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Given the high prevalence rates of comorbidity of anxiety and depressive disorders, identifying a common neural pathway to both disorders is important not only for better diagnosis and treatment, but also for a more complete conceptualization of each disease. Hippocampal abnormalities have been implicated in anxiety and depression, separately; however, it remains unknown whether these abnormalities are also implicated in their comorbidity. Here we address this question by testing 32 adults with generalized anxiety disorder (15 GAD only and 17 comorbid MDD) and 25 healthy controls (HC) using multimodal MRI (structure, diffusion and functional) and automated hippocampal segmentation. We demonstrate that (i) abnormal microstructure of the CA1 and CA2-3 is associated with GAD/MDD comorbidity and (ii) decreased anterior hippocampal reactivity in response to repetition of the threat cue is associated with GAD (with or without MDD comorbidity). In addition, mediation-structural equation modeling (SEM) reveals that our hippocampal and dimensional symptom data are best explained by a model describing a significant influence of abnormal hippocampal microstructure on both anxiety and depression-mediated through its impact on abnormal hippocampal threat processing. Collectively, our findings show a strong association between changes in hippocampal microstructure and threat processing, which together may present a common neural pathway to comorbidity of anxiety and depression.

Objective Serotonin reuptake inhibitors (SRIs) are a first-line treatment for obsessive-compulsive disorder (OCD). Yet, most patients with OCD who are taking SRIs do not show excellent response. Recent studies show that augmenting SRIs with risperidone benefits a minority of patients. We evaluated the effectiveness of exposure and response prevention (EX/RP) among nonresponders to SRI augmentation with 8 weeks of risperidone or placebo. Method The study was conducted from January 2007 to August 2012. Nonresponders to SRI augmentation with risperidone or pill placebo (N = 32) in a randomized controlled trial for adults meeting DSM-IV-TR criteria for OCD were offered up to 17 twice-weekly EX/RP sessions. Independent evaluators, blind to treatment, evaluated patients at crossover baseline (week 8), midway through crossover treatment (week 12), post-EX/RP treatment (week 16), and follow-up (weeks 20, 24, 28, and 32). The primary outcome was OCD severity, measured with the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). Secondary outcomes were depression, quality of life, insight, and social functioning. Results Between crossover baseline and follow-up, nonresponders to SRI augmentation with risperidone or placebo who received EX/RP showed significant reductions in OCD symptoms and depression, as well as significant increases in insight, quality of life, and social functioning (all P Conclusions Exposure and response prevention is an effective treatment for patients who have failed to respond to SRI augmentation with risperidone or placebo. This study adds to the body of evidence supporting the use of EX/RP with patients who continue to report clinically significant OCD symptoms after multiple pharmacologic trials. Trial registration ClinicalTrials.gov Identifier: NCT00389493.

We previously reported the rapid and robust clinical effects of ketamine versus saline infusions in a proof-of-concept crossover trial in unmedicated adults with obsessive-compulsive disorder (OCD). This study examined the concurrent neurochemical effects of ketamine versus saline infusions using proton magnetic resonance spectroscopy ((1)H MRS) during the clinical proof-of-concept crossover trial. Levels of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) and the excitatory neurochemicals glutamate+glutamine (Glx) were acquired in the medial prefrontal cortex (MPFC), a region implicated in OCD pathology. Seventeen unmedicated OCD adults received two intravenous infusions at least 1 week apart, one of saline and one of ketamine, while lying supine in a 3.0 T GE MR scanner. The order of each infusion pair was randomized. Levels of GABA and Glx were measured in the MPFC before, during, and after each infusion and normalized to water (W). A mixed effects model found that MPFC GABA/W significantly increased over time in the ketamine compared with the saline infusion. In contrast, there were no significant differences in Glx/W between the ketamine and saline infusions. Together with earlier evidence of low cortical GABA in OCD, our findings suggest that models of OCD pathology should consider the role of GABAergic abnormalities in OCD symptomatology.

This narrative review gathers together a range of international experts to critically appraise the existing trial-based evidence relating to the efficacy and tolerability of pharmacotherapy for obsessive compulsive disorder in adults. We discuss the diagnostic evaluation and clinical characteristics followed by treatment options suitable for the clinician working from primary through to specialist psychiatric care. Robust data supports the effectiveness of treatment with selective serotonin reuptake inhibitors (SSRIs) and clomipramine in the short-term and the longer-term treatment and for relapse prevention. Owing to better tolerability, SSRIs are acknowledged as the first-line pharmacological treatment of choice. For those patients for whom first line treatments have been ineffective, evidence supports the use of adjunctive antipsychotic medication, and some evidence supports the use of high-dose SSRIs. Novel compounds are also the subject of active investigation. Neurosurgical treatments, including ablative lesion neurosurgery and deep brain stimulation, are reserved for severely symptomatic individuals who have not experienced sustained response to both pharmacological and cognitive behavior therapies.

This chapter discusses the Research Domain Criteria (RDoC) project, an initiative of the National Institutes of Mental Health (NIMH) of the United States to develop for research purposes new ways of classifying mental disorders based on dimensions of observable behavior and neurobiological measures, and explores how the hallmark symptoms of OCD (obsessions, compulsions, and anxiety) can be mapped onto RDoC domains. Unlike current categorical diagnostic systems (e.g., DSM), RDoC seeks to integrate many levels of information (from genomics to self-report) to validate dimensions defined by neurobiology and behavioral measures that cut across current disorder categories. The chapter explores, for heuristic reasons, how the RDoC matrix might be used to elucidate the neurobehavioral domains of dysfunction that lead to the characteristic symptoms of OCD. It then selectively reviews the OCD literature from the perspective of the RDoC domains, aiming to guide future transdiagnostic studies to examine specific neurobehavioral domains across disorders.

Dimensional definitions of transdiagnostic mental health problems have been suggested as an alternative to categorical diagnoses, having the advantage of capturing heterogeneity within diagnostic categories and similarity across them and bridging more naturally psychological and neural substrates.To examine whether a self-reported compulsivity dimension has a stronger association with goal-directed and related higher-order cognitive deficits compared with a diagnosis of obsessive-compulsive disorder (OCD).In this cross-sectional study, patients with OCD and/or generalized anxiety disorder (GAD) from across the United States completed a telephone-based diagnostic interview by a trained rater, internet-based cognitive testing, and self-reported clinical assessments from October 8, 2015, to October 1, 2017. Follow-up data were collected to test for replicability.Performance was measured on a test of goal-directed planning and cognitive flexibility (Wisconsin Card Sorting Test [WCST]) and a test of abstract reasoning. Clinical variables included DSM-5 diagnosis of OCD and GAD and 3 psychiatric symptom dimensions (general distress, compulsivity, and obsessionality) derived from a factor analysis.Of 285 individuals in the analysis (mean [SD] age, 32 [12] years; age range, 18-77 years; 219 [76.8%] female), 111 had OCD; 82, GAD; and 92, OCD and GAD. A diagnosis of OCD was not associated with goal-directed performance compared with GAD at baseline (β [SE], -0.02 [0.02]; P = .18). In contrast, a compulsivity dimension was negatively associated with goal-directed performance (β [SE], -0.05 [0.02]; P = .003). Results for abstract reasoning task and WCST mirrored this pattern; the compulsivity dimension was associated with abstract reasoning (β [SE], 2.99 [0.63]; P .001) and several indicators of WCST performance (eg, categories completed: β [SE], -0.57 [0.09]; P .001), whereas OCD diagnosis was not (abstract reasoning: β [SE], 0.39 [0.66]; P = .56; categories completed: β [SE], -0.09 [0.10]; P = .38). Other symptom dimensions relevant to OCD, obsessionality, and general distress had no reliable association with goal-directed performance, WCST, or abstract reasoning. Obsessionality had a positive association with requiring more trials to reach the first category on the WCST at baseline (β [SE], 2.92 [1.39]; P = .04), and general distress was associated with impaired goal-directed performance at baseline (β [SE],-0.04 [0.02]; P = .01). However, unlike the key results of this study, neither survived correction for multiple comparisons or was replicated at follow-up testing.Deficits in goal-directed planning in OCD may be more strongly associated with a compulsivity dimension than with OCD diagnosis. This result may have implications for research assessing the association between brain mechanisms and clinical manifestations and for understanding the structure of mental illness.

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.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).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).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.ClinicalTrials.gov identifier: NCT00389493.

Abtract Introduction A single subanesthetic intravenous (IV) dose of ketamine leads to rapid anti-obsessional effects in obsessive-compulsive disorder (OCD) patients with near-constant intrusive obsessions, but these effects usually do not persist. We tested whether a brief course of exposure-based cognitive behavioral therapy (CBT) could extend ketamine’s effects in a two week pilot open trial and if this effect was maintained (without additional treatment) two weeks later. Our rationale was: 1) ketamine is reported to enhance plasticity and extinction learning in rodents, and 2) enhanced extinction learning may facilitate CBT gains, as reported in trials that combined CBT with agents thought to facilitate extinction learning (e.g. D-cycloserine). Mimicking those trials, CBT was abbreviated (i.e. 10 one-hour exposure sessions) but delivered during the putative time interval when ketamine facilitates extinction learning (within 14 days). Methods Ten unmedicated OCD outpatients (aged 18-55) with near-constant intrusive obsessions (>8 hours/day) and at least moderate symptoms (Y-BOCS score ≥16) were recruited. Exclusion criteria included severe depression (HDRS >25), current CBT, and comorbid psychiatric or medical conditions that made participation unsafe. In an open-label design, participants received a single 40-minute IV infusion of ketamine (dose=0.5 mg/kg), followed by 10 one-hour exposure sessions delivered over two weeks. The CBT treatment was planned in a 90-minute session the day before the ketamine infusion. At baseline, during the infusion, at 20, 90, 110, 230 minutes post-infusion, patients rated their obsessional severity using the OCD-VAS. At baseline and weekly for four weeks post-ketamine, an independent evaluator, blind to study design, evaluated patients using the Y-BOCS, which appraises obsessive and compulsive symptoms over the prior week. Treatment response was defined a priori as ≥35% Y-BOCS reduction at week 2. Y-BOCS outcomes were analyzed using mixed-effects regression to model symptoms as a function of time. Results Of the 10 patients who started ketamine, nine completed the infusion. Eight reported a rapid reduction in obsessive severity as measured by the OCD-VAS, which persisted up to 230 minutes post-infusion in seven patients. Eight completed the 10 hours of exposure and the two week follow-up and were included in the Y-BOCS analyses. From baseline to four weeks post-infusion, OCD severity, as measured by the YBOCS, was significantly decreased over time (F=14.36, df=4,28, p Conclusions These results corroborate prior findings that IV ketamine can rapidly reduce obsessions in unmedicated OCD patients. The data suggest that a brief course of CBT may help some individuals maintain the improvement they experienced from ketamine; however, this needs to be formally tested in a randomized controlled trial to determine whether the improvement seen after two weeks of CBT is due to the addition of CBT, or whether the effects of ketamine persist longer in some than previously described.

This article describes the long-term effects of augmenting serotonin reuptake inhibitors (SRIs) with exposure and ritual prevention or stress management training in patients with DSM-IV obsessive-compulsive disorder (OCD).Between November 2000 and November 2006, 111 OCD patients from 2 academic outpatient centers with partial SRI response were randomized to the addition of exposure and ritual prevention or stress management training, delivered twice weekly for 8 weeks (acute phase); 108 began treatment. Responders (38 of 52 in the exposure and ritual prevention condition, 11 of 52 in the stress management training condition) entered a 24-week maintenance phase. The Yale-Brown Obsessive Compulsive Scale (YBOCS) was the primary outcome measure.After 24 weeks, patients randomized to and receiving exposure and ritual prevention versus stress management training had significantly better outcomes (mean YBOCS scores of 14.69 and 21.37, respectively; t = 2.88, P = .005), higher response rates (decrease in YBOCS scores ≥ 25%: 40.7% vs 9.3%, Fisher exact test P.001), and higher rates of excellent response (YBOCS score ≤ 12: 24.1% vs 5.6%, Fisher exact test P = .01). During the maintenance phase, the slope of change in YBOCS scores was not significant in either condition (all P values ≥ .55), with no difference between exposure and ritual prevention and stress management training (P.74). Better outcome was associated with baseline variables: lower YBOCS scores, higher quality of life, fewer comorbid Axis I diagnoses, and male sex.Augmenting SRIs with exposure and ritual prevention versus stress management training leads to better outcome after acute treatment and 24 weeks later. Maintenance outcome, however, was primarily a function of OCD severity at entrance. Greater improvement during the acute phase influences how well patients maintain their gains, regardless of treatment condition.

The core feature of body dysmorphic disorder (BDD) is distressing or impairing preoccupation with nonexistent or slight defects in one's physical appearance. BDD beliefs are characterized by varying degrees of insight, ranging from good (ie, recognition that one's BDD beliefs are not true) through “absent insight/delusional” beliefs (ie, complete conviction that one's BDD beliefs are true). The Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., rev. (DSM-III-R) and The Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) classified BDD's nondelusional form in the somatoform section of the manual and its delusional form in the psychosis section, as a type of delusional disorder, somatic type (although DSM-IV allowed double-coding of delusional BDD as both a psychotic disorder and BDD). However, little or no evidence on this issue was available when these editions were published. In this article, we review the classification of BDD's delusional and nondelusional variants in earlier editions of DSM and the limitations of their approaches. We then review empirical evidence on this topic, which has become available since DSM-IV was developed. Available evidence indicates that across a range of validators, BDD's delusional and nondelusional variants have many more similarities than differences, including response to pharmacotherapy. Based on these data, we propose that BDD's delusional and nondelusional forms be classified as the same disorder and that BDD's diagnostic criteria include an insight specifier that spans a range of insight, including absent insight/delusional BDD beliefs. We hope that this recommendation will improve care for patients with this common and often-severe disorder. This increased understanding of BDD may also have implications for other disorders that have an “absent insight/delusional” form.

There will be several changes to the diagnosis of obsessive–compulsive and related disorders (OCRDs) in DSM-5. Several disorders, including body dysmorphic disorder (BDD), hoarding disorder (HD), trichotillomania (hair-pulling disorder) (TTM), and excoriation (skin-picking) disorder (SPD), will be included alongside obsessive compulsive disorder (OCD) in a distinct diagnostic category of OCRDs. Also, dimensional assessments of psychopathology will be included to supplement traditional categorical diagnoses. The DSM-5 subworkgroup on obsessive–compulsive spectrum disorders developed a set of brief self-rated scales for BDD, HD, TTM, and SPD that are consistent in content and structure, reflect DSM-5 criteria, and can be used by clinicians to help generate a dimensional severity rating for the disorders. In the present paper, we discuss the scales’ creation and examine their psychometric properties in a large non-clinical sample (n=296). The scales each demonstrated a single factor structure, strong internal consistency (α=.80–.89), convergent validity (rs=.74–.92), and significantly higher total scores in individuals who indicated the presence of the respective disorder’s core symptom on a binary diagnostic screener (Cohen’s d=0.57–2.18). The results provide support for further evaluation of these scales in clinical samples and take an important step toward the integration of standardized dimensional measurement into DSM-5.

Objective To explore the acceptability of currently available treatments and services for individuals who self-report hoarding behaviors. Method Between 10/2013 and 8/2014, participants were invited to complete an online survey that provided them descriptions of eleven treatments and services for hoarding behaviors and asked them to evaluate their acceptability using quantitative (0 [not at all acceptable]−10 [completely acceptable]) Likert scale ratings. The a priori definition of acceptability for a given resource was an average Likert scale score of six or greater. Two well-validated self-report measures assessed hoarding symptom severity: the Saving Inventory-Revised and the Clutter Image Rating Scale. Results Two hundred and seventy two participants who self-reported having hoarding behaviors completed the questionnaire. Analyses focused on the 73% of responders ( n =203) who reported clinically significant hoarding behaviors (i.e., Saving Inventory-Revised scores of ≥40). The three most acceptable treatments were individual cognitive behavioral therapy (6.2±3.1 on the Likert scale), professional organizing service (6.1±3.2), and use of a self-help book (6.0±3.0). Conclusion In this sample of individuals with self-reported clinically significant hoarding behaviors ( n =203), only 3 out of 11 treatments and services for hoarding were deemed acceptable using an a priori score. While needing replication, these findings indicate the need to design more acceptable treatments and services to engage clients and maximize treatment outcomes for hoarding disorder.

Background Cell lines provide a powerful model to study cancer and here we describe a new spontaneously immortalised epithelial ovarian cancer cell line (NUOC-1) derived from the ascites collected at a time of primary debulking surgery for a mixed endometrioid / clear cell / High Grade Serous (HGS) histology. Results This spontaneously immortalised cell line was found to maintain morphology and epithelial markers throughout long-term culture. NUOC-1 cells grow as an adherent monolayer with a doubling time of 58 hours. The cells are TP53 wildtype, positive for PTEN, HER2 and HER3 expression but negative for oestrogen, progesterone and androgen receptor expression. NUOC-1 cells are competent in homologous recombination and non-homologous end joining, but base excision repair defective. Karyotype analysis demonstrated a complex tetraploid karyotype. SNP array analysis of parent and derived subpopulations (NUOC-1-A1 and NUOC-1-A2) cells demonstrated heterogeneous cell populations with numerous copy number alterations and a pro-amplification phenotype. The characteristics of this new cell line lends it to be an excellent model for investigation of a number of the identified targets. Materials and Methods The cell line has been characterised for growth, drug sensitivity, expression of common ovarian markers and mutations, clonogenic potential and ability to form xenografts in SCID mice. Copy number changes and clonal evolution were assessed by SNP arrays.

Task control is an executive control mechanism that facilitates goal-directed task selection by suppressing irrelevant automatic "stimulus-driven" behaviors. In the current study, we test the hypothesis that less efficient task control in individuals diagnosed with obsessive-compulsive disorder (OCD) is associated with OCD symptoms, and specifically, with the inability to inhibit unwanted behaviors in OCD. Thirty-five healthy controls, 30 participants with OCD, and 26 participants with generalized anxiety disorder (GAD) completed the object-interference (OI) task to measure task control, the stop-signal task to measure response inhibition, and the arrow-flanker task to evaluate executive abilities not contingent upon task control. OCD patients, but not GAD patients or healthy controls, exhibited impaired performance on the OI task. The deficit in task control, but not in response inhibition, correlated with OCD symptom severity. We suggest that reduced task control may be one of the neurocognitive processes that underlie the inability to inhibit unwanted behaviors in OCD.

Glutamatergic abnormalities in corticostriatal brain circuits are thought to underlie obsessive-compulsive disorder (OCD). Whether these abnormalities exist in adults with OCD is not clear. We used proton magnetic resonance spectroscopy (¹H MRS) to test our hypothesis that unmedicated adults with OCD have reduced glutamate plus glutamine (Glx) levels in the medial prefrontal cortex (MPFC) compared with healthy controls. Levels of γ-aminobutyric acid (GABA) were also explored. Twenty-four unmedicated adults with OCD and 22 matched healthy control subjects underwent ¹H MRS scans at 3.0 T. Resonances of both Glx and GABA were obtained using the standard J-editing technique and assessed as ratios relative to voxel tissue water (W) in the MPFC (the region of interest) and the dorsolateral prefrontal cortex (DLPFC) to explore the regional specificity of any finding. In the MPFC, Glx/W did not differ by diagnostic group (p=0.98) or sex (p=0.57). However, GABA/W was decreased in OCD (2.16±0.46 × 10⁻³) compared with healthy controls (2.43±0.45 × 10⁻³, p=0.045); moreover, age of OCD onset was inversely correlated with MPFC GABA/W (r=-0.50, p=0.015). MPFC GABA/W was higher in females than in males. In the DLPFC, there were no main effects of diagnosis or gender on Glx/W or GABA/W. These data indicate that unmedicated adults with OCD do not have Glx abnormalities in a MPFC voxel that includes the pregenual anterior cingulate cortex. However, they may have decreased MPFC GABA levels. How GABA abnormalities might contribute to corticostriatal dysfunction in OCD deserves further study.

Although the provision of publicly funded health and mental health services to homeless persons has expanded greatly in the past decade, primary prevention of homelessness has received relatively little attention (O’Connell et al., 2005). Evictions are a major proximate cause of homelessness, and numerous studies show that evictions primarily result from tenants’ nonpayment of rent (Stenberg and van Laere, 2009; Van Laere et al., 2009). However, evidence also suggests that, for some housed persons, untreated mental health problems may also increase eviction risk by contributing to behaviors that jeopardize continued tenancy (Crane et al., 2005; Van Laere et al., 2009). Hoarding disorder (HD; Mataix-Cols et al., 2010) is one mental health condition that may precipitate homelessness by placing housed individuals at risk of eviction (Mataix-Cols D, Grayton L, Bonner A, Luscombe C, Taylor PJ, van den Bree M. A putative link between compulsive hoarding and homelessness: A pilot study [submitted for publication]; Tolin, et al., 2008). Also known as “compulsive hoarding syndrome” (Saxena, 2008), HD is defined as persistent difficulty in discarding personal possessions of limited value, which results in clutter that precludes normal use of living spaces and causes clinically significant distress or impairment (Frost and Gross, 1993; Frost and Hartl, 1996; Mataix-Cols et al., 2010). Once considered a subtype of obsessive-compulsive disorder (OCD), HD is now considered a separable syndrome and has been proposed as a new diagnostic category in DSM-V (Mataix-Cols et al., 2010; Phillips et al., 2010). Epidemiological surveys estimate a 2% to 5% prevalence of HD in the general population (Iervolino et al., 2009; Mataix-Cols et al., 2010; Samuels et al., 2008). Recommended treatment strategies for HD include medication (e.g., paroxetine and venlafaxine) and cognitive behavioral therapy (Saxena, 2008, 2011; Steketee and Frost, 2003). HD is associated with high levels of disability and impairment (Frost et al., 2000; Tolin et al., 2008). It causes public health problems when clutter attracts pest infestations or obstructs fire exits in apartment buildings, endangering both personal and neighbors’safety (Frost et al., 2000; Frost et al., 1999; Patronek, 1999). These conditions may lead neighbors and landlords to complain, resulting in legal proceedings and eviction (Frost et al., 1999). Two studies have examined the putative link between HD, eviction, and homelessness. An Internet study of the economic and social burden of HD surveyed 864 individuals with HD and found that 2% reported being evicted and 6% endorsed being threatened with eviction (Tolin et al., 2008). A study in the United Kingdom evaluated the prevalence of HD in 78 randomly selected homeless individuals newly admitted to Salvation Army shelters (Mataix-Cols D, Grayton L, Bonner A, Luscombe C, Taylor PJ, van den Bree M. A putative link between compulsive hoarding and homelessness: A pilot study [submitted for publication]): up to 21% of these individuals endorsed hoarding symptoms and 8% reported that hoarding problems directly contributed to their homeless state. Although these studies suggest that HD may contribute to eviction and homelessness, to our knowledge, no studies have examined the prevalence and correlates of HD in a population seeking housing assistance and at potential risk for eviction. To begin to address this gap, we evaluated the prevalence of HD in a sample of people seeking services from a not-for-profit community organization focused on helping individuals with housing problems including eviction. In further characterizing this sample, we also assessed sociodemographic correlates, threat of imminent eviction, history of eviction, and mental health treatment utilization.

Objective To explore preferences for the treatment of obsessive-compulsive disorder (OCD). We hypothesized that OCD patients will select a combination of medication and psychotherapy as their most preferred choice overall. Method The authors designed a treatment-preference survey using 2 health economics methods, forced-choice and contingent-ranking methods, to elicit preferences for OCD treatment available in mainstream care (serotonin reuptake inhibitors [SRIs], exposure and response prevention [EX/RP], and their combination) and for novel treatments under development at OCD research clinics. This survey was given by telephone to 89 individuals with OCD who called the OCD research clinic at the New York State Psychiatric Institute between July 2008 and January 2009. Diagnosis of OCD was based on a telephone screening evaluation adapted from the Structured Clinical Interview for DSM-IV Axis I Disorders. Results Most participants chose combination treatment (43%) or EX/RP (42%) over SRI medication (16%). Participants ranked investigational psychotherapy as their most-preferred novel treatment (endorsed by 48% of participants) and deep brain stimulation as their least-preferred novel treatment (endorsed by 77% of participants). Qualitative data suggest that prior treatment experience, concerns about medications, and logistical and practical concerns about treatment regimens affect preferences. Conclusions Patients with OCD have identifiable treatment preferences. In this sample of convenience, most preferred either combination treatment or psychotherapy. Future studies should investigate prospectively what modifies these preferences and how these preferences affect treatment outcome.

Cognitive behavioral therapy (CBT) and pharmacotherapy are each efficacious for generalized anxiety disorder (GAD). It is not known, however, whether GAD partial and nonresponders to one treatment modality benefit from the other. This study explored acceptability and efficacy of escitalopram for persons with persistent GAD symptoms after a course of CBT. Twenty-four patients with GAD were treated with CBT and 15 completed at least 12 sessions. Eight completers continued to have clinically significant symptoms and were offered 12 weeks of treatment with escitalopram, and 7 started escitalopram treatment. During CBT, patients evidenced significant improvement in GAD, depression, and quality of life. During escitalopram treatment, patients evidenced trends toward further improvement in GAD, depression, and quality of life. Escitalopram phase completers had initially reported low-to-moderate preferences for medication treatment. Escitalopram may benefit GAD patients with clinically significant symptoms after CBT and merits further study under controlled conditions in a larger sample.

Exposure and ritual prevention (EX/RP) is an efficacious treatment for obsessive-compulsive disorder (OCD), but high dropout rates and variable treatment adherence limit its effectiveness. Motivational interviewing (MI) has shown promise as an adjunct to symptom-focused treatments for improving treatment adherence and outcomes. The authors developed a manual integrating MI with EX/RP, consisting of three information-gathering/motivational enhancement sessions and 15 EX/RP sessions with an optional MI module to be used as needed. Six patients with moderate to severe OCD symptoms (Yale-Brown Obsessive Compulsive Scale [Y-BOCS] score> or =16) underwent treatment. Five showed a decrease in their baseline Y-BOCS scores and an increase in their quality of life, with three achieving an excellent response (i.e. Y-BOCS< or =12 at Session 18). The authors briefly describe the motivational strategies used in the six cases and suggest that integrating MI with standard EX/RP is a promising method to increase and sustain patient engagement with EX/RP. Challenges in combining these treatments and maintaining the integrity of each as well as limitations of the study are discussed.

Marked inconsistencies exist in how treatment response, remission, recovery and relapse are defined in clinical trials for obsessive‐compulsive disorder (OCD). This impairs the comparability of results and communication in the field. Empirical methods (e.g., signal detection analyses) have been used to calculate the optimal amount of symptom improvement to classify an individual as a “responder” or “remitter”, both in adults1, 2, 3, 4 and children5 with OCD. Unfortunately, this has led to different recommendations.

BackgroundTo present the rationale for the new Obsessive–Compulsive and Related Disorders (OCRD) grouping in the Mental and Behavioural Disorders chapter of the Eleventh Revision of the World Health Organization’s International Classification of Diseases and Related Health Problems (ICD-11), including the conceptualization and essential features of disorders in this grouping.MethodsReview of the recommendations of the ICD-11 Working Group on the Classification for OCRD. These sought to maximize clinical utility, global applicability, and scientific validity.ResultsThe rationale for the grouping is based on common clinical features of included disorders including repetitive unwanted thoughts and associated behaviours, and is supported by emerging evidence from imaging, neurochemical, and genetic studies. The proposed grouping includes obsessive–compulsive disorder, body dysmorphic disorder, hypochondriasis, olfactory reference disorder, and hoarding disorder. Body-focused repetitive behaviour disorders, including trichotillomania and excoriation disorder are also included. Tourette disorder, a neurological disorder in ICD-11, and personality disorder with anankastic features, a personality disorder in ICD-11, are recommended for cross-referencing.LimitationsAlternative nosological conceptualizations have been described in the literature and have some merit and empirical basis. Further work is needed to determine whether the proposed ICD-11 OCRD grouping and diagnostic guidelines are mostly likely to achieve the goals of maximizing clinical utility and global applicability.ConclusionIt is anticipated that creation of an OCRD grouping will contribute to accurate identification and appropriate treatment of affected patients as well as research efforts aimed at improving our understanding of the prevalence, assessment, and management of its constituent disorders.

Patients with obsessive-compulsive disorder (OCD) often only partially respond to serotonin reuptake inhibitors (SRIs), the first-line pharmacotherapy for OCD. The American Psychiatric Association's Practice Guidelines suggest augmenting SRIs with either cognitive behavioral therapy consisting of exposure and ritual prevention (EX/RP) or antipsychotic medication (e.g., risperidone) [1]. EX/RP has been shown to be more effective [2]. However, some patients prefer medications over EX/RP [3]. How should treating clinicians respond in these situations? Conventional wisdom would suggest that patients who prefer one treatment may not benefit if assigned to another. Indeed, meta-analyses of randomized controlled trials (RCTs) show that patients are less likely to improve and more likely to drop out when matched to a therapy condition they did not prefer [4]. However, this issue has never been investigated empirically for OCD treatment specifically. Therefore, we examined the effect of patient preference on outcomes in a RCT of SRI augmentation in adult OCD patients. We specifically compared the effectiveness of EX/RP in OCD patients who stated that they prefer risperidone, and vice versa.

Employing the Eliasian concepts of figuration and networked agency, this article explores the responses to labour market uncertainty of freelancers working in the British film industry.Arguing that labour process theory has yet to adequately theorize a contextualized agent, Elias’ framework is proposed as a resolution, with the concept of figuration providing a more agential notion of structure while retaining power inequalities in relationships.Tensions are also identified in the framework, in particular with reference to Elias’ treatment of the individualization process, and these will require further exploration of the two frameworks to assess compatibility.

Addressing the issue of the embeddedness of labour markets, this paper compares the processes of finding employment in the film industry within two local labour markets. Drawing on studies of freelance film crews in London (UK) and Los Angeles (US), the paper concludes that the importance of social networks in job mobility in both contexts is a consequence of common production structures. However, common labour market practice varies in each geographical space as industry processes and structures are mediated by local institutional contexts.

The World Health Organization is in the process of publishing the 11th edition of international Classification of Diseases and Related Health Problems (ICD-11). This article discusses the rationale behind the creation of the new “Obsessive-Compulsive and Related Disorders (OCRD)” section in the ICD-11 chapter on Mental and Behavioral Disorders and compares it with the ICD-10 and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The new section on OCRD was introduced in ICD-11 after a review of the relevant literature that has accumulated since the publication of ICD-10 in 1990. The proposed OCRD section includes obsessive-compulsive disorder (OCD), body dysmorphic disorder, olfactory reference disorder, hypochondriasis, hoarding disorder, trichotillomania, and skin-picking disorder. Tourette syndrome is also cross-referenced in OCRD. These disorders are grouped together on the basis of considerations of diagnostic validity and clinical utility. The ICD-11 OCRD section is somewhat similar to the DSM-5 OCRD section, reflecting efforts to harmonize the two major classificatory systems. Clustering together disorders related to OCD may encourage clinicians in diverse settings worldwide to identify these disorders early and offer timely interventions.

Cognitive-behavioral therapy consisting of exposure and response prevention (EX/RP) is an effective treatment for obsessive-compulsive disorder (OCD). However, only about half of patients achieve minimal or no symptoms by the end of treatment [1,2,3]. Identifying factors that lead to poor outcome and developing interventions to address them is one way to maximize the effects of EX/RP. Patient adherence to EX/RP is a strong predictor of EX/RP outcome [4,5]. Specifically, during EX/RP treatment, therapists teach patients to face feared situations and thoughts (exposures) and to refrain from compulsive behaviors (response prevention). However, no prior study has systematically examined what predicts patient adherence to EX/RP procedures. We examined potential predictors of patient adherence to EX/RP and whether patient adherence mediated the relationship between these predictors and post-treatment OCD severity. The sample consisted of 28 adults (18–70 years old) with OCD who received EX/RP as part of a clinical trial described in detail elsewhere [3]. In brief, patients participated in 8 weeks of EX/RP that included 3 introductory sessions and 15 twice-weekly 90-minute exposure sessions following the guidelines of Kozak and Foa. Patient adherence was measured at each exposure session using the Patient EX/RP Adherence Scale (PEAS) [7]; it assessed the quantity and quality of between-session exposures and the degree of response prevention practiced for homework. OCD symptoms were rated by independent evaluators using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) [8,9]. We examined four factors hypothesized to affect cognitive-behavioral therapy adherence in other patient groups [3,10,11,12]: treatment expectancy using the Expectancy Questionnaire [10], therapeutic alliance using the Working Alliance Inventory – Self Report (WAI-SR) [12], readiness for change using the University of Rhode Island Change Assessment (URICA) [13], and readiness for treatment using the Readiness Ruler [3]. These measures were completed after the 3 introductory sessions and before exposure sessions began. We also examined baseline characteristics that predicted EX/RP outcome in prior OCD studies [14]. These included depressive severity as measured by the 17-item Hamilton Depression Rating Scale [15], insight on the Brown Assessment of Beliefs Scale [16], quality of life as measured by the Quality of Life and Enjoyment Questionnaire [17], Axis I comorbidity using the SCID-I [18], total number of serotonin reuptake inhibitor trials, female gender, employment status, work impairment as measured by an item on the Sheehan Disability Scale [19], and hoarding subtype. Simple linear regression examined potential bivariate predictors of adherence. Significant predictors (p < 0.05) were then considered in subsequent mediation analyses (using Mplus 6.1) that involved simultaneous multiple regressions of adherence on all predictors and of treatment outcome (measured by post-treatment Y-BOCS adjusting for baseline Y-BOCS) on all predictors and adherence. Significant predictors (p < 0.05) of adherence and outcome in these multiple regressions were retained and their indirect effects (mediation effects) on treatment outcome through adherence were estimated and delta method standard errors were used for 95% confidence intervals and testing [20]. Data from all patients having a PEAS score were used (n = 28) and full information maximum likelihood was implemented in Mplus to account for missing post-treatment Y-BOCS scores (3 subjects dropped out from EX/RP treatment after session 9). Estimates were standardized to facilitate interpretation across predictors with different units. The relationship between potential predictors and patient adherence to between-session EX/RP assignments based on simple regressions is presented in table ​table1.1. The 6 significant (p < 0.05) bivariate predictors of patient adherence were entered into mediation analyses and their estimated indirect effects are presented in table ​table1.1. Therapeutic alliance (WAI-SR, beta = 0.53), treatment readiness (Readiness Ruler, beta = 0.38), and hoarding status (beta = −0.26) all had significant (p < 0.05) independent effects on patient adherence. Patient adherence also had a significant direct effect (beta = −0.57, p < 0.01) on outcome and significantly mediated the impact of these other predictors on post-treatment OCD severity (table ​(table1,1, indirect effects). The effects for treatment expectancy and readiness to change (URICA) were not significant in these mediation analyses. Work impairment (Sheehan Disability Scale) was not significantly associated with patient adherence, although it directly predicted post-treatment OCD severity (0.40, p < 0.01). Table 1 Individual predictors of patient adherence (between-session PEAS) and their indirect effects on treatment outcome through patient adherence (n = 28) Our findings have several implications. First, therapeutic alliance (measured by the WAI-SR) predicted treatment outcome through its impact on patient adherence. The WAI-SR assesses patient attitudes about EX/RP strategies and goals presented by the therapist, and patients’ trust in the therapist. This suggests that taking time to understand patients’ symptoms and to carefully explain treatment strategies and goals before conducting exposure can have a strong impact on adherence and outcome. Future studies should examine whether there are specific components of therapeutic alliance that predict patient adherence and how to bolster them to maximize EX/RP outcome. Second, readiness for treatment (measured by the Readiness Ruler) also predicted treatment outcome through patient adherence. The Readiness Ruler measures readiness to engage in specific EX/RP procedures, unlike the URICA, which measures readiness to change in general. If our findings are replicated, the simplicity of the Readiness Ruler makes it an attractive tool for identifying patients at risk for poor EX/RP adherence, which would permit early intervention to enhance readiness for EX/RP before a lengthy course of treatment is initiated. Third, hoarding status predicted poorer treatment outcome through patient adherence. This finding is consistent with prior observations that these patients often have low motivation for treatment and poor insight that makes exposure to discarding very difficult [21,22]. To improve treatment outcome for people who hoard, interventions are needed that enhance patient adherence to EX/RP procedures. Such interventions may need to focus first on addressing motivation for EX/RP treatment and insight into the need to discard. This study has several limitations. First, the sample was relatively small. Replication in larger samples is needed. Second, this sample was generally adherent to EX/RP treatment. Different factors might influence patient adherence in treatment-refractory patients. Finally, patients were relatively free of depression and had good insight, limiting inferences that can be made about the impact of either on patient adherence. If these findings are replicated, future research should develop interventions to enhance therapeutic alliance and treatment readiness, deliver these interventions to those who show poor alliance or treatment readiness, and test whether this leads to improved patient adherence and thereby outcome, as our findings suggest.

The current study examines the temporal relationship between changes in obsessive-compulsive symptoms and changes in depressive symptoms during exposure and response prevention (EX/RP) therapy for obsessive-compulsive disorder (OCD).Participants were 40 adults (53% female) who received EX/RP in a randomized controlled trial comparing serotonin reuptake inhibitor (SRI) augmentation strategies. Participants completed clinician-administered assessments of OCD (Yale-Brown Obsessive Compulsive Scale) and depressive symptoms (Hamilton Depression Rating Scale) every four weeks from baseline to 32-week follow-up.Lagged multilevel mediational analyses indicated that change in OCD symptoms accounted for 65% of subsequent change in depressive symptoms. In contrast, change in depressive symptoms only partially mediated subsequent change in OCD symptoms, accounting for 20% of the variance in outcome.These data indicate that reductions in co-morbid depressive symptoms during EX/RP for OCD are largely driven by reductions in obsessive-compulsive symptoms.

Psychiatric classifications have traditionally recognized a number of conditions as representing impulse control disorders. These have included pathological gambling, intermittent explosive disorder, kleptomania, pyromania, and trichotillomania.

ObjectiveThis study examined treatment of obsessive-compulsive disorder (OCD) in office-based practice.MethodsData from the 2003–2010 National Ambulatory Medical Care Survey, a nationally representative survey of visits to U.S. office-based physicians, were used to examine outpatient visits involving treatment of adults with OCD.ResultsAmong the 316 visits with a diagnosis of OCD, most were to a physician seen previously by the patient (96%), usually a psychiatrist (86%), and most patients (56%) had seen the physician at least six times in the previous year. Most visits included psychotropic medications (84%), most commonly a serotonin reuptake inhibitor (SRI) (69%). Visits less commonly included psychotherapy (39%).ConclusionsOCD was predominantly treated by psychiatrists using SRIs, despite the prevalence of OCD in primary care and SRI prescribing practices in that setting. Given the potential shift in OCD treatment patterns after health care reform, research on OCD treatment in primary care is warranted.