Practice guideline for the treatment of patients with obsessive-compulsive disorder.

OBJECTIVE: The purpose of the study was to test the relative and combined efficacy of clomipramine and exposure and ritual prevention in the treatment of obsessive-compulsive disorder (OCD) in adults. Serotonin reuptake inhibitors (SRIs) and cognitive behavior therapy by exposure and ritual prevention are both established treatments for OCD, yet their relative and combined efficacy have not been demonstrated conclusively. METHOD: A double-blind, randomized, placebo-controlled trial comparing exposure and ritual prevention, clomipramine, their combination (exposure and ritual prevention plus clomipramine), and pill placebo was conducted at one center expert in pharmacotherapy, another with expertise in exposure and ritual prevention, and a third with expertise in both modalities. Participants were adult outpatients (N=122 entrants) with OCD. Interventions included intensive exposure and ritual prevention for 4 weeks, followed by eight weekly maintenance sessions, and/or clomipramine administered for 12 wee...

Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder.

SummaryIn this report, recommendations for the pharmacological treatment of anxiety and obsessive-compulsive disorders are presented, based on available randomized, placebo-or comparator-controlled

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World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-Traumatic Stress Disorders – First Revision

These British Association for Psychopharmacology guidelines cover the range and aims of treatment for anxiety disorders. They are based explicitly on the available evidence and are presented as recommendations to aid clinical decision making in primary and secondary medical care. They may also serve as a source of information for patients and their carers. The recommendations are presented together with a more detailed review of the available evidence. A consensus meeting involving experts in anxiety disorders reviewed the main subject areas and considered the strength of evidence and its clinical implications. The guidelines were constructed after extensive feedback from participants and interested parties. The strength of supporting evidence for recommendations was rated. The guidelines cover the diagnosis of anxiety disorders and key steps in clinical management, including acute treatment, relapse prevention and approaches for patients who do not respond to first-line treatments.

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Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology

The efficacy of cognitive behavioral treatments (CBT) for anxiety in adults has been supported by multiple meta-analyses. However, most have focused on only 1 diagnosis, thereby disallowing diagnostic comparisons. This study examined the efficacy of CBT across the anxiety disorders. One hundred eight trials of CBT for an anxiety disorder met study criteria. Cognitive therapy and exposure therapy alone, in combination, or combined with relaxation training, were efficacious across the anxiety disorders, with no differential efficacy for any treatment components for any specific diagnoses. However, when comparing across diagnoses, outcomes for generalized anxiety disorder and posttraumatic stress disorder were superior to those for social anxiety disorder, but no other differences emerged. CBT effects were superior to those for no-treatment and expectancy control treatments, although tentative evidence suggested equal effects of CBT when compared with relaxation-only treatments.

A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders.

Background We investigated whether the combination of multi-modal behaviour therapy (BT) with fluvoxamine is superior to BT and placebo in the acute treatment of severely ill in-patients with obsessive-compulsive disorder (OCD). Method In a randomised, double-blind design, 30 patients were treated for nine weeks with BT plus placebo and 30 patients with BT plus fluvoxamine (maximum dosage 300 mg, mean dose 288.1 mg). BT included exposure with response prevention, cognitive restructuring and development of alternative behaviours. Results Both groups showed a highly significant symptom reduction after treatment. There were no significant differences between the groups concerning compulsions. Obsessions were significantly more reduced in the fluvoxamine and BT group than in the placebo and BT group. Furthermore, the group BT plus fluvoxamine showed a significantly higher response rate (87.5 v. 60%) according to a previously defined response criterion. Severely depressed patients with OCD receiving BT plus placebo presented a significantly worse treatment outcome (Y-BOCS scores) than all other groups. Conclusions The results suggest that BT should be combined with fluvoxamine when obsessions dominate the clinical picture and when a secondary depression is present.

Combination of behaviour therapy with fluvoxamine in comparison with behaviour therapy and placebo: Results of a multicentre study.

A 38-year-old patient with severe obsessive-compulsive disorder received fluvoxamine in a clinical study. Psychometric ratings showed marked clinical improvement in the third week of fluvoxamine administration, but after 8 weeks, at a dose of 300 mg per day, he suffered a grand mal seizure after drinking a glass of beer (0.2 liter). He had no history of previous epileptic seizures. Careful neurological evaluation including computer tomography and magnetic resonance imaging of the brain revealed no signs of acute disease. EEG before the fit did not show epileptiform activity; after the fit, spikes and spike-wave complexes appeared, which disappeared upon discontinuation of fluvoxamine. Since his obsessive-compulsive symptoms had responded well to fluvoxamine and worsened after its discontinuation, the drug was cautiously reintroduced. Improvement of the obsessive-compulsive symptoms was observed again, but spikes and spike-wave complexes reappeared at a dose of 50 mg per day. Under anticonvulsant treatment with carbamazepine, fluvoxamine was increased to 100 mg per day. No seizures occurred during a follow-up to two years. Language: en

A seizure, and electroencephalographic signs of a lowered seizure threshold, associated with fluvoxamine treatment of obsessive-compulsive disorder

Bei der Behandlung von Zwangen hat sich sowohl die pharmakologische Therapie mit einem Serotonin-Wiederaufnahmehemmer (Ubersicht s. Greist 1990) als auch die Verhaltenstherapie (Ubersicht s. Reinecker 1991) in einer Vielzahl von Studien als wirksam erwiesen. Bislang liegen jedoch nur wenige Untersuchungen vor, inwieweit die Kombination von Pharmakotherapie mit Psychotherapie der alleinigen Psychotherapie uberlegen ist (Marks et al. 1988, Cottraux et al. 1990, 1993). Vorliegende Multicenter-Studie sollte deshalb untersuchen, ob die Kombination von multimodaler Verhaltenstherapie mit Fluvoxamin, einem Serotonin-Wiederaufnahmehemmer, der alleinigen multimodalen Verhaltenstherapie bei der stationaren Behandlung schwerer Zwangsstorungen uberlegen ist. Des weiteren sollte geklart werden, ob die pharmakologische Behandlung einer sekundaren Depression auch die Zwangssymptomatik signifikant besser beeinflust.

Kombinationstherapie: Pharmakotherapie und Verhaltenstherapie bei Zwangsstörungen

Bei der Pathogenese von Zwangen spielen sowohl neurobiologische Faktoren (Ubersicht s. Hohagen 1992) als auch psychologische Faktoren (Ubersicht bei Reinecker 1991) eine Rolle. In Ubereinstimmung mit dieser Sichtweise stellen sowohl die somatische, pharmakologische Behandlung mit einem Serotonin-Wiederaufnahmehemmer (Ubersicht s. Greist 1990) als auch die Verhaltenstherapie (Ubersicht s. Reinecker 1991) erfolgreiche Behandlungsstrategien bei Zwangsstorungen dar. Bislang haben jedoch nur wenige Studien untersucht, ob eine Kombination von Verhaltenstherapie mit einem Serotonin-Wiederaufnahmehemmer der alleinigen Verhaltenstherapie uberlegen ist. Zwei in jungster Zeit publizierte Studien zur Kombinationsbehandlung von Verhaltenstherapie mit Clomipramin (Marks et al. 1988) und Fluvoxamin (Cottraux 1990, 1993) fanden einen vorubergehenden medikamentosen Zusatzeffekt im Vergleich zur Placebogruppe, der in den Follow-up-Untersuchungen nicht mehr nachzuweisen war.

Ist die Kombination von Verhaltenstherapie mit einem Serotonin-Wiederaufnahmehemmer der alleinigen Verhaltenstherapie bei der Behandlung von Zwangsstörungen überlegen?

G. Winkelmann

Papers

Combination of behaviour therapy with fluvoxamine in comparison with behaviour therapy and placebo: Results of a multicentre study.

A seizure, and electroencephalographic signs of a lowered seizure threshold, associated with fluvoxamine treatment of obsessive-compulsive disorder

Kombinationstherapie: Pharmakotherapie und Verhaltenstherapie bei Zwangsstörungen

Ist die Kombination von Verhaltenstherapie mit einem Serotonin-Wiederaufnahmehemmer der alleinigen Verhaltenstherapie bei der Behandlung von Zwangsstörungen überlegen?