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Inpatient Therapy Effective for Treatment-Resistant Obsessive-Compulsive Disorder in Adolescents

Although cognitive-behavioral therapy (CBT) is the preferred treatment for obsessive-compulsive disorder (OCD) in adolescents, studies have shown that 37% of outpatients receiving CBT fail to show clinically significant improvement. In addition, there have been few studies evaluating the efficacy of inpatient CBT for OCD treatment.
 

Thröstur Björgvinsson, PhD, of The Menninger Clinic and Baylor College of Medicine, both in Houston, Texas, and colleagues, assessed an in-house sample of 23 adolescent patients receiving treatment for OCD to determine if inpatient programs are more effective than outpatient methods in OCD treatment.

 

Inpatients received 24-hour care including behavioral interventions and medication, among other treatment methods, and regular patient monitoring. Patients also participated in Exposure and Response Prevention treatment, a treatment plan in which patients are gradually exposed to situations that trigger compulsive reactions, while in the Menninger OCD Treatment Program.

“This type of treatment is needed to help patients with severe OCD and other anxiety disorders gradually manage their anxiety symptoms more effectively,” Dr. Björgvinsson said. “This provides the structure and accountability for treatment execution that outpatient and self-directed treatment lack.”

All patients, who ranged from 13–17 years of age (mean age=15.3 years), had a primary diagnosis of OCD, and 65% of patients had comorbid diagnoses including anxiety disorders. Treatment response was measured by the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS), Reynolds Adolescent Depression Scale (RADS), and the Intolerance to Uncertainty Scale (IUS). 

Björgvinsson and colleagues found that inpatients showed a significant decrease in symptom severity and a reduction in the strength of beliefs in constructs believed to contribute to OCD maintenance, although depression scores were not as robust as expected. Mean value for CY-BOCS at admission was 23.9 (SD=8.6); mean discharge value was 14.3 (SD=9.3). The mean RADS score at admission was 56.1 (SD=12.6), decreasing to 49.0 at discharge (SD=16.0). 

“The depression result is not too surprising,” Dr. Björgvinsson said. “At discharge, we often see increases in depression and worry because of the uncertainty of transitioning back into the community.” 

The researchers also found a non-significant increase in the mean IUS score, which rose from 89.7 at admission (SD=26.8) to 99.0 at discharge (SD=31.7), possibly also due to patient transition back into the community. They concluded that patients made progress despite past failed treatments.

“It is important to remember that these positive treatment effects were found with adolescents who have struggled tremendously in outpatient therapy, both utilizing psychotherapy and pharmacotherapy,” Dr. Björgvinsson said. “Hence, the findings are very encouraging and indicate that a significant proportion of adolescents who failed previous outpatient treatment can be helped through specialized hospital treatment.”
 

Study limitations included a small sample size, which could not determine the influence of comorbid diagnoses on OCD treatment. (2007 ADAA, Poster 55). —LS

Anxiety and Bodily Sensations Prevalent Among Patients Who Engage in Skin-Picking Behavior 

Skin picking—which is commonly defined as the picking, biting, and/or scratching of the skin—has been shown to occur in significant rates among young adults. These behaviors often lead to skin sores, scars, dental deformities, and infection as well as psychosocial distress. While prior studies have shown that patients who chronically pick at their skin report urges, physical sensations, and obsessions before beginning the behavior, there have been no studies that empirically examine the potential antecedent phenomenology to skin picking. 

Thomas G. Adams, BA, Chad T. Wetterneck, MS, and Douglas W. Woods, PhD, of the University of Wisconsin in Milwaukee evaluated the prevalence of skin-picking behavior among 387 participants through an Internet-based questionnaire. They hypothesized that, of participants who engage in skin-picking behavior, most will report autonomic anxiety, bodily sensation, and generalized feelings of discomfort before beginning the behavior. Elevated levels of anxiety and stress may also be present among participants who perform skin-picking behavior.

The mean age of study participants was 24.5 years, and no participants reported any medical condition that may interfere with the evaluation, such as autism or Tourette’s syndrome. The study questionnaire incorporated elements from the Habit Questionnaire, which identified the presence of skin-picking behavior, and the University of Sao Paulo-Harvard Repetitive Behaviors Interview, which assessed sensory, cognitive, and autonomic phenomena related to tics, compulsions, and other stereotyped repetitive behaviors. The Depression, Anxiety and Stress Scale (DASS) was also used to determine the prevalence of anxiety and stress in participants.

The authors found that 125 participants (32%) met the operational definition of skin picking, and 24 participants were found to engage in clinically significant skin-picking behavior, according to the Habit Questionnaire.

Adams and colleagues analyzed differences in depression, anxiety, and stress prevalence among the 24 clinically significant participants who picked their skin and a control group of 40 participants who engaged various repetitive behaviors. Sensory phenomena were only assessed in the clinically significant skin-picking group. 

The authors found that among participants who performed skin picking behavior, 75% reported bodily sensations, 50% reported uncomfortable feelings, and 45.8% reported anxiety prior to beginning the behavior. Additional analysis showed that skin-picking participants had higher scores on the DASS anxiety scale, when compared to controls. The most commonly reported bodily sensation was an unpleasant itch, tingle, or feeling of numbness. Uncomfortable feelings included a vague urge of discomfort, frustration, or pressure; feelings of being incomplete or imperfect; and a general “not right” feeling.

They concluded that the majority of skin-picking patients report a bodily sensation or feeling of discomfort prior to engaging in picking behavior. Many patients also feel a sense of relief or pleasure after the behavior is performed. 

In addition, Adams and colleagues state that these findings illustrate that anxiety may play a role in the development and/or maintenance of skin picking. They said such knowledge of the process of skin picking would aid clinicians in the creation of treatment programs aimed at habit reversal, which would identify warning signs for the patient to help deter the behavior. (2007 ADAA, Poster 66). —CP

FDA Approves Duloxetine HCL for Generalized Anxiety Disorder in Adults 

The United States Food and Drug Administration approved duloxetine HCl delayed-release capsules (Cymbalta, Eli Lilly) for the treatment of generalized anxiety disorder (GAD) in adults. Although clinical trials studied doses of 120 mg/day, the recommended daily dose of duloxetine is 60 mg/day, taken once daily.

Approval was based on three randomized, double-blind, placebo-controlled studies with 800 adults that showed duloxetine significantly improved anxiety symptoms, as measured by the Hamilton Rating Scale for Anxiety (46% versus 32% for patients in the placebo group). Scores measuring functional improvement were also significantly increased (46% versus 26%), as measured by the Sheehan Disability Scale.

The most common side effects found in £10% of patients receiving duloxetine delayed-release capsules were nausea, fatigue, drowsiness, dry mouth, constipation, insomnia, decreased appetite, hyperhidrosis (ie, excessive sweating), decreased libido, vomiting, ejaculation delay, and erectile dysfunction.

Duloxetine is not recommended for patients with renal disease or severe renal impairment, patients with a hepatic insufficiency, and women in the third trimester of pregnancy due to the potential risk for neonatal complications. Duloxetine is also approved for the treatment of major depressive disorder and management of diabetic peripheral neuropathic pain.
 

For more information, please visit the medication’s full prescribing information. (www.lilly.com). —CP

FDA Approves Lisdexamfetamine Dimesylate for Childhood Attention-Deficit/Hyperactivity Disorder

The United States Food and Drug Administration approved lisdexamfetamine dimesylate (Vyvanse, Shire/New River) for the treatment of pediatric attention-deficit/hyperactivity disorder (ADHD). The drug will be available in 30, 50, and 70 mg/day dosage strengths.
 

Phase II and III clinical trials indicated lisdexamfetamine dimesylate led to major improvements in ADHD symptoms for children (6–12 years of age) versus those treated with placebo.

In the phase II study, patients significantly demonstrated improved behavior when receiving lisdexamfetamine dimesylate or dextroamphetamine extended release. Each medication led to significantly improved behavior versus placebo (P<.0001). Patients also exhibited significantly improved academic productivity with both treatments compared with placebo (P<.0001). 

In the phase III randomized, double-blind, placebo-controlled study, each dose of lisdexamfetamine dimesylate 30, 50, and 70 mg/day resulted in increased improvement in the ADHD Rating Scale in the drug group compared with the placebo group (P<.0001) after 4 weeks of once-daily treatment.

Furthermore, in a recent study, the medication led to a 60% improvement in the primary rating scale scores for symptoms of ADHD in children 6–12 years of age who received 6 months of treatment in an open-label phase III study. At 6-month follow-up, 95% of patients taking lisdexamfetamine dimesylate showed a “much improved” or “very much improved” rating on the Clinical Global Impressions improvement score.

Side effects found in the clinical trial included decreased appetite, difficulty falling asleep, stomach ache, and irritability.
 

For more information, please visit the medication’s full prescribing information. (www.vyvanse.com). —JRR


Psychiatric Dispatches is written by Carlos Perkins, Jr., José R. Ralat, and Lonnie Stoltzfoos.