contamination/washing, aggression/checking, symmetry/ordering/arranging, sexual/religious (also known as ‘taboo thoughts’) and hoarding ( Rosario-Campos et al., 2006 ). Importantly, according to DSM-5, a diagnosis of Hoarding Disorder should be assigned when symptoms pertain to this single dimension ( American Psychiatric Association, 2013 ). The presence and severity of symptoms can be measured by validated instruments ( Goodman et al., 1989 ; Rosario-Campos et al., 2006 ; Storch et al., 2010 ), which is relevant to tailoring the behavioural treatment and monitoring treatment response objectively. For the OCD diagnosis, while free-form interviews by clinicians are commonly used, structured interviews offer advantages in terms of objectivity and psychometric properties ( Rapp et al., 2016 ). Suitable interviews for the diagnosis of OCD in adulthood include the Structured Clinical Interview for DSM-5 Disorders ( First et al., 2016 ), or the Mini International Neuropsychiatric Interview ( Sheehan et al., 1998 ). The Yale–Brown Obsessive-Compulsive Scale (Y-BOCS) is the gold-standard for assessing symptom severity in diagnosed adult patients, and incorporates a detailed checklist for individual symptoms ( Goodman et al., 1989 ). For initial screening, six brief questions can be used. These include as follows: (1) Do you wash or clean a lot? (2) Do you check things a lot? (3) Is there any thought that keeps bothering you that you would like to get rid of but can’t? (4) Do your daily activities take a long time to finish? (5) Are you concerned about orderliness or symmetry? (6) Do these problems trouble you? Positive response to one or more statements would indicate a need for more detailed assessment ( Fineberg et al., 2008 ).

Obsessions and compulsions tend to occur concomitantly in the vast majority of people with OCD ( Shavitt et al., 2014 ). In addition, compulsions are commonly preceded not only by obsessions but also by subjective experiences of incompleteness, or ‘not feeling just-right’, or so-called sensory phenomena (perceptual experiences that precede or accompany compulsions) ( Shavitt et al., 2014 ). We could expect these phenomena to be targeted by cognitive-behavioural techniques in a way similar to the premonitory urges in the behavioural treatment of tic disorders ( McGuire et al., 2015 ).

Another relevant clinical feature that merits attention when assessing subjects with OCD is the degree of insight, meaning the extent to which the person recognizes that his/her beliefs are not true ( Eisen et al., 1998 ). Insight (good or fair insight, poor insight, absent insight/delusional beliefs) is a diagnostic specifier for OCD, body dysmorphic disorder (BDD) and hoarding disorder in the DSM-5 ( American Psychiatric Association, 2013 ). In general, subjects with OCD have at least good insight, with only a minority presenting poor insight or delusional OCD ( Shavitt et al., 2014 ). The presence of tic symptomatology represents another clinically relevant diagnostic specifier in the DSM-5, as tic may predict a more favourable response to dopamine antagonist agents ( Bloch et al., 2006 ). Finally, the clinician must obtain information regarding avoidance behaviours, which commonly occurs as a means to handle the distress evoked by the obsessions and constitutes one of the main targets of the cognitive-behavioural treatment for this disorder ( Drummond, 2014 ). Functional impairment varies in OCD. It is an important domain that reflects clinical severity and constitutes an indirect measure of improvement during treatment. Impairment can be measured indirectly with OCD severity scales or with specific measures [e.g., the WHO Disability Assessment Schedule 2.0 ( Üstün et al., 2010 ) or the Cognitive Assessment Instrument of Obsessions and Compulsions ( Dittrich et al., 2011 )].

Comorbidity is almost always present with OCD and is often ‘phase-specific’ ( Pallanti and Grassi, 2014 ). Assessment of specific comorbidities, like tic disorders, anxiety and depressive disorders, disruptive disorders, eating disorders, autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD) and schizophrenia ( Zohar, 1997 ), is essential in guiding the formulation of an effective treatment strategy. Comorbidity has also been a focus of emerging genetic studies of OCD. For example, a recent study in 4645 OCD patients found different genotypes to be associated with different OCD comorbidities. Thus, OCD comorbid with bipolar disorders was associated with COMT , OPRM1 and GRIK1 genotypes; OCD and depressive disorders were associated with OPRM1 and CYP3A4/5 genotypes; OCD comorbid with ADD/ADHD was associated with 5HT2C genotypes; and OCD comorbid with anxiety was associated with CYP3A4/5 genotypes ( Nezgovorova et al., 2018 ). However, these findings should be viewed with caution, as the ‘candidate gene’ approach, in which specific genes are tested for association with specific disorders, chosen for the biological plausibility of their relationship, using relatively small samples of affected subjects and healthy controls, has been criticized for overestimating statistical associations. Attempts to replicate the findings have tended to produce disappointing results. Therefore, more unbiased forms of the association study, such as genome-wide association studies (GWAS), which test the association between a disease and multiple genetic variants across the whole genome, are to be preferred ( Gordon, 2018 ; National Advisory Mental Health Council Workgroup on Genomics, 2019 ). A recent meta-analysis of GWAS of eight psychiatric disorders identified a common genetic factor linking OCD, anorexia nervosa and Tourette’s syndrome (Lee et al ., 2019b).

Interestingly, comorbid disorders that start before the onset of OCD symptoms seem to influence the occurrence of additional comorbidities over time. In a cohort of 1001 patients with OCD, separation anxiety disorder preceded OCD in 17.5% of individuals and was associated with a higher lifetime frequency of posttraumatic stress disorder; ADHD preceded OCD in 5.0% of subjects, and was associated with higher lifetime frequencies of substance abuse and dependence; tic disorders preceded OCD in 4.4% of subjects and were associated with higher lifetime frequencies of OCD spectrum disorders ( de Mathis et al., 2013 ). In children and adolescents, in addition to the considerations for the adult subjects, a history of paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) should be taken, as this could also have treatment implications ( Wilbur et al., 2019 ). Taken together, these findings emphasize the importance of identifying comorbid disorders, as they may serve as markers of different biological or clinical substrates of potential relevance for treatment planning (see section Future directions for research).

OCD needs to be differentiated from: anxiety disorders presenting with recurrent fears (as in the phobias) and excessive worry (as in generalized anxiety disorder); ruminations accompanying depressive mood in depressive disorders; OCD-related disorders like BDD (where there are specific concerns with one’s appearance), hair-pulling disorder (the only compulsion); tic disorders; eating disorders (concerns focussed on weight and shape and food); psychotic disorders (especially in poor-insight OCD and so-called schizo-obsessive disorder) and obsessive-compulsive personality disorder (with the hallmarks of enduring rigidity and perfectionism over the lifetime) ( American Psychiatric Association, 2013 ).

Along with the identification of the most bothersome symptoms, the clinician should investigate the age of onset of symptoms and the age when a diagnosis of OCD has been determined, because these data can help to predict the prognosis ( Fineberg et al., 2019 ). OCD frequently emerges in childhood, in which group accurate diagnosis is essential for care planning. Paediatric clinicians can ask simple screening questions such as ‘do you ever have unwanted thoughts or worries that won’t go away? Are there things you have to do over and over again, even though you don’t want to or that don’t make sense?’ The formal diagnosis should be made with a structured interview and the nationwide translated versions of the standardized Children’s Y-BOCS (CY-BOCS), which has good reliability ( López-Pina et al., 2015a , b ).

Awareness of other conditions associated with the onset and course of OCD symptoms can also be of help in treatment planning, because OCD frequently follows a chronic course, with most patients reporting residual symptoms, or present an episodic course with long symptom-free periods (Skoog and Skoog, 1999 ). For example, a cross-cultural study has shown an association between reproductive cycle events and the onset (mostly menarche) or exacerbation of OCD during the premenstruum, pregnancy, postpartum and menopause ( Guglielmi et al., 2014 ). Relevant to prevention strategies, exacerbation during or after first pregnancy posed a significant risk to exacerbation in or after a subsequent pregnancy. The underlying factors responsible for triggering exacerbation remain to be understood, especially the role of oestrogen and oxytocin ( Guglielmi et al., 2014 ).

Information on the family history of OCD, tics and other psychiatric disorders and the understanding of OCD among family members and family accommodation are also relevant to treatment-planning and adherence. Evidence shows that successful treatment depends on the reduction of the participation of the family members in the patient’s compulsive behaviours (i.e., reduction of accommodation) ( Gomes et al., 2017 ). Moreover, a recent analysis suggested that children with a family history of OCD have a six times lower response to CBT ( Garcia et al., 2010 ).

Suicidality should be included when assessing people with OCD ( Dell’Osso et al., 2018 ). A recent meta-analysis ( Angelakis et al., 2015 ) found that OCD patients showed relatively increased risk of ‘suicidality’, when compared with healthy controls. In terms of absolute risk, estimates vary. Among 582 patients with OCD, 36% reported lifetime suicidal thoughts, 20% had made suicidal plans, 11% had already attempted suicide and 10% presented with current suicidal thoughts ( Torres et al., 2011 ). In another study of 425 outpatients, recruited by the ICOCS network, 14.6% of the sample reported at least one suicide attempt during their lifetime ( Dell’Osso et al., 2018 ). In the study by Torres et al. (2011 ), comorbid depressive disorder and posttraumatic stress disorder were associated with a range of suicidal behaviours. Sexual/religious symptoms and comorbid substance use disorders were associated with suicidal thoughts and plans, while impulse control disorders were associated with current suicidal thoughts, suicide plans and attempts. In the study of Dell’Osso et al. (2018 ), comorbid tic disorders as well as medical disorders and a previous history of hospitalization were also associated with increased suicidality.

Neuropsychological assessment of patients with OCD suggests that there are deficits across a broad range of domains (Fineberg et al ., 2018a). For example, a recent meta-analysis found that patients with symptoms related to symmetry and orderliness were more likely to have poor performance on memory, visuospatial ability, verbal working memory and cognitive flexibility tests, whereas patients with doubting and checking were more likely to perform poorly on memory and verbal memory tasks ( Bragdon et al., 2018 ). Other meta-analyses have found cognitive flexibility and response inhibition to be impaired in OCD in general (all literature pooled), with medium–large effect sizes ( Lipszyc and Schachar, 2010 ; Chamberlain et al., 2019 ). It must be considered that comorbid neurodevelopmental disorders, such as ASD ( Postorino et al., 2017 ), or ADHD are expected to influence performance on distinct tests, especially but not exclusively in youth.

Behavioural analysis of OCD involves obtaining a history to ascertain the specific situations that provoke obsessions, anxious thoughts or uncomfortable feelings and then separating out the compulsions or anxiolytic behaviours. This is important, as during therapy the patient needs to face up to the anxiety-provoking thoughts or uncomfortable feelings while resisting the urge to ‘put this right’ using compulsive thoughts, behaviours or avoidance. Full descriptions of behavioural analysis are given elsewhere ( Drummond, 2014 ). From a cognitive perspective, there have been several theories about the underlying beliefs that may trigger OCD, such as the failure to challenge underlying beliefs sufficiently ( Emmelkamp et al., 1988 ), inflated responsibility and guilt if compulsions were not acted upon and negative consequences occurred ( Salkovskis, 1985 , 1999 ), or an overinflated idea of danger ( Jones and Menzies, 1998 ) (see section Novel forms of psychotherapy below).

Early intervention in obsessive-compulsive disorder

OCD frequently has an onset early in life ( Fineberg et al., 2019 ). Childhood or adolescent onset accounted for more than 50% of the sample in a recent international multisite report ( Dell’Osso et al., 2016 ). Unfortunately, early onset is all too often not associated with early help-seeking and recognition of the illness. OCD has been consistently associated with a long duration of untreated illness (DUI) – around 7 years on average ( Dell’ Osso et al. , 2019 ) – with this period accounting, in many cases, for more than half of the overall duration of illness ( Albert et al., 2019 ; Dell’ Osso et al. , 2019 ). Longer DUI implies late interventions and poor therapy response, particularly in relation to pharmacological treatment ( Dell’Osso et al., 2010 ; Albert et al., 2019 ). The need for service investment in early intervention for OCD is further highlighted by studies indicating that OCD is among the top 10 most disabling of all disorders, accounting for 2.2% of all years lost to disability ( Ayuso-Mateos, 2006 ), with economic costs to society including those associated with lost productivity, which are long-lasting and profound. It has been estimated that in the USA, over $10 billion dollars per year are spent on treatments for OCD alone ( Hollander et al., 2016 ).

OCD has been traditionally viewed as a secretive illness with some phenotypes (e.g., with sexual, religious or aggressive content) being particularly associated with reluctance to seek help ( Dell’Osso et al., 2015 ). There may also be difficulty detecting the disorder in childhood ( Storch et al., 2014 ). Nonetheless, a greater effort needs to be made at multiple levels (e.g., education, service development and screening of ‘at risk’ individuals) to implement effective strategies for prevention, early diagnosis and intervention. For instance, there have been reports indicating that the earliest symptoms shown by OCD patients belong to the symmetry and ordering dimension ( Kichuk et al., 2013 ) and these may represent a red flag for early detection of subthreshold/early symptoms.

Children of individuals with OCD represent another high-risk group deserving attention and potentially needing preventive interventions. The presence of tic, paediatric acute-onset neuropsychiatric syndrome, obsessive-compulsive personality disorder and impulse control disorders may be indicators of comorbid OCD or herald the subsequent development of OCD ( Fineberg et al., 2019 ). Staging models may also be useful ( Fineberg et al., 2019 ; Fontenelle and Yücel, 2019 ), with four major stages proposed (from stage 0 ‘increased risk, asymptomatic’ to stage 4 ‘severe illness’). However, their clinical utility and applicability remain to be investigated. Interventions such as psychoeducation and reduction of family accommodation represent promising areas for prevention and early intervention when OCD is at its early stages in high-risk groups ( Brakoulias et al., 2018 ). One Australian health service ( Brakoulias, 2018 ) has recently begun using existing early intervention services for psychosis to provide early intervention to patients with OCD ( Brakoulias, 2018 ) (Western Sydney Obsessive-Compulsive and Related Disorders Service).

Cognitive behavioural therapy, selective serotonin reuptake inhibitor or their combination as a first-line treatment for adults with obsessive-compulsive disorder

Pharmacological therapies (SSRIs and the tricyclic clomipramine) ( Zohar et al., 1996 ; Fineberg et al., 2012 ) and psychological therapies (ERP, CBT) ( Abramowitz, 2006 ) are often efficacious in treating OCD in adults. As SSRIs and CBT have been thought to have broadly similar efficacy in acute treatment, current guidelines recommend taking account of patients’ clinical features, needs and preference as well as service availability when choosing a first-line treatment ( Baldwin et al., 2014 ). Monotherapy with CBT involving ERP is particularly recommended as an initial treatment in those with mild–to-moderate OCD, in the absence of severe depression, in those who do not prefer medications and where this form of treatment is accessible, available and preferred by patients (National Institute for Health and Clinical Excellence, 2005a; Koran et al., 2007 ; Katzman et al., 2014 ; Janardhan Reddy et al., 2017 ). In contrast, SSRIs are particularly recommended as a first-line treatment option in more severe OCD, in those who have comorbid depression, in those with previous history of good response to SSRIs, in those who are uncooperative with CBT or in situations where ERP/CBT is not available, accessible or preferred by patients. A combination of CBT involving ERP and SSRIs is often recommended in severe OCD, in the presence comorbid depression and in poor responders to CBT or SSRIs alone (National Institute for Health and Clinical Excellence, 2005b; Skapinakis et al., 2016b ; Hirschtritt et al., 2017 ; Janardhan Reddy et al., 2017 ). In essence, most guidelines recognize SSRIs and CBT involving ERP as first-line monotherapies, but prefer CBT involving ERP over SSRIs.

Several meta-analyses and systematic reviews have demonstrated SSRIs and clomipramine ( Ackerman and Greenland, 2002 ; Soomro et al., 2008 ; Skapinakis et al., 2016b ) and CBT involving ERP to be more effective than placebo (frequently waiting list in CBT trials) in the treatment of OCD ( Gava et al., 2007 ; Rosa-Alcázar et al., 2008 ). Although an earlier meta-analysis suggested superiority of clomipramine over SSRIs ( Ackerman and Greenland, 2002 ), a recent network meta-analysis failed to demonstrate the superiority of clomipramine over SSRIs ( Skapinakis et al., 2016b ). Direct head-to-head comparisons of various medications are few and there seems to be no individual differences in efficacy among SSRIs ( Skapinakis et al., 2016b ), although, of course, they may differ in side effect profiles.

Most studies of CBT involving ERP included symptomatic patients stabilized on antidepressants ( Skapinakis et al., 2016b ). Although the observed effect size of CBT was larger than the SSRIs and clomipramine, this superiority could well be attributed to the additive or synergistic effects of two effective treatment modalities. Therefore, it is not clear whether the efficacy data attributed to CBT with ERP can be generalized to patients who are not taking medication for OCD. The efficacy of CBT as monotherapy still needs to be established clearly in drug-naïve or drug-free patient population for it to be recommended as initial monotherapy in this population.

Some studies suggest that a combination of CBT and an SSRI may be superior to SSRI monotherapy ( Foa et al., 2005 ; Liu et al., 2005 ; Franklin et al., 2011 ; Romanelli et al., 2014 ; Meng et al., 2019 ), exposure monotherapy ( Cottraux et al., 1990 , Fineberg et al., 2018a ) or multimodal CBT ( Hohagen et al., 1998 ). However, it is uncertain whether combining ab-initio CBT and an SSRI is advantageous compared to either treatment used alone ( Albert et al., 2012 ). Confidence in the superiority of the combination of medications and psychotherapy partly stems from the fact that, as described above, most psychotherapy trials are considered variants of combination trials because most patients in these studies were stabilized on SSRI or clomipramine ( Skapinakis et al., 2016b ). Most guidelines and literature recommend a combination of SSRIs and CBT involving ERP in severe OCD, but the recommendation is based on evidence of its efficacy as an augmenting strategy in patients who have clinically significant symptoms despite treatment with medications and not necessarily in severe OCD ( Simpson et al., 2008 , 2013 ). A recent randomized feasibility study that included patients treated in primary care found that although combined treatment with SSRI and ERP was associated with the largest improvement after 16 weeks, SSRI monotherapy was the most efficacious and cost effective treatment after 52 weeks ( Fineberg et al., 2018b ). If replicated, this finding would carry major implications for health services planning, especially where resources are limited, such as lower and middle income countries.

The critical importance of adequate treatment of obsessive-compulsive disorder in children and young people

For children and young people, CBT should always be the first-line approach ( Sánchez-Meca et al., 2014 ; Skapinakis et al., 2016a ), with ERP as core elements ( Lewin et al., 2014 ). ERP is both highly effective and also an acceptable intervention for youth ages 3–8 years with OCD ( Lewin et al., 2014 ). Children with a strong family history of OCD are reported to respond less well to conventional CBT ( Garcia et al., 2010 ), possibly owing to family accommodation of their symptoms. Key adaptations for younger children include extensive parental involvement targeting family accommodation and frequent family meetings while delivering a full course of ERP. According to the study of Sánchez-Meca et al. (2014 ), effect sizes were large for CBT ( d + = 1.742) and combined (medication plus CBT) interventions ( d + = 1.710) and moderate for pharmacological only treatments ( d + = 0.746). Family-based CBT ( Piacentini et al., 2011 ; Freeman et al., 2014 ) is also effective for children and adolescents with OCD, especially when there is a high degree of accommodation. The extant literature also supports CBT when delivered in group settings. More recently, the use of technical devices (smart phones and tablets) using App-delivered CBT seems promising.

Medication is, however, indicated for children and young people when symptoms are more severe, CBT has failed, skilled CBT is unavailable, and there is a comorbid disorder (e.g., depression) that may respond to medication, or when, in the judgement of the parent or clinician, earlier introduction of medicines is clinically indicated. SSRIs have been shown in randomized controlled trials to be well tolerated and effective in youth ( Geller et al., 2004 ; Skarphedinsson et al., 2015 ). Sertraline and fluvoxamine have been approved for children from 6 to 8 years of age. Dosing schedules should include low starting doses, slow titration schedules and maximum recommended doses. Following adequate response and stabilization, treatment should be reviewed after 6–12 months.

In the case of nonresponse or inadequate response, another SSRI should be tried ( Geller et al., 2004 , 2012 ; Locher et al., 2017 ). Treatment with SSRIS in CBT-resistant patients may improve OCD symptoms. Although clomipramine may be effective, it is not recommended as a first-line treatment because of its potential side effects. However, if there are no cardiac contraindications, clomipramine* is also an option in youth but requires electrocardiogram monitoring. In the case of insufficient efficacy of drug treatment with several SSRIs and clomipramine, or in the presence of tic disorder, augmentation with antipsychotics, for example, aripiprazole* or risperidone* in low dosage may be used. Minimal duration on antipsychotics (these medications are not approved or indicated for paediatric use) is encouraged and close monitoring is required.

Relapse prevention

Relapse prevention strategies play an essential role for the optimal clinical management of OCD, considering its frequently chronic course and relapsing nature. Recovery occurs in only about one-fifth of adult cases, while for children, the mean persistence rates for full or subthreshold OCD have been estimated at around 60% ( Maina et al., 2001 ; Stewart et al., 2004 ). Earlier age of OCD onset, increased illness duration, inpatient status, the presence of comorbidities and a positive family history seem to predict greater rates of persistence ( Geller et al., 2003 ; Stewart et al., 2004 ). Furthermore, relapses in OCD are associated not only with considerable distress, significant functional impairment and impairment of quality of life ( Hollander et al., 2010 ) but also with a decreased response to a previous efficacious treatment ( Maina et al., 2001 ).

To date, relapse prevention studies in OCD have mainly investigated SSRIs and clomipramine as the maintenance treatment, with the duration of treatment under placebo-controlled conditions extending up to 12 months. Studies with a longer follow-up period or investigating relapse following CBT are relatively scarce. In the case of adults, the majority of relapse prevention studies have shown an overall superiority of SSRI compared with placebo in preventing relapse ( Fineberg et al., 2007 ) and that discontinuation of maintenance treatment, even after a period of prolonged well-being under SSRI, is associated with a heightened relapse risk. Relapse was particularly prominent in patients with comorbidities, which is the rule rather than the exception in children with OCD. As childhood and adolescence are critical periods for achievement of social, educational and occupational milestones, relapse prevention is particularly relevant for the younger patient population ( Fineberg et al., 2019 ). There has been one randomized controlled relapse prevention study in paediatric OCD, which showed an advantage for paroxetine* over placebo ( Geller et al., 2004 ). As there is no available evidence suggesting a duration of treatment beyond which treatment can be discontinued safely, more recent guidelines emphasized the importance of maintaining medication for at least 12 months to reduce relapse risk ( Baldwin et al., 2014 ).

The clinician’s role in enabling an informed choice about whether or not to discontinue medication at any particular time is challenging, considering the limitations of the available relapse prevention studies. Strategies for safely managing emerging relapse, such as reinstating either ‘booster’ CBT or medication at the first sign of symptoms, do not have established evidence of efficacy. Nevertheless, it is advisable to establish a relapse-management plan, in cooperation with patients and their families based on vigilance for emergent symptoms and rapid access to treatment previously known to be effective. If medication is to be discontinued, this should be done gradually, after a careful explanation of the potential consequences, such as withdrawal symptoms and relapse risk. SSRI tapering over a period of months, rather than weeks, may reduce the risk of withdrawal symptoms ( Horowitz and Taylor, 2019 ).

Treatment-resistant obsessive-compulsive disorder – novel pharmacotherapies tested in adults

After well supported first- and second-line treatments and strategies have been exhausted, some patients will continue to experience impairing OCD symptoms. Next-step treatment strategies may include continuing with the chosen SRI for an extended period of time, switching to another SRI, augmenting the SRI with a second-generation antipsychotic agent* or raising the dose of SRI to the highest tolerated level* ( Fineberg and Craig, 2007 ; Bandelow et al., 2008 ; Fineberg et al., 2012 ; Stein et al., 2012 ).

Although switching to another SRI often is recommended, there is little evidence to support this approach in OCD. When a partial or moderate response has been achieved following the adequate first-line treatment, there is randomized controlled trial (RCT) and meta-analytic evidence to support augmentation with an second-generation antipsychotic ( Brakoulias and Stockings, 2019 ; Dold et al., 2015 ; Stein et al., 2012 ; Zhou et al., 2019 ); however, the use of these agents would be considered off-label. Of these agents, risperidone* is supported by the greatest number of studies, which have generally been positive ( Brakoulias and Stockings, 2019 ). Two RCTs ( Muscatello et al., 2011 ; Sayyah et al., 2012 ), several open-label studies (Connor et al ., 2005; Pessina et al ., 2009; Ak et al ., 2011), and multiple case reports have demonstrated the efficacy in OCD of aripiprazole* as an augmentation agent (Matsunaga et al ., 2011; Higuma et al ., 2012; Hou and Lai, 2014; Ercan et al ., 2015; Akça and Yilmaz, 2016; Patra, 2016; Brakoulias and Stockings, 2019 ). One meta-analysis also found a larger effect size for aripiprazole than for risperidone: Cohen’s d = 1.11 (aripiprazole) versus d = 0.53 (risperidone) (Veale et al ., 2014). Quetiapine* has also been examined as an augmentation agent in OCD, but the evidence is conflicting. Despite several positive studies (Atmaca et al ., 2002; Denys et al ., 2004; Vulink et al ., 2010; Diniz et al ., 2011), negative results have been found in many placebo-controlled trials (Carey et al ., 2005; Kordon et al ., 2008; Fineberg et al ., 2013).

Contrary to the depression literature, a meta-analysis of SSRIs in OCD found that high doses (high end of recommended dosage, not higher than recommended doses) were more effective than medium or low doses in the first-line treatment of OCD ( Bloch et al., 2010 ). Response was more robust for patients with comorbid tics and in individuals who had received more than 12 weeks of maximal SSRI monotherapy ( Bloch et al., 2008 ). However, tolerability is a significant issue as compared with lower doses so that this strategy requires caution in primary care settings ( Stein et al., 2012 ). The Food and Drug Administration in the USA raised a safety warning in 2011 against citalopram doses higher than 40 mg/day due to a modest but probable risk of arrhythmias ( US Food and Drug Administration, 2012 ). However, a more recent meta-analysis identified only 18 cases where electrocardiogram QTc prolongation or torsades de pointes was associated with citalopram at doses between 20 and 60 mg/day. The authors concluded that these cardiac adverse events were infrequent ( Tampi et al., 2015 ).

When an inadequate treatment response persists, less well supported treatment strategies (lacking multiple randomized, controlled trials or meta-analyses) may be considered ( Koran et al., 2007 ; Koran and Simpson, 2013 ), including use of glutamate modulators*, d-amphetamine* or oral morphine sulfate*.

Glutamate modulators such as memantine*, riluzole*, topiramate*, lamotrigine*, N-acetylcysteine* and ketamine* have varying levels of support ( Koran et al., 2007 ; Pittenger et al., 2011 ; Koran and Simpson, 2013 ; Pittenger, 2015 ). Memantine augmentation showed benefit in case studies and open-label trials ( Poyurovsky et al., 2005 ; Pasquini and Biondi, 2006 ; Aboujaoude et al., 2009 ; Feusner et al., 2009 ; Stewart et al., 2010 ; Bakhla et al., 2013 ). In addition, two RCTs of memantine showed exceptionally high response rates (100% in one study), inconsistent with the literature ( Ghaleiha et al., 2013 ; Haghighi et al., 2013 ). Riluzole augmentation showed promise in a case series and open-label trial ( Coric et al., 2003 , 2005 ). Subsequent small controlled studies have been mixed ( Pittenger et al., 2008 ; Emamzadehfard et al., 2016 ). While topiramate augmentation showed promise in case studies and open-label trials ( Rubio et al., 2006 ; Van Ameringen et al., 2006 ; Van Ameringen and Patterson, 2015 ), small RCTs have also produced mixed results ( Mowla et al., 2010 ; Berlin et al., 2011 ; Afshar et al., 2014 ). Lamotrigine augmentation showed mixed results in case reports ( Kumar and Khanna, 2000 ; Uzun, 2010 ; Arrojo-Romero et al., 2013 ; Hussain et al., 2015 ) and benefits in two small RCTs ( Bruno et al., 2012 ; Khalkhali et al., 2016 ). Limited data suggest that N-acetylcysteine is of benefit in some cases of refractory OCD ( Lafleur et al., 2006 ), with mixed data in four RCTs ( Afshar et al., 2012 ; Sarris et al., 2015 ; Paydary et al., 2016 ; Costa et al., 2017 ). N-acetylcysteine is generally well tolerated. A single intravenous dose of ketamine has been reported to be of rapid (in hours) and robust benefit in unmedicated adults with OCD in case report and open-label studies ( Rodriguez et al., 2011 , 2016 ) and a randomized controlled cross-over study ( Rodriguez et al., 2013 ). In an open-label trial of medicated OCD adults with multiple comorbidities, depression improved on ketamine but improvement in OCD symptoms was minimal, and two patients developed new-onset irritability and suicidal ideation ( Bloch et al., 2012 ; Niciu et al., 2013 ). Experience with intranasal ketamine in OCD is very limited ( Adams et al., 2017 ; Rodriguez et al., 2017 ). Ketamine should only be administered at sites with expertise in this approach, with appropriate precautions including monitoring for side effects and screening individuals who have a current or past substance abuse problem ( Sanacora et al., 2017 ).

In two double-blind, placebo-controlled studies, d-amphetamine was superior to placebo in unmedicated OCD adults ( Insel et al., 1983 ; Joffe et al., 1991 ). A subsequent double-blind comparison of SSRI augmentation with d-amphetamine versus high-dose caffeine showed benefit of both drugs ( Koran et al., 2009 ). Oral morphine showed benefit in a case series ( Warneke, 1997 ) and in a double-blind crossover study ( Koran et al., 2005 ) in adults with OCD. Precautions should be taken in the case of both d-amphetamine and morphine to screen out individuals who have current or past substance abuse ( Koran et al., 2007 ).

Other drugs, such as pindolol*, clonazepam*, buspirone*, or lithium*, have been tested, but the results have been mixed and some of the placebo-controlled trials have not found positive results. Some promising results have been found with the 5HT3 antagonist ondansetron* ( Serata et al., 2015 ) and a clinical trial is currently underway ( ClinicalTrials.gov, 2017 ) though a double-blind placebo-controlled trial of low daily dosages of odansetron* (0.5 and 0.75 mg) in a relatively large sample was negative ( ClinicalTrials.gov, 2015 ).

Treatment-resistant obsessive-compulsive disorder – noninvasive neurostimulation

Noninvasive neuromodulatory interventions targeting the corticostriatothalamocortical (CSTC) circuits hold promise as augmenting intervention for treatment-resistant OCD ( Lusicic et al., 2018 ). Repetitive transcranial magnetic stimulation (rTMS)* is the best studied noninvasive modulatory intervention in OCD. rTMS delivered at low-frequency rTMS (≤1 Hz) (LF-rTMS) is thought to inhibit the activity of underlying cortical regions, while high-frequency rTMS, provided at ≥5 Hz, is thought to enhance cortical activity ( Lefaucheur et al., 2014 ). Conventional rTMS, provided through the figure-8 coil, is relatively focal, modulating superficial cortical regions over a depth of around 2 cm ( Lefaucheur et al., 2014 ). LF-rTMS* protocols targeting the supplementary motor area (SMA) have been found to be helpful for OCD in multiple RCTs and meta-analyses ( Mantovani et al., 2010 ; Gomes et al., 2012 ; Hawken et al., 2016 ; Zhou et al., 2017 ; Rehn et al., 2018 ). This effect has been found to last up to 3 months ( Gomes et al., 2012 ). A recent trial demonstrated superior efficacy of this protocol over antipsychotic augmentation in treatment-resistant OCD subjects ( Pallanti et al., 2016 ). However, given recent inconsistent reports on inhibitory rTMS protocols targeting the SMA ( Arumugham et al., 2018 ; Harika-Germaneau et al., 2019 ; Pelissolo et al., 2016 ), there is a need for large multicentre trials to confirm its efficacy at this location.

LF-rTMS targeting the orbitofrontal cortex (OFC)* has also shown promise in small RCTs ( Ruffini et al., 2009 ; Nauczyciel et al., 2014 ). There is a need for larger trials targeting the OFC to confirm its efficacy and tolerability. RCTs targeting the dorsolateral prefrontal cortex have, in contrast – and unlike in major depressive disorder – shown highly inconsistent findings in OCD ( Lusicic et al., 2018 ). A multisite randomized sham-controlled trial found high-frequency deep rTMS, using an H7 coil, over the dorsomedial prefrontal cortex/anterior cingulate cortex to be efficacious and well tolerated in a treatment resistant OCD population ( Carmi et al., 2019 ). This FDA approval and CE (Conformité Européene) certification device for the treatment of resistant OCD. However, considering the cost of this device, there is a need for replication studies confirming the efficacy of the above protocol, which included personalized symptom provocation as an interventional component. Less-expensive deep coils, which have shown promise in targeting the dorsomedial prefrontal cortex in open-label trials on OCD ( Modirrousta et al., 2015 ; Dunlop et al., 2016 ), are yet to be evaluated under controlled conditions.

Transcranial direct current stimulation (tDCS)* involves administration of low-amplitude (1–2 mA) electric current to the brain between a cathode and anode. Anodal tDCS is thought to enhance cortical excitability and cathodal tDCS to have an inhibitory effect ( Rachid, 2019 ). The SMA and OFC are key targets. A randomized sham-controlled trial ( n = 24 treatment-resistant OCD subjects) demonstrated efficacy for anodal tDCS administered over bilateral pre-SMA and cathodal tDCS over right supraorbital regions ( Gowda et al., 2019 ). However, another randomized crossover trial ( n = 12) found clinical improvement with cathodal tDCS over pre-SMA, while anodal tDCS was ineffective ( D’urso et al., 2016 ). Thus, replication studies are needed to determine the optimal stimulation protocol for tDCS over SMA in OCD*. Another randomized sham-controlled trial ( n = 21 treatment-resistant OCD patients) showed efficacy for cathodal tDCS delivered over the OFC and the anode over the right cerebellum, but the effect was not sustained at follow-up ( Bation et al., 2019 ). Other promising results in treatment-resistant OCD for protocols targeting OFC and other cortical regions, such as dorsolateral prefrontal cortex and dorsomedial prefrontal cortex, are found in case reports and small uncontrolled studies and have to be confirmed in well designed trials ( Brunelin et al., 2018 ; Rachid, 2019 ). Furthermore, studies present significant heterogeneity and methodological differences in sample selection criteria, concomitant treatment and tDCS stimulation protocols ( da Silva et al., 2019 ; Rachid, 2019 ). Some authors suggest that overall cathodal tDCS may be better than anodal in treating OCD ( Rapinesi et al., 2019 ).

Currently, there are no RCTs to support the efficacy of electroconvulsive therapy* (ECT) in OCD ( Fontenelle et al., 2015 ). Hence, ECT may be recommended only for acute treatment of comorbid conditions such as depression or psychosis*.

To summarize, LF-rTMS delivered over the SMA (with figure-8 coil) and HF-deep-rTMS over the dorsomedial prefrontal cortex/anterior cingulate cortex (with H7 coil) appear promising interventions in treatment-resistant OCD. There is a pressing need for large replication studies and evaluation of long-term effects/maintenance protocols. The evidence for tDCS is highly preliminary and further exploratory studies are encouraged.

Treatment-resistant obsessive-compulsive disorder – deep brain stimulation and ablative neurosurgery

A significant number (10–40%) of patients do not respond to any available therapy and suffer from severe, enduring symptoms and dysfunction ( Fineberg and Gale, 2005 ; Denys, 2006 ; Gupta et al., 2019 ). For this highly refractory patient group, ablative neurosurgery* and deep brain stimulation* (DBS) remain modalities to be considered. These procedures are usually delivered as an adjunct to existing pharmacological treatments, and CBT is frequently also administered, either during the acute treatment phase or follow-up. DBS is considered an experimental treatment, but has an FDA ‘humanitarian device exemption’ for severe refractory OCD ( US Food and Drug Administration, 2009 ).

Stereotactic neurosurgical procedures for intractable OCD have been available for >50 years ( Miguel et al., 2019 ). The procedures include dorsal anterior cingulotomy and anterior capsulotomy and are reserved for the most severe, treatment nonresponsive patients. A systematic review involving 10 studies and 193 participants suggested both procedures were efficacious ( Brown et al., 2016 ). The authors reported a mean Y-BOCS reduction of 37% for cingulotomy and 57% for capsulotomy. The rates of serious or permanent adverse events were 5.2% in the cingulotomy studies and 21.4% in the capsulotomy studies. Another recent review of publications on anterior capsulotomy spanning over five decades ( Pepper et al., 2019 ) reported ‘significant clinical response’ in 73–90% of patients and ‘remission’ in 24–39% of patients with treatment-resistant OCD.

DBS was investigated as a partially reversible alternative to surgical ablation ( Nuttin et al., 1999 ). The original stimulation target was similar to the site of anterior capsulotomy, that is, ventral capsule/ventral striatum (VC/VS). Three reasonably sized studies have provided evidence in favour of the acute efficacy of DBS in the VC/VS. The first involved 24 patients who were followed up to four years and reported a 37% median improvement in baseline Y-BOCS scores ( Luyten et al., 2016 ). ‘ON’ phases of stimulation were compared with ‘OFF’ phases (no stimulation), demonstrating that improvements were unlikely to represent ‘placebo’ effects. The second study investigated 16 patients, initially as open label, reporting a 46% reduction in baseline Y-BOCS at 8 months as well as a significant difference (25%) in Y-BOCS scores when compared with sham stimulation in a subsequent month-long double-blind phase ( Denys et al., 2010 ). A recent 12-month multicentre study of 30 patients given VC/VS DBS ( Menchón et al., 2019 ) reported a mean reduction of baseline Y-BOCS of 42%. Sixty percent of patients were responded (reduction in baseline Y-BOCS > 40%).

The long-term benefits of VC/VS DBS are less certain. An open-label follow up study of 10 patients ( Greenberg et al., 2006 ) reported a reduction in mean Y-BOCS from 34.67 at baseline (severe) to 22.37 (moderate) at 36 months. In addition, significant improvements in global functioning, depression and anxiety persisted.

The anteromedial subthalamic nucleus (amSTN) has been identified as another promising target for DBS in OCD. Sixteen patients were randomized according to a crossover design to either 3 months active or sham treatment, resulting in a significantly greater reduction in mean Y-BOCS in the stimulation versus sham group (endpoint 19 ± 8 versus 28 ± 7) ( Mallet et al., 2008 ). It remains unclear whether VC/VS holds any advantage over amSTN DBS. A recent ‘mechanism of effect’ study of six OCD patients, in which electrodes were implanted in both these sites, found differential improvements in mood (VC/VS) and cognitive flexibility (amSTN), suggesting that DBS exerts therapeutic effects at these targets via different brain networks ( Tyagi et al., 2019 ).

There have been no head-to-head trials comparing ablative neurosurgery with DBS. A recent review ( Pepper et al., 2015 ) retrospectively evaluated 20 studies of varying methodological quality involving 62 patients who underwent DBS of the VC/VS or the nucleus accumbens and 108 patients who underwent anterior capsulotomy. The capsulotomy group showed a significantly higher (51%) mean reduction in Y-BOCS than the DBS group (40%). No difference in surgical complication rates was observed. Adverse events across both modalities included intracranial haemorrhage (2–5%), persisting postoperative side effects (5–7%), cognitive and personality changes (7–13%) and suicide (1–2%). Weight gain (defined by an increase >10%) was significantly higher in the capsulotomy group (29 versus 3%). In other studies ( Mallet et al., 2008 ; Menchón et al., 2019 ), hypomania after electrode implantation is commonly (6%) reported.

In summary, studies of both DBS and ablative neurosurgery have shown these techniques are clinically effective for this highly refractory and extremely chronically disabled patient group. However, there is as yet insufficient evidence to determine which technique to choose at an individual patient level. Further clarification of the differential effects of ablation and stimulation across the different candidate neural targets, as well as better understanding of the interaction between somatic, pharmacological and psychological interventions, have the potential to advance the field towards a personalized approach. Agreement over standardized patient selection and treatment protocols that would allow clinical outcomes data to be collected and compared across treatment centres, represents an achievable milestone towards this goal ( Menchón et al., 2019 ). Meanwhile, technological innovations, for example, MRI-guided focussed ultrasound, laser interstitial thermal therapy ( Miguel et al., 2019 ), offer potential for safer and more cost-effective surgical approaches.

Future directions for research

Problematic usage of the internet.

Problematic use of the internet (PUI) is an umbrella term for a range of repetitive functionally impairing compulsive behaviours including gambling, gaming, sexual behaviour, shopping, video-streaming or social media use. While advances have been made in defining diagnostic criteria and developing rating scales for some forms of PUI (e.g., Gaming Disorder) ( Király et al., 2015 ), a considerable amount of research is needed to understand better the broad range of PUI phenomena and translate the known behavioural phenotypes into valid and reliable diagnostic criteria and assessment tools, to facilitate the systematic investigation of aetiological factors and brain-based mechanisms, as a platform for the development of preventive and therapeutic interventions ( Fineberg et al., 2018c ).

Significant cross-sectional associations between PUI and OCD symptoms have been found ( Carli et al., 2013 ). For example, in a two-site international online survey, ADHD and social anxiety disorder were associated with high PUI scores in young participants, whereas OCD and generalized anxiety disorder were associated with high PUI scores in older participants ( Ioannidis et al., 2018 ).

Novel digital interventions in obsessive-compulsive disorder

Digital technology offers new opportunities for monitoring and interventions. The extensive use of smartphones and the vast amounts of information they contain has positioned them as a proxy for behavioural and social interactions ( WHO, 2016 ). Harnessing smartphone technology along with smart wearables (e.g., smart watches) is expected to be a valuable source of continuous, objective and reliable data for clinical characterization, behavioural monitoring and treatment support ( Marzano et al., 2015 ). This is true for several disorders, but especially true for obsessive-compulsive problems such as PUI, as the digital media that is directly linked to the disorder is the same one that can accurately monitor the behaviour ( Ferreri et al., 2019 ).

Accordingly, using digital technology along with big data analyses may enable the potential to characterize the ‘digital phenotype’ of the disorder ( Ferreri et al., 2019 ) and to identify those individuals most at risk (e.g., by monitoring online internet usage in comparison with changes in diurnal variation, lack of human contact, lack of geographical movement, restricted circles of friends, etc.). A research avenue in this direction is to use (real time) big data analysis, alongside machine learning algorithms, to establish identifiable OCRD-specific illness patterns and use those real-time results to create an immediate feedback loop with the patient, which could then be used therapeutically by providing direct feedback on their behaviour and progress.

Other forms of active online intervention have become increasingly available for OCRD ( Whiteside et al., 2013 ) and may potentially enhance and facilitate treatment adherence ( Andersson et al., 2014 ; Marzano et al., 2015 ). For example, WhatsApp group interventions, in which the patient reports to their clinician, in real time, their difficulties, daily achievement and progress, enable continual communication, real-time reporting, prompt responses and rapid intervention when needed. In addition, the digital intervention may serve as a platform for continuous monitoring of tasks delivered in face-to-face meetings. Another example of existing digital interventions is the proactive use of webcams and smartphone cameras. Using this domain and with patient’s consent, the clinician has the opportunity to monitor patients in their natural environment. As the digital platform bridges the elapsed time between therapeutic sessions, it overcomes geographical distances and enables therapeutic practice in the patient’s natural environment ( WHO, 2016 ), where symptoms are manifested daily. In addition to enriching the clinical picture by direct observation of symptoms, it confers the general assertive outreach benefits of telemedicine, which can be critical for otherwise difficult to treat socially isolated patients who cannot access help otherwise.

In practice, this approach breaks down the traditional terminology of ‘outpatient’, ‘in-patient’ and ‘day hospitalization’, by allowing real time, objective and continuous monitoring ( WHO, 2016 ). The combination of digital monitoring and online communication produces a form of ‘virtual hospitalization’, enabling comprehensive and intensive treatment by offering continued monitoring and delivery of therapy in the patient’s natural environment, where the OCD usually occurs, and not within the artificial setting of the clinic. While such approaches are still under development, digital tools seem to bear great potential and may change the landscape of treatment in OCRDs, providing potentially cost-effective alternatives to hospitalization or outpatient clinics.

Immunological therapies

Inflammation and release of inflammatory cytokines affect brain circuitry involving both reward and threat-sensitivity, producing potentially adaptive and beneficial behavioural responses ( Raison and Miller, 2013 ). There is growing evidence of dysfunctional immunological function in the pathogenesis of a significant subset of OCD patients. Elevated levels of basal ganglia antibodies have been detected in adult OCD patients’ plasma compared with psychiatric control groups ( Nicholson et al., 2012 ). In addition, significantly increased levels of CSF autoantibodies directed against basal ganglia and thalamus were found among drug-naive OCD patients, and were associated with increased levels of CSF glutamate and glycine, indicating underpinning abnormalities in excitatory neurotransmission and correlating with hyperactivity in the ventral cognitive circuit ( Bhattacharyya et al., 2009 ). Translocator protein distribution volume, a marker of the microglial component of neuroinflammation, was found to be significantly elevated in the CSTC circuit of OCD subjects compared with healthy controls, demonstrating inflammation within the neurocircuitry extending beyond the basal ganglia, and affecting the adult population rather than solely childhood OCD ( Attwells et al., 2017 ).

A common genetic link may explain an excess of some autoimmune comorbidities. For example, in the acute paediatric onset subset of children (PANDAS), there is immunological cross-reactivity with epitopes associated with streptococcal infection expressed on the surface of basal ganglia neurons. About 20% of the mothers of children fulfilling criteria for PANDAS ( Chang et al., 2015 ) had at least one autoimmune disease. Multigenerational studies also show that OCD patients’ relatives are more likely to have an autoimmune disease such as Sjögren’s syndrome, coeliac disease, Guillian Barrè, Crohn’s disease, Hashimotos Thyroiditis, type I diabetes mellitus, ulcerative colitis, multiple sclerosis and psoriasis vulgaris ( Mataix-Cols et al., 2018 ). A subset of patients with PANDAS with motor symptoms demonstrated antineural antibodies against dopamine (D1) receptors as well as elevated antibodies against tubulin, lysoganglioside and higher activation of calmodulin-dependent protein kinase II (Cox et al ., 2015).

Immunomodulatory therapy represents a new field of investigation in OCD. While treatment with antimicrobials has delivered inconsistent results ( Burchi and Pallanti, 2018 ), other immunological modulators, such as celecoxib* ( Shalbafan et al., 2015 ) and nonspecific nonsteroidal anti-inflammatory drugs ( Spartz et al., 2017 ), have produced some positive findings, the latter only in a subset of young people. Thus, evidence of the usefulness of this approach in OCD remains insufficient. Nevertheless, researchers and clinicians should consider genetic and immunological profile differences in the search for precise individualized therapy for OCD.

Novel forms of psychotherapy

Although it may seem logical to try to tackle OCD using cognitive therapy, little evidence suggests that it offers any advantage to graded exposure and self-imposed response prevention ( Tyagi et al., 2010 ; Ougrin, 2011). Poorly applied cognitive therapy, such as that expecting patients to re-evaluate actual dangers, may make some patients with OCD worse. This is because the process of looking for evidence to confirm or refute the obsessions can become incorporated into rituals. Cognitive therapy may also turn out to be less cost-efficient, as it requires more training and supervision for the therapist and usually takes more time in therapy. It is therefore probably best used in situations where there is OCD refractory to ERP therapy ( Drummond and Edwards, 2018 ).

Rational emotive therapy, on the other hand, has been shown to have some possible beneficial effects in OCD ( Emmelkamp et al., 1988 ). Australian researchers have developed danger ideation reduction therapy (DIRT), using rational emotive therapy but with instructions not to undergo exposure for patients with contamination fears; good outcomes in case reports and some small controlled trials have been found ( Jones and Menzies, 1998 ; Krochmalik et al., 2001 ; Maqbool et al., 2017 ). The techniques used in DIRT include cognitive restructuring using rational emotive therapy ( Ellis, 1962 ); filmed interviews with people who work in feared situations; corrective information about the real risks of ‘contamination’ as opposed to the deleterious effects of overzealous hand-washing and attentional focussing whereby patients are taught to focus the mind away from the danger-related intrusive thoughts.

In recent years, the so-called Third Wave Therapies have been used in a number of psychiatric conditions ( Pérez Álvarez, 2012 ). The therapy of this type most commonly used in OCD is mindfulness, which teaches an individual to focus on the world around them rather than their internal dialogue. A recent study demonstrated that both cognitive restructuring and also mindfulness led to a small improvement in Y-BOCS score when compared with waiting list controls. However, the strength of efficacy for both treatments appeared to be less than that generally found with ERP ( Rupp et al., 2019 ). Despite promising results for metacognitive therapy in patients with OCD in case series, a full controlled trial has yet to be performed ( Melchior et al., 2019 ).

Many OCD patients describe their compulsions as habitual, that is, fixed ‘stimulus-response ’acts that, through habit learning, occur automatically in response to a specific environmental trigger. Habit reversal therapy (HRT) ( Azrin and Nunn, 1973 ) is a long-established form of therapy that helps patients alter habitual performance through a variety of behavioural methods. HRT is reported to be efficacious for the treatment of Tourette syndrome and Tic Disorders and has more recently been applied with success in OCRDs such as trichotillomania and skin picking behaviours. However, there remains a scarcity of evidence from controlled trials to support the efficacy of HRT in OCRDs in general and OCD in particular (Lee et al ., 2019a). Emerging neurosciences evidence identifying faulty habit learning in OCD (Fineberg et al ., 2018a) suggests further study of HRT in OCD would be worthwhile.

Pharmacogenetics

Pharmacogenetics or pharmacogenomics define genetic variants that influence either drug metabolism, delivery, affinity to receptors or transporters may contribute to the prediction of drug efficacy or toxicity, promoting precision medicine (Hess et al ., 2015). Because approximately one-quarter of OCD patients do not respond to treatment with either SSRIs or CBT alone, or their combination ( Hirschtritt et al., 2017 ), it has been suggested that pharmacogenetics may contribute to better drug-response prediction and side effect tolerance ( Zai et al., 2014 ).

Currently, several pharmacogenetic approaches using hypothesis-free GWAS have been conducted into the association between candidate genes and drug response in OCD patients ( Di Bella et al., 2002 ; Denys et al., 2007 ; Van Nieuwerburgh et al., 2009 ; Miguita et al., 2011 ; Grünblatt et al., 2014 ; Zai et al., 2014 ; Umehara et al., 2015 ; Mas et al., 2016 ; Qin et al., 2016 ; Umehara et al., 2016 ; Taj et al ., 2018; Lisoway et al., 2018 ; Sina et al., 2018 ; Abdolhosseinzadeh et al., 2019a , b ; Alizadeh et al., 2019 ). The candidate genes investigated belong to: (1) pharmacokinetic regulating genes, such as the CYP450 liver enzymes such as CYP2D6 and CYP2C19; (2) serotonergic systems, such as SLC6A4 and its promoter, HTTLPR, HTR2A, HTR2C, HTR1B and TPH2; (3) glutamatergic systems, such as SLC1A1, DLGAP2, DLGAP2, GRIN2B, GRIK2, SLIT, SLITRK5; (4) dopaminergic systems, such as COMT, MAOA, DRD2 and DRD4 and (5) other systems, such as BDNF, NTRK3, MOG, OLIG2 and DISP1.

Currently, no consensus with sufficiently robust results exists in the pharmacogenetics of OCD, due to the fact that many studies used naturalistic approaches, did not employ double blinded designs or crossed over with the tested drug, used a variety of drugs and doses, as well as used various cutoffs and measures determining response. Although there is still a need systematically to assess the pharmacogenetic link between treatment response (to SSRIs, tricyclics, antipsychotics, clomipramine, etc.) and certain genes, some data are already available, though very limited, on the Internet (e.g., https://www.pharmgkb.org ; Whirl-Carrillo et al., 2012 ) summarizing some findings on pharmacogenetics of some drugs and giving some recommendations aligning with those of the FDA, European Medicine Agency, Pharmaceutical and Medical Devices Agency, Japan and Health Canada (Sante Canada).

Until just 40 years ago, OCD was considered rare, of psychological origin and without effective treatment. Now, all have changed; the finding in the 1970s and 1980s that serotonergic medication (clomipramine, followed by SSRIs) was effective ( Montgomery, 1980 ; Zohar et al., 1987 ; Zohar and Insel, 1987 ) opened the door to great interest in OCD ( Zohar, 2012 ). This led to the development of specific forms of psychological intervention (ERP) which replaced the dynamic approach and to a focus on the serotonergic system in the treatment and pathophysiology of OCD. As a result of neuroscience insights including endophenotype-based approaches (reviewed in Fineberg et al., 2018a ), OCD has been removed from the anxiety disorder grouping in the DSM-5 ( American Psychiatric Association, 2013 ) and ICD-11 ( WHO, 2018 ) and now stands at the head of a new family of OCRDs.

The realization that OCRDs as a group are different from other anxiety disorders has led to significant changes in understanding their impact (the prevalence of OCRD in the population is more than 9%) ( Carmi et al., 2019 , in submission) and to refinement of the treatment approach (e.g., focussing on the urge to perform compulsions and the need for higher doses of serotonergic medication).

This position statement highlights the major changes that have been taking place in the last few years in the field of OCD, in terms of conceptualization, diagnosis, assessment, intervention (with focus on early intervention), strategies for optimizing the efficacy of specific pharmacological intervention (SRI) with specific psychological intervention (ERP), the critical role of treatment of children and young adults and the importance of maintenance of well-being.

As new neuroscience insights are revealed, new therapeutic interventions are being explored (e.g., glutamatergic agents, dopaminergic modulators, etc.). This position statement also covers invasive and noninvasive neuromodulation as experimental interventions, including deep TMS (achieving FDA indication for OCD in 2018) ( US Food and Drug Administration, 2018 ).

Looking to the future, other exciting avenues for investigation include the use of digital tools to monitor (and eventually to diagnose OCRDs), better understanding of links between excessive Internet use and OCRDs, advanced genetic methods and new pharmacological domains (e.g., immunological systems). Indeed, it seems that the future was never so bright for OCRD patients. We trust that this position statement has managed to capture, describe, explain and shed light on many of these developments, including those in the front line of understanding and treatment of OCRD in the future.

Acknowledgements

The authors wish to acknowledge the members of the International College of Obsessive-Compulsive Disorders ( www.ICOCS.org ), who have contributed to the development of this article. With particular thanks for critically reviewing the statement and editing the manuscript, to Rajshekhar Bipeta, Julius Burkauskas, Artemisa Dores, Giacomo Grassi, Donatella Marazziti, Pedro Morgado and Humberto Nicolini. We grateful to the European College of Neuropsychopharmacology (ECNP) Obsessive-Compulsive and Related Disorders Research Network (OCRN) for providing monetary support for the open access article processing charges for this article. We are also grateful to the ECNP OCRN, American College of Neuropsychopharmacology and the World Psychiatric Association Scientific Section for Anxiety and Obsessive-Compulsive and Related Disorders, for providing networking support.

This article refers to studies funded by the National Institute for Health Research (NIHR) RFPB (Grant Reference Number PB-PG-0712-28044, NIHR RfPB PB-PG-1216-20005). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

N.A.F. was supported by a COST Action Grant (CA16207; European Network for Problematic Usage of the Internet; European Cooperation in Science and Technology; www.cost.eu .) and a NIHR grant [NIHR RfPB PB-PG-1216-20005; FEasibility and Acceptability of Transcranial Stimulation in Obsessive-Compulsive Symptoms (FEATSOCS)]. S.R.C. was supported by a Wellcome Trust Clinical Fellowship. E.H. was funded by DOD, and OPD-FDA. E.G. was funded by the University of Zurich.

All authors were involved in drafting the manuscript and agreed to its publication. All authors read and approved their sections of the final version of the manuscript.

Conflicts of interest

N.A.F. declares that in the past 3 years, she had held research or networking grants from the ECNP, UK NIHR, EU H2020, MRC, University of Hertfordshire. In the past 3 years, she had either accepted travel or hospitality expenses or both from the BAP, ECNP, RCPsych, CINP, International Forum of Mood and Anxiety Disorders, World Psychiatric Association and Indian Association for Biological Psychiatry. In the past 3 years, she had received payment from Taylor and Francis and Elsevier for editorial duties. In the past 3 years, she had accepted a paid speaking engagement in a webinar sponsored by Abbott. Previously, she had accepted paid speaking engagements in various industry supported symposia and have recruited patients for various industry-sponsored studies in the field of OCD treatment. She leads an NHS treatment service for OCD. She holds Board membership for various registered charities linked to OCD. She gives expert advice on psychopharmacology to the UK MHRA and NICE. S.W. has received royalties from Thieme, Hogrefe, Kohlhammer, Springer, Beltz in the last 5 years. Her work was supported by the Swiss National Science Foundation (SNF), diff. EU FP7s, HSM Hochspezialisierte Medizin of the Kanton Zurich, Switzerland, Bfarm Germany, ZInEP, Hartmann Müller Stiftung, Olga Mayenfisch, Gertrud Thalmann and Vontobel Fonds in the last 5 years. She received no honoraria from pharmaceutical or other industrial companies in the last 36 months. Outside professional activities and interests are declared under the link of the University of Zurich, https://www.uzh.ch/prof/ssl-dir/interessenbindungen/client/web . V.B. has received lecture honoraria from Lundbeck and Otsuka. V.B. is a clinical investigator in a clinical trial funded by Boeringher Ingelheim and has obtained competitive grant funding from a Pfizer Neuroscience Grant, the Nepean Medical Research Foundation, the University of Sydney, Western Sydney University, Western Sydney Local Health District and the Better Foundation. C.I.R. has served as a consultant for Allergan, BlackThorn Therapeutics, Rugen Therapeutics and Epiodyne, receives research grant support from Biohaven Inc. and a stipend from APA Publishing for her role as Deputy Editor at The American Journal of Psychiatry . J.M.M. has received honoraria and travel grants from Exeltis, Janssen, Servier, AbBiotics and Medtronic in the last 36 months. B.M.D. has received lecture honoraria from Lundbeck, Angelini, Janssen, Neuraxpharma, Arcapharma and Livanova. Y.C.J.R. has received grants from the Department of Biotechnology (DBT) and the Indian Council of Medical Research (ICMR) of the Government of India and is currently involved in a study funded by the National Institute of Mental Health (NIMH), USA. Y.C.J.R. is the lead author of the Indian Psychiatric Society (IPS) Clinical Practice Guidelines for Obsessive-Compulsive Disorder and is also the lead author of the Clinical Practice Guidelines for Cognitive Behaviour Therapies in Anxiety Disorders and Obsessive-Compulsive Related Disorders (in press). D.J.S. has received either research grants or consultancy honoraria from Lundbeck and Sun or both. S.P. declares funding from the National Institute of Mental Health, USA; R21 NCTID NCT03669315. J.Z. received grants and research support from Lundbeck, Servier, Brainsway, Pfizer and the DOD, honoraria and consultation fees from Lundbeck, Roche, Lilly, Servier, Pfizer. S.R.C. consults for Promentis and Ieso Digital Health. S.S.A. has received research funding grant from the Wellcome Trust-DBT India alliance and Indian Council of Medical Research. M.V.A. reports being on the Advisory Boards of Allergan, Almatica, Brainsway, Janssen, Lundbeck, Myriad Neuroscience, Otsuka and Purdue Pharma (Canada); M.V.A. is on the Speaker’s Bureau for Allergan, Lundbeck, Otsuka, Pfizer, Purdue Pharma (Canada) and Takeda; and has received research support from Janssen, Purdue Pharma (Canada), the Canadian Foundation for Innovation and Hamilton Academic Health Sciences Organization (HAHSO). D.A.M.D.G. has received grant or research support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development subcontract with Duke Clinical Research Center Pediatric Trials Network, Biohaven Pharmaceuticals, Neurocrine Biosciences, Nuvelution Pharma, Peace of Mind Foundation, Syneos Health and Teva Pharmaceutical Industries. He has served as a consultant to the Arlington Youth Counseling Center. He has served on the editorial board of Annals of Clinical Psychiatry . He has received honoraria from the Massachusetts Psychiatry Academy and the American Academy of Child and Adolescent Psychiatry. He has held stock options/ownership in Assurex Health and Revolutionary Road. R.G.G.S. receives a productivity grant from the National Council for Scientific and Technological Development, Brazilian Federal Government (CNPq). L.D. declares that she holds small investments in pharmaceutical and biotechnology firms, including AstraZeneca, Bioventic, Hikma Pharmaceutical, International Biotech Trust, Reneuron, Syncona and Yourgene. U.A. has received lecture honoraria from Lundbeck, Angelini, Janssen, Neuraxpharma and Innova Pharma. There are no conflicts of interest for the remaining authors.

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Obsessive-Compulsive Related Disorders: Towards an Advancement of the Knowledge of These Internalizing Disorders

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• Experience of Obsessive Compulsive Disorder The obsessive-compulsive disorder is a rather common psychiatric illness, which has a tendency to occupy a significant time in the mind of the patient and provides a feeling that he/she is not in control of […]
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Research priorities set by people with OCD and OCD researchers: Do the commonalities outweigh the differences?

Franziska kühne.

1 Department of Psychology, Clinical Psychology and Psychotherapy, University of Potsdam, Potsdam Germany

Anna Levke Brütt

2 Department for Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg Germany

Mara Jasmin Otterbeck

Florian weck, associated data.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

In contrast to research agendas being predominantly set by scientists or funders, a collaborative approach was used to spot future goals for research on obsessive‐compulsive disorder.

First, we conducted a meta‐review and then compared the results of two online surveys with OCD professionals and patients on research priorities. The literature search was performed in three comprehensive databases, and ten research goals were extracted. Sixty‐four patients and eight professionals responded to open questions on their five most important goals. Then, they ranked the ten aims extracted from the literature on a 6‐point Likert scale.

For patients and professionals, research on treatment gains that persist long‐term was most important. Concerning the top five goals listed in an open format, for patients, development and maintenance of the disease was as important as psychotherapy and its efficacy. In contrast, for professionals, the efficacy and the optimization of psychotherapy were the far most important research goals.

Conclusions

We proposed one possibility to involve patients in OCD research, and the multitude of answers presents a wealth of research ideas.

Practice Implications

Since consistent research involvement may contribute to its clinical impact, researchers are now invited to translate our findings into empirical studies.

1. INTRODUCTION

Patient involvement (PI) may be described as the participation of patients or users based on their individual experience with a disease or with specific treatments. 1 Tritter 2 characterizes the following types of PI: participation in treatment decisions, in service development and the evaluation of services, in education and training, and in research activities. Participation is generally indicated as an active and collaborative process, 3 and involvement into research gives credit to patients’ perspectives, interests and values. 4 For example, it aims at asking meaningful research questions, improving study feasibility, supporting the dissemination of relevant findings into clinical practice or improving health outcomes. 4 , 5 Against this backdrop, PI was acknowledged by the Lancet Psychiatry Commission on Psychological Treatments Research as one means for advancing psychotherapy research. 6

The scope of PI varies considerably, from organizational involvement to writing lay summaries, from single to continuous participation. 4 Considering Farin‐Glattacker and colleagues’ 7 matrix, we aimed at early involvement and at equal collaboration; that is, in our study, research priorities will be identified equally by researchers and patients, and patients will have the final say. This is also in line with results of a former own study, in which some patients encouraged earlier involvement, especially as to defining the research agenda. 4

One of the most prominent associations asking patients to prioritize research goals is the James Lind Alliance, which also published a guidebook to enhance identifying the ten most important research aims from patients, carers and professionals, also to inform funding agencies. 8 Although we had to align to the resources available within our institutions, we still got inspired by their inclusive, transparent and evidence‐based approach.

Former PI studies in our field referred to research priorities in mental health in general 9 or to uncertainties in the treatment of specific subgroups, such as patients diagnosed with Parkinson's disease. 10 Regarding mental health, during the online survey conducted by Haarig and colleagues, 11 patients diagnosed with bipolar disorder were asked for the individually most important therapeutic goals. Coping with the symptoms of the disease was most important to the participants, and clearly inferior were improvement of quality of life, participation in psychotherapy itself and the management of adverse effects of the medication. 11 Another study focused on research questions of patients with depression. 12

To our knowledge, there is no PI study specifically on the psychotherapy for obsessive‐compulsive disorder (OCD) and respective research priorities to date. Analysing former studies, Ennis & Wykes 5 pointed out that studies on difficult‐to‐treat populations such as patients diagnosed with developmental and personality disorders were associated with lower PI. Similar prejudices seem to persist on OCD, for example, that patients were rather difficult to treat, 13 which could also explain the scarcity of PI in this field. OCD is characterized by recurrent and persistent thoughts, urges or images experienced as intrusive and unwanted causing anxiety or distress (obsessions), and consequently, repetitive behaviours or mental acts to reduce discomfort (compulsions). 14 Whereas untreated OCD tends to be a rather chronic disease, 15 , 16 a number of patients are not reached by existing evidence‐based approaches, namely cognitive‐behavioural therapy (CBT) or selective serotonin reuptake inhibitors (SSRI), and therapists do not always implement CBT as intended. 16 , 17 , 18 Although therapy improved during the last decades, relapse rates are still unsatisfactory. 16 Since there is still room for improvement in the psychotherapy for OCD, 19 PI has the potential to contribute to a meaningful research agenda. Further, at least in Germany, PI into psychotherapy research is still in its infancy. Furthermore, current therapy is stretched to its limits as prominent emotions in OCD, such as disgust, tend to habituate more slowly than anxiety, which may impair the efficacy of therapy if not considered sufficiently. 20 As outlined above, OCD differs from other anxiety disorders as it is still considered difficult to treat, due to other susceptibilities to change, through less appropriate care, and thus higher relapse rates and chronic trajectories. With that said, the aim was to spot future goals for research specifically on obsessive‐compulsive disorder (OCD). Therefore, we examined the current literature through a meta‐review and surveyed professionals (Study 1) and patients (Study 2) with regard to psychotherapy and OCD‐related research priorities. Subsequently, we compared patients’ and professionals’ views in order to examine commonalities and differences and, thus, to support patient‐focused research agendas.

To derive research aims from the current literature, three databases (the International Prospective Register of Systematic Reviews (Prospero), the Cochrane Database of Systematic Reviews (CDSR) and the Campbell Collaboration) were searched in June 2017 for reviews on obsessive‐compulsive and related disorders published between 2002 and 2017. From n = 47 records without duplicates screened by title and abstract, n = 34 were excluded due to different reasons (no adult population (n = 15), review uncompleted (n = 12), no OCD (n = 7)); thus, n = 13 reviews were included from that search. Searching the references of the German S3‐Guideline on Obsessive‐Compulsive Disorders 17 resulted in n = 6 additional reviews, so that N = 19 reviews were included in the meta‐study. From these reviews (see Appendix S1 ), the top ten aims for future research on the psychotherapy of OCD were extracted from the discussion sections by one researcher (xx), discussed with another (xx), and then phrased as concise items for the subsequent surveys (Studies 2 and 3).

2.1. Study 1: professionals’ survey

In November 2017, national professionals in the field of OCD research and treatment were contacted via e‐mail and asked for participation in the online survey, or asked for forwarding the invitation to other experts. Interested professionals were redirected to the survey implemented via UP Survey, a protected web‐based survey offered by the University of Potsdam. The first section of the survey comprised the study description and sociodemographic questions. Two open questions to name and rank the five individually most important aims for OCD research in general and research on psychotherapy with OCD patients in particular followed. Then, professionals were presented with the ten research aims extracted from the meta‐review (Study 1) and asked to rate the priority of each on a 6‐point Likert scale from very unimportant (1) to very important (6). Altogether, eight professionals participated (Table ​ (Table1 1 ).

Demographic data ( n if not otherwise specified)

2.2. Study 2: patient survey

To anonymously gather data on OCD patients’ perspectives on psychotherapy research, we again conducted an independent Internet‐based survey. Participants’ health expertise was addressed, and they were invited online (via the German Society for Obsessive‐Compulsive Disorders (DGZ), a self‐help website and our department's website. Interested patients were again forwarded to the survey implemented via UP Survey. Recruitment proceeded from January 2018 to January 2019. Only adult patients who indicated that their OCD diagnosis had been established by a physician or psychologist were included. No monetary compensation was offered.

The survey contained the study description, an electronic informed consent, sociodemographic questions, and questions regarding pre‐experience with psychotherapy. Then, patients were asked with an open question to name and rank the five individually most important aims for psychotherapy research on OCD. Like the experts, they were then presented with the ten research aims extracted from the meta‐review and asked to rate the priority of each on the 6‐point Likert scale. The ethical aspects of study 3 were approved by the University of Potsdam ethics review board (no. 9/2017).

2.3. Data analysis

Due to the different sample sizes between professionals and patients, we mainly used descriptive statistics. According to the means, standard deviations and ranges, the items were ranked in descending order and independently for patients and professionals. In line with Banfield et al 9 and due to skewness, we also dichotomized the scale (ie combined important and very important ratings versus all others) and ranked the items again. Due to the data structure and unequal sample sizes, we then examined differences between the central tendencies of patients and professionals via a non‐parametric Mann‐Whitney U ‐test, that is, one analysis over the 10 goals. To determine agreement among participants regarding the 10 goals, we used Krippendorff's α, a flexible reliability measure considering any number of categories, any number of judges and missing data, 21 , 22 that is implemented within an SPSS macro. 23 Krippendorff's α  = 1 presents perfect agreement, whereas α  = 0 defines its absence. 22 All analyses were performed using IBM SPSS Statistics 25 and Microsoft Excel at a 0.05 level of significance.

Open questions regarding the top 5 research priorities were analysed qualitatively using inductive content analysis techniques. 24 First, three researchers (xx, xx, xx) read all answers to familiarize with the data. Preliminary categories were developed separately for patients and professionals and then discussed to foster a common understanding. Following this, the final categories were derived by two independent researchers (xx, xx/xx). Inter‐rater agreement reached κ  = 0.81 (patients’ category system) resp. κ  = 0.92 (professionals’ category system). To generate a hierarchy, the priorities given by the participants in the quantitative part were inverted (ie the individual priority 1 was inverted to 5 to give it the most weight) and summed up within each category. Then, for indications and priorities, their number per category was divided by their total number in order to obtain scores comparable between the two groups. Since for professionals, very similar qualitative answers were given with respect to both research questions (top 5 aims for OCD research in general and for research on psychotherapy with OCD patients in particular), we summarized the two into a joint category system. In the subsequent patient survey, we therefore focused on the psychotherapy question only.

3.1. Goals from the meta‐review

The research goals extracted from the current literature (Table ​ (Table2, 2 , Appendix S1 ) concerned the following overarching topics: comparative effectiveness, mechanisms, moderators, administration, target groups, motivation, dissemination, quality of life and treatment gains that persist long‐term.

Prioritized research goals (from 1 = very unimportant to 6 = very important; patients’ ranges were 1 ‐ 6 for all items)

Abbreviations: CBT, cognitive‐behavioural therapy; PT, psychotherapy. Ranks are prinited in bold.

3.2. Quantitative ranking results

A total of 150 persons followed the link, and of these, N = 63 were included in the final analyses (Table ​ (Table1). 1 ). The others were excluded because they did not give electronic informed consent (n = 22), were younger than 18 years (n = 5), did not proceed until the ranking questions (n = 59), or filled in the questionnaire twice (n = 1).

Patients’ (N = 63) age varied from 18 to 70 years, and their age mean was 38 (SD = 13) years (Table ​ (Table1). 1 ). Most participants (75%) were female, well‐educated and had rather long disease and treatment experiences. Most were treated with CBT (30%) or medication (27%). The professionals (N = 8) were mainly experienced psychologists and licensed psychotherapists practicing research, teaching and patient care.

According to the quantitative rankings of the 10 predefined aims by patients and professionals, the most prominent goal was doing research ensuring treatment gains that persist long‐term (goal 7, Table ​ Table2). 2 ). Both groups also agreed on the least important aim for future research, that is, the effectiveness of group versus individual psychotherapy (goal 5). For OCD patients, the comparative effectiveness of psychotherapy approaches (goal 1) and the dissemination of effective treatments into practice (goal 9) were mutually important. Still, there was less agreement among the two groups on the other research goals. Concerning ranges and percentage‐wise agreement on importance, professionals evaluated the given goals more consistently than the patients did, but this may also be attributable to small sample size. For the ten research goals, differences in the central tendencies between the two groups were non‐significant ( P >.05); that is, patients and professionals evaluated every goal as comparably important. Neither was there agreement among the patients (Krippendorff's α  = .097) nor among the professionals (Krippendorff's α  = .124) regarding prioritization of the 10 predefined goals.

3.3. Qualitatively found priorities

Considering the open answers, that is, to name the five individually most important aims for psychotherapy in OCD, six (patients) and five (professionals) relatively comparable categories emerged (Table 3 ). Most often, patients indicated aspects that fell within the category ‘Disease development and maintenance’. Example statements were ‘What is the cause for OCD, and how should psychotherapy that is related to the causes look like? [P22]’ or ‘What's going on in the body? [P37]’. Second most often, patients were asking for research on ‘Psychotherapy and its efficacy’, for example, the indication for different therapeutic approaches especially for exposure, its alternatives, for group and in‐patient therapy or treatments whose gains persist long‐term. At a distance, questions regarding the ‘Course of the disease’ were mentioned, and concerned for example the probabilities for complete recovery, of relapses or of exacerbation. Fourth, although not in the focus of the survey, patients asked for more effective ‘Psychopharmacotherapy’ with less side effects. Concerning the category ‘Improving the quality of care’, patients mentioned aspects such as ‘Why is there still a deficit in OCD treatment (too few experts, too long waiting times)? [P116]’. The last category (‘Others’) was mainly comprised of therapy‐related questions and of questions concerning self‐help, but also of research‐related criticism (eg ‘Why is so little research conducted on OCD? [P20]’ or ‘Why is there so little progress in OCD research? [P15]’; Appendix S2 ).

Categories inductively derived from open questions on the top 5 research goals

The professionals’ qualitative answers far most often fell within the category ‘Psychotherapy and its efficacy’. Example items were ‘What is effective psychotherapy for OCD? [E4]’, ‘How can we help patients (therapy resistant) who do not benefit from standard therapy (ERP)? [E2]’, or referred to motivation, nonresponse, differential indication, dismantling or the active ingredients of therapy. The second category concerned ‘Optimizing existing therapies’ but also referred to developing new approaches (such as extinction learning, reduction of subjective units of distress during exposure, virtual reality or the combination with medical therapies). Third were questions on ‘Disease development and maintenance’ (eg biographical and neurobiological factors), and fourth ‘Improving the quality of care’ (eg dissemination of effective therapies into health care, improving therapists’ willingness to treat OCD, expanding professional networks, reducing waiting lists for therapy). The last category comprised questions on OCD subtypes and on related disorders like trichotillomania (Appendix S3 ).

4. DISCUSSION AND CONCLUSION

4.1. discussion.

In order to examine priorities for future OCD research, we conducted a meta‐review and two subsequent online surveys with OCD patients and professionals. As one of the first OCD studies, we involved patients and combined quantitative and qualitative data. Whereas the development and maintenance of OCD and more therapy‐related questions were central to patients, professionals prioritized future research on the efficacy and optimization of psychotherapy. Both patients and professionals indicated treatment gains that persist long‐term as the most important research goal. In contrast, most current studies on psychotherapy and medication in OCD make use of short‐term durations of approximately 12 weeks 25 or of on average 15‐month follow‐ups. 15 Since OCD is often, at least without treatment, proceeding chronically, 18 naturalistic research is on the one hand clearly necessary, but on the other complex and expensive. As Hansen and colleagues 26 pointed out, so far only three trials examining exposure and response prevention (ERP) in OCD used follow‐ups of 24 months or longer, and all of them had severe problems with dropout. According to their analysis of ten trials, only 41% of OCD patients showed clinically significant improvement of OCD symptoms following ERP at post‐treatment and at on average 25 months of follow‐up. They conclude that ‘the question of what predicts long‐term outcome is basically not investigated’. 26 (p91)

Furthermore, patients probably consider different indicators of treatment success than professionals. In one of our own studies, 4 patients indicated increased autonomy (eg larger scopes of action), the applicability of an intervention (eg in everyday life or in crises), better self‐perception (eg coping with oneself) and empowerment (ie knowing what helps oneself) as important treatment outcomes. Interview studies or focus groups would be appropriate to follow these issues.

Regarding the other research goals, there was low agreement, both within and between patients and professionals. Still, most goals were assessed as highly relevant by both groups underscoring the findings from the meta‐review. There were no significant differences between the means and ranks of the two groups which again indicate the comparable importance to patients and experts. Nevertheless, the patients’ rankings were distributed a bit more which may be attributable to more scepticism or to more problems with evaluating the relevance of every aspect. Subsequent studies using a forced choice approach may yield clearer results. 9

Associated with their roles, in the open format, patients listed goals that were more therapy‐related, and professionals placed more emphasis on advancements in psychotherapy research. Research trainings adapted to patient participants are a feasible method to enable them to overlook the scope of research. 4 As the variety of the 650 individual aspects listed by the patients accessible via the Supplements demonstrates, PI has the potential to direct our attention to clinically relevant topics. Beyond, PI enhances the understandability of study information and materials, the feasibility and acceptability of study designs and the commitment of patients if they know that other patients were previously involved. 5 , 27

Research on specific symptoms of the disease was more relevant to patients diagnosed with Parkinson's (eg balance problems, dyskinesia or cognitive problems) 10 than for the OCD patients involved in our survey. In the future, studies could target the heterogeneous subgroups of OCD (such as contamination, harming, symmetry/ordering, pure obsessions) 20 to clarify differential needs. Furthermore, patients diagnosed with depressive disorders, their relatives and care providers focused more on self‐help issues and the access to adequate care 13 than our participants did. Nevertheless, the efficacy of treatment and its long‐term success were essential to both samples.

In order to aim for these patient‐derived research topics, funding requirements are one means. 5 , 27 When research agendas are set up together with patients, when study objectives are discussed with patients, and when grant applications require a statement on how patients have been and will be involved, researchers are guided to more PI in their studies. During the survey, one patient asked ‘Who is this “research” and when will “it” answer me?’, and called for more and understandable feedback of research results to patients. Thus, we prepared a summary of our results using plain language for publication in the DGZ magazine. Although the current study used indirect involvement, 2 it is targeted at direct participation of patients into the whole cycles of future research projects. 28 According to experiences from other countries with a longer tradition in PI, coordination and collaboration across institutions, identification and evaluation of effective PI strategies for divergent contexts, and eventually, a change in the research culture is strongly recommended. 29

Limitations of the study are firstly attributable to the resources available. The meta‐review was conducted only by one researcher, and priority setting was conducted more economically than proposed for example by the James Lind Alliance. 8 Other limitations refer to the small sample of rather experienced professionals who were mainly psychologists with a research focus. The sample is characterized by German‐speaking participants. Patients’ mean age was 40, and they were rather well‐educated and predominantly female. Although theoretical saturation was achieved, that is, no new categories emerged during categorization, a larger international sample could help extend the results to other health contexts. For that, the questionnaire is available upon request from the corresponding author.

5. CONCLUSION

Since patients are the ‘ultimate recipients’ of psychotherapy research results, their early involvement is especially useful. 28 In this sense, our study points out one way to involve patients into OCD research. According to the results, commonalities between patients and professionals emerged from ranking the most (treatment gains that persist long‐term) and least (effectiveness of group versus individual psychotherapy) important research goals, and also from the open items (psychotherapy and its efficacy, disease development and maintenance). Professionals viewed most research goals as more important, which may be due to their work and interests. Still, evidence‐based practice provides a framework for the combination of patient preferences, clinical expertise and research results, 30 and early research involvement of OCD patients may be especially fruitful.

6. PRACTICE IMPLICATIONS

Patients and professionals prioritized clinically relevant topics such as psychotherapy and its efficacy or disease development and maintenance for OCD research. Future research should take up these topics and should also further involve patients in the research process. Patients are experts with regard to their disease, and they are the people, research is done for. Therefore, research should focus on what ‘patients feel has most relevance to their lives’. 29

CONFLICTS OF INTEREST

Supporting information, acknowledgements.

We would like to thank all participants for their valuable contributions, the German Society for Obsessive‐Compulsive Disorders (DGZ) for their straightforward support, Tatjana Paunov, B.Sc. Psych. (TP) for her assistance with categorization, and Jana Maas, M.Sc. Psych. for her support with manuscript preparation.

Kühne F, Brütt AL, Otterbeck MJ, Weck F. Research priorities set by people with OCD and OCD researchers: Do the commonalities outweigh the differences? . Health Expect .2021; 24 :40–46. 10.1111/hex.13005 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

This research did not receive any specific grant from funding agencies in the public, commercial or not‐for‐profit sectors.

DATA AVAILABILITY STATEMENT

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Fisher, Elyse. "The process that OCD built." Thesis, University of Iowa, 2018. https://ir.uiowa.edu/etd/6101.

Hemmings, S. M. J. "Investigating the molecular aetiology of Obsessive-compulsive disorder (OCD) and clinically-defined subsets of OCD." Thesis, Stellenbosch : Stellenbosch University, 2006. http://hdl.handle.net/10019.1/1256.

Noorian, Zahra. "OCD in adolescents: the prevalence and contribution of cognitive beliefs in OCD and other emotional disorders." Doctoral thesis, Universitat Autònoma de Barcelona, 2014. http://hdl.handle.net/10803/284944.

Kartberg, Emma. "OCD and Empathy Games : Using empathy games to inform the public about ODC." Thesis, Högskolan i Skövde, Institutionen för informationsteknologi, 2019. http://urn.kb.se/resolve?urn=urn:nbn:se:his:diva-17846.

Jackson, Michelle. "Separation-distress as an affective mechanism of OCD." Doctoral thesis, University of Cape Town, 2009. http://hdl.handle.net/11427/8264.

Monzani, Benedetta. "Predisposing and maintaining factors in OCD and hoarding disorder." Thesis, King's College London (University of London), 2018. https://kclpure.kcl.ac.uk/portal/en/theses/predisposing-and-maintaining-factors-in-ocd-and-hoarding-disorder(428674c4-39e2-4980-b192-d69abff4cb6c).html.

Džiaugytė, Emilija. "Arklių OCD (osteochondritis dissecans) kulno sąnario rentgeninių pakitimų analizė." Master's thesis, Lithuanian Academic Libraries Network (LABT), 2014. http://vddb.library.lt/obj/LT-eLABa-0001:E.02~2014~D_20140305_141607-53234.

Mavrothalassitis, Mariaan Janet. "Trauma and the pathogenesis of OCD : a literature review." Thesis, Stellenbosch : Stellenbosch University, 2001. http://hdl.handle.net/10019.1/52593.

Lipton, M. "Phenomenology of intrusive imagery in obsessive compulsive disorder (OCD)." Thesis, University College London (University of London), 2008. http://discovery.ucl.ac.uk/1444223/.

Mcilwham, Harriet. "Factors influencing treatment outcome in young people with OCD : the relationship between parental psychopathology, parent relationship indicators, child inflated responsibility and OCD symptomology." Thesis, University of East Anglia, 2013. https://ueaeprints.uea.ac.uk/48749/.

Norberg, Kristin, and Christina Nyberg. "Personers upplevelser av att leva med tvångssyndrom, OCD : En litteraturstudie." Thesis, Luleå tekniska universitet, Institutionen för hälsovetenskap, 2018. http://urn.kb.se/resolve?urn=urn:nbn:se:ltu:diva-72638.

Bond, M. "Experiences of mindfulness for clients with OCD : an IPA study." Thesis, University of the West of England, Bristol, 2015. http://eprints.uwe.ac.uk/25939/.

von, Strunck Hilmar. "Exploration of the Relationship between OCD and Parenting Style Subtypes." ScholarWorks, 2016. https://scholarworks.waldenu.edu/dissertations/2017.

Stobie, Blake. "Therapist and patient beliefs associated with OCD treatment and treatment outcome." Thesis, King's College London (University of London), 2009. https://kclpure.kcl.ac.uk/portal/en/theses/therapist-and-patient-beliefs-associated-with-ocd-treatment-and-treatment-outcome(e9700445-0e37-49af-bf77-ca85ec1b0f14).html.

Challacombe, Fiona. "OCD in the postnatal period : an investigation of the impact on mothers, parenting & infants." Thesis, King's College London (University of London), 2014. http://kclpure.kcl.ac.uk/portal/en/theses/ocd-in-the-postnatal-period(46b72f29-53b6-444a-9592-15447817b0a2).html.

Wenaas, Christoffer. "Psykotiske og schizotype symptomer i tvangslidelse : Prevalens, diagnosespesifisitet og relasjon til psykoterapi." Thesis, Norges teknisk-naturvitenskapelige universitet, Psykologisk institutt, 2014. http://urn.kb.se/resolve?urn=urn:nbn:no:ntnu:diva-26538.

Dallimore, Sian. "An investigation of perceptions of OCD, caregiver burden, distress and accommodation." Thesis, University of Bath, 2015. https://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.675707.

Budajeva, Snezjana. "OCD as behavioral addiction and the reward process : A systematic review." Thesis, Högskolan i Skövde, Institutionen för biovetenskap, 2021. http://urn.kb.se/resolve?urn=urn:nbn:se:his:diva-20174.

Robson, Stacey. "Maladaptive cognitive processes during exposure in people with OCD (checking subtype)." Thesis, University of Leeds, 2007. http://etheses.whiterose.ac.uk/2048/.

Mulcahy, Melissa Anne. "Understanding Perinatal Obsessive-Compulsive Disorder (OCD): From prevention to clinical practice." Thesis, Curtin University, 2021. http://hdl.handle.net/20.500.11937/85011.

Chilvers, Rebecca. "Different for Dads? : the association between paternal OCD, parenting and child functioning." Thesis, King's College London (University of London), 2013. https://kclpure.kcl.ac.uk/portal/en/theses/different-for-dads-the-association-between-paternal-ocd-parenting-and-child-functioning(b3be0f79-4b6c-4fbc-a16a-5e3acc201d77).html.

Norman, Luke Joseph. "Comparison of brain function and structure between paediatric OCD and ADHD patients." Thesis, King's College London (University of London), 2017. https://kclpure.kcl.ac.uk/portal/en/theses/comparison-of-brain-function-and-structure-between-paediatric-ocd-and-adhd-patients(b5dafadb-0fb4-4dac-8a9a-9eff036beaf7).html.

Watson, Hunna J. "Clinical and research developments in the treatment of paediatric obsessive-compulsive disorder." Thesis, Curtin University, 2007. http://hdl.handle.net/20.500.11937/2374.

Fruehauf, Lindsay Morgan. "Cognitive Control and Context Maintenance in Individuals with Obsessive-Compulsive Disorder (OCD)." BYU ScholarsArchive, 2019. https://scholarsarchive.byu.edu/etd/8476.

Watkins, Laura H. A. "Cognitive dysfunction in Huntington's disease and related disorders." Thesis, University of Cambridge, 1999. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.313852.

Navarro, Trujillo Rodrigo. "Association of inflammation markers in young adult patients with Obsessive-compulsive disorder." Thesis, Uppsala universitet, Institutionen för medicinsk biokemi och mikrobiologi, 2018. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-355094.

Thunes, Susanne Semb. "A Metacognitive Perspective on Mindfulness: An Empirical Investigation." Thesis, Norges teknisk-naturvitenskapelige universitet, Psykologisk institutt, 2013. http://urn.kb.se/resolve?urn=urn:nbn:no:ntnu:diva-24018.

Keyes, Carly Victoria. "How young people make sense of developing and getting help for obsessive compulsive disorder." Thesis, University of Hertfordshire, 2016. http://hdl.handle.net/2299/17190.

Watson, Hunna J. "Clinical and research developments in the treatment of paediatric obsessive-compulsive disorder." Curtin University of Technology, School of Psychology, Division of Health Sciences, 2007. http://espace.library.curtin.edu.au:80/R/?func=dbin-jump-full&object_id=115091.

Boulougouris, Vasileios. "Neuroanatomical & neurochemical modulation of cognitive flexibility : implications for obsessive-compulsive disorder (OCD)." Thesis, University of Cambridge, 2009. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.611496.

Fields, Lindsay D. "Developing a Model to Predict Prevalence of Compulsive Behavior in Individuals with OCD." Scholar Commons, 2018. https://scholarcommons.usf.edu/etd/7286.

Hjärne, Maria, and Emma Valdusson. "Ungdomars föreställningar om tvångstankar och tvångshandlingar – En kvantitativ studie." Thesis, Linnéuniversitetet, Institutionen för socialt arbete, SA, 2012. http://urn.kb.se/resolve?urn=urn:nbn:se:lnu:diva-20645.

Dorfan, Nicole Michelle. "Danger appraisals as prospective predictors of disgust and avoidance." Thesis, University of British Columbia, 2008. http://hdl.handle.net/2429/935.

Dahl, Siri. "Langtidseffekten av intensiv inneliggende behandling av tvangslidelse: En behandlingsstudie." Thesis, Norges teknisk-naturvitenskapelige universitet, Psykologisk institutt, 2013. http://urn.kb.se/resolve?urn=urn:nbn:no:ntnu:diva-25189.

Mayerovitch, Jamie Isaac. "Treatment seeking for obsessive-compulsive disorder, role of OCD symptoms and comorbid psychiatric diagnoses." Thesis, National Library of Canada = Bibliothèque nationale du Canada, 2000. http://www.collectionscanada.ca/obj/s4/f2/dsk1/tape4/PQDD_0034/MQ64406.pdf.

Mayerovitch, Jamie Isaac. "Treatment seeking for obsessive-compulsive disorder : role of ocd symptons and comorbid psychiatric diagnoses." Thesis, McGill University, 2000. http://digitool.Library.McGill.CA:80/R/?func=dbin-jump-full&object_id=30702.

Negreiros, Juliana. "A study of neurocognition in OCD-affected youth, at-risk siblings, and healthy controls." Thesis, University of British Columbia, 2014. http://hdl.handle.net/2429/46994.

Smith, Alexandra C. "Explaining the Phenomenology of Parental Accommodation: Similarities and Differences Across Childhood OCD and Hoarding." Case Western Reserve University School of Graduate Studies / OhioLINK, 2019. http://rave.ohiolink.edu/etdc/view?acc_num=case1546601482680149.

Mathieu, Sharna. "An examination of maternal rearing and the development of inflated responsibility beliefs in paediatric OCD." Thesis, Griffith University, 2020. http://hdl.handle.net/10072/393958.

Bedinger, Jesper, and Mårten Skogman. "Stepped Care - Framtidens vårdform? : En pilotstudie av stegvis behandling av OCD vid Ångestenheten, Karolinska universitetssjukhuset, Solna." Thesis, Stockholm University, Department of Psychology, 2009. http://urn.kb.se/resolve?urn=urn:nbn:se:su:diva-26168.

Den vård som har starkast evidens vid behandling av tvångssyndrom, Obsessive Compulsive Disorder (OCD), är kognitiv beteendeterapi (KBT), innehållande exponering och responsprevention. Idag är tillgången till denna vård begränsad främst på grund av för få behandlare. Tidigare forskning pekar på att personer med OCD kan bli hjälpta av mindre terapeutintensiva behandlingar. Att leverera vård stegvis med ökande behandlingsintensitet; Stepped Care, kan vara ett sätt att öka tillgängligheten av KBT. Denna pilotstudie har undersökt Stepped Care för OCD i form av tre steg, på Ångestenheten, Karolinska Universitetssjukhuset. Det primära syftet har varit att bidra till kunskapsinsamlingen kring Stepped Care vid OCD. Sammanlagt 19 vuxna patienter ingår i pilotstudien. 8 blev förbättrade efter självhjälp, 5 efter gruppbehandling, 2 efter individualterapi samt 4 bortfall. Av dessa behöll 7 av självhjälps-, 3 av grupp- och ingen av individualpatienterna sina framsteg vid en uppföljning 12 veckor efter avslutad behandling. Totalt tog behandlingen 244 terapeuttimmar i anspråk, vilket är mer än en halvering mot traditionell individualbehandling. Resultaten tyder på att Stepped Care är ett intressant alternativ för att effektivisera och öka tillgängligheten av vård för OCD-patienter.

Walters, Sasha. "Doctorate in Clinical Psychology : main research portfolio." Thesis, University of Bath, 2015. https://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.675709.

Merling, Lori Francesca. "Exploring the ‘Little Engine’ Effect: The Role of Self-Efficacy in Approaching Contamination." Thesis, NSUWorks, 2018. https://nsuworks.nova.edu/cps_stuetd/116.

Keeling, Charlotte. "What is the role of magical thinking in OCD? : is magical thinking a function of perceived threat?" Thesis, University of Southampton, 2006. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.442810.

O, Jiaqing. "The incongruence model of OCD symptomatology : the relevance of superstitiousness and stress reactions from an evolutionary perspective." Phd thesis, Canberra, ACT : The Australian National University, 2015. http://hdl.handle.net/1885/151157.

Domènech, Salgado Laura 1989. "A Comprehensive multiomics approach towards understanding obsessive-compulsive disorder." Doctoral thesis, Universitat Pompeu Fabra, 2018. http://hdl.handle.net/10803/665800.

Farrell, Lara J., and n/a. "Obsessive-Compulsive Disorder Across the Developmental Trajectory: Clinical Correlates and Cognitive Processing of Threat." Griffith University. School of Applied Psychology, 2004. http://www4.gu.edu.au:8080/adt-root/public/adt-QGU20040513.132648.

Farrell, Lara J. "Obsessive-Compulsive Disorder Across the Developmental Trajectory: Clinical Correlates and Cognitive Processing of Threat." Thesis, Griffith University, 2004. http://hdl.handle.net/10072/366531.

Kelly, Jeremy MacLaren. "Exploring Retrospective Biases In Obsessive Compulsive Disorder: An Experience-Sampling Study." OpenSIUC, 2017. https://opensiuc.lib.siu.edu/theses/2212.

Duba, Sauerheber Jill, and James Robert Bitter. "Anxiety and Obsessive Compulsive Disorders." Digital Commons @ East Tennessee State University, 2014. https://dc.etsu.edu/etsu-works/5222.

McKenzie, Matthew L. "Investigating the role of Emotion Regulation in paediatric Obsessive-Compulsive Disorder (OCD): associations with symptoms and treatment response." Thesis, Griffith University, 2019. http://hdl.handle.net/10072/389848.

Ocd Thesis Statement

Name: Abdelrahman Mohamed Topic : OCD Title: Obsessive-Compulsive Disorder Thesis: Obsessive-Compulsive Disorder is an anxiety disorder. Anxiety disorders are common types of mental health conditions,and according to the National Institute of Mental Health, at least 18% of adults in America have some type of anxiety disorder.(NIMH, 2009). I. Introduction A. Defining OCD B. Thesis II. Causes A. Coexisting anxiety disorders (Eating disorders) B. Anxiety disorder (Depression) C. Hypochondriasis (The fear of having a serious disease) III. Treatments A. Pharmacotherapy (Medication) B. Behavior therapy and Psychotherapy IV) Ways to Make Treatment More Effective A. Self-help or support group B. …show more content…

They are unwanted and upsetting, causing severe anxiety or distress. For example: aggression (fears of harming others), contamination (fears of being dirty),and exactness. Separating OCD obsessions from normal obsessions are the frequencies, intensities, and annoyances in doing such habits.Consequently,Compulsions are behaviors that individuals with obsessions display in order to relieve themselves of their anxiety.The compulsive behavior is directly related to the excessive thought. For example, someone who counts their money every hour may have an obsessive fear of losing it. Obsessive-Compulsive Disorder, known as OCD, is very known today in the 21st century. OCD,today, has an estimate range of sufferers from 1% to more than 5% of the total population. Its symptoms are commonly found within a significant percentage of all ages. To get rid of these obsessive thoughts,one often carries out the bahviors,providing only a temporary relief. Not exercising the obsessive habits can cause great anxiety. Mild to severe is what a person’s level of OCD is,but if the level is severe and left untreated, it can destroy a person's capacity to function at work, at school or even at …show more content…

Cognitive behavioral therapy (CBT) is the most effective type of psychotherapy for this disorder,where the patient is exposed many times to a situation that triggers the obsessive thoughts, and learns gradually to tolerate the anxiety and resist the urge to perform the compulsion. Medication and CBT together are considered to be better than either treatment alone at reducing symptoms. The patient is strongly encouraged to refrain from his or her habits, with support provided by the therapist, and possibly by others whom the patient calls for assistance. For example, a compulsive hand washer may be encouraged to touch an object believed to be contaminated, and then urged to avoid washing for several hours until the anxiety provoked has greatly decreased.This process leads to the start of another process,which is the process of “Habituation”. Habituation causes a person to have less interest in a certain event once that person has witnessed the same event many times. For example,one would eventually stop being surprised and thrilled after his friends make him a surprise party every single day.Just as the example, if the compulsion started being normal, the obsession would become less and less interesting and eventually it’d disappear.Improvement usually takes at least three weeks or longer. “Be a willing spirit.With a

Summary Of Who Holds The Clicker By Lauran Slater

This story by Lauran Slater explains the life of a man called Mario Della Grotta who has OCD what the French would name it as obsessive compulsive disorder. In the essay Who Holds the Clicker by Lauren Slater explains the different types of procedures that were used to treat Mario's OCD such as psychosurgery, implantations, and prescription drugs. Despite the fact that Mario knew the side effects of these procedures, he still insisted in having these treatments to cure his illness. Mario was said to be the first American psychiatric patients to undergo this highly experimental procedure as there have only been 50 implantations for OCD thus far. Unfortunately, the surgery that he went through had an after effect.

Mademoiselle F Essay

PTSD (Post Traumatic Stress Disorder) occurs often in war veterans who are scarred by events they witness in combat. Along with the PTSD that can develop with a soldier comes home, OCD can also develop from PTSD. Situations such as starting at a new school, starting a new job, or ending a relationship can contribute to OCD, but that is not very often. Traumatic situations that involve injury or harm may lead to fear, so that person becomes terrified of being afflicted by that same trouble again. For example, children with traumatic experiences in their childhood may develop OCD, but different children will react differently to trauma.

Character Analysis: The Jilting Of Granny Weatherall

Although she might not seem to be a prime candidate for someone who has Obsessive Compulsive Disorder, she certainly possesses characteristics of this mental disorder. Obsessive Compulsive Disorder is defined as “a pervasive pattern of preoccupation with orderliness, perfectionism, and mental interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood” (American Psychiatric Association 678). Granny Weatherall’s actions in this short story prove that she has Obsessive Compulsive Disorder and she shows characteristics such as always having things done her way and getting

Ocd Research Paper Outline

Yes it may take up time in your normal schedule if you are performing all these routines and rituals you may do but at least you are continue to live life the way you want to. C. “People with OCD can 't control these obsessions and compulsions. Most of the time, the rituals end up controlling them.” “Being afraid of social embarrassment may prompt people with OCD to comb their hair compulsively in front of a mirror-sometimes they get “caught” in the mirror and can’t move away from it.”

Chew On This Thesis

Every major fast-food company has secrets. The secrets are out thanks to Eric Schlosser's book Chew on This. Chew on This is a non-fiction book written by Eric Schlosser to inform the readers about what really happens in a major fast-food franchise. The book Chew on This uses word choice, statistics, and one-sided arguments to show author's bias.

Ocd Persuasive Essay

(Forward: The Prologue Preamble Perambulate) SERVING NO ESSAYS BEFORE THEIR TIME While demonstrably neurotic to care about wines and worry over colleges, before their time - both of which, during the writing of these initial drafts, are in my far-flung future - I can’t help myself. If I had a nickel for every time someone told me I had OCD, I’d have $39.25!   However, the dispassionate diagnosis of Obsessive Compulsive Disorder is not so singularly simple, for example, while some excitable clinicians propose I exhibit multiple symptoms of CDO, which is almost exactly like OCD, but in alphabetical order; other more melodramatic diagnosticians advocate for a verdict of Compulsive Disorder Extreme, which is indistinguishable from OCD & CDO, but sequential - just as it should be!

Explain Two Alternative Frameworks For Understanding Mental Distress

• Anxiety disorders: People with anxiety disorders respond to certain objects or situations with fear and dread, as well as with physical signs of anxiety or panic, such as a rapid heartbeat and sweating. An anxiety disorder is diagnosed if the person's response is not appropriate for the situation, if the person cannot control the response, or if the anxiety interferes with normal functioning. Anxiety disorders include generalized anxiety disorder, panic disorder, social anxiety disorder, and specific phobias. • Mood disorders: These disorders, also called affective disorders, involve persistent feelings of sadness or periods of feeling overly happy, or fluctuations from extreme happiness to extreme sadness. The most common mood disorders

Lady Macbeth Ocd Case Study

There are various clinician-administered measures for the assessment of OCD. Clinical interviews and various self-report measures are typically used as well as behavioral avoidance tests or observational tasks in which individuals are exposed to feared stimuli while rating their distress level. It is also important to review the etiological considerations when assessing and diagnosing OCD. Being that OCD involves both genetic and environmental factors. Heredity plays a major role in the etiology of OCD, therefore it would be beneficial to examine if any of Lady Macbeth’s family members have OCD or related disorders.

Ricky Williams Research Paper

Some people may talk to or seeing someone everyday and they might not even know that the people have social anxiety. Anxiety is the most common mental illness in the U.S.A, its affects 40 million adults in the united states of the age of 18 and older or 18% of the population. Social Anxiety disorders develop from a complex set of risk factors, including genetics and etc. Many people may know the Heisman Trophy-winning running back Ricky Williams (NFL player) but some may not know that he have Social Anxiety.

Anxiety Research Paper Outline

In the past, people with mental disorders have been misunderstood and poorly treated. During, times in ancient Greece, many societies connected mental disorders to punishments from the gods or being possessed by demons. But, people still tried to find a more scientific explanation. No matter the cause, if not properly cared for, anxiety can lead to serious problems and disorders. II.

As Good As It Gets Udall

Udall in response to his diagnosis of OCD is an antidepressant medication, such as an SSRI, to control for biological factors responsible for OCD, such as high activity in the limbic system that is responsible for his impulses and fears. In addition, he will undergo exposure/response prevention treatment as a form of behavioral therapy. He will be exposed to his fear of contamination by having to wash his hands without using a new bar of soap. He will be instructed to walk on cracked floors in different settings, and enter his home without switching the lights and locks back and forth. In addition, he will undergo cognitive-behavioral therapy to address the classical and operant conditioning causing OCD, as well as thought-action fusion.

Jeffrey Dahmer Research Papers

Long with just the name, OCD is so much more than just a disorder, it affects they way people live, talk, and act ("Facts About Obsessive Compulsive Disorder"). Many people mistake OCD for regular human behavior such as being clean or wanting thongs orderly. It is so much more, deeper, and stronger than that, do controlling those behaviors would have the effect of, " Obsessions are persistent, uncontrollable. Thoughts, impulses, or images that are intrusive, unwanted and disturbing" ("Facts About Obsessive Compulsive Disorder"). Such things in OCD include counting, obsessions, and rituals.

Obsessive-Compulsive Disorder (OCD)

Evidenced based treatment for Obsessive-Compulsive Disorder (OCD) includes both pharmacological and psychological treatments. Often, treatment is most effective

Argumentative Essay On Mental Health

Mental health is a level of psychological well-being, or an absence of mental illness. It is the "psychological state of someone who is functioning at a satisfactory level of emotional and behavioural adjustment”. From the perspective of positive psychology or holism, mental health may include an individual 's ability to enjoy life, and create a balance between life activities and efforts to achieve psychological resilience. According to the World Health Organization (WHO), mental health includes "subjective well-being, perceived self-efficacy, autonomy, competence, inter-generational dependence, and self-actualization of one 's intellectual and emotional potential, among others”

Definition Essay: The Nature Of Anxiety

The experience of anxiety is common and universal. It is not an emotion restricted to the economically deprived nor to the politically oppressed. Anxiety is an inescapable part of the human condition, for life on all its levels, from the international and governmental to the domestic and personal, is marked with uncertainty, perplexity, and stress. Many may deny their personal anxiety, or at least the intensity of it (even to themselves) for a variety of reasons, such as, the desire to avoid embarrassment, the sense of pride, the fear of rejection, the threat and unease of vulnerability, etc; notwithstanding, nearly everyone experiences anxiety to some degree. Its occurrence is disturbing and debilitating.

More about Ocd Thesis Statement

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Obsessive-Compulsive Disorder (OCD) Research Annotated Bibliography Thesis

Pages: 8 (3645 words)  ·  Style: MLA  ·  Bibliography Sources: 8  ·  File: .docx  ·  Level: College Senior  ·  Topic: Psychology

TOPIC: Thesis on Obsessive-Compulsive Disorder (OCD) Research Annotated Bibliography Assignment

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