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Hoarding Disorder (HD) is a prominent and disabling neuropsychiatric condition defined by the inability to discard objects resulting in impairing levels of clutter. The prevalence rate is 2-6 % and increases with age. The aging Veteran population is a high risk group for impairment associated with HD. Medical and psychiatric comorbidities as well as associated rates of disability and poor quality of life are very common in both HD and the related disorder of OCD. We examined rates of HD and OCD diagnoses at the VA San Diego Healthcare System. Data were obtained from medical records for all Veterans with these diagnoses over 8-years and included information on medical and psychiatric care, homelessness services, and Care Assessment Needs (CAN) scores. Rates of diagnosis for both HD and OCD were well below epidemiological estimates. Veterans with HD were older, had higher rates of medical hospital admissions with longer stays; had more cardiac, neurological, and acquired medical conditions; had more psychiatric comorbidities; had more interactions with the suicide prevent team and homelessness services; and had higher CAN scores than Veterans with OCD. The low rate of diagnosis and high services utilization of Veterans with HD demonstrates an area of unmet need., Competing Interests: Declaration of competing interest The authors declare there is no conflict of interests., (Published by Elsevier B.V.)

Objective: To determine how neuropsychiatric comorbidity, modulatory indication, demographics, and other characteristics affect inpatient deep brain stimulation (DBS) outcomes., Methods: This is a retrospective study of 45 months' worth of data from the National Inpatient Sample. Patients were aged ≥ 18 years old and underwent DBS for Parkinson Disease (PD), essential tremor (ET), general dystonia and related disorders, other movement disorder (non-PD/ET), or obsessive-compulsive disorder (OCD) at a US hospital. Primary endpoints were prolonged length of stay (PLOS), high-end hospital charges (HEHCs), unfavorable disposition, and inpatient complications. Logistic models were constructed with odds ratios under 95% confidence intervals. A p-value of 0.05 determined significance., Results: Of 214,098 records, there were 27,956 eligible patients. Average age was 63.9 ± 11.2 years, 17,769 (63.6%) were male, and 10,182 (36.4%) patients were female. Most of the cohort was White (51.1%), Medicare payer (64.3%), and treated at a large-bed size (80.7%), private non-profit (76.9%), and metro-teaching (94.0%) hospital. Neuropsychiatric comorbidity prevalence ranged from 29.9% to 47.7% depending on indication. Compared with PD, odds of complications and unfavorable disposition were significantly higher with other movement disorders and dystonia, whereas OCD conferred greater risk for HEHCs (p < 0.05). Patients with ET had favorable outcomes. Neuropsychiatric comorbidity, Black race, and Charlson Comorbidity Index > 0 were significantly associated with unfavorable outcomes (p < 0.05)., Conclusion: The risk of adverse inpatient outcomes for DBS in the United States is independently correlated with non-PD/ET disorders, neuropsychiatric comorbidity, and non-White race, reflecting the heterogeneity and infancy of widespread DBS for these patients., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: Obsessive-compulsive disorder (OCD) can be a chronic and disabling illness with a lifetime prevalence of 2%, twice that of schizophrenia. Although effective treatments exist, OCD often remains underdetected and undertreated., Methods: The authors performed a scoping review of the literature (of articles in PubMed and PsycINFO published from January 1, 2000, to February 1, 2020) to define gaps in OCD diagnosis and treatment among U.S. adults. Interventions at the patient, clinician, and health care system levels used to address these gaps are described, and promising approaches from around the world are highlighted., Results: Of 102 potential studies identified in the search, 27 (including five non-U.S. studies) were included. The studies revealed that lack of clinician and patient knowledge about OCD and misdiagnosis contributes to its underdetection. Suboptimal prescribing of selective serotonin reuptake inhibitor medications and limited use of exposure and response prevention, as a first-line psychotherapy, contribute to OCD undertreatment. Digital health technologies show promise in increasing OCD detection and delivery of evidence-based care and in ensuring continuity of care (including during the COVID-19 pandemic)., Conclusions: Given the significant rates of disability, morbidity, and mortality associated with OCD, addressing gaps in OCD care will reduce the U.S. burden of mental illness. Further research is needed to determine how the use of digital health technologies can increase the detection and management of OCD.

Little is known about the diagnosis and treatment of obsessive-compulsive disorder (OCD) in the Veterans Health Administration (VHA). This study examined diagnostic rates of OCD in a national sample of veterans as well as clinical comorbidities and mental health service use following an OCD diagnosis. This study used administrative data extracted from VHA medical records to identify patients with an OCD diagnosis between 2010 and 2011 (N = 20,364). Descriptive analyses examined demographic, clinical, and system-level variables associated with OCD diagnosis as well as mental health service use in a subset of patients newly diagnosed with OCD (n = 5,229). The OCD diagnosis rate in VHA medical records was 0.31% of VHA patients seen in 2010-2011. Examination of new-onset OCD diagnoses in 2010-2011 revealed that OCD was most likely to be diagnosed by physicians (48.6%) and behavioral health providers (31.9%), predominantly in mental health settings (87.5%). In the year following OCD diagnosis, veterans had an average of 3.9 individual psychotherapy and 3.5 psychiatric medication visits. These findings suggest that OCD is likely underrecognized and inadequately treated in the VHA and highlight the need for improved diagnostic and treatment services for veterans with OCD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Objective: This study sought to assess the cost-effectiveness of 7 treatment strategies for treatment-refractory obsessive-compulsive disorder (OCD) in adults., Methods: A model was developed to evaluate treatment alternatives for adults (18-64 years old) that consisted of 2 parts: a decision analytic model and a Markov model. The decision analytic model stratified 7 outpatient treatment strategies, and the Markov model accumulated benefits and costs across the life expectancy of a simulated cohort of individuals. The model was parameterized with probabilistic and deterministic parameters from the literature and an outcomes database to perform a Monte Carlo simulation of a hypothetical cohort of 100,000 adults with OCD to estimate net health benefits (NHBs), costs, and incremental cost-effectiveness ratio (ICER) for each treatment strategy. OCD was considered treatment refractory in adults with an OCD diagnosis who failed first-line therapies. Encounters took place from 2012 to 2015, and the analyses were performed from November 2016 to February 2017., Results: Partial hospitalization with step-down to intensive outpatient treatment was the most cost-effective of the 7 strategies, with an estimated ICER of $7,983 and mean (SD) NHB of 10.96 (0.53) quality-adjusted life-years (QALYs) remaining. This result was 2.2 QALYs greater than that of the trial-based antidepressant and cognitive-behavioral therapy (ADM + CBT) strategy. Three additional ADM + CBT strategies were estimated not to be statistically significantly different from each other. These 4 ADM + CBT strategies outperformed both pharmacotherapy-only strategies., Conclusions: Treatment strategies that include higher-intensity CBT, with effectiveness outcomes that approached efficacy estimates, were superior to real-world CBT strategies. However, given the limited availability of high-quality CBT, especially through use of commercial insurance networks, specialized treatment programs offer greater effectiveness than real-world therapies in achieving wellness for this severe patient population., (© Copyright 2018 Physicians Postgraduate Press, Inc.)

Background: The course of body-focused repetitive behaviors (BFRBs) (eg, trichotillomania, skin picking, and nail biting) has received scant research attention. We sought to understand the longitudinal course of BFRBs over an 8-year period and whether the co-occurrence of a BFRB with obsessive-compulsive disorder (OCD) affects the course of OCD., Methods: Three hundred ninety-five participants with OCD completed annual interviews using the Longitudinal Interval Follow-up Evaluation to estimate BFRB and OCD symptom severity during each week of follow-up., Results: Of the 395 participants, 83 (21%) had a co-occurring BFRB. In almost one-half of the participants, BFRB onset occurred before OCD. Participants with OCD and BFRB spent the majority of the rating period experiencing full BFRB symptoms. Having a BFRB was associated with spending less time in remission from OCD., Conclusions: Although BFRBs have long been known to be common in individuals with OCD, these data demonstrate that most individuals who have a co-occurring BFRB with OCD do not experience BFRB remission and that having a BFRB predicts a worse course for OCD.

Objective: To compare outcomes after 6-month maintenance treatment of adults diagnosed with obsessive-compulsive disorder (OCD) based on DSM-IV criteria who responded to acute treatment with serotonin reuptake inhibitors (SRIs) augmented by exposure and response prevention (EX/RP) or risperidone., Method: A randomized trial was conducted at 2 academic sites from January 2007 through December 2012. In the acute phase, 100 patients on therapeutic SRI dose with at least moderate OCD severity were randomized to 8 weeks of EX/RP, risperidone, or pill placebo. Responders entered the 6-month maintenance phase, continuing the augmentation strategy they received acutely (n = 30 EX/RP, n = 8 risperidone). Independent evaluations were conducted every month. The main outcome was the Yale-Brown Obsessive Compulsive Scale (Y-BOCS)., Results: Intent-to-treat analyses indicated that, after 6-month maintenance treatment, EX/RP yielded OCD outcomes that were superior to risperidone (Y-BOCS = 10.95 vs 18.70; t40 = 2.76, P = .009); more patients randomized to EX/RP met response criteria (Y-BOCS decrease ≥ 25%: 70% vs 20%; P < .001) and achieved minimal symptoms (Y-BOCS ≤ 12: 50% vs 5%; P < .001). During maintenance, OCD severity decreased slightly in both conditions (Y-BOCS decrease = 2.2 points, P = .020). Lower Y-BOCS at entry to maintenance was associated with more improvement in both conditions (r38 = 0.57, P < .001)., Conclusions: OCD patients taking SRIs who responded to acute EX/RP or risperidone maintained their gains over 6-month maintenance. Because EX/RP patients improved more during acute treatment than risperidone-treated patients, and both maintained their gains during maintenance, EX/RP yielded superior outcomes 6 months later. The findings that 50% of patients randomized to EX/RP had minimal symptoms at 6-month maintenance, a rate double that of prior studies, suggests that EX/RP maintenance helps maximize long-term outcome., Trial Registration: ClinicalTrials.gov identifier: NCT00389493., (© Copyright 2015 Physicians Postgraduate Press, Inc.)

The United States Food and Drug Administration's recent approval of the commercial use of Deep Brain Stimulation (DBS) as a treatment for Obsessive Compulsive Disorder (OCD) will be discussed within the context of the existing USA regulatory framework. The purpose will be to illustrate the current lack of regulation and oversight of the DBS market, which has resulted in the violation of basic ethical norms. The discussion will focus on: 1) the lack of available evidence on procedural safety and efficacy, 2) the numerous conflicts of interest held by research investigators, and 3) the ambiguity of both aforementioned categories due to an inherent lack of transparency in the research. It is argued that in order to address these issues, ethical analyses of DBS for psychiatric disorders must include the role of the industry forces that have become the primary impetus for this research. As such, DBS for OCD serves as an important case example in studies of neurotechnology and innovative surgery., (© 2011 Blackwell Publishing Ltd.)

This paper reviews published randomized trials in North America to determine whether minority groups are underrepresented in clinical trials of OCD. A search of the literature produced 40 randomized trials of both adults and children with OCD, conducted in the U.S. and Canada from 1989 to 2009 (N = 3777). The groups included in this review were Caucasians/European Americans, Black/African-Americans, Hispanic/Latino-Americans, Asian-Americans, Others, and Unknown. Of these, 22 of 40 trials reported ethnic/racial information or data was available by request. We focused on the 21 trials from 1995 to 2008 providing ethnic/racial information, and among those (N = 2221), 91.5% of participants were Caucasian, 1.3% were African-American, 1.0% were Hispanic, 1.6% were Asian, 1.5% were Other, and 3.1% were Unknown. We conclude that minorities are underrepresented in North American OCD trials. Therefore, it is not known if empirically validated treatments are effective for these groups. Recommendations for improving recruitment of minorities for future studies are discussed.

Background: Anxiety disorders represent the single largest mental health problem in the United States [Greenberg et al., 1999. J Clin Psychiatry 60:427-435; Rice and Miller, 1998. Br J Psychiatry 173:4-9]. However most individuals with anxiety disorders never seek treatment [Henderson et al., 2002. Can J Psychiatry 47:819-824; Mojtabai et al., 2002. Arch Gen Psychiatry 59:77-84; Roness et al., 2005. Acta Psychiatr Scand 111:51-58]. Deficits in the ability to recognize anxiety disorders and beliefs about them, (i.e., "mental health literacy") may contribute to low levels of help seeking., Methods: Survey data assessing mental health literacy for multiple anxiety disorders and for depression were collected from 284 undergraduate students enrolled in psychology courses at a public university in the United States. Specifically, respondents were presented with vignettes portraying individuals experiencing various forms of mental illness and were asked to label the disorder, its cause and whether or not they would recommend treatment., Results: Findings showed that social phobia and obsessive compulsive disorder (OCD) were associated with recognition rates that were generally high and similar to depression (approximately 80%). In contrast, less than half of the respondents labeled panic disorder or generalized anxiety disorder (GAD) correctly. Symptoms of OCD were attributed to mental illness by approximately 50% of respondents, but such attributions were rare for the other anxiety disorders studied (<12%). Finally, data on help-seeking recommendations suggested that such recommendations are far from universal and varied between different anxiety disorders and according to perceptions of the causes of symptoms., Conclusions: Given that the current sample was well-educated young adults, mental health literacy of the general public may be even lower.

Deep brain stimulation (DBS) is an established treatment option for some movement disorders, in particular Parkinson's disease. Only recently, a number of promising studies with small samples of patients have been published in which impressive therapeutic outcomes achieved by DBS in otherwise treatment-resistant obsessive-compulsive disorder, major depression, and Tourette's syndrome were reported. It seems probable that the investigational approach to treat mental disorders by DBS will increase substantially. Neurosurgical interventions in psychiatric patients raise ethical considerations not only based on the disreputable experiences of the era of psychosurgery. Therefore, it is necessary to implement transparent and well-defined regulations for the protection of the patients as well as appropriate support for therapeutic research. The current article aims to provide a synopsis of the DBS approach in mental disorders and the hitherto existing criteria for research. It suggests some additional requirements for ethically justifiable therapeutic research employing DBS in psychiatric patients.

The development of evidence-based treatments for anxiety disorders is a major achievement of clinical psychology, and cognitive behavior therapy is the best-established and most widely used method. The first form of this therapy, behavior therapy, was a combination of Pavlovian and Behavioristic ideas and methods and was particularly successful in reducing fears. The infusion of cognitive ideas in the late 1970s generated the wider and more flexible cognitive behavior therapy that independent agencies in the United States and United Kingdom now recommend as the treatment of choice for most of the anxiety disorders. Remaining theoretical problems and clinical limitations need to be tackled.

The statistical estimates of the prevalence of Obsessive Compulsive Disorder (OCD) in the general population have increased dramatically in recent years. "Blasphemous" obsessions and religious compulsions dominate the clinical picture of many sufferers of OCD. Freud proposed that religion might be a contributing factor for many patients with mental illness. He hedged, however, that observation--something that many of his followers have not done. Others have noted the pathoplasticity of strict religious upbringing and images of God as vindictive or otherwise harsh. Only recently--since the 1970s--has much clinical attention been focused on this disorder by the other disciplines within the mental health community. The church, however, is ahead of the curve in diagnosis and treatment of scrupulosity. It has long been a concern for pastoral counselors--particularly pre-Vatican II Roman Catholic priests. Pathological religion influences OCD and pastoral counseling, the author proposes, can contributes to recovery.

Pathological doubt, a prominent feature of obsessive-compulsive disorder (OCD), may be related to difficulty tolerating ambiguous or uncertain situations. This is thought to be particularly true of those patients with checking compulsions. Intolerance of uncertainty (IU) has been studied extensively within the domains of worry and generalized anxiety; however, it has received relatively little empirical attention in OCD patients. We administered the Intolerance of Uncertainty Scale [Personality and Individual Differences 17 (1994) 791] to 55 clinic patients with OCD, 43 of whom had checking compulsions, and 14 nonanxious controls. OC checkers showed greater IU than did OC noncheckers and NACs. The latter two groups did not differ from each other. Furthermore, both repeating and checking rituals were associated with IU. Pathological doubt may be understood not only in terms of knowledge-based constructs, but also patients' emotional reaction to feelings of uncertainty. We discuss the implications for increasing tolerance via cognitive-behavioral therapy.

The paraphilias have been mostly ignored by psychiatry, even though psychiatrists are ideally suited to treat and diagnose these disorders by virtue of their medical and psychological training. The sexual deviations require an understanding of both biological and psychological causation and skills in psychological and pharmacological treatments. More recently the Supreme Court of the United States in Kansas v Hendricks (1997) upheld the constitutionality of the civil commitment of sexually deviant individuals for psychiatric treatment. As the various states adopt statutes based on Hendricks, psychiatry will be forced to take an active interest in the diagnosis and the management of the paraphilias. This paper outlines briefly where the field is in the understanding of the natural history, diagnosis, and treatment of the paraphilias.

Recent developments in the psychosocial treatments for anxiety disorders suggest that we have reached an early plateau. Evidence now exists on the effectiveness of psychosocial treatment approaches for every anxiety disorder when compared with no treatment or credible psychosocial placebos. In many cases these procedures have limited clinical effectiveness and much remains to be learned about the disseminability and clinical utility of these approaches in the context of emerging national health care plans. We are just beginning the first generation of multisite studies examining the potentially synergistic effects of proven psychosocial treatments and proven drug treatments. These studies that have substantial significance for national health care are reviewed and some preliminary results are reported.

The history of Howard Hughes illustrates an unusual variant or end state of obsessive-compulsive neurosis in which a germ phobia coincides with the deliberate avoidance of cleaning and neglect of personal hygiene. We have reported on three patients who share similar symptomatology. In these cases, the coincidence of personal filthiness and a germ phobia appear paradoxical.