Placebo Effect in Obsessive-Compulsive Disorder (OCD). Placebo Response and Placebo Responders in OCD: The Trend Over Time.

BACKGROUND: Placebo response appears to be increasing in antidepressant, antipsychotic and various internal medicine trials. A similar trend has been reported for OCD during 1989-1999. Placebo response is generally considered as the extent to which placebo treatment is associated with core symptom improvement. In this analysis, we used Joinpoint regression to assess the time trend of both placebo response and placebo responder rates according to the year of publication with no time restriction in OCD drug trials. METHODS: We included drug and/or psychotherapy trials vs. placebo from PubMed, Embase, CINAHL, and PsycINFO retrieved through the search (placebo OR sham) AND (obsessive* OR OCD). We included studies through investigator consensus. We then performed on data of included studies log-linear joinpoint segmented regression models using a p<0.05 cutoff. RESULTS: We included 113 studies from 112 published papers. Placebo mean annual response rates in OCD studies significantly increased from 1991 to 2017 with an annual percent change (APC) of 0.66%, while placebo mean annual responder rates also significantly increased from 2010 to 2017, with an APC of 5.45%. Drug mean annual response rates in OCD studies significantly increased from 1987 to 2012 with an APC of 0.72%, while the corresponding responder rates did not show statistically significant APC changes between 1984 and 2017. CONCLUSION: We observed a tendency for placebo to increase both measures of response in OCD clinical drug trials through the years that tend to approximate the responses shown by drugs. Changes in the type of study (moving from classical head to head comparisons to add-on studies in treatmentresistant populations) and countries involved in experimentation may partially account for some portion of these results. It appears that placebo effects are becoming more elusive and out of control.

Harmony of transitions in Assessing Interpersonal Motivations in Transcripts analysis can discriminate between Adult Attachment Interview secure and disorganized individuals.

AIM: Assessing Interpersonal Motivations in Transcripts (AIMIT) is a validated coding system to assess the activation of interpersonal motivational systems (IMS) in the transcripts of psychotherapy sessions. The Transition Index (TI) is an AIMIT measure that reflects the levels of organisation, synchronisation and harmony amongst two or more IMS when they are rapidly shifting or simultaneously in the clinical dialogue. It is supposed to be a measure of integration and coherence of the patient's state of mind within the psychotherapeutic sessions. It has also been hypothesized that low TI could be a marker for disorganization of attachment of the patient leading to difficulties in the therapeutic relationships and ruptures in the therapeutic alliance. In order to assess this hypothesis we tested its capability to discriminate between Adult Attachment Interview (AAI) organized and disorganized individuals. METHODS: Two groups of 15 transcriptions of AAI matched for age and sex, one classified as free-autonomous and one as disorganized, were analysed by the AIMIT method. RESULTS: Compared to organized individuals, disorganized patients at AAI reported lower TI scores (3.7±0.63 vs 3.0±0.53; F=2.98, p=0.005). Furthermore, TI showed a good discriminant capability (Wilks' Lambda=0.77, p=0.004). DISCUSSION AND CONCLUSION: This result seems to confirm the usefulness and reliability of AIMIT analysis in evaluating the interpersonal difficulties which often characterize the therapeutic relationship with disorganized attachment patients.

Neurobiological Evidence for the Primacy of Mania Hypothesis.

BACKGROUND: Athanasios Koukopoulos proposed the primacy of mania hypothesis (PoM) in a 2006 book chapter and later, in two peer-reviewed papers with Nassir Ghaemi and other collaborators. This hypothesis supports that in bipolar disorder, mania leads to depression, while depression does not lead to mania. OBJECTIVE: To identify evidence in literature that supports or falsifies this hypothesis. METHOD: We searched the medical literature (PubMed, Embase, PsycINFO, and the Cochrane Library) for peer-reviewed papers on the primacy of mania, the default mode function of the brain in normal people and in bipolar disorder patients, and on illusion superiority until 6 June, 2016. Papers resulting from searches were considered for appropriateness to our objective. We adopted the PRISMA method for our review. The search for consistency with PoM was filtered through the neurobiological results of superiority illusion studies. RESULTS: Out of a grand total of 139 records, 59 were included in our analysis. Of these, 36 were of uncertain value as to the primacy of mania hypothesis, 22 favoured it, and 1 was contrary, but the latter pooled patients in their manic and depressive phases, so to invalidate possible conclusions about its consistency with regard to PoM. All considered studies were not focused on PoM or superiority illusion, hence most of their results were, as expected, unrelated to the circuitry involved in superiority illusion. A considerable amount of evidence is consistent with the hypothesis, although indirectly so. LIMITATIONS: Only few studies compared manic with depressive phases, with the majority including patients in euthymia. CONCLUSION: It is possible that humans have a natural tendency for elation/optimism and positive self-consideration, that are more akin to mania; the depressive state could be a consequence of frustrated or unsustainable mania. This would be consistent with PoM.

Bipolar disorder presenting as stalking--a case report.

BACKGROUND: Stalking behaviour may find its roots in an individual's psychological development and culture-related factors that facilitate it. Psychiatric disorders may underlie some stalking cases, but no reports exist of the relationship of actual psychiatric status with the expression of stalking behaviour. CASE REPORT: A 22-year-old adoptive woman perpetrated stalking towards her gynaecologist, who took legal action to protect herself. She was admitted to a general hospital psychiatric department and diagnosed with bipolar disorder-I, manic phase, and personality disorder, not otherwise specified. She was prescribed lithium and valproate combination and followed-up as an outpatient. She underwent cognitive-behavioural therapy incorporating Bowlby's concepts. Stalking behaviour did not reemerge. CONCLUSION: Exacerbations of psychiatric episodes may trigger stalking behaviour. Drug treatment may prevent its clinical expression, but underlying ideation and affect may need long-term psychotherapy focusing on attachment.