Clinical features associated to refractory obsessive–compulsive disorder

Abstract

Some patients with obsessive–compulsive disorder (OCD) exhibit an unsatisfactory reduction in symptom severity despite being treated with all the available therapeutic alternatives. The clinical variables associated with treatment-refractoriness in OCD are inconsistently described in the literature.

Methods

To investigate factors associated with treatment-refractoriness of patients with OCD, we conducted a case-control study, comparing 23 patients with treatment-refractory OCD to 26 patients with treatment-responding OCD.

Results

The factors associated with refractoriness of OCD were higher severity of symptoms since the onset of OCD (p < 0.001), chronic course (p = 0.003), lack of a partner (p = 0.037), unemployment (p = 0.025), low economic status (p = 0.015), presence of obsessive–compulsive symptoms of sexual/religious content (p = 0.043), and higher scores on family accommodation (p < 0.001). Only the three latter variables remained significantly associated with treatment-refractoriness after regression analyses. Limitations: small sample size, the biases and drawbacks inherent to a case-control study, and the inclusion criteria used to define the study groups may have limited the generalisation of the results.

Conclusion

A major strength of this study is the systematic and structured evaluation of a vast array of variables related to the clinical expression of OCD, including epigenetic factors and ratings derived from instruments evaluating family accommodation. The presence of sexual/religious symptoms, low economic status and high modification on family function due to OCD were independently associated with treatment-refractoriness. Future longitudinal studies are warranted to verify if these variables represent predictive factors of treatment non-response.

Introduction

Despite the proven effectiveness of cognitive-behavioural therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) in the treatment of obsessive–compulsive disorder (OCD), trials employing these two treatment strategies have demonstrated, respectively, inadequate responses in approximately 20% (Piacentini et al., 2002, The Pediatric OCD Treatment Study (POTS) Team, 2004) and 40% (DeVaugh-Geiss et al., 1990, Jenike and Rauch, 1994, Pallanti et al., 2002) of OCD patients. Factors that have been associated with poor response to treatment in OCD include sexual/religious obsessions (Alonso et al., 2001, Mataix-Cols et al., 2002a, Mataix-Cols et al., 2002b), hoarding (Black et al., 1998, Saxena et al., 1998), psychiatric comorbidity (Minichello et al., 1987, McDougle et al., 1990, Baer, 1994, Mundo et al., 1995, Shavitt et al., in press), poor insight (Neziroglu et al., 1999, Erzegovesi et al., 2001), early onset and chronic course of obsessive–compulsive (OC) symptoms (Ackerman et al., 1994, Ravizza et al., 1995, Skoog and Skoog, 1999, Rosario-Campos et al., 2001, Erzegovesi et al., 2001, Fontenelle et al., 2003), absence of sensory phenomena and greater symptom severity (Hollander et al., 2002, Shavitt et al., in press), lack of family history (Erzegovesi et al., 2001), and family involvement in the OC symptoms (Guedes, 1997, Steketee et al., 1999, Steketee and VanNoppen, 2003). This study aimed to identify intrinsic clinical characteristics to the phenotypic expression of OCD (such as content and formal aspects of OC symptoms, as well as OCD course and patterns of co-morbidity) and other factors regarding demography, epigenetic factors and family history, as well as aspects of family functioning, that could be associated with OCD patient refractoriness to treatment.