Clinical case report: considerable improvement of severe and difficult-to-treat obsessive-compulsive disorder with comorbid depression under treatment with esketamine and concomitant psychotherapy.

A 28-year-old man was admitted to our psychiatric ward with severe obsessive-compulsive disorder (OCD) and comorbid depression. At intake, obsessive-compulsive symptoms were present most time of the day and were related to an intense fear of causing interpersonal misunderstandings. Various treatment attempts, including cognitive-behavioural therapy (CBT) with exposure and response prevention (ERP), selective serotonin reuptake inhibitors, clomipramine, and add-on antipsychotics were either ineffective and/or were not tolerated, and the patient's condition worsened progressively. Following an in-depth multidisciplinary team discussion and a shared decision-making process, an off-label treatment trial with esketamine and concomitant psychotherapy was started. The patient received 10 esketamine + psychotherapy sessions over a period of about 2 months, followed by two maintenance sessions in about 3-week intervals. After this, he was discharged into regular outpatient care where he continued to receive maintenance esketamine treatment every 4-6 weeks and, independent of this, individual CBT. Following the establishment of esketamine with concurrent psychotherapy, the patient exhibited a remarkable clinical improvement. Obsessive-compulsive symptoms showed a clear and sustained response (Y-BOCS before treatment >35, Y-BOCS at week 8 = 23, Y-BOCS at week 26 = 14). Paralleling this, depressive symptoms also decreased (MADRS before treatment = 47, MADRS at week 9 = 12, MADRS at week 26 = 3). At a naturalistic follow-up at week 66, obsessive-compulsive symptoms were still mild (Y-BOCS = 13), and depression was still in remission (MADRS < 6). This clinical case suggests that (es)ketamine plus concomitant psychotherapy may hold promise as a therapeutic strategy for difficult-to-treat OCD and depression and its full clinical potential should be evaluated in more comprehensive future studies.

[Effect of the degree of instability during therapy on the treatment outcome of in-patient psychotherapy of obsessive-compulsive disorder]. / Beeinflussung des Behandlungsergebnisses einer stationären Psychotherapie von Zwangsstörungen durch den Ausprägungsgrad der Instabilität im Therapieverlauf.

BACKGROUND: The present study evaluates a central hypothesis of synergetic psychotherapy research according to which a marked instability in the psychotherapeutic process is associated with high response rates. METHODS: 14 patients with obsessive-compulsive disorder (OCD) completed an eight-week in-patient course of multimodal behavior therapy with exposure exercises. The instability during the course of the therapy was recorded by daily selfassessment by the patient using the Synergetic Navigation System (SNS), an Internet-based real-time monitoring procedure. RESULTS: There was a negative correlation between the degree of the instability and the percentage reduction in the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) (r = -0.395; P = 0.199), the "Global Severity Index" (GSI) of the symptom check-list (SCL-90-R) (r = -0.718; P = 0.013), the scale value for obsessive-compulsiveness in the SCL-90-R (r = -0.782; P = 0.004) and the remaining sub-scales of this data-gathering instrument. CONCLUSIONS: An unstable progress of the psychotherapy causes a smaller reduction in symptoms than a stable one. The contradiction relative to the study hypothesis is possibly based on the special features of OCD, with a high level of patient insecurity when anticipating new, non-obsessive-compulsive ways of thought and behavior. The relationships between instability and reduction in symptoms appear to be diagnosis-specific.

[Cognitive behavioral therapy for social phobia]. / Verhaltenstherapie bei Sozialer Angstörung.

This article discusses diagnostic features of social phobia, social skills and (anxious) avoidant personality disorder, and gives an overview on principles of cognitive behaviour therapy strategies used in social anxiety patients. Motivation to change and the therapeutic relationship are important issues to be worked on at the beginning and throughout therapy. Functional analysis focuses on interactional and systemic features. Three specific programmes dealing with anxiety management, social skills training and relaxation techniques are presented (Gruppentraining sozialer Kompetenzen, Hinsch und Pfingsten (2007); Soziale Phobien, ein kognitiv-verhaltenstherapeutisches Behandlungsmanual, Stangier et al. (2003) und Soziales Kompetenztraining, Gruppentherapie bei sozialen Angsten und Defiziten, Alsleben und Hand (2006)).

[123I]-beta-CIT SPECT imaging shows reduced thalamus-hypothalamus serotonin transporter availability in 24 drug-free obsessive-compulsive checkers.

Numerous findings indicate alterations in brain serotonin systems in obsessive-compulsive disorder (OCD). We investigated the in vivo availability of thalamus-hypothalamus serotonin transporters (SERT) in patients with DSM-IV OCD who displayed prominent behavioral checking compulsions (OC-checkers). Four hours after injection of [(123)I]-2beta-carbomethoxy-3beta-(4-iodophenyl)tropane ([(123)I]-beta-CIT), single photon emission computed tomography (SPECT) scans were performed in 24 medication-free non-depressed OC-checkers and 24 age- and gender-matched healthy controls. For quantification of brain serotonin transporter availability, a ratio of specific to non-displaceable [(123)I]-beta-CIT brain binding was used (V''(3)=(thalamus and hypothalamus-cerebellum)/cerebellum). Drug-free non-depressed OC-checkers showed an 18% reduced brain serotonin transporter availability in the thalamus and hypothalamus, as compared with healthy control subjects (1.38+/-0.19 vs 1.69+/-0.21; p<0.001). There was a strong negative correlation between severity of OC symptomatology (Y-BOCS scores) and SERT availability (r=-0.80; p<0.001). Moreover, we found a significant positive correlation between illness duration and serotonin transporter availability (r=0.43; p<0.05). This first report of significantly reduced [(123)I]-beta-CIT binding in the thalamus-hypothalamus region in OC-checkers suggests reduced brain serotonin transporter availability, which is more pronounced with increased severity of OC symptomatology and short duration of illness. The results provide direct evidence for an involvement of the serotonergic system in the pathophysiology of OCD.

Magnetic resonance imaging in patients with obsessive-compulsive disorder with good versus poor insight.

The DSM-IV provides two subtypes of obsessive-compulsive disorder (OCD), labelled as OCD with insight and OCD with poor insight. For the latter, patients generally fail to recognize that the obsessions or compulsions are excessive or unreasonable. Several studies have shown significant brain abnormalities in OCD patients. However, at present, it remains unclear whether a specific pattern of structural brain abnormalities is related to poor insight in OCD. In the present study, magnetic resonance imaging (MRI) findings were compared in OCD patients with insight versus those with poor insight. Outpatients with diagnoses of OCD according to DSM-IV (300.30) and ICD-10 (F42) (n = 84; mean age 38+/-13; 35 females, 49 males) were dichotomized into the two subtypes. All subjects underwent an MRI examination. MRI findings were rated as "MRI abnormality" and "normal MRI." In our sample, 48% of the patients had MRI abnormalities. There was a highly significant difference between the two groups according to frequencies of MRI abnormalities, with 83% of the patients with poor insight showing MRI abnormalities compared with only 21% of the patients with insight. The specifier "poor insight" helps to identify a subgroup of OCD with a higher frequency of brain abnormalities of various types. This distinction should be taken into account in future studies concerning the course and therapeutic outcome of OCD.