Treating OCD: what to do when first-line therapies fail

Objective: To provide a clinically-focused review of the biological treatment of treatment-resistant obsessive compulsive disorder (OCD).Conclusions: There is a paucity of research on how to manage OCD patients who fail to respond adequately to first line therapies. High-dose selective serotonin reuptake inhibitors (SSRIs) and clomipramine have good evidence-based data. Combinations of SSRIs have little support in clinical trials, but the combination of SSRIs and clomipramine can be helpful: careful clinical and cardiac monitoring is required. Certain adjunctive antipsychotics have a reasonable evidence base in OCD, but their use also needs to be weighed against the potential side effect burden. In patients with substantial generalised anxiety symptoms, clonazepam is worth considering. Of the other augmenting strategies, memantine and ondansetron appear useful in some cases, and are well tolerated. Topiramate might ameliorate compulsions to some degree, but it is less well tolerated. If all these strategies, along with expert psychological therapy, fail, careful consideration should be given to deep brain stimulation (DBS), which has an emerging evidence base and which can result in dramatic benefits for some individuals. For some patients, gamma radiosurgery might also still have a place

Identity challenges and ‘burden of normality’ after DBS for severe OCD: a narrative case study

Abstract Background Deep Brain Stimulation (DBS) is an emerging and potentially powerful biological treatment for severe Obsessive-Compulsive Disorder (OCD), but the wider impact of the intervention and the sometimes dramatic reduction in symptoms need greater attention in research and practice. The aim of this case study is to explore the subjective experience of preparing for and undergoing DBS as a treatment for severe and treatment-refractory OCD and the experience of the impact of the treatment. Methods This study of subjective experience before and after DBS is based on narrative analysis of two in-depth interviews conducted in November 2014 (1 year after DBS surgery) with a 30-year-old man and his father, utilizing Consolidated Criteria for Reporting Qualitative Studies (COREQ) criteria. Results The parallel stories show how OCD posed severe challenges to identity and social milestones, with profound positive and negative impact on the person and family. Yet symptom remission was accompanied by expanded horizons, but also by uncertainty and intense distress associated with the changed identity. Discussion The concept of ‘burden of normality’ is discussed, in light of a treatment experience with DBS for OCD that gives rise to a new array of life challenges and opportunities, with implications for clinical care. Conclusions The concept of burden of normality has, thus far, not extended to evaluations of people who have had DBS for severe OCD and that of their lived experience and recovery trajectory thereafter. This concept highlights that there is work to be done on expectations of normal living and on the transitioning self-concept, in the post-surgical period

Research Directions for Leveraging and Supporting the Lived Experience of Mental Illness within Psychology

This paper explores the lived experience of mental illness within the field of psychology across higher education and the mental health workforce. There is a high prevalence of mental health issues among psychology students and practitioners, and it is critical not only to provide support for these populations, but also to acknowledge the value of leveraging their lived experience within their education and practice. There has been increased interest in and advocacy for the involvement of those with lived experience of mental illness within mental healthcare service provision to improve patient experiences and outcomes. However, there have been limited acknowledgement and research regarding the role of psychologists with personal lived experiences of mental illness, and how to leverage this experience. Further, there are challenges faced by both psychology students and practising psychologists with lived experience that act as barriers to leveraging their unique skills and experiences. Psychology students with lived experience face stigma, inadequate support, and incongruence between the course material and their personal experiences. Similarly, practising psychologists with lived experience encounter stigma and isolation, indicating the need for a culture change that promotes transparency and understanding. The paper calls for research in five key directions to provide evidence that can be used to support and leverage lived experience in psychology

Classification of eating disorders: comparison of relative prevalence rates using DSM-IV and DSM-5 criteria

DSM-5 contains substantial changes to eating disorder diagnoses. We examined relative prevalence rates of DSM-IV and DSM-5 eating disorder diagnoses using Eating Disorder Examination-Questionnaire diagnostic algorithms in 117 community out-patients. DSM-5 criteria produced a reduction in combined 'other specified feeding or eating disorder' and 'unspecified feeding or eating disorder' diagnoses from 46% to 29%, an increase in anorexia nervosa diagnoses from 35% to 47%, the same number of bulimia nervosa diagnoses and a 5% rate of binge eating disorder diagnoses

Neuropsychological Study of Underweight and 'Weight-Recovered' Anorexia Nervosa Compared with Bulimia Nervosa and Normal Controls

Objective: To compare executive, memory and visuospatial functioning of DSM-IV anorexia nervosa (AN), bulimia nervosa (BN), and normal controls (NC). Method: A comparison of women involving: (i) 16 AN with body mass indices (BMI) 17.5 kg/m2; (ii) 12 AN with BMI[18.5 kg/m2 for at least 3 months; (iii) 13 BN; and (iv) 16 NC participants was performed with groups of similar age and intelligence. Groups were assessed with EDE-12, MADRS, HAMA, Cognitive Drug Research (CDR) battery, and Bechara tasks. Results: Significant impairments in CDR Power of Attention were present in underweight AN and BN participants. CDR Morse Tapping was significantly impaired in all clinical groups. The BN and weight-recovered AN groups were significantly impaired on CDR immediate word recall. The BN group alone was significantly impaired on CDR delayed word recall. Conclusion: Attentional impairment is similar in AN and BN. Impaired motor tasks in AN persist after ‘‘weight-recovery’’ and are similar to impairments in BN. BN may be discriminated from AN on word recall